Helping both children and adults with Attention Deficit Hyperactivity Disorder (ADHD) is a big part of my practice. This condition is very treatable, and in most cases, significant improvement can be made. Here is some basic information to help you understand ADHD and some of the treatments involved.
What is ADHD?
Individuals with this disorder experience chronic problems with combinations of inattention, impulsiveness, and hyperactivity. The American Psychiatric Association’s Diagnostic and Statistical Manual IV (DSM IV) identifies three separate diagnoses: primarily inattentive type, hyperactive/impulsive type, or the combined type (having inattention, hyperactivity and impulsivity). Difficulties with self-regulation and motivation are common. People can experience ADHD as children, teens or adults. ADHD is not uncommon, and is estimated to affect 5 to 8 percent of school-age children, and about 4 percent of adults. In 60 percent of childhood cases, symptoms persist into adulthood.
What are the symptoms of ADHD?
People with ADHD usually display both symptoms of inattentiveness, and hyperactivity, but some may exhibit greater signs of one than the other. To be diagnosed with ADHD, a person must show symptoms in two different life settings, such as at school and at home, or at home and at work. The inattentiveness or hyperactivity must cause significant problems in functioning at school, work or home, or in social settings. Symptoms are expected to be present by age 7.
Though people may be unaware of symptoms before age 7 (a more common problem when evaluating adults), it is important to emphasize that we do not expect symptoms to appear suddenly in the adult years. A sudden emergence of ADHD-like symptoms in a teenager or adult should initially be assessed by the primary care doctor to rule out the possibility of a major medical cause.
As mentioned above, there are three major categories of ADHD; inattentive type, hyperactive/impulsive type, and “combined type.” The DSM IV lists 9 separate, common symptoms to look for in the inattentive and hyperactive/impulsive subtypes.
Doctors usually look for at least six different symptoms that have persisted for six months or more, and cannot be accounted for by any other mental or physical disorder before making a diagnosis of ADHD.
Here are some common ADHD symptoms as defined by DSM IV Criteria for ADHD (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, DC, American Psychiatric Association, 2000)
Six or more of the following symptoms of inattention have been present for six months, and to a point that is disruptive and inappropriate for the developmental level:
- Often does not give close attention to details or makes careless mistakes in schoolwork 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
- Often fidgets with hands or squirms in seat
- Often gets up from seat when remaining in the seat is expected
- Often runs about or climbs when and where it is not appropriate (adolescents or adults may 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”
- Often talks excessively
- Often blurts out answers before questions have been finished.
- Often has trouble waiting one’s turn.
- Often interrupts or intrudes on others (e.g. butts into conversations or games).
- Some symptoms that cause impairments were present before age 7 years
- Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home)
There must be clear evidence of significant impairment in social, school, or work functioning. The symptoms also do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder. They are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Symptoms in adults may be different than those in children. Here are some common signs of ADHD in adults:
- Puts things off to the last minute
- Fails to follow through on commitments
- Difficulty with prioritization. This can lead to missed deadlines, forgotten appointments or social engagements, etc.
- Has difficulty sustaining attention or reading paperwork
- Feels restless and impatient. This can include impatience waiting in lines or driving in traffic.
- Always “on the go”
- Always needs to be busy at work or on vacation
- Interrupts others at work or in class
- Has difficulty waiting their turn
- Finishes others sentences during conversation
- There is often a history of problems in work, school, or relationships
What causes ADHD?
ADHD is a psychiatric behavioral disorder. The brain uses different chemicals to help send messages across the nervous system. An imbalance in these chemicals, or understimulation of the frontal lobe, may cause the symptoms associated with ADHD, but a definitive answer is not yet in place. Other causes and risk factors, including genetics, may play a role. Some of the other possible causes include brain injury, environmental exposure (such as to lead), alcohol and tobacco use during pregnancy, premature delivery, and low birth weight.
Why is treatment important?
People with untreated ADHD can suffer social and academic failure, failure in the workplace, and chronic difficulties in maintaining relationships. For some, it can contribute to low self esteem, substance abuse, and even a possible risk of antisocial or criminal behavior.
How can ADHD be treated?
Treating ADHD in children usually involves medical, educational, behavioral and psychological interventions. This comprehensive approach is called “multimodal” and involves educating the parent, child, teachers and others involved in the child’s welfare. I always make sure that any course of treatment is tailored to the unique needs of the patient and their family.
Behavior strategies are a major part of treatment for children with ADHD.
- Create a routine for every day–same time getting up, doing homework, having playtime, going to bed.
- Get organized so that items your child needs are always in the same place where he can find them.
- Avoid distractions. Turn off the computer, TV, music etc. if your child is trying to do homework.
- Limit choices so your child doesn’t become overwhelmed or distracted.
- Communicate better by using clear, brief directions that are more easily understood.
- Use positive reinforcement to track positive behaviors and then reward your child’s efforts. Remember to set realistic goals–this kind of progress is often measured in very small steps.
- Help your child discover something they are good at so they feel good about themselves. This builds confidence and self esteem.
- Adults with ADHD can also benefit from creating a routine, minimizing distractions, limiting choices, and organizing key materials. A spouse, family member or friend can help them create a system and a plan that works for them.
For most patients with ADHD, medication is a key part of treatment. It is not used to control behavior, but rather to help with the symptoms of ADHD so the person can function more effectively. Among the most common medications used are psychostimulants, which have a long history of proven success. Contrary to their name, these medications do not increase stimulation within the individual, but rather help important networks of nerve cells within the brain communicate more effectively with each other. Between 70 to 80 percent of children with ADHD respond positively to this type of medication. Common drugs in this class are Ritalin, Concerta, Metadate, Focalin, Dexedrine, Adderall, and Vyanse. A non-stimulant treatment that is highly effective in treating ADHD, particularly when associated with aggression and impulsivity, is guanfacine. In twice per day formulation it is called Tenex. In once per day controlled release formulation it is called Intuniv. Another non-stimulant to consider is Strattera.
Medication does not cure ADHD; it alleviates symptoms during the time it is active. Use of medication should be monitored on an ongoing basis, and the dosage may initially need to be adjusted to find the most effective amount and time of day for administration. With children, medication may also need to be adjusted as they grow.
ADHD can be managed, and with the correct treatment, those with the disorder can live happy productive lives.