ADHD

What is ADHD?

ADHD is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.

Symptoms

Typically, ADHD symptoms arise in early childhood. According to the DSM-5, several symptoms are required to be present before the age of 12. Many parents report excessive motor activity during the toddler years, but ADHD symptoms can be hard to distinguish from the impulsivity, inattentiveness, and active behavior that is typical for kids under the age of four. In making the diagnosis, children should have six or more symptoms of the disorder present; adolescents 17 and older and adults should have at least five of the symptoms present. The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive, and Combined. The symptoms for each are adapted and summarized below.

ADHD Combined Presentation

• the individual meets the criteria for both inattention and hyperactive-impulsive ADHD presentations
• these symptoms can change over time, so children may fit different presentations as they get older.

ADHD Throughout the Lifespan

Children with ADHD often experience delays in independent functioning and may behave younger than their peers. Many children affected by ADHD can also have mild delays in language, motor skills or social development that are not part of ADHD but often co-occur. They tend to have low frustration tolerance, difficulty controlling their emotions and often experience mood swings.

Children with ADHD are at risk for potentially serious problems in adolescence and adulthood: academic failure or delays, driving problems, difficulties with peers and social situations, risky sexual behavior, and substance abuse. There may be more severe negative behaviors with co-existing conditions such as oppositional defiant disorder or conduct disorder. Adolescent girls with ADHD are also more prone to eating disorders than boys. As noted above, ADHD persists from childhood to adolescence in the vast majority of cases (50–80 percent), although the hyperactivity may lessen over time.

Teens with ADHD present a special challenge. During these years, academic and life demands increase. At the same time, these kids face typical adolescent issues such as emerging sexuality, establishing independence, dealing with peer pressure and the challenges of driving.

More than 75 percent of children with ADHD continue to experience significant symptoms in adulthood. In early adulthood, ADHD may be associated with depression, mood or conduct disorders and substance abuse. Adults with ADHD often cope with difficulties at work and in their personal and family lives related to ADHD symptoms. Many have inconsistent performance at work or in their careers; have difficulties with day-to-day responsibilities; experience relationship problems; and may have chronic feelings of frustration, guilt or blame.

Individuals with ADHD may also have difficulties with maintaining attention, executive function and working memory. Recently, deficits in executive function have emerged as key factors affecting academic and career success. Executive function is the brain’s ability to prioritize and manage thoughts and actions. This ability permits individuals to consider the long-term consequences of their actions and guide their behavior across time more effectively. Individuals who have issues with executive functioning may have difficulties completing tasks or may forget important things.

Co-Occurring Disorders

More than two-thirds of children with ADHD have at least one other co-existing condition. Any disorder can co-exist with ADHD, but certain disorders seem to occur more often. These disorders include oppositional defiant and conduct disorders, anxiety, depression, tic disorders or Tourette syndrome, substance abuse, sleep disorders and learning disabilities. When co-existing conditions are present, academic and behavioral problems, as well as emotional issues, may be more complex.

These co-occurring disorders can continue throughout a person’s life. A thorough diagnosis and treatment plan that takes into account all of the symptoms present is essential.

Causes

Despite multiple studies, researchers have yet to determine the exact causes of ADHD. However, scientists have discovered a strong genetic link since ADHD can run in families. More than 20 genetic studies have shown evidence that ADHD is strongly inherited. Yet ADHD is a complex disorder, which is the result of multiple interacting genes.

Other factors in the environment may increase the likelihood of having ADHD:

• exposure to lead or pesticides in early childhood
• premature birth or low birth weight
• brain injury

Scientists continue to study the exact relationship of ADHD to environmental factors, but point out that there is no single cause that explains all cases of ADHD and that many factors may play a part.

Previously, scientists believed that maternal stress and smoking during pregnancy could increase the risk for ADHD, but emerging evidence is starting to question this belief. However, further research is needed to determine if there is a link or not.

The following factors are NOT known causes, but can make ADHD symptoms worse for some children:

• watching too much television
• eating sugar
• family stress (poverty, family conflict)
• traumatic experiences

ADHD symptoms, themselves, may contribute to family conflict. Even though family stress does not cause ADHD, it can change the way the ADHD presents itself and result in additional problems such as antisocial behavior.

Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.

Diagnosis

Deciding if a child has ADHD is a process with several steps.

There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, sleep problems, and certain types of learning disabilities, can have similar symptoms.

One step of the process involves having a medical exam, including hearing and vision tests, to rule out other problems with symptoms like ADHD.

Diagnosing ADHD usually includes a checklist for rating ADHD symptoms and taking a history of the child from parents, teachers, and sometimes, the child.

The Neuroscience of the ADHD Brain

ADHD brains have low levels of a neurotransmitter called norepinephrine. Norepinephrine is linked arm-in-arm with dopamine. Dopamine is the thing that helps control the brain’s reward and pleasure center. The ADHD brain has impaired activity in four functional regions of the brain.

1. Frontal Cortex: This region control high-level functions:

• attention
• executive function
• organization

2. Limbic System: This region is located deeper in the brain. It regulates our emotions and attention.

3. Basal Ganglia: A deficiency here can cause inter-brain communication and information to "short-circuit" that results in inattention or impulsivity.

4. Reticular Activating System: This is the major relay system among the many pathways that enter and leave the brain. A deficiency here can cause inattention, impulsivity, or hyperactivity.

Treatment

• Behavior Therapy
• Medication
• Children <6 years, parent training in behavior management
• Children >6 years, medication and behavior therapy together, parent training in behavior management, classroom intervention and school supports

Behavior Therapy and Parent Training

ADHD affects not only a child’s ability to pay attention or sit still at school, it also affects relationships with family and other children.  Children with ADHD often show behaviors that can be very disruptive to others. Behavior therapy is a treatment option that can help reduce these behaviors; it is often helpful to start behavior therapy as soon as a diagnosis is made.

The goals of behavior therapy are to learn or strengthen positive behaviors and eliminate unwanted or problem behaviors. Behavior therapy for ADHD can include:

• Parent training in behavior management
• behavior therapy with children
• behavioral interventions in the classroom

These approaches can also be used together. For children who attend early childhood programs, it is usually most effective if parents and educators work together to help the child.

Medications

Medication can help children manage their ADHD symptoms in their everyday life and can help them control the behaviors that cause difficulties with family, friends, and at school.

Several different types of medications are FDA-approved to treat ADHD in children as young as 6 years of age

• Stimulants are the best-known and most widely used ADHD medications. Between 70-80% of children with ADHD have fewer ADHD symptoms when taking these fast-acting medications.

• Nonstimulants were approved for the treatment of ADHD in 2003. They do not work as quickly as stimulants, but their effect can last up to 24 hours.

• Medications can affect children differently and can have side effects such as decreased appetite or sleep problems. One child may respond well to one medication, but not to another.

• Healthcare providers who prescribe medication may need to try different medications and doses. The AAP recommends that healthcare providers observe and adjust the dose of medication to find the right balance between benefits and side effects.

• It is important for parents to work with their child’s healthcare providers to find the medication that works best for their child.

Tips for Parents

The following are suggestions that may help with your child’s behavior:

• Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime.

• Get organized

• Encourage your child to put schoolbags, clothing, and toys in the same place every day so that they will be less likely to lose them.

• Manage distractions. Turn off the TV, limit noise, and provide a clean workspace when your child is doing homework. Some children with ADHD learn well if they are moving or listening to background music. Watch your child and see what works.

• Limit choices. To help your child not feel overwhelmed or overstimulated, offer choices with only a few options. For example, have them choose between this outfit or that one, this meal or that one, or this toy or that one.

• Be clear and specific when you talk with your child. Let your child know you are listening by describing what you heard them say. Use clear, brief directions when they need to do something.

• Help your child plan. Break down complicated tasks into simpler, shorter steps. For long tasks, starting early and taking breaks may help limit stress.

• Use goals and praise or other rewards. Use a chart to list goals and track positive behaviors, then let your child know they have done well by telling them or by rewarding their efforts in other ways. Be sure the goals are realistic—small steps are important!

• Discipline effectively. Instead of scolding, yelling, or spanking, use effective directions, time-outs or removal of privileges as consequences for inappropriate behavior.

• Create positive opportunities. Children with ADHD may find certain situations stressful. Finding out and encouraging what your child does well—whether it’s school, sports, art, music, or play—can help create positive experiences.

• Provide a healthy lifestyle. Nutritious food, lots of physical activity, and sufficient sleep are important; they can help keep ADHD symptoms from getting worse.

 

Myth 7: Girls Have Lower Rates and Less severe ADHD Than Boys

ADHD in girls and women has been recognized only in the past few decades, and more research studies are reporting on the substantial impairments they experience, often to the same extent as boys. They are at risk for many of the same coexisting conditions and impairments as males―oppositional defiance disorder, conduct disorder, academic and social impairments, driving problems, substance abuse and risky sexual behavior. Adolescent girls with ADHD may be more prone than boys to eating disorders, but by young adulthood this difference is reduced (Owens et al. 2015). A 10-year follow-up study of girls aged 6–12 years by Hinshaw et al. (2012) found a higher risk for suicide attempts and self-injury by adulthood among the girls. The latest diagnosis data as reported by parents of children ages 4–17 in the National Health Interview Survey (NHIS) 2011–2013 found a diagnostic rate of 13.3% for boys and 5.6% for girls. Other large community samples have found a similar gender ratio of 2.3:1.0, but by adulthood, studies have found that prevalence is nearly the same between genders (Owens et al. 2015).

Resources

Websites

National Resource Center on ADHD | WEBSITE

National Institute of Mental Health | WEBSITE

Information for parents from the American Academy of Pediatrics | WEBSITE

Children and Adults with Attention-Deficit/Hyperactivity Disorder | WEBSITE

ADDitude | WEBSITE

Attention Deficit Disorder Association (ADDA) | WEBSITE

Palooza Central WEBSITE

Books

Books for Parents | WEBSITE

The Survival Guide for Kids with ADHD by John F. Taylor

Free Association, Where My Mind Goes During Science Class by Barbara Esham

10 Middle Grade Books with ADHD Characters Who Slay

Great Books for Readers with ADHD

• Get a Grip, Vivy Cohen!

• The Thing About Jellyfish

• El Deafo

• Tornado Brain

Podcasts

ADHD 365 and All Things ADHD | PLAY PODCAST

Dr. Ross Greene by Dr. Ross Greene | PLAY PODCAST

Dr. Ross Greene, originator of the Collaborative & Proactive Solutions model and author of The Explosive Child, Lost at School, Lost & Found, and Raising Human Beings, provides guidance to parents on understanding and helping kids with social, emotional, and behavioral challenges...along with his co-hosts Kim Hopkins-Betts (Director of Outreach at Lives in the Balance) and parents Jennifer Trethewey, and Stella Hastings.

Webinars

ADHD Palooza for Parents

When Behavior Impedes Learning

Boost Your Child’s Social Smarts: A Parent’s Guide for Kids with ADHD and ASD

Articles

5 Strategies parents of children with ADHD can implement

Could Your Child Benefit from a Functional Behavior Assessment?

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References

Barkley, Russell A. (2015). History of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. (pp. 356–390). New York, NY: Guilford Press.

Barkley, Russell A. (2015). Etiologies of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. (pp. 356–390). New York, NY: Guilford Press.

Biederman, Joseph et al. (2012). Adult Outcome of Attention-Deficit/Hyperactivity Disorder: A Controlled 16-Year Follow-Up Study. Journal of Clinical Psychiatry 73(7):941–950.

Ellis, Brandi & Joel Nigg (February 2009). Parenting Practices and Attention-Deficit/Hyperactivity Disorder: New Findings Suggest Partial Specificity of Effects. Journal of the American Academy of Child & Adolescent Psychiatry 48(2):146–154.

Hinshaw, Stephen P. et al. (2012). Prospective Follow-Up of Girls With Attention-Deficit/Hyperactivity Disorder Into Early Adulthood: Continuing Impairment Includes Elevated Risk for Suicide Attempts and Self-Injury. Journal of Consulting and Clinical Psychology 80(6):1041–1051.

Matthews, Marguerite et al. (2013). Attention Deficit Hyperactivity Disorder. Current Topics in Behavioral Neurosciences 16:235–266.

Merikangas, Kathleen et al. (2013). Medication Use in US Youth With Mental Disorders. JAMA Pediatrics167(2):141–148.

Morgan, Paul L. et al. (2013). Racial and Ethnic Disparities in ADHD Diagnosis From Kindergarten to Eighth Grade. Pediatrics 132(1):85–93.

Owens, Elizabeth et al. (2015). Developmental Progression and Gender Differences among Individuals with ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. (pp. 223–255). New York, NY: Guilford Press.

Pastor, Patricia N. et al. (2015). Association between diagnosed ADHD and selected characteristics among children aged 4–17 years: United States, 2011–2013. NCHS Data Brief, no 201. Hyattsville, MD: National Center for Health Statistics.

Roberts, Walter et al. (2015). Primary Symptoms, Diagnostic Criteria, Subtyping, and Prevalence of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. (pp. 51–80). New York, NY: Guilford Press.

Russell, Abigail E. et al. (2015). Socioeconomic Associations with ADHD: Findings from a Mediation Analysis. PLoS One 10(6):e0128248.

Visser, Susanna N. et al. (September 3, 2015). Diagnostic experiences of children with attention-deficit/hyperactivity disorder. National Health Statistics Reports; no 81. Hyattsville, MD: National Center for Health Statistics.