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Engelska - What is ADHD?

We can all sometimes find it difficult to sit still, focus our attention and control our impulses, particularly if we are under stress or tired. For some children, adolescents and adults, however, these problems are so substantial and constantly present that they seriously affect their ability to function in everyday life. There can then be justification for talking about a disability commonly known as ADHD or, in certain cases, DAMP. ADHD is used here as a collective term.

ADHD is a neuropsychiatric disability (that is to say the disability is due to certain parts of the brain not working the way they should) that occurs in around five per cent of all schoolchildren. It is more common among boys and men than among girls and women, although the proportion of girls/women who do not have their problems identified is now thought to be higher than was previously realised. It was thought for many years that ADHD was a children’s disability that faded as the child grew up. This turned out to be incorrect. It is now clear that in the majority of cases the problems remain during the years of adolescence and into adulthood.

If children with ADHD are not noticed early and do not receive understanding and help for their problems, there is a great risk of them failing at school, losing their self-esteem and having serious difficulties in adapting socially. In adulthood they are at risk of suffering depression, problems with relationships, difficulties in coping with the world of work and everyday existence and ending up in a life of drug and alcohol abuse and crime.

Definitions

In the medical literature, children with attention problems, hyperactivity and inadequate control of their impulses were described for the first time a hundred years ago, and it was already thought at that time that there was probably a biological background to the problems. Various designations have been used in the meantime, for example MBD, hyperactivity syndrome, ADD, motor perceptual handicap (MPH) and now ADHD. The various names given to the condition reflect the fact that over the years different views have been taken of what the characteristic difficulties in this disability are.

ADHD

The term Attention Deficit Hyperactivity Disorder or ADHD focuses on attention problems and the problems of impulse control and hyperactivity. ADHD is used as a collective term for three different subgroups, namely:

Those who mainly have attention problems
Those who mainly have hyperactivity/impulsivity problems
Those who have a combination of attention problems and hyperactivity/impulsivity problems.

ADD

By no means all children, adolescents and adults with ADHD are hyperactive. Some instead have a lower than normal level of activity. In clinical practice and everyday language the term ADD (Attention Deficit Disorder) is therefore used, or AD(H)D to characterise the group that mainly have attention problems as described above but are not hyperactive/ impulsive.

DAMP

If a child, as well as ADHD, also has motor difficulties and sometimes also perceptual difficulties, the usual diagnosis is DAMP. The acronym DAMP stands for Deficits in Attention, Motor control and Perception, sometimes also known as DCD (Developmental Coordination Disorder). These problems may become more serious in the longer term than those of children who only have ADHD. Several researchers therefore consider there to be particular reasons for paying attention to children with this combination of difficulties and making a separate diagnosis - DAMP.

The core symptoms of ADHD

Children, adolescents and adults with ADHD are a widely varied group. Their problems may differ in emphasis and degree of severity and vary over different periods from childhood to adulthood. The child’s characteristics, such as intelligence and the environment he or she grows up in, determine what consequence the fundamental difficulties will have.

The core symptoms in ADHD are attention problems, impulsivity and hyperactivity. These may occur individually or in combinations. In DAMP there are additional problems with motor control and perception. The diagnostic criteria are very strict in order to prevent normal conditions being defined as disabilities.

Significant difficulties that differ markedly from what can be expected on the basis of the child’s age are required for symptoms in children to be defined as ADHD. They must be difficulties that have had an early onset and are lasting and persistent. They have to be prominent in several different situations and cause such great difficulties that there is justification for talking of a disability.

Attention problems

The attention problems in ADHD can be manifested in many different ways. The child or adult does not appear to listen to what other people say even when spoken to directly, may find it difficult to understand instructions, is generally careless, does not get started on tasks, tires quickly, does not finish things that have been started, is disorganised, appears torn in different directions and absent-minded, forgets and loses things, loses the thread of what he or she is talking about, get caught up in in irrelevant details etc. This can create a generally unfocused, unconcentrated and confused impression.

In some the attention deficit is manifested in particular in being easily disturbed by things happening around them from which they are unable to shield themselves.

In others it appears more as though they seek stimulation from outside because they become bored unusually quickly. Unless the task is sufficiently exciting and motivating, they cannot overcome the impulse to do something more exciting instead.

Characteristic of most people with ADHD is a lack of perseverance and difficulty in summoning up energy to carry out a task, particularly if this task is boring and monotonous and does not directly satisfy a need.

The ability to focus attention on the essentials and sift out whatever is not essential and to allocate attention in an appropriate way is often also reduced.

Impulsivity and hyperactivity

Persons with ADHD who belong to the impulsive/hyperactive group tend to be described as extremely prone to action. They cannot stop themselves reacting to both big and small things, and they often also react without thinking. In exactly the same way as in a young child, the person’s action is controlled by stimuli coming from outside and impulses at the time, and not, as in the more mature person, from inside through consideration, thoughts, plans and intentions. The result may be unconsidered decisions and sometimes excessively spontaneous reactions, the consequences of which the person is not prepared to face. The present moment and what is most tangible at the time gain the upper hand and life therefore will be characterised by short-termism, lack of planning and inadequate goal orientation. The person with ADHD wants their needs to be met immediately rather than working towards long-term goals.

Motivation is a decisive factor in whether the person copes with a task or not. The person often finds it difficult to tolerate setbacks or obstacles. Impulsivity often means reacting in an exaggeratedly emotional way and sometimes finding it difficult to control one’s emotions. The person with ADHD finds it difficult to stop and listen to other people, and this obviously affects co-existence and interaction with others.

The impulsivity is sometimes manifested in finding it difficult to control and plan one’s movements, which results in motor clumsiness and sweeping patterns of movement. Impulsivity is more tangible in situations that are unstructured, if the task demands a great deal of reflection and consideration, and if there is a lack of external control and clear goals and rewards.

Hyperactivity was long considered to be the most prominent feature of ADHD. What was formerly described as hyperactivity is now usually regarded more as a difficulty in finding a suitable level of activity in relation to what a task demands. The level of activity is either too high or too low. This is closely related to impulsivity. The person rushes around aimlessly, is unable to sit still, is torn in different directions and wound up, and the next moment appears completely drained of energy and becomes passive and almost apathetic.

The notable motor hyperactivity common in young children often declines with age. In adults, however, it may be manifested differently, in being intolerant and restless, always needing to be busy with something, finding it difficult to unwind, tapping the fingers, constantly chewing gum, finding it difficult to sleep and so on.

Additional problems

Children, adolescents and adults with ADHD often have a number of other difficulties. As well as motor and perceptual difficulties, as in DAMP, these include language difficulties, cognitive problems, learning problems/dyslexia, difficulties in interaction with others, social behaviour problems such as obstinacy and misconduct, inadequate self-esteem, apprehension, anxiety and depression.

Closely related conditions such as Tourette’s syndrome and Asperger’s syndrome or other autism-like difficulties also occur relatively often. The more additional difficulties there are, the more serious the disability obviously becomes. However, many of the additional problems can be avoided or their effects can be limited if people around understand how the person with ADHD functions and can adapt their demands and expectations accordingly.

Causes

Researchers familiar with this area are now agreed that ADHD is a biologically based disability. Biological factors are decisive in the development of ADHD, and heredity plays a significant role in this context.

Various risk factors and stresses during pregnancy and delivery may also have a role to play. Various abnormalities have been found in the functioning of the brain in persons with ADHD. The common denominator is disturbances in the transfer of impulses in the parts of the brain that manage attention, regulation of activity and control of impulses. Biochemical models to explain this, mainly relating to the supply of dopamine in the brain, are most under discussion at present. This ties in well with the neuropsychological models proposed in recent years. According to these models the difficulties can be explained as deficiencies in executive functions, that is to say processes in the brain that are responsible for planning, organisation, coordination, control of impulses etc.

Deficiencies in what is known as the working memory are another element. Expressed simply, the working memory is responsible for keeping several things in the head at the same time, and being able to use previous experiences to understand new situations, as a guide to how to act.

There is no evidence that psychosocial factors such as bad upbringing, deficiencies in family functioning, stress, traumatic events, environmental factors or the like might explain the development of ADHD.

On the other hand, such factors are of great significance to how serious the consequences of the disability will be.

Understanding and support from people in the person’s environment can prevent the disability developing into a serious handicap.

Written by Agneta Hellström, Child and Adolescent Psychiatry Unit, Uppsala University Hospital

Factual material reviewed by: Henrik Pelling, Head of Child and Adolescent Psychiatry Unit, Uppsala University Hospital