Attention Deficit Hyperactivity Disorder

Lisa's son Jack had always been a handful. Even as a preschooler, he would tear through the house like a tornado, shouting, roughhousing, and climbing the furniture. No toy or activity ever held his interest for more than a few minutes and he would often dart off without warning, seemingly unaware of the dangers of a busy street or a crowded mall.

It was exhausting to parent Jack, but Lisa hadn't been too concerned back then. Boys will be boys, she figured. But at age 8, he was no easier to handle. It was a struggle to get Jack to settle down long enough to complete even the simplest tasks, from chores to homework. When his teacher's comments about his inattention and disruptive behavior in class became too frequent to ignore, Lisa took Jack to the psychiatric provider, who recommended an evaluation for attention deficit hyperactivity disorder (ADHD).

ADHD is a common behavioral disorder that affects an estimated 8% to 10% of school-age children. Boys are about three times more likely than girls to be diagnosed with it, though it's not yet understood why.

Kids with ADHD act without thinking, are hyperactive, and have trouble focusing. They may understand what's expected of them but have trouble following through because they can't sit still, pay attention, or attend to details.

Of course, all kids (especially younger ones) act this way at times, particularly when they're anxious or excited. But the difference with ADHD is that symptoms are present over a longer period of time and occur in different settings. They impair a child's ability to function socially, academically, and at home.

The good news is that with proper treatment, kids with ADHD can learn to successfully live with and manage their symptoms.

Symptoms^back to top

ADHD used to be known as attention deficit disorder, or ADD. In 1994, it was renamed ADHD and broken down into three subtypes, each with its own pattern of behaviors:

1. an inattentive type, with signs that include:
   

   inability to pay attention to details or a tendency to make careless errors in schoolwork or other activities difficulty with sustained attention in tasks or play activities apparent listening problems difficulty following instructions problems with organization avoidance or dislike of tasks that require mental effort tendency to lose things like toys, notebooks, or homework distractibility forgetfulness in daily activities

2. a hyperactive-impulsive type, with signs that include:
   

   fidgeting or squirming difficulty remaining seated excessive running or climbing difficulty playing quietly always seeming to be "on the go" excessive talking blurting out answers before hearing the full question difficulty waiting for a turn or in line problems with interrupting or intruding

3. a combined type, which involves a combination of the other two types and is the most common

Although it can be challenging to raise kids with ADHD, it's important to remember they aren't "bad," "acting out," or being difficult on purpose. And they have difficulty controlling their behavior without medication or behavioral therapy.

Diagnosis^back to top

Because there's no test that can determine the presence of ADHD, a diagnosis depends on a complete evaluation. Many children and adolescents diagnosed with ADHD are evaluated and treated by primary care psychiatric providers including pediatricians and family practitioners, but your child may also be referred to one of several different specialists (psychiatric providers, psychologists, neurologists) especially when the diagnosis is in doubt, or if there are other concerns, such as Tourette syndrome, a learning disability, anxiety, or depression.

To be considered for a diagnosis of ADHD:

a child must display behaviors from one of the three subtypes before age 7 these behaviors must be more severe than in other kids the same age the behaviors must last for at least 6 months the behaviors must occur in and negatively affect at least two areas of a child's life (such as school, home, day-care settings, or friendships)

The behaviors must also not only be linked to stress at home. Kids who have experienced a divorce, a move, an illness, a change in school, or other significant life event may suddenly begin to act out or become forgetful. To avoid a misdiagnosis, it's important to consider whether these factors played a role in the onset of symptoms

First, your child's psychiatric provider will take a medical history by performing a physical examination and asking you about any concerns and symptoms, your child's past health, your family's health, any medications your child is taking, any allergies your child may have, and other issues.

The psychiatric provider may also check hearing and vision so other medical conditions can be ruled out. Because some emotional conditions, such as extreme stress, depression, and anxiety, can also look like ADHD, you'll fill out questionnaires to help rule them out.

You'll be asked many questions about your child's development and behaviors at home, school, and among friends. Other adults who see your child regularly (like teachers, who are often the first to notice ADHD symptoms) probably will be consulted, too. An educational evaluation, which usually includes a school psychologist, may also be done. It's important for everyone involved to be as honest and thorough as possible about your child's strengths and weaknesses.

Causes of ADHD^back to top

ADHD is not caused by poor parenting, too much sugar, or vaccines.

ADHD has biological origins that aren't yet clearly understood. No single cause has been identified, but researchers are exploring a number of possible genetic and environmental links. Studies have shown that many kids with ADHD have a close relative who also has the disorder.

Although experts are unsure whether this is a cause of the disorder, they have found that certain areas of the brain are about 5% to 10% smaller in size and activity in kids with ADHD. Chemical changes in the brain also have been found.

Recent research also links smoking during pregnancy to later ADHD in a child. Other risk factors may include premature delivery, very low birth weight, and injuries to the brain at birth.

Some studies have even suggested a link between excessive early television watching and future attention problems. Parents should follow the American Academy of Pediatrics' (AAP) guidelines, which say that children under 2 years old should not have any "screen time" (TV, DVDs or videotapes, computers, or video games) and that kids 2 years and older should be limited to 1 to 2 hours per day, or less, of quality television programming.

Related Problems^back to top

One of the difficulties in diagnosing ADHD is that it's often found in conjunction with other problems. These are called coexisting conditions, and about two thirds of kids with ADHD have one. The most common coexisting conditions are:

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)^back to top

At least 35% of kids with ADHD also have oppositional defiant disorder, which is characterized by stubbornness, outbursts of temper, and acts of defiance and rule breaking. Conduct disorder is similar but features more severe hostility and aggression. Kids who have conduct disorder are more likely to get in trouble with authority figures and, later, possibly with the law. Oppositional defiant disorder and conduct disorder are seen most commonly with the hyperactive and combined subtypes of ADHD.

Mood Disorders^back to top

About 18% of kids with ADHD, particularly the inattentive subtype, also experience depression. They may feel inadequate, isolated, frustrated by school failures and social problems, and have low self-esteem.

Anxiety Disorders^back to top

Anxiety disorders affect about 25% of kids with ADHD. Symptoms include excessive worry, fear, or panic, which can also lead to physical symptoms such as a racing heart, sweating, stomach pains, and diarrhea. Other forms of anxiety that can accompany ADHD are obsessive-compulsive disorder and Tourette syndrome, as well as motor or vocal tics (movements or sounds that are repeated over and over). A child who has symptoms of these other conditions should be evaluated by a specialist.

Learning Disabilities^back to top

About half of all kids with ADHD also have a specific learning disability. The most common learning problems are with reading (dyslexia) and handwriting. Although ADHD isn't categorized as a learning disability, its interference with concentration and attention can make it even more difficult for a child to perform well in school.

If your child has ADHD and a coexisting condition, the psychiatric provider will carefully consider that when developing a treatment plan. Some treatments are better than others at addressing specific combinations of symptoms.

Treating ADHD^back to top

ADHD can't be cured, but it can be successfully managed. Your child's psychiatric provider will work with you to develop an individualized, long-term plan. The goal is to help a child learn to control his or her own behavior and to help families create an atmosphere in which this is most likely to happen.

In most cases, ADHD is best treated with a combination of medication and behavior therapy. Any good treatment plan will require close follow-up and monitoring, and your psychiatric provider may make adjustments along the way. Because it's important for parents to actively participate in their child's treatment plan, parent education is also considered an important part of ADHD management.

Medications^back to top

Several different types of medications may be used to treat ADHD:

• Stimulants are the best-known treatments – they've been used for more than 50 years in the treatment of ADHD. Some require several doses per day, each lasting about 4 hours; some last up to 12 hours. Possible side effects include decreased appetite, stomachache, irritability, and insomnia. There's currently no evidence of long-term side effects.
• Nonstimulants were approved for treating ADHD in 2003. These appear to have fewer side effects than stimulants and can last up to 24 hours.
• Antidepressants are sometimes a treatment option; however, in 2004 the U.S. Food and Drug Administration (FDA) issued a warning that these drugs may lead to a rare increased risk of suicide in children and teens. If an antidepressant is recommended for your child, be sure to discuss these risks with your psychiatric provider.

Medications can affect kids differently, and a child may respond well to one but not another. When determining the correct treatment, the psychiatric provider might try various medications in various doses, especially if your child is being treated for ADHD along with another disorder.

Behavioral Therapy^back to top

Research has shown that medications used to help curb impulsive behavior and attention difficulties are more effective when combined with behavioral therapy.

Behavioral therapy attempts to change behavior patterns by:

• reorganizing a child's home and school environment
• giving clear directions and commands
• setting up a system of consistent rewards for appropriate behaviors and negative consequences for inappropriate ones

Here are examples of behavioral strategies that may help a child with ADHD:

• Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime. Post the schedule in a prominent place, so your child can see what's expected throughout the day and when it's time for homework, play, and chores.
• Get organized. Put schoolbags, clothing, and toys in the same place every day so your child will be less likely to lose them.
• Avoid distractions. Turn off the TV, radio, and computer games, especially when your child is doing homework.
• Limit choices. Offer a choice between two things (this outfit, meal, toy, etc., or that one) so that your child isn't overwhelmed and overstimulated.
• Change your interactions with your child. Instead of long-winded explanations and cajoling, use clear, brief directions to remind your child of responsibilities.
• Use goals and rewards. Use a chart to list goals and track positive behaviors, then reward your child's efforts. Be sure the goals are realistic (think baby steps rather than overnight success).
• Discipline effectively. Instead of yelling or spanking, use timeouts or removal of privileges as consequences for inappropriate behavior. Younger kids may simply need to be distracted or ignored until they display better behavior.
• Help your child discover a talent. All kids need to experience success to feel good about themselves. Finding out what your child does well – whether it's sports, art, or music – can boost social skills and self-esteem.

Alternative Treatments^back to top

Currently, the only ADHD therapies that have been proven effective in scientific studies are medications and behavioral therapy. But your psychiatric provider may recommend additional treatments and interventions depending on your child's symptoms and needs. Some kids with ADHD, for example, may also need special educational interventions such as tutoring, occupational therapy, etc. Every child's needs are different.

A number of other alternative therapies are promoted and tried by parents including: megavitamins, body treatments, diet manipulation, allergy treatment, chiropractic treatment, attention training, visual training, and traditional one-on-one "talking" psychotherapy. However, scientific research has not found them to be effective, and most have not been studied carefully, if at all.

Parents should always be wary of any therapy that promises an ADHD "cure." If you're interested in trying something new, speak with your psychiatric provider first.

Parent Training^back to top

Parenting a child with ADHD often brings special challenges. Kids with ADHD may not respond well to typical parenting practices. Also, because ADHD tends to run in families, parents may also have some problems with organization and consistency themselves and need active coaching to help learn these skills.

Experts recommend parent education and support groups to help family members accept the diagnosis and to teach them how to help kids organize their environment, develop problem-solving skills, and cope with frustrations. Training can also teach parents to respond appropriately to a child's most trying behaviors with calm disciplining techniques. Individual or family counseling can also be helpful.

ADHD in the Classroom^back to top

As your child's most important advocate, you should become familiar with your child's medical, legal, and educational rights.

Kids with ADHD are eligible for special services or accommodations at school under the Individuals with Disabilities in Education Act (IDEA) and an anti-discrimination law known as Section 504. Keep in touch with teachers and school officials to monitor your child's progress.

In addition to using routines and a clear system of rewards, here are some other tips to share with teachers for classroom success:

• Reduce seating distractions. Lessening distractions might be as simple as seating your child near the teacher instead of near the window.
• Use a homework folder for parent-teacher communications. The teacher can include assignments and progress notes, and you can check to make sure all work is completed on time.
• Break down assignments. Keep instructions clear and brief, breaking down larger tasks into smaller, more manageable pieces.
• Give positive reinforcement. Always be on the lookout for positive behaviors. Ask the teacher to offer praise when your child stays seated, doesn't call out, or waits his or her turn instead of criticizing when he or she doesn't.
• Teach good study skills. Underlining, note taking, and reading out loud can help your child stay focused and retain information.
• Supervise. Check that your child goes and comes from school with the correct books and materials. Sometimes kids are paired with a buddy to can help them stay on track.
• Be sensitive to self-esteem issues. Ask the teacher to provide feedback to your child in private, and avoid asking your child to perform a task in public that might be too difficult.
• Involve the school counselor or psychologist. He or she can help design behavioral programs to address specific problems in the classroom.

Helping Your Child^back to top

You're a stronger advocate for your child when you foster good partnerships with everyone involved in your child's treatment – that includes teachers, psychiatric providers, therapists, and even other family members. Take advantage of all the support and education that's available, and you'll help your child navigate toward success.

Reviewed by: Richard S. Kingsley, MD