- A common adult disorder, thought to be persistence of childhood attention deficit hyperactivity disorder (ADHD). Prevalence of 2% to 5% in the general population.
- Childhood ADHD persists into adulthood in up to 15% of patients. Subthreshold ADHD symptoms, primarily inattention and agitation, may persist in up to 50% more.
- Diagnosed by clinical history, DSM-V criteria, psychiatric interview and collateral information.
- About 75% of adults with ADHD will have at least one other mental health disorder, often anxiety, mood disorders, personality disorder, substance misuse, and other neurodevelopmental conditions. The interdependency of the conditions is presently being debated.
- Stimulant medications (methylphenidate, amphetamine derivatives) are first-line treatment options for patients not prone to substance misuse. Nonstimulant medications, including atomoxetine, can also be effective and form a second-line management. Cognitive behavior therapy can be effective in reduction of symptoms in combination with medication.
What is Attention Deficit Hyperactivity Disorder (ADHD, ADD)?
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).
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 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 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.
Signs & Symptoms
Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.
Children who have symptoms of inattention may:
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty focusing on one thing
- Become bored with a task after only a few minutes, unless they are doing something enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning something new
- Have 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.
Children who have symptoms of hyperactivity may:
- 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.
Children who have symptoms of impulsivity may:
- 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
- Often interrupt conversations or others' activities.
ADHD Can Be Mistaken for Other Problems
Parents and teachers can miss the fact that children with symptoms of inattention have the disorder because they are often quiet and less likely to act out. They may sit quietly, seeming to work, but they are often not paying attention to what they are doing. They may get along well with other children, compared with those with the other subtypes, who tend to have social problems. But children with the inattentive kind of ADHD are not the only ones whose disorders can be missed. For example, adults may think that children with the hyperactive and impulsive subtypes just have emotional or disciplinary problems.
Who Is At Risk?
ADHD is one of the most common childhood disorders and can continue through adolescence and into adulthood. The average age of onset is 7 years old.
ADHD affects about 4.1% American adults age 18 years and older in a given year. The disorder affects 9.0% of American children age 13 to 18 years. Boys are four times at risk than girls.
Studies show that the number of children being diagnosed with ADHD is increasing, but it is unclear why.
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.
ADHD also may coexist with a sleep disorder, bed-wetting, substance abuse, or other disorders or illnesses.
Recognizing ADHD symptoms and seeking help early will lead to better outcomes for both affected children and their families.
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 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.
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.
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.
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.
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 prescribing doctor and the dose is adjusted based on the child's needs.
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.
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 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 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.
Tips to Help Kids Stay Organized and Follow Directions
Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or on a bulletin board in the kitchen. Write changes on the schedule as far in advance as possible.
Organize everyday items. Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys.
Use homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home the necessary books.
Be clear and consistent. Children with ADHD need consistent rules they can understand and follow.
Give praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior, and praise it.
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.