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Attention-deficit/hyperactivity disorder (ADHD) is a chronic condition that affects millions of children and often continues into adulthood. ADHD includes a combination of persistent problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior.
Children with ADHD may also struggle with low self-esteem, troubled relationships and poor performance in school. Symptoms sometimes lessen with age. However, some people never completely outgrow their ADHD symptoms. But they can learn strategies to be successful.
While treatment won't cure ADHD, it can help a great deal with symptoms. Treatment typically involves medications and behavioral interventions. Early diagnosis and treatment can make a big difference in outcome.
Symptoms
The primary features of ADHD include inattention and hyperactive-impulsive behavior. ADHD symptoms start before age 12, and in some children, they're noticeable as early as 3 years of age. ADHD symptoms can be mild, moderate or severe, and they may continue into adulthood.
ADHD occurs more often in males than in females, and behaviors can be different in boys and girls. For example, boys may be more hyperactive and girls may tend to be quietly inattentive.
There are three subtypes of ADHD:
- Predominantly inattentive. The majority of symptoms fall under inattention.
- Predominantly hyperactive/impulsive. The majority of symptoms are hyperactive and impulsive.
- Combined. This is a mix of inattentive symptoms and hyperactive/impulsive symptoms.
Inattention
A child who shows a pattern of inattention may often:
- • Fail to pay close attention to details or make careless mistakes in schoolwork
- • Have trouble staying focused in tasks or play
- • Appear not to listen, even when spoken to directly
- • Have difficulty following through on instructions and fail to finish schoolwork or chores
- • Have trouble organizing tasks and activities
- • Avoid or dislike tasks that require focused mental effort, such as homework
- • Lose items needed for tasks or activities, for example, toys, school assignments, pencils
- • Be easily distracted
- • Forget to do some daily activities, such as forgetting to do chores
Hyperactivity and impulsivity
A child who shows a pattern of hyperactive and impulsive symptoms may often:
- • Fidget with or tap his or her hands or feet, or squirm in the seat
- • Have difficulty staying seated in the classroom or in other situations
- • Be on the go, in constant motion
- • Run around or climb in situations when it's not appropriate
- • Have trouble playing or doing an activity quietly
- • Talk too much
- • Blurt out answers, interrupting the questioner
- • Have difficulty waiting for his or her turn
- • Interrupt or intrude on others' conversations, games or activities
Typical developmental behavior vs. ADHD
Most healthy children are inattentive, hyperactive or impulsive at one time or another. It's typical for preschoolers to have short attention spans and be unable to stick with one activity for long. Even in older children and teenagers, attention span often depends on the level of interest.
The same is true of hyperactivity. Young children are naturally energetic — they often are still full of energy long after they've worn their parents out. In addition, some children just naturally have a higher activity level than others do. Children should never be classified as having ADHD just because they're different from their friends or siblings.
Children who have problems in school but get along well at home or with friends are likely struggling with something other than ADHD. The same is true of children who are hyperactive or inattentive at home, but whose schoolwork and friendships remain unaffected.
When to see a doctor
If you're concerned that your child shows signs of ADHD, see your pediatrician or family doctor. Your doctor may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist, but it's important to have a medical evaluation first to check for other possible causes of your child's difficulties.
Causes
While the exact cause of ADHD is not clear, research efforts continue. Factors that may be involved in the development of ADHD include genetics, the environment or problems with the central nervous system at key moments in development.
Risk factors
Risk factors for ADHD may include:
- • Blood relatives, such as a parent or sibling, with ADHD or another mental health disorder
- • Exposure to environmental toxins — such as lead, found mainly in paint and pipes in older buildings
- • Maternal drug use, alcohol use or smoking during pregnancy
- • Premature birth
Although sugar is a popular suspect in causing hyperactivity, there's no reliable proof of this. Many issues in childhood can lead to difficulty sustaining attention, but that's not the same as ADHD.
Complications
ADHD can make life difficult for children. Children with ADHD:
- • Often struggle in the classroom, which can lead to academic failure and judgment by other children and adults
- • Tend to have more accidents and injuries of all kinds than do children who don't have ADHD
- • Tend to have poor self-esteem
- • Are more likely to have trouble interacting with and being accepted by peers and adults
- • Are at increased risk of alcohol and drug abuse and other delinquent behavior
Coexisting conditions
ADHD doesn't cause other psychological or developmental problems. However, children with ADHD are more likely than others to also have conditions such as:
- Oppositional defiant disorder (ODD), generally defined as a pattern of negative, defiant and hostile behavior toward authority figures
- Conduct disorder, marked by antisocial behavior such as stealing, fighting, destroying property, and harming people or animals
- Disruptive mood dysregulation disorder, characterized by irritability and problems tolerating frustration
- Learning disabilities, including problems with reading, writing, understanding and communicating
- Substance use disorders, including drugs, alcohol and smoking
- Anxiety disorders, which may cause overwhelming worry and nervousness, and include obsessive compulsive disorder (OCD)
- Mood disorders, including depression and bipolar disorder, which includes depression as well as manic behavior
- Autism spectrum disorder, a condition related to brain development that impacts how a person perceives and socializes with others
- Tic disorder or Tourette syndrome, disorders that involve repetitive movements or unwanted sounds (tics) that can't be easily controlled
Prevention
To help reduce your child's risk of ADHD:
- During pregnancy, avoid anything that could harm fetal development. For example, don't drink alcohol, use recreational drugs or smoke cigarettes.
- Protect your child from exposure to pollutants and toxins, including cigarette smoke and lead paint.
- Limit screen time. Although still unproved, it may be prudent for children to avoid excessive exposure to TV and video games in the first five years of life.
Diagnosis
In general, a child shouldn't receive a diagnosis of attention-deficit/hyperactivity disorder unless the core symptoms of ADHD start early in life — before age 12 — and create significant problems at home and at school on an ongoing basis.
There's no specific test for ADHD, but making a diagnosis will likely include:
- Medical exam, to help rule out other possible causes of symptoms
- Information gathering, such as any current medical issues, personal and family medical history, and school records
- Interviews or questionnaires for family members, your child's teachers or other people who know your child well, such as caregivers, babysitters and coaches
- ADHD criteria from the Diagnostic and Statistical Manual of Mental Disorders DSM-5, published by the American Psychiatric Association
- ADHD rating scales to help collect and evaluate information about your child
Diagnosing ADHD in young children
Although signs of ADHD can sometimes appear in preschoolers or even younger children, diagnosing the disorder in very young children is difficult. That's because developmental problems such as language delays can be mistaken for ADHD.
So children preschool age or younger suspected of having ADHD are more likely to need evaluation by a specialist, such as a psychologist or psychiatrist, speech pathologist, or developmental pediatrician.
Other conditions that resemble ADHD
A number of medical conditions or their treatments may cause signs and symptoms similar to those of ADHD. Examples include:
- • Learning or language problems
- • Mood disorders such as depression or anxiety
- • Seizure disorders
- • Vision or hearing problems
- • Autism spectrum disorder
- • Medical problems or medications that affect thinking or behavior
- • Sleep disorders
- • Brain injury
Treatment
Standard treatments for ADHD in children include medications, behavior therapy, counseling and education services. These treatments can relieve many of the symptoms of ADHD, but they don't cure it. It may take some time to determine what works best for your child.
Stimulant medications
Currently, stimulant drugs (psychostimulants) are the most commonly prescribed medications for ADHD. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters. These medications help improve the signs and symptoms of inattention and hyperactivity — sometimes effectively in a short period of time.
Examples include:
- Amphetamines. These include dextroamphetamine (Dexedrine), dextroamphetamine-amphetamine (Adderall XR, Mydayis) and lisdexamfetamine (Vyvanse).
- Methylphenidates. These include methylphenidate (Concerta, Ritalin, others) and dexmethylphenidate (Focalin).
Stimulant drugs are available in short-acting and long-acting forms. A long-acting patch of methylphenidate (Daytrana) is available that can be worn on the hip.
The right dose varies from child to child, so it may take some time to find the correct dose. And the dose may need to be adjusted if significant side effects occur or as your child matures. Ask your doctor about possible side effects of stimulants.
Stimulant medications and certain health risks
Some research indicates that using ADHD stimulant medications with certain heart problems may be a concern, and the risk of certain psychiatric symptoms may be increased when using stimulant medications.
- Heart problems. Stimulant medication may cause an increased blood pressure or heart rate, but the increased risk of serious adverse effects or sudden death is still unproved. However, the doctor should evaluate your child for any heart condition or family history of heart disease before prescribing a stimulant medication and monitor your child during stimulant use.
- Psychiatric problems. Stimulant medications may rarely increase the risk for agitation or psychotic or manic symptoms with stimulant medications use. Contact the doctor immediately if your child has sudden new or worsening behavior or sees or hears things that aren't real while taking stimulant medication.
Other medications
Other medications that may be effective in treating ADHD include:
- • Atomoxetine (Strattera)
- • Antidepressants such as bupropion (Wellbutrin SR, Wellbutrin XL, others)
- • Guanfacine (Intuniv)
- • Clonidine (Catapres, Kapvay)
Atomoxetine and antidepressants work slower than stimulants do and may take several weeks before they take full effect. These may be good options if your child can't take stimulants because of health problems or if stimulants cause severe side effects.
Suicide risk
Although it remains unproved, concerns have been raised that there may be a slightly increased risk of suicidal thinking in children and teenagers taking nonstimulant ADHD medication or antidepressants. Contact your child's doctor if you notice any signs of suicidal thinking or other signs of depression.
Giving medications safely
It's very important to make sure your child takes the right amount of the prescribed medication. Parents may be concerned about stimulants and the risk of abuse and addiction. Stimulant medications are considered safe when your child takes the medication as prescribed by the doctor. Your child should see the doctor regularly to determine if the medication needs to be adjusted.
On the other hand, there's concern that other people might misuse or abuse stimulant medication prescribed for children and teenagers with ADHD. To keep your child's medications safe and to make sure your child is getting the right dose at the right time:
- Give medications carefully. Children and teens shouldn't be in charge of their own ADHD medication without proper supervision.
- At home, keep medication locked in a childproof container. And store medication away from the reach of children. An overdose of stimulant drugs is serious and potentially fatal.
- Don't send supplies of medication to school with your child. Deliver any medication yourself to the school nurse or health office.
ADHD behavior therapy
Children with ADHD often benefit from behavior therapy, social skills training, parent skills training and counseling, which may be provided by a psychiatrist, psychologist, social worker or other mental health professional. Some children with ADHD may also have other conditions such as an anxiety disorder or depression. In these cases, counseling may help both ADHD and the coexisting problem.
Examples of therapy include:
- Behavior therapy. Teachers and parents can learn behavior-changing strategies, such as token reward systems and timeouts, for dealing with difficult situations.
- Social skills training. This can help children learn appropriate social behaviors.
- Parenting skills training. This can help parents develop ways to understand and guide their child's behavior.
- Psychotherapy. This allows older children with ADHD to talk about issues that bother them, explore negative behavior patterns and learn ways to deal with their symptoms.
- Family therapy. Family therapy can help parents and siblings deal with the stress of living with someone who has ADHD.
The best results occur when a team approach is used, with teachers, parents, therapists and physicians working together. Educate yourself about ADHD and available services. Work with your child's teachers and refer them to reliable sources of information to support their efforts in the classroom.