SYMPTOMS: Attention deficit hyperactivity disorder (ADHD) can cause three categories of symptoms: hyperactivity, impulsivity, and inattention. A hyperactive child can be very fidgety or talk excessively, has difficulty remaining seated when required to do so, has difficulty playing quietly, and is very restless and always seems to be “on the go”. Impulsive behavior can cause difficulty waiting for turns, blurting out answers too quickly, disruptive classroom behavior, intruding or interrupting others’ activities and unintentional injury. Inattention may take many forms, including forgetfulness, being easily distracted, losing or misplacing things, disorganization, underachievement in school, poor follow-through with assignments or tasks, poor concentration, and poor attention to detail.
In most situations, the child has difficulty controlling his or her behavior or attention and may have difficulty anticipating the consequences of his or her behavior. The child does not usually misbehave because he or she is willful or wants to annoy those around him or her. Approximately 8 to 10 percent of children aged 4 to 17 years have ADHD, making it one of the most common disorders of childhood.
ADHD EVALUATION AND DIAGNOSIS: Early recognition and treatment of ADHD are important to prevent or limit emotional, academic, and behavioral difficulties. Parents who suspect that their child has ADHD should begin by talking to the child’s teacher and school staff. This will help them find if the child has difficulties with behavior and/or learning in school. The next step is to make an appointment with the child’s Pediatrician. The Pediatrician will evaluate the child and determine if further testing or evaluation is needed, and if ADHD or any another condition is a possible cause of symptoms. Bringing school records to the appointment may help the Pediatrician to have a better understanding of the child’s situation.
HOW CAN WE HELP: We recommend that every child with suspected ADHD should be evaluated by a specialist (Child and Adolescent psychiatrist or a Developmental Pediatrician). There is no simple test to diagnose ADHD. In addition, many of the symptoms of ADHD are common among four- to six-year-old children but tend to occur with less frequency and/or intensity than in children with ADHD. Thus, it may be difficult for parents to tell if their young child has ADHD or is simply behaving as young children often do. Other psychologic and developmental disorders exist in as many as one-half of children with ADHD. These can be difficult to distinguish from ADHD because there are frequently overlapping symptoms. The most common coexisting disorders include learning disabilities, oppositional defiant disorder (ODD), anxiety, mood disorders (depression or bipolar disorder) and autism spectrum disorder. Treatment of the associated problems may help improve functioning at school or in social settings. However, treatment of these associated problems will not replace the need for medication or behavioral treatment of ADHD. Once the diagnosis is made and treatment begins, the parent, teacher, and health care provider will continue to monitor the child to ensure that treatment is effective and the diagnosis is correct.
TREATMENT: Some parents wonder if treatment for ADHD is necessary. Most experts agree that untreated ADHD can have serious consequences, including school failure and drop out, poor behavior, failed relationships, poor performance in the workplace, and increased risk of accidents, increase risk of illegal behavior like stealing, increase risk of substance abuse. Treatment can help a child to:
- Have better relationships with parents, teachers, siblings, or peers (eg, play without fighting at recess)
- Perform better in school (eg, finish schoolwork)
- Follow rules (eg, not appear to be disobedient to the teacher)
What treatment is the best? — Behavioral treatments usually are recommended for preschool-age children. Medications are sometimes added if necessary. The most effective treatment for most school-aged children with ADHD is a stimulant medicine together with behavioral treatments and counseling. While it is reasonable to consider using behavioral treatments alone, this may not work as well without the medicines.
MEDICATIONS FOR ADHD:
Stimulant Medications like Methylphenidate (brand name Ritalin), Concerta, Metadate, Adderall, Focalin, Vyvanse and others. Despite their name, stimulants do not cause a child with ADHD to become more stimulated but instead improve communication between several areas of the brain. This helps to improve attention, concentration, and self-control. However, medicines do not cure ADHD or teach the child to behave, work well with others, follow rules in school, or be motivated. Behavioral treatments should be added to the medicine to address these issues. At least 80 percent of children with ADHD will respond to a stimulant. However, it is not clear if stimulants have a long-term benefit for the child’s thinking, school performance, behavior, or feelings.
Side effects: Stimulant medicines have a long history of being safe and working well when used properly, and a very few children have serious side effects. However, they have the potential to be misused if they are not taken as instructed. One of the most common side effects include decreased appetite, trouble with sleep, weight loss. Less common side effects include increased heart rate and blood pressure, headache, nervousness, irritability, moodiness, stomach pain and poor circulation in the hands and feet. Many of these side effects are temporary. Decreases in appetite can improve by taking the medicines after meals or eating within 30 minutes after taking the medicine.
Serious side effects are rare. They may include:
- Cardiovascular effects: Stimulants are not recommended for children with serious heart problems. There have been rare reports of sudden unexpected death in children taking stimulant medicines. However, it is not clear that the stimulant was the cause of death. Millions of children with ADHD have used stimulants and very few have had serious side effects.
- Psychiatric effects: Very rarely children taking stimulant medicines can develop suicidal thinking, hallucinations, skin picking and feelings of bugs crawling on the skin. Call your child’s doctor or nurse if you notice excessive irritability, anger, suicidal thinking or behavior, or other unusual changes in behavior.
Atomoxetine (brand name Strattera) is a non-stimulant medicine used in the treatment of ADHD. It is an alternative to stimulants that can be used in patients with a history of drug abuse or if patient’s family members have a history of drug abuse. It can also be used if a child has intolerable side effects with stimulants. Side effects of atomoxetine can include weight loss, decreased appetite, vomiting, nausea, upset stomach, and trouble sleeping. Severe liver injury has been reported in children and adults treated with atomoxetine. Call your child’s doctor or nurse immediately if the child develops jaundice (yellowing of the skin or whites of the eyes), which is a sign of liver injury. There can also be a small increased risk of suicidal thinking with atomoxetine, similar to stimulant medicines.
Clonidine (Brand name Kapvay) & Guanfacine (Brand Name Tenex & Intuniv): These medications help with impulsivity and hyperactivity but generally do not help with inattention. They work well as an add on to stimulants to help with ADHD symptoms as their side effect profile is different than stimulants. These medications can also counteract certain side-effects of stimulants like tics & insomnia. Common side effects of these medications include tiredness, drowsiness & dizziness. If your child is taking this medication, his/her blood pressure needs to be monitored regularly and these medications can lower blood pressure. We recommend buying a home BP monitor and monitor your child’s blood pressure at least twice a week and share reading with your doctor.
ADHD BEHAVIORAL TREATMENTS: Behavioral treatments for ADHD include changes in a child’s environment, which are designed to help the child change his or her behavior. Behavioral treatments work to improve problems with:
- Behavior and learning at school
- Relationships with friends, parents, and siblings
- Following through with adult requests
A professional training program is recommended for parents because it can be difficult to learn these techniques and use them effectively without support. Adults can help to shape the behavior of a child who has ADHD with the following techniques:
- Follow a daily schedule
- Keep distractions to a minimum
- Provide specific and logical places for the child to keep school work, toys, and clothes
- Set small, reachable, and clear goals
- Reward positive behavior (eg, a sticker chart with a bigger reward for a certain number of stickers)
- Use charts and checklists to help the child stay “on task”
- Suggest physical activity breaks during tasks that require attention
- Limit choices
- Find activities where the child can be successful (eg, hobbies, sports)
- Use calm discipline (eg, time out, distraction, removing the child from the situation)
ADHD AND SCHOOL: Children who are diagnosed with ADHD may need changes in how they are taught, including extra help with school work during or after class. This extra help can be given in the classroom or in a “resource” room setting.
Other suggestions for teachers include:
- Write homework assignments down (on paper or send by email)
- Have the child sit near the front of the classroom
- Allow the child extra time to complete school work
- Give the child a private signal when he or she is “off-task”
- Use a daily report card to help parents to monitor their child’s symptoms and how well the current ADHD treatment plan is working
Sometimes children with ADHD also have learning disabilities. If attention and behavior improve with treatment, but the child still struggles with specific types of school work (eg, reading comprehension or mathematics), he or she may need to be evaluated for a specific learning disability. ADHD is also considered to be a disability under the Individuals with Disabilities Education Act (IDEA). Under this act, children with ADHD may qualify for special education or related services. Alternatively, the child may qualify for changes in the regular classroom setting under Section 504 of the Rehabilitation Act of 1973. In addition, the Americans with Disabilities Act may provide individuals with ADHD reasonable accommodations in certain private schools and colleges. To learn more about a child’s educational rights, contact a local Parent Technical Assistance Center (available in every state in the United States).
ALTERNATIVE TREATMENTS FOR ADHD: Alternative treatments are treatments or products that are not considered to be part of conventional medicine. Alternative Medicine therapies that have been tried for ADHD include vision training, special diets (eg, avoiding sugar, allergy triggers, or particular food additives), megavitamins, herbal and mineral supplements, electroencephalogram biofeedback, and applied kinesiology. These treatments are often used by parents of children with ADHD because they may believe that these treatments “are safer than traditional medicines,” “are natural,” “are holistic,” or “can cure ADHD. “However, studies have not confirmed the benefits of these treatments, and the risks are not well understood. One significant risk is that the treatment will fail and cause a setback for the child if symptoms of ADHD continue. Another risk is that these treatments are expensive as they are not covered by health insurance. Any parent who is considering use of an alternative treatment should gather information about the safety, risks, and benefits of the treatment. You can find reliable information about alternative treatments from your child’s health care team and the National Center for Complementary and Integrative Health.
If you are considering a complementary or alternative treatment for your child, ask the following questions:
- Does it claim to cure ADHD and multiple other health problems? There is no known cure for ADHD, and no single treatment is likely to cure multiple health problems.
- Does it claim to be harmless or natural? Natural does not necessarily mean safe.
- Is it offered by only one individual or is it a secret that only certain people can share? Reputable treatments that work well should be available from any licensed health care professional.
- Is it based on multiple studies that have been published? To confirm the safety and benefit of a treatment, multiple clinical studies should be published in mainstream medical journals (see www.pubmed.gov).
- Is it expensive? Spending a large amount of money on a treatment that is not proven might not be justifiable.
- Is the group or person promoting the treatment an expert in ADHD treatment? Verify the education and licensing of any person who claims to be an expert. All states within the United States have a licensing board that can verify a person’s credentials.
WHERE TO GET MORE INFORMATION?
Your child’s health care provider is the best source of information for questions and concerns related to your child’s medical problem.
The following organizations also provide reliable health information.
- National Library of Medicine (www.nlm.nih.gov/medlineplus/attentiondeficithyperactivitydisorder.html)
- National Institute of Mental Health (www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml)
- Children and Adults with Attention Deficit Hyperactivity Disorder (www.chadd