George A. Sprecace M.D.,
J.D., F.A.C.P. and Allergy Associates of New London,
ATTENTION DEFICIT / HYPERACTIVITY DISORDER (ADHD)
- More Information
The following information was obtained during a lecture by Joseph Beiderman,
M.D., Professor of Psychiatry at Harvard Medical School, and a noted researcher
in the field. His topic was: "The Neurobiology, Diagnosis and
Treatment of ADHD Across The Life Cycle." As will be seen
from the scope and variability of the information, my commentary
which precedes it in this section remains relevant. All medical care
requires a diagnosis, including a differential diagnosis, before comprehensive
treatment is embarked upon. And when the diagnosis remains in doubt,
it is better to call the situation “diagnosis undetermined” rather
than to label it prematurely and thus terminate the critical thinking
of others in the matter.
GOT IT? IF NOT, STAY TUNED. MEANWHILE, BE CAREFUL.
This diagnosis, with even its own DSM lV code, includes a heterogeneous
group of conditions with multiple possible etiologies: neuroanatomic /
neurochemical, central nervous system, genetic and environmental.
Estimated prevalence in children is 5%. There is a lower incidence
in Ireland; there is a higher incidence in Puerto Rico, Spain, and in the
The symptom areas include: inattention; and impulsivity / hyperactivity.
The symptoms often vary in pervasiveness and in frequency of occurrence.
30% of ADD/ADHD patients do not have hyperactivity. Subtypes include
Pathology: the pre-frontal cortex is the main site involved in ADHD, followed
by the anterior cingulate gyrus. The pathophysiology is a dysfunction
of dopaminergic pathways. PET scans can show pre-frontal and motor
activation disturbances, in addition to smaller size of the implicated
brain areas. However, MRI and PET studies are not yet useful
It has recently been found that the cerebellum is much more involved in
cognitive issues than earlier recognized. (?)
“Genetics accounts for 80% of ADHD; this is a highly familial illness (6Xnormal)”.
Furthermore, twin studies show some further correlation with bi-polar affective
disorder and with schizophrenia.
Non-genetic issues account for 20%. The most common is maternal smoking
during pregnancy; other factors include fetal alcohol exposure, low birth
weight, and psychologic adversity.
Co-Morbidity: ADHD tends to be associated with other diagnoses in
the same individual: oppositional - destructive behavior, conduct disorder,
mood - anxiety and learning disorders. (Much more prevalent in males).
Also bi-polar disorders in 10% of ADHD. Also drug abuse starting in adolescence,
perhaps to a greater degree in girls.
Remissions in ADHD: there is no sure pace for remissions. The sequence
seems to be: hyperactivity first, then impulsivity, and then inattention.
Remissions may occur in up to 60% of those affected.
Predictors of persistence: positive family history; co-morbid conditions;
“ADHD is a valid diagnosis for adults”. “It is estimated that 25%
of criminal inmates may have ADHD”.
Treatment: “Medications are fundamental to the treatment of ADHD;
treatment works, as distinguished from only behavioral and/or community-based
treatment”. Best are the drugs ritalin, dexedrine, adderal, cylert...
of patients respond selectively, to one or to the other of these agents.
One-third of children do not respond or can’t tolerate these medications.
The main alternatives are the tri-cyclics.