Attention deficit hyperactivity disorder - InDepth

An in-depth report on the causes, diagnosis, treatment, and prevention of ADHD.

Highlights

ADHD Definition

Attention deficit hyperactivity disorder (ADHD) is a long-term (chronic) disorder of inattention with or without hyperactivity and impulsivity.

ADHD Guidelines

The American Academy of Pediatrics (AAP) has guidelines for the diagnosis and treatment of ADHD in children. Their recommendations include:

• ADHD should be recognized and treated as a chronic illness that can last through adolescence and into adulthood.
• Children as young as 4 years old and as old as 18 years old can be diagnosed with ADHD.
• ADHD should be diagnosed based on behavioral problems that occur both at home and at school. Symptoms should have lasted for at least 6 months for older children, and at least 9 months for preschoolers (children ages 4 to 5 years old).
• For preschoolers, behavioral therapy should be the first treatment. If behavioral methods don't work, the stimulant drug methylphenidate (Ritalin, generic) may be prescribed in some cases. For older children, a combination of medication and behavioral therapy is recommended.

ADHD Drugs and Heart Risks

All ADHD stimulant drugs, and atomoxetine (Strattera), have warnings on their prescription labels that they should not be used by people with structural heart problems or pre-existing heart conditions (high blood pressure, heart failure, heart rhythm disturbances, or congenital heart disease). Methylphenidate (Ritalin, generic) is the most commonly prescribed stimulant drug for treating ADHD.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by the following symptoms:

• Inattention.

  Wandering off task, having difficulty maintaining focus, being disorganized.

• Hyperactivity.

  Excessive running about, fidgeting, tapping, or talking.

• Impulsivity.

  Hasty actions, often for immediate reward or gratification, which occur spontaneously, without thinking about the consequences.

ADHD is usually diagnosed during childhood and often persists into adulthood. It is the most commonly diagnosed behavioral disorder in children and can cause significant problems with home, school, and social interaction. In adult years, ADHD can adversely affect job performance and increase the risk for substance abuse and other mental health problems.

Types of ADHD

ADHD is classified into three types:

• Predominantly Hyperactive-Impulsive Type.

  Behavior marked by hyperactivity and impulsivity, but not inattentiveness.

• Predominantly Inattentive Type.

  Behavior marked by inattentiveness, but not hyperactivity and impulsivity.

• Combination Type.

  A combination of hyperactivity/impulsivity and inattentive symptoms. This is the most common type of ADHD.

Childhood ADHD

In the United States, more than 6 million children under age 18 years have been diagnosed with ADHD at some time in their lives, usually during the grade school years. This accounts for about 9% of all American children in this age range.

Symptoms of ADHD typically become apparent at a young age. According to the American Academy of Pediatrics (AAP), ADHD symptoms can first emerge in children as young as age 4 years. To meet the American Psychiatric Association's criteria for ADHD, symptoms must have started before age 12 years. (See Symptoms and Diagnosis sections of this report.)

In young preschool children, hyperactivity may be the initial sign of ADHD. As the child enters grade school, attention problems become more noticeable. During adolescence, hyperactivity usually diminishes, but issues with impulse control and inattention persist. Adolescents with ADHD often have problems with restlessness, and difficulty making and carrying out plans.

Adult ADHD

ADHD is a long-term (chronic) condition that begins in childhood and often persists into adulthood. Adult ADHD is a continuation of childhood ADHD symptoms. Some people with ADHD may be diagnosed when they are adults, but this condition never initially develops in adulthood. Studies estimate that around 4% of adults may have ADHD.

Adults and adolescents who have ADHD often have problems with inattention, impulsivity, and restlessness. They struggle with planning, organization, distractions, and difficulty prioritizing and completing tasks. These impairments can cause significant problems with employment, marital relationships, and financial affairs, and increase the risk for physical injuries.

Accompanying Mental Health Disorders

People with ADHD are at increased risk for also having:

• Oppositional defiant disorder.

  Characterized by persistent angry and irritable mood, and argumentative and defiant behavior. It very commonly occurs in children with ADHD.

• Conduct disorders.

  A complex group of behavioral and emotional disturbances that include aggression toward people and animals, destruction of property, deceitfulness, and stealing, and serious violation of rules.

• Disruptive mood dysregulation disorder (DMDD).

  Characterized by persistent irritability, angry mood, and frequent and explosive temper outbursts that far exceed normal "temper tantrums." While many children with DMDD also have ADHD, fewer children with ADHD have DMDD.

• Learning disorders.

  Impairments in ability to perceive and process information that affect a child's ability to gain fundamental skills in reading, writing, and mathematics.

• Anxiety disorders and depression.

  Occur more often in people with ADHD than the general population. People with ADHD may also have an increased risk for substance abuse problems with drugs and alcohol. Abuse with medications used to treat ADHD is also a concern.

Causes

Doctors are not exactly sure what causes ADHD. Most likely a combination of genetics, biological factors, and environmental factors plays a role in the development of the condition.

Brain Structure

Research using advanced imaging techniques shows there is a difference in the size of certain parts of the brain in children with ADHD compared to children who do not have ADHD. The areas showing change include the prefrontal cortex, the caudate nucleus and globus pallidus, and the cerebellum.

Brain Chemicals

Abnormal activity of certain brain chemicals may contribute to ADHD. The chemicals dopamine, serotonin, and norepinephrine are of special interest. They are neurotransmitters (chemical messengers in the brain) that affect both mental and emotional functioning.

Genetic Factors

Genetic factors most likely play some role in ADHD. Twin and other family studies show that the relatives of children with ADHD (both boys and girls) have much higher rates of ADHD and related disorders than the families of non-ADHD children.

Most of the research on the underlying genetic mechanisms target genetic pathways associated with the neurotransmitter dopamine. Variations in genes that regulate specific dopamine receptors have been identified in a high proportion of people with ADHD.

Risk Factors

Gender and ADHD

ADHD is diagnosed more often in boys than in girls. Boys are more likely to have the combined type of ADHD. Girls are more likely to have the predominantly inattentive type.

Family History

ADHD tends to run in families. A child who has a parent or sibling with ADHD has an increased risk of also developing ADHD.

Environmental Factors

Research suggests that maternal alcohol use, drug abuse, and cigarette smoking during pregnancy may lead to the development of ADHD in the child. Low birth weight has also been possibly linked to ADHD. Environmental lead exposure before age 6 years may also raise the risk for ADHD.

Dietary Factors

Several dietary factors have been researched in association with ADHD, including sensitivities to certain food chemicals, deficiencies in fatty acids (compounds that make up fats and oils) and zinc, and sensitivity to sugar. No clear evidence has emerged, however, that implicates any of these nutritional factors as risk factors for developing ADHD.

Complications

ADHD can pose challenges for people and their families.

Social Problems

ADHD can affect children's relationships with their peers. Children with ADHD can have difficulty with social skills and appropriate behavior, which can lead to bullying (both as victim and perpetrator) and rejection. Impulsivity and aggression can provoke fights and volatile relationships. Within the family, the time and attention needed to deal with a child with ADHD can place stress on internal family relationships and create conflicts with parents and siblings.

Risk of Injury

Impulsivity in young people with ADHD can cause them to take chances without considering the consequences. Children with ADHD are at increased risk for accidents and injuries. For example, a child with ADHD may not check for oncoming traffic when running into the street or may engage in high-risk physical activities. Adults and adolescents with ADHD are at a higher risk for driving recklessly and have more frequent traffic accidents than peers without the disorder.

Substance Abuse

Many studies report that young people with ADHD have a higher than average risk for substance abuse and that it starts at younger ages. The risk is particularly high for people who also have a conduct or mood disorder in addition to ADHD. Biologic factors associated with ADHD may make these individuals susceptible to substance abuse. Many of these young people may actually be self-medicating their condition.

Learning Problems

Children with ADHD encounter significant problems at school. Low academic achievement can affect a child's self-esteem and self-confidence, and contribute to teasing and other social problems with peers.

Experts recommend that children with ADHD also get screened for learning disorders. Although speech and learning disorders are common in children with ADHD, the disorder does not affect intelligence. People with ADHD span the same IQ range as the general population.

Problems in Adulthood

ADHD is very often a chronic condition. According to the American Academy of Child and Adolescent Psychiatry, about 30% to 65% of children with ADHD continue to experience symptoms through adolescence and into adulthood. ADHD can cause many problems in adulthood including impaired physical and mental health, poor work performance, and financial stress.

Symptoms

Symptoms for ADHD are classified as either "inattention" or "hyperactivity and impulsivity."

Childhood ADHD Symptoms

A diagnosis of ADHD in children requires 6 or more symptoms that have persisted for at least 6 months. Symptoms typically appear before age 12 years, and they can be observed both at home and at school.

Symptoms of inattention in children include:

• Often fails to give close attention to detail or makes careless mistakes
• Often has difficulty sustaining attention in tasks or play
• Often does not seem to listen when spoken to directly
• Often does not follow through and fails to finish tasks
• Often has difficulty organizing tasks and activities
• Often avoids or dislikes tasks requiring sustained mental effort
• Often loses things necessary for tasks or activities
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

Symptoms of hyperactivity and impulsivity in children include:

• Often fidgets, squirms, or taps when sitting
• Often has difficulty remaining seated when required to do so
• Often runs about or climbs in inappropriate situations
• Has difficulty playing quietly
• Is often "on the go" and is unable to sit still for extended periods
• Often talks excessively
• Often blurts out answers to questions before they have been completed
• Has difficulty waiting for his or her turn
• Often interrupts or intrudes on others

Based on these symptoms, a child may be diagnosed with predominantly inattentive type ADHD, predominantly hyperactive-impulsive type ADHD, or combination type ADHD.

Adult ADHD Symptoms

In adults, ADHD symptoms can affect many dimensions of work and personal life. For adults and adolescents, a minimum of 5 symptoms are required for a diagnosis of ADHD.

Symptoms of inattention in adults may include:

• Making careless mistakes at work
• Overlooking important details
• Being unable to stay focused during lectures or lengthy readings
• Becoming easily sidetracked -- starts a task but can't finish it
• Having a messy or disorganized desk
• Poor time management skills, inability to meet deadlines
• Reluctance to prepare reports or complete forms or other tasks that require sustained mental effort
• Often losing things (phones, keys, paperwork, glasses)
• Forgetting to pay bills, keep appointments, return phone calls

Symptoms of hyperactivity and impulsivity in adults may include:

• Leaving the office or other place where seating is required
• Unable to sit quietly in meetings
• Talking excessively and interrupting people
• Intruding into people's conversations or personal space
• Using people's things without asking for permission
• Engaging in fast-paced, often risky behavior (driving recklessly)
• Making rash decisions without considering the outcome (leaving or changing jobs or relationships abruptly)

Diagnosis

Diagnosing ADHD in Children

There is no single test to diagnose ADHD. The doctor will do a physical exam of the child to make sure that no underlying condition, such as a hearing or vision problem, is causing ADHD-like symptoms. Still, a diagnosis of ADHD is based primarily on observations and reports of a child's behavior patterns. Your child's pediatrician may also refer you to a mental health professional who is experienced in childhood disorders such as ADHD.

The doctor will ask for a detailed history of the child's behavior. Parents should describe specific problems encountered during the child's development, family history of ADHD, and any recent life changes that may have affected the child. The doctor will inquire about your child's behavior at school and other settings outside the home. Written reports from teachers, school counselors, or other caretakers involved with the child provide additional important observations.

A physical exam should include a hearing and vision test to rule out any hearing and vision problems. The doctor will inquire about history of other medical problems, including allergies, sleep disturbances, poor vision, or chronic ear infections.

The American Psychiatric Association (APA) has specific criteria that must be met for a diagnosis of ADHD. These symptoms should have started before age 12 and have occurred in more than one major setting (such as home and school). They should not be due to a learning disability or another mental health disorder (such as bipolar disorder, depression, anxiety, schizophrenia, or substance abuse). The symptoms must significantly impair the child's ability to function in academic or social settings. These diagnostic criteria evaluate symptoms in comparison to what is considered normal for a child's developmental level.

For a childhood diagnosis of ADHD, at least 6 symptoms of inattention or hyperactivity and impulsivity should have been present for at least 6 months. (See Symptoms section of this report.)

A psychiatrist or other mental health professional may also evaluate the child for an accompanying mental health condition such as a learning disorder, oppositional defiant disorder, conduct disorder, or anxiety or depression.

A device measuring brain waves has been approved by the FDA as a tool to diagnosing ADHD. However, due to the low quality of these studies, the ability of this device to improve on the diagnosis of this disorder over clinical assessment by a trained provider has not been proven.

Diagnosing ADHD in Adults

Childhood ADHD can affect children ages 4 to 18 years. ADHD in adults always occurs as a continuation of childhood ADHD. Symptoms that begin in adulthood are due to factors other than ADHD.

ADHD in adults can be difficult to diagnose. The doctor will inquire about childhood history of ADHD or ADHD-type symptoms. The person may be asked to provide school records or information from parents or former teachers.

The same diagnostic criteria are used for adult ADHD and childhood ADHD. The only difference is that a diagnosis of adult or adolescent ADHD requires at least 5 symptoms instead of 6.

Treatment

ADHD is considered a chronic condition, like asthma or diabetes, which requires long-term, ongoing monitoring of symptoms and adjustments of medications and other treatment programs. Although symptoms may lessen over time, ADHD does not usually "go away." People can, however, learn how to control their condition through behavioral techniques, often supported by medication.

Treatment for ADHD does not cure the condition but focuses on controlling symptoms and improving functioning. Treatment typically includes a combination of behavioral therapy and a psychostimulant medication, most commonly methylphenidate (Ritalin, generic) or amphetamine-dextroamphetamine (Adderall). Treatment often involves a team approach that includes the child's pediatrician, other health professionals, parents, and teachers.

The AAP recommends that children with ADHD be treated according to the following age groups:

• Preschool children (ages 4 to 5 years old) should be treated first with behavior therapy provided by parents and teachers. For many children, behavioral therapy alone will produce significant improvement. If further treatment is needed, and benefits appear to outweigh the risks, a doctor may prescribe the stimulant methylphenidate (Ritalin, generic)
• Elementary school-aged children (ages 6 to 11 years old) should be treated with a combination of a stimulant medication and behavior therapy. Alternatives to stimulant medication, in order of recommendation, are atomoxetine (Strattera), guanfacine (Tenex, generic), or clonidine (Catapres, generic).
• Adolescents (ages 12 to 18 years old) should be treated with medication, and behavior therapy if necessary. Some people in this age range may be able to take a "drug holiday" by temporarily stopping medications. The doctor should closely monitor the child during this time. Adolescents may also need to have their medications or dosages adjusted as their bodies change through puberty.

As with children, adults with ADHD are treated with a combination of medication and therapy. For medication, stimulant drugs or the non-stimulant drug atomoxetine (Strattera) are usually first-line treatments, with antidepressants a secondary option. Most stimulant drugs, as well as atomoxetine, are approved for adults with ADHD.

Adults who have heart problems or heart condition risk factors should be aware of the cardiovascular risks associated with ADHD medication. There have been ADHD medication-associated incidents of sudden death in people with underlying serious heart problems, and reports of stroke and heart attack in adults with cardiac risk factors.

Medications

Several types of medication are used to treat ADHD.

Psychostimulants: Methylphenidate (Ritalin) and Similar Drugs

Psychostimulants are the primary drugs used to treat ADHD. Although these drugs stimulate the central nervous system, they have a calming effect on people with ADHD.

These drugs include:

• Methylphenidate (Ritalin, Concerta, Daytrana, Metadate, Methylin, Quillivant, generic)
• Dexmethylphenidate (Focalin, generic)
• Amphetamine-Dextroamphetamine (Adderall, generic)
• Dextroamphetamine (Dexedrine, Dextrostat, generic)
• Lisdexamfetamine (Vyvanse)

Methylphenidate drugs (Ritalin, Concerta, Daytrana, Metadate, Methylin, Quillivant XR, and generic versions) are the most commonly used psychostimulants for treating ADHD in both children and adults. Dexmethylphenidate (Focalin, generic) is a similar drug. These drugs increase dopamine, a neurotransmitter important for cognitive functions such as attention and focus.

With the exception of Daytrana and Quillivant XR, all of these drugs are pills taken by mouth. Daytrana is a skin patch drug for ADHD. A patch is applied to the hip each day and delivers a 9-hour dose of methylphenidate. Quillivant is a liquid form of methylphenidate that is approved for people age 6 years and older who may have difficulty swallowing pills.

These drugs are available in short-acting and long-acting dosage forms. The short-acting forms need to be taken several times a day, including during school hours. As the drug wears off, a rebound effect can occur, and ADHD symptoms can intensify. For this reason, the long-acting dosage forms have become popular.

Amphetamine-dextroamphetamine (Adderall, generic), dextroamphetamine (Dexedrine, Dextrostat, generic), and lisdexamfetamine (Vyvanse) work by blocking the reabsorption of the brain chemicals dopamine and norepinephrine.

Decreased appetite, stomach pain, headaches, and sleeplessness are the most common side effects of stimulant drugs. Tics or jerky movements develop in a small percentage of children, but this side effect usually goes away when the dosage is lowered.

Stimulant drugs may also:

• Worsen behavior and thought disturbance in people with a pre-existing psychotic disorder. These drugs may also slightly increase the risk for auditory hallucinations, paranoia, and psychotic and manic behavior even in people who do not have a history of psychiatric problems.
• Cause a mixed or manic episode in people who have both ADHD and bipolar disorder.
• Increase aggressive behavior or hostility. People beginning stimulant drug treatment should be monitored for worsening of these behaviors.
• Reduce growth and weight gain in children, and weight loss in adults. Children who take stimulant drugs should have their growth monitored. If they do not gain height or weight at a normal rate, they may need to stop taking the drug.
• In rare cases, methylphenidate drugs can cause painful and long-lasting erections (priapism) even in young children. People who experience erections lasting longer than 4 hours should seek immediate medical attention to prevent permanent damage to the penis.

All ADHD stimulant drugs carry warnings that they should not be used by people with structural heart problems or pre-existing heart conditions (high blood pressure, heart failure, heart rhythm disturbances, or congenital heart disease). These drugs have been associated with sudden death in children with heart problems. They have also been associated with sudden death, stroke, and heart attack in adults with a history of heart disease. According to recent large studies, these medications appear to be safe for children and adults who do not have underlying heart disease.

Symptoms of overdose include changes in heart rhythm and rate, hypertension, confusion, breathing difficulties, sweating, vomiting, and muscle twitches. If they occur, parents should immediately call the doctor.

Stimulant drugs can be habit forming, but they are not considered addictive, particularly when they are taken as prescribed in the doses used for treating ADHD. The primary danger for drug abuse from stimulants appears to occur in young people without ADHD who purchase and use these drugs illegally. If a child abuses another drug (alcohol, prescription medication) along with the ADHD medication, the chance for serious side effects is increased.

Non-Stimulant: Atomoxetine

Atomoxetine (Strattera) was the first non-stimulant approved for ADHD in children and the first treatment approved for adult ADHD. The drug works by increasing levels of both norepinephrine and dopamine, which are generally lower than normal in ADHD. The most common side effects are drowsiness, decreased appetite, and upset stomach.

A few cases of atomoxetine-associated liver injury have been reported, and the FDA warns that the drug should be discontinued at the first signs of jaundice (yellowing of skin and eyes) and liver problems. Long-term effects, such as any impact on growth, are still unknown. Although rare, atomoxetine poses an even greater risk than methylphenidate for severe, long-lasting erections (priapism).

Atomoxetine may cause suicidal thinking in children and adolescents, particularly during the first few months of treatment. Parents should monitor children taking atomoxetine for any changes in mood or behavior, and immediately contact their doctor if changes occur.

Alpha-2 Agonists (Guanfacine and Clonidine)

Alpha-2 agonists stimulate the neurotransmitter norepinephrine, which appears to be important for concentration. They include guanfacine (Tenex, Intuniv, generic) and clonidine (Catapres, generic). These drugs may be prescribed in combination with a stimulant.

Alpha-2 agonists have a number of side effects. Sleepiness and dry mouth are the most common, followed by headache and fatigue. Because clonidine slows the heart down, it can have adverse effects in some children. Discontinuing the drug abruptly or missing doses can cause rapid heartbeats and other symptoms that may lead to severe problems. Doctors strongly recommend that no child be given clonidine without a preliminary examination for heart problems, and no child with existing heart, kidney, or circulatory problems should take it.

Antidepressants

Antidepressants are not FDA-approved for ADHD treatment, but may be helpful in certain circumstances. Because antidepressants appear to work about as well as behavioral therapy, doctors recommend that people first try psychotherapy before using antidepressants.

Bupropion (Wellbutrin, generic) and tricyclics are the types of antidepressants sometimes used for ADHD. Bupropion affects the reuptake of the serotonin, norepinephrine, and dopamine neurotransmitters. Side effects include restlessness, agitation, sleeplessness, headache, and stomach problems. Bupropion should not be used by people who have a seizure disorder. Bupropion may also be associated with the development of suicidal thoughts and behavior, even in people who have no previous history of depression.

Tricyclics are an older type of antidepressant that can be beneficial but have many side effects. Imipramine (Tofranil, generic) and nortriptyline (Pamelor, generic) are the tricyclics most commonly prescribed for ADHD. A third tricyclic, desipramine (Norpramin, generic) should only be used if people are not helped by other tricyclics. Desipramine has caused sudden death in some children and adolescents and is particularly dangerous for people with a family history of heart rhythm disturbances.

Tricyclic antidepressants can cause disturbances in heart rhythm. Children should have an electrocardiogram when they first begin to take this drug, and after any dose increase.

Behavioral Management

Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers. To learn them, caregivers may need help from qualified mental health care professionals or from ADHD support groups.

Behavioral Techniques at Home

Bringing up a child with ADHD, like bringing up any child, is a process. No single point is ever reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to do anything more." The child's behavior will improve with an increasing ability to step back and consider the consequences of an action and then to control that action before taking it. But this does not happen overnight. A growing child with ADHD is different from other children in very specific ways, presenting challenges at every age.

Parents must first establish their own levels of tolerance. Some parents are easygoing and can accept a wide range of behaviors, while others cannot. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some tips to help parents include:

• Parents should prepare a list giving priority to those behaviors they think are the most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (such as refusing to wear anything but red T-shirts).
• Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (making up silly songs). These should be accepted as part of the child's unique and positive development, even if they seem peculiar to the parent.
• It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm.

Parents must be as consistent as possible in their approach to the child, which should reward good behavior and discourage destructive behavior. Rules should be well-defined but flexible enough to incorporate harmless idiosyncrasies. It is important to understand that children with ADHD have much more difficulty adapting to change than do children without the condition. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.) Keep rules simple, clear, and consistent.

Parents should establish a predictable routine, and provide a neat, well-organized home environment (particularly in the child's room). Have a consistent daily schedule with regular times for homework, meals, and outdoor activities. Make any changes to the schedule in advance, not at the last moment. Adequate sleep is very important for children with ADHD so make sure your child follows a consistent bedtime routine. Help your child learn organizational skills and maintain a neat environment by providing suitable places to store toys, clothing, and school supplies. Make sure your child keeps track of homework assignments and projects.

Children with ADHD perform significantly better when their interest is engaged and distractions are limited. Parents should be on the lookout for activities that hold the child's concentration. Options include swimming, tennis, and other sports that focus attention and limit peripheral stimuli. (Children with ADHD may have difficulty with team sports require constant alertness, such as football or basketball.)

Martial arts, such as karate, can also offer an appropriate and controlled emotional outlet, and help to focus attention, and teach self-restraint, self-discipline, and tolerance. Learning to play a musical instrument can help a child to develop a more rhythmic and balanced sense of self.

Children with ADHD respond particularly well to reward systems. Some suggested tips for rewarding are:

• Create charts with points or stars for good behavior or for completed tasks. It is important to give points for even simple positive behaviors, which may be taken for granted by other children (responding happily to a change in plans, changing an obscenity to a more acceptable expletive).
• Rewards for any child can include playing a favorite game, extending bedtime by an hour, or allowing an extra half-hour of TV.
• Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects.
• To avoid boredom, a reward system should rotate different types of rewards.
• Children with ADHD respond better with small rewards promised in the short-term than large rewards offered in the future. One approach that uses both short- and long-term rewards is a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game.
• Rewards should be promised only when caregivers are fairly certain they can follow through. Children with ADHD respond with much greater frustration to disappointment than children without ADHD and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the child's make-up and not necessarily in their control.

Management at School

Even if a parent is successful in managing the child at home, difficulties often arise at school. The ultimate goal for any educational process should be the happy and healthy social integration of children with ADHD with their peers.

Although teachers can expect at least one student in every classroom to have ADHD, there is generally little training that prepares them for managing these children. The teacher should be prepared for certain behaviors in the child with ADHD:

• Students with ADHD are often demanding, talkative, and highly visible.
• Inattention is a major factor in low academic performance and can cause children to frequently forget homework or miss assignments. Children with ADHD often require frequent reminders or visual cues (such as posters) for rules and regulations. Having the child sit in the front of the classroom may be helpful for both increasing attention and reducing noisy activity.
• Lack of fine motor control makes taking notes very difficult, and handwriting is often poor. Using a computer can compensate for this.
• Rote memorization and math computation, which require following a set of ordered steps, are often difficult. (Children with ADHD may do better with math concepts.)
• Many children with ADHD respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision.

The parent can help the child by talking to the teacher before the school year starts about their child's situation. The first priority for the parent is to develop a positive, not adversarial, relationship with the child's teacher. Finding a tutor to help after school may also be helpful

The Individuals with Disabilities Education Act (IDEA) requires the school to identify and evaluate children who may need help and to provide special services. However, parents sometimes report pressure by the school to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally.

High-quality special education can be extremely helpful in improving learning and developing a child's sense of self-worth. Still, programs vary widely in their ability to provide quality education, hiring and keeping well trained and empathetic staff, and may not accommodate the specific needs of a child with ADHD.

Special programs are also required under the Rehabilitation Act and by the Americans with Disabilities Act (ADA) for students at institutions of higher learning. It is the student's responsibility, however, to inform the administration at their college or university that they need such services.

Non-medication Treatments

Trigeminal Nerve Stimulation

The FDA has recently approved a medical device for external trigeminal nerve stimulation (eTNS) to be used for patients ages 7 to 12 who are not taking ADHD medication. This device generates a low-level electrical pulse that is transmitted to branches of the trigeminal nerve through a skin patch placed on the forehead. It is used under a parent or caregiver's supervision during sleep, at home. Side effects may include drowsiness, appetite increase, trouble sleeping, teeth clenching, headache and fatigue. The effectiveness of this type of treatment has not been established yet in large clinical trials.

Lifestyle Changes

Dietary Approaches

A number of diets have been suggested for people with ADHD. Several well-conducted studies have failed to support dietary effects of sugar and food additives on behavior, except possibly in a very small percentage of children. Still, various studies have reported behavioral improvement with diets that restrict potential allergens in the diet. Parents may want to discuss with their doctor a trial of an elimination diet directed at specific foods. Additives and foods that parents and studies report as possible triggers of behavioral changes include:

• Any artificial colorings (particularly yellow, red, or green)
• Other chemical additives -- for example, BHT or BHA
• Milk
• Chocolate
• Eggs
• Wheat
• Foods containing salicylates, including all berries, chili powder, apples and cider, cloves, grapes, oranges, peaches, peppers (bell and chili), plums, prunes, and tomatoes

The most well-known diet for ADHD is the Feingold diet, a salicylate- and additive-free diet, which requires rigorous vigilance over a child's eating habits. This diet also prohibits aspirin, which contains salicylates. There are no well-designed studies proving any effect of the Feingold diet on ADHD behaviors. Some parents report success with this diet, although it may be difficult to impose. In any case, it is certainly wise to provide a healthy balance of fresh, natural foods, and perhaps to avoid food with artificial colors and flavors.

Omega-3 fatty acids, found in fatty fish and canola oil, are important for normal brain function and may have some benefits for people with ADHD. Some studies have suggested that supplements or medical foods containing fatty acids, such as docosahexaenoic acid (DHA) and eicosapentaneoic acid (EPA) fish oils, may help reduce ADHD symptoms. The evidence for this effect is limited and currently no expert clinical recommendation for ADHD therapy includes fatty acids supplements.

Although parents often blame sugar for causing children to become impulsive or hyperactive, evidence does not show that sugar plays a role in hyperactivity.

Other Non-Drug Therapies

A number of alternative approaches are tried by children and adults with mild ADHD symptoms. For example, daily massage therapy may help some people with ADHD feel happier, fidget less, be less hyperactive, and focus on tasks. Other alternative approaches that may be helpful include biofeedback relaxation training, meditation, and music therapy. Based on existing evidence, these treatments may be helpful for symptom management but cannot cure the underlying disorder.

Many parents resort to alternative remedies instead of psychostimulants and other medications. These products include St. John's wort, ginkgo biloba, panax ginseng, melatonin, and pine bark extract. There is no scientific evidence that they are effective, and several adverse reactions and drug interactions have been reported.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Resources

• National Institute of Mental Health -- www.nimh.nih.gov/index.shtml
• Centers for Disease Control and Prevention (CDC): Attention-Deficit/Hyperactivity Disorder (ADHD) -- www.cdc.gov/ncbddd/adhd
• American Psychiatric Association -- www.psychiatry.org/
• American Academy of Child & Adolescent Psychiatry -- www.aacap.org
• American Academy of Pediatrics -- www.aap.org
• CHADD: The National Resource on ADHD -- www.chadd.org
• Attention Deficit Disorder Association -- add.org
• National Center for Learning Disabilities -- www.ncld.org
• Learning Disabilities Association of America -- ldaamerica.org