It's becoming heartbreakingly common in my practice. Parents bring a child in because they are worried about his or her behavior. "He's always in motion," I hear. "Her teacher says she gets distracted too easily." "He can't finish his work, and his grades are getting worse." The question parents are asking me, again and again, is whether their child has attention deficit hyperactivity disorder, or ADHD.
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The Scope of the Problem
I'm not the only pediatrician who hears this question. According to parent report, 1 in 10 children ages 4 to 17 years has ADHD.
The number of children with ADHD has been steadily increasing. In part, this may be because we are better at diagnosing it.
However, not all that fidgets is ADHD. Diagnosing and treating attention problems should be approached with caution — and care.
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This may be a surprise: Diagnosing ADHD is remarkably subjective. The main characteristics of ADHD must start before age 7 and last for at least 6 months. They are:
- Hyperactivity – always being in motion, touching things, talking all the time, having trouble sitting still and fidgeting
- Impulsivity – acting without thinking, blurting out things that shouldn’t be said, answering questions too soon, having trouble waiting for a turn, hitting or otherwise acting out when angry
- Inattention – getting easily distracted, moving from one task to another without finishing, having trouble following directions and making careless mistakes.
But these can be normal behaviors in some children, especially young ones. Other health issues can cause these symptoms or be affecting the child at the same time. These include:
- Depression, anxiety, bipolar disorder or other mental health problems
- A significant life change, such as a death in the family, divorce or a major move
- Hearing difficulties
- Learning disabilities
- Visual problems
- Medical problems that affect the brain, such as lead poisoning or thyroid disorders
- Substance abuse.
There are standardized questionnaires with scoring systems for parents and teachers to help tell the difference between ADHD and other problems. The child has to have many symptoms to have ADHD. In addition, the symptoms need to be causing problems. If the child is active and distractible but is doing well in school and at home, they don't have a problem.
Doctors are encouraged to use the questionnaires, too. Some have their own surveys or tests they do in the office. Some primary care doctors do the evaluations themselves. Others refer children to mental health professionals or neurologists, each of whom may approach the diagnosis differently.
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Treatment can be equally subjective. Medications have been shown to help 70% to 80% of those with ADHD. But it's important to know that:
- Stimulant medications can make a child better at sitting still and paying attention even if they don't have ADHD, so responding to medication doesn't make the diagnosis correct.
- There are definitely short-term benefits of medication, but there are few long-term studies.
- Medications have side effects. The most common ones are mild, such as loss of appetite, trouble sleeping, or headache. These can be helped by changing the dose or switching to a different medication. However, more serious side effects are possible, including tics (uncontrollable movements) or even heart problems.
- Studies show that children with ADHD do best when they get both medication and behavioral therapy.
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What Parents Can Do
If you are concerned that your child might have ADHD here are some suggestions.
- A child should never get a diagnosis of ADHD without a thorough evaluation. At a minimum, the evaluation should include
- a complete physical examination, including a blood test for lead if the child is young or may have been exposed
- lots of questions about the child's health and development (when he walked and talked, for example) as well as questions about the family's situation and health history
- detailed questions about the child's behavior, with careful consideration of possible mental health problems
- input from the school, if the child attends one
- vision and hearing testing.
- Never hesitate to ask for a second opinion. More tests may be necessary, depending on the situation.
- Approach medication carefully:
- Ask lots of questions about possible side effects. If there is any history of heart problems in the child or the family, it's crucial that the doctor know.
- Start with a low dose and increase it slowly.
- Make sure there's close communication between you, teachers and doctors to figure out the best medication and dose for the child.
- See your pediatrician regularly while your child is on medication to monitor growth and watch for side effects.
- There's more to treating ADHD than pills:
- A good school program is essential. Many children with ADHD have learning disabilities, but even those who don't may need a different teaching approach.
- Behavioral help, such as lots of structure and strategies to help the child concentrate and finish tasks, can make a big difference.
- Counseling is a great idea to help sort out any psychological factors involved, and to head off self-esteem problems. Family therapy can give everyone strategies and support.
But before you get scared off and are tempted to think that it's better to do nothing about a child's behavior problem then open up this can of worms, doing nothing comes with its own risks. Untreated ADHD can lead to
- School failure
- Poor self-esteem
- Strained relationships with family and peers
- A higher risk of accidents and injuries
- Substance abuse.
With help, children with attention problems can get better and succeed in school, at home and in life. Talk to your doctor. For more information, visit the Centers for Disease Control and Prevention's ADHD website.
Claire McCarthy, M.D. is an assistant professor in pediatrics at Harvard Medical School, an attending physician at Children's Hospital of Boston, and medical director of the Martha Eliot Health Center, a neighborhood health service of Children's Hospital. She is a senior medical editor for Harvard Health Publications.