What is attention deficit/hyperactivity disorder?
ADHD (commonly known as ADD) is a behavioral disorder. Basically, kids who have it are unable to concentrate, extremely restless, or both. The American Psychiatric Association calls the distinct types "inattentive" and "hyperactive-impulsivity." Some adolescents with attention deficit disorder can't organize or complete tasks, get distracted easily, and seem not to listen. Others may be rebellious and reckless -- they can't wait their turn, keep quiet, or keep their friends. Still others have both kinds of problems.
Don't be alarmed if those behaviors seem familiar: As your child enters his teens, he probably talks back, argues with his best buddy, loses his keys, or fails to finish his homework from time to time -- almost every kid does. A child with ADHD will do these things more often (though, unless he has a severe case, you wouldn't be able to pick him out from a group of kids watching TV). This can give him a real disability in school, at home, or in social settings.
ADHD is controversial for two reasons: Researchers aren't sure precisely what causes it, and physicians, other medical experts, and parents all tend to have strong opinions on using drugs to treat it.
How common is ADHD, and why do kids develop it?
According to the American Academy of Pediatrics, ADHD affects 4 to 12 percent of schoolchildren in the United States. Signs usually appear before the age of 7. Studies indicate that more boys than girls are diagnosed with ADHD, and there is often a strong family history of other males with the condition.
Boys may be more often diagnosed than girls is because they tend to be disruptive in school and attract the attention of teachers and parents. Girls are less likely to be noticed because the ADHD usually shows up in poor academic performance and less in hyperactive behavior.
Most researchers and ADHD experts believe the disorder has a neurological cause. Researchers are exploring the possibility that these kids inherit a physical inability to regulate levels of neurotransmitters (substances that transmit signals in the brain), such as dopamine. Less plausible explanations include drug or alcohol abuse by the mother during pregnancy or psychological trauma early in the child's life. But these hypotheses don't account for the vast majority of children with ADHD whose mothers didn't use harmful substances and who didn't go through emotionally rocky times as babies and toddlers.
A minority of medical experts have argued that the ADHD diagnosis is overused for children who simply have difficulty adjusting to the structure of classroom life. If you're the parent of such a child, your child may not need medical treatment. You may just need to exercise more patience and take responsibility for creating the right environment for your child to prosper in school, experts say.
What are the symptoms?
To be diagnosed with inattentive ADHD, your child must consistently exhibit six of the following symptoms for at least six months:
- Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities
- Often has trouble sustaining attention
- Often doesn't appear to listen to what's being said to him
- Often doesn't follow through on instructions and fails to finish schoolwork or chores (not out of rebellion or failure to understand)
- Often has difficulty organizing tasks and other activities
- Avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
- Often loses things necessary for tasks or activities (such as pencils, books, and sports equipment)
- Is easily distracted by the world around him
- Is often forgetful
To be diagnosed with hyperactive-impulsivity ADHD, your child must consistently exhibit most of the following symptoms for at least six months:
- Has trouble keeping still and may run about in situations where that's inappropriate
- Has difficulty working or playing quietly
- Often blurts out answers before the whole question has been stated
- Has difficulty waiting in lines or waiting his turn
- Often proceeds in a headlong or rash manner
- Often interrupts
Symptoms of ADHD must be apparent by the age of 7, though the disorder is most frequently diagnosed when kids are between 8 and 10. According to the National Institute of Mental Health, half of all children with ADHD also have oppositional defiant disorder, which is characterized by stubbornness, outbursts, and belligerent behavior.
When should I seek help?
Make an appointment with your child's doctor if his behavior is hindering his academic performance or eroding his relationships at home or school. Disobedience that goes beyond normal rebellion, such as destroying property, also is cause for concern.
Just because your child has reached (or nearly reached) his teens, don't think it's too late to seek professional help; in fact, it's probably crucial that you do so. Your child's doctor and a child psychologist (or other mental health professional) can assess his condition and work with you on a treatment plan that could make a big difference.
What will my child's doctor do?
She'll perform a physical exam of your teenager and review your medical and social history. She may ask you about your pregnancy, family members who've been diagnosed with ADHD, and any emotional trauma your teen has suffered.
Your child's doctor will also rule out obvious problems that could be causing your child to lose focus and fall behind in school, such as hearing loss or poor vision. She might order an IQ test, too; ADHD doesn't directly affect IQ, so a child with it will have an IQ in the normal range (unless the ADHD has an environmental cause such as lead poisoning). But the result of the test can be useful in measuring memory, problem-solving, and listening skills. Your child's doctor will most likely refer you to a child psychologist, who will administer a battery of tests in addition to the IQ evaluation. One of these may be a "continuous performance test," which appraises attention span by having your child do boringly repetitive tasks on a computer. The psychologist will also ask you or your child's teacher to fill out one of the many rating scale forms, which present such questions as "How often does your child pay attention in class?" and ask for a numerical rating on a five-point scale between "never" and "always."
Your child's doctor or psychologist also will assess him for the behaviors associated with ADHD in teens, such as excessive talking and interrupting. She will also evaluate him for oppositional defiant disorder. Checking out conduct can be tough, however, since even kids with ADHD may not chatter or disobey during an office visit. The doctor may want to talk to your child's teachers about his behavior.
Together, your child's regular doctor and the psychologist (or other mental health professional) can make a definitive diagnosis.
What are the treatment options?
There are three basic ones: family therapy, behavioral therapy, and medication. Through family therapy or "parent training," you can learn more about ADHD and adjust your expectations for your child. You can also learn to deal with your own frustration and to parent consistently and positively. Behavioral therapy can teach you how to structure situations at home and school so that your teen isn't confused about your rules or his responsibilities.
Some medical experts feel that family counseling and behavioral therapy are enough to treat ADHD. Kathleen Holton of American University has written in the Journal of Attention Disorders that a "healthy lifestyle" could be used in place of medication to combat ADHD. Her "prescription" includes 1) no more than an hour a day of screen time; 2) getting enough sleep (9 to 11 hours); 3) drinking 7 to 10 cups of water a day; 4) getting at least an hour of exercise each day.
Other experts have suggested using "nature therapy" -- that is, taking your child for hikes in parks and other natural settings -- to manage symptoms of ADHD. One study found children were able to concentrate better ("shockingly better," as one researcher put it) after taking a walk in the park rather than suburban streets.
Other experts believe in using medication to control the disorder. If a drug is part of the treatment plan for your child, you'll have to work with his physician or psychiatrist to find the right dosage.
ADHD drugs: serious side effects
Ironically, the drugs most often prescribed are stimulants, including methylphenidate (better known by its brand name, Ritalin) and dextroamphetamine (Dexedrine). Another drug used for ADHD is Adderall, an amphetamine; its slow-release formulation means kids don't have to take a second dose while they're at school. Both classes of drugs have the potential for serious side effects, including heart rhythm problems, addiction, and psychosis, as well as others such as trouble sleeping, anxiety, irritability, headaches, and dizziness.
The FDA directed the manufacturers of all ADHD drugs like Adderall, Dexedrine, or Ritalin to include a medication guide with their products. The guide warns of the risk of cardiovascular complications and psychiatric problems -- such as hearing voices and paranoia -- in patients with no history of them. If your child develops these symptoms, talk with your doctor immediately about changing the treatment. Patients or parents of children taking these drugs should talk to their doctors before altering or discontinuing treatment, however.
The FDA has also issued an advisory on atomoxetine (Strattera), a non-stimulant ADHD medication, warning of an "increased risk of suicidal thinking" in children and teenagers taking this drug.
Researchers believe these medications help modulate levels of neurotransmitters in the brain. Side effects can include loss of appetite, stomach pain, insomnia, and rapid heartbeat. Long-term use of stimulants in children has been associated with slow growth, so the doctor will monitor your teenager carefully if she prescribes these medications. However, stimulants can be habit-forming , so you may want to think about your long-term plan; some parents use medication to address immediate needs but see behavioral therapy as the key to a smoother road for their kids as they mature.
Finally, be sure to keep an eye on your child's medication. Adderall, for example, can cause high blood pressure, stroke and other problems if misused. Many teens with ADHD have illegally sold their Adderall medications at high school, and it is a "study drug" of choice on college campuses, according to various news reports. Emergency room visits due to Adderall also rose 156 over a 5-year-period, according to the Journal of Clinical Psychiatry.
If your teenager has already been diagnosed with ADHD and the current treatment isn't helping, make an appointment with his doctor to discuss options. She may need to adjust the dosage of his medication, or she may refer you to a behavioral therapist who can teach you approaches to schoolwork and discipline that work for older children.
As far as your child's schooling is concerned, you should know that he is eligible for special education services. Under federal law, public schools must evaluate children with ADHD to determine their particular needs and then make reasonable efforts to meet those needs.
Your child almost certainly could benefit, too, from some counseling, perhaps starting with group-style therapy (his struggles with the authorities in his life may have made him mistrustful of adults) and eventually moving to one-on-one sessions. Children with ADHD who reach middle-school age without being diagnosed and getting on a treatment plan are at high risk for conduct problems, drug use, and other worrisome expressions of frustration and hopelessness. Often their self-esteem is low. A child psychologist or psychiatrist can work with your youngster on developing people skills, self-acceptance, and compassion for himself and others.
One last point to keep in mind is that ADHD is a relatively new term and the condition has received a lot of media attention in recent years. Researchers are still trying to determine the best ways to treat it, and as new studies appear in the press, your friends and family may give you an earful on what you should do. The best solution to the confusion and anxiety you naturally feel is to work closely with your child's doctor, focusing on the solutions that seem to bring results.
What should I be doing?
Poor academic performance and a lack of friendships may have damaged your child's self-regard. The challenges you face include building up his confidence, channeling his energy in positive directions, and disciplining him without making him feel like a failure. It's a tall order, but these strategies can help:
Set firm rules, clarify your expectations, and establish consequences. Children of all ages and personalities need structure, but no kid has greater need than a defiant, restless, or dreamy adolescent. Don't be too rigid, but do make sure your approach won't take him by surprise. He needs to know how you want him to behave and what will happen if he doesn't.
Go to school. If you haven't already, talk to your child's teachers about his problems in the classroom. Kids with ADHD are capable of excellent work but may struggle with taking timed tests, responding to spoken instructions, or completing projects that haven't been broken down into manageable parts. On the other hand, they often flourish if an unconventional approach gives them the opportunity to put their energy and creativity to good use. You and your child's teachers can brainstorm ways to develop and evaluate your child's abilities.
Share responsibility. This can be difficult if you have a troublesome teen who doesn't listen. But giving him the vague directive to be more responsible doesn't open up an opportunity to succeed. Instead, show trust and direct all that energy toward something you need done -- give him the keys to the family car, and ask him to wash it once a week. Make sure that whatever you ask him to do isn't beyond his capabilities, and keep your instructions simple.
Write "contracts." Kids with ADHD benefit from any process that requires them to organize their thoughts and actions. You can write down a short agreement that offers your teen a reward; for example, if he completes an hour or more of homework every weeknight this month, he gets a trip to the theme park he's been dying to visit. You can also use a contract to control negative behavior, perhaps to clarify when your teen may use the family car and what will happen if he uses it at other times or keeps forgetting to fill the tank.
Take away privileges -- with care. Don't make rash declarations when you're angry or upset, and don't deprive your child of activities that foster his development, such as participating in a sports team or a religious youth group. On the other hand, your child can do without television time, access to computer games, and trips to the shopping mall. Be clear about your reasons for suspending a privilege, and say how long the suspension will last.
Show your love. It's probably been a long time since your child climbed into your lap and asked for a hug, but that doesn't mean he doesn't want one. Don't worry if he is often surly and sarcastic; that will pass (eventually); he is still a child who needs your love and understanding. Adolescence is especially confusing for kids with ADHD. Spend time with your child; when he's going through a particularly rough period, voice your empathy and open your arms to him. Many teens with ADHD grow up to be successful adults, but they need their families to support them emotionally and nurture their self-esteem.
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