.
reversals or transpositions of letters, numbers or words
Often confuses left/right, over/under
Has difficulty telling or managing time, being on time or learning sequenced information or tasks
Mispronounces long words; transposes phrases, words and syllables while speaking
Often has poor working memory so finds it difficult to work things out in their heads.
WHAT IS ADHD?
ADHD was first talked about at the turn of the twentieth century. In 1902, Dr George Still, a physician with an interest in children’s diseases, described to the Royal College of Physicians in London those children who seemed to him to be restless, passionate and apt to get into trouble. Dr Still suggested they had ‘an abnormal defect of moral control’. He wrote an article in The Lancet on the subject. For a while, the condition was linked to the influenza encephalitis pandemic of 1917–18, when it was called Post-Encephalitic Behaviour Disorder.
Over the years the hyperkinetic (increased energy levels) activities were thought to be the predominant feature and the term ‘Hyperkinetic Impulse Disorder’ was coined in the fifties and ‘Hyperactive Child Syndrome’ in the sixties. The Diagnostic and Statistical Manual (DSM) of mental disorders was established by the American Psychiatric Association and is now a standard method recognised internationally to assess various behavioural and mental conditions. Now well established, it described the condition for the first time in 1980 calling it the ‘Hyperkinetic Reaction of Childhood’ disorder. Later, the emphasis fell very much in the direction of attention deficits and the term ADD was first used, defining the disorder as with or without hyperactivity and focusing on inattention and impulsivity. Further revisions defined the term ADHD, its symptoms and cut-off scores for diagnosis.
The current fourth edition of DSM criteria further split the disorder into ADHD (predominantly inattentive), ADHD (predominantly hyperactive) and ADHD combined type (both inattention and hyperactivity). Unfortunately, too little is really understood about the brain-based causes of the condition and experts continue to argue over the underlying disorder.
There are a number of different diagnostic procedures available, none of which is 100 per cent reliable and all, until now, are dependent on subjective opinions. But modern technology is now lending a hand in clarifying the biological basis of this complex disorder. The advent of MRI (Magnetic Resonance Imaging) and functional MRI (which analyses blood flow during brain activity and can identify areas of activity during rest and when performing tasks) has lead to the observation of both structural and functional differences in the brains of ADHD subjects compared to normal subjects. The most consistent findings appear to be a reduced size of the lower mid-line cerebellum (at the back of the brain) and the mid-brain area.
In the past, it has been presumed that the problems lay with the front part of the brain. However, we believe that this is not always the case and that, in fact, in the majority of cases a person is likely to suffer because it is their cerebellum that is not functioning appropriately. Supporting this are several pieces of evidence. We know from a number of studies over the past 20 years that the cerebellum appears to be poorly developed when ADHD is present. We also know from functional scans that the cerebellum is poorly activated in ADHD, whereas in other studies there is inconsistency in the frontal lobe activity ranging from underactivity to normal activity and overactivity.
Recent research at Harvard University in the United States has shown that the drug Ritalin (commonly prescribed for its treatment) appears to increase the activity in this same area of the cerebellum that is found to be poorly developed in ADHD. We also know that ADHD rarely stands alone as a disorder and normally exists side by side with disorders such as dyslexia, developmental co-ordination disorder (dyspraxia) and even autism. This either implies multiple areas of brain disorder or a common area of poor brain functioning impacting on all other separate brain areas involved. Some current independent research into these supposedly separate disorders now suggests a single underlying cerebellar cause. This could easily explain how these different disorders are seen together so often.
THE COMMON SYMPTOMS OF ADHD
Generally, ADHD can be divided into attention symptoms, hyperactivity symptoms and impulsivity symptoms. The hyperactivity symptoms are usually grouped with the impulsivity symptoms when being assessed.
The DSM IV criteria define nine separate symptoms for both attention and hyperactive/impulsive conditions, and that six or more must be seen to confirm a diagnosis. Also, these symptoms must occur within more than one environmental setting – for example, both at school and at home. Other requirements for diagnosis are that symptoms should have been present from before the age of seven and that there should be no other psychiatric conditions present that could account for these behaviours.
Most specialists use a ‘yes’ or ‘no’ response to each question but recently a more rigorous method has been developed which asks that the responses be graded into four choices ranging from ‘all the time’ to ‘never’. This leads to a more sensitive measure of the behaviour problems. As yet, there are unfortunately no biological tests which can be applied to detect this disorder but this might change in the near future.
The following are the attention-based criteria used during diagnosis:
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions)
Often has difficulty organising tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
The following are the hyperactivity-based criteria used:
Often fidgets with hands or feet, or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
Often has difficulty playing or engaging in leisure activities quietly
Often ‘on the go’ or often acts as if ‘driven by a motor’
Often talks excessively
The following are the impulsivity-based criteria used:
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn
Often interrupts or intrudes on others (e.g. butts into conversations or games)
WHAT IS DYSPRAXIA (OR DEVELOPMENTAL CO-ORDINATION DISORDER)?
Dyspraxia literally translates as difficulty (dys-) with movement (-praxia). This can be evident with the large movements of arms and legs, making people appear awkward or clumsy. Sometimes, it is the small (fine motor) movements where difficulties may be experienced – for instance, pen-handling skills including writing and drawing, also sometimes called dysgraphia.
There are varying