Attention-deficit/hyperactivity disorder (ADHD) is 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 and developmental (neurodevelopmental) condition 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 medications plus structured environments, routines, a school intervention plan, and modified parenting techniques are often needed.
Attention-deficit/hyperactivity disorder (ADHD) is 1 type of neurodevelopmental disorder. Neurodevelopmental disorders are neurologically based conditions that can interfere with the acquisition, retention, or application of specific skills or sets of information. They may involve dysfunction in attention, memory, perception, language, problem-solving, or social interaction.
Although there is considerable controversy about the number of children affected, it is estimated that ADHD affects 7 to 9% of children and adolescents worldwide and is twice as common among boys.
ADHD is not diagnosed before age 4, although symptoms may be present at young ages. Although the diagnosis may be made at any time, it does require symptoms to be observed before age 12. Symptoms may not interfere significantly with academic performance and social functioning until the middle school years.
ADHD was previously called 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 3 forms
Inattentive
Hyperactive/impulsive
Combined
The symptoms of ADHD range from mild to severe and can become exaggerated or problematic in certain environments, such as at home, in school, or in communal places of worship. The constraints of school and organized lifestyles make appropriate management of ADHD more critical. Although some of the symptoms of ADHD can also occur in children without ADHD, they are more frequent and severe in children with ADHD.
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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. About half of people continue to have behavior symptoms in adulthood.
In adults, symptoms include
Difficulty concentrating
Difficulty completing tasks (poor executive function)
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 illicit drugs may also have similar symptoms, and adults with ADHD are more likely to abuse drugs and alcohol, be unemployed, and be in motor vehicle crashes than those without ADHD. 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 medications as do affected children. They may also need counseling to help them improve their time management and develop other coping skills.
Causes of ADHD
ADHD has no known single specific cause, but genetic (inherited) factors are often present. Research indicates that ADHD likely involves abnormalities in neurotransmitters (substances that transmit nerve impulses within the brain). Some other risk factors include low birth weight (under about 3 pounds [1500 grams]), head injury, brain infection, iron deficiency, obstructive sleep apnea, and lead exposure, as well as exposure to alcohol, tobacco, or possibly cocaine before birth. ADHD also is associated with traumatic events during childhood, for example, violence, abuse, or neglect.
Symptoms of ADHD
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.
Symptoms of hyperactivity and impulsivity tend to lessen over time, while symptoms of inattentiveness tend to persist.
About 20 to 60% of children with ADHD have learning disabilities affecting reading, math, or written language, and most have academic problems such as poor grades due to disorganization or incomplete homework (executive skills). 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. Many young children have problems such as temper tantrums, and older children often have a low tolerance for frustration.
Diagnosis of ADHD
A doctor's evaluation
The diagnosis of ADHD is based on the number, frequency, and severity of signs. Children must have 6 or more signs of inattention or of hyperactivity and impulsivity (or 6 from each group to diagnose the combined type of ADHD; see Signs of ADHD). Signs must be present for at least 6 months in at least 2 separate environments (typically, home and school) so that a child's reaction to specific problems in 1 situation is not mistaken for ADHD. Occurrence of signs just at home or just at school and nowhere else does not qualify as ADHD because such signs may be related the to specific environment. Signs must also be more pronounced than would be expected for the child’s developmental level and must be present for 6 months or more. 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 and development can help doctors and psychologists make the diagnosis. Because learning disorders are common, many children receive psychological 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 coexisting problem.
A physical examination and sometimes various blood and other tests to rule out other disorders are also done.
Treatment of ADHD
Psychostimulant and other medications
Behavior modification
Treatment recommendations for children with ADHD vary by age:
Preschool-aged children: Initial treatment is with behavioral therapy. Medications may be considered if the response to behavioral interventions is inadequate or if the symptoms are moderate to severe.
School-aged children: Initial treatment is behavioral therapy in combination with medications.
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, a setting in which the children have every opportunity to interact with peers who do not have a disability and have equal access to community resources. The Americans with Disability Act and Section 504 of the Rehabilitation Act also provide for accommodations in schools and other public settings.
Medication therapy
Psychostimulant medications are the most effective medication treatment. Methylphenidate and other amphetamine-like medications 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 and may help to prevent inappropriate use.
Side effects of psychostimulant medications may include
Sleep disturbances (such as insomnia)
Appetite suppression
Slow weight gain
Headaches
Stomachaches
Elevated heart rate and blood pressure
Depression, sadness, or anxiety
Most children have no side effects except perhaps a decreased appetite. All side effects disappear when the medication is stopped. However, when taken in large doses for a long time, stimulants can slow children’s growth, and this slowed growth can continue into adulthood, 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 medication at times when children do not need to be as attentive and focused, for example on weekends or during vacations from school. However, some children have great difficulty functioning even outside of school and may not tolerate drug holidays.
A number of other medications can be used to treat inattentiveness and behavioral symptoms. These medications include
Atomoxetine (a nonstimulant ADHD medication)
Certain medications typically used for high blood pressure such as clonidine and guanfacine
Antidepressants
Antianxiety medications
Sometimes, a combination of medications 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 medication 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 medication treatment.
Prognosis for ADHD
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. Those with aggressive behavior, particularly conduct disorder and antisocial behavior, are more likely to have difficulties with ADHD as adults.
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 medications.
Other problems that may emerge or persist in adolescence and adulthood include poor academic achievement, unemployment, substance abuse, car accidents, unstable relationships, disorganization (known as poor executive skills), low self-esteem, anxiety, depression, and difficulty in learning appropriate social behaviors.
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.
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