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Attention-Deficit/Hyperactivity Disorder (ADHD)

By Stephen Brian Sulkes, MD, Golisano Children’s Hospital at Strong, University of Rochester School of Medicine and Dentistry

Attention-deficit/hyperactivity disorder (ADHD) is poor or short attention span and/or excessive activity and impulsiveness inappropriate for the child’s age that interferes with functioning or development.

  • ADHD is a brain disorder that is present from birth or develops shortly after birth.

  • Some children mainly have difficulty with sustained attention, concentration, and ability to complete tasks; some children are overactive and impulsive; and some are both.

  • Doctors use questionnaires completed by parents and teachers as well as observations of the child to make the diagnosis.

  • Psychostimulant or other drugs plus structured environments, routines, a school intervention plan, and modified parenting techniques are often needed.

Although there is considerable controversy about the number of children affected, it is estimated that ADHD affects 11% of school-aged children and is diagnosed 2 to 9 times more often in boys than in girls.

Many features of ADHD are often noticed before age 4 and invariably before age 12, but they may not interfere significantly with academic performance and social functioning until the middle school years.

ADHD was previously called just attention deficit disorder (ADD). However, the common occurrence of hyperactivity in affected children—which is really a physical extension of attention deficit and impulsivity—led to a change to the current terminology.

ADHD has three forms

  • Inattentive

  • Hyperactive/impulsive

  • Combined

The symptoms of ADHD range from mild to severe and can become exaggerated or become a problem in certain environments, such as at home or at school. The constraints of school and organized lifestyles make ADHD a problem, whereas in prior generations, the symptoms may not have interfered significantly with children’s functioning because people had different expectations about normal childhood behavior. Although some of the symptoms of ADHD can also occur in children without ADHD, they are more frequent and severe in children with ADHD.

Did You Know...

  • Hyperactivity in ADHD is really a physical extension of attention deficit and impulsivity.

ADHD in adults

Although ADHD is considered a disorder of children and always starts during childhood, it may not be recognized until adolescence or adulthood. Many people continue to have symptoms during adulthood.

In adults, symptoms include

  • Difficulty concentrating

  • Difficulty completing tasks

  • Restlessness

  • Mood swings

  • Impatience

  • Difficulty in maintaining relationships

ADHD can be more difficult to diagnose during adulthood. Symptoms may be similar to those of mental disorders, including mood disorders and anxiety disorders. Adults who abuse alcohol and recreational drugs may also have similar symptoms. Doctors ask adults to complete questionnaires to diagnose ADHD, but they may also need to review records from school to confirm a pattern of inattention or impulsivity.

Adults with ADHD may benefit from the same types of stimulant drugs as do affected children. They may also need counseling to help them improve their time management and develop other coping skills.

Causes

Research indicates that ADHD likely involves abnormalities in neurotransmitters (substances that transmit nerve impulses within the brain). ADHD has no known single specific cause, but genetic (inherited) factors are often present. Some other risk factors include low birth weight (under 3 lb [1500 g]), head injury, brain infection, iron deficiency, obstructive sleep apnea, and lead exposure, as well as exposure to alcohol, tobacco, or cocaine before birth.

Some people have raised concerns about whether food additives and sugar may cause ADHD. Although some children seem to become overactive or impulsive after eating foods containing sugar, studies have confirmed that ADHD is present at birth and that food and environmental factors do not cause the disorder.

Symptoms

ADHD is primarily a problem with sustained attention, concentration, and task persistence (ability to finish a task). Affected children may also be overactive and impulsive. Preschool children with ADHD may have problems with communication and appear to have social interaction problems. As children reach school age, they may seem inattentive. They may fidget and squirm. They may be impulsive and talk out of turn. During later childhood, such children may move their legs restlessly, move and fidget their hands, talk impulsively, and forget easily, and they may be disorganized. They are generally not aggressive.

From 20 to 60% of children with ADHD have learning disorders, and most have academic problems. Work may be messy, with careless mistakes and an absence of considered thought. Affected children often behave as if their mind is elsewhere and they are not listening. They often do not follow through on requests or complete schoolwork, chores, or other duties. There may be frequent shifts from one incomplete task to another.

Affected children may have issues with self-esteem, depression, anxiety, or opposition to authority by the time they reach adolescence. About 60% of young children have such problems as temper tantrums, and most older children have a low tolerance for frustration.

Diagnosis

  • A doctor's evaluation

The diagnosis is based on the number, frequency, and severity of symptoms. Symptoms must be present in at least two separate environments (typically, home and school)—occurrence of symptoms just at home or just at school and nowhere else does not qualify as ADHD because such symptoms may be caused by the specific situation. Symptoms must also be more pronounced than would be expected for the child’s developmental level. Often, diagnosis is difficult because it depends on the judgment of the observer. Also, children who are primarily inattentive may escape notice until their academic performance becomes adversely affected.

There is no laboratory test for ADHD. Questionnaires about various aspects of behavior can help doctors and psychologists make the diagnosis. Because learning disorders are common, many children receive psychologic testing both to help determine whether ADHD exists and to detect the presence of a specific learning disorder, either as a cause for inattention or as a co-existing problem.

Prognosis

Children with ADHD generally do not outgrow their inattentiveness, although children with hyperactivity tend to become somewhat less impulsive and hyperactive with age. However, most adolescents and adults learn to adapt to their inattentiveness. About one third of people find that they continue to benefit from the use of stimulant drugs.

Other problems that may emerge or persist in adolescence and adulthood include poor academic achievement, disorganization (known as poor executive skills), low self-esteem, anxiety, depression, and difficulty in learning appropriate social behaviors. Importantly, the vast majority of children with ADHD become creative and productive adults, and people who have ADHD may adjust better to work than to school situations. However, if the disorder is untreated in childhood, the risk of alcohol or substance abuse or suicide may increase.

Treatment

  • Stimulant drugs

  • Behavior modification

Children are treated with both behavioral therapy and stimulant drugs. Drugs help to relieve symptoms and allow children to participate more easily in school and other activities. Younger children, especially, benefit from combination therapy. For preschool-aged children, behavioral therapy alone may be all that they need.

The federal Individuals with Disabilities Education Act (IDEA) requires public schools to provide free and appropriate education to children and adolescents with ADHD. Education must be provided in the least restrictive, most inclusive setting possible—that is, settings in which the children have every opportunity to interact with nondisabled peers and have equal access to community resources.

Drug therapy

Psychostimulant drugs are the most effective drug treatment. Methylphenidate and other amphetamine-like drugs are the psychostimulants most often prescribed. They are equally effective and have similar side effects. A number of slow-release (longer-acting) preparations are available in addition to the regular forms and allow for once-daily dosing.

Side effects of psychostimulant drugsinclude

  • Sleep disturbances (such as insomnia)

  • Appetite suppression

  • Depression, sadness, or anxiety

  • Headaches

  • Stomachaches

  • High blood pressure

Most children have no side effects except perhaps a decreased appetite. All side effects disappear when the drug is stopped. However, when taken in large doses for a long time, stimulants can occasionally slow children’s growth, so doctors monitor weight and height. If children are growing slowly or have other significant side effects, doctors may advise drug holidays. A drug holiday is stopping the stimulant drug at times when children do not need to be as attentive and focused, for example on weekends or during the summer. However, some children have great difficulty functioning even outside of school and may not tolerate drug holidays.

A number of other drugs can be used to treat inattentiveness and behavioral symptoms. These drugs include

  • Atomoxetine (a nonstimulant ADHD drug)

  • Certain drugs typically used for high blood pressure such as clonidine and guanfacine

  • Antidepressants

  • Antianxiety drugs

Sometimes, a combination of drugs is used.

Behavior management

To minimize the effects of ADHD, structures, routines, a school intervention plan, and modified parenting techniques are often needed. Children without significant behavior challenges may benefit from drug treatment alone. However, stimulants do not work around the clock, so adaptations may be needed to help with organizational and other skills. Behavioral therapy conducted by a child psychologist is sometimes combined with drug treatment.

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  • CONCERTA, RITALIN
  • TENEX
  • CATAPRES
  • STRATTERA
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