Understanding ADHD

Understanding ADHD
Information for Parents About Attention-Deficit/Hyperactivity Disorder

  Almost all children have times when their behavior veers out of control. They may speed about in constant motion, make noise nonstop, refuse to wait their turn, and crash into everything around them. At other times they may drift as if in a daydream, failing to pay attention or finish what they start. However, for some children, these kinds of behaviors are more than an occasional problem. Children with attention-deficit/hyperactivity disorder (ADHD), have behavior problems that are so frequent and severe that they interfere with their ability to live normal lives.

These children often have trouble getting along with siblings and other children at school, at home, and in other settings. Those who have trouble paying attention usually have trouble learning. An impulsive nature may put them in actual physical danger. Because children with ADHD have difficulty controlling this behavior, they may be labeled “bad kids” or “space cadets.”

Left untreated, more severe forms of ADHD can lead to serious, lifelong problems such as poor grades in school, run-ins with the law, failed relationships, and the inability to keep a job.

Effective treatment is available. If your child has ADHD, your pediatrician can offer a long-term treatment plan to help your child lead a happy and healthy life. As a parent, you have a very important role in this treatment.
  What is ADHD?

ADHD is a condition of the brain that makes it difficult for children to control their behavior. It is one of the most common chronic conditions of childhood.

It affects 4% to 12% of school-aged children. About 3 times more boys than girls are diagnosed with ADHD.

The condition affects behavior in specific ways.
  What are the symptoms of ADHD?

ADHD includes 3 behavior symptoms: inattention, hyperactivity, and impulsivity. Table 1 explains these symptoms.
    TABLE 1. Symptoms of ADHD
    Symptom How a child with this symptom may behave
   

Inattention

 Has a hard time paying attention, daydreams

Does not seem to listen

Is easily distracted from work or play

Does not seem to care about details, makes careless mistakes

Does not follow through on instructions or finish tasks

Is disorganized

Loses a lot of important things

Forgets things

Does not want to do things that require ongoing mental effort
    Hyperactivity Is in constant motion, as if “driven by a motor”

Cannot stay seated

Squirms and fidgets

Talks too much

Runs, jumps, and climbs when this is not permitted

Cannot play quietly
    Impulsivity Acts and speaks without thinking

May run into the street without looking for traffic first

s trouble taking turns

Cannot wait for things

Calls out answers before the question is complete

Interrupts others
  Are there different types of ADHD?

Children with ADHD may have one or more of the symptoms listed in Table 1.

The symptoms usually are classified as the following types of ADHD:
   
bullet Inattentive only (formerly known as attention-deficit disorder [ADD]}—Children with this form of ADHD are not overly active. Because they do not disrupt the classroom or other activities, their symptoms may not be noticed. Among girls with ADHD, this form is most common.
bullet Hyperactive/Impulsive—Children with this type of ADHD show both hyperactive and impulsive behavior, but can pay attention.
bullet Combined Inattentive/Hyperactive/Impulsive—Children with this type of ADHD show all 3 symptoms. This is the most common type of ADHD.
  How can I tell if my child has ADHD?

Remember, it is normal for all children to show some of these symptoms from time to time. Your child may be reacting to stress at school or home.

She may be bored or going through a difficult stage of life. It does not mean she has ADHD.

Sometimes a teacher is the first to notice inattention, hyperactivity, and/or impulsivity and bring these symptoms to the parents’ attention.

Perhaps questions from your pediatrician raised the issue. At routine visits, pediatricians often ask questions such as the following:
   
bullet How is your child doing in school?
bullet Are there any problems with learning that you or your child’s teachers have seen?
bullet Is your child happy in school?
bullet Is your child having problems completing class work or homework?
bullet Are you concerned with any behavior problems in school, at home, or when your child is playing with friends?
  Your answers to these questions may lead to further evaluation for ADHD.

If your child is 6 years of age or older and has shown symptoms of ADHD on a regular basis for more than 6 months, discuss this with your pediatrician.
  Keep safety in mind

If your child shows any symptoms of ADHD, it is very important that you pay close attention to safety. A child with ADHD may not always be aware of dangers and can get hurt easily. Be especially careful around the following:

bullet Traffic
bullet Firearms
bullet Swimming pools
bullet Tools such as lawn mowers

 

  DiagnosisYour pediatrician will determine whether your child has ADHD using standard guidelines developed by the American Academy of Pediatrics. These diagnosis guidelines are for children 6 to 12 years of age.

It is difficult to diagnose ADHD in children 5 years of age and younger.

This is because many preschool children have some ADHD symptoms in various situations. In addition, children change very rapidly during the preschool years. It is also difficult to diagnose ADHD once a child becomes a teenager.

There is no single test for ADHD. The process requires several steps and involves gathering a lot of information from multiple sources. You, your child, your child’s school, and other caregivers should be involved in assessing your child’s behavior.

Children with ADHD, show signs of inattention, hyperactivity, and/or impulsivity in specific ways. (See the behaviors listed in Table 1.) Your pediatrician will look at how your child’s behavior compares to that of other children his own age, based on the information reported about your child.
  To confirm a diagnosis of ADHD, these behaviors must
   
bullet Occur in more than 1 setting, such as home, school and social situations.
bullet Be more severe than in other children the same age.
bullet Start before the child reaches 7 years of age. (However, these may not be recognized as ADHD symptoms until a child is older.)
bullet Continue for more than 6 months.
bullet Make it difficult to function at school, at home, and/or in social situations.
  In addition to looking at your child’s behavior, your pediatrician will do a physical examination. A full medical history will be needed to put your child’s behavior in context and screen for other conditions that may affect your child’s behavior. Your pediatrician also will talk to your child about how he acts and feels.

Your pediatrician may refer your child to a pediatric subspecialist if there are concerns in one of the following areas:
   
bullet Mental retardation
bullet Developmental disorders such as speech problems, motor problems, or a learning disability
bullet Chronic illness being treated with a medication that may interfere with learning
bullet Trouble seeing and/or hearing
bullet History of abuse
bullet Major anxiety or major depression
bullet Severe aggression
bullet Possible seizure disorder
  How can parents help with the diagnosis?

As a parent, you will provide crucial information about your child’s behavior and how it affects her life at home, in school, and in other social settings.

Your pediatrician will want to know what symptoms your child is showing, how long the symptoms have occurred, and how the behavior affects your child and your family. You may need to fill in checklists or rating scales about your child’s behavior.

In addition, sharing your family history can offer important clues about your child’s condition.
  How will my child’s school be involved?

For an accurate diagnosis, your pediatrician will need to get information about your child directly from your child’s classroom teacher or another school professional. Children 6 to 12 years of age spend many of their waking hours at school. Teachers provide valuable insights. Your child’s teacher may write a report or discuss the following with your pediatrician:
   
bullet Your child’s behavior in the classroom
bullet Your child’s learning patterns
bullet How long the symptoms have been a problem
bullet How the symptoms are affecting your child’s progress at school
bullet Ways the classroom program is being adapted to help your child
bullet Whether other conditions may be affecting the symptoms

In addition, your pediatrician may want to see report cards and samples of your child’s schoolwork
  How will others who care for my child be involved?

Other caregivers may also provide important information about your child’s behavior. Former teachers, religious leaders, or coaches may have valuable input. If your child is homeschooled, it is especially important to assess his behavior in settings outside of home.

Your child probably does not behave the same way at home as he does in other settings. Direct information about the way your child acts in more than one setting is required. It is important to consider other possible causes of your child’s symptoms in these settings.

In some cases, other mental health care professionals may also be involved in gathering information for the diagnosis.
  Coexisting conditions

As part of the diagnosis, your pediatrician will look for other conditions that show the same types of symptoms as ADHD. Your child may simply have a different condition or ADHD and another condition. Many children who have been diagnosed with ADHD have at least 1 coexisting condition.

Common coexisting conditions include the following:
   
bullet Oppositional defiant disorder or conduct disorder—Up to 35% of children with ADHD also have oppositional defiant disorder or conduct disorder. Children with oppositional defiant disorder tend to lose their temper easily and annoy people on purpose and are defiant and hostile toward authority figures. Children with conduct disorder break rules, destroy property, and violate the rights of other people. Children with coexisting conduct disorder are at much higher risk for getting into trouble with the law than children who have only ADHD. Studies show that this type of coexisting condition is more common among children with the primarily hyperactive/impulsive and combination types of ADHD.

Your pediatrician may recommend counseling for your child if she has this condition.
bullet Mood disorders/depression—About 18% of children with ADHD also have mood disorders such as depression. There is frequently a family history of these types of disorders. Coexisting mood disorders may put children at higher risk for suicide, especially during the teenage years.

These disorders are more common among children with inattentive and combined types of ADHD. Children with mood disorders or depression often require a different type of medication from those normally used to treat ADHD.
bullet Anxiety disorders—These affect about 25% of children with ADHD.

Children with anxiety disorders have extreme feelings of fear, worry, or panic that make it difficult to function. These disorders can produce physical symptoms such as racing pulse, sweating, diarrhea and nausea.

Counseling and/or medication may be needed to treat these coexisting conditions.
bullet Learning disabilities—Learning disabilities are conditions that make it difficult for a child to master specific skills such as reading or math. ADHD is not a learning disability. However, ADHD can make it hard for a child to do well in school. Diagnosing learning disabilities requires evaluations such as IQ and academic achievement tests.

 

  Are there other tests for ADHD?You may have heard theories about other tests for ADHD. There are no other proven tests for ADHD at this time.

Many theories have been presented. But studies have shown that the following tests have little value in diagnosing an individual child:

bullet Screening for high lead levels in the blood
bullet Screening for thyroid problems
bullet Computerized continuous performance tests
bullet Brain imaging studies such as CAT scans, MRIs, etc
bullet Electroencephalogram (EEG) or brain-wave test

While these tests are not helpful in diagnosing ADHD, your pediatrician may see other signs or symptoms in your child that warrant blood tests, brain imaging studies, or an EEG.

 

  What causes ADHD?ADHD is one of the most studied conditions of childhood. But, the cause of ADHD is still not clear at this time.

Research to date has shown the following:
   
bullet ADHD is a biological disorder. Children with ADHD have problems with chemicals that send messages in the brain.
bullet A lower level of activity in the parts of the brain that control attention and activity level may be associated with ADHD.
bullet ADHD appears to run in families. Sometimes a parent is diagnosed with ADHD at the same time as the child.
bullet In very rare cases, toxins in the environment may lead to ADHD.
bullet Very severe head injuries may cause ADHD in some cases.
  There is no evidence that ADHD is caused by the following:
   
bullet Eating too much sugar
bullet Food additives
bullet Allergies
bullet Immunizations
  Treatment

Once the diagnosis is confirmed, the outlook for most children who receive treatment for ADHD is very encouraging. There is no specific cure for ADHD, but there are many treatment options available.

Each child’s treatment must be tailored to meet individual needs. In most cases, treatment for ADHD should include the following:
   
bullet A long-term management plan with

bullet Target outcomes for behavior
bullet Follow-up activities
bullet Monitoring

 
bullet Education about ADHD
bullet Teamwork among doctors, parents, teachers, caregivers, other health care professionals, and the child
bullet Medication
bullet Behavior therapy
bullet Parent training
bullet Individual and family counseling
  Treatment for ADHD uses the same principles that are used to treat other chronic conditions like asthma or diabetes. Long-term planning is needed because these conditions continue or recur for a long time. Families must manage them on an ongoing basis. In the case of ADHD, schools and other caregivers must also be involved in managing the condition.

Educating the people involved about ADHD is a key part of treating your child. As a parent, you will need to learn about ADHD. Read about the condition and talk to people who understand it. This will help you manage the ways ADHD affects your child and your family on a day-to-day basis. It will also help your child learn to help himself.
  Setting target outcomes

At the beginning of treatment, your pediatrician should set 3 to 6 “target outcomes” (goals) for your child’s behavior. These goals will guide the treatment plan. Your child’s target outcomes should focus on helping her function as well as possible at home, at school, and in your community.

The following are examples of target outcomes:
   
bullet Improved relationships with parents, siblings, teachers, and friends
bullet Better schoolwork
bullet More independence in self-care or homework
bullet Improved self-esteem
bullet Fewer disruptive behaviors
bullet Safer behavior in the community (e.g., when crossing streets)
  The target outcomes should be
   
bullet Realistic
bullet Something your child will be able to do
bullet Behaviors that you can observe and measure (e.g., with rating scales)
  Your child’s treatment plan will be set up to help your child achieve these goals.
  Medication
For most children, stimulant medications are a safe and effective way to relieve ADHD symptoms. As glasses help people focus their eyes to see, these medications help children with ADHD focus their thoughts better and ignore distractions. This makes them more able to pay attention and control their behavior.

Stimulants may be used alone or combined with behavior therapy. Studies show that about 80% of children with ADHD who are treated with stimulants improve a great deal.

Different types of stimulants are available, in both short-acting (immediate release), intermediate-acting, and long-acting forms. (See Table 2.) Short-acting forms usually are taken every 4 hours when the medication is needed. Long-acting medications usually are taken once in the morning.
Table 2. Common stimulants
   

Generic Class

Brand Names
   

Methylphenidate, short-acting

 Ritalin®

Methylin®
   

Methylphenidate, intermediate-acting

 Ritalin SR®

Metadate ER®

Methylin ER®
    Methylphenidate, long-acting Concerta®

Metadate CD®

Ritalin LA®*
    Amphetamine, short-acting Dexadrine®

Dextrostat®
    Amphetamine, intermediate-acting Adderall®

Dexedrine spansule
    Amphetamine, long-acting Adderal-XR®*
    *Not Food and Drug Administration (FDA) approved at the time of original publication
  Children who use long-acting forms of stimulants can avoid taking medication at school or after school. It is important not to chew or crush long-acting capsules or tablets.
  Which medication is best for my child?

It may take some time to find the best medication, dosage, and schedule for your child.
Your child may need to try different types of stimulants. Some children respond to one type of stimulant but not another.

The amount of medication (dosage) that your child needs also may need to be adjusted. The dosage is not based solely on her weight. Your pediatrician will vary the dosage over a period of time to get the best results and control possible side effects.

The medication schedule also may be adjusted depending on the target outcome. For example, if the goal is to get relief from symptoms at school, your child may take the medication only on school days.

It is important for your child to have regular medical checkups to monitor how well the medication is working and check for possible side effects.
  What side effects can stimulants cause?

Side effects occur sometimes. These tend to happen early in treatment and are usually mild and short-lived. The most common side effects include the following:
   
bullet Decreased appetite/weight loss
bullet Sleep problems
bullet Headaches
bullet Jitteriness
bullet Social withdrawal
bullet Stomachaches
  Some less common side effects include the following:
   
bullet Dry mouth
bullet Dizziness
bullet Rebound effect (increased activity or a bad mood as the medication wears off)
bullet Transient tics
  Very rare side effects include the following:
   
bullet Stuttering
bullet Increase in blood pressure or heart rate
bullet Growth delay
  More than half of children who have tic disorders such as Tourette syndrome also have ADHD. Tourette syndrome is an inherited condition associated with frequent tics and unusual vocal sounds. The effect of stimulants on tics is not predictable, although most studies indicate that stimulants are safe for children with ADHD and tic disorders.

Most side effects can be relieved using one of the following strategies:
   
bullet Changing the medication dosage
bullet Adjusting the schedule of medication
bullet Using a different stimulant
  If your child has tried 2 or 3 stimulants and none have helped, or if your child had side effects that could not be controlled, another medication may be an option. Ask your pediatrician for advice.

Stimulants may not be an option for children who are taking certain other medications or who have some medical conditions.
  Behavior therapy

Most experts recommend using both medication and behavior therapy to treat ADHD. This is known as a multimodal treatment approach.

There are many forms of behavior therapy, but all have a common goal—to change the child’s physical and social environments to help the child improve his behavior.

Under this approach, parents, teachers, and other caregivers learn better ways to work with and relate to the child with ADHD. You will learn how to set and enforce rules, help your child understand what he needs to do, use discipline effectively, and encourage good behavior. Your child will learn better ways to control his behavior as a result.

Behavior therapy has 3 basic principles.

Principles for behavior therapy:
   
  1. Set specific goals. Set clear goals for your child such as staying focused on homework for a certain time or sharing toys with friends.
  2. Provide rewards and consequences. Give your child a specified reward (positive reinforcement) when she shows the desired behavior. Give your child a consequence (unwanted result or punishment) when she fails to meet a goal.
  3. Keep using the rewards and consequences. Using the rewards and consequences consistently for a long time will shape your child’s behavior in a positive way.
  Table 3 shows specific behavior therapy techniques that can be effective with children with ADHD
    Table 3. Behavior therapy techniques
    Technique Description Example
    Positive reinforcement Providing rewards or privileges in response to desired behavior. Child completes an assignment and is permitted to play on the computer.
    Time-out Removing access to desired activity because of unwanted behavior. Child hits sibling and, as a result, must sit for 5 minutes in the corner of the room.
    Response cost Withdrawing rewards or privileges because of unwanted behavior. Child loses free-time privileges for not completing homework.
    Token economy Combining reward and consequence. The child earns rewards and privileges when performing desired behaviors. She loses rewards and privileges as a result of unwanted behavior Child earns stars for completing assignments and loses stars for getting out of seat. The child cashes in the sum of her stars at the end of the week for a prize.
  Behavior therapy recognizes the limits that having ADHD puts on a child. It focuses on how the important people and places in the child’s life can adapt to encourage good behavior and discourage unwanted behavior. It is different from play therapy or other therapies that focus mainly on the child and his emotions.

How can I help my child control her behavior?

As the child’s primary caregivers, parents play a major role in behavior therapy.

Parent training is available to help you learn more about ADHD and specific, positive ways to respond to ADHD-type behaviors. This will help your child improve.

 

  Tips for helping your child control his behavior

bullet Keep your child on a daily schedule. Try to keep the time that your child wakes up, eats, bathes, leaves for school, and goes to sleep the same each day.
bullet Cut down on distractions. Loud music, computer games, and television can be overstimulating to your child. Make it a rule to keep the TV or music off during mealtime and while your child is doing homework. Whenever possible, avoid taking your child to places that may be too stimulating, like busy shopping malls.
bullet Organize your house. If your child has specific and logical places to keep his schoolwork, toys, and clothes, he is less likely to lose them. Save a spot near the front door for his school backpack so he can grab it on the way out the door.
bullet Reward positive behavior. Offer kind words, hugs, or small prizes for reaching goals in a timely manner or good behavior. Praise and reward your child’s efforts to pay attention.
bullet Set small, reachable goals. Aim for slow progress rather than instant results. Be sure that your child understands that he can take small steps toward learning to control himself.
bullet Help your child stay “on task.” Use charts and checklists to track progress with homework or chores. Keep instructions brief. Offer frequent, friendly reminders.
bullet Limit choices. Help your child learn to make good decisions by giving your child only 2 or 3 options at a time.
bullet Find activities at which your child can succeed. All children need to experience success to feel good about themselves.
bullet Use calm discipline. Use consequences such as time-out, removing the child from the situation, or distraction. Sometimes it is best to simply ignore the behavior. Physical punishment, such as spanking or slapping, is not helpful. Discuss your child’s behavior with him when both of you are calm. Treatment plans for ADHD usually require long-term efforts on the part of families and schools. Medication schedules may be complex. Behavior therapies require education and patience. Sometimes it can be hard for everyone to stick with it. Your efforts play an important part in building a healthy future for your child.
  Taking care of yourself also will help your child. Being the parent of a child with ADHD can be tiring and trying. It can test the limits of even the best parents. Parent training and support groups made up of other families who are dealing with ADHD can be a great source of help. Learn stress management techniques to help you respond calmly to your child. Seek counseling if you feel overwhelmed or hopeless.

Ask your pediatrician to help you find parent training, counseling, and support groups in your community. Additional resources are listed at the end of this brochure.

How can my child’s school help my child?

Your child’s school is a key partner in providing effective behavior therapy for your child. In fact, these principles work well in the classroom for most students.

Classroom management techniques may include the following:
   
bullet Keeping a set routine and schedule for activities
bullet Using a system of clear rewards and consequences, such as a point system or token economy (see Table 3)
bullet Sending daily or weekly report cards or behavior charts to parents to inform them about the child’s progress
bullet Seating the child near the teacher
bullet Using small groups for activities
bullet Encouraging students to pause a moment before answering questions
bullet Keeping assignments short or breaking them into sections
bullet Close supervision with frequent, positive cues to stay on task
  Your child’s school should work with you and your pediatrician to develop strategies to assist your child in the classroom. When a child has ADHD that is severe enough to interfere with the child’s ability to learn, two federal laws offer help. These laws require public schools to cover the costs of evaluating the educational needs of the affected child and providing the needed services.

The laws are:
   
bullet The Individuals with Disabilities Education Act, Part B (IDEA)
bullet Section 504 of the Rehabilitation Act of 1973
  If your child has ADHD and a coexisting condition, she may need additional special services such as a classroom aide, private tutoring, special classroom settings, or, in rare cases, a special school.

It is important to remember that once diagnosed and treated, children with ADHD are more likely to achieve their goals in school.

Keeping the treatment plan on track

Ongoing monitoring of your child’s behavior and medications is required to find out if the treatment plan is working. Office visits, phone conversations, behavior checklists, written reports from teachers, and behavior report cards are common tools for following the child’s progress.

Ask your pediatrician to help you find ways to keep your child’s treatment plan on track.

What if my child does not reach his target outcomes?

Most school-aged children with ADHD respond well when their treatment plan includes stimulant medications and behavior therapy. If your child is not achieving his goals, your pediatrician will assess the following factors:
   
bullet Were the target outcomes realistic?
bullet Is more information needed about the child’s behavior?
bullet Is the diagnosis correct?
bullet Is another condition hindering treatment?
bullet Is the treatment plan being followed?
bullet Has the treatment failed?

While treatment for ADHD should improve your child’s behavior, it may not completely eliminate the symptoms of inattention, hyperactivity, and impulsivity. Children who are being treated successfully may still have trouble with their friends or schoolwork.

However, if your child clearly is not meeting his specific target outcomes, your pediatrician will reassess the treatment plan.

 

  Teenagers with ADHD

The teenage years can be a special challenge. Academic and social demands increase. In some cases, symptoms may appear to be less severe as the child grows older, but, in most cases, ADHD symptoms persist. According to the National Institute of Mental Health, about 80% of those who required medication for ADHD as children still need it as teenagers.

Parents play an important role in helping teenagers become independent.
Encourage your teenager to help herself with strategies such as the following:

bullet Using a daily planner for assignments and appointments
bullet Making lists
bullet Keeping a routine
bullet Setting aside a quiet time and place to do homework
bullet Organizing storage for school supplies, clothes, CDs, sports equipment, etc
bullet Being safety conscious (e.g., always wearing seat belts, using protective gear for sports)
bullet Talking about problems with someone she trusts
bullet Getting enough sleep

Activities such as sports, drama, and debate teams can be good places to channel excess energy and develop friendships. Find what your teenager does well and support her efforts to “go for it.”

Milestones such as learning to drive and dating offer new freedom and risks. Parents must stay involved and set limits for safety.

It remains important for parents of teenagers to keep in touch with teachers and make sure that their teenager’s schoolwork is going well.

Talk to your pediatrician if your teenager shows signs of severe problems such as depression, drug abuse, or gang-related activities.