ADHD: Attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD): Description

ADHDAttention deficit hyperactivity disorder (ADHD) is one of the most common chronic psychiatric conditions diagnosed in childhood. Although thought of as a child's condition, adult ADHD is not uncommon. The chronic nature of ADHD is revealed in its rates of persistence. Sixty to seventy percent of children diagnosed with ADHD still struggle with symptoms as adults.

The hallmark ADHD symptoms are inattention, distractibility, and impulsivity. These symptoms are frequently accompanied by physical or motor hyperactivity, often described as restlessness, fidgetiness, and the inability to sit still. The "inattentive" component refers not only to difficulty in focusing and sustaining attention appropriately, but also to a basic inability to match attention to the demands of the particular environment and to specific tasks.

ADHD has three subtypes:

1. Predominantly hyperactive-impulsive: Most symptoms (six or more) are in the hyperactivity-impulsivity categories. Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.

2. Predominantly inattentive: The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.

Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.

3. Combined hyperactive-impulsive and inattentive: Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present. Most children have the combined type of ADHD.

Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives.

Symptoms

Wide arrays of symptoms indicate the presence of ADHD. A common ADHD symptom is the difficulty or inability to sustain attention. Other symptoms include the failure to follow directions, frequent careless mistakes, inability to organize activities, and distractibility. Bossiness, stubbornness, extreme mood swings, and low or poor self-esteem are also ADHD symptoms.

Causes and Risk factors

The cause of ADHD seems to be neurobiological or genetic. Environmental factors influence the severity of the disorder, but environmental factors do not seem to give rise to the condition by themselves. ADHD research is finding more and more evidence that ADHD does not stem from home environment, but from biological causes.

Possible causes of ADHD disorder that have been studied include:

Environmental Agents: Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD. High levels of lead in the bodies of young preschool children are another possible environmental cause of ADHD.

Traumatic Brain Injury: Children who have been in accidents that resulted in brain injury occasionally show some signs of behavior similar to that of ADHD, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

Food Additives and Sugar: Some research suggests that attention disorders are caused by refined sugar or food additives, or that symptoms of ADHD are exacerbated by sugar or food additives. In 1982, the National Institutes of Health held a scientific consensus conference to discuss this issue. It was found that diet restrictions helped about 5 percent of children with ADHD.

Genetics and Hereditary Factors: ADHD hereditary factors appear to run in families. There are likely to be genetic influences to ADHD. Around 25 percent of close relatives in the families of ADHD children also have ADHD. Twin studies show there is a strong genetic influence to ADHD.

Brain abnormalities: Some ADHD studies have shown structural differences in the brains of ADHD patients.

Diagnosis

If ADHD is suspected, the child should be carefully screened for the condition by a physician. Since there is still no biological test that can identify ADHD, a series of evaluations are required to make an accurate diagnosis.

A complete physical examination by a physician is necessary to make sure the child doesn't have hearing or vision problems, allergies, eczema, or epilepsy - all of which can cause symptoms similar to ADHD.

The physician will also study the child's medical history to see whether an earlier experience such as childhood disease or injury, or prenatal exposure to toxins, may have caused ADHD. The child may also need to be examined by a neurologist, child psychologist, or another health professional.

It's essential that the physician also has detailed information about the child's developmental, behavioral and academic history. Through direct discussions with parents, teachers and the child himself, and with questionnaires such as the Conner's Form, the physician will gather information about:

The history and nature of the child's behavioral difficulties.

The quality of the child's relationships with his family and peers.

The family's medical and personal history.

The child's social and academic performance at school, including any learning disorders.

Other conditions which can produce ADHD-like symptoms will need to be ruled out before a diagnosis of ADHD can be made. But conditions such as learning disorders, physical disabilities, or emotional problems, can sometimes occur in combination with ADHD. Information gathered from the team's input should be used to determine the nature, severity, and possible causes of the child's condition.

Parents need to describe the history and nature of the child's behavior. Although ADHD symptoms often become most apparent and problematic in the school setting, they may have been present earlier in the child's life. Parents should also provide details about the quality of the child's relationships with family members and peers.

Family history: Information about the family's history is also important. Parents or siblings may have experienced symptoms similar to the child's, or may have themselves been diagnosed with ADHD. The family history should also take into account events at home, such as a recent divorce or other stressful life events which may be causing the child to experience emotional difficulties, or may be interfering with his or her ability to concentrate. Certain emotional disturbances may produce ADHD-like symptoms, but need to be treated differently.

Performance at school: The child's performance at school must also be evaluated. Teacher input is crucial for helping to determine whether the child's social and academic development are appropriate for his or her age.

The teacher can also help discern whether the child has an underlying learning disorder which may be causing - or contributing to - ADHD-like symptoms. Reports about the child's activity in the classroom, and his ability to pay attention during instruction are highly useful - as are any reports from school psychologists or special educators.

The child's input: The child himself is usually another excellent source of information, and so he should not be ignored in the diagnostic process. Questions about how he perceives himself in relation to his environment might provide some important insights.

Treatment

Initial treatment: Successful treatment of attention deficit hyperactivity disorder (ADHD) begins with an accurate diagnosis and understanding of a child's weaknesses and strengths. Learning about ADHD will help you and your child's siblings better understand how to help your child.

The American Academy of Pediatrics guidelines recommend medicine and/or behavior therapy to treat children with ADHD. This recommendation is based on numerous studies, including the landmark Multimodal Treatment Study of Children with ADHD (MTA), funded by the U.S. National Institute of Mental Health (NIMH). In this large study, researchers found that school-age children with it who received stimulant medicine had a significant decrease in core it symptoms (inattention, impulsivity, and hyperactivity).

Your child's doctor may recommend that your child takes a stimulant medicine, such as amphetamine (for example, Dexedrine, Adderall) or methylphenidate (for example, Ritalin, Concerta, Metadate CD). These medicines improve symptoms in about 70% of children who have the condition.

Although it may seem contradictory, stimulants usually decrease hyperactivity and impulsivity and improve focus. Some parents worry about their children becoming addicted to stimulants. Research has shown that these medicines, when taken correctly, do not cause dependence. But parents should closely supervise the use of ADHD medicines, because abuse by siblings, classmates, and adults has been reported.

Parents are also often concerned about medicine side effects, including loss of appetite, nervousness, tics or twitches, and problems sleeping. Children should be closely monitored after they start medicines, to assess whether they are receiving the correct dose. These side effects usually decrease after a few weeks on the medicines, or the dosage can be lowered to offset side effects. For more information, see:

The AAP guidelines also encourage behavior therapy. Through behavior therapy, parents learn strategies, such as positive reinforcement, to improve a child's behaviors. Children learn to develop problem-solving, communication, and self-advocacy skills. Behavior therapy is more helpful when used with medicine than it is when used by itself.

Counseling may help children and adults with ADHD recognize problem behaviors and learn ways to deal with them. For both parents and children, counseling can be a place to air frustrations and deal with stress.

Some children with this also have other conditions, such as anxiety or oppositional defiant disorder. Behavioral therapy can help treat some of these conditions.

Elementary school teachers are often the first to recognize ADHD symptoms because in the classroom more demands are placed on children to sit still, pay attention, listen, and follow class rules. Many times teachers recommend to parents that a child be tested or see a health professional.

Most children with ADHD qualify for educational services within the public schools. If your child qualifies, you will meet with school personnel to identify goals and establish an individualized education program (IEP). IEPs are based on the evaluation of a child's disability and his or her specific needs. This usually means your school will try to accommodate your child's extra needs, which may be as minor as placing him or her at the front of the class or as involved as providing classroom staff to assist your child.

Your doctor will talk with you about setting realistic and measurable goals for your child's behavior at school and at home. Each child must be considered individually, taking into account his or her specific problems and needs.

If your child is preschool age, your doctor may encourage behavioral therapy in an effort to curb symptoms and avoid using medicine at an early age. But if behavioral therapy is not effective in controlling symptoms, some doctors recommend medicines. Whether preschool-age children should receive medicine is somewhat controversial, because there are few studies in this age group. But the recently completed Preschool ADHD Treatment Study (PATS) has shown that the stimulant medicine methylphenidate (such as Ritalin) is safe and effective for preschool-age children.

Regular communication among parents, teachers, and doctors benefits a child who has attention deficit hyperactivity disorder.

Teens will benefit from continuing to take a stimulant medicine—such as amphetamine (for example, Dexedrine, Adderall) or methylphenidate (for example, Ritalin, Concerta, Metadate CD, Focalin)—or non-stimulant atomoxetine (Strattera) if either type of medicine has been helpful in the past.

Parents can also be reassured that taking stimulant medicine for ADHD does not increase the risk for substance abuse later. In fact, a recent analysis that followed children and teens with ADHD for at least 4 years found less alcohol and drug abuse in those who had taken stimulant medicines than in those who did not receive a medicine.

Staying closely involved with your teen and continuing behavior therapy takes a lot of hard work but may pay off in the long run. The teen years present many challenges, including increased schoolwork and the need to be more attentive and organized. Making good decisions becomes especially important during these years when peer pressure, emerging sexuality, and other issues surface. Use consequences that are meaningful to your teenager, such as losing privileges or having increased chore assignments. Parents and teens can work together to establish reasonable, obtainable goals and negotiate appropriate rewards when those goals are met.

ADHD in adulthood: Attention deficit hyperactivity disorder (ADHD) often goes undiagnosed in adults. The right treatment can help those who have struggled with the condition for years. Like ADHD in children, adults may benefit from medicine combined with psychological support, including education about the disorder, support groups and/or counseling, and skills training. Skills training can include time management, organizational techniques, and academic and vocational counseling.

Studies have found that about 58% of adults who have ADHD report a better ability to focus and less hyperactivity and impulsivity when taking stimulant medicines.14. If stimulant medicines have bothersome side effects or are not effective, your doctor might recommend atomoxetine (Strattera), a non-stimulant medicine. Strattera is not a controlled drug, which means refills and telephone prescriptions are allowed.

Certain antidepressants, such as bupropion (for instance, Wellbutrin) or tricyclics (for example, imipramine, nortriptyline, desipramine), are sometimes also recommended for adults with ADHD.

Medicine and medications

According to ADHD Guidelines from the American Academy of Child and Adolescent Psychiatry, first line medications that can be used to treat children with ADHD include stimulants, like Ritalin and Adderall, and the newer non-stimulant medication Strattera.

Forms of Ritalin: There are now many different forms of methylphenidate or Ritalin, including short (twice a day) and long acting (once a day) preparations. Some available forms include:

1. Concerta (long acting).

2. Daytrana (long acting Ritalin patch).

3. Focalin (short acting) and Focalin XR (long acting).

4. Metadate CD (long acting).

5. Metadate ER (long acting).

6. Methylin (short acting) - chewable tables and oral solution.

7. Ritalin (short acting) - generic.

8. Ritalin LA (long acting).

9. Forms of Amphetamine.

Amphetamine stimulants are also available in different forms, including short-acting (twice a day) and long-acting (once a day) forms, including:

1. Adderall (short acting) - generic.

2. Adderall XR (long acting).

3. Dexedrine (short acting) - generic.

4. Vyvanse

Second-line medications or alternatives to the stimulants and Strattera include antidepressants, like buproprion (Welbutrin), imipramine (Tofranil), and Nortriptyline (Pamelor), and alpha-2-adrenergic agonists, like Clonidine (Catapres) and guanfacine (Tenex).

In general, doctors usually go to a second line medication when a child has either failed or not tolerated two or more first-line medications.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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