Attention-Deficit/Hyperactivity Disorder, Children
Attention-Deficit/Hyperactivity Disorder is a neurobehavioral disorder characterized by a combination of inattention, 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 material, completing tasks, or being easily distracted by others. Around 5 percent of school-age children are diagnosed with ADHD, and boys are diagnosed twice as often as girls, according to the DSM-5. Girls are more likely to present with inattentive features.
Kids may experience learning problems, engage in rebellious or defiant behavior, and have difficulties with mood including anxiety and depression. More than half of children diagnosed with ADHD continue to have symptoms during adolescence and adulthood. Symptoms of ADHD can 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 is diagnosed when a teen experiences six or more of the following symptoms. If they are 17 or older, they need to experience just five symptoms. The symptoms must persist for six months and be severe enough to negatively impact academic or social functioning. They must also be inconsistent with the teen's developmental level, and not be attributable to other mental disorders such as an anxiety disorder, mood disorder, or personality disorder. The teen 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 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)
Children with the inattentive type of ADHD, characterized by the symptoms above, are less disruptive and are often not diagnosed.
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
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.
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 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.
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 children with ADHD also have the condition, indicating that genes play an important role in the development of ADHD. Research on the casual 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 an important role in the development of ADHD. Research by Child Psychiatry Branch of the National Institute of Mental Health found that compared to children without ADHD, children with the condition generally have a 3-4 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.
Current research suggests that ADHD may be caused by interactions between genes and environmental factors. These 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 head injuries.
Social theorists and clinicians sometimes refer to ADHD as the epidemic of modern times, implicating the role of a fast paced, consumerist lifestyle that immerses people in "a world of instant messaging and rapid-fire video games and TV shows." The effects of a lifestyle in which one's needs can instantly be met with the click of a button may extend beyond genetics or biology to interact with one's biological predisposition in a different way.
Treatments for ADHD are determined by the needs of the individual child and severity of their symptoms. ADHD in children is successfully treated with a three-pronged approach that includes close coordination between the child, family, and school-based interventions.
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. Those commonly prescribed include Amphetamine/Dextroamphetamine (Adderall), 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 sometimes considered to treat 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.
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, maintain a schedule, and stay focussed. 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 encourage new behaviors by giving praise or rewards each time the child acts in the desired way.
Social skills training can also help children 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, 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 give 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.
Support groups help parents connect with other people who have similar problems and concerns with their ADHD children. Members of support groups 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.
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 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 requesting specific accommodations and remedial services