Published: May 3, 2007
Updated: May 3, 2007
I bet every teacher in the country calls a couple of parents every year complaining that their students are “not on task,” “not listening,” “not turning in work,” “too fidgety,” “a non-stop chatterbox,” or “acting like a class clown.”
Almost all children show some of these behaviors from time to time. But when such behaviors are chronic, interfere with learning, and are accompanied by a short attention span, disorganization, impulsiveness, or excessive restlessness, they may be the signs of attention-deficit/hyperactivity disorder, also known as ADHD.
Dr. Richard D’Alli, a pediatric psychiatrist at Duke Children’s Hospital, discusses this widespread disorder below.
-- Dennis Clements MD, PhD, MPH
Attention-deficit/hyperactivity disorder (ADHD) occurs in 3 to 5 percent of school-age children -- not only in the United States, but also in every country on every continent where child behavior has been studied in community settings.
Sometimes still known by the outmoded term ADD (officially changed to ADHD in 1994), ADHD is a neurodevelopmental problem that runs in families and is occasionally associated with disturbances of brain development, such as birth trauma, substance abuse during pregnancy, autistic spectrum disorders, and other problems.
ADHD usually shows up before first grade and affects children regardless of their environment. The core problems of inattention, distractibility, impulsiveness, and hyperactivity, all of which must greatly exceed age-appropriate behaviors, impair not only school performance, but also family and social functioning.
Untreated, ADHD can lead to school failure, substance abuse, and accidents. ADHD may also be accompanied by temper tantrums, defiance, and other conduct problems. ADHD persists into adulthood, when some of the symptoms may be less apparent, but the consequences are more complex.
Not all children with ADHD are hyperactive, and some hyperactive children with ADHD actually have no trouble paying attention.
In other words, ADHD is a spectrum disorder. Mental health professionals recognize three main types:
Parents often say that their child was “tested for ADHD.” However, this doesn’t mean the child was tested by laboratory methods. Despite intriguing research and promising claims, there are no reliable blood, imaging (brain scan), or genetic tests for ADHD available today.
Instead, ADHD is diagnosed clinically, which means that trained professionals arrive at a diagnosis after carefully considering the child’s history (based on observations of caregivers, teachers, and other reliable adults), their own direct observations of the child, and, occasionally, computerized measurements of attention. (Interestingly, children themselves often cannot tell that anything is wrong.)
The clinician then assesses this information using the American Psychiatric Association’s criteria for ADHD and noting other typical ADHD behaviors not listed in these criteria (such as risk-taking, sloppy handwriting, boredom, low frustration tolerance, and more). Other medical conditions, psychiatric illnesses, or learning problems that might mimic ADHD must also be ruled out.
If ADHD is suspected, many parents wonder why their child can sit for hours playing a video game, or can occasionally complete a creative project in school, or can finish a homework assignment when an adult works with them one-on-one.
One explanation for these curiosities is that having ADHD does not mean that a child never pays attention or never sits quietly or resists impulses, but rather that a child cannot do these things most of the time.
Another explanation is that the action and excitement of a colorful, noisy video game can be riveting to a child, sufficient to overcome his or her deficit of attention. Similarly, one-on-one time with a child acts as an external force to focus attention. Of course, neither attractive toys nor one-to-one attention is very practical in an active family or busy classroom of 25 to 30 children.
Researchers have proven in study after study that three concurrent treatments work well to reduce the symptoms of ADHD: medication, school structure, and parent management training.
Medication is the most powerful of these treatments. There are several classes of medicines that help children with ADHD, but the most effective by far are the psychostimulants.
There are only two basic psychostimulant compounds in use today: methylphenidate (known by the brand names Ritalin, Concerta, Focalin, Methylin, Metadate, Daytrana, and others) and amphetamine (known by the brand names Dexedrine, Adderall, and others).
The psychostimulants are among the safest and most well-studied drugs in psychiatry, and all are approved for use in children by the U.S. Food and Drug Administration (FDA). They work by improving the function of attention circuits in the brain, increasing appreciation of reward, and inhibiting impulsive actions.
When managed by an experienced clinician, nearly nine out of every 10 children with correctly diagnosed ADHD will improve on one of the psychostimulants.
Establishing which psychostimulant and dose will be effective for an individual child is always a trial, because there is no reliable way to predict or calculate either one. When the right dose is found, the psychostimulants take effect very quickly.
It is not necessary to give these medications every day, but they will only be effective the day they are taken. Despite marketing claims to the contrary, sustained-release psychostimulants are generally effective for the length of a school day, or perhaps a little longer.
The disadvantages of psychostimulants include their time-limited effectiveness, appetite reduction, occasional insomnia, nausea, headaches, stomachaches, and, rarely, tics, irritability, or even psychosis. Fortunately, these side effects disappear immediately when the medication is stopped.
The FDA has raised concerns about the extremely rare occurrence of death in adults and children taking a psychostimulant. The best scientific evidence as of June 2006 indicates that these individuals had structural defects in their hearts; thus, thoughtful guidelines are being developed to warn clinicians and patients about the use of psychostimulants when there is a pre-existing heart condition.
Other Medicinal Options
For children who do not respond to a psychostimulant, the relatively new drug atomoxetine (Strattera) is effective for ADHD and approved for use in children by the FDA. Strattera is chemically similar to older antidepressants known as tricyclics (imipramine, desipramine, nortiptyline).
Unlike the psychostimulants, the appropriate dose of Strattera can be calculated by knowing the weight of the child. Strattera may take up to a few weeks before becoming effective and must be taken every day. Its side effects are very similar to the psychostimulants. Strattera carries a warning from the FDA about possible changes in mood and very rare occurrences of liver damage.
When neither psychostimulants nor atomoxetine control ADHD symptoms, bupropion (Wellbutrin), an antidepressant, may be used. It must be taken daily and may take several weeks before becoming effective. Common side effects are remarkably similar to the psychostimulants, but may also include dizziness, agitation, sweating, and dry mouth.
When excessive arousal and inability to fall asleep trouble the ADHD child, two additional medicines -- guanfacine (Tenex) and clonidine (Catapres) -- may be used. Neither is approved for use in ADHD by the FDA and both were originally developed to lower blood pressure in adults. However, very careful study of these medicines in children has demonstrated their effectiveness in reducing hyperactivity. Clonidine is sedating and may be helpful at bedtime, while guanfacine, to a limited extent, may assist in improving attention.
These two medications also have unwanted side effects, including drowsiness, lethargy, and slight reduction in blood pressure.
Finally, despite Internet claims, no alternative, complementary, or “natural” product or device on the market has ever been shown in well-controlled tests to effectively reduce the symptoms of ADHD.
School Structure and Parent Training
Non-medical treatments are also very important in the comprehensive treatment of ADHD.
Providing school structure includes seating closer to the teacher or blackboard, making sure daily planning and homework tracking forms are signed by teachers and parents, creating behavior contracts, using technological aids, and, of course, educating teachers about ADHD. Formalized plans, known as IEPs or 504s, are often put into place by school counselors to accomplish the same goals.
Parent training, sometimes called contingency management, usually means helping parents maintain consistent rules at home, teaching them how to deliver effective commands, and showing them how to reward desirable behaviors (to reinforce them) and create consequences for unacceptable behaviors (to reduce their recurrence).
Reward programs often use stickers or other tokens of good behavior to be traded in by the child for special treats. Supervising homework time and encouraging relaxing bedtime rituals also play an important role. Occasionally group therapies designed to help children improve social skills are helpful.
To learn more about ADHD visit the American Academy of Child and Adolescent Psychiatry (click "Facts for Families"), the American Academy of Pediatrics (click " Children’s Health Topics"), or Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
-- Richard D’Alli, MD, is Chief of the Child Development and Behavioral Health Division in Duke’s Department of Pediatrics.
-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.