What is Attention-Deficit Hyperactivity Disorder?
What Other Disorders Have the Same Symptoms as Attention-Deficit Hyperactivity Disorder?
Who Has Attention-Deficit Hyperactivity Disorder?
How Serious Is Attention-Deficit Hyperactivity Disorder?
What Causes Attention-Deficit Hyperactivity Disorder?
How Is Attention-Deficit Hyperactivity Disorder Diagnosed?
What Are the General Guidelines for Treating Attention Deficit Hyperactivity Disorder?
What Are the Medications for Attention-Deficit Hyperactivity Disorder?
How Is Attention-Deficit Hyperactivity Disorder Behavior Managed?
Where Else Can Help Be Obtained for Attention-Deficit Hyperactivity Disorder?
Recent Literature
The National Institute of Mental Health has recently agreed that attention-deficit hyperactivity disorder (ADHD) is indeed a legitimate psychologic condition but its definition has not been fully pinned down. ADHD is a syndrome generally characterized by inattention, distractibility, impulsivity, and hyperactivity [see Table, below]. It is further categorized into three subtypes: behavior marked by hyperactivity and impulsivity but not inattentiveness; behavior that is marked by the reverse characteristics; and a mixed type. Some experts are concerned that these refinements may increase the diagnosis in children who may simply be aggressive. No laboratory or imaging tests have yet detected specific abnormalities that might make a diagnosis of ADHD clearer. In addition, although, according to the criteria, ADHD is not diagnosed in people whose symptoms appear after age seven, some studies show that the disorder, particularly the subtype marked by inattentiveness, can first show up in older children and adolescents. Defining ADHD is made more difficult because it is often accompanied by learning disabilities and other neurologic or emotional problems. It is likely that, eventually, the term attention deficit hyperactivity disorder will give way to subgroups of problems that include some of these general symptoms.General Description of a Child with ADHD.
Studies now indicate that ADHD can be diagnosed in children by age four. Parents may notice symptoms even earlier. (One mother reported that three days after delivery, nurses were referring to her ADHD son as "Wild Willie".) Even before the "terrible two's", impulsive behavior is often apparent; the toddler may gleefully exhibit erratic and aggressive gestureshair pulling, pinching, hitting. Temper tantrums, normal in children after two, are usually exaggerated and not necessarily linked to a specific negative event in the life of an ADHD child. One of the most painful events a parent may experience is an abrupt and aggressive attack that may occur after cuddling a young ADHD child. Often this reaction seems to be caused not by anger, but by the child's apparent inability to endure overstimulationeven displays of physical affection. In a busy environment, such as a class room or a crowded store, ADHD children often become distracted and react by pulling items off the shelves, hitting people, or spinning out of control into erratic, silly, or strange behavior. As ADHD children grow and develop, parents discover that these children have a very difficult time adapting to even minor changes in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to bed. Any shift in a situation can precipitate a strong and noisy negative response. ADHD children are often hypersensitive to sights, sounds, and touch and complain excessively about stimuli that seem low key or bland to others. Sleeping problems usually occur well after the point at which most small children sleep through the night. In one study, 63% of children with ADHD had trouble sleeping.
The classic ADHD symptomsinattention, distractibility, impulsivity, and hyperactivityoften do not adequately describe the child's behavior. The term hyperactive, for example, is often confusing for those who expect to observe a child racing unceasingly about. A boy with ADHD playing a game, for instance, may have the same level of activity as the other children without the syndrome. If a high demand is placed on the ADHD child's attention, however, then his motor activity intensifies beyond the levels of the other children, and he becomes suddenly impulsive, perhaps hitting another child or behaving in a giddy silly manner. The symptom of inattention may also be misleading. Because ADHD children are usually distracted by over-stimulating situations, some learn to compensate by developing a kind of "super concentration". Such children become over-attentive, so absorbed in a project that they cannot modify or change the direction of their attention. Many experts now believe that an essential feature in ADHD, as well as in learning disabilities, is impaired working, or short-term, memory. People with ADHD are unable to "hold" groups of sentences and images in their mind until they can extract organized thoughts from them. Such people then may not necessarily be inattentive so much as be unable to remember a full explanation (such as a homework assignment) or are unable to complete processes that require remembering sequences, such as model building. In general, children with ADHD are often attracted to activities that do not tax this working memory or produce distractionstelevision, computer games, or active individual sports.
The ADHD child's relationship with others is volatile, and he or she is often unhappy from a very young age. A best friend can turn into an enemy overnight when, for example, an ADHD boy does not perceive his friend's fearful response to over-aggressive roughhousing and fails to let up. The next day the ADHD child has forgotten the event; the ex-friend hasn't. This is a classic situation repeated time and again. The ADHD child hurts someone; he either may go into a state of denial because he can't accept his lack of self-control or he may blame himself excessively. As ostracism, fear, and ridicule from his peers persist from year to year, the unstable behavior, originally neurologic, becomes emotionally based as well. Unless this cycle is broken, serious adult disorders can evolve.
Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder
A. Either 1 or 2:
1. Should have 6 or more of the following symptoms of inattention, persisting for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.
2. Should have 6 or more of the following symptoms of hyperactivity-impulsivity
persisting for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level.
C. Symptoms occur in two or more settings (for example home and school).
D. Clear evidence of significant impairment in social or academic functioning.E. Not caused by a pervasive development disorder or another other psychologic disorder, including anxiety or depression.
In addition, there are three subtypes: (1) Predominantly inattentive type (A1 is met but not A2 for the past six months); (2) Predominantly hyperactive-impulsive type (A2 is met but not A1 for the past six months); (3) Combined type (both A1 and A2 are met for past 6 months).Diagnostic and Statistical Manual of Mental Disorders: 4th Rev., Washington, DC., American Psychiatric Association
A number of disorders may mimic or accompany attention deficit disorder. ADHD exists alone in only about one-third of children. Many professionals object to the use of the single term, attention deficit disorder, to encompass such a wide spectrum of behaviors, which, they believe, should be categorized into subgroups. Many of these problems require other modes of treatment and should be diagnosed separately, even if they accompany ADHD.Attention-Deficit Disorder Without Hyperactivity.
Attention deficit disorder can appear without hyperactivity, in which case the child's primary symptoms are distractibility and an inability to persist in tasks.Oppositional Defiant Disorder.
About half the children diagnosed with ADHD also have oppositional defiant disorder (ODD). The most common symptom for this disorder is the child's refusal to follow any or all instructions or directives. In addition to displaying inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper tantrums, and display antisocial behavior. Up to 25% of children with ODD have phobias and other anxiety disorders, which should be treated separately.Pervasive Developmental Disorder.
Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behaviorhand-flapping, repetitive statements, slow social development, and speech and motor problems. If a child who has been diagnosed with ADHD does not respond to treatment, the parents might inquire about PDD, which often responds to antidepressants.Primary Disorder of Vigilance.
Primary disorder of vigilance is a term for a syndrome that includes poor attention and concentration as well as difficulties staying awake. People with vigilance disorder tend to fidget, yawn and stretch, and appear to be hyperactive in order to remain alert; they typically have kind and affectionate temperaments. The condition is inherited and gets worse with age, but is treatable with stimulants.Bipolar Disorder (Manic Depression)
A recent study found that as many as 25% of children diagnosed with attention deficit disorder may also have bipolar disorder, commonly called manic depression. Indications of this problem include episodes of depression and mania (with symptoms of irritability, rapid speech, and disconnected thoughts), sometimes occurring at the same time [see Well-Connected Report #66 Bipolar Disorder]Other Diagnoses.
Lead. Children who ingest even low amounts of lead exhibit many symptoms similar to ADHD; they are easily distractible, disorganized, and have trouble thinking logically. The major cause of lead toxicity is exposure to leaded paint, particularly in homes that are old and in poor repair.
Genetic Abnormalities. A number of genetic disorders cause symptoms resembling ADHD, including fragile X and Tourette's syndrome. About 50% of those with Tourette's syndrome also have ADHD and some of the treatments are similar.
Medical Conditions. A number of medical problems can produce ADHD-like symptoms, including hyperthyroidism and hearing or vision problems.
Posttraumatic Stress Disorder. Young children who have experienced traumatic events, including sexual or physical abuse or neglect, exhibit characteristics of ADHD, including impulsivity, emotional outbursts, and oppositional behavior.
ADHD in Children.
Estimates of the incidence of ADHD in American children typically range from 3% to 5%; other countries, using similar diagnostic criteria, report comparable percentages. Many experts believe that the disorder is both over- and underdiagnosed, depending on different factors. Ritalin's popularity has encouraged some parents and teachers to pressure physicians into prescribing this standard ADHD drug for childrenusually boyswho are simply difficult to control or who have poor grades. One study suggested that in children who are highly active or slow learners physicians may tend to diagnosis ADHD first rather than examine the child for other possible diagnosesincluding no abnormality at all. In one center, after careful testing, ADHD was the actual diagnosis in only 11% of children referred for ADHD and 18% had no disability. On the other hand, some experts believe the disorder is underdiagnosed and that its prevalence is as high as 10%. Girls with ADHD, for example may be more likely to have the inattentive subtype and so be overlooked by adults. A recent small study reported that the condition may be less severe and more treatable in African American children with the disorder than in Caucasian children. In spite of this, African-American children with ADHD are half as likely to receive medications for the problem as Caucasian children. And although ADHD has been carefully researched and is well-validated, some physicians still do not believe it is an actual disorder and may not diagnose it in any child,ADHD in Adults.
Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit disorder in adults are definitely on the rise. It was estimated that Ritalin would be prescribed in nearly 800,000 adults in the U.S. in 1997, nearly three times the number in 1992. One study found, however, that only 32% of adults who believed they had ADHD actually fulfilled diagnostic criteria for the disorder, and another 36% met some of the criteria but did not have a history of childhood ADHD. Good diagnostic tests, however, are not yet available to definitely diagnose adult ADHD. Symptoms in adults may differ from those in children, with severe attention problems being most prominent one in older people. In one study, only 2% of adults diagnosed with ADHD referred to themselves as hyperactive and impulsive.
Accompanying Problems.
More than half of children with attention deficit disorder also have accompanying disorders, including anxiety, depression, and conduct disorders. One study found that 25% of children with ADHD have or develop bipolar disorder (commonly called manic depression). Speech and learning disorders are also common in children with ADHD. About 20% have reading difficulties and 60% have serious handwriting problems [see also, What Other Disorders Have the Same Symptoms As Attention-Deficit Hyperactivity Disorder? in this report]. Adults with ADHD are also at very high risk for these conditions.Long Term Outlook.
Little is known about the long-term effects of ADHD, although studies are now underway to determine them. One study reported that only 4% of boys with ADHD still had the disorder when they grew up, although recent studies indicate that the symptoms of ADHD in adults may differ from those in children. In one analysis, investigators reported that almost all ADHD patients improve over time, with the rate of the disorder declining by 50% over every 5-year period. In other studies, half of ADHD children functioned normally when they grew upeven if symptoms remained. The other half had difficulties; a small percentage of these problems were severe. Attention-deficit disorder does not affect intelligence; people with the problem span the same IQ range as the general population. One study suggested, however, that 90% of ADHD children were underachievers and that half were held back at least once. ADHD has been associated with a higher risk for alcoholism, drug abuse, and criminal activity. Generally, ADHD children with conduct problems or accompanying emotional or mental disorders are at significantly higher risk for anti-social activities later on than those without early behavioral problems or accompanying problems.Lifelong psychologic or social damage may certainly stem from an on-going cycle of punishment and ostracism for behaviors that the child cannot control without help. It is be coming evident that an accurate early diagnosis, education, support, and medication, if necessary, can overcome many of the early problems in most people and help prevent long-term negative behavior.
Effect on Family.
The time and attention needed to deal with the ADHD child can change internal family relationships and have devastating effects on parents and siblings. Mothers generally get the brunt of the emotional and physical abuse that an ADHD child can cause, which is ironic because the child tends to love the mother intensely and feel safe with her. She must protect herself and her child by establishing tough but kind rules about where her space ends and the child's begins. She may have to give up on the idea of an immaculate house and a hot meal every night. (One advantage of an ADHD child in the family is that the parents learn that they are not perfect, nor do they have to be. In fact, striving for perfection is among the most counterproductive goals to pursue in raising an ADHDor anychild). The ADHD child is wonderful one day and terrible the next and can hurt the parent's feelings as drastically as an adult can. Parents must face the dislike and anger of other parents and see their own child rejected. It is very easy to fall into an emotional black hole, and feel alone, inadequate, and helpless. Marriages are often stressed to the breaking point. Siblings of ADHD children have particular difficulties, and studies are showing that they are also at risk for psychologic impairment, including depression, drug abuse, and language disorders. They are often victimized by an ADHD brother or sister who is intense, demanding, often bullying, and who may be receiving positive attention from the parent for behavior for which they would be punished or ignored. The non-ADHD sibling also does not have the control a parent does in the management of the ADHD child's behavior and is likely to feel alienated. A sibling who is not given attention in his or her own right may begin to imitate undesirable behaviors or act out negatively in other ways. It is very important to make the siblings equally vital to the family's functioning, although their value in the family should never be as fellow-caregivers of the ADHD sibling.
Physical Factors.
Advanced imaging techniques have detected differences in the brains of ADHD children compared to those of non-ADHD children. In some studies, brain scans reveal that the right side of the brain is smaller in ADHD children than in non-ADHD children (ordinarily they are the same size). The right side contains three important areas: the prefrontal cortex; the caudate nucleus; and globus pallidus. The prefrontal cortex, which is located in the front of the brain, is thought to be the brain's command center and regulates the ability to inhibit responses. The caudate nucleus and globus pallidus, located near the center of the brain, speed up or stop orders coming from the prefrontal cortex. Abnormalities in these areas may impair a person's ability to brake actions, resulting in the impulsivity typical of ADHD people. Also located here are important neurotransmitterschemicals messages in the brainincluding norepinephrine, dopamine, and serotonin, which affect mental and emotional functioning. Dopamine is under particularly scrutiny. One recent study, for example, reported that adults with ADHD had abnormally low levels of DOPA decarboxylase, the enzyme that produces dopamine.Problems Surrounding Pregnancy.
ADHD is often associated with problem pregnancies and with difficult deliveries. Maternal smoking during pregnancy is also associated with a higher risk for ADHD. One study indicated that an increased risk also existed in children of women who were exposed during pregnancy to environmental toxins, including dioxins and polychlorinated biphenyls (PCBs).Genetic Factors.
Evidence is increasing that genetic factors increase susceptibility. In a twin study, 90% of children with a full diagnosis of ADHD shared it with their twin. Most likely more than one gene is responsible for inherited cases; this is not surprising, since there is no consensus that ADHD is even a single disorder. Researchers are reporting underlying genetic mechanisms that regulate hyperactivity, particularly those that affect the neurotransmitter dopamine. Studies are finding that a variation of a dopamine D4 receptor gene is common in a high proportion of people with addictions and ADHD and appears to be associated with novelty seeking and extroversion.
About 50% of adults and 70% of children with a genetic resistance to thyroid hormone essential for normal brain development have ADHD. People who have this condition appear to have a more severe form of ADHD. The thyroid disorder is not a common cause of ADHD, however, and only those with a family history of thyroid disease are at risk.Diet.
A number of studies have suggested that sugar plays no role in hyperactivity. One study reported, in fact, that ADHD children had fewer problems after a high-carbohydrate breakfast than after a high-protein one. Another reported that children actually moved more slowly after a high-sugar meal, suggesting the carbohydrates may have a sedative effect. Studies on the effect of food and food-additive allergies are controversial. For example, one reported that 62% of ADHD children had symptoms provoked by various foods and additives. Another study indicated, however, that less than 5% of children with attention-deficit hyperactivity disorder are affected by food additives and even then, the effect is very slight. Among the additives and foods that parents report as culprits in inciting behavioral changes are any artificial flavors or coloring (particularly red), milk, chocolate, eggs, and wheat. Allergies themselves have recently been associated with a higher risk for behavioral problems; children who respond to allergen-restrictive diets, then, may not have had true ADHD in the first place.Infant Malnutrition.
Even if they receive enough food later on, children who suffer from malnutrition as infants may develop behavior problems, the most prevalent being attention deficit disorder.
Parents usually seek professional help after repeated problems with the child's classmates and teachers. A diagnosis of ADHD is often the first step in treatment; identifying the behavioral problems as a treatable medical problem can relieve much of the stress and guilt. Diagnosis of attention-deficit hyperactivity disorder is difficult. Some children can display marked inattention and impulsivity without hyperactivity. Other children are inappropriately inattentive but are not hyperactive or impulsive. Physicians can fail to diagnose children with attention-deficit hyperactivity disorder because they often behave normally in the quiet physician's office where there are no distractions to trigger symptoms. A study showed that a mother's description of her child's behavior was a very accurate and reliable guide for diagnosing ADHD. Parents should not be shy about insisting on further evaluation if their experience does not match a doctor's single observation of their child. This is particularly important now, because under managed care the cost of pursuing a diagnosis is not always covered.
The physician will first require a detailed history of the child's behavior. They will match this against a standardized check-list used to define the disorder [see Table, Diagnostic Criteria for Attention-Deficit Disorder]. The parents should describe specific problems they have encountered during the child's development, beginning as early as possible. School reports are very helpful. The health professional will want to know how the parents handle different situations and may want to observe them interacting with the child. The physician should also ask about any other factors that might affect the child's behavior, such as sibling relationships, recent life changes, a family history of ADHD, eating habits, sleep patterns, and speech and language development. A medical history will then be taken, not only of the child, but also of the mother's pregnancy and delivery. The child should also be given a general physical examination to determine if any medical causes are present. A series of screening tests are available to test neurologic, intellectual, and emotional development problems. Most involve learning and problem solving tasks and help define the particular areas that are most disabling. Laboratory tests are rarely recommended unless the physician suspects lead toxicity or other medical problems.
It is fairly common to use a trial of a psychostimulant (usually Ritalin) to achieve a diagnosis. An improvement in symptoms is considered an indication of ADHD. In non-ADHD children, however, the stimulant often increases agitation and hyperactivity, Experts, however, strongly recommend against this method of diagnosis, since it is not always accurate and may lead to unnecessary prescriptions of this drug.
Brain scans using imaging techniques, including magnetic resonance imagine (MRI) or single photon emission computed tomography (SPECT) may eventually help confirm a diagnosis. At this time, however, abnormalities detected in ADHD patients do not provide enough evidence for widespread use.
Both psychostimulant drugs and behavioral therapy are available and proving to be effective for treating many children with ADHD. At this time, there are five steps in the management of a child with ADHD: (1) diagnosis; (2) appropriate treatment; (3) vigilant monitoring; (4) communication between physicians, caretakers, and schools; and (5) an on-going exchange of information. Behavioral techniques should usually be tried first before resorting to medications. If the symptoms are severe or do not respond, then medication is advisable. In general, a combination of drugs and behavioral methods are usually recommended. Family therapy may help ADHD children and their parents and siblings cope with the emotional conflicts that nearly always arise in the lifelong process of managing the condition. Separate psychological therapies for specific family members might be needed, particularly in light of the high incidence of psychiatric and other emotional problems in families with ADHD children.
According to an expert panel at the National Institutes of Mental Health, there are many important questions regarding treatments that remain unanswered. First, no major studies have been conducted on the long-term effects of medications or behavioral therapies on ADHD. Second, there are no reliable guidelines on how to treat the inattentive subtype of ADHD, which might be more common in girls. There are also no authoritative treatment guidelines for treating adolescents and adults with ADHD. In addition, no studies have been conducted to determine the long-term (more than a year) effectiveness of medications and behavioral therapies. Finally, no therapies target other problems specific to many people with ADHD, including impaired working memory and deficits in language processing. Such treatments are important given the lack of proven effectiveness of drugs on improving academic achievement and social skills.
Many parents are very disturbed by the idea of putting their children on an intensive drug regimen, possibly for years. Indeed, although short-term studies report the effectiveness of drug treatment, no long-term studies (more than a year) have been conducted on either medications or behavioral therapies. The choice, then, is highly individual. Some can manage their children entirely with behavioral methods, but, for others, medication seems like a miracle and can provide desperate families with a quality of life they had almost given up on. The negative side effects of the drug should not become the basis for not trying them if other methods fail, since the negative effects of the disorder itself can be much more severe and life-long.Before any drug is administered, a child should be given a thorough examination for any medical problems. Both the physician and the parents should be very clear about the specific behaviors they hope the medication will target. Physicians still have a difficult time predicting which medications will produce beneficial results, so treatment is individualized and performed on a trial and error basis, which requires close observation and cooperation between all participants. If an initial regimen doesn't work, changing the dosage, adding another drug, or changing to a different medication often brings improvement. The goal is to use the lowest possible dosage that produces improved behavior. Frequent follow-up visits should be scheduled to assess the response and to detect possible side effects. As children enter adolescence, the social stigma associated with ADHD often makes them reluctant to continue drug treatment. If the drug has proven to be effective, it is very important to keep the young person on the regimen during this critical period.
Methylphenidate (Ritalin) and Other Central Nervous System Stimulants.
It is estimated that 75% of children with an attention deficit disorder will benefit from stimulants. In general, stimulants have proven to reduce disruptive behavior and raise intelligence test scores, even in children who have accompanying disorders, such as autism, pervasive developmental disorder, and mental retardation. Stimulants are not a cure-all. They do not, for example, improve a child's ability to memorize facts by rote, and a child may still have social problems. Children who suffer from anxiety have less success with stimulants.
Methylphenidate (Ritalin). Methylphenidate (Ritalin) is the most commonly used drug for ADHD. Unless sustained-release preparations are used, Ritalin needs to be administered several times a day, making compliance difficult. Under investigation is a purer form of methylphenidate, which may eventually prove to be more effective in treating symptoms in children and have fewer side effects. Medication regimens are generally recommended for hours spent at school with drug holidays during the evenings, weekends, and vacations. Some physicians argue, however, that too much emphasis is placed on improvement only during school hours. When taken in the morning, the medication usually wears off in the late afternoon; at this point, a rebound effect can occur and ADHD symptoms intensify. The family members, whose affection and on-going support is so important, become victims of the disruptions generated by rebound, and the quality of life can worsen for everyone. Some physicians recommend a "homework" dose given after school to prevent rebound.
The most common side effects of any stimulant are nervousness and sleeplessness, although some parents have reported improved sleep patterns in their children after taking stimulants. Other side effects include irritability, withdrawal, depression, hallucinations, and lack of spontaneity. Tics or jerky, disordered movements occur in about 9% of children, although studies indicate that low doses are often effective in controlling ADHD symptoms without causing tics, even in many children who also have Tourette's syndrome.Symptoms of overdose include confusion, breathing difficulties, sweating, vomiting, and muscle twitches; if they occur, parents should call the doctor immediately. Children may also lose weight and growth may be retarded during long-term treatment, although not permanently. Many people have taken Ritalin for years without experiencing adverse effects or loss of effectiveness. Of some concern were studies reporting liver cancers in mice given very high doses of Ritalin. There have been no reports of an increased risk in people, and, in fact, studies on population groups have observed an unexpected decrease in cancers in people taking methylphenidate. (There is no evidence at all, however, that the drug is protective.)
Some people have become concerned about Ritalin abuse and the risk of addiction. Although Ritalin is a stimulant with properties similar to amphetamines, at the oral doses given for ADHD, levels of Ritalin rise very slowly in the brain, which prevents a so-called "high" and subsequent addiction to the drug. Dependence has not been reported in children who have taken this drug for long periods in appropriate dosages. Crushing the pills and inhaling them nasally, however, can provide a euphoric state. The primary danger for drug abuse appears to come from peers; in one study, 16% of ADHD children reported pressure from their fellow students to sell or give them their medication.
Other Stimulants. Dextroamphetamine (Dexedrine) is similar to Ritalin, but is subject to greater abuse. A drug that combines four kinds of amphetamine salts (Adderall) has been approved for ADHD patients; it is inexpensive and has shown benefits in improving symptoms. Long-term clinical studies are still needed for its use in children. Pemoline (Cylert) is used less frequently than either Dexedrine or Ritalin. It takes longer (sometimes weeks) to produce improvement than the other drugs; its advantage, however, is that it allows once-daily administration. Cylert increases the risk of liver damage, particularly when taken in combination with other medications or alcohol. Although the risk is small, physicians should test children if they exhibit any symptoms of liver toxicity, including tenderness of the abdomen, yellow skin or eyes, vomiting, weight loss, or malaise.Antidepressants.
Bupropion (Wellbutrin) and venlafaxine (Efexor) are unique antidepressants that may actually be helpful for treating ADHD itself as well as for accompanying depression. The antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), are effective and safe and often recommended for treating depression with ADHD. It should be noted, however, that some SSRIs may increase the risk for impulsive behavior. Sertraline has also helped adults with pervasive development disorder, but its effect on children is unknown; other SSRIs have not been very helpful for childhood PDD. Antidepressants known as tricyclics, which include desipramine (Norpramin, Pertofrane), desipramine (Norpramin), or imipramine (Janimine, Tofranil), have also been prescribed for children who do not respond to stimulants or who have accompanying anxiety or depression. Such drugs appear to have a mild effect on blood pressure and heart rate that does not appear to be harmful. Reports of sudden death of a few children taking tricyclics, however, have caused alarm, although these occurrences are extremely rare and the role tricyclics may have played is not clear. Reports of delirium and increased heart rate have occurred in adolescents who take tricyclics and smoke marijuana. Tranylcypromine (Parnate) is an antidepressant known as a monoamine oxidase inhibitor (MAOI) that has helped some children. Patients prescribed MAOIs, however, have a restricted diet and cannot eat certain foods including cheese, dried meats and fish, canned figs, fava beans, and concentrated yeast products. They must also avoid certain drugs, including some common over-the-counter cough medications. It is important to note that fatal reactions have occurred when SSRIs and MAOIs were taken at the same time. There should be a two to five-week break, depending on the specific medication, when a patient is changing from one type of antidepressant to the other.Anti-Anxiety Drugs.
The drug buspirone (BuSpar), developed for treatment of anxiety disorders, is currently being investigated for ADHD.Alpha-2 Agonists.
Clonidine (Catapres), a drug known as an alpha-2 agonist, is used for Tourette's syndrome and for ADHD children with tics and whose problems tend more toward impulsivity and aggression than inattentiveness. The drug stimulates the neurotransmitter norepinephrine, which appears to be important for concentration. Sedation is the most common side effect. A clonidine skin patch, which gradually releases the medication, helps reduce the sedative effect. Few major studies have been conducted on its efficacy in ADHD children, however.Because the drug slows the heart down, it can have very adverse effects in some children. Going off too quickly or missing doses can cause rapid heart beats and other symptoms that may lead to severe problems. Of great concerns are reports of severe adverse effects, including four deaths from heart events, in children taking the drug in combination with Ritalin for improving sleep. Experts strongly recommend that no child be given this medication without a preliminary examination of any heart problems, and no child with existing heart, kidney, or circulatory problems should take it. A similar drug, guanfacine (Tenex) also improves symptoms in ADHD children and may cause less drowsiness than clonidine.Other Medications.
One small study reported that when levodopa/carbidopa (Sinemet) was given to children with ADHD to treat restless legs syndrome, a sleep disorder, that it also reduced symptoms of ADHD. More research may be warranted in children who have both conditions.
Behavioral Techniques.
Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers; to learn them, both sets of caregivers may need help from qualified health care professionals or from ADHD support groups.
Management at Home. Bringing up an ADHD child, like bringing up any child, is a continuing process. No single point is ever reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to do anything more." An ADHD child, however, is different from other children in very specific ways. The ADHD toddler is physically aggressive and the parent must teach the child to channel this into verbal expression. The young ADHD child becomes verbally abusive, and the parent must encourage the child to redirect this form of aggression into more acceptable physical or intellectual activities, such as competitive one-on-one sports, energetic music, or big colorful paintings. It is futile and damaging to try to force an ADHD child to be just like most children. It is possible, however, to limit destructive behavior and to instill a sense of self-worth that will help overcome negativity toward life, which is one of the great dangers of this disorder. Self-worth evolves from self-disciplinethe ability to step back and consider the consequences of an action and then to control that action before taking it. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness.
At first, the idea of changing the behavior of a highly energetic, obstinate, willful child is daunting. Some parents are easy going and can accept a wide range of behavior, while others can't. Parents should prepare a list giving priority to those behaviors they think are most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (e.g., refusing to wear anything but red T-shirts). Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (e.g., making up silly songs or drawing violent pictures). These should be accepted as part of the child's unique and positive development, even if they seem peculiar to the parent. It is very important to understand that ADHD children have much more difficulty adapting to change than do children without the condition.
Parents must be as consistent as possible in their discipline, which should reward good behavior and discourage destructive behavior. Rules should be well-defined but flexible enough to incorporate harmless idiosyncrasies. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.) In young children, creating charts with points or stars for good behavior or completed tasks is helpful. It is valuable to give points for even simple positive behaviors that are taken for granted in most people (e.g., responding happily to a change in plans, changing an obscenity to a more acceptable expletive). A reward system should rotate different types of rewards, because such children are easily bored. Rewards of food or gifts should be used infrequently, if at all; they can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects. Rewards that don't cost money can include playing a favorite game with the child, extending bedtime by an hour, or allowing an extra half hour of TV. These children respond better with small rewards promised in the short term than large rewards offered in the future. It is important to note that ADHD children respond with much greater frustration than non-ADHD children to disappointment; rewards should be promised only when caregivers are fairly certain they can follow through. If they can't, caregivers should anticipate a strong negative reaction. A parent must remember that this response is part of the ADHD child's make-up and not necessarily in their control. Some experts suggest a behavioral program called cost punishing technique, which combines elements of both positive and negative reinforcement of a child's behavior. It is best summed up as, "If your behavior is OK, you can have a reward. But you can only keep the reward if your appropriate behavior continues."
Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional. In these cases, the child should be disciplined or restrained immediately, or he or she will quickly learn to manipulate the caregiver. Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave and plan ahead, but all too often the child explodes for no apparent reason. When the child is out of control, the best solution is to isolate the child immediately for a short period of time in the bedroom. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible. It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm.
Parents should be on the look-out for activities that hold the child's concentration. The computer is a potentially attractive tool. ADHD children are particularly lured by video and computer games, which, until recently, have nearly all been based on repetitive violent events governed by hand-eye coordination. Fortunately, many adventure games are now available that offer problem-solving techniques using characters, narrative, and humor. ADHD children often do not do well with team sports, although if a child is interested in baseball, positions such as pitching or catching are preferable to the outfield, where attention easily wanders. Swimming, tennis, and other sports that focus attention and limit peripheral stimuli are often appealing. Some experts are enthusiastic about the martial art Tae Kwon Do, which offers an appropriate and controlled emotional outlet and helps to focus attention, and to develop self-restraint, self-discipline, and tolerance.Management at School.
Even if a parent is successful in managing the child at home, difficulties often arise at school. Although teachers can expect that at least one student in every classroom will have ADHD, there is currently little training that prepares them for managing these children. The ADHD child is often demanding, highly visible, and often forgets homework or misses assignments. Lack of fine motor control makes taking notes very difficult. Rote memorization and math computation that requires following a set of ordered steps are often difficult. (ADHD children may do better with math concepts). Many ADHD children respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision.The first priority is to develop a positivenot adversarialrelationship with the child's teacher and to acknowledge the teacher's situation, who must deal not only with the ADHD child's behavior but also with the needs of all the other children. Frequent brief and sympathetic conversations with the teacher can be helpful and can lead to coordination of efforts, particularly if they provide reciprocal information about progress or set-backs. One useful skill that has helped some ADHD children is learning to type at an early agearound the third or fourth grade. Many times lack of small motor coordination can be a stumbling block in the writing and educational process; using a typewriter or computer can compensate for this. Having the child sit in the front of the classroom and finding a tutor to help after school may be helpful.
A number of legal issues have become both positively and negatively important in the management of ADHD in the classroom. In some districts teachers are not allowed to tell parents that they suspect their child has ADD or ADHD because of the risk of lawsuits, therefore preventing an unknowing parent from seeking help for their child. Parents sometimes report pressure by school administrators or teachers to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally. While high-quality special education can be extremely helpful in improving learning, it may also increase the child's feelings of social alienation. Such programs also vary widely in their ability to provide quality education, and there is no federally funded special education category specifically targeted to ADHD. Many families, then, may not have appropriate programs available for them. In addition, if the child's behavior is perceived only as abnormal, educational strategies may fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior. If, in fact, ADHD is as common as studies are indicating, one approach should be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom. The ultimate goal for any educational process should be the happy and healthy social integration of the ADHD child with his or her peers.Dietary Changes.
A number of diets have been suggested for people with ADHD. The most popular is the Feingold diet, a salicylate- and additive-free diet, which requires rigorous vigilance over a child's eating habits. Although some parents report great success with this diet, it is very difficult to impose it on any child, particularly one with ADHD. Any minor deviation in the diet presumably throws the child immediately into hyperactive mode. One study that reported its efficacy suggested, however, that it might not provide enough nutritive value. It is certainly wise to avoid food with high sugar content and artificial colors and flavors, but the imposition of too rigorous a diet can easily reinforce the ADHD child's sense of alienation from his or her peers. Parents would do better to provide a healthy balance of fresh, natural foods and to try other treatment methods before forcing the Feingold diet on their children.
National Attention Deficit Disorder Association
9930 Johnnycake Ridge Road, Suite 3E
Mentor, OH 44061-0972
call (800-487-2282 or 440-350-9595) or on the Internet (http://www.add.org/)
Membership is $35, which provides the newsletter Focus, support groups lists, and other information.
Children and Adults with Attention Deficit Disorder
8181 Professional Place, Suite 201
Landover, MD 20785
call (800-233-4050) or (301-306-7070) or on the Internet (http://www.chadd.org/).
CH.A.D.D. publishes Attention, and has many regional chapters providing local support.
The National Information Center for Children and Youth with Disabilities
PO Box 1492
Washington, DC 20013-1492
call (800-695-0285) or on the Internet (http://www.nichcy.org/)
This organization provides information on educational and legal rights by state as well as parent guides for attention-deficit disorder and learning disabilities.
National Institutes of Mental Health
Room 7C-02, 5600 Fishers Land
Rockville, MD 20857
call (301-443-4513) or on the Internet (http://www.nimh.nih.gov/)
A.D.D. Warehouse
300 Northwest 70th Avenue, Suite 102
Plantation, FL 33317
call (800-233-9273) or on the Internet (http://www.addwarehouse.com/)
Offers a wide selection of information and educational resources.
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Differential access to care for children with ADHD in special education programs. Psychiatric Service, September 1998
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Implication of right frontostriatal circuitry in response inhibition and attention-deficit disorders Journal of the American Academy of Child and Adolescent Psychiatry. March 1997
Intranasal abuse of prescribed methylphenidate. Journal of the American Academy of Childhood and Adolescent Psychiatry, June 1998, Vol. 37, p. 573
Long-term stimulant treatment of children with attention-deficit hyperactivity disorder symptoms. Archives of General Psychiatry. September 1997
Psychopharmacology of ADHD: children and adolescents. Journal of Clinical Psychiatry 1998;59 Suppl 7:42-9
Radical disparity in psychotropic medications prescribed for youths with Medicaid insurance in Maryland. Journal of the American Academy of Childhood and Adolescent Psychiatry, February 1998, Vol. 37, p. 179
Shedding light on medical misconceptions. Consumer Reports on Health, May 1998
Validity of DSM-IV Attention-deficit/hyperactivity disorder for younger children. Journal of the American Academy for Childhood and Adolescent Psychiatry, July 1998, Vol. 37, p. 695
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