Attention deficit hyperactivity disorder (ADHD)

ADD; ADHD; Childhood hyperkinesis

Last reviewed: February 22, 2010.

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for a child's age and development.

Causes, incidence, and risk factors

Imaging studies suggest that the brains of children with ADHD are different from those of other children. These children handle neurotransmitters (including dopamine, serotonin, and adrenaline) differently from their peers. ADHD may run in families, but it is not clear exactly what causes it. Whatever the cause may be, it seems to be set in motion early in life as the brain is developing. Depression, lack of sleep, learning disabilities, tic disorders, and behavior problems may be confused with, or appear with, ADHD. Every child suspected of having ADHD should have a careful evaluation to determine what is contributing to the behaviors that are causing concern. ADHD is the most commonly diagnosed behavioral disorder of childhood. It affects about 3 - 5% of school aged children. ADHD is diagnosed much more often in boys than in girls. Most children with ADHD also have at least one other developmental or behavioral problem. They may also have another psychiatric problem, such as depression or bipolar disorder.

Symptoms
The symptoms of ADHD are divided into inattentiveness, and hyperactivity and impulsivity. Some children with ADHD primarily have the inattentive type, some the hyperactive-impulsive type, and some the combined type. Those with the inattentive type are less disruptive and are more likely to miss being diagnosed with ADHD. Inattention symptoms: 1. 2. 3. 4. 5. 6. 7. 8. 9. Fails to give close attention to details or makes careless mistakes in schoolwork Has difficulty sustaining attention in tasks or play Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace Has difficulty organizing tasks and activities Avoids or dislikes tasks that require sustained mental effort (such as schoolwork) Often loses toys, assignments, pencils, books, or tools needed for tasks or activities Is easily distracted Is often forgetful in daily activities

Hyperactivity symptoms: 1. Fidgets with hands or feet or squirms in seat

2. 3. 4. 5.

Leaves seat when remaining seated is expected Runs about or climbs in inappropriate situations Has difficulty playing quietly Is often "on the go," acts as if "driven by a motor," talks excessively

Impulsivity symptoms: 1. 2. 3. Blurts out answers before questions have been completed Has difficulty awaiting turn Interrupts or intrudes on others (butts into conversations or games)

Signs and tests

Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue. The diagnosis is based on very specific symptoms, which must be present in more than one setting. Children should have at least 6 attention symptoms or 6 hyperactivity/impulsivity symptoms, with some symptoms present before age 7. The symptoms must be present for at least 6 months, seen in two or more settings, and not caused by another problem. The symptoms must be severe enough to cause significant difficulties in many settings, including home, school, and in relationships with peers.

In older children, ADHD is in partial remission when they still have symptoms but no longer meet the full definition of the disorder. The child should have an evaluation by a doctor if ADHD is suspected. Evaluation may include: Parent and teacher questionnaires (for example, Connors, Burks) Psychological evaluation of the child AND family, including IQ testing and psychological testing Complete developmental, mental, nutritional, physical, and psychosocial examination

Treatment
The American Academy of Pediatrics has guidelines for treating ADHD: Set specific, appropriate target goals to guide therapy. Start medication and behavior therapy. When treatment has not met the target goals, re-evaluate the original diagnosis, the possible presence of other conditions, and how well the treatment plan has been implemented. Follow-up regularly with the doctor to check on goals, results, and any side effects of medications. During these check-ups, information should be gathered from parents, teachers, and the child.

MEDICATIONS

Children who receive both behavioral treatment and medication often do the best. There are now several different classes of ADHD medications that may be used alone or in combination. Psychostimulants (also known as stimulants) are the most commonly used ADHD drgus. Although these drugs are called stimulants, they actually have a calming effect on people with ADHD. These drugs include: Amphetamine-dextroamphetamine (Adderall) Dexmethylphenidate (Focalin) Dextroamphetamine (Dexedrine, Dextrostat) Lisdexamfetamine (Vyvanse) Methylphenidate (Ritalin, Concerta, Metadate, Daytrana) The Food and Drug Administration (FDA) has approved the nonstimulant drug atomoxetine (Strattera) for use in ADHD. It may be as effective as stimulants, and may be less likely to be misused. Some ADHD medicines have been linked to rare sudden death in children with heart problems. Talk to your doctor about which drug is best for your child. BEHAVIOR THERAPY Both before and after a child is diagnosed, there is stress on the family. Families can experience blame, anger, and frustration. Talk therapy for both the child and family can help everyone overcome these feelings and move forward. Parents should use a system of rewards and consequences to help guide their child's behavior. It is important to learn to handle disruptive behaviors. Support groups can help you connect with others who have similar problems. Other tips to help your child with ADHD include: Communicate regularly with the child's teacher. Keep a consistent daily schedule, including regular times for homework, meals, and outdoor activities. Make changes to the schedule in advance and not at the last moment. Limit distractions in the child's environment. Make sure the child gets a healthy, varied diet, with plenty of fiber and basic nutrients. Make sure the child gets enough sleep. Praise and reward good behavior. Provide clear and consistent rules for the child.

ADHD can be a frustrating problem. Alternative remedies have become popular, including herbs, supplements, and chiropractic manipulation. However, there is little or no solid evidence for many remedies marketed to parents.

Expectations (prognosis)
ADHD is a long-term, chronic condition. If it is not treated appropriately, ADHD may lead to: Drug and alcohol abuse Failure in school Problems keeping a job Trouble with the law

About half of children with ADHD will continue to have troublesome symptoms of inattention or impulsivity as adults. However, adults are often more capable of controlling behavior and masking difficulties.

Calling your health care provider

Call your doctor if you or your child's school personnel suspect ADHD. You should also tell your doctor about any: Difficulties at home, school, and in relationships with peers Medication side effects Signs of depression

Prevention
Although there is no proven way to prevent ADHD, early identification and treatment can prevent many of the problems associated with ADHD.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
Attention deficit hyperactivity disorder (ADHD or AD/HD or ADD) is a neurobehavioral developmental disorder. It is primarily characterized by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone" and symptoms starting before seven years of age.
[3] [1] [2]

ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 percent of children globally a chronic disorder
[7] [4][5]

and diagnosed in about 2 to 16 percent of school aged children.

[6]

It is

with 30 to 50 percent of those individuals diagnosed in childhood continuing to have

[8][9]

symptoms into adulthood.

[11]

Adolescents and adults with ADHD tend to develop coping mechanisms to

[10]

compensate for some or all of their impairments. with ADHD.

It is estimated that 4.7 percent of American adults live

ADHD is diagnosed two to four times more frequently in boys than in girls,

[12][13] [14]

though studies suggest ADHD

this discrepancy may be partially due to subjective bias of referring teachers.

management usually involves some combination of medications, behavior modifications, lifestyle changes, and counseling. Its symptoms can be difficult to differentiate from other disorders, increasing the likelihood that the diagnosis of ADHD will be missed.
[15]

Additionally, most clinicians have not received

[15]

formal training in the assessment and treatment of ADHD, particularly in adult patients.

ADHD and its diagnosis and treatment have been considered controversial since the 1970s.

[16]

The

controversies have involved clinicians, teachers, policymakers, parents and the media. Topics include the actuality of the disorder, its causes, and the use of stimulant medications in its treatment.
[20][21][22] [17][18][19]

Most

healthcare providers accept that ADHD is a genuine disorder with debate in the scientific community centering mainly around how it is diagnosed and treated. The American Medical

Associationconcluded in 1998 that the diagnostic criteria for ADHD are based on extensive research and, if applied appropriately, lead to the diagnosis with high reliability.

assification
ADHD may be seen as one or more continuous traits found normally throughout the general population.
[24]

It is a developmental disorder in which certain traits such as impulse control lag in

[25]

development. Using magnetic resonance imaging of the prefrontal cortex, this developmental lag has been estimated to range from 3 to 5 years. neurological disease.
[24][clarification needed]

A diagnosis of ADHD does not, however, imply a

[26]

ADHD is classified as a disruptive behavior disorder along

with oppositional defiant disorder, conduct disorderand antisocial disorder. ADHD has three subtypes:
[27]

Predominantly hyperactive-impulsive Most symptoms (six or more) are in the hyperactivity-impulsivity categories. Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.

Predominantly inattentive The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree. Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.

Combined hyperactive-impulsive and inattentive Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present. Most children with ADHD have the combined type.

Signs and symptoms

Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. The symptoms of ADHD are especially difficult to define because it is hard to draw the line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin.
[28] [15]

To be

diagnosed with ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.

The symptom categories of ADHD in children yield three potential classifications of ADHD predominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met:
[15]:p.4

Predominantly inattentive type symptoms may include:

[29]

Be easily distracted, miss details, forget things, and frequently switch from one activity to another Have difficulty maintaining focus on one task Become bored with a task after only a few minutes, unless doing something enjoyable Have difficulty focusing attention on organizing and completing a task or learning something new or trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities

Not seem to listen when spoken to Daydream, become easily confused, and move slowly Have difficulty processing information as quickly and accurately as others Struggle to follow instructions.
[29]

Predominantly hyperactive-impulsive type symptoms may include: Fidget and squirm in their seats Talk nonstop

Dash around, touching or playing with anything and everything in sight Have trouble sitting still during dinner, school, and story time Be constantly in motion Have difficulty doing quiet tasks or activities.
[29]

and also these manifestations primarily of impulsivity: Be very impatient

Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences

Have difficulty waiting for things they want or waiting their turns in games

Most people exhibit some of these behaviors, but not to the degree where such behaviors significantly interfere with a person's work, relationships, or studies. The core impairments are consistent even in different cultural contexts.
[30]

Symptoms may persist into adulthood for up to half of children diagnosed with ADHD. Estimating this is difficult as there are no official diagnostic criteria for ADHD in adults.
[15]

ADHD in adults remains a clinical

diagnosis. The signs and symptoms may differ from those during childhood and adolescence due to the adaptive processes and avoidance mechanisms learned during the process of socialisation.
[31]

A 2009 study found that children with ADHD move around a lot because it helps them stay alert enough to complete challenging tasks.
[32]

Comorbid disorders
ADHD may accompany other disorders such as anxiety or depression. Such combinations can greatly complicate diagnosis and treatment. Academic studies and research in private practice suggest that depression in ADHD appears to be increasingly prevalent in children as they get older, with a higher rate of increase in girls than in boys, and to vary in prevalence with the subtype of ADHD. Where a mood disorder complicates ADHD it would be prudent to treat the mood disorder first, but parents of children who have ADHD often wish to have the ADHD treated first, because the response to treatment is quicker.
[33]

Inattention and "hyperactive" behavior are not the only problems in children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it. Many co-existing conditions require other courses of treatment and should be diagnosed separately instead of being grouped in the ADHD diagnosis. Some of the associated conditions are: Oppositional defiant disorder (35%) and conduct disorder (26%) which both are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, or stealing,
[35] [34]

inevitably linking these comorbid disorders withantisocial personality

disorder (ASPD); about half of those with hyperactivity and ODD or CD develop ASPD in adulthood.

Borderline personality disorder, which was according to a study on 120 female psychiatric patients diagnosed and treated for BPD associated with ADHD in 70 percent of those cases.
[36]

Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.
[34]

Mood disorders. Boys diagnosed with the combined subtype have been shown likely to suffer from a mood disorder.
[37]

Bipolar disorder. As many as 25 percent of children with ADHD have bipolar disorder. Children with this combination may demonstrate more aggression and behavioral problems than those with ADHD alone.
[34]

Anxiety disorder, which has been found to be common in girls diagnosed with the inattentive subtype of ADHD.
[38]

Obsessive-compulsive disorder. OCD is believed to share a genetic component with ADHD and shares many of its characteristics.
[34]

Cause
The specific causes of ADHD are not known.
[39]

There are, however, a number of factors that may

contribute to, or exacerbate ADHD. They include genetics, diet and the social and physical environments.

Genetics

PET scan: ADHD brains dopamine transporters

Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases.
[24]

Hyperactivity also seems to be primarily a genetic condition; however, other

[40]

causes do have an effect.

Researchers believe that a large majority of ADHD cases arise from a combination of various genes, many of which affect dopamine transporters. Candidate genes include 2A adrenergic receptor, dopamine transporter, dopamine receptors D2/D3,
[41]

dopamine beta-hydroxylasemonoamine
[42] [43]

oxidase A, catecholamine-methyl transferase, serotonin transporter promoter (SLC6A4), 5HT2A receptor, 5HT1B receptor, of the DRD4 gene,
[43]

the 10-repeat allele of the DAT1 gene,

[44]

the 7-repeat allele

and the dopamine beta hydroxylase gene (DBH TaqI).

A common variant of a
[45]

gene called LPHN3 is estimated to be responsible for about 9% of the incidence of ADHD, and ADHD cases where this gene is present are particularly responsive to stimulant medication.

The broad selection of targets indicates that ADHD does not follow the traditional model of "a simple genetic disease" and should therefore be viewed as a complex interaction among genetic and environmental factors. Even though all these genes might play a role, to date no single gene has been shown to make a major contribution to ADHD.
[46]

Evolutionary theories
See also: Hunter vs. farmer theory The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of ADHD. The theory proposes that hyperactivity may be an adaptive behavior in pre-modern

humans

[47]

and that those with ADHD retain some of the older "hunter" characteristics associated with
[48]

early pre-agricultural human society. According to this theory, individuals with ADHD may be more adept at searching and seeking and less adept at staying put and managing complex tasks over time. Further

evidence showing hyperactivity may be evolutionarily beneficial was put forth in 2006 in a study which found it may carry specific benefits for certain forms of ancient society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk or competition (i.e. hunting, mating rituals, etc.).
[50] [49]

A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele), has been

found to be at higher frequency in more nomadic populations and those with more of a history of migration. Consistent with this, another group of researchers observed that the health status of
[51]

nomadic Ariaal men was higher if they had the ADHD associated genetic variant (7R alleles). However in recently sedentary (non-nomadic) Ariaal those with 7R alleles seemed to have slightly worse health.

Environmental
Twin studies to date have suggested that approximately 9 to 20 percent of the variance in hyperactiveimpulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared environmental (nongenetic) factors.
[52][53][54][55]

Environmental factors implicated include alcohol and tobacco smoke

[56]

exposure during pregnancy and environmental exposure to lead in very early life.
[58]

The relation of
[57]

smoking to ADHD could be due to nicotine causing hypoxia (lack of oxygen) to the fetus in utero. could also be that women with ADHD are more likely to smoke
[60] [59]

It

and therefore, due to the strong genetic Complications during pregnancy and

component of ADHD, are more likely to have children with ADHD. birthincluding premature birthmight also play a role. higher than average rates of head injuries;
[61]

ADHD patients have been observed to have

however, current evidence does not indicate that head

[62]

injuries are the cause of ADHD in the patients observed.

Infections during pregnancy, at birth, and in

[63][64]

early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.

A 2007 study linked the organophosphate insecticide chlorpyrifos, which is used on some fruits and vegetables, with delays in learning rates, reduced physical coordination, and behavioral problems in children, especially ADHD.
[65]

A 2010 study found that pesticide exposure is strongly associated with an increased risk of ADHD in children. Researchers analyzed the levels of organophosphate residues in the urine of more than 1,100 children aged 8 to 15 years old, and found that those with the highest levels of dialkyl phosphates, which are the breakdown products of organophosphate pesticides, also had the highest incidence of ADHD. Overall, they found a 35 percent increase in the odds of developing ADHD with every 10-fold increase in urinary concentration of the pesticide residues. The effect was seen even at the low end of exposure:

children who had any detectable, above-average level of pesticide metabolite in their urine were twice as likely as those with undetectable levels to record symptoms of ADHD.
[66][67]

Diet
Main article: Diet and attention deficit hyperactivity disorder A study
[68]

published in The Lancet in 2007 found a link between childrens ingestion of many commonly

used artificial food colors, the preservative sodium benzoate and hyperactivity. In response to these findings, the British government took prompt action. According to theFood Standards Agency, the food regulatory agency in the UK, food manufacturers are being encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009.
[citation needed]

Following the FSAs actions, the European

Commission ruled that any food products containing the Southampton Six (The contentious colourings are: sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124)) must display warning labels on their packaging by 2010. the US, little has been done
[69] [clarification needed] [citation needed]

In

to curb food manufacturers use of specific food colors, despite

the new evidence presented by the Southampton study. However, the existing US Food Drug and Cosmetic Act had already required that artificial food colors be approved for use, that they must be
[70]

given FD&C numbers by the FDA, and the use of these colors must be indicated on the package. is why food packaging in the USA may state something like: "Contains FD&C Red #40."

This

Social
The World Health Organization states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology.
[71]

Other researchers

believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD.
[72]

Researchers have found behavior typical of ADHD in children who have suffered violence and
[24][73]

emotional abuse.
[75]

Furthermore,Complex Post Traumatic Stress Disorder can result in attention

[74]

problems that can look like ADHD. dysfunction.

ADHD is also considered to be related to sensory integration

A 2010 article by CNN suggests that there is an increased risk for internationally adopted children to develop mental health disorders, such as ADHD and ODD.
[76]

The risk may be related to the length of

time the children spent in an orphanage, especially if they were neglected or abused. Many of these families who adopted the affected children feel overwhelmed and frustrated, since managing their children may entail more responsibilities than originally anticipated. The adoption agencies may be aware of the child's behavioral history, but decide to withhold the information prior to the adoption. This in turn has resulted in some parents suing adoption agencies, the abuse of children, and even the relinquishment of the child.

Neurodiversity
Main article: Neurodiversity Proponents of the neurodiversity theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected just like any other human difference. Social critics argue that while biological factors may play a large role in difficulties with sitting still in class and/or concentrating on schoolwork in some children, these children could have failed to integrate others' social expectations of their behavior for a variety of other reasons.
[77]

As genetic research into ADHD

proceeds, it may become possible to integrate this information with the neurobiology in order to distinguish disability from varieties of normal or even exceptional functioning in people along the same spectrum of attention differences.
[78]

Social construct theory of ADHD

Main article: Social construct theory of ADHD Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Thus society members including physicians, parents, teachers, and others are the ones who determine which diagnostic criteria are applied and thus determine the number of people affected.
[79]

This is exemplified in the fact that the DSM IV arrives at levels of ADHD three to four
[13]

times higher than those obtained with use of the ICD 10.

Thomas Szasz, an extreme proponent of this

[80][81]

theory, has gone so far as to state that ADHD was "invented and not discovered."

Low arousal theory

Main article: Low arousal theory According to the low arousal theory, people with ADHD need excessive activity as self-stimulation because of their state of abnormally lowarousal.
[82][83]

The theory states that those with ADHD cannot self[82] [84]

moderate, and their attention can only be gained by means of environmental stimuli,

which in turn

results in disruption of attentional capacity and an increase in hyperactive behaviour.

Without enough stimulation coming from the environment, an ADHD child will create it him or herself by walking around, fidgeting, talking, etc. This theory also explains why stimulant medications have high success rates and can induce a calming effect at therapeutic dosages among children with ADHD. It establishes a strong link with scientific data that ADHD is connected to abnormalities with the neurochemical dopamine and a powerful link with low-stimulation PET scan results in ADHD subjects.
[82]

Pathophysiology

Diagram of the human brain

The pathophysiology of ADHD is unclear and there are a number of competing theories.

[85]

Research on

children with ADHD has shown a general reduction of brain volume, but with a proportionally greater reduction in the volume of the left-sided prefrontal cortex. These findings suggest that the core ADHD features of inattention, hyperactivity, and impulsivity may reflectfrontal lobe dysfunction, but other brain regions particularly the cerebellum have also been implicated.
[86]

Neuroimaging studies in ADHD have not

[87]

always given consistent results and as of 2008 are only used for research not diagnostic purposes. 2005 review of published studies involving neuroimaging, neuropsychological genetics, and

neurochemistry found converging lines of evidence to suggest that four connected frontostriatal regions play a role in the pathophysiology of ADHD: The lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, and putamen.
[88]

In one study a delay in development of certain brain structures by an average of three years occurred in ADHD elementary school aged patients. The delay was most prominent in thefrontal cortex and temporal lobe, which are believed to be responsible for the ability to control and focus thinking. In contrast, the motor cortexin the ADHD patients was seen to mature faster than normal, suggesting that both slower development of behavioral control and advanced motor development might be required for the fidgetiness that characterizes ADHD.
[89]

It should be noted that stimulant medication itself may affect growth factors
[90]

of the central nervous system.

The same laboratory had previously found involvement of the "7-repeat" variant of the dopamine D4 receptor gene, which accounts for about 30 percent of the genetic risk for ADHD, in unusual thinness of the cortex of the right side of the brain; however, in contrast to other variants of the gene found in ADHD patients, the region normalized in thickness during the teen years in these children, coinciding with clinical improvement.
[91]

Additionally, SPECT scans found people with ADHD to have reduced blood circulation (indicating low neural activity),
[92]

and a significantly higher concentration of dopamine transporters in the striatum which

[93][94]

is in charge of planning ahead.

A study by the U.S. Department of Energys Brookhaven National

Laboratory in collaboration with Mount Sinai School of Medicine in New York suggest that it is not the dopamine transporter levels that indicate ADHD, but the brain's ability to produce neurotransmitters like dopamine itself. The study was done by injecting 20 ADHD subjects and 25 control subjects with a radiotracer that attaches itself to dopamine transporters. The study found that it was not the transporter levels that indicated ADHD, but the dopamine itself. ADHD subjects showed lower levels of dopamine (hypodopaminergia) across the board. They speculated that since ADHD subjects had lower levels of dopamine to begin with, the number of transporters in the brain was not the telling factor. In support of this notion, plasma homovanillic acid, an index of dopamine levels, was found to be inversely related not only to childhood ADHD symptoms in adult psychiatric patients, but to "childhood learning problems" in healthy subjects as well.
[95]

One interpretation of dopamine pathway tracers is that the biochemical

"reward" mechanism works for those with ADHD only when the task performed is inherently motivating; low levels of dopamine raise the threshold at which someone can maintain focus on a task which is otherwise boring.
[96]

Neuroimaging studies also found that neurotransmitters level (e.g. dopamine and
[97][98]

serotonin) in the synaptic cleft goes down during depression.

A 1990 PET scan study by Alan J. Zametkin et al. found that global cerebral glucose metabolism was 8 percent lower in medication-naive adults who had been hyperactive since childhood. found that chronic stimulant treatment had little effect on global glucose metabolism,
[99]

Further studies a 1993 study in

[100]

girls failed to find a decreased global glucose metabolism, but found significant differences in glucose metabolism in 6 specific regions of the brains of ADHD girls as compared to control subjects. The study also found that differences in one specific region of the frontal lobe were statistically correlated with symptom severity.
[101]

A further study in 1997 also failed to find global differences in glucose metabolism,

but similarly found differences in glucose normalization in specific regions of the brain. The 1997 study also noted that their findings were somewhat different than those in the 1993 study, and concluded that sexual maturation may have played a role in this discrepancy.
[103][104][105] [102]

The significance of the research by

Zametkin has not been determined and neither his group nor any other has been able to replicate the 1990 results.

Critics, such as Jonathan Leo and David Cohen, who reject the characterization of ADHD as a disorder, contend that the controls for stimulant medication usage were inadequate in some lobar volumetric studies which makes it impossible to determine whether ADHD itself orpsychotropic medication used to treat ADHD is responsible for the decreased thickness observed
[106]

in certain brain regions. While the

main study in question used age-matched controls, it did not provide information on height and weight of the subjects. These variables it has been argued could account for the regional brain size differences

rather than ADHD itself.

[107]

[107][108]

They believe many neuroimaging studies are oversimplified in both

popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.

Diagnosis
ADHD is diagnosed via a psychiatric assessment; to rule out other potential causes or comorbidities, physical examination, radiological imaging, and laboratory tests may be used.
[109]

In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD-10. If the DSM-IV criteria are used, rather than the ICD-10, a diagnosis of ADHD is 34 times more likely.
[13]

Factors other than those within the DSM or ICD however have been found to
[110]

affect the diagnosis in clinical practice. A child's social and school environment as well as academic pressures at school are likely to be of influence.

Many of the symptoms of ADHD occur from time to time in everyone; in patients with ADHD, the frequency of these symptoms is greater and patients' lives are significantly impaired. Impairment must occur in multiple settings to be classified as ADHD.
[28]

As with many other psychiatric and medical

disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified: 1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months 2. ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 3. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but criterion 1A is not met for the past six months.
[111]

The previously used term ADD expired with the most recent revision of the DSM. Consequently, ADHD is the current nomenclature used to describe the disorder as one distinct disorder which can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD, predominately hyperactiveimpulsive type) or inattention (ADHD predominately inattentive type) or both (ADHD combined type).

DSM-IV
IA. Six or more of the following signs of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: Inattention:

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 2. Often has trouble keeping attention on tasks or play activities. 3. Often does not seem to listen when spoken to directly. 4. 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). 5. Often has trouble organizing activities. 6. 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). 7. Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools). 8. Is often easily distracted. 9. Often forgetful in daily activities. IB. Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: Hyperactivity: 1. Often fidgets with hands or feet or squirms in seat. 2. Often gets up from seat when remaining in seat is expected. 3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). 4. Often has trouble playing or enjoying leisure activities quietly. 5. Is often "on the go" or often acts as if "driven by a motor". 6. Often talks excessively. Impulsiveness: 1. Often blurts out answers before questions have been finished. 2. Often has trouble waiting one's turn. 3. Often interrupts or intrudes on others (example: butts into conversations or games). II. Some signs that cause impairment were present before age 7 years. III. Some impairment from the signs is present in two or more settings (such as at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning. V. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or aPersonality Disorder).
[112]

ICD-10
In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name "Hyperkinetic disorders". When a conduct disorder (as defined by ICD-10
[113]

) is present, the condition

is referred to as "Hyperkinetic conduct disorder". Otherwise the disorder is classified as "Disturbance of Activity and Attention", "Other Hyperkinetic Disorders" or "Hyperkinetic Disorders, Unspecified". The latter is sometimes referred to as, "Hyperkinetic Syndrome".
[113]

Other guidelines
The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria: The use of explicit criteria for the diagnosis using the DSM-IV-TR. The importance of obtaining information about the childs signs in more than one setting. The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning. All three criteria are determined using the patient's history given by the parents, teachers and/or the patient. Adults often continue to be impaired by ADHD. Adults with ADHD are diagnosed under the same criteria, including the stipulation that their signs must have been present prior to the age of seven.
[115] [114]

Adults face some of their greatest challenges in the areas of self[116]

control and self-motivation, as well as executive functioning, usually having more signs of inattention and fewer of hyperactivity or impulsiveness than children do.

The American Academy of Child Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child: The behaviors must appear before age 7.

They must continue for at least six months. The symptoms must also create a real handicap in at least two of the following areas of the childs life: in the classroom, on the playground, at home, in the community, or in social settings.
[117]

If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.
[117]

Differential
To make the diagnosis of ADHD, a number of other possible medical and psychological conditions must be excluded. Medical conditions Medical conditions that must be excluded include: hypothyroidism, anemia, lead poisoning, chronic illness, hearing or vision impairment,substance abuse, medication side effects, sleep impairment and child abuse, others. Sleep conditions As with other psychological and neurological issues, the relationship between ADHD and sleep is complex. In addition to clinical observations, there is substantial empirical evidence from a neuroanatomic standpoint to suggest that there is considerable overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal.
[119] [118]

and cluttering (tachyphemia) among

Primary sleep disorders play a role in the clinical presentation of

symptoms of inattention and behavioral dysregulation. There are multilevel and bidirectional relationships among sleep, neurobehavioral functioning and the clinical syndrome of ADHD.
[120]

Behavioral manifestations of sleepiness in children range from the classic ones (yawning, rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to mood lability and inattentiveness.
[119][121][122]

Many sleep disorders are important causes of

symptoms which may overlap with the cardinal symptoms of ADHD; children with ADHD should be regularly and systematically assessed for sleep problems.
[119][123]

From a clinical standpoint, mechanisms that account for the phenomenon of excessive daytime sleepiness include: Chronic sleep deprivation, that is insufficient sleep for physiologic sleep needs, Fragmented or disrupted sleep, caused by, for example, obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD), Primary clinical disorders of excessive daytime sleepiness, such as narcolepsy and Circadian rhythm disorders, such as delayed sleep phase syndrome (DSPS). A study in the Netherlands compared two groups of unmedicated 6-12-year-olds, all of them with "rigorously diagnosed ADHD". 87 of them had problems getting to sleep, 33 had no sleep problems. The larger group had a significantly later dim light melatonin onset (DLMO) than did the children with no sleep problems.
[124]

Management
Main article: Attention-deficit hyperactivity disorder management Methods of treatment often involve some combination of behavior modification, life-style changes, counseling, and medication. A 2005 study found that medical management and behavioral treatment is the most effective ADHD management strategy, followed by medication alone, and then behavioral treatment.
[126] [125]

While medication has been shown

to improve behavior when taken over the short term, they have not been shown to alter long term outcomes. people.
[127]

Medications have at least some effect in about 80% of

Psychosocial
The evidence is strong for the effectiveness of behavioral treatments in ADHD.
[129] [128]

It is

recommended first line in those who have mild symptoms and in preschool aged children. Psychological therapies used include psychoeducational input, behavior

therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training and parent management training.
[24]

Parent training and education have been found to have short term benefits. therapy has shown to be of little use in the treatment of ADHD,
[131]

[130]

Family

though it may be worth

noting that parents of children with ADHD are more likely to divorce than parents of children without ADHD, particularly when their children are younger than eight years

old.

[132]

Several ADHD specific support groups exist as informational sources and to help

families cope with challenges associated with dealing with ADHD.

Medication

Methylphenidate (Ritalin 10 mg tablets)

Stimulant medication are the medical treatment of choice.

[133]

There are a number of non[133]

stimulant medications, such as atomoxetine, that may be used as alternatives.

There

are no good studies of comparative effectiveness between various medications, and there is a lack of evidence on their effects on academic performance and social behaviors.
[134]

While stimulants and atomoxetine are generally safe, there are side effects
[133]

and contraindications to their use.

Medications are not recommended for preschool

[24][135]

children, as their long-term effects in such young people are unknown.

[136]

There is

very little data on the long-term adverse effects or benefits of stimulants for ADHD. Guidelines on when to use medications vary internationally, with the

UK's National Institute of Clinical Excellence, for example, only recommending use in severe cases, while most United States guidelines recommend medications in nearly all cases.
[137]

Prognosis
Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment.
[138]

In the United States, 37 percent of those with ADHD do not get a high
[139]

school diploma even though many of them will receive special education services.

1995 briefing citing a 1994 book review says the combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish high school. degree
[140]

Also in the US, less than 5 percent of individuals with ADHD get a college compared to 28 percent of the general population.
[142]

[141]

Those with ADHD as

children are at increased risk of a number of adverse life outcomes once they become teenagers. These include a greater risk of auto crashes, injury and higher medical expenses, earlier sexual activity, and teen pregnancy.
[143]

Russell Barkley states that adult

ADHD impairments affect "education, occupation, social relationships, sexual activities, dating and marriage, parenting and offspring psychological morbidity, crime and drug abuse, health and related lifestyles, financial management, or driving. ADHD can be found to produce diverse and serious impairments".
[144]

The proportion of children

meeting the diagnostic criteria for ADHD drops by about 50 percent over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD. cases.
[8] [118][145][146]

ADHD persists into adulthood in about 30 to 50 percent of

[10]

Those affected are likely to develop coping mechanisms as they mature, thus

compensating for their previous ADHD.

Epidemiology

Percent of United States youth 4-17 ever diagnosed with ADHD as of 2007

Percent of United States youth 4-17 ever diagnosed with ADHD as of 2003[147]

ADHD's global prevalence is estimated at 3 to 5 percent in people under the age of 19. There is, however, both geographical and local variability among studies. Geographically, children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East,
[148]

well published studies have found rates of ADHD as low as 2

[149]

percent and as high as 14 percent among school aged children.

The rates of

diagnosis and treatment of ADHD are also much higher on the East Coast of the USA

than on the West Coast.

[150]

The frequency of the diagnosis differs between male children

[151]

(10%) and female children (4%) in the United States.

[152]

This difference between genders

may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.

Rates of ADHD diagnosis and treatment have increased in both the UK and the USA since the 1970s. In the UK an estimated 0.5 per 1,000 children had ADHD in the 1970s, while 3 per 1,000 received ADHD medications in the late 1990s. In the USA in the 1970s 12 per 1,000 children had the diagnosis, while in the late 1990s 34 per 1,000 had the diagnosis and the numbers continue to increase.
[24]

In the UK in 2003 a prevalence of 3.6 percent is reported in male children and less than 1 percent is reported in female children.
[153]

History
Main article: History of attention-deficit hyperactivity disorder Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An Inquiry Into the Nature and Origin of Mental Derangement written in 1798.
[154][155]

The terminology used to describe

[156]

the symptoms of ADHD has gone through many changes over history including: "minimal brain damage", "minimal brain dysfunction" (or disorder), "learning/behavioral

disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood". In the DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced. In 1987 this was changed to ADHD in the DSM-III-R and subsequent editions.
[157] [158]

The use of stimulants to treat ADHD was first described in 1937.

http://en.wikipedia.org/wiki/Attention_deficit_hyperactivity_disorder

What is attention deficit hyperactivity disorder?

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity). 1 ADHD has three subtypes: Predominantly hyperactive-impulsive Most symptoms (six or more) are in the hyperactivity-impulsivity categories. Fewer than six symptoms of inattention are present, although inattention may still be present to some degree. Predominantly inattentive The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivityimpulsivity are present, although hyperactivity-impulsivity may still be present to some degree.

o o o o

o o o

Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD. Combined hyperactive-impulsive and inattentive Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present. Most children have the combined type of ADHD. Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it.

What Causes ADHD?

Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD. Genes. Inherited from our parents, genes are the "blueprints" for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make 2,3 people more likely to develop the disorder. Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments. Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also 4 improved. Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during 5,6 pregnancy and ADHD in children. In addition, preschoolers who are exposed to high levels of lead, which can 7 sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD. Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury. Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities 8 than those who received the sugar substitute. Another study in which children were given higher than average 9 amounts of sugar or sugar substitutes showed similar results. In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical 10 of their behavior, compared to mothers who thought their children received aspartame. Food additives. Recent British research indicates a possible link between consumption of certain food additives like 11 artificial colors or preservatives, and an increase in activity. Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity.

How is ADHD diagnosed?

Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD. ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other children, or seems constantly "out of control." Often, teachers

notice the symptoms first, when a child has trouble following rules, or frequently "spaces out" in the classroom or on the playground. No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment. A family may want to first talk with the child's pediatrician. Some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in childhood mental disorders such as ADHD. The pediatrician or mental health specialist will first try to rule out other possibilities for the symptoms. For example, certain situations, events, or health conditions may cause temporary behaviors in a child that seem like ADHD. Between them, the referring pediatrician and specialist will determine if a child: Is experiencing undetected seizures that could be associated with other medical conditions Has a middle ear infection that is causing hearing problems Has any undetected hearing or vision problems Has any medical problems that affect thinking and behavior Has any learning disabilities Has anxiety or depression, or other psychiatric problems that might cause ADHD-like symptoms Has been affected by a significant and sudden change, such as the death of a family member, a divorce, or parent's job loss. A specialist will also check school and medical records for clues, to see if the child's home or school settings appear unusually stressful or disrupted, and gather information from the child's parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted. The specialist also will ask: Are the behaviors excessive and long-term, and do they affect all aspects of the child's life? Do they happen more often in this child compared with the child's peers? Are the behaviors a continuous problem or a response to a temporary situation? Do the behaviors occur in several settings or only in one place, such as the playground, classroom, or home? The specialist pays close attention to the child's behavior during different situations. Some situations are highly structured, some have less structure. Others would require the child to keep paying attention. Most children with ADHD are better able to control their behaviors in situations where they are getting individual attention and when they are free to focus on enjoyable activities. These types of situations are less important in the assessment. A child also may be evaluated to see how he or she acts in social situations, and may be given tests of intellectual ability and academic achievement to see if he or she has a learning disability. Finally, if after gathering all this information the child meets the criteria for ADHD, he or she will be diagnosed with the disorder.

How is ADHD treated?

Currently available treatments focus on reducing the symptoms of ADHD and improving functioning. Treatments include medication, various types of psychotherapy, education or training, or a combination of treatments.

Medications
The most common type of medication used for treating ADHD is called a "stimulant." Although it may seem unusual to treat ADHD with a medication considered a stimulant, it actually has a calming effect on children with ADHD. Many types of stimulant medications are available. A few other ADHD medications are non-stimulants and work differently than stimulants. For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Medication also may improve physical coordination.

However, a one-size-fits-all approach does not apply for all children with ADHD. What works for one child might not work for another. One child might have side effects with a certain medication, while another child may not. Sometimes several different medications or dosages must be tried before finding one that works for a particular child. Any child taking medications must be monitored closely and carefully by caregivers and doctors. Stimulant medications come in different forms, such as a pill, capsule, liquid, or skin patch. Some medications also come in short-acting, long-acting, or extended release varieties. In each of these varieties, the active ingredient is the same, but it is released differently in the body. Long-acting or extended release forms often allow a child to take the medication just once a day before school, so they don't have to make a daily trip to the school nurse for another dose. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends, too.

What are the side effects of stimulant medications? The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomachaches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered. Decreased appetite. Be sure your child eats healthy meals. If this side effect does not go away, talk to your child's doctor. Also talk to the doctor if you have concerns about your child's growth or weight gain while he or she is taking this medication.

Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose of the medication or a shorteracting form. The doctor might also suggest giving the medication earlier in the day, or stopping the afternoon or evening dose. Adding a prescription for a low dose of an antidepressant or a blood pressure medication called clonidine sometimes helps with sleep problems. A consistent sleep routine that includes relaxing elements like warm milk, soft music, or quiet activities in dim light, may also help.

Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects. Are stimulant medications safe? Under medical supervision, stimulant medications are considered safe. Stimulants do not make children with ADHD feel high, although some kids report feeling slightly different or "funny." Although some parents worry that stimulant medications may lead to substance abuse or dependence, there is little evidence of this.

Do medications cure ADHD? Current medications do not cure ADHD. Rather, they control the symptoms for as long as they are taken. Medications can help a child pay attention and complete schoolwork. It is not clear, however, whether medications can help children learn or improve their academic skills. Adding behavioral therapy, counseling, and practical support can help children with ADHD and their families to better cope with everyday problems. Research funded by the National Institute of Mental Health (NIMH) has shown that medication works best when treatment is regularly monitored by the 12 prescribing doctor and the dose is adjusted based on the child's needs.

Psychotherapy
Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before

acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, and other structured routines can help a child control his or her behavior. Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training. How can parents help? Children with ADHD need guidance and understanding from their parents and teachers to reach their full potential and to succeed in school. Before a child is diagnosed, frustration, blame, and anger may have built up within a family. Parents and children may need special help to overcome bad feelings. Mental health professionals can educate parents about ADHD and how it impacts a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other. Parenting skills training helps parents learn how to use a system of rewards and consequences to change a child's behavior. Parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors they want to discourage. In some cases, the use of "time-outs" may be used when the child's behavior gets out of control. In a time-out, the child is removed from the upsetting situation and sits alone for a short time to calm down. Parents are also encouraged to share a pleasant or relaxing activity with the child, to notice and point out what the child does well, and to praise the child's strengths and abilities. They may also learn to structure situations in more positive ways. For example, they may restrict the number of playmates to one or two, so that their child does not become overstimulated. Or, if the child has trouble completing tasks, parents can help their child divide large tasks into smaller, more manageable steps. Also, parents may benefit from learning stress-management techniques to increase their own ability to deal with frustration, so that they can respond calmly to their child's behavior. Sometimes, the whole family may need therapy. Therapists can help family members find better ways to handle disruptive behaviors and to encourage behavior changes. Finally, support groups help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.

What conditions can coexist with ADHD?

Some children with ADHD also have other illnesses or conditions. For example, they may have one or more of the following:

A learning disability. A child in preschool with a learning disability may have difficulty understanding certain sounds or words or have problems expressing himself or herself in words. A school-aged child may struggle with reading, spelling, writing, and math.

Oppositional defiant disorder. Kids with this condition, in which a child is overly stubborn or rebellious, often argue with adults and refuse to obey rules.

Conduct disorder. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes, or carry or use weapons. These children or teens are also at a higher risk of using illegal substances. Kids with conduct disorder are at risk of getting into trouble at school or with the police.

Anxiety and depression. Treating ADHD may help to decrease anxiety or some forms of depression.

Bipolar disorder. Some children with ADHD may also have this condition in which extreme mood swings go from mania (an extremely high elevated mood) to depression in short periods of time.

Tourette syndrome. Very few children have this brain disorder, but among those who do, many also have ADHD. Some people with Tourette syndrome have nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others clear their throats, snort, or sniff frequently, or bark out words inappropriately. These behaviors can be controlled with medication. ADHD also may coexist with a sleep disorder, bed-wetting, substance abuse, or other disorders or illnesses. For more information on these disorders, visit the NIMH website. Recognizing ADHD symptoms and seeking help early will lead to better outcomes for both affected children and their families.

Do teens with ADHD have special needs?

Most children with ADHD continue to have symptoms as they enter adolescence. Some children, however, are not diagnosed with ADHD until they reach adolescence. This is more common among children with predominantly inattentive symptoms because they are not necessarily disruptive at home or in school. In these children, the disorder becomes more apparent as academic demands increase and responsibilities mount. For all teens, these years are challenging. But for teens with ADHD, these years may be especially difficult. Although hyperactivity tends to decrease as a child ages, teens who continue to be hyperactive may feel restless and try to do too many things at once. They may choose tasks or activities that have a quick payoff, rather than those that take more effort, but provide bigger, delayed rewards. Teens with primarily attention deficits struggle with school and other activities in which they are expected to be more self-reliant. Teens also become more responsible for their own health decisions. When a child with ADHD is young, parents are more likely to be responsible for ensuring that their child maintains treatment. But when the child reaches adolescence, parents have less control, and those with ADHD may have difficulty sticking with treatment. To help them stay healthy and provide needed structure, teens with ADHD should be given rules that are clear and easy to understand. Helping them stay focused and organizedsuch as posting a chart listing household chores and responsibilities with spaces to check off completed itemsalso may help. Teens with or without ADHD want to be independent and try new things, and sometimes they will break rules. If your teen breaks rules, your response should be as calm and matter-of-fact as possible. Punishment should be used only rarely. Teens with ADHD often have trouble controlling their impulsivity and tempers can flare. Sometimes, a short time-out can be calming. If your teen asks for later curfews and use of the car, listen to the request, give reasons for your opinions, and listen to your child's opinion. Rules should be clear once they are set, but communication, negotiation, and compromise are helpful along the way. Maintaining treatments, such as medication and behavioral or family therapy, also can help with managing your teenager's ADHD.

Can adults have ADHD?

Some children with ADHD continue to have it as adults. And many adults who have the disorder don't know it. They may feel that it is impossible to get organized, stick to a job, or remember and keep appointments. Daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD.

These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. Like teens, adults with ADHD may seem restless and may try to do several things at once, most of them unsuccessfully. They also tend to prefer "quick fixes," rather than taking the steps needed to achieve greater rewards. How is ADHD diagnosed in adults? Like children, adults who suspect they have ADHD should be evaluated by a licensed mental health professional. But the professional may need to consider a wider range of symptoms when assessing adults for ADHD because their symptoms tend to be more varied and possibly not as clear cut as symptoms seen in children. To be diagnosed with the condition, an adult must have ADHD symptoms that began in childhood and continued 15 throughout adulthood. Health professionals use certain rating scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health professional also will look at the person's history of childhood behavior and school experiences, and will interview spouses or partners, parents, close friends, and other associates. The person will also undergo a physical exam and various psychological tests. For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had the disorder since childhood, but who have not been diagnosed, may have developed negative feelings about themselves over the years. Receiving a diagnosis allows them to understand the reasons for their problems, and treatment will allow them to deal with their problems more effectively. How is ADHD treated in adults? Much like children with the disorder, adults with ADHD are treated with medication, psychotherapy, or a combination of treatments. Medications. ADHD medications, including extended-release forms, often are prescribed for adults with ADHD, but 16 not all of these medications are approved for adults. However, those not approved for adults still may be prescribed by a doctor on an "off-label" basis. Although not FDA-approved specifically for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. Older antidepressants, called tricyclics, sometimes are used because they, like stimulants, affect the brain chemicals norepinephrine and dopamine. A newer antidepressant, venlafaxine (Effexor), also may be prescribed for its effect on the brain chemical norepinephrine. And in recent clinical trials, the antidepressant 17 bupropion (Wellbutrin), which affects the brain chemical dopamine, showed benefits for adults with ADHD. Adult prescriptions for stimulants and other medications require special considerations. For example, adults often require other medications for physical problems, such as diabetes or high blood pressure, or for anxiety and depression. Some of these medications may interact badly with stimulants. An adult with ADHD should discuss potential medication options with his or her doctor. These and other issues must be taken into account when a medication is prescribed. Education and psychotherapy. A professional counselor or therapist can help an adult with ADHD learn how to organize his or her life with tools such as a large calendar or date book, lists, reminder notes, and by assigning a special place for keys, bills, and paperwork. Large tasks can be broken down into more manageable, smaller steps so that completing each part of the task provides a sense of accomplishment. Psychotherapy, including cognitive behavioral therapy, also can help change one's poor self-image by examining the experiences that produced it. The therapist encourages the adult with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.

What efforts are under way to improve treatment?

This is an exciting time in ADHD research. The expansion of knowledge in genetics, brain imaging, and behavioral research is leading to a better understanding of the causes of the disorder, how to prevent it, and how to develop more effective treatments for all age groups. NIMH has studied ADHD treatments for school-aged children in a large-scale, long-term study called the Multimodal Treatment Study of Children with ADHD (MTA study). NIMH also funded the Preschoolers with ADHD Treatment Study (PATS), which involved more than 300 preschoolers who had been diagnosed with ADHD. The study found that low doses of the stimulant methylphenidate are safe and effective for preschoolers, but the children are more

sensitive to the side effects of the medication, including slower than average growth rates. Therefore, preschoolers 19,20 should be closely monitored while taking ADHD medications. PATS is also looking at the genes of the preschoolers, to see if specific genes affected how the children responded to methylphenidate. Future results may help scientists link variations in genes to differences in how people respond to 21 ADHD medications. For now, the study provides valuable insights into ADHD. Other NIMH-sponsored clinical trials on children and adults with ADHD are under way. In addition, NIMH-sponsored scientists continue to look for the biological basis of ADHD, and how differences in genes and brain structure and function may combine with life experiences to produce the disorder.

18

http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/completeindex.shtml