Attention-Deficit Hyperactivity Disorder

Photo courtesy of HelpGuideOpens in new window In 1998, the National Institutes of HealthOpens in new window addressed concerns about the validity of the ADHD construct by holding a Consensus Development Conference that concluded that, though no independent diagnostic test existed, there was sufficient evidence to establish the validity of ADHD as a disorder.

The Symptoms of ADHD

In the DSM-IV, the American Psychiatric Associaton categorized the diagnostic criteria of ADHD into two major groups:

1. inattention and
2. hyperactivity/impulsivity.

At least six symptoms of inattention or hyperactivity/impulsivity must exist in order for a child to receive the diagnosis of ADHD.

These symptoms must be present for at least six months continuously and should be inconsistent with the developmental level of the child.

According to the DSM-IV, a child with inattention often:

• fails to pay close attention to details or makes careless mistakes;
• has difficulty in tasks that require sustained attention in play, school, or work;
• does not seem to listen when spoken to;
• has difficulty organizing tasks and activities;
• avoids tasks that require prolonged mental effort;
• loses things easily;
• is distracted by extraneous stimuli; and
• is forgetful in his or her daily activities.

A child with hyperactivity/impulsivity often:

• fidgets with hands or feet or squirms in his or her seat; is up out of his or her classroom seat or in other places when remaining seated is expected;
• runs or climbs when it is inappropriate (for teens the symptom may be restless behavior);
• has difficulty engaging quietly in leisure activities;
• is “on the go”;
• talks excessively;
• blurts out answers before the question is complete;
• has difficulty waiting his or her turn; and
• interrupts or intrudes on others.

Although the name may be a bit confusing, ADHD is the diagnostic term given whether or not the symptom of hyperactivity exists, and the disorder is now divided into three main types:

1. ADHD — combined type (ADHD-CT): The symptoms of inattention, impulsivity, and hyperactivity occur in generally equal proportions.
2. ADHD—primarily inattentive type (ADHD-I): Inattention is the overriding symptom. The child is not a bother to anyone but sits and stares out of the window or is distracted by any movement. This type seems to affect girls more often than boys but can occur in both sexes.
3. ADHD—primarily hyperactive type (ADHD-H): Hyperactivity and impulsivity are the overriding symptoms.

According to the DSM-IV diagnostic criteria, symptoms must be present prior to seven years of age. The reasoning behind this is that ADHD is a developmental disorder that likely has a genetic cause. Thus, the manifestation of symptoms should occur at least by the time the child enters primary school, when real demands on attention and self-control are made on the child. A bright child who works hard with a supportive and organized family may not have the ADHD-I diagnosed until after seven years of age because of the family assistance, but retrospectively, the symptoms should have been present.

The DSM-IV criteria also state that the symptoms must be continuous and present in more than one setting, such as at home, school, and work. This requirement dictates that the disorder is pervasive and not situational.

• If a child is only hyperactive at home, but problems do not occur in school, the hyperactivity may be behavioral or there may be inappropriate demands placed on the child at home.
• If the child is only inattentive in math class and not in others, then it may be a problem with math rather than ADHD or the particular teacher may have very strict behavioral expectations in the classroom.

Another important point in the criteria is that the problems should cause a significant impairment.

Many individuals will have some of the symptoms described as ADHD at one time or another in their life. Some individuals are more calm and attentive than others, and the range of normal behaviors should not be so narrow that everyone is expected to behave exactly the same way. This requirement of a significant impairment is an attempt to keep the range of normal behaviors in proper perspective.

1.   ADHD in the Young Child

Toddlers are naturally active, but occasionally a child stands out far beyond what is recognized as normal. ADHD-HI is apparent in some cases as early as three or four years of age. Parents of these children frequently complain about never being able to go anywhere due to the behavioral difficulties.

Shopping trips, going out to eat, or other family outings are not only difficult, they are impossible. The impulsive behaviors of these very active toddlers can put them in dangerous situations, and parents are often exhausted due to the need for constant vigilance when caring for them.

Often the parents of a child with ADHD may not recognize the behaviors as being atypical until the child enters preschool or a childcare situation and they receive complaints from the teachers and childcare workers. Disruptive behaviors that interfere with the rest of the class are common in the ADHD child.

Naptime for these children is often an impossibility, and settling down to sleep at night is usually difficult. The rate for minor accidents and injuries is higher due to the impulsive nature of the child, and parents’ skills are questioned by others due to their inability to control the child’s behavior. Parents may make the initial visit to a pediatrician to discuss ADHD because their child has been kicked out of childcare or preschool. At this point, the stress on the family integrity can be extreme, and parents express feelings of not knowing what to do next.

2.   ADHD in the School-Age Child

Entry into elementary school is the most common event that initiates an evaluation for ADHD. Disruptive, fidgety behavior, failure to follow directions, and incomplete work are common complaints. On the playground, these children fail to take turns and follow rules or they exhibit aggressive behaviors.

The ADHD child may have to repeat kindergatten, with the reason cited as “immaturity.” Unfortunately, a repeat of kindergarten alone without recognition of the disorder will do little to help the child succeed the following year.

Children with ADHD-I are not overly active; instead, there are complaints that the child is slow moving, misses instructions, loses things easily, and is never prepared. The proper diagnosis of ADHD-I is often made later in the child’s school career. There may be suspicion of something being wrong as the child enters middle school, when reading comprehension becomes especially important in academic success.

3.   ADHD in Teens

Teens with ADHD-CT or ADHD-HI will have a shift of symptoms from excessive activity to more internal and subjective feelings of restlessness and complaints of easy boredom, incomplete work, and poor grades. Although the obvious symptoms of hyperactivity and impulsivity seem to improve, the inattention can result in academic underachievement.

An intelligent teen may be passed over for many opportunities because his true skill level is not recognized, leaving the teen feeling frustrated. The longer the frustration and underachievement go on, the more likely it is that the teen will develop problems with anxiety and depression.

This downward spiral regularly occurs in later teen years in unrecognized, poorly understood, or untreated individuals with ADHD. Frustrated teens will often migrate to fringe groups in an attempt to fit in. The teen years are when increased drug and alcohol use occurs in an attempt to “feel better” or “fit in better.”

Impulsivity is another misunderstood symptom in teens with ADHD. Social and family function and work performances are all affected by this symptom. These individuals are often viewed as rude, self-absorbed, or difficult to be around.

Self reports by teens with ADHD reveal difficulty waiting in line, interrupting others, impulsive spending, difficulty driving, and an inability to inhibit emotional reactions when dealing with others. Although the hyperactivity does improve in most teens, some may continue to have problems with fidgeting, nail biting, picking at sores, and excessive talking. Appropriate treatment of these symptoms can make a major difference in the ultimate life adjustment and outcome as teens become adults.

4.   ADHD in Adults

More than half of those diagnosed with ADHD as children will continue to have symptoms as adults. As in teens, the hyperactivity and impulsivity of the disorder evolve into more subjective feelings of restlessness and boredom.

As in teens, studies have shown that adults who continue to have significant symptoms of ADHD have greater problems with accidents and injuries requiring emergency room visits and a greater number of traffic citations.

Relationships and job longevity also suffer in some cases due to the impulsive nature of the adult with ADHD and the resultant problems that occur when one acts without first thinking of the consequences.

Treatment and Therapies

While there is no cure for ADHD, currently available treatments may reduce symptoms and improve functioning. Treatments include medication, psychotherapy, education or training, or a combination of treatments.

Medication

For many people, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Sometimes several different medications or dosages must be tried before finding the right one that works for a particular person. Anyone taking medications must be monitored closely by their prescribing doctor.

1.   Stimulants.

The most common type of medication used for treating ADHD is called a “stimulant.” Although it may seem unusual to treat ADHD with a medication that is considered a stimulant, it works by increasing the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention.

Under medical supervision, stimulant medications are considered safe. However, like all medications, they can have side effects, especially when misused or taken in excess of the prescribed dose, and require an individual’s health care provider to monitor how they may be reacting to the medication.

2.   Non-stimulants.

A few other ADHD medications are non-stimulants. These medications take longer to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD.

Doctors may prescribe a non-stimulant: when a person has bothersome side effects from stimulants, when a stimulant was not effective, or in combination with a stimulant to increase effectiveness.

Although not approved by the U.S. Food and Drug Administration (FDA)Opens in new window specifically for the treatment of ADHD, some antidepressants are used alone or in combination with a stimulant to treat ADHD.

AntidepressantsOpens in new window may help all of the symptoms of ADHD and can be prescribed if a patient has bothersome side effects from stimulants. Antidepressants can be helpful in combination with stimulants if a patient also has another condition, such as an anxiety disorder, depression, or another mood disorder. Non-stimulant ADHD medications and antidepressants may also have side effects.

Doctors and patients can work together to find the best medication, dose, or medication combination. Learn the basics about stimulants and other mental health medications on the NIMH Mental Health Medications webpage and check the FDA website for the latest medication approvals, warnings, and patient information guides.

Psychotherapy and Psychosocial Interventions

Several specific psychosocial interventions have been shown to help individuals with ADHD and their families manage symptoms and improve everyday functioning.

For school-age children, frustration, blame, and anger may have built up within a family before a child is diagnosed. Parents and children may need specialized help to overcome negative feelings. Mental health professionals can educate parents about ADHD and how it affects a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other.

All types of therapy for children and teens with ADHD require parents to play an active role. Psychotherapy that includes only individual treatment sessions with the child (without parent involvement) is not effective for managing ADHD symptoms and behavior. This type of treatment is more likely to be effective for treating symptoms of anxiety or depression that may occur along with ADHD.

1.   Behavioral Therapy.

Behavioral therapyOpens in new window is a type of psychotherapy that aims to help a person change their behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a person how to:

• monitor their own behavior
• give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting

Parents, teachers, and family members also can give feedback on certain behaviors and help establish clear rules, chore lists, and structured routines to help a person control their behavior. Therapists may also teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

2.   Cognitive Behavioral Therapy

Cognitive behavioral therapyOpens in new window helps a person learn how to be aware and accepting of one’s own thoughts and feelings to improve focus and concentration. The therapist also encourages the person with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.

3.   Family Therapy

Family and marital therapyOpens in new window can help family members and spouses find productive ways to handle disruptive behaviors, encourage behavior changes, and improve interactions with the person with ADHD.

4.   Parenting Skills Training

Parenting skills training (behavioral parent management training)Opens in new window teaches parents skills for encouraging and rewarding positive behaviors in their children.

Parents are taught to use a system of rewards and consequences to change a child’s behavior, to give immediate and positive feedback for behaviors they want to encourage, and to ignore or redirect behaviors they want to discourage.