Web Business
Review
Article Directory
·
Symptoms
·
Disorders that Sometimes Accompany ADHD
·
The Family and the ADHD Child
·
Attention Deficit Hyperactivity Disorder in Adults
·
References and Resource Books
Attention Deficit Hyperactivity Disorder (ADHD) is a
condition that becomes apparent in some children in the preschool and early
school years. It is hard for these children to control their behavior and/or
pay attention. It is estimated that between 3 and 5 percent of children have
ADHD, or approximately 2 million children in the United States. This means that
in a classroom of 25 to 30 children, it is likely that at least one will have
ADHD.
ADHD was first described by Dr. Heinrich Hoffman in 1845.
A physician who wrote books on medicine and psychiatry, Dr. Hoffman was also a
poet who became interested in writing for children when he couldn't find
suitable materials to read to his 3-year-old son. The result was a book of
poems, complete with illustrations, about children and their characteristics.
"The Story of Fidgety Philip" was an accurate description of a little
boy who had attention deficit hyperactivity disorder. Yet it was not until 1902
that Sir George F. Still published a series of lectures to the Royal College of
Physicians in England in which he described a group of impulsive children with
significant behavioral problems, caused by a genetic dysfunction and not by
poor child rearing—children who today would be easily recognized as having
ADHD.1 Since then, several thousand scientific
papers on the disorder have been published, providing information on its
nature, course, causes, impairments, and treatments.
A child with ADHD faces a difficult but not
insurmountable task ahead. In order to achieve his or her full potential, he or
she should receive help, guidance, and understanding from parents, guidance
counselors, and the public education system. This document offers information
on ADHD and its management, including research on medications and behavioral
interventions, as well as helpful resources on educational options.
Because ADHD often continues into adulthood, this
document contains a section on the diagnosis and treatment of ADHD in adults.
The principal characteristics of ADHD are inattention,
hyperactivity, and impulsivity. These
symptoms appear early in a child’s life. Because many normal children may have
these symptoms, but at a low level, or the symptoms may be caused by another
disorder, it is important that the child receive a thorough examination and
appropriate diagnosis by a well-qualified professional.
Symptoms of ADHD will appear over the course of many
months, often with the symptoms of impulsiveness and hyperactivity preceding
those of inattention, which may not emerge for a year or more. Different
symptoms may appear in different settings, depending on the demands the
situation may pose for the child’s self-control. A child who “can’t sit still”
or is otherwise disruptive will be noticeable in school, but the inattentive
daydreamer may be overlooked. The impulsive child who acts before thinking may
be considered just a “discipline problem,” while the child who is passive or
sluggish may be viewed as merely unmotivated. Yet both may have different types
of ADHD. All children are sometimes restless, sometimes act without thinking,
sometimes daydream the time away. When the child’s hyperactivity,
distractibility, poor concentration, or impulsivity begin to affect performance
in school, social relationships with other children, or behavior at home, ADHD
may be suspected. But because the symptoms vary so much across settings, ADHD
is not easy to diagnose. This is especially true when inattentiveness is the
primary symptom.
According to the most recent version of the Diagnostic
and Statistical Manual of Mental Disorders2 (DSM-IV-TR), there
are three patterns of behavior that indicate ADHD. People with ADHD may show
several signs of being consistently inattentive. They may have a pattern of
being hyperactive and impulsive far more than others of their age. Or they may
show all three types of behavior. This means that there are three subtypes of
ADHD recognized by professionals. These are the predominantly
hyperactive-impulsive type (that does not show significant
inattention); the predominantly inattentive type (that does
not show significant hyperactive-impulsive behavior) sometimes called ADD—an
outdated term for this entire disorder; and the combined type
(that displays both inattentive and hyperactive-impulsive symptoms).
Hyperactive
children always seem to be “on the go” or constantly in motion. They dash
around touching or playing with whatever is in sight, or talk incessantly.
Sitting still at dinner or during a school lesson or story can be a difficult
task. They squirm and fidget in their seats or roam around the room. Or they
may wiggle their feet, touch everything, or noisily tap their pencil.
Hyperactive teenagers or adults may feel internally restless. They often report
needing to stay busy and may try to do several things at once.
Impulsive children seem
unable to curb their immediate reactions or think before they act. They will
often blurt out inappropriate comments, display their emotions without
restraint, and act without regard for the later consequences of their conduct.
Their impulsivity may make it hard for them to wait for things they want or to
take their turn in games. They may grab a toy from another child or hit when
they’re upset. Even as teenagers or adults, they may impulsively choose to do
things that have an immediate but small payoff rather than engage in activities
that may take more effort yet provide much greater but delayed rewards.
Some signs of hyperactivity-impulsivity
are:
·
Feeling restless, often fidgeting with
hands or feet, or squirming while seated
·
Running, climbing, or leaving a seat in
situations where sitting or quiet behavior is expected
·
Blurting out answers before hearing the
whole question
·
Having difficulty waiting in line or taking
turns.
Children who are inattentive have a hard time keeping their
minds on any one thing and may get bored with a task after only a few minutes.
If they are doing something they really enjoy, they have no trouble paying
attention. But focusing deliberate, conscious attention to organizing and
completing a task or learning something new is difficult.
Homework is particularly hard for these children. They
will forget to write down an assignment, or leave it at school. They will
forget to bring a book home, or bring the wrong one. The homework, if finally
finished, is full of errors and erasures. Homework is often accompanied by
frustration for both parent and child.
The DSM-IV-TR gives these signs of inattention:
·
Often becoming easily distracted by
irrelevant sights and sounds
·
Often failing to pay attention to details
and making careless mistakes
·
Rarely following instructions carefully and
completely losing or forgetting things like toys, or pencils, books, and tools
needed for a task
·
Often skipping from one uncompleted
activity to another.
Children diagnosed with the Predominantly Inattentive
Type of ADHD are seldom impulsive or hyperactive, yet they have significant
problems paying attention. They appear to be daydreaming, “spacey,” easily
confused, slow moving, and lethargic. They may have difficulty processing information
as quickly and accurately as other children. When the teacher gives oral or
even written instructions, this child has a hard time understanding what he or
she is supposed to do and makes frequent mistakes. Yet the child may sit
quietly, unobtrusively, and even appear to be working but not fully attending
to or understanding the task and the instructions.
These children don’t show significant problems with
impulsivity and overactivity in the classroom, on the school ground, or at
home. They may get along better with other children than the more impulsive and
hyperactive types of ADHD, and they may not have the same sorts of social
problems so common with the combined type of ADHD. So often their problems with
inattention are overlooked. But they need help just as much as children with
other types of ADHD, who cause more obvious problems in the classroom.
Not everyone who is overly hyperactive, inattentive, or
impulsive has ADHD. Since most people sometimes blurt out things they didn’t
mean to say, or jump from one task to another, or become disorganized and
forgetful, how can specialists tell if the problem is ADHD?
Because everyone shows some of these behaviors at times,
the diagnosis requires that such behavior be demonstrated to a degree that is
inappropriate for the person’s age. The diagnostic guidelines also contain
specific requirements for determining when the symptoms indicate ADHD. The
behaviors must appear early in life, before age 7, and continue for at least 6
months. Above all, the behaviors must create a real handicap in at least two
areas of a person’s life such as in the schoolroom, on the playground, at home,
in the community, or in social settings. So someone who shows some symptoms but
whose schoolwork or friendships are not impaired by these behaviors would not
be diagnosed with ADHD. Nor would a child who seems overly active on the
playground but functions well elsewhere receive an ADHD diagnosis.
To assess whether a child has ADHD, specialists consider
several critical questions: Are these behaviors excessive, long-term, and
pervasive? That is, do they occur more often than in other children the same
age? Are they a continuous problem, not just a response to a temporary
situation? Do the behaviors occur in several settings or only in one specific
place like the playground or in the schoolroom? The person’s pattern of
behavior is compared against a set of criteria and characteristics of the
disorder as listed in the DSM-IV-TR.
Some parents see signs of inattention, hyperactivity, and
impulsivity in their toddler long before the child enters school. The child may
lose interest in playing a game or watching a TV show, or may run around
completely out of control. But because children mature at different rates and
are very different in personality, temperament, and energy levels, it’s useful
to get an expert’s opinion of whether the behavior is appropriate for the
child’s age. Parents can ask their child’s pediatrician, or a child
psychologist or psychiatrist, to assess whether their toddler has an attention
deficit hyperactivity disorder or is, more likely at this age, just immature or
unusually exuberant.
ADHD may be suspected by a parent or caretaker or may go
unnoticed until the child runs into problems at school. Given that ADHD tends
to affect functioning most strongly in school, sometimes the teacher is the
first to recognize that a child is hyperactive or inattentive and may point it
out to the parents and/or consult with the school psychologist. Because teachers
work with many children, they come to know how “average” children behave in
learning situations that require attention and self-control. However, teachers
sometimes fail to notice the needs of children who may be more inattentive and
passive yet who are quiet and cooperative, such as those with the predominantly
inattentive form of ADHD.
If ADHD is suspected, to whom can the family turn? What
kinds of specialists do they need?
Ideally, the diagnosis should be made by a professional
in your area with training in ADHD or in the diagnosis of mental disorders.
Child psychiatrists and psychologists, developmental/behavioral pediatricians,
or behavioral neurologists are those most often trained in differential
diagnosis. Clinical social workers may also have such training.
The family can start by talking with the child’s
pediatrician or their family doctor. Some pediatricians may do the assessment
themselves, but often they refer the family to an appropriate mental health specialist
they know and trust. In addition, state and local agencies that serve families
and children, as well as some of the volunteer organizations listed at the end
of this document, can help identify appropriate specialists.
|
Specialty |
Can Diagnose ADHD |
Can prescribe
medication, if needed |
Provides counseling
or training |
|
Psychiatrists |
yes |
yes |
yes |
|
Psychologists |
yes |
yes* |
yes |
|
Pediatricians or Family Physicians |
yes |
yes |
no |
|
Neurologists |
yes |
yes |
no |
|
Clinical Social workers |
yes |
no |
yes |
* As of October 2006, Louisiana and New Mexico laws and
regulations allow psychologists who have completed specific training and meet
other requirements to prescribe psychotropic medications. The other 48 states
and the District of Columbia allow only physicians to prescribe medications.
Knowing the differences in qualifications and services
can help the family choose someone who can best meet their needs. There are
several types of specialists qualified to diagnose and treat ADHD. Child
psychiatrists are doctors who specialize in diagnosing and treating childhood
mental and behavioral disorders. A psychiatrist can provide therapy and
prescribe any needed medications. Child psychologists are also qualified to
diagnose and treat ADHD. They can provide therapy for the child and help the
family develop ways to deal with the disorder. But psychologists are not
medical doctors and must rely on the child’s physician to do medical exams and
prescribe medication. Neurologists, doctors who work with disorders of the
brain and nervous system, can also diagnose ADHD and prescribe medicines. But
unlike psychiatrists and psychologists, neurologists usually do not provide
therapy for the emotional aspects of the disorder.
Within each specialty, individual doctors and mental
health professionals differ in their experiences with ADHD. So in selecting a
specialist, it’s important to find someone with specific training and
experience in diagnosing and treating the disorder.
Whatever the specialist’s expertise, his or her first
task is to gather information that will rule out other possible reasons for the
child’s behavior. Among possible causes of ADHD-like behavior are the
following:
·
A sudden change in the child’s life—the
death of a parent or grandparent; parents’ divorce; a parent’s job loss
·
Undetected seizures, such as in petit mal
or temporal lobe seizures
·
A middle ear infection that causes
intermittent hearing problems
·
Medical disorders that may affect brain
functioning
·
Underachievement caused by learning
disability
·
Anxiety or depression.
Ideally, in ruling out other causes, the specialist
checks the child’s school and medical records. There may be a school record of
hearing or vision problems, since most schools automatically screen for these.
The specialist tries to determine whether the home and classroom environments
are unusually stressful or chaotic, and how the child’s parents and teachers
deal with the child.
Next the specialist gathers information on the child’s
ongoing behavior in order to compare these behaviors to the symptoms and diagnostic
criteria listed in the DSM-IV-TR. This also involves talking with the child
and, if possible, observing the child in class and other settings.
The child’s teachers, past and present, are asked to rate
their observations of the child’s behavior on standardized evaluation forms,
known as behavior rating scales, to compare the child’s behavior to that of
other children the same age. While rating scales might seem overly subjective,
teachers often get to know so many children that their judgment of how a child
compares to others is usually a reliable and valid measure.
The specialist interviews the child’s teachers and
parents, and may contact other people who know the child well, such as coaches
or baby-sitters. Parents are asked to describe their child’s behavior in a
variety of situations. They may also fill out a rating scale to indicate how
severe and frequent the behaviors seem to be.
In most cases, the child will be evaluated for social
adjustment and mental health. Tests of intelligence and learning achievement
may be given to see if the child has a learning disability and whether the
disability is in one or more subjects.
In looking at the results of these various sources of
information, the specialist pays special attention to the child’s behavior
during situations that are the most demanding of self-control, as well as noisy
or unstructured situations such as parties, or during tasks that require
sustained attention, like reading, working math problems, or playing a board
game. Behavior during free play or while getting individual attention is given
less importance in the evaluation. In such situations, most children with ADHD
are able to control their behavior and perform better than in more restrictive
situations.
The specialist then pieces together a profile of the
child’s behavior. Which ADHD-like behaviors listed in the most recent DSM does
the child show? How often? In what situations? How long has the child been
doing them? How old was the child when the problem started? Are the behavior problems
relatively chronic or enduring or are they periodic in nature? Are the
behaviors seriously interfering with the child’s friendships, school
activities, home life, or participation in community activities? Does the child
have any other related problems? The answers to these questions help identify
whether the child’s hyperactivity, impulsivity, and inattention are significant
and long-standing. If so, the child may be diagnosed with ADHD.
A correct diagnosis often resolves confusion about the
reasons for the child’s problems that lets parents and child move forward in
their lives with more accurate information on what is wrong and what can be
done to help. Once the disorder is diagnosed, the child and family can begin to
receive whatever combination of educational, medical, and emotional help they
need. This may include providing recommendations to school staff, seeking out a
more appropriate classroom setting, selecting the right medication, and helping
parents to manage their child’s behavior.
One of the first questions a parent will have is “Why?
What went wrong?” “Did I do something to cause this?” There is little
compelling evidence at this time that ADHD can arise purely from social factors
or child-rearing methods. Most substantiated causes appear to fall in the realm
of neurobiology and genetics. This is not to say that environmental factors may
not influence the severity of the disorder, and especially the degree of
impairment and suffering the child may experience, but that such factors do not
seem to give rise to the condition by themselves.
The parents’ focus should be on looking forward and
finding the best possible way to help their child. Scientists are studying
causes in an effort to identify better ways to treat, and perhaps someday, to
prevent ADHD. They are finding more and more evidence that ADHD does not stem
from the home environment, but from biological causes. Knowing this can remove
a huge burden of guilt from parents who might blame themselves for their child’s
behavior.
Over the last few decades, scientists have come up with
possible theories about what causes ADHD. Some of these theories have led to
dead ends, some to exciting new avenues of investigation.
Studies have shown a possible correlation between the use
of cigarettes and alcohol during pregnancy and risk for ADHD in the offspring
of that pregnancy. As a precaution, it is best during pregnancy to refrain from
both cigarette and alcohol use.
Another environmental agent that may be associated with a
higher risk of ADHD is high levels of lead in the bodies of young preschool
children. Since lead is no longer allowed in paint and is usually found only in
older buildings, exposure to toxic levels is not as prevalent as it once was.
Children who live in old buildings in which lead still exists in the plumbing
or in lead paint that has been painted over may be at risk.
One early theory was that attention disorders were caused
by brain injury. Some children who have suffered accidents leading to brain
injury may show some signs of behavior similar to that of ADHD, but only a
small percentage of children with ADHD have been found to have suffered a
traumatic brain injury.
It has been suggested that attention disorders are caused
by refined sugar or food additives, or that symptoms of ADHD are exacerbated by
sugar or food additives. In 1982, the National Institutes of Health held a
scientific consensus conference to discuss this issue. It was found that diet
restrictions helped about 5 percent of children with ADHD, mostly young
children who had food allergies.3 A more recent study on the effect
of sugar on children, using sugar one day and a sugar substitute on alternate
days, without parents, staff, or children knowing which substance was being
used, showed no significant effects of the sugar on behavior or learning.4
In another study, children whose mothers felt they were
sugar-sensitive were given aspartame as a substitute for sugar. Half the
mothers were told their children were given sugar, half that their children
were given aspartame. The mothers who thought their children had received sugar
rated them as more hyperactive than the other children and were more critical
of their behavior.5
Attention disorders often run in families, so there are
likely to be genetic influences. Studies indicate that 25 percent of the close
relatives in the families of ADHD children also have ADHD, whereas the rate is
about 5 percent in the general population.6 Many studies of twins
now show that a strong genetic influence exists in the disorder.7
Researchers continue to study the genetic contribution to
ADHD and to identify the genes that cause a person to be susceptible to ADHD.
Since its inception in 1999, the Attention-Deficit Hyperactivity Disorder
Molecular Genetics Network has served as a way for researchers to share
findings regarding possible genetic influences on ADHD.8
Some knowledge of the structure of the brain is helpful in
understanding the research scientists are doing in searching for a physical
basis for attention deficit hyperactivity disorder. One part of the brain that
scientists have focused on in their search is the frontal lobes of the
cerebrum. The frontal lobes allow us to solve problems, plan ahead,
understand the behavior of others, and restrain our impulses. The two frontal
lobes, the right and the left, communicate with each other through the corpus
callosum, (nerve fibers that connect the right and left frontal lobes).
The basal ganglia are the interconnected gray
masses deep in the cerebral hemisphere that serve as the connection between the
cerebrum and the cerebellum and, with the cerebellum, are responsible
for motor coordination. The cerebellum is divided into three parts. The middle
part is called the vermis.
All of these parts of the brain have been studied through
the use of various methods for seeing into or imaging the brain. These methods
include functional magnetic resonance imaging (fMRI) positron emission
tomography (PET), and single photon emission computed tomography (SPECT). The
main or central psychological deficits in those with ADHD have been linked
through these studies. By 2002 the researchers in the NIMH Child Psychiatry
Branch had studied 152 boys and girls with ADHD, matched with 139 age- and
gender-matched controls without ADHD. The children were scanned at least twice,
some as many as four times over a decade. As a group, the ADHD children showed
3-4 percent smaller brain volumes in all regions—the frontal lobes, temporal
gray matter, caudate nucleus, and cerebellum.
This study also showed that the ADHD children who were on
medication had a white matter volume that did not differ from that of controls.
Those never-medicated patients had an abnormally small volume of white matter.
The white matter consists of fibers that establish long-distance connections
between brain regions. It normally thickens as a child grows older and the
brain matures.9
Although this long-term study used MRI to scan the
children’s brains, the researchers stressed that MRI remains a research tool
and cannot be used to diagnose ADHD in any given child. This is true for other
neurological methods of evaluating the brain, such as PET and SPECT.
Many children with ADHD—approximately 20 to 30
percent—also have a specific learning disability (LD).10 In
preschool years, these disabilities include difficulty in understanding certain
sounds or words and/or difficulty in expressing oneself in words. In school age
children, reading or spelling disabilities, writing disorders, and arithmetic
disorders may appear. A type of reading disorder, dyslexia, is quite
widespread. Reading disabilities affect up to 8 percent of elementary school
children.
A very small proportion of people with ADHD have a
neurological disorder called Tourette syndrome. People with Tourette syndrome
have various nervous tics and repetitive mannerisms, such as eye blinks, facial
twitches, or grimacing. Others may clear their throats frequently, snort,
sniff, or bark out words. These behaviors can be controlled with medication.
While very few children have this syndrome, many of the cases of Tourette
syndrome have associated ADHD. In such cases, both disorders often require
treatment that may include medications.
As many as one-third to one-half of all children with
ADHD—mostly boys—have another condition, known as oppositional defiant disorder
(ODD). These children are often defiant, stubborn, non-compliant, have
outbursts of temper, or become belligerent. They argue with adults and refuse
to obey.
About 20 to 40 percent of ADHD children may eventually
develop conduct disorder (CD), a more serious pattern of antisocial behavior.
These children frequently lie or steal, fight with or bully others, and are at
a real risk of getting into trouble at school or with the police. They violate
the basic rights of other people, are aggressive toward people and/or animals,
destroy property, break into people’s homes, commit thefts, carry or use
weapons, or engage in vandalism. These children or teens are at greater risk
for substance use experimentation, and later dependence and abuse. They need immediate
help.
Some children with ADHD often have co-occurring anxiety
or depression. If the anxiety or depression is recognized and treated, the
child will be better able to handle the problems that accompany ADHD.
Conversely, effective treatment of ADHD can have a positive impact on anxiety
as the child is better able to master academic tasks.
There are no accurate statistics on how many children
with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar
disorder in childhood can be difficult. In its classic form, bipolar disorder
is characterized by mood cycling between periods of intense highs and lows. But
in children, bipolar disorder often seems to be a rather chronic mood
dysregulation with a mixture of elation, depression, and irritability.
Furthermore, there are some symptoms that can be present both in ADHD and
bipolar disorder, such as a high level of energy and a reduced need for sleep.
Of the symptoms differentiating children with ADHD from those with bipolar
disorder, elated mood and grandiosity of the bipolar child are distinguishing
characteristics.11
Every family wants to determine what treatment will be
most effective for their child. This question needs to be answered by each
family in consultation with their health care professional. To help families
make this important decision, the National Institute of Mental Health (NIMH)
has funded many studies of treatments for ADHD and has conducted the most
intensive study ever undertaken for evaluating the treatment of this disorder.
This study is known as the Multimodal Treatment Study of Children with
Attention Deficit Hyperactivity Disorder (MTA).12 The NIMH is now
conducting a clinical trial for younger children ages 3 to 5.5 years (Treatment
of ADHD in Preschool-Age Children).
The MTA study included 579 (95-98 at each of 6 treatment
sites) elementary school boys and girls with ADHD, who were randomly assigned
to one of four treatment programs: (1) medication management alone; (2)
behavioral treatment alone; (3) a combination of both; or (4) routine community
care. In each of the study sites, three groups were treated for the first 14
months in a specified protocol and the fourth group was referred for community
treatment of the parents’ choosing. All of the children were reassessed
regularly throughout the study period. An essential part of the program was the
cooperation of the schools, including principals and teachers. Both teachers
and parents rated the children on hyperactivity, impulsivity, and inattention,
and symptoms of anxiety and depression, as well as social skills.
The children in two groups (medication management alone and
the combination treatment) were seen monthly for one-half hour at each
medication visit. During the treatment visits, the prescribing physician spoke
with the parent, met with the child, and sought to determine any concerns that
the family might have regarding the medication or the child’s ADHD-related
difficulties. The physicians, in addition, sought input from the teachers on a
monthly basis. The physicians in the medication-only group did not provide
behavioral therapy but did advise the parents when necessary concerning any
problems the child might have.
In the behavior treatment-only group, families met up to
35 times with a behavior therapist, mostly in group sessions. These therapists
also made repeated visits to schools to consult with children’s teachers and to
supervise a special aide assigned to each child in the group. In addition,
children attended a special 8-week summer treatment program where they worked
on academic, social, and sports skills, and where intensive behavioral therapy
was delivered to assist children in improving their behavior.
Children in the combined therapy group received both
treatments, that is, all the same assistance that the medication-only received,
as well as all of the behavior therapy treatments.
In routine community care, the children saw the
community-treatment doctor of their parents’ choice one to two times per year
for short periods of time. Also, the community-treatment doctor did not have
any interaction with the teachers.
The results of the study indicated that long-term
combination treatments and the medication-management alone were superior to
intensive behavioral treatment and routine community treatment. And in some
areas—anxiety, academic performance, oppositionality, parent-child relations,
and social skills—the combined treatment was usually superior. Another
advantage of combined treatment was that children could be successfully treated
with lower doses of medicine, compared with the medication-only group.
Because many children in the preschool years are
diagnosed with ADHD and are given medication, it is important to know the
safety and efficacy of such treatment. The NIMH is sponsoring an ongoing
multi-site study, “Preschool ADHD Treatment Study” (PATS). It is the first
major effort to examine the safety and efficacy of a stimulant,
methylphenidate, for ADHD in this age group. The PATS study uses a randomized,
placebo-controlled, double-blind design. Children ages 3 to 5 who have severe
and persistent symptoms of ADHD that impair their functioning are eligible for
this study. To avoid using medications at such an early age, all children who
enter the study are first treated with behavioral therapy. Only children who do
not show sufficient improvement with behavior therapy are considered for the
medication part of the study. The study is being conducted at New York State
Psychiatric Institute, Duke University, Johns Hopkins University, New York
University, the University of California at Los Angeles, and the University of
California at Irvine. Enrollment in the study will total 165 children.
For children with ADHD, no single treatment is the answer
for every child. A child may sometimes have undesirable side effects to a
medication that would make that particular treatment unacceptable. And if a
child with ADHD also has anxiety or depression, a treatment combining
medication and behavioral therapy might be best. Each child’s needs and
personal history must be carefully considered.
For decades, medications have been used to treat the
symptoms of ADHD.
The medications that seem to be the most effective are a
class of drugs known as stimulants. Following is a list of the stimulants,
their trade (or brand) names, and their generic names. “Approved age” means
that the drug has been tested and found safe and effective in children of that
age.
|
Trade Name |
Generic Name |
Approved Age |
|
Adderall |
amphetamine |
3 and older |
|
Concerta |
methylphenidate |
6 and older |
|
Cylert* |
pemoline |
6 and older |
|
Dexedrine |
dextroamphetamine |
3 and older |
|
Dextrostat |
dextroamphetamine |
3 and older |
|
Focalin |
dexmethylphenidate |
6 and older |
|
Metadate ER |
methylphenidate |
6 and older |
|
Metadate CD |
methylphenidate |
6 and older |
|
Ritalin |
methylphenidate |
6 and older |
|
Ritalin SR |
methylphenidate |
6 and older |
|
Ritalin LA |
methylphenidate |
6 and older |
|
*Because of its potential for serious side
effects affecting the liver, Cylert should not ordinarily be considered as
first-line drug therapy for ADHD. |
||
The U.S. Food and Drug Administration (FDA) recently
approved a medication for ADHD that is not a stimulant. The medication,
Strattera®, or atomoxetine, works on the neurotransmitter norepinephrine,
whereas the stimulants primarily work on dopamine. Both of theses
neurotransmitters are believed to play a role in ADHD. More studies will need
to be done to contrast Strattera with the medications already available, but
the evidence to date indicates that over 70 percent of children with ADHD given
Strattera manifest significant improvement in their symptoms.
Some people get better results from one medication, some
from another. It is important to work with the prescribing physician to find
the right medication and the right dosage. For many people, the stimulants
dramatically reduce their hyperactivity and impulsivity and improve their
ability to focus, work, and learn. The medications may also improve physical coordination,
such as that needed in handwriting and in sports.
The stimulant drugs, when used with medical supervision,
are usually considered quite safe. Stimulants do not make the child feel
“high,” although some children say they feel different or funny. Such changes
are usually very minor. Although some parents worry that their child may become
addicted to the medication, to date there is no convincing evidence that
stimulant medications, when used for treatment of ADHD, cause drug abuse or
dependence. A review of all long-term studies on stimulant medication and
substance abuse, conducted by researchers at Massachusetts General Hospital and
Harvard Medical School, found that teenagers with ADHD who remained on their
medication during the teen years had a lower likelihood of substance use or
abuse than did ADHD adolescents who were not taking medications.13
The stimulant drugs come in long- and short-term forms.
The newer sustained-release stimulants can be taken before school and are
long-lasting so that the child does not need to go to the school nurse every
day for a pill. The doctor can discuss with the parents the child’s needs and
decide which preparation to use and whether the child needs to take the
medicine during school hours only or in the evening and on weekends too.
If the child does not show symptom improvement after
taking a medication for a week, the doctor may try adjusting the dosage. If
there is still no improvement, the child may be switched to another medication.
About one out of ten children is not helped by a stimulant medication. Other
types of medication may be used if stimulants don’t work or if the ADHD occurs
with another disorder. Antidepressants and other medications can help control
accompanying depression or anxiety.
Sometimes the doctor may prescribe for a young child a
medication that has been approved by the FDA for use in adults or older
children. This use of the medication is called “off label.” Many of the newer
medications that are proving helpful for child mental disorders are prescribed
off label because only a few of them have been systematically studied for
safety and efficacy in children. Medications that have not undergone such
testing are dispensed with the statement that “safety and efficacy have not
been established in pediatric patients.”
Most side effects of the stimulant medications are minor
and are usually related to the dosage of the medication being taken. Higher
doses produce more side effects. The most common side effects are decreased
appetite, insomnia, increased anxiety, and/or irritability. Some children
report mild stomach aches or headaches.
Appetite seems to fluctuate, usually being low during the
middle of the day and more normal by suppertime. Adequate amounts of food that
is nutritional should be available for the child, especially at peak appetite
times.
If the child has difficulty falling asleep, several
options may be tried—a lower dosage of the stimulant, giving the stimulant
earlier in the day, discontinuing the afternoon or evening dosage, or giving an
adjunct medication such as a low-dosage antidepressant or clonidine. A few
children develop tics during treatment. These can often be lessened by changing
the medication dosage. A very few children cannot tolerate any stimulant, no
matter how low the dosage. In such cases, the child is often given an
antidepressant instead of the stimulant.
When a child’s schoolwork and behavior improve soon after
starting medication, the child, parents, and teachers tend to applaud the drug
for causing the sudden changes. Unfortunately, when people see such immediate
improvement, they often think medication is all that’s needed. But medications
don’t cure ADHD; they only control the symptoms on the day they are taken.
Although the medications help the child pay better attention and complete
school work, they can’t increase knowledge or improve academic skills. The
medications help the child to use those skills he or she already possesses.
Behavioral therapy, emotional counseling, and practical
support will help ADHD children cope with everyday problems and feel better
about themselves.
·
Medications for ADHD help many children
focus and be more successful at school, home, and play. Avoiding negative
experiences now may actually help prevent addictions and other emotional
problems later.
·
About 80 percent of children who need
medication for ADHD still need it as teenagers. Over 50 percent need medication
as adults.
Since a child with bipolar disorder will probably be
prescribed a mood stabilizer such as lithium or Depakote®, the doctor will
carefully consider whether the child should take one of the medications usually
prescribed for ADHD. If a stimulant medication is prescribed, it may be given
in a lower dosage than usual.
Medication can help the ADHD child in everyday life. He
or she may be better able to control some of the behavior problems that have
led to trouble with parents and siblings. But it takes time to undo the
frustration, blame, and anger that may have gone on for so long. Both parents
and children may need special help to develop techniques for managing the
patterns of behavior. In such cases, mental health professionals can counsel
the child and the family, helping them to develop new skills, attitudes, and
ways of relating to each other. In individual counseling, the therapist helps
children with ADHD learn to feel better about themselves. The therapist can
also help them to identify and build on their strengths, cope with daily
problems, and control their attention and aggression. Sometimes only the child
with ADHD needs counseling support. But in many cases, because the problem
affects the family as a whole, the entire family may need help. The therapist
assists the family in finding better ways to handle the disruptive behaviors
and promote change. If the child is young, most of the therapist’s work is with
the parents, teaching them techniques for coping with and improving their
child’s behavior.
Several intervention approaches are available. Knowing
something about the various types of interventions makes it easier for families
to choose a therapist that is right for their needs.
Psychotherapy
works to help people with ADHD to like and accept themselves despite their
disorder. It does not address the symptoms or underlying causes of the
disorder. In psychotherapy, patients talk with the therapist about upsetting
thoughts and feelings, explore self-defeating patterns of behavior, and learn
alternative ways to handle their emotions. As they talk, the therapist tries to
help them understand how they can change or better cope with their disorder.
Behavioral therapy (BT)
helps people develop more effective ways to work on immediate issues. Rather
than helping the child understand his or her feelings and actions, it helps
directly in changing their thinking and coping and thus may lead to changes in
behavior. The support might be practical assistance, like help in organizing
tasks or schoolwork or dealing with emotionally charged events. Or the support
might be in self-monitoring one’s own behavior and giving self-praise or
rewards for acting in a desired way such as controlling anger or thinking
before acting.
Social skills training
can also help children learn new behaviors. In social skills training, the
therapist discusses and models appropriate behaviors important in developing
and maintaining social relationships, like waiting for a turn, sharing toys,
asking for help, or responding to teasing, then gives children a chance to
practice. For example, a child might learn to “read” other people’s facial
expression and tone of voice in order to respond appropriately. Social skills
training helps the child to develop better ways to play and work with other
children.
Support groups
help parents connect with other people who have similar problems and concerns
with their ADHD children. Members of support groups often meet on a regular
basis (such as monthly) to hear lectures from experts on ADHD, share
frustrations and successes, and obtain referrals to qualified specialists and
information about what works. There is strength in numbers, and sharing
experiences with others who have similar problems helps people know that they
aren’t alone. National organizations are listed at the end of this document.
Parenting skills training,
offered by therapists or in special classes, gives parents tools and techniques
for managing their child’s behavior. One such technique is the use of token or
point systems for immediately rewarding good behavior or work. Another is the
use of “time-out” or isolation to a chair or bedroom when the child becomes too
unruly or out of control. During time-outs, the child is removed from the
agitating situation and sits alone quietly for a short time to calm down.
Parents may also be taught to give the child “quality time” each day, in which
they share a pleasurable or relaxing activity. During this time together, the
parent looks for opportunities to notice and point out what the child does
well, and praise his or her strengths and abilities.
This system of rewards and penalties can be an effective
way to modify a child’s behavior. The parents (or teacher) identify a few
desirable behaviors that they want to encourage in the child—such as asking for
a toy instead of grabbing it, or completing a simple task. The child is told
exactly what is expected in order to earn the reward. The child receives the
reward when he performs the desired behavior and a mild penalty when he
doesn’t. A reward can be small, perhaps a token that can be exchanged for
special privileges, but it should be something the child wants and is eager to
earn. The penalty might be removal of a token or a brief time-out. Make an
effort to find your child being good. The goal, over time, is to help
children learn to control their own behavior and to choose the more desired
behavior. The technique works well with all children, although children with
ADHD may need more frequent rewards.
In addition, parents may learn to structure situations in
ways that will allow their child to succeed. This may include allowing only one
or two playmates at a time, so that their child doesn’t get overstimulated. Or
if their child has trouble completing tasks, they may learn to help the child
divide a large task into small steps, then praise the child as each step is
completed. Regardless of the specific technique parents may use to modify their
child’s behavior, some general principles appear to be useful for most children
with ADHD. These include providing more frequent and immediate feedback
(including rewards and punishment), setting up more structure in advance of
potential problem situations, and providing greater supervision and encouragement
to children with ADHD in relatively unrewarding or tedious situations.
Parents may also learn to use stress management methods,
such as meditation, relaxation techniques, and exercise, to increase their own
tolerance for frustration so that they can respond more calmly to their child’s
behavior.
Children with ADHD may need help in organizing.
Therefore:
·
Schedule. Have the same routine every day, from wake-up time to bedtime. The
schedule should include homework time and playtime (including outdoor
recreation and indoor activities such as computer games). Have the schedule on
the refrigerator or a bulletin board in the kitchen. If a schedule change must
be made, make it as far in advance as possible.
·
Organize needed everyday
items. Have a place for everything and keep
everything in its place. This includes clothing, backpacks, and school
supplies.
·
Use homework and notebook
organizers. Stress the importance of writing
down assignments and bringing home needed books.
Children with ADHD need consistent rules that they can
understand and follow. If rules are followed, give small rewards. Children with
ADHD often receive, and expect, criticism. Look for good behavior and praise
it.
You are your child’s best advocate. To be a good advocate for your child, learn as much as you can about ADHD
and how it affects your child at home, in school, and in social situations.
If your child has shown symptoms of ADHD from an early
age and has been evaluated, diagnosed, and treated with either behavior
modification or medication or a combination of both, when your child enters the
school system, let his or her teachers know. They will be better prepared to
help the child come into this new world away from home.
If your child enters school and experiences difficulties
that lead you to suspect that he or she has ADHD, you can either seek the
services of an outside professional or you can ask the local school district to
conduct an evaluation. Some parents prefer to go to a professional of their own
choice. But it is the school’s obligation to evaluate children that they
suspect have ADHD or some other disability that is affecting not only their
academic work but their interactions with classmates and teachers.
If you feel that your child has ADHD and isn’t learning
in school as he or she should, you should find out just who in the school
system you should contact. Your child’s teacher should be able to help you with
this information. Then you can request—in writing—that the school system
evaluate your child. The letter should include the date, your and your child’s
names, and the reason for requesting an evaluation. Keep a copy of the letter
in your own files.
Until the last few years, many school systems were reluctant
to evaluate a child with ADHD. But recent laws have made clear the school’s
obligation to the child suspected of having ADHD that is affecting adversely
his or her performance in school. If the school persists in refusing to
evaluate your child, you can either get a private evaluation or enlist some
help in negotiating with the school. Help is often as close as a local parent
group. Each state has a Parent Training and Information (PTI) center as well as
a Protection and Advocacy (P&A) agency. (For information on the law and on
the PTI and P&A, see the section on support groups and organizations at the
end of this document.)
Once your child has been diagnosed with ADHD and
qualifies for special education services, the school, working with you, must
assess the child’s strengths and weaknesses and design an Individualized
Educational Program (IEP). You should be able periodically to review and
approve your child’s IEP. Each school year brings a new teacher and new
schoolwork, a transition that can be quite difficult for the child with ADHD.
Your child needs lots of support and encouragement at this time.
Never forget the cardinal rule—you are your
child’s best advocate.
Your child with ADHD has successfully navigated the early
school years and is beginning his or her journey through middle school and high
school. Although your child has been periodically evaluated through the years,
this is a good time to have a complete re-evaluation of your child’s health.
The teen years are challenging for most children; for the
child with ADHD these years are doubly hard. All the adolescent problems—peer
pressure, the fear of failure in both school and socially, low self-esteem—are
harder for the ADHD child to handle. The desire to be independent, to try new
and forbidden things—alcohol, drugs, and sexual activity—can lead to unforeseen
consequences. The rules that once were, for the most part, followed, are often
now flaunted. Parents may not agree with each other on how the teenager’s
behavior should be handled.
Now, more than ever, rules should be straightforward and
easy to understand. Communication between the adolescent and parents can help
the teenager to know the reasons for each rule. When a rule is set, it should
be clear why the rule is set. Sometimes it helps to have a chart,
posted usually in the kitchen, that lists all household rules and all rules for
outside the home (social and school). Another chart could list household chores
with space to check off a chore once it is done.
When rules are broken—and they will be—respond to this
inappropriate behavior as calmly and matter-of-factly as possible. Use
punishment sparingly. Even with teens, a time-out can work. Impulsivity and hot
temper often accompany ADHD. A short time alone can help.
As the teenager spends more time away from home, there
will be demands for a later curfew and the use of the car. Listen to your
child’s request, give reasons for your opinion and listen to his or her
opinion, and negotiate. Communication, negotiation, and compromise
will prove helpful.
Teenagers, especially boys, begin talking about driving
by the time they are 15. In some states, a learner’s permit is available at 15
and a driver’s license at 16. Statistics show that 16-year-old drivers have
more accidents per driving mile than any other age. In the year 2000, 18
percent of those who died in speed-related crashes were youth ages 15 to 19.
Sixty-six percent of these youth were not wearing safety belts. Youth with
ADHD, in their first 2 to 5 years of driving, have nearly four times as many
automobile accidents, are more likely to cause bodily injury in accidents, and
have three times as many citations for speeding as the young drivers without
ADHD.14
Most states, after looking at the statistics for
automobile accidents involving teenage drivers, have begun to use a graduated
driver licensing system (GDL). This system eases young drivers onto the roads
by a slow progression of exposure to more difficult driving experiences. The
program, as developed by the National Highway Traffic Safety Administration and
the American Association of Motor Vehicle Administrators, consists of three
stages: learner’s permit, intermediate (provisional) license, and full
licensure. Drivers must demonstrate responsible driving behavior at each stage
before advancing to the next level. During the learner’s permit stage, a
licensed adult must be in the car at all times.15 This period of
time will give the learner a chance to practice, practice, practice. The more
your child drives, the more efficient he or she will become. The sense of
accomplishment the teenager with ADHD will feel when the coveted license is
finally in his or her hands will make all the time and effort involved
worthwhile.
Note: The State Legislative Fact Sheets—Graduated Driver
Licensing System can be found at web site http://www.nhtsa.dot.gov/people/outreach/safesobr/21qp/html/fact_sheets/Graduated_Driver.html,
or it can be ordered from NHTSA Headquarters, Traffic Safety Programs, ATTN:
NTS-32, 400 Seventh Street, S.W., Washington, DC 20590; telephone 202-366-6948.
Attention deficit hyperactivity disorder is a highly
publicized childhood disorder that affects approximately 3 percent to 5 percent
of all children. What is much less well known is the probability that, of
children who have ADHD, many will still have it as adults. Several studies done
in recent years estimate that between 30 percent and 70 percent of children
with ADHD continue to exhibit symptoms in the adult years.16
The first studies on adults who were never diagnosed as
children as having ADHD, but showed symptoms as adults, were done in the late
1970s by Drs. Paul Wender, Frederick Reimherr, and David Wood. These
symptomatic adults were retrospectively diagnosed with ADHD after the
researchers’ interviews with their parents. The researchers developed clinical
criteria for the diagnosis of adult ADHD (the Utah Criteria), which combined
past history of ADHD with current evidence of ADHD behaviors.17
Other diagnostic assessments are now available; among them are the widely used
Conners Rating Scale and the Brown Attention Deficit Disorder Scale.
Typically, adults with ADHD are unaware that they have
this disorder—they often just feel that it’s impossible to get organized, to
stick to a job, to keep an appointment. The everyday tasks of getting up,
getting dressed and ready for the day’s work, getting to work on time, and
being productive on the job can be major challenges for the ADHD adult.
Diagnosing an adult with ADHD is not easy. Many times,
when a child is diagnosed with the disorder, a parent will recognize that he or
she has many of the same symptoms the child has and, for the first time, will
begin to understand some of the traits that have given him or her trouble for
years—distractibility, impulsivity, restlessness. Other adults will seek professional
help for depression or anxiety and will find out that the root cause of some of
their emotional problems is ADHD. They may have a history of school failures or
problems at work. Often they have been involved in frequent automobile
accidents.
To be diagnosed with ADHD, an adult must have
childhood-onset, persistent, and current symptoms.18 The accuracy of
the diagnosis of adult ADHD is of utmost importance and should be made by a
clinician with expertise in the area of attention dysfunction. For an accurate
diagnosis, a history of the patient’s childhood behavior, together with an
interview with his life partner, a parent, close friend, or other close
associate, will be needed. A physical examination and psychological tests
should also be given. Comorbidity with other conditions may exist such as
specific learning disabilities, anxiety, or affective disorders.
A correct diagnosis of ADHD can bring a sense of relief.
The individual has brought into adulthood many negative perceptions of himself
that may have led to low esteem. Now he can begin to understand why he has some
of his problems and can begin to face them. This may mean, not only treatment
for ADHD but also psychotherapy that can help him cope with the anger he feels
about the failure to diagnose the disorder when he was younger.
Medications.
As with children, if adults take a medication for ADHD, they often start with a
stimulant medication. The stimulant medications affect the regulation of two
neurotransmitters, norepinephrine and dopamine. The newest medication approved
for ADHD by the FDA, atomoxetine (Strattera®), has been tested in controlled
studies in both children and adults and has been found to be effective.19
Antidepressants are considered a second choice for
treatment of adults with ADHD. The older antidepressants, the tricyclics, are
sometimes used because they, like the stimulants, affect norepinephrine and
dopamine. Venlafaxine (Effexor®), a newer antidepressant, is also used for its
effect on norepinephrine. Bupropion (Wellbutrin®), an antidepressant with an
indirect effect on the neurotransmitter dopamine, has been useful in clinical
trials on the treatment of ADHD in both children and adults. It has the added
attraction of being useful in reducing cigarette smoking.
In prescribing for an adult, special considerations are
made. The adult may need less of the medication for his weight. A medication
may have a longer “half-life” in an adult. The adult may take other medications
for physical problems such as diabetes or high blood pressure. Often the adult
is also taking a medication for anxiety or depression. All of these variables
must be taken into account before a medication is prescribed.
Education and psychotherapy. Although medication gives needed support, the individual must succeed on
his own. To help in this struggle, both “psychoeducation” and individual
psychotherapy can be helpful. A professional coach can help the ADHD adult
learn how to organize his life by using “props”—a large calendar posted where
it will be seen in the morning, date books, lists, reminder notes, and have a
special place for keys, bills, and the paperwork of everyday life. Tasks can be
organized into sections, so that completion of each part can give a sense of
accomplishment. Above all, ADHD adults should learn as much as they can about
their disorder.
Psychotherapy can be a useful adjunct to medication and
education. First, just remembering to keep an appointment with the therapist is
a step toward keeping to a routine. Therapy can help change a long-standing
poor self-image by examining the experiences that produced it. The therapist
can encourage the ADHD patient to adjust to changes brought into his life by
treatment—the perceived loss of impulsivity and love of risk-taking, the new
sensation of thinking before acting. As the patient begins to have small
successes in his new ability to bring organization out of the complexities of
his or her life, he or she can begin to appreciate the characteristics of ADHD
that are positive—boundless energy, warmth, and enthusiasm.
1. Still GF. Some abnormal psychical conditions in
children: the Goulstonian lectures. Lancet, 1902;1:1008-1012.
2. DSM-IV-TR workgroup. The Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision. Washington,
DC: American Psychiatric Association.
3. Consensus Development Panel. Defined Diets and
Childhood Hyperactivity. National Institutes of Health Consensus
Development Conference Summary, Volume 4, Number 3, 1982.
4. Wolraich M, Milich R, Stumbo P, Schultz F. The effects
of sucrose ingestion on the behavior of hyperactive boys. Pediatrics,
1985; 106; 657-682.
5. Hoover DW, Milich R. Effects of sugar ingestion
expectancies on mother-child interaction. Journal of Abnormal Child
Psychology, 1994; 22; 501-515.
6. Biederman J, Faraone SV, Keenan K, Knee D, Tsuang MF.
Family-genetic and psychosocial risk factors in DSM-III attention deficit
disorder. Journal of the American Academy of Child and Adolescent
Psychiatry, 1990; 29(4): 526-533.
7. Faraone SV, Biederman J. Neurobiology of
attention-deficit hyperactivity disorder. Biological Psychiatry,
1998; 44; 951-958.
8. The ADHD Molecular Genetics Network. Report from the
third international meeting of the attention-deficit hyperactivity disorder
molecular genetics network. American Journal of Medical Genetics,
2002, 114:272-277.
9. Castellanos FX, Lee PP, Sharp W, Jeffries NO,
Greenstein DK, Clasen LS, Blumenthal JD, James RS, Ebens CI, Walter JM,
Zijdenbos A, Evans AC, Giedd JN, Rapoport JL. Developmental trajectories of
brain volume abnormalities in children and adolescents with
attention-deficit/hyperactivity disorder. Journal of the American Medical
Association, 2002, 288:14:1740-1748.
10. Wender PH. ADHD: Attention-Deficit
Hyperactivity Disorder in Children and Adults. Oxford University Press,
2002, p. 9.
11. Geller B, Williams M, Zimerman B, Frazier J, Beringer
L, Warner KL. Prepubertal and early adolescent bipolarity differentiate from
ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal
of Affective Disorders, 1998, 51:81-91.
12. The MTA Cooperative Group. A 14-month randomized
clinical trial of treatment strategies for attention-deficit hyperactivity
disorder (ADHD). Archives of General Psychiatry,
1999;56:1073-1086.
13. Wilens TC, Faraone, SV, Biederman J, Gunawardene S.
Does stimulant therapy of attention-deficit/hyperactivity disorder beget later
substance abuse? A meta-analytic review of the literature. Pediatrics,
2003, 111:1:179-185.
14. Barkley RA. Taking Charge of ADHD. New
York: The Guilford Press, 2000, p. 21.
15. U.S. Department of Transportation, National Highway
Traffic Safety Administration. State Legislative Fact Sheet, April
2002.
16. Silver LB. Attention-deficit hyperactivity disorder
in adult life. Child and Adolescent Psychiatric Clinics of North America,
2000:9:3: 411-523.
17. Wender PH. Pharmacotherapy of
attention-deficit/hyperactivity in adults. Journal of Clinical Psychiatry,
1998; 59 (supplement 7):76-79.
18. Wilens TE, Biederman J, Spencer TJ. Attention
deficit/hyperactivity disorder across the lifespan. Annual Review of
Medicine, 2002:53:113-131.
19. Attention Deficit Disorder in Adults.
Harvard Mental Health Letter, 2002:19;5:3-6.
The following books were helpful resources in the writing of this document. Many other informative bo