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. Symptoms include difficulty sitting still, problems maintaining attention on school or homework, and responding before thinking. Hyperactivity symptoms can include being fidgety, restless, and talking or interrupting others excessively.

ADHD is generally identified early in life and manifests through behavioral problems in school, with difficulty understanding, completing tasks, or being easily distracted by others. It is estimated that 5 percent of school-age children are diagnosed with ADHD; with boys receiving the diagnosis more often than girls. Females are more likely to present with inattentive features.

Untreated ADHD has been shown to have long-term adverse affects on academic performance, vocational success, relationships with others and social-emotional development. Kids may experience learning problems, engage in rebellious or defiant behavior, and have difficulties with their mood such as depression, or anxiety. More than half the children diagnosed with ADHD continue to have symptoms during their adolescent years and into adulthood. As they grow older, they are at times more prone to drug abuse, other risk taking behavior and antisocial behavior.

Symptoms

To be diagnosed with ADHD, a child must present with problems related to inattention and/or hyperactivity-impulsivity for a period of at least six months that significantly negatively impacts their performance or functioning. These behaviors must also exist in two or more settings such as home, work, with friends and family.

Children should have exhibited several of these symptoms prior to age 12.

Symptoms of inattention include:

  • Making careless mistakes, overlooking details
  • Difficulty remaining focused on tasks, conversations
  • Being easily distractible
  • Difficulty following through on instructions, or duties in the workplace
  • Difficulty organizing tasks and activities
  • Avoidance, or refusal of activities that require sustained attention (reports, forms, reviewing 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
  • Impulsively blurting out
  • Difficulty waiting for a turn
  • Intruding or interrupting others

A diagnosis of combined presentation is made both hyperactivity-impulsivity and inattention symptoms 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.

Children suspected of having ADHD deserve 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/environmental stressors may be inciting symptoms like those of ADHD. 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.

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.

Causes

There are several theories about potential causes of ADHD. Research on the casual factors related to ADHD tend to study younger children with ADHD. In terms of genetics, 25 percent of the close relatives in the families of ADHD children also have ADHD. This indicates that genes are an important factor in the development of ADHD. Research by the NIMH Child Psychiatry Branch, which compared kids diagnosed with and without ADHD found that ADHD children generally have a 3-4 percent reduction in brain volumes 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 allowing us to solve problems, plan ahead, understand the behavior of others, and restrain our impulses. 

Current research suggests ADHD may be caused by interactions between genes and environmental or non-genetic factors. These include cigarette smoking, alcohol or drug use during pregnancy, exposure to environmental toxins such as high levels of lead (found in buildings built before 1978), prematurity leading to low birth weight, and head injuries. 

Social theorists and clinicians have sometimes referred to ADHD as the epidemic of modern times, implying the role of a fast paced, consumerist model and lifestyle that allows us to be immersed in "a world of instant messaging and rapid-fire video games and TV shows." The implications of a lifestyle that affords us the luxury of not having to wait and have our needs met by the click of a button or text, may extend beyond our genetic history or biology and further interact with a biological predisposition.

Treatments

Treatments for ADHD are determined by the need of the child and severity of problems and issues. ADHD in children is successfully treated with a three-pronged approach that includes close coordination between the child, family, and school-based interventions. 

Medications

Medications concurrently can help the child gain more focus, feel less restless or impulsive, and can further improve the results of skills applied and learned in therapy. Medications most commonly prescribed in the treatment of ADHD include 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. Those commonly prescribed include Amphetamine/Dextroamphetamine (Addreall), Dexmethylphenidate (Focalin), Lisdexamfetamine (Vyvanse), Methylphenidate (Concerta, Ritalin). Psychostimulants are at times limited in terms of severe adverse effects that may include decreased appetite leading to weight loss, insomnia, and headache.

Antidepressants are considered as a choice for treatment for ADHD in children who may also exhibit problems with mood or anxiety. Similar to stimulants, antidepressants also target norepinephrine and dopamine neurotransmitters. These include the older class of drugs called tricyclics but also newer antidepressants such as Venlafaxine (Effexor), and Bupropion (Wellbutrin). Antidepressants have their potential benefits and side effects as well. The most common side effects are decreased appetite, insomnia, increased anxiety, and/or irritability. Some children report mild stomachaches or headaches.

It is important to work with the prescribing physician to find the right medication and the right dosage. 

Psychotherapy

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 better. Children are also provided tools to stay organized, and keeping a routine and a schedule to stay focussed and on task. Psychotherapy can help kids like and accept themselves despite their disorder. The support might also include 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 to respond more appropriately. Social skills training can help teach how behavior affects others and develop new ways to respond when angry or pushed.

Parenting-skills training offered by therapists or in special classes give parents tools and techniques for managing their child's behavior. Mental health professionals can help 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 his or her 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.

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. Sharing experiences with others who have similar problems helps people know that they aren't alone.

Structuring the child's school environment may also be helpful and this can include:

  • Limiting distractions in the child's environment
  • Providing one-on-one instruction with teacher
  • 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
  • Requesting an IEP (Individualized Education Plan) based on assessments of the child's strengths and weaknesses and to request for specific accommodations and remedial services

References

  • 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
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  • 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
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Last reviewed 03/05/2018