Attention-Deficit / Hyperactivity Disorder (ADHD) in Children

Attention-Deficit/Hyperactivity Disorder (ADHD) is a behavioral condition most commonly presenting in childhood. Primary symptoms of ADHD include problems with inattention/distractibility, hyperactivity, and poor impulse control. However, these symptoms vary and some children with ADHD present with mostly hyperactive and impulsive symptoms, some with primarily inattentive symptoms, and others with all of these symptoms combined.

ADHD (all types) is fundamentally a disorder of behavioral inhibition. In general, this means that children with ADHD often struggle to

  • Tune out distractions
  • Control the impulse to respond or react to the surrounding environment
  • Persist or give a sustained effort to complete everyday tasks
  • Shift or change from one mental demand to another

It is important to note that ADHD is a disorder of performance not ability. In fact, most children with ADHD have average intelligence, but they may perform below average on cognitive and other tasks. 

What are the different types of ADHD?

3 major types of ADHD are specified by the following:

  • ADHD, Combined Type. The most common type of ADHD is characterized by impaired behavioral self-regulation (hyperactivity, impulsivity) and impaired attention (distractibility, poor sustained mental effort).
  • ADHD, Hyperactive/Impulsive Type. This is the least common type of ADHD and it is often believed to reflect a Combined Type presentation, but with severe behavioral symptoms that might be overshadowing the less noticeable inattentive symptoms. These symptoms are characterized by poor impulse control, hyperactive behaviors, and more general difficulties related to behavioral self regulation (e.g. poor personal space boundaries, interrupting others).
  • ADHD, Inattentive and Distractible Type. This type of ADHD is characterized by problems with distractibility, poor sustained mental effort, difficulty initiating tasks, problems organizing materials and/or information, and poor planning and time management. This ADHD specification was previously referred to as Attention-Deficit Disorder (ADD) and consists of primary executive functioning problems with much less interfering behavioral concerns.

What causes attention-deficit/hyperactivity disorder?

ADHD is one of the most researched areas in child and adolescent mental health. While the precise cause of the disorder is still unknown, there are several known risk factors associated with ADHD. These include difficulties occurring during pregnancy (e.g. exposure to toxins such as lead, illicit drugs), during child birth (e.g. premature delivery, low birth weight, trauma), from early neurological insult/head trauma, and those resulting from a genetic predisposition (i.e. family history of ADHD).  

While most noticeable in a child’s behavior, ADHD is a brain-based biological disorder. It is not caused by poor parenting or a chaotic home environment, although good parenting practices are the key to symptom management.  Low levels of dopamine (a brain chemical), which is a neurotransmitter (a type of brain chemical), are found in children with ADHD. Brain imaging studies using PET scanners (positron emission tomography, a form of brain imaging that makes it possible to observe the human brain at work) show that brain metabolism in children with ADHD is lower in the areas of the brain that control attention, planning, social judgment, and movement.

Who is affected by attention-deficit/hyperactivity disorder?

ADHD occurs in 5-9% of all school-aged children and it is one of the most frequent reasons pediatricians refer children for psychological care.1-2  Boys are 2 to 3 times more likely to have ADHD of the hyperactive or combined type than girls. Symptoms of ADHD do not typically emerge later in life, but rather they are almost always apparent by the age of 12 (and often noticeable prior to age 7).

Many parents of children with ADHD experienced symptoms of ADHD when they were younger. ADHD is commonly found in brothers and sisters within the same family. Most families seek help when their child's symptoms begin to interfere with learning and adjustment to the expectations of school and age-appropriate activities.

What are the symptoms of attention-deficit/hyperactivity disorder?

The following are the most common symptoms of ADHD. However, each child may experience symptoms differently. The 3 categories of symptoms of ADHD include the following:

  • Inattention:
    • Short attention span/easily distracted for age (difficulty sustaining attention)
    • Difficulty listening to others
    • Difficulty following instructions (especially those with multiple steps)
      • Struggling to find a way to get started on tasks
      • Difficulty staying on-task without tuning out distractions
      • Poor task completion
    • Tendency to make careless errors or difficulty attending to details
    • Forgetfulness and often appearing  absent-minded 
    • Poor organizational skills for age and tendency to lose or misplace things often
    • Poor planning and time management
    • Poor study skills for age
  • Impulsivity:
    • Often interrupts others
    • Has difficulty waiting for his or her turn in school and/or social games
    • Tends to blurt out answers instead of waiting to be called upon
    • Takes frequent risks, and often responds like a reflex without thinking before acting
    • Can be physically intrusive by touching, grabbing, or disregarding personal space needs
  • Hyperactivity:
    • Seems to be in constant motion; runs or climbs, at times with no apparent goal except motion, acting as if “driven by a motor”
    • Has difficulty remaining in his seat or sitting still even when it is expected
    • Fidgets with hands or squirms when in his or her seat
    • Fidgets excessively
    • Talks excessively and may seem restless
    • Has difficulty engaging in quiet activities or monitoring the volume of his speech
    • Frequently shifts from one task to another without fully engaging in any one activity or completing tasks

Symptoms of ADHD may resemble other medical conditions, mental health problems, learning difficulties or other behavior problems. Keep in mind that many of these symptoms may occur in children and teens who do not have ADHD. A key element in diagnosis is that the symptoms must significantly impair adaptive functioning in both home and school environments. If you have concern that your child may have ADHD, consult your child's doctor to request a diagnostic evaluation.

How is attention-deficit/hyperactivity disorder diagnosed?

ADHD is the most commonly diagnosed behavior disorder of childhood. A pediatrician, psychologist, child psychiatrist, or a qualified mental health professional usually identifies ADHD in children.  Diagnostic evaluations for ADHD should include a detailed interview to account for the child's developmental, health, and psychosocial history, observations of the child's behavior, and review of standardized rating scales that are completed by the child’s parents and teachers. Though psychoeducational testing may be helpful, it is not necessary for making an informed diagnosis of ADHD.

Because ADHD symptoms are “normal behaviors” that occur more frequently or in ways that interfere with everyday functioning, diagnosis depends on the clinician’s ability to rule out other possible explanations for these symptoms (e.g. underlying medical issues, learning difficulties, emotional problems, reactions to life stressors, etc.). Consult your child's doctor for more information.

Treatment for attention-deficit/hyperactivity disorder

Specific treatment for ADHD will be determined by your child's doctor based on:

  • Your child's age, overall health, and medical history
  • Extent of your child's symptoms
  • Your child's tolerance for specific medications or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Major components of treatment for children with ADHD include parental support and education in behavioral training, appropriate school placement, and medication. Treatment with a psychostimulant is highly effective in most children with ADHD. Effective treatment may include:

  • Psychostimulant medications. These medications are used for their ability to balance chemicals in the brain that prohibit the child from maintaining attention and controlling impulses. They help "stimulate" areas of the brain that control attention and behavioral self-regulation. Medications that are commonly used to treat ADHD include the following:
    • Methylphenidate (Concerta, Daytrana Transdermal, Metadate, Methylin, Ritalin)
    • Dextroamphetamine Sulfate (Dexedrine, Zenzedi)*
    • Dexmethylphenidate (Focalin)
    • Amphetamine salts, D- and L-amphetamine (Adderall)*
    • Lisdexamfetamine Dimesylate (Vyvanse)

*only psychostimulants that are FDA approved for children under age 6

Psychostimulants have been used to treat childhood behavior disorders since the 1930s and have been widely studied.  While there are many types, they are all within the same class of medications and they serve the same function – to stimulate inhibitory and self-regulation centers in the brain. Immediate release stimulants take effect in the body quickly, work for 1 to 4 hours, and then they are eliminated from the body. Many long-acting stimulant medications are also available, lasting 8 to 9 hours, and require only 1 daily dose.

The common side effects of stimulants often include decreased appetite, stomach aches, headaches, jitteriness and irritability when medications are wearing off.  With the exception of decreased appetite, most of these are considered “nuisance” side effects, suggesting that they are likely to go away after a period of repeated use (typically 1-2 weeks) allows the child’s body to adjust. 

Other Medications for ADHD: There is recent scientific evidence to support the benefits of Omega-3 fatty acid (e.g. Fish Oil, prescription level Vayarin) supplements for improving attention and concentration.3 These are not medications per se, but rather they are considered “medical food.” Although benefits have been observed across a number of different studies, the benefits of these supplements are small and not equivalent to those of psychostimulants or behavior therapies. 

There are also many medications advertised as “non-stimulant” ADHD medication alternatives. Examples of non-stimulants used to treat ADHD are Atomoxine (Straterra), Guanfacine (Intuniv, Tenex), and Catapres (Clonidine, Kapvay). These medications are simply not as effective for reducing ADHD symptoms and have greater potential for negative side effects compared to psychostimulant medications. 

  • Psychosocial treatments. Parenting children with ADHD may be difficult and can present challenges that create stress within the family. Psychosocial/non-medical treatments for ADHD include (1) Behavioral Parent Training or Parent Management Training and (2) Classroom Behavioral Management Strategies, and (3) Summer Treatment Programs that combine parent training and classroom strategies. These scientifically supported interventions target adults for implementation and monitoring. Individual child therapy (especially play therapy) has NOT been shown to be effective for children with ADHD.
    • Behavioral Parent Training/Parent Management Training  emphasizes increasing desired behaviors and decreasing disruptive behaviors using positive reinforcement, improving parent-child interactions and communication, and improving family coping and well-being.
    • Behavioral Classroom Management involves individualized behavioral goal-setting, monitoring, and reinforcement systems in the school environment. One of the most common strategies used is a daily report card or school to home note for monitoring progress and allocating rewards for classroom behaviors.
    • Summer Treatment Programs provide typical camp activities such as sports and other outdoor recreational activities, but use a great deal of behavioral modification strategies to help children participate and succeed. These programs also provide parent training and classroom behavior management activities as well.

Prevention of attention-deficit/hyperactivity disorder

Preventive measures to reduce the incidence of ADHD are not known at this time. However, early detection and intervention can reduce the severity of symptoms, decrease the interference of behavioral symptoms on school functioning, enhance the child's normal growth and development and improve the quality of life experienced by children or adolescents with ADHD.

Children with ADHD often experience significant challenges with their annual transition back to school. One of the best things that parents can do to prevent adjustment problems is to be more proactive before each new school year begins. 4 specific ways that parents can prevent school problems are:

  1. Set good routines and establish consistent daily schedules 2-3 weeks before school begins.
  2. Seek parent management training/behavioral consultation to promote better coping and adaptive functioning for your child (and family). If you have already done this, consider scheduling “booster sessions” with your psychologist before the school year begins.
  3. Establish a stable dose of medication (if the child is taking an ADHD medication). Note that pediatricians become very busy toward the end of summer with well-child exams, vaccinations and pre-athletic physicals. Schedule your child’s visit several weeks before the end of summer.
  4. Make a plan with your child’s teacher and other educators at the school to ensure effective classroom accommodations for ADHD are in place.

References:

  1.  Froehlich, T. E., Lanphear, B. P., Epstein, J. N., Barbaresi, W. J., Katusic, S. K., & Kahn, R. S. (2007). Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Archives of pediatrics & adolescent medicine, 161(9), 857-864.
  2. Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., ... & Blumberg, S. J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 34-46.
  3. Bloch, M. H. & Qawasmi, A. (2011). Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry, 50, 991-1000. doi: 10.1016/j.jaac.2011.06.008.