The Relationship Between Prematurity and ADHD

By Dr. Dina O’Brien

Prevalence of ADHD in Children

©iStockphoto.com/SerrNovik

©iStockphoto.com/SerrNovik

Attention-deficit/hyperactivity disorder (AD/HD) is one of the most common mental health disorders in children, affecting 3-10% of school-age children (between 2 to 5.4 million children aged 4-17). The diagnosis in boys far outnumbers the diagnosis in girls, likely, in part, because boys more often display the hyperactive behavior that is readily noticed by teachers and parents.  The current diagnostic classification system highlights the key features as developmentally inappropriate levels of inattention, impulsivity, and/or hyperactivity, which impact the child’s functioning across settings including home, school, and social situations.  Symptoms can range from mild to more severe, and not all children will have the same symptoms.  Based on current diagnostic guidelines, there are 3 subtypes of ADHD:

What Does ADHD Look Like?

  •  ADHD, Primarily Inattentive Type (commonly referred to as ADD by the general public)
  • ADHD, Primarily Hyperactive-Impulsive Type
  • ADHD, Combined Type (symptoms of both inattention and hyperactivity/impulsivity)

Most symptoms center on the “executive functions”, often called the “CEO” of the brain. Some of the more common difficulties include:

  • Easily distracted/frequent complaints of boredom
  • Often does not seem to listen when spoken to directly
  • Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
  • Needs directions and requests repeated multiple times
  • “In constant motion” (e.g. running, talking, wandering, tapping feet)
  • Sleep difficulties
  • Trouble completing tasks/projects
  • Difficulty paying attention except if doing something he/she particularly enjoys
  • Difficulty with peer relationships (e.g. waiting his/her turn, bossy, invades personal space)
  • Low frustration tolerance/prone to temper outbursts
  • Difficulty with academic expectations (e.g. forgets to turn in homework, makes careless mistakes, fails to complete assignments)
  • Difficulty controlling one’s behavior, emotions, and reactions, as well as thinking about the potential consequences of that behavior before acting
  • Difficulty following multi-step commands (e.g. get your shoes, then get dressed, and brush your teeth)
  • Often loses/misplaces items

When Should Families Seek a Diagnosis?

Onset usually begins in early childhood, often by the age of 3, though many parents report remembering the child to have been very active even as an infant.   Frequently, ADHD is not recognized or officially diagnosed until the child begins formal schooling.  It is at this time that expectations and demands for paying attention and for managing behavior increase.  Based on current diagnostic guidelines, the symptoms must be present before the age of 7.  About one-third to one-half of children with ADHD will also have a Learning Disability or other mental health condition such as Anxiety, Oppositional Defiant Disorder or Depression along with their attention difficulties.  It is important to note, however, that ADHD is not related to IQ.  Children with ADHD fall into the same IQ ranges as the general population, including giftedness.  According to most experts in the field, ADHD is a chronic condition that persists across the lifespan, though the symptoms and the way those symptoms present, usually change as the child enters adolescence and adulthood.  Often the hyperactivity decreases, while the impulsivity and attention difficulties tend to persist.  Current research also indicates that there are multiple pathways or factors that can lead to the development of ADHD, though there is much we still do not know! In most cases, ADHD is NOT a result of anything the parent(s) did or did not do! Although no clear gene has yet been identified, we do know that a genetic connection exists, as ADHD is a highly inheritable disorder (40-50% of all children with ADHD have at least one parent with ADHD and 30% have a sibling with the condition).  However, it can also be acquired, typically meaning that one or more environmental factors affected normal brain growth before, during, or after birth.  Some examples of such environmental factors include exposure to toxic substances such as lead, maternal nicotine use, and pregnancy or birth complications such as toxemia, prematurity, loss of oxygen, and even brain injury from disease or trauma.  At the present time, it is often not possible to distinguish between these types of ADHD as the presentation is similar and both usually respond to treatment.  

Is there a Relationship Between Prematurity and ADHD?

About 8-10% of children are born prematurely in the United States each year and of those preterm deliveries, 1.5% (60,000) are Very Low Birth Weight babies, weighing less that 1500g (3lbs, 5oz).  We know that preemies and/or low birth weight children face higher rates of health problems as a result of being born early, and now researchers are finding that they are also more susceptible to developing ADHD.  Severe prematurity-being born between 23 and 28 weeks-was found to put an infant at the greatest risk for later developing ADHD.  But even mild prematurity–being born in weeks 37 or 38–was found to result in an elevated risk.  At 34 weeks gestation, the overall weight of the brain is only 65% of what it weighs at 40 weeks gestation.  Therefore, many researchers speculate that premature birth results in disruption to the maturational processes of the brain. Since the risk of ADHD increases the more premature the baby is, and decreases gradually in closer-to-term babies, it seems to point to the role of brain development in explaining the link between preterm birth and ADHD.  However, some also suggest that the effects of stress that preemies experience such as neonatal pain, maternal separation during intensive care, increased auditory and visual stimulation, and sleep deprivation, may also play a role as these are developmentally unexpected events.  Studies with animals have shown that these stressors lead to changes in arousal and attention.  In humans, such changes are associated with learning disabilities and cognitive difficulties which may manifest as ADHD.

What Can Parents Do?

The current research clearly indicates that more attention is needed on why premature babies are more susceptible to this developmental disorder.  The results also stress the underlying importance of advancing the care and follow-up for infants born prematurely. If you suspect your child may be experiencing some symptoms commonly associated with ADHD, talk to your child’s pediatrician or seek out an evaluation with a qualified mental health provider that specializes in treating children with ADHD. Clarifying the diagnosis is important, but knowledge of how ADHD plays out in a particular individual is critical for tailoring interventions and putting the right supports in place—academically, socially, and at home.

When Your Child is Diagnosed

If your child is diagnosed with ADHD, empower yourself with information! You can appropriately advocate for your child when you are armed with facts and knowledge. Acceptance of the diagnosis may be difficult for some families at first, but it is important to remember that a diagnosis of ADHD should not and does not need to define your child!  Children with ADHD have many positive traits and strengths—they are creative, resilient, social, bright, humorous, and passionate! Fortunately, we have proven treatments for ADHD which can limit the negative impact it has on children and their families, and help kids lead very productive and fulfilling lives!

 **Research references for this article can be provided upon request

RESOURCES:

WEBSITES:

CHADD-Children and Adults with Attention-Deficit/Hyperactivity Disorder www.chadd.org

Official Website of Dr. Russell Barkley, an expert on ADHD www.russellbarkley.org

National Institute of Mental Health (NIMH) www.nimh.nih.org

ADHD Online Community www.adhd.com

The ADHD Report www.guilford.com

BRAKES: The Interactive Newsletter for Kids with ADHD www.maginationpress.com

 BOOKS:

Taking Charge of ADHD, Revised Edition: The Complete, Authoritative Guide for Parents by Dr. Russell Barkley

The ADHD Parenting Handbook: Practical Advice for Parents from Parents by Colleen Alexander-Roberts

The ADHD Book of Lists by Sandra Rief

Dr. O’Brien is a licensed Psychologist specializing in treating children and adolescents who are experiencing a wide variety of concerns including Anxiety, ADHD, Autism Spectrum Disorders/Developmental Delays, Pain Management, Adjustment to Medical Problems/Disability, and Grief/Loss.  Dr. O’Brien’s fourth child was born preterm.  She serves on the Hand to Hold Advisory Council.  For more information about her practice, visit   http://www.drdinaobrien.com

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