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gene These animals display behavioral symptoms that are said to replicate those of ADHD in children and also to respond to stimulants These observations implicate an abnormality of dopamine and serotonin; the idea is provocative because several genetic linkage studies have suggested an association between ADHD and a polymorphism of the gene that codes for the same dopamine transporter gene Apart from the reports of parents and teachers and observation of the child, one is aided in the diagnosis of the attention de cit disorder (and other learning disabilities) by psychometry An observant psychologist, in performing intelligence tests, notes distractibility and dif culty in sustaining any activity Erratic performance that is not due to a defect in comprehension is characteristic The treatment of the hyperactive child can proceed intelligently only after medical and psychologic explorations have elucidated the context in which the hyperactivity occurs If the child is hyperactive and inattentive mainly in school and less so in an unstructured environment, it may be that mental retardation or dyslexia, which prevents scholastic success, is a source of frustration and boredom The child then turns to other activities that may happen to disturb the classroom Or the hyperactive child may have failed to acquire self-control because of a disorganized home life, and the overactivity may be but one manifestation of anxiety or intolerance of constraint Clearly problems such as these require a modi cation of the educational program Treatment For overactive children of normal intelligence who have failed to control their impulses, who at all times have boundless energy, require little sleep, exhibit a wriggling restlessness (the choreiform syndrome of Prechtl and Stemmer), and manifest incessant exploratory activity that repeatedly gets them into mischief, even to their own dismay, medical therapy is in order Paradoxically, stimulants have a quieting effect on these children, whereas phenobarbital and other sedatives may have the opposite effect Methylphenidate is the drug most widely used Children under 30 kg are given 5 mg each morning on school days for 2 weeks, after which the dose can be raised to 5 mg morning and noon Children weighing less than 30 kg can be given a single 20-mg sustained-release tablet each morning If methylphenidate proves ineffective after several weeks or cannot be tolerated, dextroamphetamine 25 to 5 mg three times daily is a suitable substitute Pemoline is a weaker but sometimes better-tolerated stimulant than the others If these agents control the activity and improve school performance (they can be continued for a number of years), there is then no need to alter the child s school program If stimulants are ineffective, tricyclic antidepressants, particularly desipramine, should be tried Classroom behavioral conditioning techniques and psychotherapy may be needed for brief periods Remedial education is reserved for recalcitrant cases Certainly the disease is a lifelong problem for a proportion of children, although it is just as clear that many or most outgrow it Hill and Schoener estimate that there is a 50 percent decline in prevalence with each 5 years of growth In addition to the child with ADHD who grows to adulthood with persistent problems, there has recently emerged an interest in a group of adults who present for the rst time with features that they or their physicians attribute to ADHD Most often these adults come to realize they have had lifelong problems that are similar to the motor restlessness and wandering attention that led to the diagnosis of ADHD in their own children The ef cacy and safety of stimulant drugs in the adult group is not known with certainty, but this class of medications as well as antidepressants has been tried with some success.

In relation to persistent traits of ADHD, 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 connection in a few cases to tic disorders such as Tourette syndrome (page 95) However, it can be said from our general clinical experience that these problems do not arise in the great majority of such children

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 bi da or another form of dysraphism, 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 af icts 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 mentally retarded 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 It is our impression that night terrors are frequent in this group Some psychiatrists have insisted that overzealous parents pressure the child until he develops a complex about his bedwetting; this is highly doubtful Punishment, shaming, rewards, etc, may have this effect, but the underlying condition is believed by most neurologists to be a delay in the maturation of higher control of spinal re ex centers during sleep These and other abnormalities of bladder function in the enuretic child, as well as treatment, are discussed in the chapter on sleep (page 349)

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