Attention-Deficit/Hyperactivity Disorder (Children)

Definition

Attention-deficit/hyperactivity disorder is a neurobehavioral disorder characterized by a combination of inattentiveness, distractibility, hyperactivity, and impulsive behavior.

AD/HD appears early in life. It is estimated that 3 percent to 7 percent of school-age children are diagnosed with AD/HD; boys are diagnosed more often than girls. Untreated AD/HD has been shown to have long-term adverse affects on academic performance, vocational success, and social-emotional development. AD/HD children have difficulty sitting still and paying attention in class and do not do well at school, even when they have normal or above-normal intelligence. They engage in a broad array of disruptive behaviors and experience peer rejection.

As they grow older, children with untreated AD/HD are more prone to drug abuse, antisocial behavior, and injuries of all sorts. More than half the children diagnosed with AD/HD continue to have symptoms during their adolescent years and into adulthood.

Symptoms

According to the most recent version of the Diagnostic and Statistical Manual-IV, AD/HD is indicated when six or more of the following symptoms have a) persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level; b) some symptoms are present before age 7; and c) symptoms cause significant impairment of functioning in two or more settings (school, work, home, after-school activities, etc.); d) symptoms are not better accounted for by another mental disorder such as learning disorder, conduct disorder, or anxiety disorder. The symptoms of AD/HD are:

1. Symptoms of inattention:

  • Has difficulty sustaining attention, organizing tasks, or setting up tools needed for a task
  • Easily distracted by irrelevant sights and sounds
  • Does not pay attention to detail or follow instructions carefully
  • Makes careless mistakes in schoolwork and other activities
  • Fails to finish school assignments and chores
  • Loses things and is forgetful
  • Does not seem to listen when spoken to directly; lethargic, appears to be daydreaming

Children with the "inattentive" type of AD/HD characterized by the symptoms above are less disruptive and are often not diagnosed.

2. Symptoms of hyperactivity/impulsivity:

  • May often be "on the go"
  • Restless; often fidgeting with hands or feet or squirming while seated
  • Unable to stay seated or play quietly
  • Smaller children may run, jump, or climb about constantly
  • Talks excessively at inappropriate times
  • Blurts out answers before questions are completed
  • Trouble taking turns or waiting in line
  • Interrupts or intrudes on others; grabs things from people

The combined inattentive/hyperactivity type displays equal, predominant symptoms of the above types; this is the most common type of AD/HD type among children and adolescents.

The predominantly inattentive type displays symptoms of inattention but fewer than six hyperactivity/impulsivity symptoms.

The predominantly hyperactive-impulsive type displays criteria for hyperactivity/impulsivity symptoms but fewer than six inattentive symptoms.

Every child suspected of having AD/HD deserves a careful evaluation both to distinguish between AD/HD and AD/HD-like symptoms commonly seen in other psychiatric and medical conditions and to determine if some situational/environmental stressors may be inciting symptoms like those of AD/HD. Psychiatrists, psychologists, pediatricians/family physicians, 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.

Possible causes of AD/HD-like behavior include 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 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, and depression.

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 nutrition problems like chronic caffeine highs that might make the child seem overly active. The assessment may also include interviews with the child's teachers, parents, and other people who know the child well.

Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most children with AD/HD are able to control their behavior and perform well.

Causes

Health professionals are still unsure about what causes AD/HD. It may be a genetically determined disorder, as attention disorders often run in families. Studies indicate that 25 percent of close relatives in the families of AD/HD children also have AD/HD, whereas the rate is about 5 percent in the general population. Many studies of twins now show that a strong genetic influence exists in the disorder.

Recent studies show that AD/HD is caused by neurobiological dysfunction. Scientists using neuroimaging and brain scanning tools for studying the brain have demonstrated a link between a person's ability to maintain attention and the level of activity in the brain. For example, scientists have found differences between the frontal lobes of individuals who have AD/HD and those who do not.

Current research is exploring the structure of the brain to determine if there are differences that might indicate a physical basis for attention-deficit/hyperactivity disorder.

There is correlating evidence between the use of cigarettes and alcohol during pregnancy and the risk for developing AD/HD in the unborn child. These substances may endanger the fetus' developing brain. It is best to refrain from smoking, alcohol use, and use of other drugs during pregnancy, as they may distort developing nerve cells and lead to AD/HD.

Toxins in the environment may also disrupt brain development or brain processes, which may lead to AD/HD. Lead is one such possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline or paint were once used. It is also present in some older water pipes.

There is, however, little compelling evidence that AD/HD stems from the home environment. Researchers report that not all children from unstable or dysfunctional homes have AD/HD, and not all children with AD/HD come from dysfunctional families. Scientists have also found no real evidence that head injury, undetectable damage to the brain, early infection, or complications at birth cause AD/HD.

Researchers have found that refined sugar and food additives do not generally make children hyperactive and inattentive. In 1982, NIH, the federal agency responsible for biomedical research, concluded that diet restrictions seemed to help about 5 percent of children with AD/HD, mostly young children with food allergies.

Treatments

Every family wants to determine which treatment will be most effective for their child. This question needs to be answered by each family in consultation with a health-care professional. To help families make this important decision, the National Institute of Mental Health (NIMH) has funded many studies of treatments for AD/HD and conducted the most intensive study ever undertaken for evaluating the treatment of this disorder, the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder.

The results of the study indicated that long-term combination treatments (medication and behavioral therapy) and medication management alone were superior to intensive behavioral treatment and routine community treatment. 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.

No single treatment is the answer for every child with AD/HD. A child may sometimes have side effects from a medication that would make that particular treatment unacceptable. And if a child with AD/HD 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.

Medications

For decades, medications have been used to treat the symptoms of AD/HD. 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, and the lowest age for which they have been found safe and effective.

Trade name (generic name; approved age)

Adderall (amphetamine; 3 and older)

Concerta (methylphenidate (long acting); 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 (extended release); 6 and older)

Metadate CD (methylphenidate (extended release); 6 and older)

Ritalin (methylphenidate; 6 and older)

Ritalin SR (methylphenidate (extended release); 6 and older)

Ritalin LA (methylphenidate (long acting); 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 AD/HD. NOTE: The U.S. Food and Drug Administration (FDA) recently approved a medication for AD/HD that is not a stimulant. The medication, Strattera®, or atomoxetine, works on a different neurotransmitter (norepinephrine) than stimulants, which primarily work on dopamine. (Both of these neurotransmitters are believed to play a role in AD/HD.) 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 AD/HD given Strattera manifest significant improvement in their symptoms.

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 hyperactivity and impulsivity and improve the 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, there is no convincing evidence that stimulant medications, when used for treatment of AD/HD, 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 AD/HD who remained on their medication as teens had a lower likelihood of substance use or abuse than did adolescents with AD/HD who were not taking medications.

The stimulant drugs come in long- and short-term forms. The newer sustained-release stimulants can be taken before school and are long-lasting; the child does not need to go to the school nurse every day for a pill. The doctor can discuss the child's needs with the parents 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 10 children is not helped by a stimulant medication. Other types of medication may be used if stimulants don't work or if the AD/HD 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."

Side Effects of the Medications

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 stomachaches or headaches.

Appetite seems to fluctuate, usually being low during the middle of the day and more normal by suppertime. Adequate amounts of nutritional food 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, taking 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. Changing the medication dosage can often lessen these.

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 credit the drug for the sudden changes. Unfortunately, when people see such immediate improvement, they often think medication is all that's needed. But medications don't cure AD/HD; they only control the symptoms on the day they are taken. Although the medications help the child pay better attention and complete schoolwork, they can't increase knowledge or improve academic skills. The medications help the child use those skills he or she already possesses.

Behavioral therapy, emotional counseling, and practical support will help AD/HD children cope with everyday problems and feel better about themselves.

Facts to Remember About Medication for AD/HD

  • Medications for AD/HD 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 AD/HD still need it as teenagers
  • Over 50 percent need medication as adults

Psychosocial Treatments

Medication can help a child with AD/HD 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, including the development of new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children with AD/HD learn to feel better about themselves, help them to identify and build on their strengths, cope with daily problems, and control their attention and aggression. Sometimes only the child with AD/HD needs counseling support, but because the problem affects the family, in many cases, everyone may need help. 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.

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 AD/HD to like and accept themselves, despite their 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.

Cognitive-behavioral therapy helps people work on immediate issues. Rather than helping people understand their feelings and actions, it supports them directly in changing their behavior. The support might be practical assistance, like helping a child learn how to think through tasks and organize his or her work. Or the support might be to encourage new behaviors by giving praise or rewards each time the person acts in the desired way.

Social-skills training can also help a child learn new behaviors. In this training, the therapist discusses and models appropriate behaviors like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives the child 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 more appropriately. Social skills training can help teach how behavior affects others and develop new ways to respond when angry or pushed.

Support groups (local and national) help parents connect with other people who have similar problems and concerns with their AD/HD children. Members of support groups share frustrations, successes, referrals to qualified specialists, and information about what works, as well as their hopes for themselves and their children. There is strength in numbers, and sharing experiences with others who have similar problems helps people know that they aren't alone.

Parenting-skills training offered by therapists or in special classes give parents tools and techniques for managing their child's behavior. One such technique is the use of "time-outs" 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 be taught to give the child "quality time" each day, in which they share a pleasurable or relaxed activity.

A token system or a system of rewards and penalties is 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 the desired behavior is performed and a mild penalty when it isn't. A reward can be small, 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. 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 AD/HD may need more frequent rewards.

Structured situations may help children with AD/HD by:

  • Limiting distractions in the child's environment
  • Providing one-on-one instruction with teacher
  • Ensuring the child gets enough sleep
  • Ensuring the child gets a healthy, varied diet, with plenty of fiber and basic nutrients
  • 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 parents it is beneficial to 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.

The American Academy of Pediatrics has provided guidelines for treating children with AD/HD

  • Set specific target goals to guide therapy
  • Medication and/or behavior therapy should be started
  • When treatment plan has not met target goal, re-evaluate the original diagnosis, the possibility of other conditions, and how well the treatment plan has been implemented
  • Systematically follow up; regularly reassess target goals, results, and any side effects of medications. Information should be gathered from parents, teachers, and the child.

Your AD/HD Child and Education

You are your child's best advocate. To be a good advocate for your child, learn as much as you can about AD/HD and how it affects your child at home, in school, and in social situations.

If your child has shown symptoms of AD/HD from an early age and has been evaluated, diagnosed, and treated with either behavior modification or medication or a combination of both, let his or her teachers know when he or she begins school. They will be better prepared to help the child come into this new world away from home.

Children with AD/HD have a variety of needs. Some children are too hyperactive or inattentive to function in a regular classroom, even with medication and a behavior-management plan. In order to assess these needs, the special-education teacher, along with the parents, the school psychologist, school administrators, and the classroom teacher, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). The IEP outlines the specific skills the child needs to develop as well as appropriate learning activities that build on the child's strengths. Parents play an important role in the process. They must be included in meetings and given an opportunity to review and approve their child's IEP. Some children may be placed in a special education class for all or part of the day. However, most children are able to stay in the regular classroom and learn along with their peers. Special accommodations may be used in order to assist the child with AD/HD to function in a regular classroom.

In general, children with AD/HD are fully capable of learning, but their hyperactivity and inattention make learning difficult. As a result, many students with AD/HD repeat a grade or drop out of school. Fortunately, with the right combination of appropriate educational practices, medication, and counseling, these outcomes can be avoided.

Right to a Free Public Education

Individuals with AD/HD or other disabilities are entitled to a free and appropriate public education (FAPE), including special education services that are guaranteed by two federal laws: The Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504). IDEA requires that a student must first qualify for special education, according to the following criteria:

  1. The student must be diagnosed with AD/HD by either the school district or a qualified professional
  2. The severity of AD/HD must increase the student's sensitivity to his/her surroundings and impair alertness to academic tasks
  3. The effects of AD/HD must have a significant impact and/or be a long-standing condition
  4. AD/HD must impair educational achievement in a manner that requires special educational services

The National Rehabilitation Act, Section 504, defines disabilities more broadly. Often called "504 Eligibility," it qualifies children that have a diagnosed physical or mental impairment that substantially limits learning and requires special education or related services. Children who need assistance in certain areas may qualify even if they do not need special education.

The Americans with Disabilities Act (ADA), Title II, requires that state and local governments give people with disabilities an equal opportunity to benefit from all of their programs, services, and activities (e.g., public education, employment, transportation, recreation, health care, social services, courts, voting, and town meetings). Title III has the same requirements for private, independent, and nonreligious schools. This act prohibits discrimination against otherwise qualified students who are limited by a disability such AD/HD, and it requires that educational institutions that receive federal funds to provide academic and other adjustments so that students can avail themselves of courses, examinations, and other activities.

Private schools are required to facilitate participation in educational and other activities; however, they are not required to provide remedial services to improve skills in an area of disability.

Sources

  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
  • Barkley R.A. (2000). Taking Charge of AD/HD. New York: The Guilford Press, p. 21.
  • Biederman J, Faraone SV, Keenan K, Knee D, Tsuang MF. (1990) Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29(4): 526-533.
  • Consensus Development Panel (CDP) (1982). Defined Diets and Childhood Hyperactivity. National Institutes of Health Consensus Development Conference Summary, Volume 4(3).
  • Faraone SV, Biederman J. (1998) Neurobiology of attention-deficit hyperactivity disorder. Biological Psychiatry, 44, 951-958.
  • Harvard Mental Health Letter (2002). Attention Deficit Disorder in Adults. Vol. 19:5, 3-6.
  • The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder (AD/HD) (1999). Archives of General Psychiatry, 56:1073-1086.
  • National Institute of Mental Health (2006). Attention-Deficit/Hyperactivity Disorder. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services. http://www.nimh.nih.gov/publicat/AD/HD.cfm#teen
  • National Institutes of Health - National Library of Medicine - MedlinePlus, 2007. Attention deficit hyperactivity disorder (AD/HD). http://www.nlm.nih.gov/medlineplus/ency/article/001551.htm
  • US Department of Justice (USDOJ) (2006). A Guide to Disability Rights Laws. Civil Rights Division: Disability Rights Section http://www.usdoj.gov/crt/ada/cguide.htm#anchor62335
  • U.S. Department of Transportation, National Highway Traffic Safety Administration. State Legislative Fact Sheet, April 2002.
  • Wilens TC, Faraone, SV, Biederman J, Gunawardene S. (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111:1:179-185.
  • Wilens TE, Biederman J, Spencer TJ. Attention (2002). deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 53:113-131.
Last reviewed 02/17/2015