Attention-Deficit/Hyperactivity Disorder, Children
Attention-deficit/hyperactivity disorder is a neurobehavioral disorder characterized by a combination of inattention, hyperactivity, and impulsive behavior. In children, symptoms related to inattention typically include problems maintaining attention on school or homework, frequent daydreaming, forgetfulness, and difficulties organizing tasks or possessions. Hyperactivity symptoms can include difficulty sitting still, frequent fidgeting, reckless or impulsive behavior, acting as if “driven by a motor,” and talking or interrupting others excessively.
ADHD is generally identified early in life—though it may not be diagnosed until adolescence or adulthood—and often manifests through behavioral problems in school, difficulty understanding academic material or completing tasks, or being easily distracted by others. According to the CDC, more than 9 percent of school-age children were diagnosed with ADHD in 2016. Boys make up the majority of diagnoses, and are more likely to present with hyperactive symptoms; girls, by contrast, are more likely to present with inattentive features.
In addition to symptoms of inattention or hyperactivity, children with ADHD may have diagnosable learning disabilities, engage in rebellious or defiant behavior, or have difficulties with mood, including anxiety and depression. The majority of children diagnosed with ADHD will continue to have symptoms during adolescence and adulthood; it is possible, however, for a child’s symptoms to lessen significantly—or even disappear altogether—with age. Symptoms of ADHD can usually be treated effectively with a combination of medication and therapy. When left untreated, however, ADHD can have long-term adverse effects on academic performance, vocational success, relationships, and social-emotional development.
According to the DSM-5, ADHD can be diagnosed when a child experiences six or more of the symptoms listed below. (Adolescents and adults need only experience five symptoms.) The symptoms must persist for at least six months and be severe enough to negatively impact academic or social functioning.
Symptoms of inattention include:
- Making careless mistakes, overlooking details
- Difficulty remaining focused on tasks or conversations
- Being easily distractible
- Difficulty following through on instructions or assignments
- Difficulty organizing tasks and activities
- Avoidance or refusal of activities that require sustained attention (reports, forms, papers)
- Losing things frequently
- Being forgetful of daily activities (appointments, chores)
Symptoms of hyperactivity and impulsivity include:
- Frequent fighting, squirming, tapping
- Often leaving seat when remaining seated is expected
- Feeling overly restless
- Difficulty being still for an extended period of time
- Difficulty engaging in leisure activities
- Talking excessively
- Preemptively blurting out answers to questions
- Difficulty waiting for a turn
- Intruding or interrupting others
Symptoms must be inconsistent with the child’s developmental level and not be attributable to other psychiatric or developmental disorders, such as generalized anxiety disorder or a learning disability.
There are 3 types of ADHD. A diagnosis of combined presentation is made when both hyperactivity-impulsivity and inattention symptoms persist for at least six months. A diagnosis of predominantly inattentive type is made when criteria are met for inattention symptoms but not for hyperactivity-impulsivity symptoms for at least six months. A diagnosis of predominantly hyperactive-impulsive type is made when criteria are met for hyperactivity-impulsivity symptoms but not for inattention symptoms for at least six months. The types exist across all age groups, though children are more likely than adults to be diagnosed with hyperactive type. Children with inattentive type are typically less disruptive than children with hyperactive type, and thus may be less likely to be diagnosed.
Children suspected of having ADHD should undergo a careful evaluation both to distinguish between ADHD and ADHD-like symptoms commonly seen in other psychiatric and medical conditions and to determine if some situational or environmental stressors may be creating symptoms similar to those of ADHD. Psychiatrists, psychologists, pediatricians, neurologists, and clinical social workers most often are trained in providing an evaluation and diagnosis of mental disorders and ruling out other reasons for the child's behavior. A thorough evaluation should include a clinical assessment of the individual's performance in academic and social settings, emotional functioning, and developmental abilities. Additional tests may include intelligence tests, measures of attention span, and parent and teacher rating scales. A medical exam by a physician is also important. A doctor may look for allergies or nutritional problems that may contribute to energy spikes. The assessment may also include interviews with the child's teachers, parents, and other people who know the child well.
To learn more about how ADHD is diagnosed, visit our ADHD Center.
ADHD diagnoses are most often granted to school-age children (6+), as symptoms may not be noticeable or problematic until a child starts school. However, guidelines set by the American Academy of Pediatrics state that children can be diagnosed as young as 4, as long as their symptoms of hyperactivity or inattention are developmentally inappropriate. Children may also be diagnosed in middle or high school, often because symptoms that were imperceptible in elementary school become more difficult to manage as schoolwork becomes more challenging.
There are several theories about the potential causes of ADHD, and most current research suggests that ADHD is likely caused by interactions between genes and environmental factors. Research on the causal elements of ADHD tends to focus on younger children.
In terms of genetics, 25 percent of close relatives of a child with ADHD also have the condition—indicating that genetics play a key role in the development of ADHD. Relevant environmental factors include cigarette smoking, alcohol or drug use during pregnancy, exposure to environmental toxins such as high levels of lead (found in older buildings), prematurity leading to low birth weight, and early-life head injuries.
Children with ADHD show measurable brain differences compared to those without ADHD. Research by the Child Psychiatry Branch of the National Institute of Mental Health found that compared to children without ADHD, children with the condition generally have a 3 to 4 percent reduction in volume in important regions of the brain including the frontal lobes, temporal gray matter, caudate nucleus, and cerebellum. These brain structures play a vital role in solving problems, planning ahead, restraining impulses, and understanding the behavior of others.
Social theorists and clinicians sometimes refer to ADHD as an epidemic of modern times, implicating the possible role of a fast-paced, consumerist lifestyle with many competing demands for children’s attention. Some experts also argue that modern academic environments—many of which limit physical activity, discourage free play and academic exploration, and focus intensely on test scores and other objective metrics—contribute to learning and behavior problems in children by forcing them to sit still and tamp down their natural curiosity.
Many people believe that excessive amounts of sugar are to blame for hyperactive behaviors, or even for ADHD itself. However, research investigating the effect of sugar on behavior is mixed, with many studies finding no association between refined sugar consumption and increased hyperactivity and others finding only a weak association. On the other hand, some children—with and without ADHD—do appear to be more sensitive to sugar than others, and may experience increased hyperactivity after consumption. Sugary foods alone are not to blame for a child’s ADHD diagnosis.
ADHD cannot be caused by poor parenting alone, as it is thought to be due to a mix of genetic, prenatal, and environmental factors, many of which are out of parents’ control. However, some experts caution that inconsistent or lax parenting styles may exacerbate symptoms of the disorder. Children with ADHD typically do best with structure, fair and consistent discipline, and parental support.
Many factors thought to contribute to ADHD occur during pregnancy; for example, research suggests that mothers who smoke, use drugs, or eat a poor diet while pregnant may be at higher risk of having a child with ADHD. Other health conditions, such as gestational diabetes, may also increase the risk of a child being born with ADHD. Thus, avoiding cigarettes and other substances, eating a nutritious diet, and receiving adequate prenatal care could offer some protective benefits. However, it’s important to remember that ADHD is due to a complex confluence of factors, and even mothers who receive excellent prenatal care or engage in healthy behaviors may still give birth to children who later go on to develop ADHD.
Treatments for ADHD are determined by the needs of the individual child and the severity of their symptoms. ADHD in children is often successfully treated with a three-pronged approach that includes close coordination between the child’s family, school, and medical team.
Medications can help the child gain more focus, feel less restless or impulsive, and can further improve the skills applied and learned in therapy. The medications most commonly prescribed to treat ADHD are a class of drugs called stimulants that have both short-acting and long-acting properties. Short-acting medications may need to be taken more often, and long-acting drugs can usually be taken once daily.
Commonly prescribed stimulants include amphetamine/dextroamphetamine (sold under the brand names Adderall and Mydayis), dexmethylphenidate (Focalin), lisdexamfetamine (Vyvanse), and methylphenidate (sold as Ritalin, Quillivant, Daytrana, QuilliChew, Concerta, and others). Nonstimulant medications—including atomoxetine (sold under the brand names Strattera), guanfacine (Intuniv), and clonidine (Kapvay)—may be tried if the child reacts poorly to stimulants or finds that they don’t reduce problematic symptoms.
Antidepressants are sometimes considered to treat ADHD in children, especially those who also exhibit problems with mood or anxiety. Similar to stimulants, antidepressants also target norepinephrine and dopamine neurotransmitters. Those most often used include the older class of drugs called tricyclics, as well as newer antidepressants such as venlafaxine (Effexor), and bupropion (Wellbutrin).
All medications used to treat ADHD carry some risk of side effects. The most common side effects of stimulants are decreased appetite, insomnia, increased anxiety, and/or irritability, while nonstimulants may lead to nausea, dizziness, or fatigue. Some children report mild stomach aches or headaches with both classes of drugs. Many find that these side effects resolve with time, but if they don’t, another medication can be tried. Finding the most effective medication can be a process of trial and error; it is important to work closely with the prescribing physician to find the right drug and dosage.
Therapy provides skills to help the child more easily direct themselves to tasks and assignments, as well become more knowledgeable about their behavior to regulate it more effectively. Therapy also provides children with tools to stay organized, maintain a schedule, and stay focused. The support might include practical assistance, like helping a child learn how to think through tasks and organize his or her work. Alternatively, it may encourage new behaviors by giving praise or rewards each time the child acts in the desired way. Psychotherapy can also help kids with ADHD build self-esteem and recognize their strengths.
Because children with ADHD can struggle to make or keep friends, social skills training can also be valuable. In this training, the therapist discusses and models appropriate behaviors like waiting for a turn, sharing toys, asking for help, or responding to teasing, and then gives the child a chance to practice. For example, a child might learn to read people's facial expressions and tone of voice to respond more appropriately. Social skills training can help teach how behavior affects others and develop new ways to respond when angry or upset.
Parenting skills training offered by therapists or in special classes gives parents tools and techniques to manage their child's behavior. Mental health professionals can educate the parents of a child with ADHD about the condition and how it affects the child and family. They can also help the child and parents develop new skills, attitudes, and ways of relating to each other. Parents may benefit from learning to develop more collaborative relationships with their children and manage their stress better by increasing their ability to deal with frustration and respond more calmly to their child’s behavior. The therapist assists the family in finding better ways to handle the disruptive behaviors and promote change and works with the parents of young children to teach techniques for coping with and improving their child's behavior.
Structuring the child's school environment may also be helpful. This can include limiting distractions in the child's environment, providing one-on-one instruction with teachers, or helping the child divide a large task into small steps if the child has trouble completing tasks( and then praising the child as each step is completed). For children whose ADHD is significantly interfering with academic progress, requesting an IEP (Individualized Education Plan) or 504 Plan based on assessments of the child's strengths and weaknesses can allow the child to receive specific accommodations and remedial services, such as curriculum modifications or occupational therapy.
To learn more about academic accommodations, visit our ADHD Center.
There is no one-size-fits-all treatment plan for children with ADHD; however, many parents find that a mix of therapy and medication is most effective. Medication can help with day-to-day symptom management, while behavioral therapy and parent training is often necessary to help children learn coping mechanisms, apply time management and organizational skills, and build self-esteem. Many parents also find that supplemental approaches—such as neurofeedback, dietary changes, or increased exercise—can further reduce symptoms and improve a child’s quality of life.
When taken appropriately, stimulant medications are considered safe by the vast majority of experts. As with many medications, however, there are certain groups of people for whom stimulants should be approached with caution, such as children with pre-existing heart conditions or tic disorders. In these cases, parents should work closely with their child’s doctor to determine whether a medication can be used safely. Parents should also take possible side effects into account when deciding whether or not to medicate, such as decreased appetite or insomnia.
Many parents agonize over the decision to put their child on medication. Most clinicians agree that medication is safe and effective when used appropriately—however, it’s natural for parents to worry about possible risks, side effects, or whether putting a child on medication for his or her behavior means they’re “failing” as a parent. Experts recommend that parents take their time with the decision, talking to their doctor and discussing the pros and cons of medicating. Exploring behavioral treatments in addition to medication can also help parents ensure they’re making the treatment choices that are best for their child. It can also be helpful to keep in mind that the decision to medicate need not be a permanent one; if the child experiences a negative reaction or does not see a reduction in symptoms, medication can be stopped at any time.
Parenting a child with ADHD can be challenging and at times lonely. Online or in-person support groups can be immensely valuable, helping parents connect with other people who have similar problems, worries, and experiences. Members of support groups typically share frustrations, successes, referrals to qualified specialists, and information about what is effective, as well as their hopes for themselves and their children. Sharing experiences with others who have similar concerns helps people know that they aren't alone.
To learn more about parenting a child with ADHD, visit our ADHD Center.