Attention deficit hyperactivity disorder (ADHD)

What is ADHD?

Attention deficit hyperactivity disorder (ADHD), usually first diagnosed in childhood, can appear in a variety of forms and has many possible causes. People with ADHD probably have an underlying genetic vulnerability to developing it, but the severity of the problem is also influenced by the environment. Conflict and stress tend to make it worse.

The main features of this disorder are found in its name. Attention problems include daydreaming, difficulty focusing, and being easily distracted. Hyperactivity refers to fidgeting or restlessness. A person with the disorder may be disruptive or impulsive, may have trouble in relationships, and may be accident-prone. Hyperactivity and impulsiveness often improve as a person matures, but attention problems tend to last into adulthood.

ADHD is the most common problem seen in outpatient child and adolescent mental health settings. It is estimated that ADHD affects more than 5% of children. Boys are diagnosed with ADHD about twice as much as girls.

ADHD can continue into adulthood. The activity component is less apparent in adults, who tend to have problems with memory and concentration. They may have trouble staying organized and meeting commitments at work or at home. The consequence of poor functioning may be anxiety, low self-esteem, or mood problems. Some people turn to substances to manage these feelings.

Symptoms of ADHD

The symptoms of ADHD — inattention, hyperactivity, or impulsive behavior — often show up first at school. A teacher may report to parents that their child won't listen, is "hyper," or causes trouble and is disruptive. A child with ADHD often wants to be a good student, but the symptoms get in the way. Teachers, parents, and friends may be unsympathetic because they see the child's behavior as bad or odd.

A high level of activity and occasional impulsiveness or inattentiveness is often normal in a child. But the hyperactivity of ADHD is typically more haphazard, poorly organized, and has no real purpose. And in children with ADHD, these behaviors are frequent enough that the child has a harder-than-average time learning, getting along with others, or staying reasonably safe.

ADHD symptoms can vary widely. Here are common characteristics of the disorder in the two major groups (inattention and hyperactivity).

Inattention

• carelessness
• difficulty paying attention over time
• not appearing to be listening
• failing to follow through with teachers' or parents' requests
• trouble organizing work, often giving the impression of not having heard the teacher's instructions
• avoiding tasks that require sustained attention
• losing materials necessary to complete tasks
• becoming easily distracted
• forgetfulness in day-to-day activities.

Hyperactivity

• excessive restlessness or fidgety behavior
• inability to stay seated
• running or climbing that is inappropriate
• inability to sustain quiet leisure activities
• driven behavior, as if "on the go" all the time
• excessive talking
• impulsive behavior (acts without thinking)
• frequently calling out in class (without raising hand, yelling out answer before question is finished)
• difficulty waiting for his or her turn in group settings
• frequent intrusive behavior or interrupting of others.

Many children with ADHD also show symptoms of other behavioral or psychiatric conditions. In fact, such problems may be different ways that the same underlying biological or environmental problems come to light. These associated conditions include learning disabilities and disorders characterized by disruptive behavior.

• Learning disabilities — Up to a quarter of children with ADHD may also have learning disabilities. This rate is much greater than the rate found in the general population.
• Oppositional, defiant, or conduct disorders — These behavior disorders, which involve frequent outbursts of extremely negative, angry, or mean behavior, affect as many as half of all children who have ADHD. Children who have both ADHD and behavioral disturbances are more likely to have a poor long-term outcome, with higher rates of school failure, antisocial behaviors, and substance abuse.

Diagnosing ADHD

There is no single test to diagnose ADHD. For a child, a pediatrician may make the diagnosis or may make a referral to a specialist. Parents and teachers may be alert to the problem and may have the child evaluated. For adults, a mental health professional generally performs the evaluation.

The clinician will ask about symptoms related to ADHD. Since, in children, many of these characteristics are seen in a school setting, the clinician will also ask about behavior in school. To help collect this information, the evaluator will often interview parents, teachers, and other caregivers or ask them to fill out special behavioral checklists.

Since other conditions may cause the symptoms of ADHD, the medical history and physical examination are important. For example, the doctor may look for trouble with hearing or vision, learning disabilities, speech problems, seizure disorders, anxiety, depression, or other behavior problems. In some cases, other medical or psychological testing may be useful to check for one or more of these conditions. These tests can sometimes help clinicians and teachers develop practical suggestions.

Expected duration of ADHD

In most children with ADHD, symptoms begin before age 12 and last through adolescence. Symptoms of ADHD may continue into adulthood.

Risk factors and prevention

The causes of ADHD are not fully understood. There are numerous factors that are associated with the development of ADHD. It may be difficult to avoid these factors, but addressing them may reduce the risk of developing the disorder.

Common risk factors

• temperament — novelty seeking, negative emotion, difficulty controlling impulses
• psychosocial adversity — child abuse or neglect, severe marital conflict, father's criminal behavior, mother's mental disorder, poverty, the child's foster care placement
• complications during pregnancy or delivery — poor maternal health, fetal distress, low birthweight
• premature birth
• mother's use of tobacco, alcohol, or other drugs during pregnancy
• exposure to neurotoxins, such as lead
• a history of ADHD in close relatives.

Treating ADHD

Although no treatment eliminates ADHD completely, many helpful options are available. The goal of treatment is to help children improve social relationships, do better in school, and keep their disruptive or harmful behaviors to a minimum. Medication can be very helpful, and it is often necessary.

Drug treatment by itself is rarely the answer. Medication and psychotherapy together usually have the best results. For example, a behavioral program may be put in place where structured, realistic expectations are set.

Stimulants, such as methylphenidate (Ritalin, Concerta) and forms of amphetamine (Adderall, Dexedrine) have been used for many decades. They are relatively safe and effective for most children to help them focus their thoughts and control their behavior. Long-acting forms of stimulants are usually preferred for children, because one dose in the morning can provide a daylong effect.

Despite their name, stimulants do not cause increased hyperactivity or impulsivity. If the disorder has been properly diagnosed, the medication should have the opposite effect. Common mild side effects are decreased appetite, weight loss, stomachaches, sleep problems, headaches, and jitteriness. Adjusting the dose can often help eliminate these problems. Stimulant drugs are associated with some serious concerns and side effects, including:

• Tics. There is some evidence that tics (uncontrolled movements) are more likely in patients with a family history of tic disorders, but that is still controversial.
• Substance abuse. Stimulant drugs can be and are abused. Research has also shown that stimulant treatment may reduce the risk of substance abuse for some people with ADHD. There is not enough evidence to say that stimulants either increase or decrease the risk of later substance abuse.
• Growth delays. Experts disagree about the effects of stimulants on growth. There is some evidence that children taking stimulants grow at a rate that is less than expected. Some doctors recommend stopping stimulants periodically during periods of expected growth.
• Cardiovascular risk. Children taking stimulants do show small increases in blood pressure and heart rate. But major heart complications in children, teens, and adults taking these drugs are extremely rare. If your child does not have underlying heart disease, your doctor may not recommend getting an electrocardiogram before starting a stimulant.

Since such risks vary widely depending on the individual, it is important to discuss the potential benefits and risks of each treatment with your doctor.

Another potential problem, which strictly speaking is not a side effect, is that stimulants can find their way to people other than the person being treated for ADHD. Called diversion, it is fairly common among adolescents and young adults. The drugs are most often taken to improve academic performance. Some individuals do take stimulants to get high.

Other nonstimulant medications are also available to treat ADHD. These are especially useful when there is reluctance to start a stimulant. Atomoxetine (Strattera) or viloxazine (Qelbree) can be effective for treating ADHD. They work by a different chemical mechanism than stimulants. The antidepressant bupropion (Wellbutrin) is helpful in some cases. Two other medicines — guanfacine and clonidine — also have shown some benefit for ADHD symptoms, but they have weaker effects than stimulants.

Other treatment approaches, used alone or in combination, may include:

• Behavioral therapy — This refers to techniques that try to improve behavior, usually by rewarding and encouraging desirable behaviors and by discouraging unwanted behaviors and pointing out the consequences.
• Cognitive therapy — This is psychotherapy designed to change thinking to build self-esteem, stop having negative thoughts, and improve problem-solving skills.
• Social skill training — Developing social skills improves friendships.
• Parent education and support — Training classes, support groups, and counselors can help to teach and support parents about ADHD, including strategies for dealing with ADHD-related behaviors.

Because many children with ADHD also are troubled by poor grades and school behavior problems, schools may need to provide educational adjustments and interventions (such as an individualized educational plan) to promote the best possible learning environment for the child.

When to call a professional

Call your doctor if your child shows symptoms of ADHD, or if teachers notify you that your child is having academic difficulties, behavioral problems, or difficulty paying attention.

Prognosis

ADHD can cause significant emotional, social, and educational problems. However, when ADHD is diagnosed early and treated properly, the condition can be managed effectively, so children can grow up to have productive, successful, and fulfilling lives. Although some children appear to grow out of their ADHD as they reach their adolescent years, others have lifelong symptoms.

Additional info

American Academy of Child and Adolescent Psychiatry (AACAP)
https://www.aacap.org/