ATTENTION DEFICIT HYPERACTIVITY DISORDER
October is Attention Deficit/Hyperactivity Disorder Awareness month. What is ADHD? How is ADHD diagnosed? This week we will learn about ADHD, the symptoms as well as how it is diagnosed. We will learn about treatment options, what other conditions you can see with ADHD. We will also discuss special considerations to take when raising a child with ADHD.
ATTENTION DEFICIT/HYPERACTIVITY DISORDER
Attention Deficit/Hyperactivity Disorder (ADHD) is a neurobiological condition that results in developmentally inappropriate levels of inattention, impulsivity and/or hyperactivity. Children with ADHD are unable to control or direct their focus. They also have a harder time controlling their actions or impulses. There are three types of ADHD. Inattentive type, Hyperactive/Impulsive type, or Combined type. Diagnosis will be based on which symptoms each individual exhibits. Not all individuals exhibit all the symptoms (these will be discussed below.)
ADHD is diagnosed in 9-11% of children aged 2 through 17. It is four times more prevalent in males though ADHD is underdiagnosed in females. Females are more likely to have inattentive type ADHD, more subtle or different symptoms.
ADHD can be diagnosed at any age but are usually diagnosed during early school years. Often, as children enter school it highlights areas that problematic leading for parents and teachers to seek help. Most children are diagnosed before age 12, although females and those individuals with more inattentive type symptoms may delay evaluation and be diagnosed after age 12. Some children are diagnosed later because they use coping techniques or “masking” techniques to help manage their symptoms. They manage their symptoms until some challenge, often academic, arrives that can’t be managed by their coping or masking skills. They can often present with anxiety because they no longer can function as well as before and often do not understand why.
Because children under the age of 5 can be naturally impulsive, very active, and lack attention, ADHD can be difficult to diagnose before preschool and during the preschool years. Diagnosis at this age depends on the intensity of the symptoms and if these symptoms interfere with their life, development, self-esteem and general functioning.
The symptoms of ADHD result in a functional disability. This means the symptoms prevent a person from being successful at school, sports, extracurricular activities and family life. They may have a hard time following rules at home and school. They may struggle with social interactions and reading social or emotional cues in others. They may not have positive interactions with friends and family and may struggle to maintain friendships. They may struggle to manage their environment.
ADHD is considered a chronic condition. This does not mean it is stagnant. A person’s ADHD may change over time as they learn how their brain works and learn strategies to help overcome difficulties. ADHD symptoms may even improve over time. Over 75% of children diagnosis with ADHD will continue to have symptoms that impair their function through adulthood.
There are multiple causes of ADHD. Brain anatomy or functional changes result in ADHD when there is decreased activity in the centers of the brain that control attention. There is also a genetic component with ADHD running in families. A child who is diagnosed with ADHD has a 1 in 4 chance of having a parent diagnosed with ADHD. Often the parent is diagnosed around the time of the child as they learn more about ADHD and see how it may apply to them as well!
Significant head injuries can also result in ADHD especially when the frontal cortex of the brain is damaged. Prematurity as well as prenatal exposure to alcohol, nicotine, or drugs may result in ADHD. Lead poisoning as a child can also result in a diagnosis of ADHD.
ADHD is NOT caused by laziness or lack of motivation. It is also not caused by poor parenting or lack of structure in the home environment.
Symptoms of ADHD can be broken down to symptoms of inattention, hyperactivity, impulsivity. There may also be executive function deficits and emotion-based symptoms.
Symptoms of inattention include:
• Having a hard time paying attention
• Not seeming to listen
• Being easily distracted
• Not paying attention to details
• Making careless mistakes
• Rushing through tasks
• Not following through on tasks
• Not finishing tasks
• Being disorganized
• Losing important items
• Forgetting things or items
• Avoiding activity that requires ongoing mental effort
Hyperactivity may present with a person
• Being in constant motion
• Not being able to stay seated
• Frequent squirming or fidgeting
• Talking too much
• Running/climbing/jumping when not allowed
• Not being able to play quietly
Children may show signs of impulsivity when they
• Frequently act or speak without thinking
• Have trouble taking turns
• Engage in risky behavior (such as running out into the street without looking)
• Are unable to wait for things
• Call out answers before questions are complete
• Frequently interrupt others
Executive function skills are those skills that help the behaviors needed to plan and achieve goals. There are 12 executive function skills that may be affected by ADHD including
• Self-restraint and self-awareness
• Working memory
• Emotion control
• Task initiation
• Time management
• Defining and achieving goals
• Stress tolerance
Many children with ADHD struggle with emotion control and can easily become emotionally dysregulated. They may feel emotions more intensely. They also may have a harder time managing those emotions. They may also be more prone to feelings of rejection, whether real or perceived.
Another symptom you may see in children with ADHD is hyper-focus! High interest subjects or activities may result in the ability to take their focus away from that activity or interest for hours!
There is no single test that can diagnose ADHD. If you suspect your child has ADHD, please speak to your primary care provider. At CHC we have an evaluation packet to for you to fill out about your child. You will also need your child’s teacher to fill out a portion. For a diagnosis of ADHD your child must have symptoms present in 2 or more settings such as home and school. These symptoms must be impacting functioning and relationships and they must be present for longer than 6 months. Your provider will also want to rule out any other causes of your child’s symptoms.
If you are at all questioning learning disabilities or other diagnoses, your child may benefit from Neuropsychological testing which is done by a trained provider such as a psychologist or developmental pediatrician. These tests can help diagnose learning disabilities, mood disorders, ADHD, and developmental disorders.
Comorbid conditions are diagnoses we often see together. ADHD has a number of comorbid conditions. When your child has a comorbid condition, the most disabling condition should be treated first.
People with ADHD can also have a Tic disorder or Tourette syndrome. Tics are repetitive sudden movements that you cannot control. They include blinking eyes, vocal tics such as grunts or coughs, nose twitches, or shoulder shrugs. Over 50-70% of children with ADHD may also have a Tic disorder. Tourette syndrome is a neurological disorder that causes repeated physical movement and vocal outbursts. Over 90% of people with Tourette syndrome also have ADHD.
Other neurological disorders that can be seen with ADHD include autism and learning disabilities.Learning disabilities include reading disorders, mathematic disorders, written expression disorders, non-verbal learning disorders, motor skills disorders, and communication disorders.
MENTAL HEALTH DISORDERS
Mood disorders are also very c0mmon comorbid conditions. Depression including major depression or dysthymic disorder (chronic low-grade depression) and bipolar disorder occur in 18-20% of people with ADHD. Most mood disorders aren’t seen for several years after ADHD diagnosis. Bipolar disorder in children is complex and can often overlap symptoms with ADHD including emotional instability and social problems in addition difficulties with behavior.
Anxiety can also occur in people with ADHD. The rate of this comorbidity is 25%. Anxiety can be present in people with ADHD. And the symptoms of ADHD can cause anxiety in some people when they unsuccessfully try to manage those ADHD symptoms. And coping and masking techniques that help “hide” their diagnosis can result in anxiety as well as perfectionism and people pleasing behaviors.
Oppositional Defiant Disorder or Conduct Disorder can be seen in 35% of people with ADHD. Many symptoms of these behavioral disorders can overlap with those seen with ADHD. Sometimes the symptoms of these behavior disorders improves when the impulsivity of the ADHD is treated.
People with ADHD are more likely to engage in risky behaviors including smoking, drinking alcohol, and using illicit drugs. They are also more likely to experiment at younger ages than kids without ADHD. They are at a greater risk of developing a substance use disorder. Over 50% of people with untreated ADHD also have a substance abuse disorder and 25% of people with ADHD will seek treatment for alcohol or drug addiction at some point Adolescents and young adults with ADHD are twice as likely as the general population, 46% to 24%, to be addicted to nicotine.
A person with ADHD may be more likely to use these substances to self-medicate or to help relieve symptoms. Substance abuse may also be related to impulsive behavior, poor judgement, and problems with social relationships. There may also possibly be a genetic predisposition to abuse substances.
Using a stimulant based medication does NOT increase the risk of substance abuse. Early treatment with stimulant based medication has actually been shown to decrease the risk of substance abuse.
People with ADHD are at increased risk for video game addiction. Video games stimulate the brain and dopamine system, they excite the brain, and provide social connections. Video games are not bad in moderation as they provide exercise for the brain. Boundaries around video game playing or use need to be set and strongly enforced. Children and parents should also find alternative activities that provide the same type of brain stimulation without risk of addiction.
People with ADHD are four times more likely to be obese than people without ADHD. This may be due to brain chemistry. People with ADHD have less dopamine and GABA in their brains. Dopamine increases when eating and low GABA levels result in lower inhibition, meaning it is easier to eat more. ADHD symptoms including poor impulse control make stopping eating or making healthy choices that much harder. Executive function deficits make it harder to plan out healthy meals and an exercise routine thereby making it harder to maintain a healthy lifestyle. Some people with ADHD also avoid tasks by eating instead. The term coined is “procrastin-eating”.
Sleep disorders affect 25-50% of people with ADHD. People with ADHD have short sleep times, problems falling asleep, a higher risk of nightmares, and insomnia. They may also get a burst of energy right at bedtime. The risk of sleep issues increases during adolescence. People with Inattentive-type ADHD are more likely to have problems falling asleep, where people with Hyperactive-Impulsive type are more likely to have insomnia. People with Combined-type and Inattentive-type ADHD both have poor sleep quality. Poor sleep quality and poor sleep duration can make ADHD symptoms worse.
People with ADHD are also more likely to have Circadian Rhythm Sleep Disorder, Sleep-Disordered Breathing (up to 30% of people with ADHD), Restless Leg Syndrome (seen in 50% of people with ADHD), or Narcolepsy (twice as likely).
Treatment of ADHD is multifaceted. A treatment plan should include setting goals or outcomes about relationships, school performance, self-esteem, behavior, and safety.
If your child is diagnosed with ADHD, they may require help in the classroom. Classroom management of ADHD can include
• Frequent progress reports home
• Behavior systems
• Preferential seating placement
• Seating options such as a standing desk or wiggle seat
• Use of small groups
• Movement breaks
• Breaking down tasks or assignments
• Visual cues
• Longer time for test taking
• Special education services
There are laws in the United States to help aid students with disabilities including ADHD. The IDEA part B (Individuals with Disabilities Education Act) covers the cost of evaluating educational needs and providing special educational services if your child qualifies. Section 504 of the Rehabilitation Act of 1973 provides for children who don’t meet the strict qualifying criteria of the IDEA act but need changes in the classroom or modifications to work or homework.
School accommodations are not just for elementary, middle, and high school. They may also be needed in college. Colleges can provide these services for students with ADHD
• Special orientations to identify services/resources
• Specialized academic advisors
• Priority scheduling (picking classes at times of day where they function better)
• Reduced course loads
• Private dorm rooms if quiet is needed for studying
• Academic skills support such as math labs, reading help, writing workshops
• Specialized tutoring
• Personal coaches
• Classroom technologies
• Academic aides such as note takers or homework helpers
• Special testing arrangements
• Support groups
Behavior therapy helps your child manage their behavior and emotions. This therapy may be with a therapist or counselor or be part of a behavior management program. This is the first line therapy used with preschool aged children who are diagnosed with ADHD.
Behavior therapy includes setting goals for behavior and focusing on long term behavioral intervention. It also includes working on strategies to control behaviors as well as regulate emotions. We want to increase positive behaviors and decrease negative behaviors. Behavior therapy should include interventions that are consistent, and disciplines used should have logical and immediate consequences.
Behavior therapy may also include parent training classes. You may need to modify your parenting techniques if you have a child with ADHD and parent training classes can help with this. You may need to make sure to get your child’s attention, maintain eye contact, and use physical contact to sustain their attention when providing directions and behavioral intervention.
Behavior therapy programs can be found here.
Medications are available to treat ADHD. While medications are not necessary for every patient and some patients may not need the medication at certain ages or in certain situations, medications are a first line treatment for many with ADHD. Medications help with school but also help with the ability to be social, maintain relationships, and limit risky behavior.
Medications are prescribed by your primary care provider, psychiatrists, psychiatric nurse practitioners, as well as Developmental Pediatricians and Neurologists. If your child is a prescribed a medication, the prescriber will meet with you frequently at first until you find the right medication and right dose, then periodically to evaluate the effectiveness of the medication and any side effects. Your medication, medication dose, or medication schedule may be changed to help with side effects or effectiveness.
Stimulant medications are the most commonly prescribed ADHD medications and considered best medication for treating ADHD. Multitudes of studies show stimulant medications to be superior to non-stimulant mediations in treating symptoms of ADHD.
These medications can be short acting or long acting. The short-acting medications last around 4 hours where the long-acting medications can last 8-12 hours. Stimulant medications work for short periods of time and do not need to be taken daily or “build up” in your system to work. Therefore, patients have the flexibility of taking weekends or holidays off their medication if needed.
These medications are Schedule II controlled substances. Scheduled II controlled medications are at risk of being abused if used incorrectly. This means they are heavily regulated. We must follow strict rules provided by the Federal Government for prescribing and providing refills for these medications. Because these medications are controlled substances and may be abused, they must be locked up and supervised at all times. They may not be shared with anyone. Teenagers should never be left in charge of their own medication.
Stimulant medications fall into the amphetamine category (Adderall or Vyvanse) or the methylphenidate category (Concerta, Focalin, Quillavant, Ritalin, Daytrana and Journay). Over 80% of all patients will respond to one of these categories of stimulant medications. Dosing for medication is not weight based. There is no test to predict the best dose of medication. Dosing is affected by metabolism and neurochemistry which is individual to each person. “Trial and error” dosing is the only way to find the best dose for your child. A dose is correct if your child is functioning well at school and in relationships. If they take too much medication, they often become slow and “flat” or like a zombie. Other’s on too high of a dose may be revved up or have personality changes.
Side effects of stimulant medication include decreased appetite, weight loss, sleep problems, social withdrawal, rebound effect (moodiness or increased activity as medication wears off), tics, and minor growth delay. Your medication provider will work with you to minimize side effects and maximize the therapeutic effect of the medication.
Non-stimulant medications are used in patients that do not tolerate or do not respond to stimulant medications or patients who have risk factors or pre-existing conditions that prohibit using stimulant medications. These medications are second-line or third-line medications. These medications must be taken daily with no days off. They provide round the clock symptom relief.
Alpha-agonists such as clonidine (Kapvay) or guanfacine (Intuniv) were used to treat high blood pressure but are now approved to treat ADHD. These medications can be useful if your child has a Tic disorder. They also can be helpful if your child has sleep problems or aggression. This medication can be taken in conjunction with a stimulant based medication.
These medications must be swallowed whole and cannot be crushed. Guanfacine is taken once daily, and clonidine is taken twice daily. These medications can take up to 3-4 weeks to see full effect. They must be taken daily and cannot be stopped suddenly, and you cannot take weekend or holiday breaks from medication. Side effects include sleepiness, headaches, fatigue, stomachaches, nausea, dizziness, irritability, and decreased blood pressure. The sleepiness may improve over time.
Strattera is another non-stimulant medication used for children with ADHD. It was developed to treat mood disorders and works like many other mood disorder medications but instead of inhibiting the uptake of serotonin, Strattera inhibits the uptake of another brain neurotransmitter called norepinephrine.
Strattera only works for half the patients who try it. It is only 2/3rds as effective as stimulant based medications. Patients with comorbid depression or anxiety can see some improvement in those symptoms as well as ADHD symptoms. Strattera tends to work better in elementary aged students and is less effective in adolescents and adults. Because it doesn’t work as well as other medications, it is considered a third-line medication. It is a daily medication that can take 6 weeks to notice any effect. It must be taken daily, and you cannot stop the medication suddenly or take days off from the medication.
Side effects of Strattera include decreased appetite, stomach upset, nausea, fatigue, problems sleeping, dizziness, and very rarely jaundice. It should be taken with food to minimize side effects.
It is important to educate yourself, your child and friend and family about ADHD. Children need to know that people with ADHD are just as smart as people without ADHD. They have amazing brains that are creative and imaginative. They are great at problem solving and adapting to new situations. People with ADHD are funny, kind and compassionate to others. They often have to work harder than their peers and they have great perseverance. People with ADHD can use that laser or hyper-focus to their advantage in their career.
If you want to help your child learn about their ADHD, here are some great books for them to read.
BOOKS FOR YOUNGER CHILDREN
BOOKS FOR OLDER CHILDREN/TEENS
Your child may also suffer from low self-esteem due to their ADHD. This may be in relation to academics or relationships. Our goal is to foster connections to help improve their self-esteem. Spend quality time with your child. Also provide your child with unconditional love and support. Parenting a child with ADHD can be hard but being a child with ADHD can be harder. Make sure you know that you support them no matter their diagnosis.
Notice successes and praise small and large successes. Help your child with social skills and encourage friendships. Identify your child’s strengths and help them put these strengths to use in activities or in relationships so they can feel successful.
SPECIAL PARENTING CONSIDERATIONS
Children with ADHD are just like children without ADHD. They have friends, do activities, have homework, hold jobs, learn to drive and have relationships. But sometimes these need to have special considerations to make your child more successful.
Homework can be an issue for children with ADHD. They can forget assignments or items needed to complete homework. You may need to work with their school or teachers to help them organize their work and supplies to get home. Once they are ready to do their homework, you need to evaluate how they work best. Do they need a quiet spot to work? Do they work better at the dining room table? Do they need background noise?
You may also need to work on how to organize homework and studying. One technique that many people with ADHD find helpful to aid with longer task, projects, or study sessions is the Pomodoro technique. This technique helps balance work time and breaks. This diagram below illustrates the Pomodoro technique:
You may also need to consider adding in a short acting medication dose in the afternoon if their long-acting medication has worn off by the time your child is able to do their homework. We see this more commonly in high school and college age students.
Many children attend camps, play sports, or participate in extra-curricular activities. These activities often require the same focus, attention, and behavior that school requires. If your child needs medication for school, they should stay on their medication during these activities. You should also alert their camp, camp counselor, coach, or instructor to their diagnosis and any management techniques that can be helpful. We want your child to have fun and enjoy their activities and this is more likely to happen if we take time to educate their activity leaders about their diagnosis and needs.
Teenagers and young adults will seek employment to learn skills, gain experience, and make money. If your child has ADHD, this can also affect their job. They may be affected by distractibility, impulsivity, hyperactivity, poor memory, boredom, time management difficulties, procrastination, difficulty managing projects, difficulty with paperwork or task requiring details, and difficulty with social interactions.
If your child is having difficulty at work, identify what the problem is and work with them on solutions. They many need to ask their employer for help if they can’t figure out solutions to their challenges. Based on the Rehabilitation Act of 1973, they cannot be discriminated against due to their disability including ADHD. This applies to workplaces with over 15 employees. It includes state and local government jobs as well as places with public accommodations including colleges and private schools. To be eligible for this protection, you must disclose your disability to your employer. Unfortunately, this can also result in discrimination. ADHD experts recommend disclosing your diagnosis only if your performance may be affected by your ADHD but not if you are performing well at your job.
People with ADHD are more likely to have issues at a job if they have no interest or the job is too out of their comfort zone or skill set. Help your child figure out what they are interested in, what their strengths are, what skills they have, and what job fits their personality.
Adolescent and young adult years are times for developing friendships and romantic relationships. These can be challenging for people with ADHD. People with ADHD can hyper-focus on a crush or be too forceful entering into relationships. They can be impulsive in ways that upset their partner. They can have strong emotions or have inconsistent feelings. They may get bored easily. They may misread cues and react very strongly if they are rejected or think they may be rejected. They may over-analyze their partners actions. They may also struggle to communicate their thoughts and feelings.
But, people with ADHD bring a lot of great things to relationships! They bring empathy and thoughtfulness. They can be fun, surprising, and spontaneous. Being honest with their partner about challenges they may have in relationships improves communication and understanding. There are also resources for people with ADHD and their partners including a great YouTube series called How to ADHD.
Having your child learn to drive is frightening to all parents. When your child has ADHD and their symptoms include being distracted, inattention, and increased chance of risk-taking behavior, it is even more frightening.
People with ADHD are twice as likely to have their license suspended. During car tests with teen drivers who have ADHD, they are more likely to have collisions or crashes, are more likely to speed, make more driving errors, exhibit hard braking and sudden decelerations more often, and are noted to have more weaving of the car. On simulation tests the same was seen as well as increased lane swerving, slower reaction times, and more fatigue during driving.
Your teen should understand the risks inherent to driving and the increase in risks that ADHD may cause when driving. They may need medication adjustments, extra training, or limits set on driving. You will need to make sure distractions are reduced or eliminated as much as possible in the car. There are also driving education programs that focus on people with ADHD.
As our children prepare to enter adulthood, go to college, enter the workforce, and move into their own place, we must prepare them for this independence. Teaching your child how to do tasks required for daily living including managing money and a household can increase their success in making the transition to independent living. Work with your child to figure out strategies that will help including using planners, making lists, keeping a routine, using automatic bill pay and learning how to organize in a way that makes sense to them. Also discuss health goals including nutrition and getting enough sleep and the importance of these in managing their ADHD..
BOOKS FOR PARENTS
Stop, Breath, Think is a mindfulness appl that helps with emotional regulation
Conversation Planner has over 130 scenarios that kids can practice to improve their social skills
Remember the Milk is an app that lists tasks, subtasks and provides reminders
Brain Focus is a Pomodoro method timer that helps with focus and task performance
Clear Lock (android), Freedom (iOS), Time Out (Mac), and Stay Focus (Chrome) are apps that provide scheduled locks on browsers and social media to increase focus.
Visual Schedule and Social Story helps with social skills and visual timetables.
Google is used in schools. Google Calendar can integrate school and home schedules, provide reminders, and schedule tasks.
If you suspect your child has ADHD, please do not hesitate to discuss your concern with your child’s primary care provider. Based on this discussion, we can begin the evaluation process.
Children’s Health Care of Newburyport, Massachusetts, and Haverhill, Massachusetts is a pediatric healthcare practice providing care for families across the North Shore, Merrimack Valley, southern New Hampshire, and the Seacoast regions. The Children’s Health Care team includes pediatricians and pediatric nurse practitioners who provide comprehensive pediatric health care for children, including newborns, toddlers, school-aged children, adolescents, and young adults. Our child-centered and family-focused approach covers preventative and urgent care, immunizations, and specialist referrals. Our services include an on-site pediatric nutritionist, special needs care coordinator, and social workers. We also have walk-in appointments available at all of our locations for acute sick visits. Please visit chcmass.com where you will find information about our pediatric doctors, nurse practitioners, as well as our hours and services.
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.