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my.clevelandclinic.org - Attention-Deficit/Hyperactivity Disorder (ADHD) in Children & Adults

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Overview What is attention-deficit/hyperactivity disorder (ADHD)? Does your child fail to sustain attention, behave within appropriate limits at home and in public, or sit quietly when they’re expected to do so? Not being able to stay within limits or sit quietly is normal childhood behavior if it happens at different ages and from time to time, but if this behavior occurs frequently and interferes with your child’s daily life, they may have ADHD. ADHD is a neurodevelopmental condition that can affect family life. The word “neurodevelopmental” refers to the nervous system, which includes the brain as it develops across the lifespan. ADHD behavior usually appears by age 7, though symptoms behavior may appear before this. With ADHD, children can have trouble with impulsivity, hyperactivity, distractedness, following instructions and completing tasks. But ADHD is treatable. When symptoms of attention-deficit/hyperactivity disorder occur in childhood, they tend to persist into adulthood in about half of all cases. Adults with ADHD often find it difficult to follow directions, remember information, and concentrate on or organize tasks. Without proper acknowledgment and management of these behaviors, ADHD can result in behavioral, emotional, academic, vocational and social problems that decrease the quality of life. What is the difference between ADHD and ADD (Attention-Deficit Disorder)? ADHD is the only term assigned to this diagnosis but there are different presentations of ADHD — ADHD Inattentive Presentation, ADHD Hyperactive/Impulsive Presentation, ADHD Combined Presentation (both inattention and H/I behavior) and a fourth type called Unspecified ADHD, a diagnosis used when symptoms are unclear. How common is ADHD? About 11% of children between the ages of four and 17 have ADHD. Symptoms of ADHD typically first appear between the ages of three and six years old. The average age of ADHD diagnosis is seven years old. In children, it’s three times more common in young boys than girls. ADHD isn’t just a childhood disorder. About 4% of American adults over the age of 18 contend with ADHD behaviors on a daily basis. In adulthood, it’s diagnosed equally between males and females. Is ADHD a mental illness? By definition, ADHD is better referred to as a neurodevelopmental disorder, not a “mental illness.” The term “mental illness” is a very broad term for any type of condition that affects mood, behavior or thinking. ADHD is better described as a pattern of behavior — something different in the way a person does things — rather than describing it as something “wrong” with people. Evidence indicates that ADHD is associated with neural pathways in brain functioning (the default mode and the task positive mode). This functioning yields problematic behavioral at certain ages (stages of development) — thus the term neurodevelopmental disorder is a better broad category name for the problem of ADHD. Is ADHD a form of autism? No, although they are both neurodevelopmental disorders. Except, many children with autism have ADHD. But the two conditions are by expression and definition quite different. Is ADHD a learning disability? ADHD is not a learning disability, though it certainly can impair learning. About 30% to 40% of children with ADHD also have a learning disability. Like those with a learning disability, children with ADHD are eligible to receive special education services. Difficulty sustaining attention to tasks. Impulsivity : Doing things on sudden urges, without thinking such as talking out in class, throwing a toy, or interrupting someone in conversation. In adults, the impulses may be irresponsible such as spending too much money. : Doing things on sudden urges, without thinking such as talking out in class, throwing a toy, or interrupting someone in conversation. In adults, the impulses may be irresponsible such as spending too much money. Hyperactivity: Restlessness such as fidgeting, inability to stay seated when sitting is expected such as in church or school, moving or climbing when it’s inappropriate to do so. Children, teens and adults with ADHD are diagnosed by the behavior pattern that is most actively present. The three most common ADHD presentations are Predominantly Inattentive, Predominantly Hyperactive/Impulsive and the combination of these types. ADHD Predominantly Inattentive Presentation is defined by the following nine behaviors: Fails to pay close attention to details or makes careless mistakes in schoolwork, at work or during other activities.

Has trouble paying attention during tasks or play.

Appears to not listen even when spoken to directly.

Has difficulty following through on instructions (for example, doesn't finish schoolwork, chores or other duties in the workplace).

Often has trouble organizing tasks or activities.

Avoids or dislikes tasks that require continuous mental effort, such as schoolwork, homework or preparing reports, completing forms and reviewing lengthy papers. Frequently loses needed items, such as books, pencils, tools, wallets/purses, keys, paperwork, phone and eyeglasses. Can be easily distracted by actions or thoughts unrelated to the current task. Is often forgetful in daily activities (such as doing chores, running errands, returning phone calls, paying bills and keeping appointments). Behaviors of the ADHD Predominantly Hyperactivity/Impulsive type include: Fidgets with or taps hands or feet or squirms frequently. Leaves seat in the classroom or in the workplace when remaining seated is expected. Runs or climbs excessively when it's not appropriate; constantly feels restless (if an adolescent or adult).

Has trouble playing or engaging in leisure activities quietly.

Always seems “on the go” or “driven by a motor.”

Talks too much.

Blurts out the answers before questions have been completely asked; older children may often finish sentences for others who are talking.

Frequently has trouble waiting for his or her turn.

Often interrupts or intrudes on others' conversations or games. What are the risk factors of ADHD? ADHD is largely a hereditary condition. If one or both parents have been diagnosed with ADHD, their children are more likely to have it as well. Although the exact etiology (i.e., origins) of ADHD are ill-defined, healthcare providers report other associated risk factors: Biological : ADHD is associated with the way certain neurotransmitters (chemicals in the brain that help control behavior) work, especially dopamine and norepinephrine, and this difference causes changes in two different attentional networks of the brain — the default network, associated with automatic attention and the task positive network, associated with directed or effortful attention. : ADHD is associated with the way certain neurotransmitters (chemicals in the brain that help control behavior) work, especially dopamine and norepinephrine, and this difference causes changes in two different attentional networks of the brain — the default network, associated with automatic attention and the task positive network, associated with directed or effortful attention. Environment : Exposure to toxins (poisons) in the environment (lead, for example) has been linked to ADHD in children. : Exposure to toxins (poisons) in the environment (lead, for example) has been linked to ADHD in children. Prenatal substance exposure (during pregnancy): Smoking and/or drug and alcohol use during pregnancy is associated with ADHD in children. What makes ADHD symptoms worse? Certain behaviors are expected depending on the age of a person. Because the brain doesn’t develop at the same rate in everyone, cognitive functions may be poor in some people and not in others. A child 10 years old, for example, might only have the abilities of a younger child 8 years old rather than his or her same age peers. Therefore, as you or your child get older, the problem is not that ADHD gets worse, it’s that the child’s abilities are not developing synchronized with age. Although ADHD doesn’t get “worse,” the tasks expected of the person become more complicated with age and circumstances, such as increased demands in school, therefore, the problematic behaviors (such as completing things on time) become more problematic. For example, as the child may get a lower grade for turning in late work. Examples of other complications include: Undertaking new challenges without sufficient support : New and more complex challenges frequently arise in school. As a child advances in grade level, academic tasks become more complex, such as having to write lengthy reports or studying numerous chapters of a history book. Task complexity in reading, spelling, math and interacting with classmates pose problems to the child who has limited ability to meet demand. The student with ADHD may struggle even more without additional collateral support from parents and teachers. : New and more complex challenges frequently arise in school. As a child advances in grade level, academic tasks become more complex, such as having to write lengthy reports or studying numerous chapters of a history book. Task complexity in reading, spelling, math and interacting with classmates pose problems to the child who has limited ability to meet demand. The student with ADHD may struggle even more without additional collateral support from parents and teachers. Often, children are punished for actions they cannot control : Children with ADHD may be criticized and punished by parents and teachers, they may be looked down on by peers because of their inability to finish tasks or remember their schoolwork, and some may not know how to play appropriately with their friends. Adults can be penalized by supervisors at their jobs for forgetting to do work and, at times, even by family members for failing to stay organized, or stay focused on tasks to completion.

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: Children with ADHD may be criticized and punished by parents and teachers, they may be looked down on by peers because of their inability to finish tasks or remember their schoolwork, and some may not know how to play appropriately with their friends. Adults can be penalized by supervisors at their jobs for forgetting to do work and, at times, even by family members for failing to stay organized, or stay focused on tasks to completion. Additional problems with thinking, emotions and behaviors : Psychiatric disorders like depression and anxiety are common in people with ADHD. Children are 62% more likely to have at least one disorder. Adults with ADHD are six times more likely to have a disorder. People with ADHD are also more likely to abuse drugs and alcohol. : Psychiatric disorders like depression and anxiety are common in people with ADHD. Children are 62% more likely to have at least one disorder. Adults with ADHD are six times more likely to have a disorder. People with ADHD are also more likely to abuse drugs and alcohol. Stress : So many things can cause additional stress in the life of someone with ADHD. Examples include serious medical illnesses, domestic violence, divorce, loss of employment or the death of a friend or family member. : So many things can cause additional stress in the life of someone with ADHD. Examples include serious medical illnesses, domestic violence, divorce, loss of employment or the death of a friend or family member. No treatment: According to recent data, 17.5% of children ages four to 17 in the United States received no treatment — behavioral or pharmacological — for ADHD. Treatment is vital for managing ADHD symptoms. Diagnosis and Tests How is ADHD diagnosed in children, teens and adults? To diagnose a child, the healthcare provider must perform three tasks. The healthcare provider must: 1) identify the presence of ADHD symptom criteria, 2) rule out alternative causes of symptoms, and 3) identify comorbid conditions (other conditions such as depression or anxiety). But, the job is not yet done. Certain conditions must also be met. First, the symptom behaviors must be present in two or more settings such as at home and in school. Second, the symptoms must be impairing. It’s not just that they occur as everyone engages in these behaviors sometimes. Third, symptom behaviors must have been present in childhood, typically before the age of 12 years. Last, the symptoms cannot be corollaries to another disorder that is not ADHD. For example, sometimes, when a person is depressed or anxious, inattentive behaviors may occur. The clinician will identify ADHD symptoms by asking you questions about your child’s behavior s at home and school (that is, behaviors your child’s teachers shared with you). Next, your provider will rule out other possible conditions that share some similar symptoms. These conditions include: Anxiety.

Depression.

Learning disabilities.

Autism.

Undetected seizures.

Medical disorders that affect the functioning of the brain.

Thyroid disorders.

Lead toxicity (poisoning).

Sleep problems. A sudden life change (such as divorce, death in the family, or moving to a new home) may also result in behaviors that could be confused with ADHD). Sometimes, an adult will recognize the behaviors of ADHD in himself or herself when a son or daughter is diagnosed. Other times, adults will seek professional help for themselves and find that their depression or anxiety is related to ADHD. The American Psychological Association has guidelines to help healthcare providers make the diagnosis. To be diagnosed with ADHD, children must have six or more symptoms in one of the two (or both) main categories — 1) inattention and/or 2) hyperactivity/impulsivity (see the symptom section) — of ADHD over the last six months. To be diagnosed with ADHD as an adult, you must have five or more of the established ADHD behaviors in either of these categories for at least six months and there must be evidence such as recall of school experiences that indicates symptoms were present in childhood. To reiterate, in addition to having ADHD behaviors, children, teens and adults must meet the following criteria: The symptoms must interfere with school, home or work life. The symptoms must be present in two or more settings (such as home, church, school, work, with friends, or social groups/activities). The symptoms were present before the age of 12. Based on review of the collected information, your healthcare provider may diagnose an adult or child with one of types of ADHD: Predominately hyperactive/impulsive type : You or your child must have behaviors of hyperactive/impulsive behavior for the past six months, but not meet the criteria for inattention. : You or your child must have behaviors of hyperactive/impulsive behavior for the past six months, but not meet the criteria for inattention. Predominately inattentive type (formerly known as attention deficit disorder, or ADD ): You or your child must have behaviors of inattention present for six months, but do not meet the criteria for hyperactive/impulsive. ): You or your child must have behaviors of inattention present for six months, but do not meet the criteria for hyperactive/impulsive. Combined type (inattentive and hyperactive/impulsive) : Symptoms from both types of ADHD must be present for the past six months. This is the most common form of ADHD in children. : Symptoms from both types of ADHD must be present for the past six months. This is the most common form of ADHD in children. Other specified/unspecified ADHD: Children, teens or adults have inattentive type behaviors but do not meet the above conditions for diagnosis. Keep in mind that symptoms can change over time and therefore so can the diagnosis of the type of ADHD. How should I prepare for my child’s appointment to discuss ADHD? If you think your child has a problem with attention, hyperactivity or impulsivity, and it seems that his or her behavior at home and performance at school are being affected, your next step is to see your pediatrician. If the symptoms are affecting your child’s schoolwork, contact the school and request an evaluation. When making this request, be as specific as possible about the type of educational or behavioral issues your child has. Schools are required to evaluate children (ages three to 21) if there’s evidence of a disability that affects their learning. This evaluation is free and must, by law, include appropriate standardized tests. School testing can lead to accommodations in the classroom. The school will not diagnose ADHD, but will take note of the symptoms and will often assign a designation of “Other Health Impaired” (OHI). Get a copy of the school’s report and bring it with you to the appointment with the pediatrician. If necessary, the family provider may suggest you take your child to a professional who specializes in ADHD and other developmental, behavioral or mental health concerns. Management and Treatment How is pharmacotherapy used to treat ADHD? A group of drugs called psychostimulants are an effective treatment for ADHD. The two most commonly used medicines in this class are methylphenidates (often known as Ritalin) and dextroamphetamines (similar to Adderall). These medicines help people with ADHD focus their thoughts and ignore distractions. Stimulant medicines are effective in 70% to 90% of patients with ADHD. New medicines are also being developed. Examples of short-acting (immediate-release), intermediate-acting and long-acting forms of these medications include: Methylphenidates Short-acting: Ritalin®, Focalin®, Methylin Chewable®, Methylin Solution®. Ritalin®, Focalin®, Methylin Chewable®, Methylin Solution®. Long-acting intermediate release: Ritalin SR®, Methylin®, Metadate ER®.

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Ritalin SR®, Methylin®, Metadate ER®. Long-acting extended-release: Concerta®, Aptensio® XR, Metadate CD®, Metadate ER®, Ritalin LA®, Focalin XR®, Daytrana®, Quillivant XR® (liquid) Jornay. D-Amphetamines Short-acting: Dextrostat®, Dexedrine Tabs®, Evekeo®, Zenzedi®, Adderall®, ProCentra®. Dextrostat®, Dexedrine Tabs®, Evekeo®, Zenzedi®, Adderall®, ProCentra®. Long-acting intermediate release: Adderall®, Dexedrine Spansule®. Adderall®, Dexedrine Spansule®. Long-acting extended-release: Vyvanse®, Adderall XR®, Dyanavel® XR, Adzenys® XR-ODT. Non-stimulant medicines include atomoxetine (Strattera®,) guanfacine (Intuniv®), and clonidine (Kapvay®). They are often used as additional treatment, or can be used on their own if the healthcare provider approves. New nonstimulant formulations are in the pipeline of several pharmaceutical companies. There’s no way to really know which medicine(s) and dosage level(s) will work best for you or your child until you try it out. Your healthcare provider may need to prescribe several different formulations and see how you your or your child react. Typically the physician will “start low (in dose) and go slow.” The most common side effects of ADHD medications include decreased appetite, trouble sleeping and irritability. Fortunately, side effects are often mild and short-lived and usually happen early in treatment. If they continue or interfere with you or your child’s daily life, your provider will probably change your medication or lower the dose. The most important question to ask is, “Does the benefit of the medicine outweigh the side effect?” The most effective treatment is medicine combined with behavioral therapy. What behavioral treatments are used to treat childhood and adult ADHD? The best prevention for ADHD, supported by substantial research, is to use a combined approach of both behavioral intervention and pharmacotherapy. Medicines are not enough to treat you or your child’s ADHD. The old adage — pills don’t teach skills — is certainly appropriate here. Thus it’s best to combine medical treatments with behavioral treatments. Behavioral treatments for childhood ADHD include: Behavior modification: With this treatment, your child’s behavior is analyzed, and strategies are designed to increase appropriate behaviors and decrease inappropriate behaviors. One model program for children with ADHD is called the Summer Treatment Program developed by Dr. William Pelham of Florida International University. With this treatment, your child’s behavior is analyzed, and strategies are designed to increase appropriate behaviors and decrease inappropriate behaviors. One model program for children with ADHD is called the Summer Treatment Program developed by Dr. William Pelham of Florida International University. Behavioral parent training : This training helps parents respond to a child’s behaviors in ways that will strengthen growth and development and encourage a positive parent-child relationship. Parent training often occurs at the same time as behavior modification or social skills training for the child. A good parent training program is 1-2-3 Magic by Thomas Phelan. : This training helps parents respond to a child’s behaviors in ways that will strengthen growth and development and encourage a positive parent-child relationship. Parent training often occurs at the same time as behavior modification or social skills training for the child. A good parent training program is 1-2-3 Magic by Thomas Phelan. Social skills training : This training teaches social skills that will improve the child’s ability to act positively and effectively with peers and adults in school and at home. It also provides a setting to practice the skills in a safe, accepting atmosphere. : This training teaches social skills that will improve the child’s ability to act positively and effectively with peers and adults in school and at home. It also provides a setting to practice the skills in a safe, accepting atmosphere. School interventions : A specialist may work with your child’s educational team to conduct a multi-factored evaluation, or MFE, as noted above to create an individualized education plan (IEP), 504 plan or other classroom-based intervention. : A specialist may work with your child’s educational team to conduct a multi-factored evaluation, or MFE, as noted above to create an individualized education plan (IEP), 504 plan or other classroom-based intervention. Organizational skills training: This training teaches older children skills to help them improve time management, organizational skills and effectively use executive functions to increase efficiency and work completion at home and school. Behavioral treatments in adults help you navigate the demand of jobs, relationships and educational opportunities. ADHD coaches are trained and certified to assist adults with ADHD in managing their symptoms. Behavioral treatments for adults with ADHD include: Individual cognitive behavioral treatment (“talk therapy”) to enhance a person’s sense of self-efficacy.

Relaxation training and stress management to reduce anxiety and stress.

Behavioral coaching to teach strategies for organizing home and work activities.

Job coaching or mentoring to support better working relationships and improve on-the-job performance. Family education and therapy to ensure that everyone in the family understands ADHD and its symptoms. What happens if ADHD is left untreated? Symptoms will continue if ADHD is left untreated and people are left to manage them on their own. Children may struggle at school, home and in social situations, and adults may struggle with work, education, interactions with friends and family and more. Untreated ADHD makes life harder than it has to be. Prevention How can I prevent ADHD? There are certain risk factor categories for the development of ADHD, some of which can be changed, some that can’t. They are: Heredity.

Biology.

Environment.

Prenatal exposure to toxic substances. If you or your parents have ADHD, there is a higher probability that your children will, too. Unfortunately, there’s nothing that can be done to prevent the genetics from ADHD expression. The same goes for biologic factors. People can be born with chemical imbalances or they can have adequately functioning neurotransmitters. Environmental toxins have been linked to ADHD in children. Parents may have their home tested for lead, for example, to prevent lead poisoning which increases the risk of ADHD. Another way to help reduce the risk of ADHD is to avoid smoking, alcohol and drugs while pregnant with your child. Outlook / Prognosis What can I expect if I or my child has ADHD? ADHD is a complicated condition with various symptom expressions. If you or your child have ADHD, educate yourself as much as possible about the challenges associated with this diagnosis. Consider medicines and behavioral treatments. Your healthcare provider will help you with these. They will sum up the results of the ADHD evaluation and will recommend the appropriate treatment— usually a combination of pharmacotherapy and behavioral treatment. A trained behavioral health clinician can give general guidelines for managing ADHD and these can be tailored to your family’s needs and your child’s strengths and weaknesses. Also, it is always useful to have appropriate expectations. Don’t expect your child to get out of bed the first time you wake them up, and don’t be too hard on yourself if making progress is difficult. It is always best to have your partner and friends help with tasks like organizing and time management. Stay in contact with your healthcare provider, especially if there is a change in behavior or there is a reaction to prescribed medications. Two important questions to ask yourself are: 1) "Am I moving forward in the world of action or am I living in my head? 2) "Am I moving closer to my values or am I moving away from what I value?" How long will I have ADHD? ADHD does not go away but many people learn to manage it successfully in their adult lives. ADHD is a lifelong condition, and behaviors are often successfully managed with medicine and behavioral treatment.

my.clevelandclinic.org - Attention-Deficit/Hyperactivity Disorder (ADHD) in Children & Adults

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