Attention-Deficit / Hyperactivity Disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder marked by trouble controlling impulsive behavior, difficulty paying attention, or overactivity. It is one of the most common neurodevelopmental disorders of childhood. ADHD interferes with a person’s ability to stay on task and maintain focus. The person may act without thinking or have difficulty with self-control.

There are three different ways ADHD presents itself, depending on which types of symptoms are strongest in the individual:

• Predominantly Inattentive Presentation: It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.
• Predominantly Hyperactive-Impulsive Presentation: The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.
• Combined Presentation: Symptoms of the above two types are equally present in the person.

Because symptoms can change over time, the presentation may change over time as well.

The causes and risk factors for ADHD are unknown, although genes and a combination of environmental factors may play a role. In addition to genetics, scientists are studying other possible causes and risk factors, including:

• Brain injury
• Exposure to environmental risks (e.g., lead) during pregnancy or at a young age
• Alcohol and tobacco use during pregnancy
• Premature delivery
• Low birth weight

Research does not support the popularly held views that ADHD is caused by eating too much sugar, watching too much television, parenting, or social and environmental factors such as poverty or family chaos. Of course, many things, including these, might make symptoms worse, especially in certain people. But the evidence is not strong enough to conclude that they are the main causes of ADHD.

Scientists are studying cause(s) and risk factors in an effort to find better ways to manage and reduce the chances of a person having ADHD. The cause(s) of and risk factors for ADHD are unknown, but current research shows that genetics plays an important role. Recent studies link genetic factors with ADHD.

In addition to genetics, scientists are studying other possible causes and risk factors, including:

• Brain injury
• Exposure to environmental risks (e.g., lead) during pregnancy or at a young age
• Alcohol and tobacco use during pregnancy
• Premature delivery
• Low birth weight

Research does not support the popularly held views that ADHD is caused by eating too much sugar, watching too much television, parenting, or social and environmental factors such as poverty or family chaos. Of course, many things, including these, might make symptoms worse, especially in certain people. But the evidence is not strong enough to conclude that they are the main causes of ADHD.

Developmental screening takes a closer look at how your child is developing and is more formal than developmental monitoring. It is a regular part of some well-child visits even if there is not a known concern.

The American Academy of Pediatrics (AAP) recommends developmental and behavioral screening for all children during regular well-child visits at 9, 18, 24 and 30 months.

Screening questionnaires and checklists are based on research that compares your child to other children of the same age. Questions may ask about language, movement and thinking skills, as well as behaviors and emotions. Developmental screening can be done by a doctor or nurse, or other professionals in healthcare, community or school settings. Your doctor may ask you to complete a questionnaire as part of the screening process. Screening at times other than the recommended ages should be done if you or your doctor have a concern. 

Additional screening should also be done if a child is at high risk for (a sibling or other family member has a diagnosis) or if behaviors sometimes associated with disorders are present. If your child’s healthcare provider does not periodically check your child with a developmental screening test, you can ask that it be done.

Although ADHD is not a preventable condition, here are some tips for early detection and better management:

• If you think your child may have ADHD, talk with your child’s healthcare provider. The diagnosis can be made by a mental health professional, like a psychologist or psychiatrist, or by a primary care provider, like a pediatrician.
• After diagnosis, you and your child’s healthcare provider will discuss options for care. In most cases, ADHD is best treated with a combination of behavior therapy and medication.
• For preschool-aged children (four to five years of age) with ADHD, behavior therapy, particularly training for parents, is recommended as the first line of treatment before medication is tried.
• Schools are an important part of treatment. Public schools can also help with diagnosis and with finding out what kind of support your child may need.
• ADHD can put children’s healthy development at risk. In addition to recommended treatments like behavioral therapy and medication, a healthy lifestyle can help children with ADHD manage their ADHD symptoms.
• CDC sponsors the ADHD National Resource Center, a program of Children and Adults with ADHD (CHADD), with trained staff to answer questions about ADHD (1-866-200-8098). 

It is normal for children to have trouble focusing and behaving at one time or another. However, children with ADHD do not just grow out of these behaviors. The symptoms continue, can be severe, and can cause difficulty at school, at home or with friends.

Some of the warning signs of ADHD in children include:

• Failure to listen to instructions and miss details
• Inability to organize oneself and schoolwork
• Trouble paying attention to and responding to details
• Restlessness
• Fidgeting with hands and feet
• Talking too much
• Leaving projects, chores and homework unfinished

Some people with ADHD have symptoms related to hyperactivity/impulsiveness, while others may be mainly inattentive. Some people have a combination of both types of symptoms. There are several types of ADHD, which is usually diagnosed in childhood, although the condition can continue into the adult years.

Researchers from the Centers for Disease Control and Prevention (CDC) found from parent reports that about half of children were diagnosed by a primary care physician, behavior rating scales were used for nine in 10 children to assess for ADHD, and about eight in 10 diagnoses incorporated information from an adult other than a family member.

This is important information for healthcare providers, public health officials and researchers who seek to determine how closely current practice matches with best practice for diagnosing ADHD. The findings from the CDC studies provided more information on who is diagnosing ADHD and described some of the features of those initial diagnostic visits. The estimates suggested that physicians who diagnose ADHD are largely using two recommended practices—behavior rating scales and incorporating feedback from adults other than family members—in their diagnosis of ADHD in children. This information also informed further efforts to make sure that the diagnosis of ADHD reflects best practice recommendations.

Based on the parent reports about their children’s ADHD diagnosis:

• About three-quarters of children with ADHD were diagnosed before age nine and one-third of those by age six.
• A family member (which can include a parent) was usually the one first concerned about a child’s behavior, rather than someone from the child’s school or daycare.
• A primary care physician (usually a pediatrician) first made the diagnosis for about half of the children.
• Children with ADHD first diagnosed by a psychiatrist were more likely to be under six years of age than older.
• Children with ADHD first diagnosed by a psychologist were more likely to be older than six years of age than under six.
• Healthcare providers nearly always had a conversation with a parent about their child’s behavior.
• Healthcare providers used behavior rating scales or checklists to assess nine in 10 children for ADHD.
• An adult outside of the family was usually involved in the diagnostic process.

According to studies, treatment types among young children with ADHD vary, with 33.7 percent receiving behavioral intervention only, 19.1 percent receiving behavioral intervention and medication, 25.1 percent receiving medication only, and 22.1 percent receiving neither behavioral intervention nor medication.

When a child is diagnosed with ADHD, parents often have concerns about which treatment is right for their child. ADHD can be managed with the right treatment. There are many treatment options, and what works best can depend on the individual child and family. To find the best options, it is recommended that parents work closely with others involved in their child’s life—healthcare providers, therapists, teachers, coaches and other family members.

Types of treatment for ADHD include behavior therapy combined with training for parents and medications.

For children with ADHD younger than six years of age, the American Academy of Pediatrics (AAP) recommends parent training in behavior management as the first line of treatment, before medication is tried. For children six years of age and older, the recommendations include medication and behavior therapy together—parent training in behavior management for children up to age 12, and other types of behavior therapy and training for adolescents. Schools can be part of the treatment as well. AAP recommendations also include adding behavioral classroom intervention and school support.  

Good treatment plans will include close monitoring of whether and how much the treatment helps the child’s behavior, as well as making changes as needed along the way. 

ADHD affects more than a child’s ability to pay attention or sit still at school; it also affects relationships with family and other children. Children with ADHD often show behaviors that can be very disruptive to others, including parents and siblings. Behavior therapy is a treatment option that can help reduce these behaviors; it is often helpful to start behavior therapy as soon as a diagnosis is made.

The goals of behavior therapy are to learn or strengthen positive behaviors and eliminate unwanted or problem behaviors. For young children with ADHD, behavior therapy is an important first step before trying medication because:

• Parent training in behavior management gives parents the skills and strategies to help their child.
• Parent training in behavior management has been shown to work as well as medication for ADHD in young children.
• Young children have more side effects from ADHD medications than older children.
• The long-term effects of ADHD medications on young children have not been well studied.

For children ages six years and older, AAP recommends combining medication treatment with behavior therapy. Several types of behavior therapies are effective, including:

• Parent training in behavior management
• Behavioral interventions in the classroom
• Peer interventions that focus on behavior
• Organizational skills training

These approaches are often most effective if they are used together, depending on the needs of the individual child and the family.

Medication can help children manage their ADHD symptoms in their everyday life and can help them control the behaviors that cause difficulties with family, with friends and at school.

Several different types of medications are FDA approved to treat ADHD in children as young as six years of age:

• Stimulants are the best-known and most widely used ADHD medications. Between 70 and 80 percent of children with ADHD have fewer ADHD symptoms when taking these fast-acting medications.
• Nonstimulants were approved for the treatment of ADHD in 2003. They do not work as quickly as stimulants, but their effect can last up to 24 hours.

Medications can affect children differently and can have side effects such as decreased appetite or sleep problems. One child may respond well to one medication but not to another.

Healthcare providers who prescribe medication may need to try different medications and doses. The AAP recommends that healthcare providers observe and adjust the dose of medication to find the right balance between benefits and side effects. It is important for parents to work with their child’s healthcare providers to find the medication that works best for their child.

ADHD lasts into adulthood for at least one-third of children with ADHD. Treatments for adults can include medication, psychotherapy, education or training, or a combination of treatments.

When a child is diagnosed with ADHD, parents often have concerns about which treatment is right for their child. ADHD can be managed with the right treatment. There are many treatment options, and what works best can depend on the individual child and family. To find the best options, it is recommended that parents work closely with others involved in their child’s life—healthcare providers, therapists, teachers, coaches and other family members.

Types of treatment for ADHD include behavior therapy, including training for parents and medications.

For children with ADHD younger than six years of age, the American Academy of Pediatrics (AAP) recommends parent training in behavior management as the first line of treatment, before medication is tried. For children six years of age and older, the recommendations include medication and behavior therapy together—parent training in behavior management for children up to age 12 and other types of behavior therapy and training for adolescents. Schools can be part of the treatment as well. AAP recommendations also include adding behavioral classroom intervention and school support.  

Good treatment plans will include close monitoring of whether and how much the treatment helps the child’s behavior, as well as making changes as needed along the way. 

ADHD affects not only a child’s ability to pay attention or sit still at school, it also affects relationships with family and other children. Children with ADHD often show behaviors that can be very disruptive to others, including parents and siblings. Behavior therapy is a treatment option that can help reduce these behaviors; it is often helpful to start behavior therapy as soon as a diagnosis is made.

The goals of behavior therapy are to learn or strengthen positive behaviors and eliminate unwanted or problem behaviors. For young children with ADHD, behavior therapy is an important first step before trying medication because:

• Parent training in behavior management gives parents the skills and strategies to help their child.
• Parent training in behavior management has been shown to work as well as medication for ADHD in young children.
• Young children have more side effects from ADHD medications than older children.
• The long-term effects of ADHD medications on young children have not been well studied.

For children ages six years and older, AAP recommends combining medication treatment with behavior therapy. Several types of behavior therapies are effective, including:

• Parent training in behavior management
• Behavioral interventions in the classroom
• Peer interventions that focus on behavior
• Organizational skills training

These approaches are often most effective if they are used together, depending on the needs of the individual child and the family.

Medication can help children manage their ADHD symptoms in their everyday life and can help them control the behaviors that cause difficulties with family, with friends and at school.

Several different types of medications are FDA-approved to treat ADHD in children as young as six years of age.

• Stimulants are the best-known and most widely used ADHD medications. Between 70 and 80 percent of children with ADHD have fewer ADHD symptoms when taking these fast-acting medications.
• Nonstimulants were approved for the treatment of ADHD in 2003. They do not work as quickly as stimulants, but their effect can last up to 24 hours.

Medications can affect children differently and can have side effects such as decreased appetite or sleep problems. One child may respond well to one medication but not to another.

Healthcare providers who prescribe medication may need to try different medications and doses. The AAP recommends that healthcare providers observe and adjust the dose of medication to find the right balance between benefits and side effects. It is important for parents to work with their child’s healthcare providers to find the medication that works best for their child.

ADHD lasts into adulthood for at least one-third of children with ADHD. Treatments for adults can include medication, psychotherapy, education or training, or a combination of treatments. 

The following are suggestions that may help with your child’s behavior:

• Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime.
• Get organized and guide your child in organization.
• Encourage your child to put school bags, clothing and toys in the same place every day so that they will be less likely to lose them.
• Manage distractions. Turn off the TV, limit noise and provide a clean workspace when your child is doing homework. Some children with ADHD learn well if they are moving or listening to background music. Watch your child and see what works.
• Limit choices. To help your child not feel overwhelmed or overstimulated, offer choices with only a few options. For example, have them choose between this outfit or that one, this meal or that one, or this toy or that one.
• Be clear and specific when you talk with your child. Let your child know you are listening by describing what you heard them say. Use clear, brief directions when they need to do something.
• Help your child plan. Break down complicated tasks into simpler, shorter steps. For long tasks, starting early and taking breaks may help limit stress.
• Use goals and praise or other rewards. Use a chart to list goals and track positive behaviors, then let your child know they have done well by telling them or by rewarding their efforts in other ways. Be sure the goals are realistic—small steps are important!
• Discipline effectively. Instead of scolding, yelling or spanking, use effective directions, time-outs or removal of privileges as consequences for inappropriate behavior.
• Create positive opportunities. Children with ADHD may find certain situations stressful. Finding out and encouraging what your child does well—whether it’s school, sports, art, music or play—can help create positive experiences.
• Provide a healthy lifestyle. Nutritious food, lots of physical activity and sufficient sleep are important; they can help keep ADHD symptoms from getting worse.