ADHD in Children

Attention deficit hyperactivity disorder (ADHD, formerly ADD) causes the following symptoms in children: excessive activity, problems concentrating, and difficulty controlling impulses. Stimulant medications are the most common medication used to treat ADHD.

ADHD, formerly called ADD, is a mental health condition called attention deficit hyperactivity disorder. People with ADHD have problems with impulse control, excessive activity, and/or distractibility on a day-to-day basis.

These symptoms are difficulties with what are known as executive functions, the brain functions that are best understood as being the boss or chief executive officer of brain. Examples of executive functioning include planning, prioritizing, organizing, disciplining, and controlling what the person does.

• Statistics show that up to 7% of children and teens suffer from this disorder at any time, with up to 11% of children being assigned the diagnosis at some point during their childhood.
• Health professionals tend to diagnose boys with ADHD in children at a rate of more than twice that of girls. That is partly due to the diagnosis in girls being missed because of gender differences in ADHD symptoms.
• There are also racial and ethnic disparities in ADHD diagnosis and treatment, in that Latino and African-American children are underdiagnosed with this diagnosis.
• Increasing access to care as well as family psychoeducation and culturally sensitive assessments of ADHD are important measures to alleviate those disparities. These measures combat implicit biases of people who are in the role of identifying possible mental health symptoms and referring for assessment (like teachers and pediatricians) so that ADHD symptoms are appropriately interpreted as potential illness rather than defiance or other intentional misbehavior.
• Children who are younger than their peers in the same class are at risk for being overdiagnosed with ADHD since mere months in age may make the difference in a child's ability to sit still, manage their impulses, and pay attention.
• Educating professionals, especially teachers, about these developmental differences is key to helping these children and their families.

There are three presentations for ADHD:

• Predominantly hyperactive-impulsive
• Predominantly inattentive
• Combined presentation (impulsive, inattentive, and hyperactive)

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is the gold standard of mental health diagnoses, symptoms of ADD/ADHD include the following:

Inattention

1. Often makes careless mistakes or has problems paying attention to detail
2. Poor concentration during tasks or leisure activities
3. Does not seem to be listening and appears to zone out when spoken to directly
4. Frequently fails to complete instructions or to complete work tasks or chores
5. Often has trouble organizing a task or activity
6. Short attention span
7. Frequently avoids, dislikes, or resists participating in activities that require sustained concentration/mental effort, due to difficulty focusing, a tendency to waste time
8. Repeatedly loses things needed to complete tasks or activities
9. Easily distracted by extraneous input or unrelated thoughts
10. Frequent forgetfulness/absentmindedness

Hyperactivity and impulsivity

1. Often engages in fidgeting, squirming, or tapping hands or feet
2. Frequently has trouble staying seated
3. Frequent restlessness or boredom
4. Has trouble engaging in leisure activities quietly
5. Engages in multiple activities at once
6. Often talks excessively
7. Repeatedly interrupts others talking
8. Trouble waiting for his or her turn
9. Often intrudes on others

Other considerations

1. The fact that children with ADHD may be able to highly focus on activities they enjoy (such as watching television or playing video games), even excessively, does not mean that they do not have the condition.
2. The difference in the attention of ADHD children is that they tend to have suboptimal memory, be less able to pay attention consistently, particularly when required to complete less pleasurable activities. Their trouble sitting still may involve engaging in behaviors like running or climbing in situations where it is unsafe or otherwise inappropriate.
3. While symptoms like insomnia, irritability, tantrums, otherwise quick temper, or difficulty managing their anger, as well as low frustration tolerance, are not specific to ADHD or required for its diagnosis, many children with this illness have these symptoms.
4. Besides insomnia, other sleep problems like sleep apnea, low sleep efficiency, and trouble staying awake during the day often plague children who have ADHD.

Although there is no single cause for ADHD, there are a number of biological, environmental, and social factors that seem to increase the risk of a person developing the disorder.

• Brain imaging studies show that the brains of people with ADHD tend to be smaller. The connections between certain parts of the brain are fewer, and the brain's regulation of the neurochemical dopamine tends to be less than in people who do not have the condition.
• Some medical conditions have been found to have a higher occurrence of ADHD compared to people without those conditions. Examples include seizures, asthma, as well as gastrointestinal disorders such as celiac disease and gluten sensitivity.

ADHD risk factors

• Risk factors for ADHD that can occur in the womb include maternal stress, smoking or exposure to lead during pregnancy, and low weight at birth.
• Being male and having a family history of ADHD increase the likelihood that an individual is diagnosed with ADHD.
• This illness has also been linked to being exposed to tobacco smoke at home (secondhand smoke) or lead during childhood.
• Socially, low family income, low paternal education, exposure to childhood trauma, or a sudden life change are risk factors for developing ADHD.
• Behavioral expectations based on the culture of an area, from a school district, town, state, or country can influence how often this diagnosis is made, as well.

In order for a child to receive an ADHD diagnosis, he or she must exhibit six symptoms of inattention or six symptoms of combined hyperactivity and impulsivity, while an older teen or adult need only have five of either group of symptoms. The ADD symptoms should start before 12 years of age, be present in more than one setting (for example, home and school), be severe enough to cause problems for the person, and not be able to be better explained by another condition for criteria for the diagnosis of ADHD to be met.

There are three kinds of ADHD:

• predominantly inattentive presentation,
• predominantly hyperactive/impulsive presentation, and
• the combined (inattentive, hyperactive, and impulsive) presentation.

Who performs ADHD tests?

• Many health care professionals, including licensed mental health therapists, pediatricians, and other primary care providers, psychiatrists, clinical psychologists, psychiatric nurses, physician assistants, and social workers may help make the diagnosis of ADHD in children. One of these professionals will likely perform or refer for an extensive medical interview and physical examination as part of the assessment.
• One of the key issues in assessing children and teens for ADHD is determining whether the behaviors being exhibited are part of normal behavior for their age or of ADHD.

What is involved in ADHD testing?

• Individuals with ADHD also often have a learning disability or one of a number of other mental health problems, like symptoms associated with exposure to trauma, as well as depression, bipolar disorder, obsessive-compulsive disorder, and other anxiety disorders, Asperger's syndrome, and other autism-spectrum disorders.
• Childhood ADHD is also often associated with other behavior disorders, like conduct disorder and oppositional defiant disorder. Therefore, the health care professional will likely screen for signs of depression, manic depression, anxiety, and other mental health symptoms.
• The symptoms of ADHD may also be the result of a number of medical disorders that affect brain function or can be a side effect of various medications. For this reason, health care professionals often perform routine laboratory tests during the initial evaluation to rule out other causes of ADD symptoms.
• Occasionally, an X-ray, brain scan, or another imaging study may be needed.
• As part of this examination, the sufferer may be asked a series of questions from a standardized questionnaire or self-test to help establish the diagnosis.
• Some ADHD screening tests of symptom scales or checklists for children include the Vanderbilt Rating Scale and the Connors' Rating Scales.

What is the approach to ADHD testing?

In an effort to encourage thoughtful, deliberate assessment and treatment of ADHD rather than premature treatment with medication, a stepped diagnostic approach to this condition is being encouraged by many mental health practitioners, except if the child's symptoms are severe such that the need for treatment is urgent. The steps in this approach include the following:

• Gathering information about the child from more than one source (such as from the school and home)
• Exploring what other issues may be causing symptoms (such as symptoms of a medical illness or reaction to trauma)
• Continue to monitor and assess potential symptoms over time
• If issues continue, provide an intervention like education materials on ADHD
• If the minimal intervention does not result in adequate symptom management, provide or refer for a brief number of counseling sessions to teach the child and his or her family ways to decrease and manage the child's symptoms and implement educational accommodations to help improve the child's educational performance.
• If issues continue despite the previous interventions, consider assessment for treatment with medication for ADHD.

Can a child in preschool have ADHD?

Scientists at the Centers for Disease Control and Prevention estimate that about 2 million preschool-aged children are currently diagnosed with ADHD. While this condition can be diagnosed in children under 5 years of age, there is a significant risk of misdiagnosis of ADHD given how quickly younger children grow and develop.

Children who are of preschool age or younger also have less opportunity to be in settings that illuminate the symptoms of the condition than their school-aged counterparts.

Symptoms of ADHD in toddlers may include problems with self-control, in that they experience trouble sitting still, a tendency to be in constant motion, talking constantly, as well as having difficulty focusing, listening, or settling down to sleep or eat.

Children with ADHD often benefit from being prescribed medication, started at low doses followed by titration upward to the dose found to effectively treat each individual. The most common medications used to treat this disorder are stimulant medications.

• Perhaps the oldest prescribed stimulant for the treatment of ADHD is methylphenidate (Ritalin). However, given the side effects associated with shorter-acting medications, as well as the longer days that older children and teens have compared to young children, stimulants that last longer are usually prescribed for those age groups.
• Examples of these prescribed drugs include long-acting preparations of methylphenidate (Ritalin-LA, Concerta), dexmethylphenidate (Focalin), and lisdexamfetamine (Vyvanse). 

What are the side effects of ADHD medications for children?

Some children and adolescents may need to take a non-stimulant medication for the treatment of ADHD. For those whose symptoms early in the morning or late in the evening (before the stimulant medication is taken or after it has worn off, respectively) are an issue, stimulants may not be the optimal medication treatment.

• For others, side effects like low appetite, stomach upset, insomnia, tremors, depression, loss of exuberance, irritability, less frequent tics, and rarely hallucinations may make it unwise for the child to take a stimulant medication.
• While stimulant treatment of people with ADHD who have no history of drug abuse tends to contribute to a decreased likelihood of developing a substance-abuse problem, later on, those who have a recent history of alcohol or other drug abuse may make the small but real addiction potential of stimulants a reason not to prescribe a medication from that group.
• For children who either experience suboptimal effects, or significant stimulant medication side effects, non-stimulant medications like guanfacine, clonidine, or atomoxetine may be considered. The prescription dietary supplement Vayarin has also been found to be effective in treating childhood ADHD.
• Children who suffer from ADHD are at higher risk for developing mood problems during adulthood. They may therefore benefit from medications that have been found to be helpful for people who have both ADHD and depression or anxiety, like bupropion or venlafaxine.

Behavioral therapy and other treatment options

While medications are often prominent in the treatment of ADHD, there are a number of other evidence-based treatments without drugs. Psychoeducation for the ADHD sufferer and his or her loved ones can be invaluable in improving understanding about the challenges of this condition and ways to cope.

• Applied Behavioral Analysis (ABA) is an approach that can address parent-child interactions, as well as those that the child with ADHD has with his or her parents, peers, and in school are also important in improving the kid's ability to function. ABA uses a number of strategies for encouraging positive observable (as opposed to reported) behaviors and discouraging the continuation of negative observable behaviors by holding the individual accountable, establishing achievable goals, empowering the person's strengths, and maintaining an optimistic stance throughout the treatment process.
• Parenting skills and family therapy: Mental health professionals often work with parents through specialized parenting skills training and/or through family therapy to enhance the family structure and support, develop ways to manage a child's behaviors, promote the child's self-esteem, and cope with any distress that the symptoms of ADHD cause within the family.
• Support groups: Kids with ADHD, their parents, or other family members may also benefit from being part of a support group, in that such groups have the unique perspective of people who have similar experiences and can therefore give first-hand advice on ways to cope.
• Academic support: ADHD treatment specialists may assist teachers in developing ways to provide academic accommodations, thereby encouraging and reinforcing the child's strengths, decreasing the kid's counterproductive behaviors, and maximizing the child's academic success. 
• Anger management and social skills: Mental health practitioners may enlist the child with ADHD in anger management or social-skills training group of their peers to improve the child's ability to manage his or her emotions, as well as their success at making and keeping friends.
• Individual psychotherapy that uses a cognitive-behavioral approach has been found to be an effective part of comprehensively treating ADHD. This method teaches time management, organization, and planning in an attempt to decrease the negative impact that distractibility, restlessness, hyperactivity, and impulsivity can have on the life of the ADHD sufferer. It also seeks to alleviate ways of thinking that encourage depression and anxiety.

ADHD dietary changes

• Gluten: For people who have ADHD with celiac disease or gluten sensitivity, foods to avoid may include wheat-based products in an effort to decrease symptoms of hyperactivity, impulsivity, and distractibility.
• Dyes: Although potentially difficult to implement in children, another change in nutrition that may decrease symptoms includes eliminating food dyes.
• Sugar: Limiting dietary sugar has seemed to decrease hyperactivity, impulsivity, or distractibility in some children, but research articles show inconsistent results in this regard. The Feingold diet (developed in the 1970s) involves omitting food additives in an attempt to alleviate ADHD symptoms. While the Feingold diet may help some individual children, it has long ago been deemed ineffective for most.
• Fish oil: Dietary supplements are sometimes used as homeopathic treatments for ADHD. For example, fish oil (particularly in its prescription form [Vayarin]) has been found to effectively treat ADHD in some individuals, particularly for those who have mild symptoms. 
• Herbs: Some herbs, both alone and in combination with other herbs, have been found to reduce ADHD symptoms in some people with the disorder. Examples of such herbs include Ginkgo Biloba, Brahmi, green oats, and pine bark. 
• Vitamins that are thought to improve thinking (B vitamins) may also help improve the thinking and functioning of ADHD sufferers).

Lifestyle changes

• Exercise: Lifestyle improvements have been found to help reduce some symptoms in some children. Such improvements include regular exercise and ensuring the person receives adequate sleep every night. In fact, there is research that indicates that regular physical activity can measurably decrease ADHD symptoms, particularly in young children.
• Sleep aids: Children who have trouble sleeping may benefit from over-the-counter medications that are not habit-forming, such as melatonin.

Current estimates are that 85% of children receiving the diagnosis of ADHD are at risk for having the disorder in some form as an adult. About one-third of those children may seem to grow out of it; however, that does not occur for all symptoms. The remaining two-thirds of children with ADHD continue to have most symptoms, but those symptoms may look differently in adulthood than in childhood. 

• Studies indicate that breastfeeding up to 6 months of age may help protect individuals from developing ADHD.
• As environmental and social insults like maternal drug use and exposure to community violence, medical, and emotional issues are risk factors for developing ADHD, prevention or treatment of those issues can help prevent or decrease the severity of this condition.
• Much of the latest research on ADHD in children focuses on how exposure to environmental toxins may increase the risk of developing this condition. For example, studies indicate that exposure to fluoride, lead, pesticides, dry cleaning chemicals, and other chemicals can increase the likelihood that a child develops ADHD.
• Also, research indicates that mothers who use acetaminophen (Tylenol) during pregnancy may be at higher risk of having a child with ADHD, particularly with more frequent use and during more than one trimester of the pregnancy.

Attention Deficit Disorder Association
800-939-1019
add.org

Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD)
4221 Forbes Blvd., Suite 270
Lanham, MD 20706
301-306-7070

National Institute of Mental Health Information Resource Center
6001 Executive Blvd.
Room 6200, MSC 9663
Bethesda, MD 20892-9663
866-615-6464
Email: [email protected]