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Article title: Attention Deficit Hyperactivity Disorder (ADHD): NWHIC
Conditions: Attention Deficit Hyperactivity Disorder
What is Attention
Deficit Hyperactivity Disorder (ADHD)?
What are the symptoms of ADHD?
How do I tell the difference between normal and problem behaviors?
How is ADHD diagnosed?
How many children are diagnosed with ADHD?
How are adults affected by ADHD?
Why is it important to diagnose ADHD in adults?
Do girls and women need to be more concerned about ADHD?
How are schools involved in diagnosing, assessing, and treating ADHD?
Is ADHD inherited?
Is ADHD on the increase? If so, why?
Can ADHD be seen in brain scans of children with the disorder?
Can a preschool child be diagnosed with ADHD?
What is the impact of ADHD on children and their families?
Are there nutritional treatments for ADHD?
What are behavioral treatments?
What medications are currently being used to treat ADHD?
Are there standard doses for these medications?
How long are children on these medications?
How common are stimulant prescriptions?
Are there differences in stimulant use across racial and ethnic groups?
Why are stimulants used when the problem is overactivity?
What are the risks of the use of stimulant medication and other treatments?
Will children taking these medications for ADHD become drug addicts?
What is the relationship between ADHD and other disorders, such as learning disabilities, anxiety disorders, bipolar disorder, or depression?
What are the future research directions for ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) refers to a family of related chronic disorders that interfere with a person's capacity to have normal activity levels (hyperactivity), hold back on impulsive behavior (impulsivity), and focus on tasks (inattention) in developmentally correct ways. ADHD is a neurobiological disorder, meaning the problem affects brain function (thinking, learning and memory) and behavior.
ADHD has been named differently over time. In the early 1970s, it was known as hyperkinesis (from the Latin word for "superactive"). In the 1980s, it was called Attention Deficit Disorder, or ADD. The term ADD (without the symptom of hyperactivity in the title) was used because hyperactivity is often, but not always, found with the disorder. Children who have the disorder without hyperactivity still struggle with impulsivity and inattention, but have more normal activity levels. However, since most people with ADHD have the symptom of hyperactivity, in 1987 the official name changed to and remains ADHD. There are varying types of ADHD.
Children with ADHD can have difficulties at home, at school, and in relationships with friends and other children their age. ADHD has also been shown to have long-term adverse effects on school performance, career or job success, and social-emotional development. Because children with ADHD are not able to sit still and pay attention in school, they may have disciplinary problems, and they can be viewed as troublemakers by teachers and other students. They experience peer rejection and show a broad range of disruptive behaviors. Their academic and social problems can have far-reaching and long-term effects. These children have higher injury rates. As they grow older, children with untreated ADHD, in combination with conduct disorders, are at risk for drug abuse, antisocial behavior, and injuries of all sorts. Up to 70% of children diagnosed with ADHD will continue to have symptoms into adulthood.
Inattention - People who are inattentive have a hard time keeping their mind on one thing and may get bored with a task after only a few minutes. Focusing conscious, deliberate attention to organizing and completing routine tasks may be difficult. Signs in children include making careless mistakes in school work, being easily distracted from play, appearing as if they are not listening when spoken to, not following instructions, and avoiding or disliking tasks that require concentration, schoolwork in particular.
Hyperactivity - People who are hyperactive always seem to be in motion. They can't sit still; they may dash around or talk constantly. Sitting still through a lesson can be an impossible task for an ADHD child. They may roam around the room, squirm in their seats, wiggle their feet, touch everything, or noisily tap a pencil. They also may feel intensely restless.
Impulsivity - People who are overly impulsive seem unable to curb their immediate reactions or consider consequences of their behavior before they act. As a result, they may blurt out answers to questions or inappropriate comments, or run into the street without looking. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they are upset. They may display immaturity in various social situations.
Behaviors can be judged as normal or "problem" by evaluating them in relation to the person's age and developmental maturity. For example, the same behaviors that are acceptable in a 5-year old may be problematic for a 10-year old. Problem behaviors are also long lasting, tend to occur more often and create more problems as time goes on. Children with ADHD will have more problems than other children their age experience in the same settings.
A reliable diagnosis of ADHD can be made with well-tested diagnostic interview methods. Diagnosis is based on history and visible behaviors in the child's normal environment. A doctor making a diagnosis should ask for input from the child, parents, teachers, and other health care providers. The doctor will collect information on a thorough history about the symptoms, and on the medical, developmental, school, psychosocial, and family histories. He or she also will consider other causes for the problem, and review other conditions that could be present. It is helpful to find out what has prompted the request for evaluation and how the problems had been approached in the past. At this time, there is no single test for ADHD. This is not unique to ADHD, but applies to most psychiatric disorders.
ADHD is the most commonly diagnosed disorder of childhood, estimated to affect 3 to 5 percent of school-age children, and occurring three times more often in boys than in girls. On average, about one child in every classroom in the United States needs help for this disorder. Among poor children, however, the problem is often undiagnosed, partly because of the lack of health care available to them.
Up to 70% of children with ADHD will continue to have symptoms into adulthood. The main symptoms of ADHD in adults are trouble managing time and struggling with memory and disorganization. ADHD in adults is often referred to as the "hidden disorder" because its symptoms can often be confused with other problems with relationships, organization, mood disorders, substance abuse, employment or other personal difficulties.
Diagnosing and treating ADHD in adults can help them put their problems into perspective, better understand the reasons for many of their lifelong symptoms, and improve their self-esteem, work performance and skills, educational abilities and social skills. Also, adults with ADHD are protected under the Americans with Disabilities Act of 1990, which does not allow discrimination in public accommodations, like education, and employment.
Many girls and women with ADHD are often undiagnosed because their symptoms look different from those in boys or men. Many girls or women may not appear hyperactive. Girls are usually less rebellious, less defiant and generally considered less difficult than boys. Boys who are hyperactive and disorganized are easier to spot and more likely to be referred for an evaluation.
There are several personality types of girls in which ADHD could be a factor. For example, there are girls who are shy and withdrawn, but disorganized. There are girls who are "tomboys," who are drawn to risky activities. They may be cooperative at school and work hard to please parents and teachers, but are often disorganized and messy. There are "daydreamers" or girls who seem to listen to teachers in class, but be in another world. They may find their minds wandering, are forgetful and disorganized. They become very anxious, depressed, worried and overwhelmed when schoolwork is due. They often are thought to be less bright than they actually are. "Chatty" girls also have high activity levels, and are very talkative and emotional, but can be forgetful and disorganized. Highly intelligent girls, with above average IQs, who have increasing problems with concentration and organization as their school life becomes more demanding also may have ADHD.
Women with ADHD who complain of feeling overwhelmed and disorganized tend to be diagnosed more often with depression. These women often feel a powerful sense of shame and inadequacy. They oftentimes need to spend all of their waking energy just fighting their natural tendency to be disorganized. Sometimes, ADHD does not become a problem until a woman has a baby or a second baby, when she is expected to be highly organized, accomplishing multiple roles under a lot of strain as both a caregiver and, in many cases, a career woman.
Doctors and parents should be aware that schools are required by federal law to perform an appropriate assessment if a child is suspected of having a disability that impairs academic functioning. The 1997 reauthorization of the Individuals with Disabilities Act (IDEA) strengthens this requirement. IDEA guarantees proper services and a public education to children with disabilities from ages three to 21. For the first time, IDEA specifically lists ADHD as a qualifying condition for special education services. If the assessment performed by the school is lacking or improper, parents may request an independent evaluation at the school's expense. Also, 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, must assess the child's strengths and weaknesses and design an Individualized Education Program. These special education services for children with ADHD are available though IDE
Research shows that ADHD tends to run in families so there are likely to be genetic influences. Children who have ADHD usually have at least one close relative who also has ADHD. And at least one-third of all fathers who had ADHD in their youth have children with ADHD. Even more convincing of a possible genetic link is that when one twin of an identical twin pair has the disorder, the other is likely to have it too.
No one knows for sure whether the number of people with ADHD has risen, but it is very clear that the number of children identified with the disorder who get treatment has risen over the past decade. This could be due to greater media interest, heightened consumer awareness, and the availability of effective treatments. Other countries are observing a similar pattern. Whether the frequency of the disorder itself has risen remains unknown, and needs to be studied.
Research on brain imaging has shown that the brains of children with ADHD differ from those of children without the disorder. Several brain regions and structures in children with ADHD tend to be smaller. Overall brain size is generally 5% smaller in affected children than in children without ADHD. While this average difference is seen over and over, it is too small to be used alone in making the diagnosis of ADHD in a particular person. Also, there appears to be a link between a person's ability to pay continued attention and the amount of their brain activity. In people with ADHD, the brain areas that control attention show to be less active. This suggests that lower levels of activity in some parts of the brain may be related to problems in sustaining attention.
The diagnosis of ADHD in the preschool child is possible, but can be difficult and should be made cautiously by experts well trained in childhood neurobehavioral disorders. Developmental problems, especially language delays, and adjustment problems can sometimes look like ADHD. Treatment should focus on placing the child in a structured preschool with parent training and support. Stimulants can reduce difficult behavior and improve mother-child interactions, but they usually are saved for severe cases, or when a child is unresponsive to environmental or behavioral interventions.
Life can be hard for children with ADHD. They're the ones who are so often in trouble at school, can't finish a game, and have trouble making friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school. It is not easy coping with these frustrations day after day for children or their families. Family conflict can increase. Also, children with ADHD often have problems with peers and friendships. In adolescence, these children are at increased risk for motor vehicle accidents, tobacco use, early pregnancy, and lower educational attainment. When a child receives a diagnosis of ADHD, parents need to think carefully about treatment choices. And when they pursue treatment for their children, they may face high out-of-pocket expenses because treatment for ADHD and other mental illnesses is often not covered by insurance policies. School programs (social skills and behavior training) to help children with problems often connected to ADHD are not available in many schools. Also, not all children with ADHD qualify for special education services. All of this leads to children who do not receive proper and adequate treatment. To overcome these barriers, parents may want to look for school-based programs that have a team approach involving parents, teachers, school psychologists, other mental health specialists, and doctors.
Many parents have tried nutritional methods, such as taking sugar out of the child's diet, before they seek medical attention. A small body of research has suggested that some children may benefit from nutritional treatments, but there are no well-established methods that have consistently shown to be helpful to most children with ADHD. Monitoring a child's diet gets more difficult as a child gets older and more independent, making effective research difficult. Also, delaying the use of proven, effective treatments, and trying things with unknown effects is likely to be harmful for many children.
There are various forms of behavioral treatments used for children with ADHD, including psychotherapy, cognitive-behavioral therapy, social skills training, support groups, and parent and educator skills training. An example of very intensive behavior therapy was used in the Multimodal Treatment Study of Children with ADHD (MTA), sponsored by the National Institute of Mental Health (NIMH). In the study, the child's teacher and the family participated in an all-day, 8-week summer camp. The camp aimed to improve social behavior, academic work, and sports skills. The therapist worked with teachers to develop behavior management strategies to help behavioral problems interfering with classroom behavior and academic performance. A trained classroom aide worked with the child for 12 weeks in his or her classroom to provide support and reinforcement for appropriate, on-task behavior. Parents met with the therapist alone and in small groups to learn ways for handling problems at home and school.
The MTA study results show that long-term combination treatment (intensive behavioral intervention combined with medication) or medication management alone are more successful in reducing ADHD symptoms than intensive behavioral treatments alone or routine community treatments alone. The study also shows that combination treatment is better for other problem areas of functioning (such as anxiety, academic performance, parent-child relations, and social skills) than routine community care-only, medication-only, and behavioral treatment-only approaches.
Psychostimulant medications, including methylphenidate (Ritalin®) and amphetamines (Dexedrine®, Dextrostat®, and Adderall®), are by far the most widely researched and commonly prescribed treatments for ADHD. Several short-term studies have proven the safety and effectiveness of stimulants and psychosocial treatments for helping the symptoms of ADHD. Again, NIMH research has found that the two most effective treatment methods for elementary school children with ADHD are a closely monitored medication treatment and a treatment that combines medication with intensive behavioral interventions. In the MTA study, which included nearly 600 elementary school children across multiple sites, nine out of ten children greatly improved on one of these treatments.
Antidepressant medications also may be used as a second line of treatments for children who show poor response to stimulants, who have unacceptable side effects, or who have other conditions with ADHD (such as tics, anxiety, or mood disorders). Clinical studies have shown that these drugs are effective in 60-70% of children with ADHD. While the medications were extremely helpful to most children, MTA study results show that medications alone may not be the best way to treat many children. For example, children who had other problems (e.g., anxiety, stressful home circumstances, lack of social skills, etc.), over and above the ADHD symptoms, seemed to benefit most from the combined treatment.
Careful medication management is important in treating a child with ADHD. The doctor is likely to begin with a low dose to test the child's response. For methylphenidate (Ritalin®), the usual dosage range is 5 to 20 mg given two to three times a day. The dose for amphetamines (Dexedrine® and Dextrostat® and Adderall®) is one-half the methylphenidate dose. Dosage requirements do not always correlate with weight, age or severity of symptoms in an individual patient. Some doctors prescribe a combination of medications. Dosages may need to be increased during childhood with increased lean body weight and decreases may be necessary after puberty. Different doctors use these medications in slightly different ways, and different children may respond differently to each medication.
The expected duration of treatment has increased during this past decade as evidence has grown that shows benefits extend into adolescence and adulthood. However, many factors make it hard for adolescents to continue using medications: once on medication, adolescents see their most obvious symptoms controlled, and think they don't need to take it regularly. The medications' short-lasting effects make it necessary to take them several times per day, although there are newer long-term medications now being offered. Parents often get frustrated with the limited results or side effects of the medication, and discontinue its use.
It is estimated that in 1995, doctors treating children and adolescents wrote six million prescriptions for stimulant medications-methylphenidate (Ritalin®) and dextroamphetamine (Dexedrine®). Of all the drugs used to treat psychiatric disorders in children, stimulant medications are the most thoroughly studied.
Stimulant use for ADHD in the United States has increased greatly over the last 25 years. A recent study saw a 2.5-fold increase in methylphenidate between 1990 and 1995. This increase appears to be mostly related to an increased length of treatment, and more girls, adolescents, adults, and inattentive persons (in addition to those persons with both hyperactivity and inattentiveness/attention deficit) receiving treatment.
Because there are large differences in access to mental health services between children of different racial groups, there are differences in medication use. African American children are much less likely than White children to receive medications, including stimulants, for treatment of mental disorders.
One theory suggests that ADHD is related to problems in controlling responses to internal and external stimuli. Evidence suggests that the areas of the brain involved in planning, foresight, considering consequences, and inhibiting actions, are underaroused in persons with ADHD. Stimulant medication may work on these same areas of the brain to increase brain activity to more normal levels, allowing the patient to focus better. More research is needed, however, to firmly establish how these stimulants work.
Stimulant drugs, when used with medical supervision, are usually quite safe. Although they can be addictive when abused by teenagers and adults, when taken as prescribed for ADHD these medications have not shown to be addictive nor to lead to substance abuse problems. They seldom make children "high" or jittery, nor do they sedate the child. If these side effects occur, doctors usually will try a different dosage of medication. Although there is little information about the long-term effects of psychostimulants, there is no evidence that careful use for treating ADHD is harmful. People taking moderate doses sometimes have a decreased appetite or are unable to sleep. These effects occur early in treatment and may decrease with time. Some medications might slow a child's growth, but ultimate height does not appear to be affected.
Actually, it appears to be just the opposite. Although an increased risk of drug abuse and cigarette smoking is linked with childhood ADHD, this risk appears mostly due to the ADHD condition itself, rather than its treatment. In a study jointly funded by the NIMH and the National Institute on Drug Abuse (NIDA), boys with ADHD who were treated with stimulants were much less likely to abuse drugs and alcohol when they got older. Caution is warranted, though, as the overall evidence suggests that persons with ADHD (especially untreated ADHD) are at greater risk for later alcohol or substance abuse. Because some studies have conflicting results, more research is needed to understand this. At any rate, parents should not avoid seeking effective treatments because of inflated claims about substance abuse risks. There are many, proven findings of the harmful effects from too little or no treatment for a child with ADHD.
Most children treated for ADHD have other conditions. ADHD can co-occur with learning disabilities (15-25%), language disorders (30-35%), conduct disorder (15-20%), oppositional defiant disorder (up to 40%), mood disorders (15-20%), and anxiety disorders (20-25%). Up to 60% of children with tic disorders also have ADHD. Problems with memory, cognitive processing, sequencing, motor skills, social skills, control of emotional response, and response to discipline are common. Sleep disorders are also more common.
Continued research on ADHD is needed from many perspectives. The impact on society needs to be determined. Studies in this area include: (1) how to have effective medication management or combination therapies in different schools and community healthcare systems; (2) what is the nature and severity of the impact on adults with ADHD beyond the age of 20, and their families; and (3) how can mental health services best assist in the diagnosis and care of persons with ADHD.
More studies are needed to improve communication across educational and health care settings to ensure better treatment methods. Basic research also is needed to better define the factors that cause and affect ADHD, not just in children with ADHD, but also in unaffected persons. This research should include: (1) studies on cognitive development, cognitive and attentional processing, impulse control, and attention/inattention; (2) studies of prevention and early intervention to help a person's risk factors that may lead to later ADHD; and (3) brain imaging studies beginning before medication and following a person through young adulthood and middle age. Lastly, there needs to be more research on the other conditions that are present with ADHD in both children and adults, and how these affect treatment.
You can find out more about ADHD by contacting the National Women's Health Information Center (800-994-9662) or the following organizations:
National Institute on Mental Health (NIMH)
Phone: (301) 443-4513
Internet Address: http://www.nimh.nih.gov/
National Mental Health Services Knowledge Exchange Network
Phone: (800) 789-2647
Internet Address: http://www.mentalhealth.org/
National Institute of Neurological Disorders and Stroke
Phone: (301) 496-5751 (Information Office)
Internet Address: http://www.ninds.nih.gov/
Children and Adults with Attention-Deficit/Hyperactivity Disorder
Phone: (800) 233-4050
Internet Address: http://www.chadd.org/
National Attention Deficit Disorder Association (ADDA)
Phone: (800) 487-2282
Internet Address: http://www.add.org/
ADDvance - A Resource for Women and Girls with ADD
Internet Address: http://www.addvance.com/
This fact sheet was adapted from the National Institute on Mental Health's, Attention Deficit Hyperactivity Disorder (ADHD) - Questions and Answers, March 2000.
All material contained in the FAQs is free of copyright restrictions, and may be copied, reproduced, or duplicated without permission of the Office on Women's Health in the Department of Health and Human Services; citation of the source is appreciated.
Publication Date: August 2001
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