Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is the most common mental health problem in children. Children with ADHD often have problems with attention span, hyperactivity, and impulsive behavior. It is often called by an older name, attention deficit disorder (ADD).

Between 3% and 7% of all school age children have ADHD. The disorder begins in the preschool years and may either continue or fade away during the teenage years. About one-third of children with ADHD also have learning problems such as a reading disability. About half of ADHD children and teenagers have behavior problems, which may include breaking rules, talking back, and hitting other children.

ADHD is 7 times more common in boys than girls. Girls are more likely to have troubles with attention and less likely to have hyperactivity.

Diagnosis

Symptoms that are a part of the diagnosis of ADHD include difficulties with hyperactivity, impulsively and attention span. Previously ADHD and ADD where separated out but the latest classification which is now about 20 years old combines these together into a single diagnosis of ADHD of different subtypes based on which group of symptoms are observed. Hyperactivity and impulsively often run together which may or may not be combined with attention span difficulties. Thus current naming describes ADHD: primarily hyperactive type, primarily inattentive type or combined. Combined is the most common though within that group children can have varying difficulties with different symptom types. In general girls do not show hyperactive symptoms as often and thus are not as often diagnosed with ADHD, though they may be struggling with school work and attention span. We also see differences in subtypes as far as when they come to the attention of teachers, parents or medical providers. Kids with hyperactivity difficulties often come to the doctor in pre-school and kindergarten years while children with primarily inattentive problems come to the office later elementary school age or middle school. This is especially true of bright kids who seem to compensate for difficulties with attention span by their intelligence.

Diagnostic criteria quoted directly from Diagnositic and Statistical Manual-IV (DSM-IV). There are many limitations, especailly apparent with young children but it is the best guideline we have at this time:

Inattention:

Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
Often has trouble organizing activities often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework)
Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools)
Is often easily distracted
Is often forgetful in daily activities

Hyperactive:

Often fidgets with hands or feet or squirms in seat
Often gets up from seat when remaining ins eat is expected
Often runs about or climbs when and where it is not appropriate (adolescents or adults my feel very restless)
Often has trouble playing or enjoying leisure activities quietly
is often “on the go” or often acts as if “driven by a motor”

Impulsive:

Often blurts out answers before questions have been finished
Often has trouble waiting one’s turn
Often interrupts or intrudes on others (eg. butts into conversations or games)
It isn’t enough that the symptoms are present but they must be causing impairment in 2 or more settings. Like we already said this is what often differentiate a group of symptoms from a disorder.
Symptoms should have been present prior to age 7 though it may not have become a problem for the child until they got older and school became more complex. If there is a more abrupt change in academics or behavior other causes should be carefully explored.

Medications

The standard medication therapy for many decades include stimulant medications based on methylphenidate and dexedrine. Newer formulations are more consistent time release formulations that have largely replaced generic short-acting forms. Both medications are equally efficacious with differences primarily in side effects experienced. While similar side effects can occur, variability in individuals can be seen such that one medication may be better tolerated and efficacious than others. There are no reliable markers for predicting which medication is best and often initial trials are necessary to find the best medication.

Common short term side effects include headaches and abdominal pain. More long term side effects that can be seen include anorexia and mood changes. Mood changes can include increased anger, tearfulness and irritability. Anorexia is very common and weight is monitored along growth curve over time.

These medications are classifed as stimulants and such are more closely regulated by the DEA than other medications. This is because they have the potential to be abused. This does NOT occur with standard dosing. If the medication is used incorrectly such as snorting or injecting than addiction is possible. Addiction is NOT seen with standard dosing used in the usual manner. In fact patients with ADHD that are treated have a LOWER risk for future substance abuse than patients with ADHD that are not treated. Untreated ADHD has the potential for academic failure and “hanging with the wrong crowd”.

Other medications

Other mental health medications are often used along with standard stimulant therapy. Clonidine is a common medication for sleep and hyperactivity. It does not help attention span so if often not used alone for ADHD except in very young children. Wellbutrin is an antidepressant with some activity with ADHD. Not a great medication on its own for that it can be used along with stimulants for additive affect especially when there is comorbid mood disorder, especially anxiety and irritability

Non-medication treatment options

While stimulant medications have been used safely for decades they aren’t always the best option for all patients. Many families ask about changes in diet. It does seem there is a subset of patients that are helped by the elimination of simple sugars and red dyes. While most don’t show a response it is a healthy option for any patient.

Through increased understanding of a child’s strengths and limitations solutions can be found in all aspects of a child’s life. Modifications in school work, expectations at home and increased attention to an issue generally helps any patient. The simple shift from punitive approach to supportive approach increases successes and improves self-esteem.

Co-Morbidities

ADHD often doesn’t exist as the only difficulty for a patient. Sleep difficulties are common. Also mood difficulties need to be monitored for. Sometimes they come about as a reaction to difficulties with peer relationships and academics, primary depression and anxiety are also possible. Opposional behaviors also can exist along with ADHD. Unfortuantely there isn’t any medication to directly target those behaviors and supportive behavioral counseling is a good option.

Educational modification and support

Academic evaluation and support is critical in any child with learning difficulties, commonly occurring in children with ADHD. The best success is a combination of modifications in the classroom, modifications and understanding at home and medication. Supporting the child in multiple ways provides the best long term success.

Most children benefit from the creation of an Individual Education Plan. This is just what it sounds like, a customized modification of learning structure and expectations in the school to maximize a child’s success. This is available to any patient by requesting directly with teacher or principal and child’s school. Also sometimes called a 504 plan. This is federally mandated program that requires schools to use resources available to give a child the best chance for learning. Unfortunately resources are limited in many school districts. A medical statement from a physician confirming medical diagnosis often allows the school to qualify for increased funding to pass on for improved educational support for the patient. This is often in the form of tutoring or other similar academic support.