Attention Deficit Hyperactivity Disorder
(ADHD) Questions and Answers
Q: What is Attention Deficit
Hyperactivity Disorder (ADHD)?
A: ADHD refers to a family of related chronic
neurobiological disorders that interfere with an
individual's capacity to regulate activity level
(hyperactivity), inhibit behavior (impulsivity), and
attend to tasks (inattention) in developmentally
appropriate ways. The core symptoms of ADHD
include an inability to sustain attention and
concentration, developmentally inappropriate levels of
activity, distractibility, and impulsivity.
Children with ADHD have functional impairment across
multiple settings including home, school, and peer
relationships. ADHD has also been shown to have
long-term adverse effects on academic performance,
vocational success, and social-emotional
development.
Children with ADHD experience an inability to sit
still and pay attention in class and the negative
consequences of such behavior. They experience
peer rejection and engage in a broad array of disruptive
behaviors. Their academic and social difficulties
have far-reaching and long-term consequences.
These children have higher injury rates. As they
grow older, children with untreated ADHD, in combination
with conduct disorders, experience drug abuse,
antisocial behavior, and injuries of all sorts.
For many individuals, the impact of ADHD continues into
adulthood.
Q: What are the symptoms of ADHD?
- Inattention. People who are inattentive
have a hard time keeping their mind on one thing and
may get bored with a task after only a few
minutes. Focusing conscious, deliberate
attention to organizing and completing routine tasks
may be difficult.
- Hyperactivity. People who are hyperactive
always seem to be in motion. They can't sit
still; they may dash around or talk incessantly.
Sitting still through a lesson can be an impossible
task. They may roam around the room, squirm in
their seats, wiggle their feet, touch everything, or
noisily tap a pencil. They may also feel
intensely restless.
- Impulsivity. People who are overly
impulsive, seem unable to curb their immediate
reactions or think before they act. As a result,
they may blurt out answers to questions or
inappropriate comments, or run into the street without
looking. Their impulsivity may make it hard for
them to wait for things they want or to take their
turn in games. They may grab a toy from another
child or hit when they are upset.
Q: How is ADHD diagnosed?
A: The diagnosis of ADHD can be made reliably
using well-tested diagnostic interview methods.
Diagnosis is based on history and observable behaviors
in the child's usual settings. Ideally, a health
care practitioner making a diagnosis should include
input from parents and teachers. The key elements
include a thorough history covering the presenting
symptoms, differential diagnosis, possible comorbid
conditions, as well as medical, developmental, school,
psychosocial, and family histories.
It is helpful to determine what precipitated the
request for evaluation and what approaches had been used
in the past. As of yet, there is no independent
test for ADHD. This is not unique to ADHD, but
applies as well to most psychiatric disorders, including
other disabling disorders such as schizophrenia and
autism.
Q: How many children are diagnosed with
ADHD?
A: ADHD is the most commonly diagnosed disorder
of childhood, estimated to affect 3 to 5 percent of
school-age children, and occurring three times more
often in boys than in girls. On average, about one child
in every classroom in the United States needs help for
this disorder.
Q: Aren't there various types of ADHD?
A: According to DSM-IV, the fourth and
most recent edition of the DSM, while most
individuals have symptoms of both inattention and
hyperactivity-impulsivity, there are some individuals in
whom one or another pattern is predominant (for at least
the past 6 months).
Q: How are schools involved in
diagnosing, assessing, and treating ADHD?
A: Physicians and parents should be aware that
schools are federally mandated to perform an appropriate
evaluation if a child is suspected of having a
disability that impairs academic functioning. This
policy was recently strengthened by regulations
implementing the 1997 reauthorization of the Individuals
with Disabilities Act (IDEA), which guarantees
appropriate services and a public education to children
with disabilities from ages 3 to 21.
For the first time, IDEA specifically lists ADHD as a
qualifying condition for special education
services. If the assessment performed by the
school is inadequate or inappropriate, parents may
request that an independent evaluation be conducted at
the school's expense. Furthermore, some children
with ADHD qualify for special education services within
the public schools, under the category of "Other Health
Impaired."
In these cases, the special education teacher, school
psychologist, school administrators, classroom teachers,
along with parents, must assess the child's strengths
and weaknesses and design an Individualized Education
Program. These special education services for
children with ADHD are available though IDEA.
Q: Is ADHD inherited?
A: Research shows that ADHD tends to run in
families, so there are likely to be genetic
influences. Children who have ADHD usually have at
least one close relative who also has ADHD. And at
least one-third of all fathers who had ADHD in their
youth have children with ADHD. Even more
convincing of a possible genetic link is that when one
twin of an identical twin pair has the disorder, the
other is likely to have it too.
Q: Is ADHD on the increase?
If so, why?
A: No one knows for sure whether the prevalence
of ADHD per se has risen, but it is very clear that the
number of children identified with the disorder who
obtain treatment has risen over the past decade.
Some of this increased identification and increased
treatment seeking is due in part to greater media
interest, heightened consumer awareness, and the
availability of effective treatments. A similar
pattern is now being observed in other countries.
Whether the frequency of the disorder itself has risen
remains unknown, and needs to be studied.
Q: Can ADHD be seen in brain scans of
children with the disorder?
A: Neuroimaging research has shown that the
brains of children with ADHD differ fairly consistently
from those of children without the disorder in that
several brain regions and structures (pre-frontal
cortex, striatum, basal ganglia, and cerebellum) tend to
be smaller.
Overall brain size is generally 5% smaller in
affected children than children without ADHD.
While this average difference is observed consistently,
it is too small to be useful in making the diagnosis of
ADHD in a particular individual. In addition,
there appears to be a link between a person's ability to
pay continued attention and measures that reflect brain
activity.
In people with ADHD, the brain areas that control
attention appear to be less active, suggesting that a
lower level of activity in some parts of the brain may
be related to difficulties sustaining attention.
Q: Can a preschool child be diagnosed
with ADHD?
A: The diagnosis of ADHD in the preschool child
is possible, but can be difficult and should be made
cautiously by experts well trained in childhood
neurobehavioral disorders. Developmental problems,
especially language delays, and adjustment problems can
sometimes imitate ADHD. Treatment should focus on
placement in a structured preschool with parent training
and support. Stimulants can reduce oppositional
behavior and improve mother-child interactions, but they
are usually reserved for severe cases or when a child is
unresponsive to environmental or behavioral
interventions.
Q: What is the impact of ADHD on children
and their families?
A: Life can be hard for children with
ADHD. They're the ones who are so often in trouble
at school, can't finish a game, and have trouble making
friends. They may spend agonizing hours each night
struggling to keep their mind on their homework, then
forget to bring it to school. It is not easy
coping with these frustrations day after day for
children or their families. Family conflict can
increase.
In addition, problems with peers and friendships are
often present in children with ADHD. In
adolescence, these children are at increased risk for
motor vehicle accidents, tobacco use, early pregnancy,
and lower educational attainment. When a child
receives a diagnosis of ADHD, parents need to think
carefully about treatment choices.
And when they pursue treatment for their children,
families face high out-of-pocket expenses because
treatment for ADHD and other mental illnesses is often
not covered by insurance policies. School programs
to help children with problems often connected to ADHD
(social skills and behavior training) are not available
in many schools. In addition, not all children
with ADHD qualify for special education services.
All of this leads to children who do not receive proper
and adequate treatment.
To overcome these barriers, parents may want to look
for school-based programs that have a team approach
involving parents, teachers, school psychologists, other
mental health specialists, and physicians.
Q: Aren't there nutritional treatments
for ADHD?
A: Many parents have exhausted nutritional
approaches, such as eliminating sugar from the diet,
before they seek medical attention. However, there
are no well-established nutritional interventions that
have been consistently demonstrated to be efficacious
for assisting the great majority of children with
ADHD. A small body of research has suggested that
some children may benefit from these interventions, but
delaying the implementation of well-established,
effective interventions while engaged in the search for
unknown, generally unproven allergens, is likely to be
harmful for many children.
Q: What are behavioral treatments?
A: There are various forms of behavioral
interventions used for children with ADHD, including
psychotherapy, cognitive-behavioral therapy, social
skills training, support groups, and parent and educator
skills training. An example of very intensive
behavior therapy was used in the NIMH Multimodal
Treatment Study of Children with ADHD (MTA), which
involved the child's teacher, the family, and
participation in an all-day, 8-week summer camp.
The consulting therapist worked with teachers to develop
behavior management strategies that address behavioral
problems interfering with classroom behavior and
academic performance.
A trained classroom aide worked with the child for 12
weeks in his or her classroom, to provide support and
reinforcement for appropriate, on-task behavior.
Parents met with the therapist alone and in small groups
to learn approaches for handling problems at home and
school. The summer day camp was aimed at improving
social behavior, academic work, and sports skills.
Q: What medications are currently being
used to treat ADHD?
A: Psychostimulant medications, including
methylphenidate (Ritalin�) and amphetamines (Dexedrine�,
Dextrostat�, and Adderall�), are by far the most widely
researched and commonly prescribed treatments for
ADHD. Numerous short-term studies have established
the safety and efficacy of stimulants and psychosocial
treatments for alleviating the symptoms of ADHD.
NIMH research has indicated that the two most
effective treatment modalities for elementary school
children with ADHD are a closely monitored medication
treatment and a treatment that combines medication with
intensive behavioral interventions.
In the NIMH Multimodal Treatment Study for Children
with ADHD (MTA), which included nearly 600 elementary
school children across multiple sites, nine out of ten
children improved substantially on one of these
treatments. Additionally, antidepressant
medications may also be used as a second line of
treatments for children who show poor response to
stimulants, who have unacceptable side effects, or who
have comorbid conditions (such as tics, anxiety, or mood
disorders).
Tricyclic antidepressants have shown clinical
efficacy in 60-70% of children with ADHD. While
the medications were extremely beneficial to most
children, MTA findings indicated that medications alone
may not necessarily be the best strategy for many
children. For example, children who had
accompanying problems (e.g., anxiety, stressful home
circumstances, social skills deficits, etc.), over and
above the ADHD symptoms, appeared to obtain maximal
benefit from the combined treatment.
Q: Are there standard doses for these
medications?
A: Careful medication management is important
in treating a child with ADHD. For methylphenidate
(Ritalin�), the usual dosage range is 5 to 20 mg given
two to three times a day. The dose for
amphetamines (Dexedrine� and Dextrostat� and Adderall�)
is one-half the methylphenidate dose. Dosage
requirements do not always correlate with weight, age or
severity of symptoms in an individual patient.
Dosages may need to be increased during childhood with
increased lean body weight and decreases may be
necessary after puberty. Different doctors use
these medications in slightly different ways.
Q: How long are children on these
medications?
A: The expected duration of treatment has
lengthened during this past decade as evidence has
accumulated that benefits extend into adolescence and
adulthood. However, many factors work against
continued treatment during adolescence including the
partial resolution of the most obvious symptoms, the
short-lasting effects of medications that require
multiple doses per day, and the need for regular
physician written prescriptions.
Additionally, parents often discontinue medication
even when benefit has been demonstrated or because they
see the child improve and don't think the medication is
necessary any longer.
Q: How often are stimulant prescriptions
used?
A: Data from 1995 show that physicians treating
children and adolescents wrote six million prescriptions
for stimulant medications?methylphenidate (Ritalin�) and
dextroamphetamine (Dexedrine�). Of all the drugs
used to treat psychiatric disorders in children,
stimulant medications are the most thoroughly studied.
Q: Isn't stimulant use on the increase?
A: Stimulant use in the United States has
increased substantially over the last 25 years. A
recent study saw a 2.5-fold increase in methylphenidate
between 1990 and 1995. This increase appears to be
largely related to an increased duration of treatment,
and more girls, adolescents, adults, and inattentive
individuals (in addition to those individuals with both
hyperactivity and inattentiveness/attention deficit)
receiving treatment.
Q: Are there differences in stimulant use
across racial and ethnic groups?
A: There are significant differences in access
to mental health services between children of different
racial groups; and, consequently, there are differences
in medication use. In particular, African American
children are much less likely than Caucasian children to
receive psychotropic medications, including stimulants,
for treatment of mental disorders.
Q: Why are stimulants used when the
problem is overactivity?
A: The answer to this question is not well
established, but one theory suggests that ADHD is
related to difficulties in inhibiting responses to
internal and external stimuli. Evidence to date
suggests that those areas of the brain thought to be
involved in planning, foresight, weighing of alternative
responses, and inhibiting actions when alternative
solutions might be considered, are underaroused in
persons with ADHD.
Stimulant medication may work on these same areas of
the brain, increasing neural activity to more normal
levels. More research is needed, however, to
firmly establish the mechanisms of action of the
stimulants.
Q: What are the risks of the use of
stimulant medication and other treatments?
A: Stimulant drugs, when used with medical
supervision, are usually considered quite safe.
Although they can be addictive when abused by teenagers
and adults, when taken as prescribed for ADHD these
medications have not been shown to be addictive nor to
lead to substance abuse problems. They seldom make
children "high" or jittery, nor do they sedate the
child. Although little information exists
concerning the long-term effects of psychostimulants,
there is no evidence that careful therapeutic use is
harmful.
When adverse drug reactions do occur, they are
usually related to dosage and are always
reversible. Effects associated with moderate doses
are decreased appetite and insomnia. These effects
occur early in treatment and may decrease with
time. There may be negative effects on growth
rate, but ultimate height appears not to be affected.
Q: Will children taking these medications
for ADHD become drug addicts?
A: Actually, it appears to be just the
opposite. Although an increased risk of drug abuse
and cigarette smoking is associated with childhood ADHD,
this risk appears mostly due to the ADHD condition
itself, rather than its treatment.
In a study jointly funded by the NIMH and the
National Institute on Drug Abuse, boys with ADHD who
were treated with stimulants were significantly less
likely to abuse drugs and alcohol when they got
older. Caution is warranted, nonetheless, as the
overall evidence suggests that persons with ADHD
(particularly untreated ADHD) are indeed at greater risk
for later alcohol or substance abuse. Because some
studies have come to conflicting conclusions, more
research is needed to understand these phenomena.
Regardless, in view of the substantial, well-established
findings of the harmful effects of inadequate or no
treatment for a child with ADHD, parents should not be
dissuaded from seeking effective treatments because of
misconstrued or exaggerated claims about substance abuse
risks.
Q: Wasn't there a large conference held
at NIH on ADHD recently?
A: In 1998, the NIH held a two-day Consensus
Conference on ADHD, bringing together national and
international experts, as well as representatives from
the public. The Consensus statement is now
available at http://odp.od.nih.gov/consensus/cons/110/110_statement.htm
.
Q: What is the relationship between ADHD
and other disorders, such as learning disabilities,
anxiety disorders, bipolar disorder, or depression?
A: Comorbidity occurs in most children
clinically treated for ADHD. ADHD can co-occur
with learning disabilities (15-25%), language disorders
(30-35%), conduct disorder (15-20%), oppositional
defiant disorder (up to 40%), mood disorders (15-20%),
and anxiety disorders (20-25%). Up to 60 percent
of children with tic disorders also have ADHD.
Impairments in memory, cognitive processing, sequencing,
motor skills, social skills, modulation of emotional
response, and response to discipline are common.
Sleep disorders are also more prevalent.
Q: What is the history of ADHD? How is it
related to ADD?
A: ADHD has assumed many aliases over time from
hyperkinesis (the Latin derivative for "superactive") to
hyperactivity in the early 1970s. In the 1980s,
DSM-III dubbed the syndrome Attention Deficit
Disorder, or ADD, which could be diagnosed with or
without hyperactivity. This definition was created
to underline the importance of the inattentiveness or
attention deficit that is often but not always
accompanied by hyperactivity. The revised edition
of DSM-III, the DSM-III-R, published in
1987, returned the emphasis back to the inclusion of
hyperactivity within the diagnosis, with the official
name of ADHD. With the publication of
DSM-IV, the name ADHD still stands, but there are
varying types within this classification, to include
symptoms of both inattention and
hyperactivity-impulsivity, signifying that there are
some individuals in whom one or another pattern is
predominant (for at least the past 6 months).
In the International Classification of
Diseases (used predominantly in other Western
countries), the term "Hyperkinetic Disorder" is used,
but the criteria are the same as for ADHD/combined type.
Q: What are the future research
directions for ADHD?
A: Continued research on ADHD is needed from
many perspectives. The societal impact of ADHD
needs to be determined. Studies in this regard include
(1) strategies for implementing effective medication
management or combination therapies in different schools
and pediatric healthcare systems; (2) the nature and
severity of the impact on adults with ADHD beyond the
age of 20, as well as their families; and (3)
determination of the use of mental health services
related to diagnosis and care of persons with
ADHD. Additional studies are needed to improve
communication across educational and health care
settings to ensure more systematized treatment
strategies.
Basic research is also needed to better define the
behavioral and cognitive components that underpin ADHD,
not just in children with ADHD, but also in unaffected
individuals. This research should include (1)
studies on cognitive development, cognitive and
attentional processing, impulse control, and
attention/inattention; (2) studies of prevention/early
intervention strategies that target known risk factors
that may lead to later ADHD; and (3) brain imaging
studies before the initiation of medication and
following the individual through young adulthood and
middle age. Finally, further research should be
conducted on the comorbid (coexisting) conditions
present in both childhood and adult ADHD, and treatment
implications. Used with permission from NIMH
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