Lisa's son Jack had always been a handful. Even as a
preschooler, he would tear through the house like a tornado,
shouting, roughhousing, and climbing the furniture. No toy or
activity ever held his interest for more than a few minutes and he
would often dart off without warning, seemingly unaware of the
dangers of a busy street or a crowded mall.
It was exhausting to parent Jack, but Lisa hadn't been too
concerned back then. Boys will be boys, she figured. But at age 8,
he was no easier to handle. It was a struggle to get Jack to settle
down long enough to complete even the simplest tasks, from chores
to homework. When his teacher's comments about his inattention
and disruptive behavior in class became too frequent to ignore,
Lisa took Jack to the doctor, who recommended an evaluation for
attention deficit hyperactivity disorder (ADHD).
ADHD is a common behavioral disorder that affects an estimated
8% to 10% of school-age children. Boys are about three times more
likely than girls to be diagnosed with it, though it's not yet
understood why.
Kids with ADHD act without thinking, are hyperactive, and have
trouble focusing. They may understand what's expected of them
but have trouble following through because they can't sit
still, pay attention, or attend to details.
Of course, all kids (especially younger ones) act this way at
times, particularly when they're anxious or excited. But the
difference with ADHD is that symptoms are present over a longer
period of time and occur in different settings. They impair a
child's ability to function socially, academically, and at
home.
The good news is that with proper treatment, kids with ADHD can
learn to successfully live with and manage their symptoms.
Symptoms
ADHD used to be known as
attention deficit disorder
, or
ADD
. In 1994, it was renamed ADHD and broken down into three subtypes,
each with its own pattern of behaviors:
1. an inattentive type
, with signs that include:
- inability to pay attention to details or a tendency to make
careless errors in schoolwork or other activities
- difficulty with sustained attention in tasks or play
activities
- apparent listening problems
- difficulty following instructions
- problems with organization
- avoidance or dislike of tasks that require mental effort
- tendency to lose things like toys, notebooks, or
homework
- distractibility
- forgetfulness in daily activities
2. a hyperactive-impulsive type
, with signs that include:
- fidgeting or squirming
- difficulty remaining seated
- excessive running or climbing
- difficulty playing quietly
- always seeming to be "on the go"
- excessive talking
- blurting out answers before hearing the full question
- difficulty waiting for a turn or in line
- problems with interrupting or intruding
3. a combined type
, which involves a combination of the other two types and is the
most common
Although it can be challenging to raise kids with ADHD, it's
important to remember they aren't "bad," "acting
out," or being difficult on purpose. And they have difficulty
controlling their behavior without medication or behavioral
therapy.
Diagnosis
Because there's no test that can determine the presence of
ADHD, a diagnosis depends on a complete evaluation. Many children
and adolescents diagnosed with ADHD are evaluated and treated by
primary care doctors including pediatricians and family
practitioners, but your child may also be referred to one of
several different specialists (psychiatrists, psychologists,
neurologists) especially when the diagnosis is in doubt, or if
there are other concerns, such as Tourette syndrome, a learning
disability, anxiety, or depression.
To be considered for a diagnosis of ADHD:
- a child must display behaviors from one of the three subtypes
before age 7
- these behaviors must be more severe than in other kids the
same age
- the behaviors must last for at least 6 months
- the behaviors must occur in and negatively affect at least
two areas of a child's life (such as school, home, day-care
settings, or friendships)
The behaviors must also not only be linked to stress at home.
Kids who have experienced a
divorce
, a
move
, an illness, a change in school, or other significant life event
may suddenly begin to act out or become forgetful. To avoid a
misdiagnosis, it's important to consider whether these factors
played a role in the onset of symptoms
First, your child's doctor will take a medical history by
performing a physical examination and asking you about any concerns
and symptoms, your child's past health, your family's
health, any medications your child is taking, any allergies your
child may have, and other issues.
The doctor may also check
hearing
and
vision
so other medical conditions can be ruled out. Because some
emotional conditions, such as extreme
stress
,
depression
, and
anxiety
, can also look like ADHD, you'll fill out questionnaires to
help rule them out.
You'll be asked many questions about your child's
development and behaviors at home, school, and among friends. Other
adults who see your child regularly (like teachers, who are often
the first to notice ADHD symptoms) probably will be consulted, too.
An educational evaluation, which usually includes a school
psychologist, may also be done. It's important for everyone
involved to be as honest and thorough as possible about your
child's strengths and weaknesses.
Causes of ADHD
ADHD is
not
caused by poor parenting, too much sugar, or vaccines.
ADHD has biological origins that aren't yet clearly
understood. No single cause has been identified, but researchers
are exploring a number of possible genetic and environmental links.
Studies have shown that many kids with ADHD have a close relative
who also has the disorder.
Although experts are unsure whether this is a cause of the
disorder, they have found that certain areas of the brain are about
5% to 10% smaller in size and activity in kids with ADHD. Chemical
changes in the brain also have been found.
Recent research also links smoking during pregnancy to later
ADHD in a child. Other risk factors may include
premature delivery
, very low birth weight, and injuries to the brain at birth.
Some studies have even suggested a link between excessive early
television
watching and future attention problems. Parents should follow the
American Academy of Pediatrics' (AAP) guidelines, which say
that children under 2 years old should not have any "screen
time" (TV, DVDs or videotapes, computers, or video games) and
that kids 2 years and older should be limited to 1 to 2 hours per
day, or less, of quality television programming.
Related Problems
One of the difficulties in diagnosing ADHD is that it's
often found in conjunction with other problems. These are called
coexisting conditions, and about two thirds of kids with ADHD have
one. The most common coexisting conditions are:
Oppositional Defiant Disorder (ODD) and Conduct Disorder
(CD)
At least 35% of kids with ADHD also have oppositional defiant
disorder, which is characterized by stubbornness, outbursts of
temper, and acts of defiance and rule breaking. Conduct disorder is
similar but features more severe hostility and aggression. Kids who
have conduct disorder are more likely to get in trouble with
authority figures and, later, possibly with the law. Oppositional
defiant disorder and conduct disorder are seen most commonly with
the hyperactive and combined subtypes of ADHD.
Mood Disorders
About 18% of kids with ADHD, particularly the inattentive
subtype, also experience depression. They may feel inadequate,
isolated, frustrated by school failures and social problems, and
have low
self-esteem
.
Anxiety Disorders
Anxiety disorders affect about 25% of kids with ADHD. Symptoms
include excessive worry, fear, or panic, which can also lead to
physical symptoms such as a racing heart, sweating, stomach pains,
and diarrhea. Other forms of anxiety that can accompany ADHD are
obsessive-compulsive disorder
and
Tourette syndrome
, as well as motor or vocal tics (movements or sounds that are
repeated over and over). A child who has symptoms of these other
conditions should be evaluated by a specialist.
Learning Disabilities
About half of all kids with ADHD also have a specific learning
disability. The most common learning problems are with reading (
dyslexia
) and
handwriting
. Although ADHD isn't categorized as a learning disability, its
interference with concentration and attention can make it even more
difficult for a child to perform well in school.
If your child has ADHD and a coexisting condition, the doctor
will carefully consider that when developing a treatment plan. Some
treatments are better than others at addressing specific
combinations of symptoms.
Treating ADHD
ADHD can't be cured, but it
can
be successfully managed. Your child's doctor will work with you
to develop an individualized, long-term plan. The goal is to help a
child learn to control his or her own behavior and to help families
create an atmosphere in which this is most likely to happen.
In most cases, ADHD is best treated with a combination of
medication and behavior therapy. Any good treatment plan will
require close follow-up and monitoring, and your doctor may make
adjustments along the way. Because it's important for parents
to actively participate in their child's treatment plan, parent
education is also considered an important part of ADHD
management.
Medications
Several different types of medications may be used to treat
ADHD:
- Stimulants
are the best-known treatments - they've been used for more
than 50 years in the treatment of ADHD. Some require several
doses per day, each lasting about 4 hours; some last up to 12
hours. Possible side effects include decreased appetite,
stomachache, irritability, and insomnia. There's currently no
evidence of long-term side effects.
- Nonstimulants
were approved for treating ADHD in 2003. These appear to have
fewer side effects than stimulants and can last up to 24
hours.
- Antidepressants
are sometimes a treatment option; however, in 2004 the U.S. Food
and Drug Administration (FDA) issued a warning that these drugs
may lead to a rare increased risk of suicide in children and
teens. If an antidepressant is recommended for your child, be
sure to discuss these risks with your doctor.
Medications can affect kids differently, and a child may respond
well to one but not another. When determining the correct
treatment, the doctor might try various medications in various
doses, especially if your child is being treated for ADHD along
with another disorder.
Behavioral Therapy
Research has shown that medications used to help curb impulsive
behavior and attention difficulties are more effective when
combined with behavioral therapy.
Behavioral therapy attempts to change behavior patterns by:
- reorganizing a child's home and school environment
- giving clear directions and commands
- setting up a system of consistent rewards for appropriate
behaviors and negative consequences for inappropriate ones
Here are examples of behavioral strategies that may help a child
with ADHD:
- Create a routine.
Try to follow the same schedule every day, from wake-up time to
bedtime. Post the schedule in a prominent place, so your child
can see what's expected throughout the day and when it's
time for homework, play, and chores.
- Get
organized
.
Put schoolbags, clothing, and toys in the same place every day so
your child will be less likely to lose them.
- Avoid distractions.
Turn off the TV, radio, and computer games, especially when your
child is doing homework.
- Limit choices.
Offer a choice between two things (this outfit, meal, toy, etc.,
or that one) so that your child isn't overwhelmed and
overstimulated.
- Change your interactions with your child.
Instead of long-winded explanations and cajoling, use clear,
brief directions to remind your child of responsibilities.
- Use goals and rewards.
Use a chart to list goals and track positive behaviors, then
reward your child's efforts. Be sure the goals are realistic
(think baby steps rather than overnight success).
- Discipline effectively.
Instead of yelling or spanking, use timeouts or removal of
privileges as consequences for inappropriate behavior. Younger
kids may simply need to be distracted or ignored until they
display better behavior.
- Help your child discover a talent.
All kids need to experience success to feel good about
themselves. Finding out what your child does well - whether
it's sports, art, or music - can boost social skills and
self-esteem.
Alternative Treatments
Currently, the only ADHD therapies that have been proven
effective in scientific studies are medications and behavioral
therapy. But your doctor may recommend additional treatments and
interventions depending on your child's symptoms and needs.
Some kids with ADHD, for example, may also need special educational
interventions such as tutoring,
occupational therapy
, etc. Every child's needs are different.
A number of other alternative therapies are promoted and tried
by parents including: megavitamins, body treatments, diet
manipulation, allergy treatment, chiropractic treatment, attention
training, visual training, and traditional one-on-one
"talking" psychotherapy. However, scientific research has
not
found them to be effective, and most have not been studied
carefully, if at all.
Parents should always be wary of
any
therapy that promises an ADHD "cure." If you're
interested in trying something new, speak with your doctor
first.
Parent Training
Parenting a child with ADHD often brings special challenges.
Kids with ADHD may not respond well to typical parenting practices.
Also, because ADHD tends to run in families, parents may also have
some problems with organization and consistency themselves and need
active coaching to help learn these skills.
Experts recommend parent education and support groups to help
family members accept the diagnosis and to teach them how to help
kids organize their environment, develop problem-solving skills,
and cope with frustrations. Training can also teach parents to
respond appropriately to a child's most trying behaviors with
calm disciplining techniques. Individual or family counseling can
also be helpful.
ADHD in the Classroom
As your child's most important advocate, you should become
familiar with your child's medical, legal, and educational
rights.
Kids with ADHD are eligible for
special services
or accommodations at school under the Individuals with Disabilities
in Education Act (IDEA) and an anti-discrimination law known as
Section 504. Keep in touch with teachers and school officials to
monitor your child's progress.
In addition to using routines and a clear system of rewards,
here are some other tips to share with teachers for classroom
success:
- Reduce seating distractions.
Lessening distractions might be as simple as seating your child
near the teacher instead of near the window.
- Use a homework folder for parent-teacher
communications.
The teacher can include assignments and progress notes, and you
can check to make sure all work is completed on time.
- Break down assignments
. Keep instructions clear and brief, breaking down larger tasks
into smaller, more manageable pieces.
- Give positive reinforcement.
Always be on the lookout for positive behaviors. Ask the teacher
to offer praise when your child stays seated, doesn't call
out, or waits his or her turn instead of criticizing when he or
she doesn't.
- Teach good study skills.
Underlining, note taking, and reading out loud can help your
child stay focused and retain information.
- Supervise.
Check that your child goes and comes from school with the correct
books and materials. Sometimes kids are paired with a buddy to
can help them stay on track.
- Be sensitive to self-esteem issues.
Ask the teacher to provide feedback to your child in private, and
avoid asking your child to perform a task in public that might be
too difficult.
- Involve the school counselor or psychologist.
He or she can help design behavioral programs to address specific
problems in the classroom.
Helping Your Child
You're a stronger advocate for your child when you foster
good partnerships with everyone involved in your child's
treatment - that includes teachers, doctors, therapists, and even
other family members. Take advantage of all the support and
education that's available, and you'll help your child
navigate toward success.
Reviewed by:
Richard S. Kingsley, MD
Date reviewed: September 2008
Originally reviewed by:
W. Douglas Tynan, PhD
Note: All information is for educational purposes only. For specific medical advice,
diagnoses, and treatment, consult your doctor.
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