Under various names, what is now usually called Attention-Deficit Hyperactivity Disorder (ADHD) describes kids who are physically overactive, inattentive and so easily distracted as to be hard to persuade to settle to any task or focus of attention for long, impulsive, and hard to cope with.

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They quite often show minor signs of other neurological malfunctions, and slight delay in reaching the usual developmental milestones, so this used to be called "Minimal Brain Dysfunction" (MBD); except that no convincing objective evidence of specific brain dysfunction was found. Fancy modern techniques such as CAT scans and other ways of visualising brain structure and function have not found consistent anomalies; recent studies with Magnetic Resonance Imaging have reported some variations in the caudate nucleus and the corpus callosum areas of the brain, but these have not been duplicated and confirmed.

Symptoms
In children, the diagnosis is made on the basis of the presence of a range of symptoms including hyperactivity, difficulty in focussing and maintaining attention, and impulsiveness. These kids fidget, can't sit still, talk a lot without saying a lot; they don't follow instructions well, are readily distracted, don't listen to anyone for long, find it difficult to wait for their turn in games or conversations, they lose things, interrupt and intrude upon others, and they may do physically dangerous things, not for fun or for the thrill of it, but mindless of the potential consequences.

While all of these behaviours are part of the routine repertoire of many normal children, for these kids, such conduct is pervasive. Such children may encounter problems in school, not through being unintelligent, but in being unable to readily listen patiently to the teacher, do what they're told, finish assignments, and so on.

A concern I have in this area is that we are talking about a range of behaviours that exist on a continuum, and problems can arise according to who draws the line of the supposed borders of normality (and where) along that continuum. At one extreme, one does see occasional children who are intolerably over-active. They are a walking (or, rather, a running, jumping, and climbing) disaster area, and with obviously serious impairment of their ability to function at home, at school, or with other children. It would be hard not to see such a child as disordered and able to benefit from intervention.

Just normal behaviour?
But it is also far too easy to use such a diagnosis to label a child who is merely inconvenient to an inattentive parent, or, especially, to an uncaring, stressed, and uninterested teacher. Too many teachers prefer children who are quiet, undemanding, obedient, and who basically learn on their own; kids who don't really need actual teaching. Too often, a "diagnosis" of ADHD can be used as an excuse to blame the child for a teacher, a chaotic and disorganised classroom or school, which is what is actually failing. When I read claims by some that 40 per cent, or more, of schoolboys - and 17 per cent or more of girls, who have ADHD, I am more concerned that essentially normal behaviour is being misinterpreted as abnormal, than I am inclined to worry about any epidemic of disease. More convincing estimates of prevalence run at below 10%.

ADHD in adults?
A reader has asked me about ADHD in adults. He writes that he has encountered some checklists while browsing on the Internet, and considers that he meets the criteria according to those.

Firstly, I must say that one should be very cautious about using some of the checklists on offer, as they are usually unscientifically constructed, and tend to be so worded that very few people fail to find themselves included within the diagnosis being thus marketed. I have seen too many checklists (usually offered by people who seek to convince you that you have the problem they specialise in solving) according to which no honest human being could possibly fail to score results that would indicate serious pathology.

They do this, very easily, by including a very wide range of entirely normal behaviours. Do you ever feel nervous before a job interview or examination? (Golly, if you DON'T, it'd be more likely that there was something wrong with you.) Do you sometimes have difficulty getting to sleep? Do you sometimes get out of breath when running up a flight of stairs? and so on. They're very like those fatuous horoscopes so many media offer to you. Yes, of course your "fortune" seems to fit you - but read all the others - can you honestly say that they don't all, also, fit your situation? A further problem is that symptoms like inattention and distractibility can also be caused, especially in adults, by other disorders as well as by other aspects of one's life situation, so making the diagnosis is not so easy.

One must be cautious about self diagnosis, lest one be like the young man who read through an entire medical textbook, and was convinced that he suffered from everything in it, except the Preface and the Index.

The standard textbooks do not describe ANY adult variety of Attention-Deficit Disorder (ADD), insisting that it "attenuates with age", that is, it fades out as one grows up. For many years the accepted consensus was that the condition resolved spontaneously. It is very rarely diagnosed in adults, and I have been able to find no convincing description or argument that it ever arises or starts in adult life.

What is happening, though, is that as larger numbers of children who have been diagnosed as having ADHD, and under treatment for it, grow up, we are coming to see more adults who could be claimed to have ADHD. The impression one gets is that there are some young adults who still have some of the symptoms of ADHD, though not necessarily all those which would lead to the diagnosis being confirmed.

There have been only a few long-term follow-up studies to see what actually happens to children who have been diagnosed with ADHD. One which followed 6-12 year-olds until they were 16-23, finding that around a quarter still met criteria for diagnosing ADHD, a third meeting criteria for diagnosing a personality disorder, and a sixth matching criteria for a substance abuse disorder.

It has been reported that 9% of the group with ADHD were found to be in jail, compared with 1% of a comparative group of otherwise normal folks. Another study looking a further seven years ahead, found the proportion diagnosable as still having ADHD had fallen to 8%.

Evidence as to whether drug treatment continues to be effective is lacking; there is some indication that methylphenidate such as Ritalin may continue to be helpful.

As to the original question from our reader, then - an over-the-Web checklist cannot diagnose anything. But if it leads you to concern that you might have a particular disorder, see your friendly neighbourhood psychiatrist and discuss your concerns - they should have the skills to assess you comprehensively and to advise you as to whether there is any problem needing treatment. If you didn't have ADHD as a child, starting early in childhood, it is unlikely that you are suffering from it now. - (Prof M.A. Simpson)

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