Kids with Restless Minds
What are the signs that your child may have attention-deficit/hyperactivity
By Richard DAlli, MD and Dennis Clements, MD, PhD, MPH
disorder (ADHD) occurs in 3 to 5 percent of school-age children
-- not only in the United States, but also in every country on every
continent where child behavior has been studied in community settings.
still known by the outmoded term ADD (officially changed to ADHD
in 1994), ADHD is a neurodevelopmental problem that runs in families
and is occasionally associated with disturbances of brain development,
such as birth trauma, substance abuse during pregnancy, autistic
spectrum disorders, and other problems.
usually shows up before first grade and affects children regardless
of their environment. The core problems of inattention, distractibility,
impulsiveness, and hyperactivity, all of which must greatly exceed
age-appropriate behaviors, impair not only school performance, but
also family and social functioning.
ADHD can lead to school failure, substance abuse, and accidents.
ADHD may also be accompanied by temper tantrums, defiance, and other
conduct problems. ADHD persists into adulthood, when some of the
symptoms may be less apparent, but the consequences are more complex.
Not all children with ADHD are hyperactive, and some hyperactive
children with ADHD actually have no trouble paying attention.
other words, ADHD is a spectrum disorder. Mental health professionals
recognize three main types:
very common type marked by combined inattention, distractibility,
impulsiveness, and hyperactivity
-A less common type where inattention and distractibility are the
main problems with little or no hyperactivity
-A relatively rare type where children are impulsive and hyperactive,
but seem to pay reasonably good attention
often say that their child was tested for ADHD. However,
this doesnt mean the child was tested by laboratory methods.
Despite intriguing research and promising claims, there are no reliable
blood, imaging (brain scan), or genetic tests for ADHD available
ADHD is diagnosed clinically, which means that trained professionals
arrive at a diagnosis after carefully considering the childs
history (based on observations of caregivers, teachers, and other
reliable adults), their own direct observations of the child, and,
occasionally, computerized measurements of attention. (Interestingly,
children themselves often cannot tell that anything is wrong.)
clinician then assesses this information using the American Psychiatric
Associations criteria for ADHD and noting other typical ADHD
behaviors not listed in these criteria (such as risk-taking, sloppy
handwriting, boredom, low frustration tolerance, and more). Other
medical conditions, psychiatric illnesses, or learning problems
that might mimic ADHD must also be ruled out.
ADHD is suspected, many parents wonder why their child can sit for
hours playing a video game, or can occasionally complete a creative
project in school, or can finish a homework assignment when an adult
works with them one-on-one.
explanation for these curiosities is that having ADHD does not mean
that a child never pays attention or never sits quietly or resists
impulses, but rather that a child cannot do these things most of
explanation is that the action and excitement of a colorful, noisy
video game can be riveting to a child, sufficient to overcome his
or her deficit of attention. Similarly, one-on-one time with a child
acts as an external force to focus attention. Of course, neither
attractive toys nor one-to-one attention is very practical in an
active family or busy classroom of 25 to 30 children.
Researchers have proven in study after study that three concurrent
treatments work well to reduce the symptoms of ADHD: medication,
school structure, and parent management training.
is the most powerful of these treatments. There are several classes
of medicines that help children with ADHD, but the most effective
by far are the psychostimulants.
are only two basic psychostimulant compounds in use today: methylphenidate
(known by the brand names Ritalin, Concerta, Focalin, Methylin,
Metadate, Daytrana, and others) and amphetamine (known by the brand
names Dexedrine, Adderall, and others).
psychostimulants are among the safest and most well-studied drugs
in psychiatry, and all are approved for use in children by the U.S.
Food and Drug Administration (FDA). They work by improving the function
of attention circuits in the brain, increasing appreciation of reward,
and inhibiting impulsive actions.
managed by an experienced clinician, nearly nine out of every 10
children with correctly diagnosed ADHD will improve on one of the
which psychostimulant and dose will be effective for an individual
child is always a trial, because there is no reliable way to predict
or calculate either one. When the right dose is found, the psychostimulants
take effect very quickly.
is not necessary to give these medications every day, but they will
only be effective the day they are taken. Despite marketing claims
to the contrary, sustained-release psychostimulants are generally
effective for the length of a school day, or perhaps a little longer.
disadvantages of psychostimulants include their time-limited effectiveness,
appetite reduction, occasional insomnia, nausea, headaches, stomachaches,
and, rarely, tics, irritability, or even psychosis. Fortunately,
these side effects disappear immediately when the medication is
FDA has raised concerns about the extremely rare occurrence of death
in adults and children taking a psychostimulant. The best scientific
evidence as of June 2006 indicates that these individuals had structural
defects in their hearts; thus, thoughtful guidelines are being developed
to warn clinicians and patients about the use of psychostimulants
when there is a pre-existing heart condition.
For children who do not respond to a psychostimulant, the relatively
new drug atomoxetine (Strattera) is effective for ADHD and approved
for use in children by the FDA. Strattera is chemically similar
to older antidepressants known as tricyclics (imipramine, desipramine,
the psychostimulants, the appropriate dose of Strattera can be calculated
by knowing the weight of the child. Strattera may take up to a few
weeks before becoming effective and must be taken every day. Its
side effects are very similar to the psychostimulants. Strattera
carries a warning from the FDA about possible changes in mood and
very rare occurrences of liver damage.
neither psychostimulants nor atomoxetine control ADHD symptoms,
bupropion (Wellbutrin), an antidepressant, may be used. It must
be taken daily and may take several weeks before becoming effective.
Common side effects are remarkably similar to the psychostimulants,
but may also include dizziness, agitation, sweating, and dry mouth.
excessive arousal and inability to fall asleep trouble the ADHD
child, two additional medicines -- guanfacine (Tenex) and clonidine
(Catapres) -- may be used. Neither is approved for use in ADHD by
the FDA and both were originally developed to lower blood pressure
in adults. However, very careful study of these medicines in children
has demonstrated their effectiveness in reducing hyperactivity.
Clonidine is sedating and may be helpful at bedtime, while guanfacine,
to a limited extent, may assist in improving attention.
two medications also have unwanted side effects, including drowsiness,
lethargy, and slight reduction in blood pressure.
despite Internet claims, no alternative, complementary, or natural
product or device on the market has ever been shown in well-controlled
tests to effectively reduce the symptoms of ADHD.
Structure and Parent Training
Non-medical treatments are also very important in the comprehensive
treatment of ADHD.
school structure includes seating closer to the teacher or blackboard,
making sure daily planning and homework tracking forms are signed
by teachers and parents, creating behavior contracts, using technological
aids, and, of course, educating teachers about ADHD. Formalized
plans, known as IEPs or 504s, are often put into place by school
counselors to accomplish the same goals.
training, sometimes called contingency management, usually means
helping parents maintain consistent rules at home, teaching them
how to deliver effective commands, and showing them how to reward
desirable behaviors (to reinforce them) and create consequences
for unacceptable behaviors (to reduce their recurrence).
programs often use stickers or other tokens of good behavior to
be traded in by the child for special treats. Supervising homework
time and encouraging relaxing bedtime rituals also play an important
role. Occasionally group therapies designed to help children improve
social skills are helpful.
learn more about ADHD visit the American
Academy of Child and Adolescent Psychiatry (click "Facts
for Families"), the American
Academy of Pediatrics (click " Childrens Health Topics"),
or Children and Adults with Attention-Deficit/Hyperactivity
DAlli, MD, is Chief of the Child Development and Behavioral
Health Division in Duke University's Department of Pediatrics. Dennis
Clements, MD, PhD, MPH, is the chief medical officer of Duke Children's
Hospital. For more information, visit www.dukehealth.org
information presented on this site is intended solely as a general
educational aid, and is neither medical nor healthcare advice for
any individual problem, nor a substitute for medical or other professional
advice and services from a qualified healthcare provider familiar
with your unique circumstances. Always seek the advice of your physician
or other qualified healthcare professional regarding any medical
condition and before starting any new treatment.