Does your hyperactive and easily distracted child have ADHD? ADHD is a heterogeneous disorder. Symptoms of ADHD and responses to treatments can vary greatly among individuals. With conflicting information on the Internet, confusion abounds. In this article, we will review the latest research and what every parent should know about ADHD.
Table of Contents
What Is ADHD
ADHD stands for Attention Deficit Hyperactivity Disorder. It was formerly called Attention Deficit Disorder (ADD).
ADHD is characterized by excessive inattention, hyperactivity and/or impulsivity. It is commonly diagnosed in school-aged children. It can have lifelong impacts on individuals.
Does Your Hyperactive Child Have ADHD
ADHD a complex disorder. Kids being hyperactive and distracted doesn’t necessarily mean that they have the disorder. Their symptoms have the meet a set of diagnostic criteria and guidelines outlined in the DSM.
ADHD’s roots are traced back to the early twentieth century. It first appeared as a diagnostic category in the 1950s under various names including Minimal Brain Dysfunction (MBD), Hyperactive Syndrome, Hyperkinesis and Hyperactive Disorder of Childhood.
Later, this disorder was renamed and re-conceptualized several times in different versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) to reflect new information and understandings from the latest research:
- DSM-II: Hyperkinetic Reaction of Childhood
- DSM-III: Attention Deficit Disorder, ADD (with and without Hyperactivity)
- DSM-III-R: Attention Deficit/Hyperactivity Disorder, ADHD (ADD without Hyperactivity was eliminated)
- DSM-IV: Attention Deficit/Hyperactivity Disorder, ADHD (with 3 specific subtypes)
- DSM-V (now): Attention Deficit/Hyperactivity Disorder, ADHD (subtype changes)
Previously grouped with other disruptive behavior disorders such as Oppositional Defiant Disorder and Conduct Disorder, ADHD is now recognized and categorized as a Neurodevelopmental Disorder in DSM-V1.
ADHD Symptoms In Kids (DSM-V)
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g. overlooks, or misses details, work is inaccurate).
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines)
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
- Hyperactivity and impulsivity
- Often fidgets with or taps hands or feet or squirms in seat.
- Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
- Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
- Often unable to play or engage in leisure activities quietly.
- Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- Often talks excessively.
- Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
- Often has difficulty waiting his or her turn (e.g., while waiting in line).
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
- For children, at least 6 symptoms from either (or both) of the above two groups of criteria have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on (interfere with or reduce quality the) social and academic/occupational activities.
- For adolescents or adults, at least 5 symptoms have persisted for at least 6 months that negatively impacts directly on (interfere with or reduce quality the) social and academic/occupational activities. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
Types Of ADHD
There are three subtypes of ADHD:
- Combined Presentation: at least 6 symptoms from both inattention and hyperactivity-impulsivity criteria.
- Predominantly Inattentive Presentation: at least 6 symptoms from inattention, but not hyperactivity-impulsivity criteria.
- Predominantly Hyperactive-Impulsive Presentation: at least 6 symptoms from hyperactivity-impulsivity but not inattention criteria.
How Is ADHD Diagnosed In Children
According to the American Academy of Pediatrics (AAP), primary care physicians can initiate an evaluation for any child aged 4 through 18 who shows symptoms of ADHD or behaviors related to ADHD. Physicians should determine if the diagnostic criteria on the DSM-V have been met and document the difficulties the child suffers from. It is recommended to obtain observation information from more than 1 major setting (for example, at home and in school).
Physicians will also assess whether other comorbid conditions might coexist with ADHD, such as emotional disorders (e.g. anxiety, depression), behavioral disorder (e.g. oppositional defiant disorder, conduct disorder), developmental issues (e.g. learning or language disorders) and physical conditions (e.g. tics, sleep apnea).
Special Consideration: Preschool-aged children (4–5 years of age)
Diagnosing preschoolers can be challenging because most young children are inherently active and easily distracted and that is age-appropriate behavior. Therefore, hyperactivity and distraction by themselves are not necessarily signs of ADHD.
If they don’t attend preschools or child care programs, they are also less likely to have a separate observer to confirm the presence of symptoms in multiple environments. Even if they do attend, staff in these programs are also less qualified than certified teachers to provide accurate observations.
When there is doubt regarding the provided observations, physicians may recommend that parents complete a parent-training program before seeking an ADHD diagnosis. Such training programs can help parents develop age-appropriate developmental expectations and specific skills for managing problem behaviors. Instructors in these programs may also have the opportunity to directly observe the child’s functions and symptoms and report the information back to the physicians for further diagnosis.
Over-Diagnosis Of ADHD
Like most psychological disorders, there are no ADHD blood tests that can diagnose the disorder. Psychiatrists, psychologists and psychotherapists can only make judgement based on their own interpretation and understanding of the DSM-V diagnostic criteria.
Although the DSM-V has very specific and clear-cut criteria, over-diagnosis or misdiagnosis can still happen.
A study conducted in Germany illustrates this problem well. 473 psychotherapists specializing in children and adolescents were asked to diagnose a random set of patients based on brief case descriptions. Researchers found that 16.7% of therapists diagnosed ADHD in cases that did not fulfilled the DSM criteria. They also found that boys were 2 times more likely than girls to be diagnosed with ADHD given the same case descriptions for both genders2.
Human makes mistakes. So it’s always wise to get a second (or even multiple) opinion before beginning any major treatment, or when in doubt.
Effects Of ADHD
ADHD can affect all aspect of a child’s life. It can also impact on parents and siblings, disrupting family functioning and parents’ marital relationship.
The adverse effects of ADHD caused by varying aspects of the disorder change throughout the patients’ lives3,4.
During elementary school years, children with ADHD often experience academic failures, rejection by peers, low self esteem, sleep deprivation, stressed parent-child relationships and family functioning disruptions.
When family relationships are severely strained, some may eventually break down causing even more social and financial stresses. When children feel sad, they may show oppositional or aggressive behavior, putting additional stress on the family relationships. Mothers of ADHD child are more likely to suffer from depression and consume more alcohol. Siblings of ADHD child often feel victimized by aggressive acts from their ADHD siblings. Many siblings also feel anxious, worried and sad because they are expected to care for and protect their ADHD brothers or sisters.
ADHD teenagers have more parent-teen conflicts and less friendships than other teenagers. They have a higher risk of dropping out, teenage pregnancy, delinquency, traffic violation such as speeding and being at fault in traffic accidents.
Previously thought to only affect children, ADHD can continue to affect patients into adulthood. As many as 60% of the affected individuals continue to show significant symptoms as adults.
Adults with ADHD are more likely to have interpersonal difficulties with employers and coworkers. They are also more likely to be dismissed from employment. ADHD adults often have difficulties in relationships. If unmedicated, ADHD adults have significantly higher risks of drug abuse. People with ADHD also tend to rake up higher healthcare costs for themselves and their families.
Cause Of ADHD
A Practitioner Review from The Journal Of Child Psychology and Psychiatry summarizes the causes of ADHD as follows.
No single risk factor explains ADHD. Both inherited and noninherited factors contribute and their effects are interdependent5.
So no one knows exactly what causes ADHD, but genetic has been identified to be a substantial component6.
ADHD usually runs in the family. Family, twin, adoption, segregation analysis, and molecular genetic studies show that the heritability rates are high, around 71-90%. Children with ADHD first degree relatives (e.g. parents, siblings) are up to eight times more likely to also have ADHD.
Despite the strong inherited contribution to ADHD, environmental interactions also play a significant role because they can influence how genes are expressed.
Several environmental factors have been identified to be associated with ADHD. Notice the word association. It means the associated factor is more likely to be found in people with ADHD. But since no causal relationships have been established, it may or may not be the cause.
Pregnancy and Birth
During pregnancy, maternal smoking, stress and (to a lesser extent) alcohol consumption are associated with ADHD occurrence. Low birth weight and prematurity are also associated, especially with the inattentive subtype.
But again, these are only associated risk factors. To date, no conclusive studies have been found to prove that these factors can cause ADHD in kids.
Pesticides and toxic industrial products such as PCB are both identified risk factors.
Despite the lack of causal proofs between these factors and the disorder, they are still dangerous and proven to cause other problems, such as memory impairments. So these toxins should be avoided whenever possible.
Lead is a toxin that should be avoided at all costs. Besides its association with ADHD occurrence, lead can cause other severe neurodevelopment damages.
Severe early adversity, low income and deprivation are associated with mental health problems, including ADHD. Similar to other environmental risk factors, no conclusive causal relationships have been found7.
Early Deprivation / Neglect
Children who have been institutionalized early in life, such as orphans in Romania, are 7 times as likely to have ADHD by age 4-5 compared to children who have never been institutionalized8.
Television Viewing And Video Games
Some parents believe that watching too much TV or playing video games can result in ADHD. But after several studies found such associations, several other studies came out and refuted those claims.
The latter researchers did similar experiments or redid previous analysis using the same data. They could not come up with the same conclusion that too much TV time can cause the disorder9.
Further studies are needed to settle this debate. For now, although the results are inconclusive, limiting television viewing in early childhood is still a sensible parenting decision.
The links between ADHD and some nutritional deficiencies (e.g. zinc, magnesium and plyunsaturated fatty acides) are found in some studies but not in others. There is not enough consistent evidence to support the associations10.
Food Color Sensitivities
One study found a mild correlation between food color additives and ADHD. However, when the study was re-analyzed with only FDA approved food colors, the correlation disappeared.
Myth: Does Sugar Make Kids Hyper
Sugar have been blamed by some parents for causing ADHD. Some studies have found that high levels of sugar consumption are associated with increased rates of inappropriate behavior in some children11. However, multiple studies and meta-analysis have shown that sugar does not cause ADHD12,13.
The ADHD Brain
ADHD is a heterogeneous disorder characterized by symptoms of inattention, impulsivity and locomotor hyperactivity.
Inside the brain, the prefrontal cortex (PFC) regulates attention, behavior and emotion. This is why injuries or lesions in PFC can also result in ADHD symptoms.
Researchers have found that the PFCs in people with ADHD are slightly different. They could be different in size, signaling, connectivity, maturity or activities. This could be why ADHD manifests different for everyone and no one treatment is for all14.
How To Treat ADHD
Young children with ADHD are at a significant risk for later oppositional defiant disorder (ODD) and Conduct Disorder (CD). This is one of the biggest concerns for parents of ADHD kids.
Parenting interventions are the first line treatment options in ADHD children. Parents receive training in behavior modification principles such as positive reinforcement to use at home15. The goal is to improve parental understanding of behavioral principles and children’s compliance with parental commands.
Behavioral School Intervention
Similar to parenting intervention, teachers receive training in classroom-based behavioral strategies to improve problematic behavior and academic performance.
Psychotherapies for ADHD children can include training in social skills, anger management and problem solving.
Medication For ADHD – Stimulants
Stimulants have effectively treated many ADHD children and is the most prevalent ADHD medical treatment. Clinical studies have found that therapeutic doses of stimulants can improve PFC functioning and efficiency, reducing ADHD symptoms16.
Parents need to make sure that their child only take the recommended dosage as directed by physicians. Over-consumption of stimulants can impair PFC functions and/or become overaroused.
For parents who have adolescents with newly diagnosed ADHD, before starting any medication treatment, they should work with physicians to assess for symptoms of substance abuse in the adolescents. If substance use is identified, the abuse has to be addressed before medication treatment can begin.
Medication – Non-Stimulants
Stimulants are not for everyone. Some people cannot tolerate treatment with stimulants. There may be negative side effects such as tics, aggressive impulses or drug abuse liability. For those individuals, non-stimulant medicines are another option.
Non-stimulants usually take longer to work. The child may have to take them for a period of time before noticing improvement in symptoms.
Treatment Plans For ADHD In Children
ADHD is an early onset disorder. The latest research shows that up to 60% of ADHD children continue to have ADHD symptoms into adulthood. For these people, it is a chronic condition that needs to be managed throughout life.
It is crucial to select the right treatment approach with the help of a physician. But it also helps to be equipped with information on each treatment option.
Here is a summary of the treatments recommended by the AAP. Recommendations are based on patient’s age17.
Preschool-aged children (4–5 years of age)
For preschool-aged children, the first line of treatment is evidence-based parent-administered (and/or teacher-administered) behavior therapy. If behavioral intervention alone does not provide significant improvement in the child’s functioning, medication may be prescribed.
Elementary school–aged children (6–11 years of age),
For elementary school-aged children, medication and/or behavior therapy is recommended, but a combination of the two is preferable. School environment, program or placement adjustment is also recommended.
For adolescents (12–18 years of age)
For adolescents, medication (with assent of the adolescent) and/or behavior therapy is recommended, but a combination of the two is preferable.
Barriers To Diagnosis And Treatment
One of the reasons often raised by parents as barriers to diagnosis is the fear of mental illness stigma.
ADHD is a neurodevelopmental disorder affecting neurostransmitter circuits. We know that the brain circuits are more flexible in younger brains than in older ones (this flexibility is called the plasticity of the brain)18.
That means the earlier the disorder is diagnosed, the sooner interventions can be provided and the more likely they can interrupt the risk pathways leading to ADHD19,20.
Latest ADHD Research And Controversies
Efficacy Of Non-Pharmacological Interventions
In 2013, Sonuga-Barke and colleagues published a meta-analysis casting a negative light on several types of psychological treatments, including cognitive training, neurofeedback and behavioral interventions.
Researchers found that the various non-pharmacological treatments showed positive effects only when the evaluators were aware of the treatment allocation. But when the evaluators rated blindly without knowing the treatment assignment, no statistically significant effects were found.
This finding is substantial because non-pharmacological treatments are usually recommended first before medications are introduced.
Mindfulness As A Treatment Option
One promising ADHD treatment option is combining mindfulness training with behavioral parenting training.
Some studies show that incorporating mindfulness training can significantly improve attentional processes in children and parenting skills in parents21,22.
Although more studies are needed to confirm the effectiveness in treating ADHD, practicing mindfulness in itself is worth doing because it provides many benefits such as improved self-regulation, positive emotions and general psychological well-being23.
The Diet Factor
Using diets to treat children with ADHD has been a popular and appealing solution since the 1920s. These treatments are controversial because there is not enough empirical evidence supporting their effectiveness24,25. Conclusive results are difficult to obtain because of flaws in the study designs. In addition, children can have different sensitivity and intolerance in food26.
Common dietary interventions include additive-free diet (e.g. artificial flavors and colors), sugar elimination diet, food allergies and sensitivities elimination diet and fatty acid supplementation diet27.
Only by trial-end-error can parents determine if a certain diet is right for their children. But it is important to do this under the guidance of nutritionists to make sure the diet is balanced and meets the needs of your growing child.
Pharmacological Treatment Safety
The first concern of using drugs to treat the disorder is safety.
Safety is a concern with all medications, not just ADHD medications. But since these drugs target the brain’s neurotransitter systems which are far more complex than other organs in our bodies, there is a greater risk of unforeseen problems.
Another concern is the negative side effects such as loss of appetite or developing tics. Abusing stimulants for non-treatment use is another major issue feared by parents.
Because of all these concerns, parents are recommended to start with non-pharmacological treatment before considering adding drugs to it.
However, if non-pharmacological treatment has not been effective or enough, parents have to weight the fear of these potential issues with the benefits gained from using medications. When ADHD goes untreated, the effects can have vast impact on the child’s learning, self-esteem, relationship and quality of life.
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