Education Matters: ADHD going back centuries

By Marsha Sutton

How many parents have watched their children, more often boys, bouncing off the walls and running wild, unable to sit still or focus on a task for more than a few seconds?

We’ve all seen these kids – they are easily distracted, can’t wait their turn, and move around like mini-tornadoes. Is this just “being a boy” disease, or is it a medical condition that needs treatment?

David Feifel, M.D., professor in the department of psychiatry at the University of California San Diego, is an expert on Attention Deficit Hyperactivity Disorder, particularly in adults, and offered insights into the phenomenon of ADHD at a recent adult lecture at UCSD titled “ADHD Across the Lifespan.”

Because ADHD has gained more attention in the past few decades doesn’t mean it’s a new disease. ADHD is an old condition, observed and documented since the late 1700s, he said, and has generally been defined as the inability to inhibit impulsive behavior.

Girls also suffer from ADHD, although they can lack the hyperactivity aspect and so are easily overlooked, he said. Teachers often don’t identify the students who are not disruptive, those who sit quietly and daydream. But girls, Feifel said, can be internally pre-occupied and have ADHD with non-activated hyperactivity.

About 8 percent of school-age children and about 4.5 percent of adults have ADHD, he said, with statistics similar across cultures and countries. So this is not just an American phenomenon.

Four times as many males are diagnosed with ADHD as females, and in 60 percent of cases the condition persists into adulthood. This means, on the positive side, that about 40 percent of children and adolescents grow out of the condition as their brains mature or they learn to cope and function appropriately.

The 8 percent adolescent figure may seem low to those living in more affluent communities, but Feifel said 8 percent is the “true rate.” He distinguished between the “true rate” and the “diagnosed rate,” which depends upon several factors.

Those who live in low-income areas may see doctors less frequently, are less knowledgeable about identifying symptoms, or are less exposed to outside sources that can alert families to the condition.

“If I went to one school and gave a free public talk to teachers and parents on ADHD, the diagnosis rate at that school may change and end up differently than the school in the next neighborhood, even though the prevalence of ADHD among the students is identical,” Feifel said in an email.

The “true rate” is the prevalence of a disease or condition in the general population. “That’s a rigorous way to determine how many people have a condition whether they know it or not, whether they see a doctor or not,” he said.

Findings consistently show that, in studies of randomly selected subjects, about 8 out of every 100 kids have ADHD. That number, he said, has stayed fairly constant over the last few decades, despite pockets of increased diagnoses in higher socio-economic communities with more awareness and access to medical attention.

The rise in the diagnosed rate of ADHD is likely due to greater education of public and health professionals and also greater recognition of the spectrum of the disease, Feifel said.

Causes of ADHD

Feifel, founder and director of the UCSD Adult ADHD Program, identified three core features of ADHD: inattention/distractibility, impulsivity, and hyperactivity which sufferers may or may not have. A fourth feature is the tendency to be impatient and easy to anger. ADHD sufferers also tend to have low self-esteem.

To be clinically diagnosed with ADHD, the subject must be observed with six of the following nine traits of inattention on a consistent basis:


•difficulty sustaining attention

•won’t listen

•no follow-through

•can’t organize

•procrastination on tasks requiring sustained mental efforts

•loses important items

•easily distracted

•forgetful in daily activities

For the second feature, impulsivity, symptoms include blurting out answers in class or responses to queries, inability to wait his or her turn, and intruding or interrupting frequently.

For hyperactivity, ADHD patients will fidget, can’t stay seated, run or climb excessively, can’t work or play quietly, talk incessantly, and are always “on the go.”

Adolescent ADHD patients are typically about three years behind their peers in brain development and maturation. This, Feifel said, was not related to intelligence, noting that these children often have very high IQs, but rather has to do with functions controlled by the pre-frontal cortex, such as inhibition and impulsivity.

Into adulthood, symptoms will change and manifest differently – specifically, the hyperactivity component will diminish. Instead, experts will see adult patients who, for example, can’t read a book through to end or can’t retain information on pages just read.

For many sufferers, Feifel said, they see the big picture but can’t focus on details, so they can be highly creative. But, overall, he said the condition is still a major handicap.

ADHD is not a psychological condition, Feifel said. “There is compelling evidence that this is a brain-based disorder,” he said, saying PET scans have revealed that ADHD patients have less activity in the pre-frontal cortex.

He presented scientific evidence that ADHD is biological and inherited, with a 75 to 80 percent genetic component. “The biggest single contributor to ADHD is genetics,” Feifel said. An ADHD parent has a 25 to 50 percent chance of having a child with ADHD, he said, and if one twin has ADHD, there’s an 80 to 90 percent chance the other twin will too.

What does not cause ADHD, he noted, is bad parenting or too much television or video games.

Feifel, whose clinical focus is the diagnosis and treatment of psychiatric disorders stressing a biological orientation, said untreated adolescent ADHD patients run high risks that include higher motor vehicle accident rates, drug use, and increased sexual activity due to inhibited impulse control.

The range of ADHD patients is broad, and those children with lesser degrees of the condition often are able to cope in elementary school and even high school but can find themselves overwhelmed in college with the extra workload. These are intelligent kids, he said, who have managed to function well until they get to college and can’t keep up.

Treatment, Feifel said, has proven to be very effective over the decades. With 70 years of safe use, he said, stimulants work well because they strengthen pre-frontal cortex activity and allow sufferers to focus. Although it seems contrary to offer stimulants to hyperactive individuals, he said ADHD patients just look stimulated on the outside but are really under-stimulated and so become easily distracted.

He said ADHD medications like Adderall are fast-acting and offer a 75 to 85 percent positive response rate. Even though Web sites and manufacturing labels sometimes warn that the drugs can be addictive, they are “less addictive than caffeine,” Feifel said.

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