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Attention deficit hyperactivity disorder (ADHD)

Definition

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for a child's age and development.

Alternative Names

ADD; ADHD; Childhood hyperkinesis

Causes, incidence, and risk factors

Imaging studies suggest that the brains of children with ADHD are different from those of other children. These children handle neurotransmitters (including dopamine, serotonin, and adrenaline) differently from their peers.

ADHD may run in families, but it is not clear exactly what causes it. Whatever the cause may be, it seems to be set in motion early in life as the brain is developing.

Depression, lack of sleep, learning disabilities, tic disorders, and behavior problems may be confused with, or appear with, ADHD. Every child suspected of having ADHD should have a careful evaluation to determine what is contributing to the behaviors that are causing concern.

ADHD is the most commonly diagnosed behavioral disorder of childhood. It affects about 3 - 5% of school aged children. ADHD is diagnosed much more often in boys than in girls.

Most children with ADHD also have at least one other developmental or behavioral problem. They may also have another psychiatric problem, such as depression or bipolar disorder.

Symptoms

The symptoms of ADHD are divided into inattentiveness, and hyperactivity and impulsivity.

Some children with ADHD primarily have the inattentive type, some the hyperactive-impulsive type, and some the combined type. Those with the inattentive type are less disruptive and are more likely to miss being diagnosed with ADHD.

Inattention symptoms:

  1. Fails to give close attention to details or makes careless mistakes in schoolwork
  2. Has difficulty sustaining attention in tasks or play
  3. Does not seem to listen when spoken to directly
  4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
  5. Has difficulty organizing tasks and activities
  6. Avoids or dislikes tasks that require sustained mental effort (such as schoolwork)
  7. Often loses toys, assignments, pencils, books, or tools needed for tasks or activities
  8. Is easily distracted
  9. Is often forgetful in daily activities

Hyperactivity symptoms:

  1. Fidgets with hands or feet or squirms in seat
  2. Leaves seat when remaining seated is expected
  3. Runs about or climbs in inappropriate situations
  4. Has difficulty playing quietly
  5. Is often "on the go," acts as if "driven by a motor," talks excessively

Impulsivity symptoms:

  1. Blurts out answers before questions have been completed
  2. Has difficulty awaiting turn
  3. Interrupts or intrudes on others (butts into conversations or games)

Signs and tests

Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue.

The diagnosis is based on very specific symptoms, which must be present in more than one setting.

  • Children should have at least 6 attention symptoms or 6 hyperactivity/impulsivity symptoms, with some symptoms present before age 7.
  • The symptoms must be present for at least 6 months, seen in two or more settings, and not caused by another problem.
  • The symptoms must be severe enough to cause significant difficulties in many settings, including home, school, and in relationships with peers.

In older children, ADHD is in partial remission when they still have symptoms but no longer meet the full definition of the disorder.

The child should have an evaluation by a doctor if ADHD is suspected. Evaluation may include:

  • Parent and teacher questionnaires (for example, Connors, Burks)
  • Psychological evaluation of the child AND family, including IQ testing and psychological testing
  • Complete developmental, mental, nutritional, physical, and psychosocial examination

Treatment

The American Academy of Pediatrics has guidelines for treating ADHD:

  • Set specific, appropriate target goals to guide therapy.
  • Start medication and behavior therapy.
  • When treatment has not met the target goals, re-evaluate the original diagnosis, the possible presence of other conditions, and how well the treatment plan has been implemented.
  • Follow-up regularly with the doctor to check on goals, results, and any side effects of medications. During these check-ups, information should be gathered from parents, teachers, and the child.

MEDICATIONS

Children who receive both behavioral treatment and medication often do the best. There are now several different classes of ADHD medications that may be used alone or in combination. Psychostimulants (also known as stimulants) are the most commonly used ADHD drgus. Although these drugs are called stimulants, they actually have a calming effect on people with ADHD.

These drugs include:

  • Amphetamine-dextroamphetamine (Adderall)
  • Dexmethylphenidate (Focalin)
  • Dextroamphetamine (Dexedrine, Dextrostat)
  • Lisdexamfetamine (Vyvanse)
  • Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)

The Food and Drug Administration (FDA) has approved the nonstimulant drug atomoxetine (Strattera) for use in ADHD. It may be as effective as stimulants, and may be less likely to be misused.

Some ADHD medicines have been linked to rare sudden death in children with heart problems. Talk to your doctor about which drug is best for your child.

BEHAVIOR THERAPY

Both before and after a child is diagnosed, there is stress on the family. Families can experience blame, anger, and frustration. Talk therapy for both the child and family can help everyone overcome these feelings and move forward.

Parents should use a system of rewards and consequences to help guide their child's behavior. It is important to learn to handle disruptive behaviors. Support groups can help you connect with others who have similar problems.

Other tips to help your child with ADHD include:

  • Communicate regularly with the child's teacher.
  • Keep a consistent daily schedule, including regular times for homework, meals, and outdoor activities. Make changes to the schedule in advance and not at the last moment.
  • Limit distractions in the child's environment.
  • Make sure the child gets a healthy, varied diet, with plenty of fiber and basic nutrients.
  • Make sure the child gets enough sleep.
  • Praise and reward good behavior.
  • Provide clear and consistent rules for the child.

ADHD can be a frustrating problem. Alternative remedies have become popular, including herbs, supplements, and chiropractic manipulation. However, there is little or no solid evidence for many remedies marketed to parents.

Expectations (prognosis)

ADHD is a long-term, chronic condition. If it is not treated appropriately, ADHD may lead to:

  • Drug and alcohol abuse
  • Failure in school
  • Problems keeping a job
  • Trouble with the law

About half of children with ADHD will continue to have troublesome symptoms of inattention or impulsivity as adults. However, adults are often more capable of controlling behavior and masking difficulties.

Calling your health care provider

Call your doctor if you or your child's school personnel suspect ADHD. You should also tell your doctor about any:
  • Difficulties at home, school, and in relationships with peers
  • Medication side effects
  • Signs of depression

Prevention

Although there is no proven way to prevent ADHD, early identification and treatment can prevent many of the problems associated with ADHD.

References

Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894-921.

National Institute of Mental Health (NIMH). Attention deficit hyperactivity disorder (ADHD). Accessed January 14, 2010.

Prince JB, Spencer TJ, Wilens TE, Biederman J. Pharmacotherapy of attention-deficit/hyperactivity disorder across the life span. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 49.


Review Date: 2/22/2010
Reviewed By: David B. Merrill, MD, Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University Medical Center, New York, NY. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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