What is attention deficit/hyperactivity disorder?
ADHD (commonly known as ADD) is a behavioral disorder. Basically, children who have it are unable to concentrate, excessively active, or both. The American Psychiatric Association calls the distinct types "inattentive" and "hyperactive-impulsivity." Some kids with attention deficit disorder repeatedly fail to finish tasks, get distracted easily, and seem not to listen. Others fidget and squirm constantly and can't wait their turn. Still others have both kinds of problems.
Don't be alarmed if those behaviors seem familiar: Your child may get overexcited or lost in his own thoughts from time to time -- those are normal passing moods for any youngster. A child with ADHD will be inattentive or frenetic with greater frequency (though, unless he has a severe case, you wouldn't be able to pick him out from a group of kids watching TV). His disability will hamper him in school, at home, or in social settings.
ADHD is controversial for two reasons: Researchers aren't sure precisely what causes it, and pediatricians, family doctors, other medical experts, and parents all tend to have strong opinions on the use of drugs to treat it in children.
How common is ADHD, and why do kids develop it?
According to the National Institute of Mental Health, ADHD affects 4 to 12 percent of US children. 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 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 basis. 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 hard times as babies and toddlers.
A 2007 study published in the journal Proceedings of the National Academy of Sciences points to possible physical changes in the brain that may contribute to ADHD. In the study, researchers used magnetic resonance imaging to measure the thickness of the brain's cortex in children with and without ADHD. (The cortex is the reasoning part of the brain that uses the senses to control body movements.) Tracking the changes over 15 years, scientists found that children with ADHD had cortices that reached peak thickness three years later than children without ADHD -- a discovery that showed delayed, not abnormal, development. The research team also found that children with ADHD had motor cortices that matured earlier. The scientists concluded that these differences may explain some of the fidgeting and restlessness common in children with ADHD.
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 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 in tasks or play
- Often doesn't seem 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 toys, school assignments, pencils, and books)
- Is easily distracted by the world around him
- Is often forgetful
To be diagnosed with hyperactive-impulsivity ADHD, your child must exhibit at least six of the following symptoms for at least six months:
- Often fidgets or squirms
- Leaves his seat in the classroom or in other situations in which remaining seated is expected
- Often runs about or climbs in situations where it is inappropriate
- Often has difficulty playing quietly
- Often talks excessively
- Always on the go
- Often blurts out answers before the whole question has been stated
- Often has difficulty waiting in lines or awaiting his turn in group play
- Often interrupts conversations or activities
For your doctor to diagnose ADHD, your child must have started showing these symptoms by age 7 and the behaviors must be taking place in more than one situation (at school and at home, for example). Also, your child's difficulties must be intense enough to significantly harm his social interactions or academic performance. And of course the symptoms shouldn't be due to a physical problem such as hearing loss or poor vision.
When should I seek help?
Make an appointment with your pediatrician if your child's unmindful or impetuous behavior becomes frequent, severe, or begins to affect his ability to get along at home or at school. If his teacher tells you there's a problem -- that your child can't get halfway through a project or repeatedly disrupts lessons -- you'll want to follow up, but don't assume this means ADHD. A physical or emotional problem could be making him unable to focus or excitable. Or he could have a learning disability such as dyslexia or a neurodevelopmental disorder that makes it hard for him to remember things or acquire language. (However, many kids with ADHD also have learning disabilities.) Your pediatrician can make a preliminary identification of such problems and refer you to someone who will thoroughly assess your child's condition.
What will my pediatrician do?
She'll perform a physical exam of your child and review your medical and social history. She may ask you about your pregnancy, other family members who have been diagnosed with ADHD, and any emotional difficulties your child has gone through.
Your doctor may order tests of your child's vision and hearing to rule out these physical problems. 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 the light of results from tests measuring memory, problem-solving, and listening skills. Your 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."
In addition, your pediatrician or the psychologist will assess your child for the behaviors associated with ADHD. Either may want you to ask your child's teacher to write a letter describing the behavior he's observed, since even a child who's lost in the clouds much of the time may focus in during an office visit.
Together, your pediatrician and the child psychologist (or other mental health professional) can make a definitive diagnosis.
What are the treatment options?
There are three: 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 child doesn't become unnecessarily stimulated or distracted.
Some medical experts feel that family counseling and behavioral therapy are enough to treat ADHD, while others believe the disorder can be controlled only through the use of medications. Prescription drugs do calm many children with ADHD as well as improve their ability to focus. If a drug is part of the treatment plan for your child, you'll have to work with your child's pediatrician or psychiatrist to find the right dosage.
Ironically, the drugs most often prescribed are stimulants, including methylphenidate (better known by its brand name, Ritalin) and dextroamphetamine (Dexedrine). But the current drug of choice for ADHD is Adderall, an amphetamine; it may have fewer side effects than Ritalin, and its slow-release formulation means kids don't have to take a second dose while they're at school.
On February 9, 2005, the FDA issued a Public Health Advisory on Adderall, following Canada's decision to suspend sales of the drug due to safety concerns. Canadian officials reviewing the manufacturers safety information found 20 international reports of sudden death and 12 incidents of stroke (that were not a result of misuse) in patients who were taking the drug. Later that year, Canadian officials allowed Adderall back on the market after warning labels were revised to reflect safety concerns.
In May 2007, 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. Patients or parents of children taking these drugs should talk to their doctors before altering or discontinuing treatment.
Then on September 29, 2005, the FDA 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. Some studies suggest that long-term use of stimulants in children can be associated with slow growth. In a review of 22 clinical trials presented to the Pediatric Academic Societies meeting in 2006, researchers reported that attention-deficit hyperactivity disorder drugs like Ritalin do significantly suppress growth in children.
Your doctor should monitor your child carefully if she prescribes these medications.
The American Psychological Association estimates that between 70 and 80 percent of children with ADHD respond to medication, with improved attention spans and better control of impulsive behavior. However, stimulants can be habit-forming and seem to benefit adults less than children, 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.
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.
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 doctor and your child's therapist, focusing on the solutions that seem to work for your child.
What can I do?
Children between the ages of 6 and 12 face new challenges as they begin formal schooling and start participating in extracurricular activities such as sports and music. As a parent, you can help your child succeed by taking steps to keep him focused and to develop his self-discipline. Here's how:
- Structure your child's home life. Routines allow him to focus on the big picture instead of fretting over the mundane details of living. Establish mealtimes, a bedtime, and quiet times. You may want to write down his schedule to help both of you stick to it and draw a step-by-step chart for any task he has particular trouble with. Manage his activities so that he isn't overstimulated or exhausted.
- Teach your child to look before he leaps. Children with ADHD tend to be impulsive and unaware of how their behavior may affect others. Help your child develop the habit of considering the consequences of his actions. Suppose he wants to play catch just outside the living room window. What might happen? Is there a better place to play?
- Develop your child's empathy. Some children with ADHD need to learn how to care about other people. Talk about the importance of feelings. If your child is responsible enough, a pet is an excellent way for him to learn to care for another being -- as well as carry out simple tasks like filling the animal's water bowl every morning.
- If your child doesn't mind, go to school with him for a day. Watch him in class to see if his teacher could easily do something that would help him concentrate -- move him to the front of the room, for example, or check that he's written out his homework assignment. Not all teachers are trained to engage children with ADHD. In the classroom, your child needs clear goals and a reward system that reinforces desirable behavior. And don't forget that federal law requires public schools to provide special education services to eligible children; these might include modified instructions, assignments, and testing; assistance from a classroom aide or a special ed teacher; or assistive technology.
- Help with homework. Think of homework as a way to teach your child how to get organized and break down big problems into small ones. First, make sure that your child has a neat, quiet place to work. Sit down with him before he begins his assignments and discuss his plan. There's a book report due Friday? You may have to sketch out what he needs to do every night of the week until it's finished. Resist the temptation to do his work for him; rather, help him figure out the best way to go about it. If homework becomes a daily battle ending in lost tempers, get your child a tutor; talk to school administrators about setting this up.
- Reward your child. You may want to use tokens of appreciation as incentives; for example, if he does his homework every night for a week, he gets a trip to the hobby store to buy a new model-making kit. Also use nonmaterial rewards that allow you to spend time together, such as a walk to the park to play catch.
- Stay cool. Keeping your emotions under control can be tough as your growing child continues to act out or ignore what you say, but remember that children learn by example. Pediatrician William Sears, author of The ADD Book, suggests using "time-ins" for older kids as an alternative to time-outs: Instead of sending your child to his room, drop what you're doing and ask him to sit down with you and be silent. The time-in should last as long as a time-out would, that is, one minute for each year of your child's age. This calming period lets your child break his pattern of misbehavior without getting angry about being sent away. After the time-in, talk with him about how he might mend his ways. If, however, this tactic seems to backfire -- your presence merely riles your child -- don't push it; just spend the quiet time in separate rooms until you're both ready to talk.
What should I tell my child?
First, that he's physically fine -- healthy and strong. Going to the doctor and having your hearing, vision, and intelligence checked is enough to rattle anyone.
Second, tell your child that he does have a problem with being attentive or staying still. This won't be news to him, but now you can explain why: He has a problem called ADHD that's been getting in the way.
Tell him what ADHD stands for, and explain any words he doesn't understand. Be precise about which type of the disorder he has, connecting it with behaviors he'll recognize ("You know how you forget to keep listening when I'm talking to you?"). Make sure he understands that it's some of his behaviors that need to change and not him as a person. Tell him the good news that you've found a way to help him focus or stay calm.
Next, tell your child what's ahead: trips to a therapist or new doctor, use of a medication, or both. Encourage him to voice his anxieties about any of this, so you can reassure him. You may also want to talk to him about how his classroom experience might change; his teacher may be offering extra guidance or moving him to a different spot.
Finally, talk to your child about the adjustments you're making at home. Perhaps you plan to use a chart to guide him through his bedtime routine, from "Put on pajamas" to "Turn off bedside light." Or maybe you'll assign him some simple tasks, like brushing the dog. Reassure him that most things about home will stay the same -- and that your love is constant. Let him know, too, that you'll be his partner in exploring which methods work for his ADHD.
Attention deficit hyperactivity disorder, Scientific American, Russell A. Barkley, September 1998
Attention deficit hyperactivity disorder, National Institute of Mental Health, NIH Publication No. 96-3572, Printed 1994, Reprinted 1996
The A.D.D. Book: New Understandings, New Approaches to Parenting Your Child, by William Sears, Little Brown & Co. 1998
FDA Statement on Adderall, February 9, 2005 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2005/ucm108411.htm
Health Canada Advisory on Adderall, February 9, 2005 http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2005/2005_01-eng.php
Children's Hospital Boston. Children's Hospital Boston presents at the 2006 Pediatric Academic Societies Annual Meeting. http://www.childrenshospital.org/newsroom/Site1339/mainpageS1339P1sublevel213.html
National Institute of Mental Health. What medications are used to treat ADHD? http://www.nimh.nih.gov/health/publications/mental-health-medications/what-medications-are-used-to-treat-adhd.shtml
US Food and Drug Administration. Safety Alerts for Human Medical Products. Strattera (atomoxetine) Sep 2005. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm152628.htm