ADHD and Parenting
Viewer asks: We have a 13-year-old with ADHD. Is this something that he might outgrow?
Doctor's response: This is a very frequently asked question from families, as well as from the adolescent with ADHD.
Attention deficit hyperactivity disorder (ADHD) is a chronic behavioral condition that initially manifests in childhood and is characterized by problems of hyperactivity, impulsivity, and/or inattention. Not all patients manifest all three behavioral categories of ADHD. These symptoms have been associated with difficulty in academic, emotional, and social functioning. The diagnosis is established by satisfying specific criteria. ADHD may be associated with other neurological, significant behavioral, and/or developmental/learning disabilities. Therapy combines the use of medication, behavioral therapy, and adjustments in day-to-day lifestyle activities. ADHD is one of the most common disorders of childhood. ADHD occurs more commonly in boys than girls. While previously believed to be "outgrown" by adulthood, current opinion indicates that many children will continue throughout life with symptoms that may affect both occupational and social functioning.
Historical figures of diverse backgrounds and accomplishment have demonstrated behavior compatible with ADHD. Mozart composed and remembered entire musical compositions but disliked the tedious task and attention to detail necessary when transcribing to paper. Einstein would spend hours and even days sitting quietly in a chair doing "thought experiments," which included complex series of mathematical calculations and revisions. Ben Franklin failed in school due to his perfectionist and impulsive behaviors. He later mastered five languages (self-taught) and is highly respected as an author, scientist, inventor, and businessman (publisher).
Viewer asks: We have a 13-year-old with ADHD. Is this something that he might outgrow?
Doctor's response: This is a very frequently asked question from families, as well as from the adolescent with ADHD.
The medical community recognizes three basic expressions of the disorder:
The combined type of ADHD is the most common. The predominantly inattentive type is being recognized more and more, especially in girls and in adults. The predominantly hyperactive-impulsive type, without significant attention problems, is rare and is commonly seen in boys during early grammar school.
In the United States, ADHD affects about 3%-10% of children. Similar rates have been reported in other developed countries such as Germany, New Zealand, and Canada.
Since 1994, the establishment of the diagnosis of childhood ADHD has relied upon specific criteria outlined in the DSM-IV. The newly published DSM-V has reaffirmed criteria for establishing a diagnosis of ADHD. The guidelines emphasize that symptoms must be present for at least six months and generally were noted to be causing disruption of age-appropriate activity before 7 years of age. According to the criteria, such disruption should occur in at least two settings (such as home and school). In addition, these symptoms must not be better explained by another mental disorder (such as anxiety disorder).
A school-age child may need evaluation for ADHD if he or she exhibits any of the following behaviors:
The evaluation of a child suspected of having ADHD involves many disciplines, including comprehensive medical, developmental, educational, and psychosocial evaluations. Interviewing parents and the patient and contacting the patient's teacher(s) is crucial. Investigation regarding the family history for behavioral and/or social problems is helpful. While direct person-to-person contact is considered vital at the outset of an investigation, follow-up studies may be guided by comparing standardized questionnaires (from parents and teachers) completed prior to intervention and subsequent to medication, behavioral therapy, or other treatment approaches. While there is no unique finding on the physical exam in patients with ADHD, unusual physical features should prompt consideration of consultation with a geneticist due to the high association with ADHD behavioral patterns and certain well-recognized genetic syndromes (for example, fetal alcohol syndrome).
At this time, no lab test, X-ray, imaging study, or procedure is known to suggest or confirm the diagnosis of ADHD. Specific tests may be ordered if indicated by specific symptoms.
Physicians and parents should be aware that schools are federally mandated to perform an appropriate evaluation if a child is suspected of having a disability that impairs academic functioning. This policy was recently strengthened by regulations implementing the 1997 reauthorization of the Individuals With Disabilities Act (IDEA), which guarantees appropriate services and a public education to children with disabilities from ages 3 to 21. If the assessment performed by the school is inadequate or inappropriate, parents may request that an independent evaluation be conducted at the school's expense. Furthermore, some children with ADHD qualify for special-education services within the public schools under the category of "Other Health Impaired." In these cases, the special-education teacher, school psychologist, school administrators, classroom teachers, along with parents, assess the child's strengths and weaknesses and design an Individualized Education Program (IEP). These special-education services for children with ADHD are available though IDEA.
Despite this "federal mandate," the reality is that many school districts, because of underfunding or understaffing, are unable to perform "an appropriate evaluation" for all children suspected of having ADHD. School districts have the latitude to define the degree of "impairment of academic functioning" necessary to approve "appropriate evaluation." This usually means the children who are failing or near-failing in their academic performance. A very large segment of the ADHD-affected children will be "getting by" (not failing) academically (at least in their early years of school), but they are usually achieving well below their potential and getting more and more behind each year on the academic prerequisite skills necessary for later school success. Unfortunately, some families will have to assume the financial burden of an independent educational evaluation. These evaluations are commonly done by an educational psychologist and may involve approximately eight to 10 hours of testing and observation spread out over several sessions. A primary goal of an educational evaluation is to exclude/include the possibility of learning disorders (including dyslexia, language disorders, etc.).
The cause of ADHD has not been defined. One theory springs from observations regarding variations in functional brain-imaging studies of those with and without symptoms. However, these variations have been shown in studies of the structure of the brain of ADHD affected and unaffected individuals. Animal studies have demonstrated differences in the chemistry of brain transmitters involved with judgment, impulse control, alertness, planning, and mental flexibility. A genetic predisposition has been demonstrated in (identical) twin and sibling studies. If one identical twin is diagnosed with ADHD, there is a 92% probability of the same diagnosis in the twin sibling. When comparing nonidentical twin sibling subjects, the probability falls to 33%. The overall population incidence is 3%-10%.
Genes that control the relative levels of chemicals in the brain called neurotransmitters seem to be different in ADHD, and levels of these neurotransmitters are out of normal balance.
While most teens and adults with ADHD are no longer hyperactive in behavior, they commonly have a suboptimal executive function skill set. The six major tasks of executive function that are most commonly distorted with ADHD are the following:
Children experiencing ADHD should be held to the same expectations as their peers of the same emotional developmental level. Assuming the child has no learning disturbance, children with ADHD will have both academic strengths and weaknesses like all non-ADHD classmates. Athletic ability will vary in a similar manner as will social interaction; some children with ADHD are very outgoing while others are more reserved. Children with ADHD are often noted to be emotionally delayed, with some individuals having a delay in maturity of up to 30% when compared with their peers. Thus, a 10-year-old student may behave like a 7-year-old; a 20-year-old young adult may respond more like a 14-year-old teenager.
The initial evaluation of a child whose behavioral issues may be indicative of ADHD can generally by managed by the pediatrician. A current physical examination is indicated to rule out potential medical issues that may either reinforce a potential ADHD diagnosis or rule out the condition. Further history regarding the various behavioral and academic strengths and weaknesses of the child are elicited and it is imperative to gather feedback from both the parents and teacher. If any concerns are developed regarding potential learning disorders (for examples, dyslexia, auditory processing disorders, etc.), specialized testing should be obtained. This evaluation may be secured either through the child's school district or private agencies. Standardized questionnaires (such as Connors Rating Scales) are often used to provide objective evaluations in both the home and school settings. In addition, these scales commonly have sections to evaluate for other mental-health issues (including depression, anxiety, etc.) that may also be present in a child with ADHD. Once a diagnosis is established, a pediatrician can discuss with the patient and the parents the various treatment options. Children whose physical or mental-health history is more complicated may warrant an evaluation by either a pediatrician with specialty training in developmental disorders, a pediatric neurologist, a psychologist, or a psychiatrist. Should a patient have a poor response or excessive side effects to commonly used medications, a pediatric neurologist or psychiatrist consultation may be especially helpful.
The two major components of treatment for children with attention deficit hyperactivity disorder (ADHD) are behavioral therapy and medication.
The medications used to treat ADHD are psychoactive. This means they affect the chemistry and the function of the brain.
Psychostimulants are by far the most widely used medications in treating ADHD. When used appropriately, approximately 80% of individuals with ADHD have a very good to excellent response in reduction of symptoms. These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.
The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.
The psychostimulants most often used in ADHD include the following:
Atomoxetine (Strattera) is a newer nonstimulant used to treat ADHD. Less is known about its long-term side effects. This drug has several benefits over stimulants, but its use may also carry several negative aspects.
Some medications originally developed to treat depression (antidepressants) also have important roles in treating some individuals with ADHD. Since these medicines have been used for many years to treat other mental-health conditions, their adverse effects are well understood.
Other medicines that were originally developed to treat high blood pressure (alpha agonists) may also be useful in the treatment of those having ADHD. Again, due to widespread and long-term use, their side effects are well known to doctors.
Stimulant medications have been successfully used to treat patients with ADHD for more than 50 years. This class of medication, when used under proper medical supervision, has an excellent safety record in patients with ADHD. In general, the side effects of the stimulant class of medications are mild, often transient over time, and reversible with adjustment in dosage amount or interval of administration. The incidence of side effects is highest when administered to preschool-aged children. Common side effects include appetite suppression, sleep disturbances, and weight loss. Less common side effects include an increase in heart rate/blood pressure, headache, and emotional changes (social withdrawal, nervousness, and moodiness). Patients treated with the methylphenidate patch (Daytrana) may develop a skin sensitization at the site of application. Approximately 15%-30% of children treated with stimulant medications develop minor motor tics (involuntary rapid twitching of facial and/or neck and shoulder muscles). These are almost always short lived and resolve without stopping the use of medication.
A recent investigation studied the possibility of stimulant medication used to treat ADHD and cardiovascular side effects. Concern focused on a possible association with heart attack, heart rate and rhythm disturbances, and stroke. At this time, there is no certainty in a proposed relationship to these events (including sudden death) when medication is used in a pediatric population screened for prior cardiovascular symptoms or structural pathology of the heart. A positive family history for certain conditions (for example, unusual heart rhythm patterns) may be considered a risk factor. The current position of the American Academy of Pediatrics is that a screening EKG is not indicated before the initiation of stimulant medication in a patient without risk factors.
"Diversion" is the transfer of medication from the patient for whom it was prescribed to another individual. Several large studies have indicated that 5%-9% of grade- and high-school students and 5%-35% of college-aged individuals reported use of nonprescribed stimulant medication, and 16%-29% of students for whom stimulant medications were prescribed reported being approached to give, trade, or sell their medication. Misuse was more frequently seen in whites, members of fraternities and sororities, and students with a lower GPA. Diversion was more likely with the short-acting preparations. The most common reasons cited for use of non-prescribed stimulants were "helped with studying," improved alertness, drug experimentation, and "getting high."
ADHD is a controversial diagnosis for several reasons. Many well-meaning individuals have spoken out against making children behave according to a norm or taking medications for the sake of improving grades. These individuals have expressed concern about addiction or drugging children. This kind of concern is valid. However, the following must also be considered:
The use of psychostimulants in children should be scrutinized carefully. Fortunately, methylphenidate (Ritalin [and its long-lasting formulation, Concerta]) has been available since 1955. This long period of clinical experience has shown that this is one of the safest medications used in children.
No specific food or diet has been clearly shown to have a significant positive or negative effect on the symptoms or course of ADHD. People with ADHD should eat a healthy diet and probably avoid caffeine, a stimulant. That having been said, some parents note that a dietary change (such as decreased refined sugar intake) is beneficial. If an individual is not deprived of necessary nutrients, there is certainly no harm in trying to follow such a dietary adjustment. A good rule of thumb is to discuss the proposed plan with the child's pediatrician.
Regular physical activity has been shown to play an important role in some of the common related conditions (for example, depression, anxiety) and to improve concentration. Regular exercise may be beneficial in people with ADHD. Several studies on children with ADHD not taking medication have shown an improvement in concentration and reduction in inattentive and hyperactive behaviors if one hour of vigorous after-school play occurs before starting homework.
CAM (complementary and alternative medicine) therapies are considered and/or tried in over half of patients with ADHD. Many times these modalities are used covertly, and it is important for the treating physician to inquire about CAM to encourage open communication and review the risks versus benefits of such an approach. CAM treatment modalities incorporating vision training, special diets and megavitamin therapy, herbal and mineral supplements, EEG biofeedback, and applied kinesiology have all been advocated. The benefits of these approaches, however, have not been confirmed in double-blinded controlled studies. Families should be aware that such programs might require a long-term financial commitment that may not have insurance reimbursement as an option.
No one knows for sure whether the prevalence of ADHD (total number of patients) has risen, but it is very clear that the number of children newly identified annually (incidence) with the disorder and who obtain treatment has risen over the past decade. Some of this increased identification and increased treatment seeking is due in part to greater media interest, heightened consumer awareness, and the availability of effective treatments. Teachers are better trained to recognize the condition and suggest that the family seek help, especially in the more mild to moderate cases. The established DSM-IV ADHD criteria are concise and more exact than those diagnostic tools used previously. This may allow establishment of the diagnosis in children with more subtle or milder expression of the symptoms. The diagnosis of ADHD is also less of a social stigma than in the past. This more enlightened perspective reflects the understanding that ADHD is a biochemical disorder and not merely an "out of control child." As such, more parents are receptive to medical therapy for the condition rather than resorting to less effective home/school discipline techniques. Interestingly, the increase in prevalence of ADHD is not solely an American phenomenon but has been noted also in other countries. Whether the number of patients with ADHD has truly increased or rather our better recognition and acceptance of ADHD as a diagnosis has "increased," the number of patients remains to be further defined.
Literature supports the clinical observation that as many as 50% of children with ADHD will have symptoms persist into adulthood. One caveat needs to be mentioned -- many studies previously conducted focused on a patient population of males who were evaluated or treated by psychiatrists/psychologists or in clinics specially developed for such a patient population. The value of generalizing these results to the entire patient population with ADHD should be done with caution. Fortunately, new studies are being conducted to address this issue.
The following are current areas of concern:
Attention deficit hyperactivity disorder (ADHD), whether it affects an adult or a child brings many challenges. People with ADHD can learn, achieve, succeed, and create a happy life for themselves with effort. But making changes is not always easy. Sometimes it helps to have someone to talk to.
This is the purpose of support groups. Support groups consist of people in the same situation. They come together to help each other and to help themselves. Support groups provide reassurance, motivation, and inspiration. They help individuals see that their situation is not unique and not hopeless, and that gives them power. They also provide practical tips on coping with ADHD and navigating the medical, educational, and social systems that people will rely on for help for themselves or their child. Being in an ADHD support group is strongly recommended by most mental-health professionals.
Support groups meet in person, on the telephone, or on the Internet. To find a support group, contact the following organizations. They also serve as an excellent source of accurate information about ADHD. Ask a health-care professional, behavioral therapist, education specialist, or look on the Internet.
Attention Deficit Disorder Association
Children and Adults With Attention-Deficit/Hyperactivity Disorder
Learning Disabilities Association of America
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, 5th Ed (DSM-V). Washington (DC): American Psychiatric Association, 2010.
United States. National Institute of Mental Health. "Attention Deficit Hyperactivity Disorder." <http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml>.
Wilms Floet, Anna Maria, Cathy Scheiner, and Linda Grossman. "Attention-Deficit/Hyperactivity Disorder." Pediatrics in Review 31.2 Feb. 2010: 56-68.
A number of vital tasks carried out during sleep help maintain good health and enable people to function at their best. Sleep needs vary from individual to individual and change throughout your life. The National Institutes of Health recommend about 7-9 hours of sleep each night for older, school-aged children, teens, and most average adults; 10-12 for preschool-aged children; and 16-18 hours for newborns. There are two stages of sleep; 1) REM sleep (rapid-eye movement), and 2) NREM sleep (non-rapid-eye movement). The side effects of lack of sleep or insomnia include:
Lack of sleep and insomnia can be caused by medical conditions or diseases, medications, stress, or pain. The treatment for lack of sleep and insomnia depends upon the cause.