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ADHD - Attention-Deficit Hyperactivity Disorder
Definition and History
Neurobiologic basis
Diagnostic Criteria
Coexisting Disorders
Protective factors
Risks for ADHD
Impairments
Treatment
Behavior Modification
Medications
Web links
ADHD Med Refill Request Form
Does My Child Have ADHD?
Many parents worry about this question. The answer comes from children, families, teachers, and doctors working together as a team. Watching your child’s behavior at home and in the community is very important to help answer this question. You doctor will ask you to fill out various rating scales about your child. Watching your child’s behavior and talking with other adults in your child’s life will be important for filling out the forms.
Here are a few tips about what you can do to help answer the question:
Watch your child closely during activities where he or she should pay attention:
- Doing homework
- Doing chores
- During storytelling or reading
Watch your child when you expect him or her to sit for a while or think before acting.
- Sitting through a family meal
- During a religious service
- Crossing the street
- Being frustrated
- With brothers or sisters
- While you are on the phone
Pay attention to how the environment affects your child’s behavior. Make changes at home to improve your child’s behavior.
- Provide structure to home life, such as regular nutritious mealtimes and bedtime. Write down the schedule and put it where the entire family can see it. Stick to the schedule.
- Ensure that your child understands what is expected. Speak slowly to your child. Have your child repeat the instructions. Children require repetition and guidance.
- Turn off the TV or computer games during meals and homework. Also, close the curtains if it will help your child pay attention to what he or she needs to be doing.
- Provide your child with planned breaks during long assignments.
- Give rewards for paying attention and sitting, not just for getting things right and finishing. Some rewards might be: dessert for sitting through a meal, outdoor play for finishing homework, and praise for talking through problems.
- Try to find out what things set off problem behaviors. See if you can eliminate these triggers.
If your child spends time in 2 households, compare observations.
- Talk with your child’s other parent about behavior in that home. Cooperation between parents in this area really helps your child.
- If your child behaves differently, consider differences in the environment that may explain this. Differences are common and not a mark of good or bad parenting.
Talk to your child’s teacher.
- Learn about your child’s behavior at school. Talk about how your child does during academic lessons and also during play with other children.
- Compare your child’s behavior in subjects he or she likes and those in which he or she has trouble with the work.
- Determine how the environment at school affects your child’s behavior. When does your child perform well? What events trigger problem behaviors?
- Consider with the teacher whether your child’s learning abilities should be evaluated at school. If he or she has poor grades in all subjects or in just a few subjects or requires extra time and effort to learn material, then a learning evaluation may be valuable.
Gather impressions from other adult caregivers who know your child well.
- Scout leaders or religious instructors who see your child during structured activities and during play with other children.
- Relatives or neighbors who spend time with your child.
- Determine how other environments affect your child’s behavior. When does your child perform well? What events trigger problem behaviors?
Make an appointment to see your child’s doctor.
- Let the receptionist know you are concerned that your child might have ADHD.
- Try to arrange a visit when both parents can attend.
Definition/Diagnostic Criteria: ADHD is a complex neurobiological disorder characterized by developmentally inappropriate levels of 4 core symptoms:
- inattention
- distractability
- impulsiveness
- hyperactivity (sometimes)
Symptoms must be present for at least 6 months.
Symptoms must start before the age of 7 years.
Symptoms must produce impairments in two or more settings (home, school, work, social settings).
Symptoms cannot be accounted for by other conditions (psychiatric, medical, or environmental )
Key Questions in Identifying ADHD:
- Are the core symptoms clearly present?
- Does objective evidence show that symptoms cause significant impairments?
- Have symptoms been observed as part of the person’s behavior across situations since childhood? If not, is there a plausible reason why symptoms were not noticed until later or seemed to come and go?
- What evidence is there that symptoms are not due to lack of effort, poor vocational match, or transient situational or environmental circumstances?
- Are symptoms better explained by another psychiatric or medical diagnosis?
- Might other psychiatric diagnoses coexist with ADHD symptoms?
ADHD types: (given in order of prevalence)
Combined: child has all four symptoms of the disorder.
Predominantly inattentive: inattentive and easily distracted but not excessively impulsive or hyperactive.
Predominantly hyperactive-impulsive: hyperactive and impulsive but not excessively inattentive.
Not all patients with ADHD are alike – The symptoms manifest in different people to varying degrees.
ADHD in Girls: The problem with the definition and diagnostic criteria for ADHD is that it was developed to describe young boys with hyperactive/ impulsive patterns. There are some important differences to remember in how ADHD manifests in girls:
- The majority of girls are in the Predominantly Inattentive Type of ADHD.
- Those who are in the Combined or Hyperactive-Impulsive Types do not show the “typical” signs of hyperactivity. They may be hyper-talkative, hyper-social, or hyper-reactive emotionally.
- Girls are much less likely to be oppositional, defiant, or have behavior problems in the classroom.
- Academic impairment in the classroom may not be evident in the elementary years. Girls tend to work harder for teacher approval, and they tend to work harder to hide their attentional difficulties.
- Girls are more likely to struggle with co-existing anxiety and depression, especially as women.
Prevalence: ADHD affects 11-16% of Americans and 2-20% worldwide. Studies show that about half of childhood ADHD persists into adulthood, affecting about 4.7% of all adults.
History:
1902 - oldest description of ADHD given in the medical journal, Lancet.
1937 - first use of Benzedrine as treatment.
1955 - methylphenidate (Ritalin) was manufactured.
1960 - called “minimal brain dysfunction”, with the main symptom being hyperactivity.
1966 - inattentiveness was added as another main symptom of ADHD.
1980 - DSM-III defined the diagnosis as: ADD with or without hyperactivity. It also provided the first
definition of ADHD in adults.
1987 - DSM-III R revised the definition of ADD and renamed it ADHD.
1994 - DSM-IV revised the definition to the one currently in use (see above).
Neurobiological basis of ADHD:
Norepinephrine and dopamine: the interaction of these compounds modulate attention and impulse control. Med Hypotheses 1989;29:33.
Brain Size: Children with ADHD have smaller cerebral and cerebellar volume than children without ADHD. Brain volumes correlate with parent and clinician ratings of ADHD severity. The smaller brain volumes are not caused by medication. JAMA 1998; 279:1100.
Brain Glucose Metabolism: is reduced in adults with ADHD by 8%. The regions of the brain most affected are the premotor cortex and the superior prefrontal cortex - areas that relate to the control of attention and motor activity. JAMA 2002; 288:1740.
2 distinct psycho-patho-physiological pathways: the executive circuit and the reward circuit. Problems with executive control impair the ability to make appropriate judgments, synthesize information, and inhibit impulsive behaviors. Problems in the reward circuit cause one to seek immediate gratification and reward without fully evaluating the consequences of the behavior Neurosci Biobehav Rev 2003; 27(7)593-604.
Coexisting Disorders: Almost 90% of ADHD children will have at least one; about 67% will have two:
- Learning Disabilities
- Obsessive Compulsive Disorder (OCD)
- Tics, Tourette’s syndrome
- Fetal Alcohol Effect or Syndrome
- Oppositional Defiant Disorder (ODD)
- Bipolar Disorder
- High Anxiety Personality
- Conduct Disorder
- Depression
- Pervasive Development Disorder
Protective factors: These decrease a child’s vulnerability to ADHD so they handle their ADHD better.
Healthy lifestyle (nutrition, exercise, sleep)
Positive family environment
Access to educational resources
High intelligence
Risks for ADHD: These can be either causative or complicating factors.
A child’s vulnerability to ADHD depends on the interaction of genetic, medical, and environmental risks, the child’s temperament, and the presence of protective factors.
Genetic risks: A child has a greater risk of ADHD if s/he has relatives with:
- ADHD
- Anger Control Issues
- Learning Disorders or School Problems
- Conduct Disorders
- Mood Disorders (anxiety, depression, bipolar)
- Minor Physical Anomalies
- Alcoholism or other Substance Abuse problems
- Sociopathy (criminal activities)
Medical risks: The 2 biggest risk factors for ADHD are:
If mother smoked during pregnancy
If mother drank alcohol in the first trimester
Other pregnancy and delivery risk factors:
- Preeclampsia
- Low Birth Weight
- Premature labor
- C-section with complications
Other medical risk factors:
- Meningitis
- Severe Allergies or Asthma
- Anemia
- Hearing Impairment
- Seizures
- Chronic Illness
- Hyper or Hypo Thyroid
- Poor Vision
- Major Head Injury
- Obstructive Sleep Apnea
Temperament risks: A child has a greater risk of ADHD if s/he:
- is impulsive, difficult to control, or fearful
- seeks novelty
- has eating and sleeping problems
- is rigid and tense (not easy to cuddle)
- has extremes of temperament (reacts intensely to stimuli, so shy s/he’s barely approachable, etc)
Environmental risks (Implicated, not proven): lead, carbon monoxide, a variety of heavy metals, dietary factors, family stress, economic problems
Impairmentsexperienced at various ages when ADHD is untreated:
(not all problems are seen in every ADHD child - symptoms manifest to varying degrees in various children)
Preschool years:
- Fearless, Energetic, Insatiable curiosity
- Always on the go, as if “driven by a motor”
- Impulsively aggressive and disruptive
- Tends to spill and/or break things
- Demanding, argumentative, noisy during play
- Has trouble playing by him or herself,
- Interrupts others, impatient, easily frustrated
- Seems to not learn from mistakes
- Resists bedtime, frequent night-waking
- More likely to have night terrors, nightmares
- Often more difficult to potty-train
- High level of oppositional attitude and behavior
Results in: Low self-esteem; Disruptions in the family; Difficulty participating in preschool or day care - often labeled as a trouble maker; Higher likelihood of having speech delay.
School-aged child:
- Fidgety, restless, difficulty sitting still in desk, frequently asks to sharpen pencil or use bathroom, etc
- Blurts out answers in class, talks excessively
- Struggles with homework, fails to complete it or it is full of careless errors.
- Easily frustrated, Unwilling to try, Temper outbursts
- Irregular performance - good days and bad days
- Inappropriate behaviors - invades other people’s personal space, doesn’t “clue in” to social cues
- Unable to wait turns in games, can’t play cooperatively with peers, who may perceive child as bossy.
- Seems not to listen, loses things, forgetful, has trouble organizing
- Predominantly inattentive child: daydreams, plays alone, more likely to be ignored by classmates
- Unwilling and/or unable to do assigned chores at home.
- Coaches may think child has an “attitude problem” and may not be able to participate in sports as much.
- Difficult to establish regular eating and sleeping patterns.
- More likely to have restless sleep patterns, night waking, nightmares, sleep talking and/or walking,
- More likely to have problems with bedwetting, daytime urinary accidents, constipation or soiling.
- Lying, stealing, and fighting are more common in ADHD children.
Results in: Alienation from peers; Problems within the family; Poor academic performance; School failure. Low self- esteem; Anxiety; Anger; Depression; Delinquency.
Child may be labeled as a trouble maker, a “bad kid”, a day dreamer, lazy, unmotivated, social butterfly, class clown, ditzy or spacey.
Adolescence/Teens:
- Inner sense of restlessness may replace hyperactivity, giving false impression that ADHD has improved.
- Angry outbursts and quick changes of mood, above and beyond the average adolescent.
- Easily frustrated and impatient - which can fuel temper outbursts - poor anger control
- Interrupts, talks excessively, says things without thinking, forgets what others have said
- Disorganized at school and home, forgetful, loses things
- Has trouble following through on responsibilities, leaves a mess
- Underestimates time needed to complete a task, procrastinates
- Poor sleeping and eating habits
- More oppositional toward parents and teachers than average adolescent.
- Junior High and High School are less nurturing and expect more personal responsibility – increased problems with learning, poor school performance, and increased lack of motivation.
- Poor decision making - impulsive, short-term thinking rather than long-term
Results in: Low self esteem; Anxiety; Anger; Depression; Increased risk of suicide; Increased risk of traffic tickets and motor vehicle accidents; More likely to smoke, drink alcohol and/or abuse drugs; More likely to acquire sexually transmitted disease and/or early pregnancy; Increased risk of antisocial behaviors and activities.
Child may be considered “class clown” or “life of the party” or ostracized as intrusive, disruptive and aggressive. Predominantly inattentive may be perceived as socially awkward, reclusive or “a loner”.
Impairments in Adults when ADHD is untreated: You might have ADHD if you tend to:
- make careless mistakes when working on a boring or difficult project.
- have difficulty keeping attention when you are doing boring or repetitive work.
- have trouble concentrating on what people say to you, even when they talk to you directly. You often don’t remember being told to do something or you “zone out” in conversations.
- have trouble finishing up projects, especially once the challenging parts have been done. You often leave a mess.
- have trouble getting things in order when doing a task that requires organization.
- delay or avoid getting started, especially on tasks that require a lot of though. You procrastinate and often underestimate the time needed to complete a task..
- misplace or have trouble finding things at home or at work
- get distracted by activity or noise around you.
- have problems remembering appointments or obligations.
- fidget or squirm with your hands or feet when you have to sit down for a long time.
- leave your seat in meetings or other situations in which you are expected to remain seated.
- Have feelings of restlessness. You have problems dealing with frustration.
- have trouble unwinding and relaxing when you have time to yourself.
- feel overly active and compelled to do things.
- find yourself talking too much when you are in social situations.
- finish other people’s sentences.
- have trouble waiting your turn in situations when turn taking is required.
- interrupt others when they are busy or say things without thinking.
(ADHD adults have at least 12 of these 18 impairments)
These impairments can result in:
Occupational difficulties caused by poor planning and organization, difficulty managing time, poor memory, emotional distress, feelings of frustration, and bad temper. More likely to lose and change jobs. Family and marital problems resulting in higher rates of separation, divorce, and multiple marriages. ADHD is a risk factor for suicidal thoughts, substance abuse, depression, alcoholism. ADHD symptoms and impairments fuel and exacerbate various other psychiatric conditions.
Treatment of ADHD: Needs to be individualized and constantly reevaluated.
ADHD is a chronic condition that can seriously disrupt the functioning of an individual throughout his or her lifetime. Left unmanaged, it is likely to give rise to ever-increasing complications as a child matures. It is a complicated mixture of symptoms (inattention, distractability, impulsivity, hyperactivity) that lead to impairments (difficulties learning, misinterpreting social cues, forgetting chores, etc) which result in outcomes (poor self-esteem, alienation of peers, disrupted family relationships, etc ).
Treatment should result in decreased impairments and improved functional outcomes.
The presence of co-existing disorders, protective factors and risk factors, also affect how ADHD appears in different children, and how they respond to treatment.
Treatment does not control a child’s behavior; it assists the child to control his/her own behavior.
Natural Remedies: No treatment plan should be started without also recognizing the importance of:
- Good nutrition
- Plenty of exercise - an active lifestyle
- Structured home and school schedules
- Consistent parenting
- Proper diagnosis and treatment of co-existing medical, environmental, or psychological conditions.
The Multimodal Treatment Study of Children with ADHD, an extremely large clinical trial, showed that using both medication and behavior modification gave the best outcomes . Second was medication alone, and third was behavior modification alone. Arch Gen Psychiatry 1999; 56:1073.
Behavior Modification:
- Important to be used for both academic performance as well as to improve a child’s interaction with peers and in the family.
- Best when used by both parents and teachers.
- Should be provided consistently.
- It is effective when used. It lessens the impairments that result from ADHD symptoms. It is for behavior management (it doesn’t “train” or “fix” the child within a few weeks). As the ADHD child matures, s/he will slowly incorporate this training into his/her own ability to regulate his/her own ADHD symptoms.
Techniques include:
Positive reinforcement in the form of rewards or privileges given for desired behaviors.
Negative reinforcement - Time outs (about 1 minute for each year of age) for undesirable behaviors. - Withdrawing rewards and privileges for unwanted or problem behavior.
When young, these can be combined in a “ token economy” where child earns or loses stickers, depending on behavior. After so many stickers over a certain amount of time, a prize is awarded. In school, teachers can give periodic report cards (daily is best). Parents can add these to the “token economy” at home.
Environmental changes such as increasing structure in child’s home and school activities, providing more supervision, limiting distractions where possible.
Ideally, parents and teachers should participate in training sessions with a therapist, meeting weekly for 8-12 weeks, and then keep in contact with the therapist as needed for help with special problems or as child goes through developmental transitions. These may be needed for 2-3 years.
Where such support is not available, parents and teachers must self-educate through books, videos, and joining organizations such as CHADD (Children and Adults with Attention Deficit Disorder) or 1-800-233-4050.
Counseling: Most ADHD patients and their families can benefit from counseling.
Behavior modification is difficult to learn and implement. A therapist can greatly help families with this.
Family problems: An ADHD child causes a lot of additional stress in a family and the resultant problems may be overwhelming and difficult to solve without the help of a counselor.
Impairments of ADHD: An ADHD child may need help from a counselor in understanding his/her own ADHD, and in dealing with low self esteem, depression, and control of anger and other oppositional behaviors.
Co-existing disorders: May be very difficult to manage without the help of a counselor.
Medication:
Stimulants: (FDA approved for ADHD):
- Methylphenidate (Ritalin, Metadate, Concerta, Focalin)
- Amphetamines (Adderall, Dexedrine, DextroStat)
Non Stimulants:
- Atomoxetine (Strattera) - the only non-stimulant with FDA approval for ADHD
- Antihypertensives: Clonidine (Catapres) and Guanfacine (Tenex)
- Antidepressants: Bupropion (Wellbutrin), Venlafaxine (Effexor), Tricyclics (Imipramine)
Stimulants have been used for ADHD since 1937 (amphetamines) and 1957 (methylphenidate).
- They stimulate that part of the brain that increases attention, filters out distractions, and controls impulses. They have been proven effective in helping children with academic productivity and accuracy, social interactions, impulsive aggression, and with compliance to therapy.
- They are not addicting. In fact, studies show that use of stimulants for ADHD is protective against substance abuse. Stimulants can be abused. They do stimulate the euphoric centers of the brain and, when taken in larger doses, they can give a “high”. This is why they are a controlled substance.
- They do not change the child’s personality. Parents are used to their ADHD child as “bouncy, flighty, distracted, argumentative, careless,” etc. Often, the only time they see their child calm is when s/he is sick. On medication, their child is calmer and able to focus, and often initially may be perceived as “zoned, spacey, or sedated.”
- They do not sedate. However, some children do seem robotic, over-focused, or compulsive on medication. This is a side-effect that is unacceptable.
- They do have side effects. Most common are: decreased appetite, weight loss, rebound insomnia, sleep difficulties, irritability. Less common are moodiness, anger, aggression, an increase in anxiety symptoms, over-focused or “zombied”, headaches, tummy aches, and dizziness. Stimulants do cause a small increase in blood pressure and a slight increase in sensitivity to heat.
- There is no evidence of cardiac problems in physically health children. It is important to know of any family or personal history of heart disease.
- They do not exacerbate tics.
- Growth deceleration can occur in the first year of treatment, but over time growth does catch back up to the same percentile.
70% of patients will respond to treatment with any one stimulant. If the first class of stimulant does not work, 66% of children will respond to the second. Research has shown that Methylphenidate works on the dopamine pathway, while Amphetamines work on both the dopamine and norepinephrine pathways.
Limitations:
- May require multiple dosing during the day because the effect lasts for only 4-10 hours. There are short-, intermediate- and long-acting forms available.
- No benefit from medication in the morning before the dose is absorbed and in the late afternoon and evening when the dose wears off.
- Some patients rebound as the medicine wears off, making them extra hyper and/or irritable, and/or have rebound insomnia (more trouble falling asleep).
- They are controlled substances which makes prescribing tedious, and gives them a stigma that may not be deserved, but does create concern.
Advantages: Can start and stop without problem. Stimulants act when they are taken and wear off in 4-10 hours. It’s easy to “take a break” on weekends, vacations, summer, etc. Stimulants are Ideal for some ADHD, predominantly inattentive patients who use medication mainly for focus at school.
Non stimulants
Atomoxetine (Strattera )
- Newest medication - received FDA approval in late 2002.
- Inhibits the re-uptake of norepinephrine; so rather than adding an artificial compound, it increases the child’s natural norepinephrine and its effects in regulating attention and controlling impulses.
Side effects: Most patients experience side effects in the first 1-2 weeks and then they lessen or disappear:
- Most commonly reported side effect is drowsiness.
- Also: Abdominal discomfort, emotional lability or moodiness, decrease in appetite.
- Diastolic blood pressure and heart rate increase slightly in some children, but not in a significant manner.
Advantages:
- Does not cause euphoria (cannot give a “high”), so it is not a controlled substance. Prescribing is easier and less stigma is attached.
- Does not increase anxiety or tics.
- Most ADHD patients have disrupted sleep patterns. Strattera, taken with dinner, helps regulate these disrupted ADHD sleep patterns, thus giving them a better night’s rest.
- 24 hour coverage with once a day dosing, so better than stimulants for social and home interactions.
Disadvantages:
- Must be taken daily to maintain a constant blood level.
- Benefits may not be seen for 1-5 weeks.
- Works best for the impulsive/hyperactive symptoms and less on the attention/distractability symptoms .
Anti-hypertensives:
Clonidine (Catapres) and Guanfacine (Tenex)
- Work on the norepinephrine pathway.
Side effects: Drowsiness. (Tenex rarely causes drowsiness while Clonidine usually does.) Also seen are dry mouth, fatigue, insomnia, and, rarely, depression
Tenex is used for impulsive/hyperactive symptoms: especially helpful for ADHD children who are more moody, emotional, angry or aggressive.
Clonidine is used to help regulate the disrupted sleep patterns of ADHD patients. It also is used to help offset the rebound insomnia caused by taking a stimulant in the morning.
Anti-depressants:
Trycyclics (Imipramine) - rarely used anymore because of limited effectiveness and significant side effects.
Bupropion (Wellbutrin) and Venlafaxine (Effexor)
- Both seem to help with the oppositional and aggressive behaviors of some ADHD patients, especially in adolescence. (coexisting condition called ODD – oppositional defiant disorder)
- Both are well tolerated and have minimal side effects.
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