Attention-deficit hyperactivity disorder (ADHD), usually first diagnosed in childhood, can appear in a variety of forms and has many possible causes. People with ADHD probably have an underlying genetic vulnerability to developing it, but the severity of the problem is also influenced by the environment. Conflict and stress tend to make it worse.
The main features of this disorder are found in its name. Attention problems include daydreaming, difficulty focusing and being easily distracted. Hyperactivity refers to fidgeting or restlessness. A person with the disorder may be disruptive or impulsive, may have trouble in relationships and may be accident-prone. Hyperactivity and impulsiveness often improve as a person matures, but attention problems tend to last into adulthood.
ADHD is the most common problem seen in outpatient child and adolescent mental health settings. It is estimated that ADHD affects between 5% and 10% of school-aged children. Boys are more often diagnosed with ADHD than girls. Studies suggest that the number of ADHD diagnoses has risen significantly over the years. But whether more people have the disorder or whether it is just being diagnosed more often is not clear. The definition of the disorder has changed over the past several decades and will continue to develop as the experts explain more about the biology behind it.
The activity component is less apparent in adult ADHD. Adults tend to have problems with memory and concentration and they may have trouble staying organized and meeting commitments at work or at home. The consequence of poor functioning may be anxiety, low self-esteem, or mood problems. Some people turn to substances to manage these feelings.
The symptoms of ADHD -- inattention, hyperactivity or impulsive behavior -- often show up first at school. A teacher may report to parents that their child won't listen, is "hyper," or causes trouble and is disruptive. A child with ADHD often wants to be a good student, but the symptoms get in the way. Teachers, parents and friends may be unsympathetic, because they see the child's behavior as bad or odd.
A high level of activity and occasional impulsiveness or inattentiveness is often normal in a child. But the hyperactivity of ADHD is typically more haphazard, poorly organized and has no real purpose. And in children with ADHD, these behaviors are frequent enough that the child has a harder than average time learning, getting along with others or staying reasonably safe.
ADHD symptoms can vary widely, but here are common characteristics of the disorder:
- Difficulty organizing work, often giving the impression of not having heard the teacher's instructions
- Easily distracted
- Excessively restless or fidgety behavior; unable to stay seated
- Impulsive behavior (acts without thinking)
- Frequently calling out in class (without raising hand, yelling out answer before question is finished)
- Failing to follow through with teachers' or parents' requests
- Difficulty waiting for his or her turn in group settings
- Unable to stay focused on a game, project or homework assignment; often moving from one activity to the next without completing any
Many children with ADHD also show symptoms of other behavioral or psychiatric conditions. In fact, such problems may be different ways that the same underlying biological or environmental problems come to light. These associated conditions include learning disabilities and disorders characterized by disruptive behavior.
- Learning disabilities. Up to a quarter of children with ADHD may also have learning disabilities. This rate is much greater than the rate found in the general population.
- Oppositional, defiant or conduct disorders. These behavior disorders, which involve frequent outbursts of extremely negative, angry or mean behavior, affect as many as half of all children who have ADHD. Children who have both ADHD and behavioral disturbances are more likely to have a poor long-term outcome, with higher rates of school failure, antisocial behaviors and substance abuse.
- Autism spectrum disorders. Sometimes an autism spectrum disorder is confused with ADHD. Children with autism spectrum disorder tend to have similar problems with attention, relationships and behavior. But in the autism spectrum, the problems in these areas result from being socially disengaged or isolated. Like children with ADHD, they may have trouble picking up on social cues.
There is no single test to diagnose ADHD. For a child, a pediatrician may make the diagnosis, or may make a referral to a specialist. For adults, a mental health professional generally performs the evaluation.
The clinician will ask about symptoms related to ADHD. Since, in children, many of these characteristics are more likely to be seen in a school setting, the clinician will also ask about behavior in school. To help collect this information, the evaluator will often interview parents, teachers and other caregivers or ask them to fill out special behavioral checklists.
Since other conditions may cause the symptoms of ADHD, the medical history and physical examination are important. For example, the doctor may look for trouble hearing or vision, learning disabilities, speech problems, seizure disorders, anxiety, depression, or other behavior problems. In some cases, other medical or psychological testing may be useful to check for one or more of these conditions. These tests can sometimes help clinicians and teachers develop practical suggestions.
In most children with ADHD, symptoms begin before age 7 and last through adolescence. In some cases, symptoms of ADHD continue into adulthood.
The exact cause of ADHD is not fully understood. If a child has a biological predisposition to developing ADHD, attention to contributing factors may reduce the severity of the disorder. There are numerous factors that are associated with the development of ADHD, most of which are difficult to avoid:
- Psychosocial adversity -- severe marital conflict, father's criminal behavior, mother's mental disorder, poverty, the child's foster care placement
- Complications during pregnancy or delivery -- poor maternal health, fetal distress, low birth weight
- Premature birth
- Mother's use of tobacco, alcohol or other drugs during pregnancy
- Lead poisoning -- although lead exposure does not account for many cases and many children who are exposed to lead do not develop ADHD
Research shows that particular foods probably do NOT cause ADHD.
Although no treatment eliminates ADHD completely, many helpful options are available. The goal of treatment is to help children improve social relationships, do better in school, and keep their disruptive or harmful behaviors to a minimum. Medication can be very helpful, and it is often necessary. Drug treatment by itself is rarely the answer. Medication and psychotherapy together usually have the best results. Children with ADHD often do require some type of structured behavioral program that includes setting realistic expectations. For preschool children, behavior therapy is tried before starting medication, but medication may be necessary if behavior therapy doesn't lead to significant improvement.
Stimulants, such as methylphenidate (Ritalin) and forms of amphetamine (Dexedrine), have been used for many decades. They are relatively safe and effective for most children to help them focus their thoughts and control their behavior. With the development of long-acting forms of stimulants, one dose in the morning can provide a day-long effect.
Despite their name, stimulants do not cause increased hyperactivity or impulsivity. If the disorder has been properly diagnosed, the medication actually has the opposite effect. Common mild side effects are decreased appetite, weight loss, stomachaches, sleep problems, headaches and jitteriness. Adjusting the dose can often help eliminate these problems. Stimulant drugs are associated with some serious concerns and side effects.
- Tics. There is some evidence that tics (uncontrolled movements) are more likely in patients with a family history of tic disorders, but that is still controversial.
- Substance abuse. Although stimulant drugs can be and are abused, newer research shows that they may actually reduce the risk of substance abuse for people with ADHD.
- Growth delays. Experts disagree about the effects of stimulants on growth. There is some evidence that children taking stimulants grow at a rate that is less than expected. Some doctors recommend stopping stimulants periodically during periods of expected growth.
- Cardiovascular risk. Children taking stimulants do show small increases in blood pressure and heart rate. But major heart complications in children, teens and adults taking these drugs are extremely rare. There is evidence that, in general, frequency of heart complications is not higher in children taking stimulants, compared to the general population. The doctor should ask and the family should discuss any history of cardiac illness the child may have, or any history of cardiac illness in the family.
Since such risks vary widely depending on the individual, it is important to discuss the potential benefits and risks of each treatment with your doctor.
Another potential problem, which is not strictly speaking a side effect, is that stimulants can find their way to people other than the person being treated for ADHD. Called "diversion," it is fairly common among adolescents and young adults. The drugs are most often taken to improve academic performance. Some individuals do take stimulants to get high.
Other non-stimulant medications are also available to treat ADHD. Atomoxetine (Strattera) is as effective as stimulants for treating ADHD. It works by a different chemical mechanism than stimulants. Atomoxetine is relatively safe, but carries a rare risk of liver toxicity. The antidepressant, bupropion (Wellbutrin), is helpful in some cases. It is also generally well-tolerated, but it should not be given to people with a history of seizures.
Other treatment approaches, used alone or in combination, may include:
- Behavioral therapy. This refers to techniques that try to improve behavior, usually by rewarding and encouraging desirable behaviors and by discouraging unwanted behaviors and pointing out the consequences.
- Cognitive therapy. This is psychotherapy designed to change thinking to build self-esteem, stop having negative thoughts and improve problem-solving skills.
- Social skill training. Developing social skills improves friendships.
- Parent education and support. Training classes, support groups and counselors can help to teach and support parents about ADHD, including strategies for dealing with ADHD-related behaviors.
Because many children with ADHD also are troubled by poor grades and school behavior problems, schools may need to provide educational adjustments and interventions (such as an individualized educational plan) to promote the best possible learning environment for the child.
Call your doctor if your child shows symptoms of ADHD, or if teachers notify you that your child is having academic difficulties, behavioral problems or difficulty paying attention.
ADHD can cause significant emotional, social and educational problems. However, when ADHD is diagnosed early and treated properly, the condition can be managed effectively, so children can grow up to have productive, successful and fulfilling lives. Although some children appear to grow out of their ADHD as they reach their adolescent years, others have lifelong symptoms.
American Academy of Child and Adolescent Psychiatry (AACAP)
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