Thousands of studies later, attention-deficit/hyperactivity disorder -- one of the most researched and recognized childhood psychiatric conditions -- continues to confuse and confound.
As one major complication beyond scientists' control, between 30 percent and 65 percent of youngsters diagnosed with ADHD suffer co-existing conditions, so-called comorbidities, that make diagnosis and treatment all the more perplexing.
Research indicates ADHD often goes hand-in-hand with other psychiatric and physical problems. These include oppositional defiant, mood, anxiety, bipolar and conduct disorders, depression, epilepsy and Tourette syndrome, a neurological disorder characterized by involuntary twitches called tics.
ADHD also often partners with such developmental abnormalities as speech and language delays, learning disabilities and mental retardation. Even though the outward signs of many of these conditions may overlap, a therapeutic crossover can prove useless and even dangerous.
"Anxiety disorders, depression can cause the same appearance of the same symptoms (as ADHD), but you have a whole different reason for these, so treatment is dramatically different," said pediatric neuropsychologist Donna Palumbo of the University of Rochester in New York.
Stimulants are doctors' No. 1 choice for treating ADHD -- but, administered to a person with anxiety or bipolar disorder, they can do more harm than good.
No one keeps official track of exactly how often such errors might occur. However, research indicates misdiagnosis of mood and behavioral conditions is not uncommon, especially among general practitioners who now see most such cases, specialists report in the American Family Physician, a publication of the American Academy of Family Physicians.
Similarly, sleep studies have awakened deep concern about mistaking slumber irregularities for ADHD, whose symptoms shadow each other but whose therapeutic options are as different as night and day.
Stimulants may work well for ADHD, but it would seem counterproductive to give drugs whose side effects include insomnia to a child who already has trouble sleeping.
On the other hand, studies show treating apnea -- which shatters peaceful slumber with a jarring series of starts and stops in breathing -- and other sleep disorders can not only arouse attention but also calm hyperactivity.
Sleep specialists caution that behavioral aberrations, such as ADHD, can shroud chronic fatigue, a prevalent problem to which much of the country shuts its eyes.
A student who cannot sit still, concentrate, or stop fidgeting may be fighting sleep deprivation, not attention deficiency. In one study, for example, researchers found half the children diagnosed with ADHD were suffering from sleep-disordered breathing.
"Instead of parents growing concerned about their children not sleeping, we have a nation of children on Ritalin," complains Dr. Rafael Pelayo, a Stanford University neurologist who specializes in the relatively new medical field of sleep disorders.
A number of research groups, including Pelayo's, are conducting trials to determine whether at least some hyperactive patients might instead be poor sleepers.
"I suspect that many children do not use their full brain capacities to learn and absorb information because of their chronic sleep deprivation," says psychologist Avi Sadeh, director of the Clinical Child Psychology Graduate Program and of the Laboratory for Children's Sleep Disorders at Tel Aviv University in Israel.
"I'm even more worried that the increasing rates of attention problems (ADHD, or hyperactivity, as well as) youth violence and other forms of lowered frustration tolerance are related to this growing tendency to shorten sleep."
Some studies have found a reduction in irritability, bad moods, anger and fear and improvements in behavior and cognitive achievements following the removal of adenoids and tonsils and other treatments to correct sleep disorders.
As a result, some specialists urge parents of hyperactive and inattentive children to check with their doctor about possible slumber-stealing conditions, treat any breathing and limb movement irregularities, establish and enforce regular appointments with the sandman and avoid giving youngsters caffeinated drinks before bedtime -- and only if all these steps fail to consider medication for ADHD.
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