Attention Deficit Hyperactivity Disorder (ADHD)

Typically, ADHD symptoms arise in early childhood. According to the DSM-5, several symptoms are required to be present before the age of 12. Many parents report excessive motor activity during the toddler years, but ADHD symptoms can be hard to distinguish from the impulsivity, inattentiveness and active behavior that is typical for kids under the age of four. In making the diagnosis, children should have six or more symptoms of the disorder present; adolescents 17 and older and adults should have at least five of the symptoms present. The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The symptoms for each are adapted and summarized below.

ADHD combined presentation

• The individual meets the criteria for both inattention and hyperactive-impulsive ADHD presentations.

• These symptoms can change over time, so children may fit different presentations as they get older.

Children with ADHD often experience delays in independent functioning and may behave younger than their peers. Many children affected by ADHD can also have mild delays in language, motor skills or social development that are not part of ADHD but often co-occur. They tend to have low frustration tolerance, difficulty controlling their emotions and often experience mood swings.

Children with ADHD are at risk for potentially serious problems in adolescence and adulthood: academic failure or delays, driving problems, difficulties with peers and social situations, risky sexual behavior, and substance abuse. There may be more severe negative behaviors with co-existing conditions such as oppositional defiant disorder or conduct disorder. Adolescent girls with ADHD are also more prone to eating disorders than boys. As noted above, ADHD persists from childhood to adolescence in the vast majority of cases (50–80 percent), although the hyperactivity may lessen over time.

Teens with ADHD present a special challenge. During these years, academic and life demands increase. At the same time, these kids face typical adolescent issues such as emerging sexuality, establishing independence, dealing with peer pressure and the challenges of driving.

More than 75 percent of children with ADHD continue to experience significant symptoms in adulthood. In early adulthood, ADHD may be associated with depression, mood or conduct disorders and substance abuse. Adults with ADHD often cope with difficulties at work and in their personal and family lives related to ADHD symptoms. Many have inconsistent performance at work or in their careers; have difficulties with day-to-day responsibilities; experience relationship problems; and may have chronic feelings of frustration, guilt or blame.

Individuals with ADHD may also have difficulties with maintaining attention, executive function and working memory. Recently, deficits in executive function have emerged as key factors affecting academic and career success. Executive function is the brain’s ability to prioritize and manage thoughts and actions. This ability permits individuals to consider the long-term consequences of their actions and guide their behavior across time more effectively. Individuals who have issues with executive functioning may have difficulties completing tasks or may forget important things.

More than two-thirds of children with ADHD have at least one other co-existing condition. Any disorder can co-exist with ADHD, but certain disorders seem to occur more often. These disorders include oppositional defiant and conduct disorders, anxiety, depression, tic disorders or Tourette syndrome, substance abuse, sleep disorders and learning disabilities. When co-existing conditions are present, academic and behavioral problems, as well as emotional issues, may be more complex.

These co-occurring disorders can continue throughout a person’s life. A thorough diagnosis and treatment plan that takes into account all of the symptoms present is essential.

Despite multiple studies, researchers have yet to determine the exact causes of ADHD. However, scientists have discovered a strong genetic link since ADHD can run in families. More than 20 genetic studies have shown evidence that ADHD is strongly inherited. Yet ADHD is a complex disorder, which is the result of multiple interacting genes.

Other factors in the environment may increase the likelihood of having ADHD:

• exposure to lead or pesticides in early childhood

• premature birth or low birth weight

• brain injury

Scientists continue to study the exact relationship of ADHD to environmental factors, but point out that there is no single cause that explains all cases of ADHD and that many factors may play a part.

Previously, scientists believed that maternal stress and smoking during pregnancy could increase the risk for ADHD, but emerging evidence is starting to question this belief. However, further research is needed to determine if there is a link or not.

The following factors are NOT known causes, but can make ADHD symptoms worse for some children:

• watching too much television

• eating sugar

• family stress (poverty, family conflict)

• traumatic experiences

ADHD symptoms, themselves, may contribute to family conflict. Even though family stress does not cause ADHD, it can change the way the ADHD presents itself and result in additional problems such as antisocial behavior.

Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.

ADHD brains have low levels of a neurotransmitter called norepinephrine. Norepinephrine is linked arm-in-arm with dopamine. Dopamine is the thing that helps control the brain’s reward and pleasure center. The ADHD brain has impaired activity in four functional regions of the brain.

1. Frontal Cortex

This region controls high-level functions:

• Attention

• Executive Function

• Organization

2. Limbic System

This region is located deeper in the brain. It regulates our emotions and attention.

3. Basal Ganglia

A deficiency here can cause inter-brain communication & information to “short-circuit.” That results in inattention or impulsivity.

4. Reticular Activating System

This is the major relay system among the many pathways that enter & leave the brain. A deficiency here can cause inattention, impulsivity, or hyperactivity.

• Behavior therapy, including training for parents; and

• Medications.

• For children with ADHD younger than 6 years of age, the American Academy of Pediatrics (AAP) recommends parent training in behavior management as the first line of treatment, before medication is tried. 

• For children 6 years of age and older, the recommendations include medication and behavior therapy together — parent training in behavior management for children up to age 12 and other types of behavior therapy and training for adolescents.  Schools can be part of the treatment as well. AAP recommendations also include adding behavioral classroom intervention and school supports. 

Medications

Medication can help children manage their ADHD symptoms in their everyday life and can help them control the behaviors that cause difficulties with family, friends, and at school.

Several different types of medications are FDA-approved to treat ADHD in children as young as 6 years of age

• Stimulants are the best-known and most widely used ADHD medications. Between 70-80% of children with ADHD have fewer ADHD symptoms when taking these fast-acting medications.

• Nonstimulants were approved for the treatment of ADHD in 2003. They do not work as quickly as stimulants, but their effect can last up to 24 hours.

• Medications can affect children differently and can have side effects such as decreased appetite or sleep problems. One child may respond well to one medication, but not to another.

• Healthcare providers who prescribe medication may need to try different medications and doses. The AAP recommends that healthcare providers observe and adjust the dose of medication to find the right balance between benefits and side effects.

•  It is important for parents to work with their child’s healthcare providers to find the medication that works best for their child.

The following are suggestions that may help with your child’s behavior:

• Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime.

• Get organized

• Encourage your child to put schoolbags, clothing, and toys in the same place every day so that they will be less likely to lose them.

• Manage distractions. Turn off the TV, limit noise, and provide a clean workspace when your child is doing homework. Some children with ADHD learn well if they are moving or listening to background music. Watch your child and see what works.

• Limit choices. To help your child not feel overwhelmed or overstimulated, offer choices with only a few options. For example, have them choose between this outfit or that one, this meal or that one, or this toy or that one.

• Be clear and specific when you talk with your child. Let your child know you are listening by describing what you heard them say. Use clear, brief directions when they need to do something.

• Help your child plan. Break down complicated tasks into simpler, shorter steps. For long tasks, starting early and taking breaks may help limit stress.

• Use goals and praise or other rewards. Use a chart to list goals and track positive behaviors, then let your child know they have done well by telling them or by rewarding their efforts in other ways. Be sure the goals are realistic—small steps are important!

• Discipline effectively. Instead of scolding, yelling, or spanking, use effective directions, time-outs or removal of privileges as consequences for inappropriate behavior.

• Create positive opportunities. Children with ADHD may find certain situations stressful. Finding out and encouraging what your child does well—whether it’s school, sports, art, music, or play—can help create positive experiences.

Provide a healthy lifestyle. Nutritious food, lots of physical activity, and sufficient sleep are important; they can help keep ADHD symptoms from getting worse.