Attention-deficit/hyperactivity disorder (ADHD) in children

Overview

Attention-deficit/hyperactivity disorder, also called ADHD, is a long-term condition that affects millions of children. It often continues into adulthood. ADHD includes a mix of ongoing problems. These can include having a hard time paying attention, being hyperactive and being impulsive.

Children with ADHD also may have low self-esteem and troubled relationships and do poorly in school. Symptoms sometimes lessen with age. Some people never completely outgrow their ADHD symptoms but they can learn strategies to be successful.

While treatment won't cure ADHD, it can help a great deal with symptoms. Besides giving education about ADHD, treatment can involve medicines and behavior therapies. Early diagnosis and treatment can make a big difference in results.

Symptoms

The main features of ADHD include not paying attention and being hyperactive and impulsive. ADHD symptoms usually start before age 12. In some children, they can be seen as early as 3 years of age. ADHD symptoms can be mild, moderate or severe. Symptoms need to be seen in two or more settings, such as at home and at school. The symptoms cause problems with development and daily life and may continue into adulthood.

ADHD occurs more often in boys than in girls. Behaviors can be different in boys and girls. For example, boys may be more hyperactive and girls may tend to quietly not pay attention.

There are three types of ADHD:

• Predominately inattentive. In this type, most symptoms fall under inattention. This means having trouble focusing and staying on a task. It also includes trouble getting and staying organized.
• Predominately hyperactive and impulsive. In this type, most symptoms involve being hyperactive and impulsive. Hyperactive means being too active and having too much energy. It may include disruptive behavior. Being impulsive means acting without thinking ahead about the results or effects of behavior.
• Combined. This type is a mix of inattentive symptoms and hyperactive and impulsive symptoms. The person meets the criteria for both predominately inattentive and predominately hyperactive and impulsive types of ADHD.

Inattentive symptoms

A child who shows a pattern of inattention may often:

• Fail to pay close attention to details or make careless mistakes in schoolwork.
• Have trouble staying focused in tasks or play.
• Seem not to listen, even when spoken to directly.
• Have a hard time following through on instructions and not finish schoolwork or chores.
• Have trouble organizing tasks and activities.
• Stay away from or not like tasks that need focused mental effort, such as homework.
• Lose items needed for tasks or activities, for example, toys, school assignments, pencils.
• Be easily distracted by other things, thoughts or activities rather than finishing a task.
• Forget to do some daily activities, such as forgetting to do chores.

Hyperactive and impulsive symptoms

A child who shows a pattern of hyperactive and impulsive symptoms may often:

• Fidget with or tap hands or feet, or squirm in the seat.
• Have a hard time staying seated in the classroom or in other situations.
• Be on the go, in constant motion.
• Run around or climb in situations when it's not proper.
• Have trouble playing or doing an activity quietly.
• Talk too much.
• Blurt out answers, interrupting the questioner.
• Have trouble waiting for a turn.
• Interrupt others' conversations, games or activities.

Typical development versus ADHD

Most healthy children are inattentive, hyperactive or impulsive at one time or another. It's typical for preschoolers to have short attention spans and not be able to stick with one activity for long. Even in older children and teenagers, attention span often depends on the level of interest.

The same is true of hyperactivity. Young children are naturally energetic. They often are still full of energy long after they've tired their parents. And some children just naturally have a higher activity level than others do. Children should never be classified as having ADHD just because they're different from their friends or siblings.

Children who have problems in school but get along well at home or with friends may likely have a concern other than ADHD. The same is true of children who are hyperactive or inattentive at home but whose schoolwork and friendships aren't affected.

When to see a doctor

If you're concerned that your child shows signs of ADHD, see your pediatrician or family healthcare professional. Your healthcare professional can do a medical evaluation to check for other causes of your child's symptoms. Then if needed, your child may be referred to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist.

Causes

While the exact cause of ADHD is not clear, research efforts continue. Factors that may be involved in the development of ADHD include genetics, the environment or central nervous system conditions at key moments in development.

Risk factors

Risk factors for ADHD may include:

• Having a blood relative, such as a parent or sibling, with ADHD or another mental health condition.
• Being around environmental toxins such as lead, which is found mainly in paint and pipes in older buildings.
• Being born to a parent who used recreational drugs, alcohol or tobacco during pregnancy.
• Being born too early, also called premature birth.

Although many people seem to believe that sugar causes hyperactivity, there's no proof of this. Many issues in childhood can lead to trouble paying attention, but that's not the same as ADHD.

Complications

ADHD can make life hard for children. Children with ADHD:

• Often have trouble in the classroom, which can lead to failing grades and being judged by other children and adults.
• Tend to have more accidents and injuries of all kinds than do children who don't have ADHD.
• Tend to have poor self-esteem.
• Are more likely to have trouble interacting with and being accepted by peers and adults.
• Are at higher risk of alcohol and drug misuse and other behavior that can cause problems with the law.
• Have a higher risk of suicidal thoughts and suicide.
• Have sleep disorders.

Conditions often linked with ADHD

ADHD does not cause other mental health or developmental problems. But children with ADHD are more likely than others to also have conditions such as:

• Oppositional defiant disorder. This condition is generally defined as a pattern of negative, defiant and hostile behavior toward people who are in authority.
• Conduct disorder. This involves antisocial behavior such as stealing, fighting, destroying property, and harming people or animals.
• Disruptive mood dysregulation disorder. This involves irritability and problems handling frustration.
• Learning disabilities. These can include problems with reading, writing, understanding and communicating.
• Substance use disorders. This involves misuse of drugs, alcohol, marijuana or nicotine.
• Anxiety. This results in constant worry and nervousness that affect daily life.
• Obsessive-compulsive disorder, also called OCD. OCD is a pattern of unwanted thoughts and fears that lead to repetitive behaviors. These get in the way of daily activities and cause a lot of distress.
• Mood disorders. These include depression and bipolar disorder. Bipolar disorder includes depression and manic behavior.
• Autism spectrum disorder. This condition is related to brain development. It impacts how a person thinks of and socializes with others.
• Tic disorders. These conditions involve repetitive movements or unwanted sounds, called tics, that can't be easily controlled.

Prevention

To help lower your child's risk of ADHD:

• During pregnancy, avoid anything that could harm your baby's development before birth. For example, don't drink alcohol, use drugs or smoke cigarettes.
• Protect your child from exposure to pollutants and toxins, including cigarette smoke and lead paint.
• Limit screen time. Although still not proved, it may be a good idea for young children to limit TV, video games and other screen time.

Diagnosis

In general, a diagnosis of attention-deficit/hyperactivity disorder is made if the core symptoms of ADHD start early in life — before age 12 — and create major problems at home and at school on an ongoing basis.

There's no specific test for ADHD. An evaluation can help find out whether symptoms are related to ADHD or another problem. Making a diagnosis will likely include:

• A medical exam. This can help rule out other possible causes of symptoms.
• Information gathering. This includes reviewing any current medical conditions, personal and family medical history, and school records.
• Interviews or surveys. These may include information from family members, teachers or other people who know your child well, such as caregivers, babysitters and coaches. This information can show how your child behaves in different situations.
• ADHD rating scales. These help collect and evaluate information about your child.

Diagnosing ADHD in young children

Signs of ADHD can sometimes be noticed in preschoolers or even younger children. But diagnosing the condition in very young children is harder. That's because developmental conditions such as language delays can be mistaken for ADHD.

Children preschool age or younger suspected of having ADHD are more likely to need evaluation by a specialist, such as a psychologist or psychiatrist, speech pathologist, or developmental pediatrician.

Other conditions with symptoms like those of ADHD

Some medical conditions or their treatments may cause symptoms much like those of ADHD. Examples include:

• Learning or language delays.
• Mood disorders such as depression.
• Anxiety disorders.
• Seizure disorders.
• Vision or hearing conditions.
• Autism spectrum disorder.
• Medical conditions or medicines that affect thinking or behavior.
• Sleep disorders.
• Brain injury.

Treatment

Standard treatments for ADHD in children include medicines, behavior therapy, counseling and education services. These treatments can lessen many of the symptoms of ADHD, but they don't cure it. Treatment also can help prevent some complications caused by ADHD. It may take some time to find what works best for your child.

Stimulant medicines

Stimulant medicines, also called psychostimulants, are currently the most prescribed medicines for ADHD. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters. The medicines help lessen the symptoms of inattention and hyperactivity. They can sometimes help in a short period of time.

Examples of stimulant medicines include:

• Amphetamines. These include dextroamphetamine (Dexedrine Spansule), dextroamphetamine-amphetamine (Adderall XR, Mydayis) and lisdexamfetamine (Vyvanse).
• Methylphenidates. These include methylphenidate (Concerta, Ritalin, others), dexmethylphenidate (Focalin) and dexmethylphenidate-serdexmethylphenidate (Azstarys).

Stimulant medicines are available in short-acting and long-acting forms. Long-acting patches of methylphenidate (Daytrana) or dextroamphetamine (Xelstrym) are available. They can be worn on the hip.

The right dose varies from child to child, so it may take time to find what works for your child. And the dose may need to be adjusted if side effects occur or as your child matures. Ask your healthcare professional about possible side effects of stimulant medicines.

Stimulant medicines and certain health risks

Some research suggests that using ADHD stimulant medicines with certain heart problems may be a concern. Weight and growth may be affected. Also, the risk of certain mental health symptoms may be higher when using stimulant medicines.

• Heart conditions. Stimulant medicines may cause a rise in blood pressure or heart rate. But the higher risk of serious side effects or sudden death is still not proved. The healthcare professional evaluates your child for any heart condition or family history of heart disease before prescribing a stimulant medicine. The healthcare professional also monitors your child when stimulant medicines are used.
• Appetite changes, weight loss and slowed growth. Stimulant medicines can affect appetite and cause weigh loss. These medicines also can slightly affect height growth.
• Mental health conditions. Stimulant medicines may rarely raise the risk for agitation or irritability. Uncommonly, manic symptoms or losing touch with reality can happen. Contact your child's healthcare professional right away if your child has sudden new or worsening behavior or sees or hears things that aren't real while taking stimulant medicine.

Other medicines

Medicines that are sometimes called nonstimulants have been approved by the U.S. Food and Drug Administration, also called the FDA, to treat ADHD. These include:

• Atomoxetine (Strattera).
• Viloxazine (Qelbree).
• Guanfacine (Intuniv).
• Clonidine (Onyda XR).

Antidepressants, such as bupropion (Aplenzin, Wellbutrin XL, others), are not specifically approved by the FDA to treat ADHD. But they may be effective if other medicines haven't worked or have too many side effects.

Atomoxetine and antidepressants work slower than stimulant medicines do and may take several weeks to show a full effect. These may be good options if your child can't take stimulant medicine because of health conditions or severe side effects.

Suicide risk

Although not proved, concerns have been raised that there may be a slightly higher risk of suicidal thinking in children and teenagers taking atomoxetine, viloxazine or antidepressants. Contact your child's healthcare professional right away if you notice any signs of depression or suicidal thinking.

Give medicines safely

It's very important to make sure your child takes the right amount of the prescribed medicine. Parents may be concerned about stimulant medicines and the risk of misuse and addiction. Stimulant medicines are considered safe when your child takes the medicine as prescribed by the healthcare professional. Your child should see the healthcare professional regularly to decide if the dose of the medicine needs to be adjusted.

There is concern that other people might misuse stimulant medicines prescribed for children and teenagers with ADHD. To keep your child's medicine safe and to make sure your child is getting the right dose at the right time:

• Give medicines carefully. Supervise children and teens when they take ADHD medicines rather than letting them be in charge on their own.
• At home, keep medicine in a childproof container. Also store medicine out of the reach of children. An overdose of stimulant medicine is serious and could result in death.
• Don't send supplies of medicine to school with your child. Deliver any medicine yourself directly to the school nurse or health office.

ADHD behavior therapy

Children with ADHD often benefit from behavior therapy, social skills training, parent skills training and counseling. These may be provided by a psychiatrist, psychologist, social worker or other mental health professional. Some children with ADHD also may have other mental health conditions such as anxiety or depression. Counseling may help both ADHD and the other condition.

Examples of therapy include:

• Behavior therapy. Teachers and parents can learn behavior-changing strategies, such as token reward systems and timeouts, for dealing with difficult situations.
• Social skills training. This can help children learn proper social behaviors.
• Parenting skills training. This can help parents develop ways to understand and guide their child's behavior.
• Talk therapy. Also called psychotherapy, this allows older children with ADHD to talk about issues that bother them, explore negative behavior patterns and learn ways to deal with their symptoms.
• Family therapy. Family therapy can help people find ways to overcome challenges that may arise when a family member has ADHD.

The best results happen when a team approach is used. Your child's team may include teachers, parents, therapists and healthcare professionals working together. Learn about ADHD and available services. Work with your child's teachers and refer them to trusted sources of information to support their efforts in the classroom.

Medical devices

The FDA has approved two devices for ADHD. They both need a prescription.

• Monarch external trigeminal nerve stimulation (eTNS) system. This is a medical device to treat children with ADHD who are 7 to 12 years old and not taking ADHD prescription medicine. The device creates low-level electrical pulses that move through a wire to a small patch placed on the child's forehead. Signals are sent to areas of the brain that relate to attention, emotion and behavior.
• EndeavorRx. This is a game-based digital therapeutic device. The game is designed to improve attention in children with predominately inattentive- or combined-type ADHD who are 8 to 17 years old.

These devices have FDA approval, but they are new and have limited evidence and data to guide treatment. If you're considering these devices, it's important to talk with your healthcare professional about precautions, expectations and possible side effects. Get complete information and instructions from your healthcare professional.

Ongoing treatment

Your child should see a healthcare professional regularly while being treated for ADHD. If symptoms are much better and stable, visits usually take place every 3 to 6 months.

Contact the healthcare professional if your child has any medicine side effects, such as loss of appetite, trouble sleeping or worse irritability. Also contact the healthcare professional if your child's ADHD symptoms are not getting better with the current treatment.

Lifestyle and home remedies

Because ADHD is complex and each person with ADHD is different, it's hard to make recommendations that work for every child. But some of the following suggestions may help create an environment in which your child can succeed.

Children at home

• Encourage your child. Children need to hear that they're loved and appreciated. Focusing only on the negative parts of your child's behavior can harm your relationship and affect self-confidence and self-esteem. If your child has a hard time accepting verbal signs of affection, a smile, a pat on the shoulder or a hug can show you care. Look for behaviors for which you can compliment your child.
• Find ways to improve self-esteem. Children with ADHD often do well with art projects, music or dance lessons, or martial arts classes. Choose activities based on their interests and abilities. All children have special talents and interests that can be encouraged. Small, frequent successes help build self-esteem.
• When giving directions, use simple words and show how something is done. Speak slowly and quietly and be very specific and concrete. Give one direction at a time. Stop and make eye contact with your child before and while you're giving directions.
• Be flexible about difficult situations. Be aware of your child's limits and adapt to meet the child's needs when possible. Try to stay away from situations that are difficult for your child. Examples include sitting through long presentations or shopping in large stores where seeing so many people and products can be too much for your child.
• Use timeouts or the proper reaction when needed. Be clear about the behavior expected. Start with firm, loving discipline that rewards good behavior and discourages negative behavior. Timeouts should be relatively brief but long enough for your child to regain control. The idea is to interrupt and calm out-of-control behavior. Children also can be expected to accept the results of the choices they make.
• Work on being organized. Help your child organize and maintain a daily assignment and activities notebook or chart. Be sure your child has a quiet place to study. Group objects in the child's room and store them in clearly marked spaces. Try to help your child keep spaces organized and free of clutter.
• Try to keep a regular schedule for meals, naps and bedtime. Children with ADHD have a hard time accepting and adjusting to change. Use a big calendar to mark everyday chores and special activities that are coming up. Don't make sudden changes from one activity to another or at least warn your child if you need to do so.
• Encourage social contacts. Help your child learn social skills by modeling, recognizing and rewarding positive communications and interactions with family members and friends.
• Adopt healthy lifestyle habits. Make sure your child is rested. Try to keep your child from becoming too tired because tiredness often makes ADHD symptoms worse. It's important that your child eat a balanced diet for healthy development. Along with medical treatment, regular exercise has health benefits and may have a positive effect on behavior.

Children in school

Learn all you can about ADHD and opportunities to help your child be successful. You are your child's best support.

• Ask about school programs. Schools are required by law to have programs that give support to children who have a disability that interferes with learning. Your child may be eligible for extra services offered under federal laws: Section 504 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA).

  These extra services can include evaluation, changes in coursework, changes in classroom setup, changes in teaching methods, study skills instruction, use of computers, and more interaction between parents and teachers. These education services can be written in your child's education plan, called an individualized education plan. Another name for this plan is IEP.

• Talk with your child's teachers. Talk often with teachers. Support their efforts to help your child in the classroom. Make sure that teachers closely monitor your child's work, give positive feedback, and are flexible and patient. Ask that they be very clear about their instructions and what they expect.

Alternative medicine

Alternative medicine means using another approach instead of standard medical care. Complementary medicine means using alternative medicine along with standard medical care. This mix is sometimes called integrative medicine.

There's little research that shows that alternative or complementary medicine can lessen ADHD symptoms. If you're thinking about trying alternative medicine, talk with your child's healthcare professional first to decide if the therapy is safe and effective. Some alternative medicine treatments that have been tried but are not yet fully proved scientifically include:

• Yoga or meditation. Regular yoga or meditation and relaxation techniques may help children relax and learn discipline. This may help them manage their symptoms of ADHD.

• Special diets. Most diets promoted for ADHD involve not eating foods thought to worsen hyperactivity, such as sugar, and foods that are common allergens, such as wheat, milk and eggs. Some diets recommend staying away from artificial food colorings and additives. So far, studies haven't found a consistent link between diet and fewer symptoms of ADHD.

  Also, limiting foods may keep children from getting a healthy well-balanced diet. Some evidence based on individual reports or personal experience suggests diet changes might make a difference in children with specific food sensitivities. Using caffeine as a stimulant for children with ADHD can have risky effects and is not recommended.

• Vitamin or mineral supplements. While certain vitamins and minerals from foods are needed for good health, there's no evidence that supplemental vitamins or minerals can lessen symptoms of ADHD. "Megadoses" of vitamins, which are doses far above the Recommended Dietary Allowance can be harmful.
• Herbal supplements. There is no evidence to suggest that herbal remedies help with ADHD, and some may be harmful.
• Proprietary formulations. These are products made from vitamins, micronutrients and other ingredients that are sold as possible treatment supplements for children with ADHD. These products have had little or no research and are not monitored by the FDA, making them possibly not effective or harmful.
• Essential fatty acids. These fats, which include omega-3 fatty acids, are needed for the brain to work properly. Researchers are still studying whether these may lessen ADHD symptoms.
• Neurofeedback training. This also is called electroencephalographic biofeedback. During these sessions, a child focuses on certain tasks while using a machine that shows brain wave patterns. Using the feedback on the monitor, the child learns to control brain activity to help manage focus and behavior. More research is needed to see if this works.

Coping and support

Caring for a child with ADHD can be challenging for the whole family. Caregivers may be distressed by their child's behavior as well as by the way other people respond. The stress of dealing with ADHD can lead to conflict in a marriage or partnership. These problems can be made worse by the financial burden that ADHD can place on families.

Siblings of a child with ADHD also may have a hard time. They can be affected by a sibling who is demanding or aggressive. They also may get less attention because the child with ADHD requires so much of a parent's time.

Resources

Many resources are available, such as social services and support groups. Support groups can offer helpful information about coping with ADHD. Ask your child's healthcare professional about support groups in your area.

There also are excellent books and guides for both parents and teachers, as well as internet sites dealing with ADHD. Be careful with websites or other resources that give advice that's risky or not proved or doesn't match your healthcare team's recommendations.

Strategies for coping

Many parents notice patterns in their child's behavior and in their own responses to that behavior. Both you and your child may need to change behavior. But changing new habits for old ones takes a lot of hard work.

Be realistic in your expectations for improvement — both your own and your child's. Also keep your child's developmental stage in mind. Set small goals for both yourself and your child. Don't try to make a lot of changes all at once.

• Stay calm and set a good example. Act the way you want your child to act. Try to stay patient and in control, even when your child is out of control. If you speak quietly and calmly, your child is more likely to calm down too. Learning stress management techniques can help you deal with your own frustrations.
• Take time to enjoy your child. Try to accept and appreciate the parts of your child's personality that aren't so hard to manage. One of the best ways to do this is simply to spend time together. Find a time without the distraction of other children or adults. Try to give your child more positive than negative attention every day.
• Strive for healthy family relationships. The relationship among all family members plays a big part in managing or changing the behavior of a child with ADHD. Couples with a strong bond often find it easier to face parenting challenges than those whose bond isn't as strong. Take time to build and support your partner relationship and relationships with your other children.
• Give yourself a break. Give yourself a break now and then. Don't feel guilty for spending a few hours apart from your child. You'll be better able to cope if you're rested and relaxed. Don't hesitate to ask relatives and friends for help. Make sure that babysitters or other caregivers understand about ADHD and are mature enough for the task.
• Get help if you need it. If you feel too stressed, frustrated or depressed, talk with a mental health professional.

Preparing for an appointment

You're likely to start by taking your child to a pediatrician or family healthcare professional. Depending on the results of the evaluation, your healthcare professional may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist.

What you can do

To prepare for your child's appointment:

• Make a list of any symptoms and troubles your child has at home or at school.
• Bring notes about important personal information, including any major stresses or recent life changes.
• Make a list of all medicines, vitamins, herbs and other supplements that your child is taking, and the doses.
• Bring any past evaluations and results of formal testing if you have them, and school report cards.
• Make a list of questions to ask your child's healthcare professional.

Questions to ask may include:

• Other than ADHD, what are possible causes for my child's symptoms?
• What kinds of tests does my child need?
• What treatments are available, and which do you recommend?
• What are options other than the main approach that you're suggesting?
• My child has other health conditions. How can I best manage these conditions together?
• Should my child see a specialist?
• Is there a generic option for the medicine you're prescribing for my child?
• What types of side effects can we expect from the medicine?
• Are there any printed materials that I can have? What websites do you suggest?

Feel free to ask other questions during your appointment.

What to expect from your doctor

Your healthcare professional may ask you questions, such as:

• When did you first notice your child's behavior issues?
• Do the troubling behaviors occur all the time or only in some situations?
• How big of a challenge are your child's behaviors at home and at school?
• What, if anything, appears to make your child's behavior worse?
• What, if anything, seems to make your child's behavior better?
• Does your child drink beverages with caffeine? How often?
• What are your child's sleep hours and patterns?
• How well has your child done in school in the past and how is your child doing now?
• Does your child read at home? Does your child have trouble reading?
• What do you do when your child doesn't behave well or doesn't follow the rules at home? Which methods of discipline work the best?
• Describe who lives at home and a typical daily routine.
• Describe your child's family and friend relationships at home and at school.

Be ready to answer questions so you have time to talk about what's most important to you.