Attention-Deficit/Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD), also known as attention-deficit disorder (ADD), is a condition in which a person's inability to focus and concentrate on a task or purpose interferes with his or her ability to be productive. It also can affect how people develop social relationships or self-esteem.

Children with ADHD often are seen as unable to settle down—impulsive, hyperactive, disruptive, and even aggressive in classroom and social settings.

The medical community recognizes 3 basic forms of the disorder, as follows:

• Primarily inattentive: Inattentiveness to tasks or activities is the primary problem.



• Primarily hyperactive-impulsive: Impulsivity and inappropriate movement (fidgeting, inability to keep still) or restlessness are the primary problems.



• Combined: This is a combination of the inattentive and hyperactive-impulsive forms.

The combined type is the most common. The predominantly inattentive type is being recognized more and more, especially in girls and in both sexes of adults. The predominantly hyperactive-impulsive type, without significant attention problems, is rare.

We are still learning about ADHD, and the experts' ideas of the disorder are still being shaped. Some believe, for example, that the term attention deficit is misleading.

• They maintain that people with ADHD actually are able to pay attention too well, rather than too little, but have difficulty regulating their attention leaving them unable to properly focus.



• Others have trouble ignoring irrelevant details and/or focus so intensely on specific details that they miss the bigger, more important, picture.



• Many cannot “shift gears” from one thing to another when they need to, leaving them unable to focus on what needs to be done. Extreme difficulty getting a child to stop playing a video game to come to dinner is a common example.

Contrary to some media accounts, attention disorders are not new. Childhood hyperactivity was a focus of interest in the early 1900s. Today, hyperactivity, impulsivity, and inattention are the focus, but disability related to hyperactivity and distractibility has been alluded to throughout medical history. What is new is the greater awareness of ADHD thanks to rapidly mounting research findings.

In the United States, ADHD affects about 3-7% of children. Similar rates are reported in other developed countries such as Germany, New Zealand, and Canada.

• In most cases, the unusual behaviors are noticed by the time the child is about 7 years old, although ADHD occasionally is diagnosed in teenagers or young adults.



• Boys are much more likely than girls to be diagnosed with ADHD. The ratio of boys to girls with ADHD was thought to be as high as 4:1 or 3:1 at one time. This ratio has been decreasing, however, as more is known about ADHD. For instance, greater recognition of the inattentive form of ADHD has increased the number of girls diagnosed with the disorder.



• People identified with ADHD in adulthood are almost as likely to be women as men, suggesting that we may have been missing the diagnosis in many young girls.

There is disagreement over whether ADHD persists as children grow into adults.

• Some believe that most children simply grow out of ADHD. Others believe that ADHD persists into adulthood in most cases. Estimates of the number of children with ADHD who continue to have the disorder in adulthood range from 30%-80%.



• Hyperactive symptoms may decrease with age, usually diminishing at puberty, perhaps because people tend to learn how to gain greater self-control as they mature.



• Inattention symptoms are less likely to fade with maturity and tend to remain constant into adulthood.



• As we learn more about ADHD, it is likely that certain subtypes will be found to cause more adult dysfunction than others.

People with ADHD are much more likely than the general population to have other related conditions such as learning disorders, restless legs syndrome, ophthalmic convergence insufficiency, depression, anxiety disorder, antisocial personality disorder, substance abuse disorder, conduct disorder, and obsessive-compulsive behavior. People with ADHD also are more likely than the general population to have a family member with ADHD or one of the related conditions.

We do not know exactly what causes attention-deficit/hyperactivity disorder.

• Although external factors, such as problems in growth and development in the womb, heavy drug use, and lower socioeconomic status, have been linked to some cases of ADHD, it is mainly a biological disorder. In other words, it is mostly a person's genes that determine whether he or she has the disorder.



• ADHD symptoms may be affected by, but are not caused by, television, video games, sugar or other foods, food allergies, bad parenting, bad schools or teaching, or a disruptive home life.

Genes that control levels of chemicals in the brain called neurotransmitters seem to be different in ADHD, and levels of neurotransmitters are out of normal balance.

• MRI and other imaging studies suggest that these imbalances occur in parts of the brain that control certain types of movement and "executive functions."



• These areas of the brain may be smaller and/or less active in people with ADHD.

The 6 major tasks of executive function that are most commonly distorted with ADHD are the following:

• Shifting from one mindset or strategy to another (that is, flexibility)



• Organization (for example, anticipating both needs and problems)



• Planning (for example, goal setting)



• Working memory (that is, receiving, storing, then retrieving information within short-term memory)



• Separating emotions from reason



• Regulating speech and movements appropriately

The symptoms of attention-deficit/hyperactivity disorder are not physical symptoms such as pain or a runny nose, but exaggerated or unusual behaviors. The type and severity of symptoms vary greatly among people with ADHD. The severity of symptoms depends on the degree of abnormality in the brain, the presence of related conditions, and the individual's environment and response to that environment.

Symptoms of the inattentive form of ADHD include any or all of the following:

• Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities



• Often has difficulty sustaining attention in tasks or play activities



• Often does not seem to listen when spoken to directly



• Often does not follow through with instructions and does not finish schoolwork, chores, or duties in the workplace (but this cannot be due to resistance or failure to understand instructions)



• Often has difficulties with organizing tasks and activities



• Often avoids, dislikes, or is reluctant to engage in homework that requires sustained mental effort



• Often loses things necessary for tasks or activities (for example, school assignments, pencils, books, tools, toys)



• Often is easily distracted by extraneous details



• Often is forgetful in daily activities

Symptoms of the hyperactive-impulsive form of ADHD include any or all of the following:

• Often fidgets with hands or feet or squirms in seat



• Often leaves seat in classroom or in other situations in which remaining seated is expected



• Often runs about or climbs excessively in situations in which this behavior is inappropriate (adolescents or adults may simply feel restless)



• Often has difficulty playing or engaging in leisure activities quietly



• Often on the go or often acts as if driven by a motor



• Often talks excessively



• Often blurts out answers to questions before questions are completed



• Often has difficulty awaiting turns



• Often interrupts or intrudes on others (for example, butts into conversations or games)

Many children without ADHD demonstrate one or more of these behaviors frequently. The difference between these children and the child with ADHD is that the behaviors are disruptive, are considered inappropriate for the child's developmental stage, persist for months or years, and occur both at home and at school. A child with ADHD almost never exhibits all of the symptoms, but the symptoms that are present appreciably hinder the child’s social, psychological, and/or educational development.

The behaviors of ADHD can mimic mood disorders (for example, depression), anxiety, or personality disorder. Those conditions must be ruled out or adequately treated before a definitive diagnosis of ADHD can be made.

A preschool child may need evaluation for ADHD if he or she continually exhibits any of the following behaviors:

• Constant activity or speech, as if driven by a motor



• Often requires constant close visual surveillance to avoid destructive, dangerous, or risky situations



• Attention not held long by any toy, video, or other attractive activity



• Resists attempts to restrict activity, such as holding hands near a street



• Physically aggressive toward other children or adults



• Regularly exhausts parents and other caregivers

A school-age child may need evaluation for ADHD if he or she exhibits any of the following behaviors:

• Has shorter attention span than peers and needs frequent teacher intervention to keep on task



• Avoids work that requires sustained attention



• Daydreams excessively while supposed to be completing tasks



• Is hyperactive or fidgety



• Disrupts classroom by leaving seat, moving around room, talking inappropriately, and/or engaging others in play



• Provokes daily arguments at home about completing homework and chores



• Has frequent mood swings and/or rage reactions

The evaluation of a child for attention-deficit/hyperactivity disorder should begin with a very thorough medical interview. Your child's health care provider should ask detailed questions about the child's medical history. When not known from previous visits, this might include questions regarding the pregnancy and delivery, psychiatric history, family history, home and daycare conditions, school performance, work and legal problems (if appropriate), illnesses, current medications and supplements, diet, sleep, other habits, and social behaviors.

A thorough physical examination is rarely needed if your child has had regular checkups and has no significant physical problems. A very important part of the evaluation, however, is careful observation of behavior, even though a child or teen with ADHD may exhibit few symptoms in the medical office.

At this time, no lab test, x-ray, or procedure is known to suggest or confirm the diagnosis of ADHD. Specific tests may be ordered if indicated by specific symptoms.

Psychometric and educational testing is often important to the diagnosis of ADHD.

• Testing can be instrumental in ruling out other conditions and specific learning disabilities.



• It can highlight the weakest areas of attention and allowing counseling for the individual, parents, and teachers about how to use strengths to best advantage.



• As useful as these tests can be, they do not diagnose ADHD. The diagnosis of ADHD can only be made by a qualified professional after reviewing all of the information.

Psychometric tests most widely used in the diagnosis of ADHD include the following:

• The Conners' Parent and Teacher Rating Scale (for children) and the Brown Attention Deficit Disorder Scale (BADDS) for teens and adults may be useful in arriving at a diagnosis.



• Impulsivity and inattention can be assessed with timed computer tests, such as the Conners Continuous Performance Test (CPT), the Integrated Visual and Auditory (IVA) CPT, or both.



• The Nadeau/Quinn/Littman ADHD Self-Rating Scale for Girls should be part of the assessment for all girls.



• Various neuropsychiatric tests can be used to identify strengths and weaknesses in executive function.

Evaluation of intellectual function (for example, intelligence quotient, or IQ) can be helpful in distinguishing between ADHD and intellectual impairment.

Educational testing can identify learning disabilities such as language or math weaknesses. It also evaluates intellectual ability and academic achievement and can suggest whether academic support such as tutoring is needed.

A baseline ECG may be done to assess heart function before prescribing certain medications, such as tricyclic antidepressants.

|Medical Treatment|

The 2 major components of treatment for children with attention-deficit/hyperactivity disorder are behaviorally focused psychotherapy and medication.
 
Usually the primary care provider refers the person with ADHD to a psychotherapist. The more common components of psychotherapy are as follows. Not all components are necessary for every individual with ADHD.

• School or education interventions: These interventions are aimed at improving the child’s study skills and behavior in the classroom setting. The age of the child and the severity of the ADHD symptoms affect the extent to which the child benefits from working with education specialists. Teachers have a very important function. Their periodic feedback on school performance through the use of standardized scales, narrative descriptions, and telephone follow-up generally is an indispensable component of ongoing care.



• Psychotherapy: ADHD coaching, a support group, or both can help teens feel more normal and provide well-focused peer feedback and coping skills. Counselors such as psychologists, child and adolescent psychiatrists, behavioral/developmental pediatricians, clinical social workers, and advanced practice nurses, can be invaluable to both the children and families. Behavior modification and family therapy are usually necessary for the best possible outcome.

|Medications|

The medications used to treat ADHD are psychoactive. This means they affect the chemistry, and thus the functioning, of the brain.

Psychostimulants are by far the most widely used medications in ADHD. They work very well in most individuals with the disorder and have a good track record of relieving symptoms with no major adverse effects when used appropriately.

• These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.



• The most common adverse effects are short term. They include loss of appetite, sleep disturbances, rebound (for example, agitation, anger, lethargy as the last dose starts to wear off), and mild anxiety.



• Most individuals who take psychostimulants for ADHD build up tolerance to adverse effects within a few weeks, but growth rate needs to be followed closely in children throughout most of the time of their treatment, since any decrease in gaining height or weight may have long-term effects.



• Individuals with certain coexistent psychiatric disorders (for example, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to adverse effects if they do not receive appropriate concurrent treatment for the coexistent condition.

The psychostimulants most often used in ADHD include the following. The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.

• Dextroamphetamine (Dexedrine, Dexedrine Spansules, Dextrostat)



• Methylphenidate (Ritalin, Concerta, Methylin, Metadate CD)



• Dexmethylphenidate (Focalin, Folacin XR)



• Dextroamphetamine and amphetamine mixture (Adderall)



• Pemoline (Cylert) – Rarely used now because of side effects in the liver (Cylert [Abbott Laboratories] is being discontinued in the US market because of declining sales. Pemoline is not considered as first-choice therapy for ADHD due to reports of severe acute liver failure. Since pemoline was introduced on the market in 1975, 15 cases of liver failure were reported as of December 1998. Twelve of these cases resulted in death or liver transplantation, usually within 4 weeks of onset. Pemoline has previously been removed from the market in the United Kingdom and Canada. As of this date, it is not known if generic pemoline products will remain on the market.)

Atomoxetine (Strattera) is a new nonstimulant used to treat ADHD. This medication has been used for only a few years and less is known about its long-term side effects. This drug has several benefits over stimulants and its popularity is growing rapidly.

• It is not a controlled substance and is not considered a drug of potential abuse by the US Food and Drug Administration (FDA).



• It is usually taken only once a day for full 24-hour effectiveness.



• It is much less likely than stimulants to disrupt eating or sleeping.



• For some children, atomoxetine is not enough to control their ADHD symptoms. Many other children do very well on this medicine alone.

Some medications originally developed to treat depression (antidepressants) also have important roles in treating some individuals with ADHD. Since these medicines have been used for many years to treat other mental health conditions, their adverse effects are well understood.

• Imipramine (Tofranil) - An antidepressant that increases levels of neurotransmitters norepinephrine and/or serotonin in the brain



• Bupropion (Wellbutrin) - An antidepressant that increases levels of neurotransmitters in the brain, especially dopamine



• Desipramine (Norpramin) - An antidepressant that increases level of the neurotransmitter norepinephrine in the brain

Other medicines that were originally developed to treat high blood pressure (alpha agonists) may also be useful in the treatment of those having ADHD. Again, due to widespread and long-term use, their side effects are well known to physicians.

• Clonidine (Catapres) - An α₂ agonist that stimulates certain receptors in the brain stem; the overall effect is to "turn down the volume" of hyperactive movement and speech



• Guanfacine (Tenex) - Another alpha agonist with an effect similar to that of clonidine

Warnings concerning psychostimulant use

The psychostimulants are controlled substances; prescriptions must follow strict federal and state guidelines.

Any psychostimulants found by legal authorities (for example, while writing a speeding ticket) can cause suspicion. Thus, if the medication must be carried away from home, it should be kept in the original pharmacy container. In some states, having the medication in any container is acceptable as long as the pills are accompanied by a doctor order on a prescription or letterhead that states that the person is under the doctor's care and takes the medication as directed by a doctor.

Although the stimulant abuse rate in ADHD specialty centers is remarkably low, it is not zero. Illicit practices include crushing the psychostimulant so that it can be snorted through the nose. Unfortunately, this is not uncommon on college campuses. Pills can also be crushed and diluted and injected intravenously. These practices, which are most widespread among adolescents, are potentially addicting and dangerous, and even fatal. Any person who knowingly supplies others with these drugs is considered partly responsible for any injury sustained by the abuser. Warn your teens about the dangers.

ADHD is a controversial diagnosis for several reasons. Many well-meaning individuals have spoken out against making children behave according to a norm or take medications for the sake of improving grades. These individuals have expressed concern about addiction or drugging children. This kind of concern is valid; however, the following must also be considered:

• The negative consequences of not using medication for children with ADHD have to be weighed against the known risks. Long-term outcome studies have now been conducted with large numbers of adults diagnosed with ADHD as children, and one clear finding is that those who received medication for their disorder in childhood are more functional and have a better life quality as adults than those who had the symptoms of the disease but did not receive medicine.



• Stimulants used for ADHD do not cause addiction. Although tolerance usually develops for the stimulant-associated effects of anorexia, insomnia, or mild euphoria, tolerance does not develop to the increased levels of neurotransmitters.



• These medications should not be used just to improve grades or quiet down classrooms. School performance should be looked at as a sign of how well the child is doing, just like other areas of health. These medications often improve school performance dramatically, which is linked to better social skills and heightened self-esteem. But the grades should be a marker, not a goal.

The use of psychostimulants in children should be scrutinized carefully. Fortunately, methylphenidate (or Ritalin, historically the most widely prescribed medication for ADHD) has been available for more than 40 years. This long period of clinical experience has shown that this is one of the safest medications used in children.

Studies that have examined whether taking a psychostimulant for ADHD in childhood contributes to future substance abuse have shown this to not be the case. In one very large study, in fact, children who received stimulant medication for ADHD had half the risk of future substance abuse of similar children with ADHD who did not receive medication.

|Other Therapy|

Diet: No specific food or diet has been clearly shown to have a significant positive or negative effect on the symptoms or course of ADHD. People with ADHD should eat a healthy diet and probably avoid caffeine. That having been said, if the family’s experience with a person having ADHD is that some sort of dietary change, such as decreased refined sugar intake, helps, then if the person is not deprived of necessary nutrients, there is certainly no harm in trying to follow such a plan. A good rule of thumb is to discuss the plan with the family doctor or whoever is providing the primary treatment for the ADHD symptoms.
 
Activity: Regular physical activity has been shown to play an important role in some of the common related conditions (for example, depression, anxiety) and to improve concentration. Regular exercise may be beneficial in people with ADHD.

|Follow-up|

Your primary care provider, behavioral pediatrician, or child and adolescent psychiatrist will want to see you or your child often at first to monitor progress and response to therapy. Once the individual's condition is stabilized, follow-up visits will be regular but less frequent.

• The frequency of follow-up visits is quite variable and is dictated by the person’s characteristics and convenience, provider experience, and use of psychotherapy.
  
  
• Follow-up visits every 4-12 weeks are often appropriate for the first year. After that, visits every 3-4 months for medication assessment may be adequate for a person whose condition is stable.
  
  
• Behavioral therapy may need to be ongoing for months or years.

Federal and state laws grant special educational accommodations for children with ADHD and learning disabilities. Become familiar with these laws.

|Prevention|

No clear methods for preventing ADHD are currently known. While some people have suggested that certain diets, teaching or parenting methods, or other approaches may keep ADHD from happening, unfortunately, none of these approaches has stood up to rigorous scientific testing so far. On the other hand, once the symptoms have begun and careful assessment has produced an ADHD diagnosis, various specific behavioral and learning techniques can be used by teachers and family to help get symptoms under better control. These should be discussed with the treating doctor so that the right interventions can be applied for the specific person.

|Outlook|

The outlook for people with ADHD is excellent as long as the following conditions are met:

• No major related conditions
• 
  
• Continued adherence to the therapy recommended by health care providers
• 
  
• Any and all coexisting learning disabilities are diagnosed and addressed
• 
  
• Any and all coexisting emotional problems are investigated and treated appropriately by a primary care physician or an appropriate mental health professional

The outlook for people with related conditions or who do not receive appropriate remediation and/or treatment for their disabilities is less promising. The actual outcome for any specific individual cannot be predicted accurately because of the many variables involved.

|Support Groups and Counseling|

Attention-deficit/hyperactivity disorder, whether it is you or your child who is affected, brings many challenges. People with ADHD can learn, achieve, succeed, and create a happy life for themselves, but not without effort. You need to change your expectations and get organized. Only then can you learn practical ways to cope with ADHD and put them into practice. But making changes is not always easy. Sometimes it helps to have someone to talk to.

This is the purpose of support groups. Support groups consist of people in the same situation you are in. They come together to help each other and to help themselves. Support groups provide reassurance, motivation, and inspiration. They help you see that your situation is not unique and not hopeless, and that gives you power. They also provide practical tips on coping with ADHD and navigating the medical, educational, and social systems that you will rely on for help for yourself or your child. Being in an ADHD support group is strongly recommended by most mental health professionals.

Support groups meet in person, on the telephone, or on the Internet. To find a support group that works for you, contact the following organizations. You can also ask your health care provider, behavioral therapist, or education specialist, or go on the Internet. If you do not have access to the Internet, check with your child's teacher or go to the public library.

• Attention Deficit Disorder Association - (484) 945-2101 



• Attention Deficit Information Network - (781) 455-9895



• Children and Adults with Attention-Deficit/Hyperactivity Disorder - (800) 233-4050



• Federation of Families for Children's Mental Health - (703) 684-7710



• Learning Disabilities Association of America - (412) 341-1515

Attention Deficit Disorder Association
PO Box 543
Pottstown, PA 19464
(484) 945-2101

The Attention Deficit Information Network, Inc.
58 Prince St
Needham, MA 02492
(781) 455-9895
 
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
8181 Professional Place, Suite 150
Landover, MD 20785
(800) 233-4050
 
Learning Disabilities Association of America
4156 Library Rd
Pittsburgh, PA 15234-1349
(412) 341-1515
 
National Center for Learning Disabilities
381 Park Avenue South, Suite 1401
New York, NY 10016
(888) 575-7373

National Dissemination Center for Children with Disabilities (NICHCY)
PO Box 1492
Washington, DC 20013
(800) 695-0285
 
National Institute of Mental Health (NIMH)
Office of Communications
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
(866) 615-6464

|Web Links|

Children and Adults with Attention-Deficit/Hyperactivity Disorder, AD/HD Fact Sheets

National Center on Birth Defects and Developmental Disabilities, Attention-Deficit/Hyperactivity Disorder

Centers for Disease Control and Prevention, National Dissemination Center for Children with Disabilities, Attention Deficit/Hyperactivity Disorder

Centers for Disease Control and Prevention, National Dissemination Center for Children with Disabilities, ADHD Fact Sheet

National Institute of Mental Health, National Institutes of Health, Attention Deficit Hyperactivity Disorder

National Institute of Neurological Disorders and Stroke, National Institutes of Health, NINDS Attention Deficit-Hyperactivity Disorder Information Page 

Attention Deficit Disorder Association, Medications: Addressing Parental Fears and Concerns

ADHD, AD/HD, ADD, ADD/ADHD, attention deficit disorder, attention deficit disorder with and without hyperactivity, attention deficit hyperactivity disorder, attention-deficit hyperactivity disorder, hyperkinetic impulse disorder, hyperactive syndrome, hyperkinetic reaction of childhood, minimal brain damage, minimal brain dysfunction, undifferentiated attention deficit disorder, attention-deficit/hyperactivity disorder

Author: Susan Louisa Montauk, MD, Medical Director, Affinity Center; Professor, Department of Family Medicine, University of Cincinnati College of Medicine.

Coauthor(s): Douglas W Pentz, MA, PhD, Cofounder and Clinical Director, The Affinity Center, Cincinnati, Ohio.

Editors: Ronald C Albucher, MD, Assistant Chief, Psychiatry Service, VA Ann Arbor Healthcare System; Clinical Assistant Professor, Department of Psychiatry, University of Michigan School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Alan D Schmetzer, MD, Professor and Assistant Chair for Education, Department of Psychiatry, Indiana University School of Medicine.