Attention-deficit/hyperactivity disorder (ADHD) in children

Overview

Attention-deficit/hyperactivity disorder (ADHD) is a chronic condition that affects millions of children and often continues into adulthood. ADHD includes a combination of persistent problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior.

Children with ADHD may also struggle with low self-esteem, troubled relationships and poor performance in school. Symptoms sometimes lessen with age. However, 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. Treatment typically involves medications and behavioral interventions. Early diagnosis and treatment can make a big difference in outcome.

Symptoms

The primary features of ADHD include inattention and hyperactive-impulsive behavior. ADHD symptoms start before age 12, and in some children, they're noticeable as early as 3 years of age. ADHD symptoms can be mild, moderate or severe, and they may continue into adulthood.

ADHD occurs more often in males than in females, and behaviors can be different in boys and girls. For example, boys may be more hyperactive and girls may tend to be quietly inattentive.

There are three subtypes of ADHD:

• Predominantly inattentive. The majority of symptoms fall under inattention.
• Predominantly hyperactive/impulsive. The majority of symptoms are hyperactive and impulsive.
• Combined. This is a mix of inattentive symptoms and hyperactive/impulsive symptoms.

Inattention

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
• Appear not to listen, even when spoken to directly
• Have difficulty following through on instructions and fail to finish schoolwork or chores
• Have trouble organizing tasks and activities
• Avoid or dislike tasks that require focused mental effort, such as homework
• Lose items needed for tasks or activities, for example, toys, school assignments, pencils
• Be easily distracted
• Forget to do some daily activities, such as forgetting to do chores

Hyperactivity and impulsivity

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

• Fidget with or tap his or her hands or feet, or squirm in the seat
• Have difficulty 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 appropriate
• Have trouble playing or doing an activity quietly
• Talk too much
• Blurt out answers, interrupting the questioner
• Have difficulty waiting for his or her turn
• Interrupt or intrude on others' conversations, games or activities

Typical developmental behavior vs. 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 be unable 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 worn their parents out. In addition, 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 are likely struggling with something other than ADHD. The same is true of children who are hyperactive or inattentive at home, but whose schoolwork and friendships remain unaffected.

When to see a doctor

If you're concerned that your child shows signs of ADHD, see your pediatrician or family doctor. Your doctor may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist, but it's important to have a medical evaluation first to check for other possible causes of your child's difficulties.

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 problems with the central nervous system at key moments in development.

Risk factors

Risk factors for ADHD may include:

• Blood relatives, such as a parent or sibling, with ADHD or another mental health disorder
• Exposure to environmental toxins — such as lead, found mainly in paint and pipes in older buildings
• Maternal drug use, alcohol use or smoking during pregnancy
• Premature birth

Although sugar is a popular suspect in causing hyperactivity, there's no reliable proof of this. Many issues in childhood can lead to difficulty sustaining attention, but that's not the same as ADHD.

Complications

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

• Often struggle in the classroom, which can lead to academic failure and judgment 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 increased risk of alcohol and drug abuse and other delinquent behavior

Coexisting conditions

ADHD doesn't cause other psychological or developmental problems. However, children with ADHD are more likely than others to also have conditions such as:

• Oppositional defiant disorder (ODD), generally defined as a pattern of negative, defiant and hostile behavior toward authority figures
• Conduct disorder, marked by antisocial behavior such as stealing, fighting, destroying property, and harming people or animals
• Disruptive mood dysregulation disorder, characterized by irritability and problems tolerating frustration
• Learning disabilities, including problems with reading, writing, understanding and communicating
• Substance use disorders, including drugs, alcohol and smoking
• Anxiety disorders, which may cause overwhelming worry and nervousness, and include obsessive compulsive disorder (OCD)
• Mood disorders, including depression and bipolar disorder, which includes depression as well as manic behavior
• Autism spectrum disorder, a condition related to brain development that impacts how a person perceives and socializes with others
• Tic disorder or Tourette syndrome, disorders that involve repetitive movements or unwanted sounds (tics) that can't be easily controlled

Prevention

To help reduce your child's risk of ADHD:

• During pregnancy, avoid anything that could harm fetal development. For example, don't drink alcohol, use recreational drugs or smoke cigarettes.
• Protect your child from exposure to pollutants and toxins, including cigarette smoke and lead paint.
• Limit screen time. Although still unproved, it may be prudent for children to avoid excessive exposure to TV and video games in the first five years of life.

Diagnosis

In general, a child shouldn't receive a diagnosis of attention-deficit/hyperactivity disorder unless the core symptoms of ADHD start early in life — before age 12 — and create significant problems at home and at school on an ongoing basis.

There's no specific test for ADHD, but making a diagnosis will likely include:

• Medical exam, to help rule out other possible causes of symptoms
• Information gathering, such as any current medical issues, personal and family medical history, and school records
• Interviews or questionnaires for family members, your child's teachers or other people who know your child well, such as caregivers, babysitters and coaches
• ADHD criteria from the Diagnostic and Statistical Manual of Mental Disorders DSM-5, published by the American Psychiatric Association
• ADHD rating scales to help collect and evaluate information about your child

Diagnosing ADHD in young children

Although signs of ADHD can sometimes appear in preschoolers or even younger children, diagnosing the disorder in very young children is difficult. That's because developmental problems such as language delays can be mistaken for ADHD.

So 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 that resemble ADHD

A number of medical conditions or their treatments may cause signs and symptoms similar to those of ADHD. Examples include:

• Learning or language problems
• Mood disorders such as depression or anxiety
• Seizure disorders
• Vision or hearing problems
• Autism spectrum disorder
• Medical problems or medications that affect thinking or behavior
• Sleep disorders
• Brain injury

Treatment

Standard treatments for ADHD in children include medications, behavior therapy, counseling and education services. These treatments can relieve many of the symptoms of ADHD, but they don't cure it. It may take some time to determine what works best for your child.

Stimulant medications

Currently, stimulant drugs (psychostimulants) are the most commonly prescribed medications for ADHD. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters. These medications help improve the signs and symptoms of inattention and hyperactivity — sometimes effectively in a short period of time.

Examples include:

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

Stimulant drugs are available in short-acting and long-acting forms. A long-acting patch of methylphenidate (Daytrana) is available that can be worn on the hip.

The right dose varies from child to child, so it may take some time to find the correct dose. And the dose may need to be adjusted if significant side effects occur or as your child matures. Ask your doctor about possible side effects of stimulants.

Stimulant medications and certain health risks

Some research indicates that using ADHD stimulant medications with certain heart problems may be a concern, and the risk of certain psychiatric symptoms may be increased when using stimulant medications.

• Heart problems. Stimulant medication may cause an increased blood pressure or heart rate, but the increased risk of serious adverse effects or sudden death is still unproved. However, the doctor should evaluate your child for any heart condition or family history of heart disease before prescribing a stimulant medication and monitor your child during stimulant use.
• Psychiatric problems. Stimulant medications may rarely increase the risk for agitation or psychotic or manic symptoms with stimulant medications use. Contact the doctor immediately if your child has sudden new or worsening behavior or sees or hears things that aren't real while taking stimulant medication.

Other medications

Other medications that may be effective in treating ADHD include:

• Atomoxetine (Strattera)
• Antidepressants such as bupropion (Wellbutrin SR, Wellbutrin XL, others)
• Guanfacine (Intuniv)
• Clonidine (Catapres, Kapvay)

Atomoxetine and antidepressants work slower than stimulants do and may take several weeks before they take full effect. These may be good options if your child can't take stimulants because of health problems or if stimulants cause severe side effects.

Suicide risk

Although it remains unproved, concerns have been raised that there may be a slightly increased risk of suicidal thinking in children and teenagers taking nonstimulant ADHD medication or antidepressants. Contact your child's doctor if you notice any signs of suicidal thinking or other signs of depression.

Giving medications safely

It's very important to make sure your child takes the right amount of the prescribed medication. Parents may be concerned about stimulants and the risk of abuse and addiction. Stimulant medications are considered safe when your child takes the medication as prescribed by the doctor. Your child should see the doctor regularly to determine if the medication needs to be adjusted.

On the other hand, there's concern that other people might misuse or abuse stimulant medication prescribed for children and teenagers with ADHD. To keep your child's medications safe and to make sure your child is getting the right dose at the right time:

• Give medications carefully. Children and teens shouldn't be in charge of their own ADHD medication without proper supervision.
• At home, keep medication locked in a childproof container. And store medication away from the reach of children. An overdose of stimulant drugs is serious and potentially fatal.
• Don't send supplies of medication to school with your child. Deliver any medication yourself 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, which may be provided by a psychiatrist, psychologist, social worker or other mental health professional. Some children with ADHD may also have other conditions such as an anxiety disorder or depression. In these cases, counseling may help both ADHD and the coexisting problem.

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 appropriate social behaviors.
• Parenting skills training. This can help parents develop ways to understand and guide their child's behavior.
• 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 parents and siblings deal with the stress of living with someone who has ADHD.

The best results occur when a team approach is used, with teachers, parents, therapists and physicians working together. Educate yourself about ADHD and available services. Work with your child's teachers and refer them to reliable sources of information to support their efforts in the classroom.

New medical device

The U.S. Food and Drug Administration approved a new medical device to treat children with ADHD who are 7 to 12 years old and not taking ADHD prescription medicine. Only available by prescription, it's called the Monarch external Trigeminal Nerve Stimulation (eTNS) System.

About the size of a cell phone, the eTNS device can be used at home under parental supervision, when the child is sleeping. The device generates low-level electrical stimulation which moves through a wire to a small patch placed on the child's forehead, sending signals to areas of the brain related to attention, emotion and behavior.

If eTNS is being considered, it's important to discuss precautions, expectations and possible side effects. Get complete information and instructions from your health care professional.

Ongoing treatment

If your child is being treated for ADHD, he or she should see the doctor regularly until symptoms have largely improved, and then typically every three to six months if symptoms are stable.

Call the doctor if your child has any medication side effects, such as loss of appetite, trouble sleeping or increased irritability, or if your child's ADHD symptoms have not shown much improvement with initial treatment.

Lifestyle and home remedies

Because ADHD is complex and each person with ADHD is unique, 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

• Show your child lots of affection. Children need to hear that they're loved and appreciated. Focusing only on the negative aspects 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 regularly.
• 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 fostered. Small frequent successes help build self-esteem.
• Use simple words and demonstrate when giving your child directions. 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.
• Identify difficult situations. Try to avoid situations that are difficult for your child, such as sitting through long presentations or shopping in malls and stores where the array of merchandise can be overwhelming.
• Use timeouts or appropriate consequences for discipline. 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 defuse out-of-control behavior. Children can also be expected to accept the results of the choices they make.
• Work on organization. Help your child organize and maintain a daily assignment and activities notebook or chart and 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 his or her environment organized and uncluttered.
• 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 special activities that will be coming up and everyday chores. Avoid or at least warn children of sudden transitions from one activity to another.
• Encourage social interaction. Help your child learn social skills by modeling, recognizing and rewarding positive interactions with peers.
• Adopt healthy lifestyle habits. Make sure your child is rested. Try to keep your child from becoming overtired because fatigue often makes ADHD symptoms worse. It's important that your child eat a balanced diet for healthy development. In addition to its health benefits, regular exercise may have a positive effect on behavior when added to treatment.

Children in school

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

• Ask about school programs. Schools are required by law to have a program to make sure children who have a disability that interferes with learning get the support they need. Your child may be eligible for additional services offered under federal laws: Section 504 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA). These can include evaluation, curriculum adjustments, changes in classroom setup, modified teaching techniques, study skills instruction, use of computers, and increased collaboration between parents and teachers.
• Talk to your child's teachers. Stay in close communication with teachers and support their efforts to help your child in the classroom. Be sure teachers closely monitor your child's work, provide positive feedback, and are flexible and patient. Ask that they be very clear about their instructions and expectations.

Alternative medicine

There's little research that indicates that alternative medicine treatments can reduce ADHD symptoms. Before considering any alternative interventions, talk with your doctor to determine if the therapy is safe. Some alternative medicine treatments that have been tried, but are not yet fully proved scientifically, include:

• Yoga or meditation. Doing regular yoga routines or meditation and relaxation techniques may help children relax and learn discipline, which may help them manage their symptoms of ADHD.
• Special diets. Most diets promoted for ADHD involve eliminating foods thought to increase hyperactivity, such as sugar, and common allergens, such as wheat, milk and eggs. Some diets recommend avoiding artificial food colorings and additives. So far, studies haven't found a consistent link between diet and improved symptoms of ADHD, though some anecdotal evidence suggests diet changes might make a difference in children with specific food sensitivities. Caffeine use 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 necessary for good health, there's no evidence that supplemental vitamins or minerals can reduce symptoms of ADHD. "Megadoses" of vitamins — doses that far exceed the Recommended Dietary Allowance (RDA) — 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 exempt from Food and Drug Administration oversight, making them possibly ineffective or potentially harmful.
• Essential fatty acids. These fats, which include omega-3 oils, are necessary for the brain to function properly. Researchers are still investigating whether these may improve ADHD symptoms.
• Neurofeedback training. Also called electroencephalographic (EEG) biofeedback, in these sessions a child focuses on certain tasks while using a machine that shows brain wave patterns. 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. Parents may be hurt by their child's behavior, as well as by the way other people respond to it. The stress of dealing with ADHD can lead to marital conflict. These problems may be compounded by the financial burden that ADHD can place on families.

Siblings of a child with ADHD also may have special difficulties. They can be affected by a brother or sister who is demanding or aggressive, and they may also receive less attention because the child with ADHD requires so much of a parent's time.

Resources

Many resources are available, such as social services or support groups. Support groups often can provide helpful information about coping with ADHD. Ask your child's doctor if he or she knows of any support groups in your area.

There also are excellent books and guides for both parents and teachers, and internet sites dealing exclusively with ADHD. But be careful of websites or other resources that focus on risky or unproved remedies or those that conflict with your health care team's recommendations.

Strategies for coping

Many parents notice patterns in their child's behavior as well as in their own responses to that behavior. Both you and your child may need to change behavior. But substituting 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. And keep your child's developmental stage in mind. Set small goals for both yourself and your child and 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 remain 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. Make an effort to accept and appreciate the parts of your child's personality that aren't so difficult. One of the best ways to do this is simply to spend time together. This should be 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. It's important for partners to take time to nurture their own relationship.
• 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 a better parent if you're rested and relaxed. Don't hesitate to ask relatives and friends for help. Make sure that babysitters or other caretakers are knowledgeable about ADHD and mature enough for the task.

Preparing for an appointment

You're likely to start by taking your child to a family doctor or pediatrician. Depending on the results of the initial evaluation, your doctor 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 difficulties your child has at home or at school.
• Prepare key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins, herbs or other supplements that your child is taking and the dosages.
• 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 doctor.

Questions to ask your child's doctor 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 the alternatives to the primary approach that you're suggesting?
• My child has other health problems. How can I best manage these conditions together?
• Should my child see a specialist?
• Is there a generic alternative to the medicine you're prescribing for my child?
• What types of side effects can we expect from the medication?
• Are there any printed materials that I can have? What websites do you recommend?

Don't hesitate to ask questions anytime you don't understand something.

What to expect from your doctor

Be ready to answer questions your doctor may ask, such as:

• When did you first notice your child's behavior issues?
• Do the troubling behaviors occur all the time or only in certain situations?
• How severe are your child's difficulties at home and at school?
• What, if anything, appears to worsen your child's behavior?
• What, if anything, seems to improve your child's behavior?
• Does your child consume caffeine? How much?
• What are your child's sleep hours and patterns?
• How is your child's current and past academic performance?
• Does your child read at home? Does he or she have trouble reading?
• What discipline methods have you used at home? Which ones are effective?
• Describe who lives at home and a typical daily routine.
• Describe your child's social relationships at home and at school.

Your doctor or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your time with the doctor.