ADD/ADHD

A biologically based condition causing a persistent pattern of difficulties resulting in inattention, hyperactivity, and impulsivity.

What Is ADHD?

Attention deficit hyperactivity disorder (ADHD) is highly common in adolescents and can continue through adulthood. The condition was previously known as attention deficit disorder (ADD), though this is considered an outdated term.

Signs & Symptoms

Inattention, hyperactivity, and impulsivity are key signs of ADHD. Though common and normal when moderately expressed, an individual with ADHD will experience these behaviors in greater frequency or severity.

  • Inattention. Inattention is characterized by difficulty completing tasks. Individuals with inattention can be easily distracted, forgetful, and experience difficulty when organizing activities. Those with ADHD often struggle to listen and are frequently distracted. They may fail to give close attention to detail, making careless mistakes.
  • Hyperactivity. Hyperactivity manifests itself in different ways depending on the patient’s age. Hyperactive children might run or move about at inappropriate times, get up from a seat when (s)he is supposed to remain seated, fidget and wriggle, or talk excessively. Hyperactive adults often experience feelings of extreme restlessness.
  • Impulsivity. Individuals with impulsive tendencies can be reckless and appear impatient. They may intrude on or interrupt others’ activities, blurt out answers to questions before they have been completed, or have difficulty awaiting their turn.

Three Subtypes of ADHD

Predominantly hyperactive-impulsive

  • The majority of symptoms (six or more) are in the hyperactivity-impulsivity categories
  • Inattention may still be present to some degree, but the individual will experience less symptoms in this category (six or less).

 Predominantly inattentive

  • The majority of symptoms (six or more) are in the inattention category
  • Hyperactivity-impulsivity may still be present to some degree, but the individual will experience less symptoms in this category (six or less).
  • Individuals with this subtype are less likely to act out or have difficulties getting along with others. Children who are predominantly inattentive may fail to receive a diagnosis, since they display less physical manifestations of the disorder.

Combined hyperactive-impulsive and inattentive

  • The individual displays many symptoms (six or more) in both the inattention and hyperactive-impulsive categories.
  • Most children have this combined type of ADHD

Causes of ADHD

Like many other illnesses, ADHD probably results from a combination of factors.

  • Genes. ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder.
  • Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children. In addition, children who are exposed to high levels of lead may have a higher risk of developing ADHD.
  • Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those who have ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury.
  • Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it.
  • Food Additives. Recent research indicates a possible link between consumption of certain food additives, such as artificial colors or preservatives, and hyperactivity.

Who Is At Risk?

 The average age of onset for ADHD is 7 years old. In a given year in the U.S., the disorder affects 9.0% of children between the ages of 13 and 18, and about 4.1% adults age 18 and older. Boys are four times more at risk than girls.

Studies show that the number of children being diagnosed with ADHD is increasing, though the cause of this is unclear.

ADHD Diagnosis in Children and Adolescents

ADHD symptoms can appear early on in life, between the ages of 3 and 6. Since symptoms vary from person to person, the disorder can be hard to diagnose. Parents may find that their child loses interest in things sooner than other children, or seems constantly "out of control." Often teachers notice the symptoms first, when a child has trouble following rules, or frequently "spaces out" in school settings.

No single test can diagnose a child as having ADHD. A family may first want to first consult with the child's pediatrician. Some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in childhood mental disorders. The pediatrician or mental health specialist will try to rule out other causes, such as an unusually stressful or disruptive home or school environment. They will gather information from the child’s parents and teachers, as well as other adults, including coaches and babysitters.

A child also may be evaluated to see how he or she functions in social situations, and may be given tests of intellectual and academic ability to see if he or she has a learning disability.

Some children with ADHD may also have other illnesses or conditions, such as oppositional defiant disorder, conduct disorder, sleep disorders, anxiety, depression, bipolar disorder, or Tourette syndrome.

Treatments for Children and Adolescents with ADHD

Treatments can relieve many of the symptoms of ADHD, but there is no cure. With treatment, most people with ADHD can lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging to better understand the disorder.

Medications

For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Medication may also improve physical coordination.

A one-size-fits-all approach is often not effective for treating children with ADHD. Sometimes several different medications or dosages must be tried before finding one that works for a particular child. Any child taking medications must be monitored closely and carefully by caregivers and doctors.

The most common type medication used to treat ADHD is considered a stimulant, and can be administered in the form of pills, capsules, liquid, or skin patches. Medications also come in short-acting, long-acting, or extended release varieties. Each of these varieties contains the same active ingredient. Long-acting or extended release can be taken once a day, so the child doesn’t have to make a daily trip to the school nurse for another dose. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends as well.

Possible Side Effects of Stimulants. The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomachaches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered. Although some parents worry that stimulant medications may lead to substance abuse or dependence, there is little evidence of this. Learn more. 

  • Decreased appetite. Be sure your child eats healthy meals. If this side effect does not go away, talk to your child's doctor. Also talk to the doctor if you have concerns about your child's growth or weight gain while he or she is taking medication.
  • Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose or a short-acting form. The doctor might also suggest giving the medication earlier in the day, or stopping the afternoon or evening dose. Adding a prescription for a low dose of an antidepressant or a blood pressure medication called clonidine sometimes helps with sleep problems. A consistent, relaxing sleep routine may also help.
  • Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage can help tics go away. Some children also may have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects.

Psychotherapy

This type of behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help with organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior and give self-praise or rewards for acting in a desired way, such as controlling anger or thinking before acting. Parents and teachers also can give positive or negative feedback for certain behaviors. Clear rules, chore lists, and other structured routines can help a child control his or her behavior.

Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. This may also include learning to read facial expressions or tone of voice, and how to respond appropriately.

The Role of Parents

Children with ADHD need guidance and understanding from their parents and teachers to reach their full potential and to succeed in school. Mental health professionals will educate parents about ADHD and its impacts on a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other.

Training in parenting skills helps parents learn how to use a system of rewards and consequences to change a child's behavior. Parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors they want to discourage. In some cases, "time-outs" may be used when the child's behavior gets out of control. In a time-out, the child is removed from an upsetting situation for a short time to calm down.

Parents are encouraged to share a pleasant or relaxing activity with their child, to notice and point out what the child does well, and to praise the child's strengths and abilities. They can structure situations to achieve more positive outcomes. For example, they may restrict the number of playmates to one or two at a time, so that their child does not become overstimulated. Or, if the child has trouble completing tasks, parents can help their child divide large tasks into smaller, more manageable steps. Parents may also benefit from learning stress-management techniques to increase their own ability to deal with frustration, so that they can respond calmly to their child's behavior.Sometimes, the whole family may need therapy. Therapists can help family members find better ways to handle disruptive behaviors and to encourage behavioral changes.

Finally, support groups help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.

Here are some tips to help kids stay organized and follow directions:

  •  Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or on a bulletin board in the kitchen.
  • Organize everyday items. Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys.
  • Use homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home the necessary books.
  • Be clear and consistent. Children with ADHD need consistent rules they can understand and follow.
  • Give praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior, and praise it.

ADHD Diagnosis in Adults

In some cases ADHD continues into adulthood. Many adults do not realize they have the disorder. They may feel that it is impossible to get organized, stick to a job, or remember and keep appointments. Daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD.

These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Like adolescents, adults with ADHD may seem restless and may try to do several things at once, often unsuccessfully. They also tend to prefer "quick fixes," rather than taking the steps needed to achieve greater rewards.

Like children, adults who suspect they have ADHD should be evaluated by a licensed mental health professional. But the professional may need to consider a wider range of symptoms when assessing adults for ADHD, because their symptoms tend to be more varied and less clear than those seen in children.

To be diagnosed with the condition, an adult must have ADHD symptoms that began in childhood. Health professionals use certain rating scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health professional also will look at the person's history of childhood behavior and school experiences, and will interview spouses or partners, parents, close friends, and other associates. The person will also undergo a physical exam and various psychological tests.

For some adults, a diagnosis of ADHD can bring a sense of relief. Receiving a diagnosis and treatment will allow them to deal with their problems more effectively.

ADHD Treatment in Adults

 Much like children, adults with ADHD are treated with medication, psychotherapy, or a combination of treatments.

Medications

Adults with ADHD are often prescribed medications, including extended-release forms, though not all medications are approved for adults. Those not approved may be prescribed by a doctor on an "off-label" basis.

Antidepressants are sometimes used to treat adults with ADHD, although they are not FDA approved for the disorder. Older antidepressants, called tricyclics, are sometimes used because they, like stimulants, affect the brain chemicals norepinephrine and dopamine. A newer antidepressant, venlafaxine (Effexor), also may be prescribed for its effect on the brain chemical norepinephrine. And in recent clinical trials, the antidepressant bupropion (Wellbutrin), which affects dopamine, showed benefits for adults with ADHD.

Adult prescriptions for stimulants and other medications require special considerations. Some of these medications may interact poorly with other stimulants. An adult with ADHD should discuss potential medication options with his or her doctor.

Education and psychotherapy

A professional counselor or therapist can help an adult with ADHD learn how to organize his or her life with tools such as a large calendar or date book, lists, reminder notes, and by assigning a special place for keys, bills, and paperwork. Large tasks can be broken down into more manageable steps, so that completing each part of the task provides a sense of accomplishment.

Psychotherapy, including cognitive behavioral therapy, can also be used to treat adults with ADHD. The therapist will help make adjustments to life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks. 

Source:  NIMH, ADHD Institute, HealthLine, NetWellness