DESCRIPTION
An ADHD diagnosis requires at least six symptoms. These may be symptoms of hyperactivity, impulsivity, or inattention.
Patients should be at least 4 years old before diagnosis. This is because development in those under age 4 may vary.
The symptoms of ADHD may be associated with low self-esteem, anxiety, and depression. They can also be associated with risk-taking behavior. Increased risk-taking looks different in children of different ages:
- Younger children. An example of risk-taking in younger children is running away from adults under unsafe conditions.
- Older children. Examples of risk-taking in older children include using drugs or driving fast.
SIGNS AND SYMPTOMS
An ADHD diagnosis should:
- Be based on clinical evaluation
- Be based on a detailed history
- Exclude physical, situational, or mental health conditions that could account for symptoms
ADHD Rating Scales
An ADHD diagnosis can be guided by rating scales. The Vanderbilt and Conners scales are both common. They can identify whether or not someone has ADHD. They are correct 90% of the time. Data for these scales come from both parents and teachers. Teachers completing these scales should have known the child for at least a few weeks.
These scales are limited. They do not determine whether symptoms are due to ADHD or another cause. Additionally, they are highly subjective. They are based on information from the rater. Yet the rater may not understand some behaviors. Further, the rater may not provide information about the child’s circumstances.
Common Symptoms
Many symptoms are associated with ADHD.
Symptoms must usually:
- Be present in more than one setting (for example, school and home)
- Persist for at least six months
- Be present often or very often
- Be present before age 12
- Impair function in academic, social, or occupational activities
Symptoms of hyperactivity and impulsivity include:
- Excessive fidgeting
- A hard time remaining seated when required (at school or work, for instance)
- Feeling restless (in adolescents)
- Inappropriate running around or climbing (in younger children)
- A hard time playing quietly
- Seeming to always be “on the go”
- Excessive talking
- A hard time waiting turns
- Blurting out answers too quickly
- Interrupting or intruding on others
Symptoms of inattention include:
- Failing to provide close attention to detail
- Making careless mistakes
- Having a hard time maintaining attention (on play, school, or home activities)
- Seeming not to listen, even when directly addressed
- Failing to follow through (on homework or chores, for instance)
- Having a hard time organizing tasks, activities, and belongings
- Avoiding tasks that require consistent mental effort
- Losing objects required for tasks or activities (schoolbooks or sports equipment, for instance)
- Getting easily distracted by irrelevant stimuli
- Forgetting things during routine activities (homework or chores, for instance)
TESTING AND INVESTIGATION
Intellectual Testing
Intellectual tests are not usually necessary in routine ADHD evaluation. However, they can serve two purposes.
- Ruling out learning disabilities. The first purpose is excluding another disorder. ADHD can look like a learning disability. Some individuals have both ADHD and a learning disability. However, ADHD is not a learning disability. Intellectual tests can help rule out coexisting disorders.
- Identifying problem areas. The second purpose is identifying specific problem areas. Children with ADHD may struggle with abstract reasoning, mental flexibility, planning, and working memory. Such skills are broadly known as “executive functions.” Intellectual tests can help pinpoint these struggles.
Neuropsychological Testing
Neuropsychological tests can look closely at problems with executive functioning. These tests, alongside direct ADHD assessments, can serve several purposes.
They can:
- Help diagnose ADHD
- Help with planning environmental and behavioral interventions
- Allow for tracking the progress of treatment
Introductory ADHD Testing
Ongoing ADHD Evaluation
Ruling Out Diseases With Similar Symptoms
Routine laboratory testing is not generally used for ADHD. However, some tests can be helpful while diagnosing ADHD. They can rule out other diseases that might mimic ADHD.
- Thyroid tests. Thyroid tests help rule out thyroid diseases.
- Lead tests. Lead tests help rule out lead poisoning.
- Genetic tests. Genetic tests help rule out medical concerns related to changes in one’s molecular DNA, which is the blueprint for the structure of the body and brain.
- Sleep studies. Sleep studies help rule out disorders such as sleep apnea and other sleep disorders, which can have an impact on behavior.
- Electroencephalograms (EEGs). EEGs can help rule out seizure disorders.
TREATMENT AND THERAPIES
Child Age and Treatment
Medication is usually the first therapy offered children ages 6 and older with ADHD. Medication is appropriate for both school-age children and adolescents. It may be used with or without added behavioral and psychological interventions.
Some preschool children also meet ADHD diagnostic criteria. (Preschool children are children ages 4 or 5.) These children may start behavioral therapy first. They may still try medication later.
In milder cases or in younger children, parents may choose a third route. They may choose to simply observe their child at first.
Treatment Options
ADHD medications are grouped into two major categories. One consists of stimulants. The other consists of nonstimulants. Most children are first treated with stimulants. However, there are reasons a doctor might choose a nonstimulant instead.
Stimulant Medications
There are two classes of stimulants.
FDA-approved stimulants include:
- Methylphenidate-based derivatives
- Amphetamine derivatives
Amphetamines may be slightly more effective. However, methylphenidate-based derivatives are generally better tolerated. Over 80% of children will respond to one of these stimulant classes.
Stimulants come in short-acting and long-acting forms. A short-acting form must be given 2 or 3 times per day. A short-acting form is sometimes used as an initial treatment in children under age 6. A long-acting form is given only once per day. A long-acting form may improve adherence. It may also be less likely misused. For these reasons, a long-acting form is the first choice for most patients.
Stimulants usually begin to work right away. They have a long record of safety and efficacy. They are typically started at the lowest dose possible. They are then steadily increased until target ADHD symptoms are controlled.
A clinician’s or family’s preferences may determine the stimulant tried first. For example, some families prefer a tablet that can be swallowed whole. Others prefer a chewable version of medicine, or one that can be sprinkled.
Nonstimulant Medications
FDA-approved nonstimulants include:
- Guanfacine
- Clonidine
- Atomoxetine
Children who do not respond to a second stimulant may respond to a nonstimulant. A nonstimulant may replace or be added to an existing therapy. For instance, extended-release clonidine or guanfacine are sometimes added to stimulant therapy.
Guanfacine and clonidine are in the same class of medications. They are both second-choice treatments. They are less effective than stimulants. However, they are used when children:
- Respond poorly to stimulants
- Have unacceptable side effects
- Have significant coexisting conditions
Atomoxetine is another alternative to stimulants. It is an antidepressant helpful for treating ADHD. It can be useful in treating those with a history of drug use. It can also be used when a family has a strong preference against stimulants. It is less effective than stimulants.
It may take 2 or 3 weeks to see the benefit of nonstimulants.
Behavior Modification
Most experts recommend behavior modification programs. They can be part of a child’s treatment plan. Modifying behavior is effective at improving academics. It can also improve family relationships. It includes:
- Preventative strategies. These focus on modifying triggers of ADHD symptoms.
- Reactive or consequence-based strategies. These use reward and punishment to shape behaviors.
- Teaching alternative behaviors. It is possible to teach children other ways to achieve a goal.
Classroom accommodations can also be helpful.
These include:
- Taking movement breaks
- Getting extended time on tests
Costs of Treatment and Insurance
Medication Costs
Medications can be covered by insurance. Generic ones in particular are typically covered. The cost may be higher for brand-name medicines. It may also be higher for newer medicines. This doesn’t mean brand-name or newer medicines are more effective. It does not mean they will be better tolerated by the patient, either.
Behavior Modification Costs
Side Effects
ADHD Stimulant Side Effects
ADHD Stimulant Side Effects
There are several side effects that can be associated with stimulants.
- Decreased appetite. This is the most common side effect. It can result in weight loss if ongoing.
- Stomachache. Stomachache is somewhat common.
- Headache. Headache is somewhat common.
- Sleep problems. Trouble sleeping is somewhat common.
- Increased ADHD symptoms. This can occur as a medication wears off. It is known as rebound.
Preschool children may also experience other side effects. Usually, these effects are mild. They often decrease after 1 to 2 weeks on medication.
They include:
- Emotional outbursts
- Repetitive behaviors or thoughts
- Irritability
Serious side effects of stimulants are rare.
They may include:
- Jitteriness
- Dizziness
- Fainting
- Irritability
- Tics
- Behavioral changes
- Increased blood pressure
- Increased heart rate
Federal and state law considers stimulants controlled substances. The possession of stimulants without a prescription is against the law. Stimulants can show up on drug screenings. However, they do not increase the risk of developing a substance use disorder in the future. In fact, the latest evidence suggests that treating ADHD actually reduces this risk. This is true even if treating with stimulants.
At least half of children who do not respond to one type of stimulant will respond to the other. Side effects may occur with one type but not another. Therefore, it is important to try a medication from each class if possible.
Reasons to avoid stimulants may include:
- Family history of early-onset heart disease. Stimulants can raise heart rate. In healthy patients, this is not usually significant.
- Family history of high blood pressure. Stimulants can raise blood pressure. In healthy patients, this is not usually significant.
- Family history of substance use. This may be important to note. It can be a reason to put off stimulant treatment.
A child’s height, weight, blood pressure, and pulse should be monitored regularly. When a dose stays the same, these things should be observed at least every 3 to 6 months.
Untreated ADHD
Children with untreated ADHD are more likely to:
- Have a hard time in school
- Become depressed
- Have accidents
It is important to discuss safety and injury prevention at each doctor’s visit. Children with ADHD or with some symptoms have higher risk of injury. This injury could be intentional or unintentional.
Length of Treatment
Treatment is based on the goals of each patient. Usually, treatment continues into adulthood if well tolerated. Untreated ADHD can be associated with impaired functioning. It can make cognitive tasks more difficult for the patient. It can also make daily life harder. For instance, it can make maintaining a successful relationship harder.
OUTLOOK
ADHD Outlook With Treatment
With treatment, ADHD symptoms generally improve. This is particularly true for stimulant treatment.
By adolescence, symptoms may be barely discernible to observers. Examples of target outcomes with treatment include:
- Improved relationships with parents, teachers, siblings, or peers
- Improved functioning at home and school
Hyperactivity Outlook
Impulsivity Outlook
ADHD Outlook Without Treatment
Left untreated, complications of ADHD can include:
- Impaired relationships
- Impaired academics
Ongoing Accommodations
Students with ADHD are often eligible for accommodations under a school’s 504 Plan. Schools must develop 504 Plans that can help children with disabilities. ADHD can substantially limit functioning in the school setting. It can affect learning, thinking, behavior, and communication. Typical services for these children may include:
- Modified seating arrangements
- Modified testing modes
- Extra ancillary help
Special education services are reserved for those children who need the most support. An Individualized Education Plan (IEP) is an example of these services.
Ongoing Strategies for Managing ADHD at Home
Families can try these strategies to assist children with ADHD:
- Maintain a daily schedule. Routines can be of benefit.
- Keep distractions to a minimum. This can prevent triggering symptoms.
- Get organized. This includes providing specific and logical places for a child to keep schoolwork, toys, and clothes.
- Set small goals. Small, reachable target goals can help.
- Reward positive behavior. This includes, for instance, starting a “token economy.”
- Look at reinforcement. Identify unintentional reinforcement of negative behaviors.
- Use charts and checklists. These can help a child stay “on task.”
- Limit choices. This can prevent ADHD triggers.
- Provide success. This includes finding activities in which the child can be successful (hobbies or sports, for instance).
- Use calm discipline. This includes using time out, distraction strategies, or removing a child from a situation.
Complementary and Integrative Medicine for ADHD
More than half of parents of children with ADHD report using complementary and integrative medicines to treat symptoms.
Dietary factors generally do not impact ADHD behavior. This has been tested in clinical studies. Diet does not account for the majority of ADHD cases. Cutting additives, sugars, or other foods from the diet is not likely to affect ADHD. Adding essential fatty acids or minerals to the diet is not likely to affect ADHD.
Some things are part of a healthy lifestyle for all. These things include sleep hygiene, more exercise, and good nutrition.
Resources
ORGANIZATIONS/GROUPS
Children and Adults with ADHD (CHADD)
The mission of Children and Adults with ADHD (CHADD) is to improve the lives of children and adults with ADHD. CHADD has three overarching goals:
- Provide evidence-based information on ADHD to the public
- Provide support, information and services to people affected by ADHD
- Advocate for ADHD supportive policies in federal and state law
CHADD is also the home of the National Resource Center on ADHD funded by the Centers for Disease Control and Prevention. You can connect with resources and find a local ADHD support group on their Nationwide Network page.
PUBLICATIONS
JCN: What Your Pediatric Neurologist Wants You to Know – ADHD
Podcast from SAGE Neuroscience and Neurology/Journal of Child Neurology (JCN). JCN’s Residents and Fellows Board Director, Dr. Alison Christy, interviews Dr. Paige Kalika of the University of Miami on ADHD.
Child Neurology Foundation (CNF) solicits resources from the community to be included on this webpage through an application process. CNF reserves the right to remove entities at any time if information is deemed inappropriate or inconsistent with the mission, vision, and values of CNF.
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