Attention deficit hyperactivity disorder (ADHD)

• Alternative Names

  ADD; ADHD; Childhood hyperkinesis

• Causes, incidence, and risk factors

  ADHD affects school performance and interpersonal relationships. Parents of children with ADHD are often exhausted and frustrated.

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

  ADHD is often genetic. Whatever the specific cause may be, it seems to be set in motion early in life as the brain is developing.

  Depression, sleep deprivation, learning disabilities, tic disorders, and behavior problems may be confused with, or appear along with, ADHD. Every child suspected of having ADHD deserves a careful evaluation to sort out exactly what is contributing to the behaviors causing concern.

  Attention Deficit Disorder (ADD) is the most commonly diagnosed behavioral disorder of childhood, affecting an estimated 3 - 5% of school aged children. It is diagnosed much more often in boys than in girls.

  Most children with ADHD also have at least one other developmental or behavioral problem.

• Symptoms

  The Diagnostic and Statistical Manual (DSM-IV) divides the symptoms of ADHD into those of inattentiveness and those of hyperactivity and impulsivity.

  To be diagnosed with ADHD, children should have at least 6 attention symptoms or 6 activity and impulsivity symptoms -- to a degree beyond what would be expected for children their age.

  The symptoms must be present for at least 6 months, observable in 2 or more settings, and not caused by another problem. The symptoms must be severe enough to cause significant difficulties. Some symptoms must be present before age 7.

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

  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 easier to miss being diagnosed with ADHD.

  Inattention symptoms:

  1. Fails to give close attention to details or makes careless mistakes in schoolwork
  2. 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. 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. Easily distracted
  9. 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. Difficulty playing quietly
  5. 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. 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. The child should have a clinical evaluation if ADHD is suspected.

  Evaluation may include:

  • Parent and teacher questionnaires (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.
  • Medication and behavior therapy should be started.
  • When treatment has not met the target goals, evaluate the original diagnosis, the possible presence of other conditions, and how well the treatment plan has been implemented.
  • Systematic follow-up is important to regularly reassess target goals, results, and any side effects of medications. Information should be gathered from parents, teachers, and the child.

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

  Children who receive both behavioral treatment and medication often do the best. Medications should not be used just to make life easier for the parents or the school. There are now several different classes of ADHD medications that may be used alone or in combination. Psychostimulants are the primary drugs used to treat ADHD. Although these drugs stimulate the central nervous system, they have a calming effect on people with ADHD.

  These drugs include:

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

  The FDA has approved the nonstimulant drug atomoxetine (Strattera) for use in ADHD. Effectiveness appears to be similar to that of stimulants. Strattera is not addicting.

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

  The following may also help:

  • Limit distractions in the child's environment.
  • Provide one-on-one instruction with the teacher.
  • Make sure the child gets enough sleep.
  • Make sure the child gets a healthy, varied diet, with plenty of fiber and basic nutrients.
• Expectations (prognosis)

  ADHD is a long-term, chronic condition. About half of the 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.

  Statistics show that there is an increased incidence of juvenile delinquency and adult encounters with the law among individuals who had ADHD as a child.

  Every effort should be made to manage symptoms and direct the child's energy to constructive and educational paths.

• Complications

  Many adults with ADHD are in successful jobs. Possible complications, if ADHD is not adequately treated, could include failure in school or other similar problems.

• Calling your health care provider
  Call your health care provider if you or your child's school personnel suspect the possibility of attention deficit disorder.
• Prevention

  While there is no proven way to prevent ADHD itself, 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.

  This article uses information by permission from Alan Greene, M.D., © Greene Ink, Inc.

Review Date: 1/20/2009

Reviewed By: Paul Ballas, DO, Department of Psychiatry, Thomas Jefferson University Hospital, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.