Certainly this disease is a lifelong problem for a proportion of children, although it is just as clear that many “outgrow” the hyperactivity and attention deficit. Hill and Schoener estimate that there is a 50 percent decline in prevalence with each 5 years that pass. Other authorities state that the problem persists in 80 percent. In addition to the child with ADHD who grows to adulthood with persistent problems, there recently has emerged an emphasis on a group of adults who present for the first time with features of difficulty focusing or concentrating that they or their physicians attribute to ADHD. The hyperactivity component is generally absent and may not have occurred in childhood, making the validity of the diagnosis uncertain in adults who were not identified as having ADHD in childhood. A study by Kessler and colleagues suggests that 4.4 percent of adults in the United States have the disorder. European investigators use more restrictive criteria for diagnosis and find far lower frequencies in both children and adults, with consequentially far fewer prescriptions being written for stimulant drugs.
An approach to screening in adults has been given by McCann and Roy-Byrne. Most often these adults come to realize they have had a lifelong problem that is similar to the motor restlessness and wandering attention that led to the diagnosis of ADHD in their own children. The efficacy and safety of stimulant drugs in the adult group are not known with certainty, but this class of medications has been tried with some benefit according to many patients. Some data have emerged that the cardiovascular risks are greater in adults than in children; reports of anxiety and palpations, as well as elevations in blood pressure, are common among adults taking the medications.
Many such individuals are of above-average intelligence and have attained high degrees of professional success, perhaps as a result of strategies developed implicitly over the years, such as note taking, organizers, mental reminders to focus, etc. These same adjustments can be quite useful to others who are struggling with the disorder so that medication is not the only alternative to surmount the cognitive problem. In relation to persistent traits of ADHD from childhood, several psychiatrists have pointed out that there may be an increase in drug and alcohol dependence among adolescents with the disorder (Zametkin and Ernst) and a slight overrepresentation of tic disorders such as Gilles de la Tourette syndrome. Our general clinical experience suggests that these additional problems do not arise in the great majority of such children. Recent studies have been reassuring in this regard, but the concern regarding tics has remained.
Voluntary sphincteric control develops according to a predetermined time scale. Usually normal children stop soiling themselves before they can remain dry, and day control precedes night control. Some children are toilet trained by their second birthday, but many do not acquire full sphincteric control until the fourth year. Constant dribbling usually indicates spina bifida, another form of dysraphism, or a tethered cord, but in the boy, one must look also for obstruction of the bladder neck, and in the girl, for an ectopic ureter entering the vagina.
When a child 5 years of age or older wets the bed nearly every night and is dry by day, the child is said to have nocturnal enuresis. This condition afflicts approximately 10 percent of children between 4 and 14 years of age, boys more than girls, and continues in many cases to be a problem even into adolescence and adulthood. Although developmentally delayed children are notably late in acquiring sphincter control (some never do), the majority of enuretic individuals are normal in other respects.
The cause of this condition is disputed. Often there is a family history of the same complaint. Some psychiatrists have insisted that overzealous parents “pressure” the child until he develops a “complex” about his bedwetting; this is highly doubtful. The underlying condition is believed by most neurologists to be a delay in the maturation of higher control of spinal reflex centers during sleep. These and other abnormalities of bladder function in the enuretic child, as well as treatment, are also discussed in Chap. 18 in relation to sleep.