Attention deficit hyperactivity disorder

Highlights

The American Academy of Pediatrics (AAP) has issued guidelines for diagnosis and treatment of ADHD in children. The 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 - 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 patients 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.

Drug Approval

In 2012, the FDA approved a liquid form of methylphenidate (Quillivant XR) for patients age 6 and older who may have difficulty swallowing pills.

Long-Term Effects of ADHD

ADHD can have serious consequences for long-term functioning according to a study that tracked more than 500 teenagers with ADHD from when they were 14 – 16 years old until they reached age 37. The researchers found that long-term ADHD increased the risks for impaired physical and mental health, poor work performance, and financial stress. The study team suggests that doctors focus on early diagnosis and treatment of adolescent ADHD.

Introduction

Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder generally characterized by the following symptoms:

Inattention

Distractibility

Impulsivity

Hyperactivity

Types of ADHD

ADHD is classified into three subtypes:

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 5 million children under age 18 have been diagnosed with ADHD at some time in their lives. This accounts for about 8% of all American children in this age range. Symptoms of ADHD usually become apparent at a young age. According to the American Academy of Pediatrics, ADHD symptoms can first emerge in children as young as age four.

ADHD is sometimes described as impairing the “executive functions” of the brain. Executive functioning refers to the cognitive abilities necessary to plan, organize, and carry out tasks. Executive function deficits can cause the following problems:

Inability to hold information in short-term memory

Impaired organization and planning skills

Difficulty in establishing and using goals to guide behavior, such as selecting strategies and monitoring tasks

Inability to keep emotions from becoming overpowering

Inability to shift efficiently from one mental activity to another

Hyperactivity. The term hyperactive is often confusing since it may suggest a child racing around non-stop. A boy with ADHD playing a game, for instance, may have the same level of activity as another child without the syndrome. But when a high demand is placed on the child's attention, his brain motor activity intensifies beyond the levels of the other children. In a busy environment, such as a classroom or a crowded store, children with ADHD often become distracted and react by pulling items off the shelves, hitting people, or spinning out of control into erratic, silly, or strange behavior.

Impulsivity and Temper Explosions. Temper tantrums, which are normal in young children, are usually exaggerated and not necessarily linked to a specific negative event in children with ADHD.

Attention and Concentration. Children with ADHD are usually distracted and made inattentive by an overstimulating environment (such as a large classroom). They are also inattentive when a situation is low-key or dull. In contrast, they may exhibit a kind of "super concentration" to a highly stimulating activity (such as a video game or a highly specific interest). Such children may even become over-attentive -- so absorbed in a project that they cannot modify or change the direction of their attention.

Impaired Short-Term Memory. An important feature in ADHD, as well as in learning disabilities, is an impaired working (also called short-term) memory. People with ADHD can't hold groups of sentences and images in their mind long enough to extract organized thoughts. They are not necessarily inattentive. Instead, a person with ADHD may be unable to remember a full explanation (such as a homework assignment), or be unable to complete processes that require remembering sequences, such as model building. In general, children with ADHD are often attracted to activities (television, computer games, or active individual sports) that do not tax the working memory, or produce distractions. Children with ADHD have no differences in long-term memory compared with other children.

Inability to Manage Time. Children with ADHD may have difficulties being on time and planning the correct amount of time to complete tasks. (This may coincide with short-term memory problems.)

Lack of Adaptability. Children with ADHD often have a very difficult time adapting to even minor changes in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to bed. Any shift in a situation can trigger a strong and noisy negative response. Even when they are in a good mood, they may suddenly shift into a tantrum if met with an unexpected change or frustration. These children can closely focus their attention when directly cued to a specific location, but they have difficulty shifting their attention to an alternative location.

Hypersensitivity and Sleep Problems. Children with ADHD are often hypersensitive to sights, sounds, and touch. They may complain excessively about stimuli that seem low key or bland to others. Many children with ADHD have trouble sleeping through the night.

Adult ADHD

ADHD is a chronic condition that begins in childhood and often persists into adulthood. Adult ADHD is a continuation of childhood ADHD symptoms.

Accompanying Mental Health Disorders. About 20% of adults with ADHD also have major depression or bipolar disorder. Up to 50% have an anxiety disorder. Bipolar disorder plus ADHD can be very difficult to differentiate from ADHD alone in adults, as well as in children.

Accompanying Learning Disorders. About 20% of adults with ADHD have learning disorders, usually dyslexia and auditory processing problems.

Effect on Work. Compared to adults without ADHD, those with the condition tend to reach lower educational levels, earn less money, and be fired more often. They may also be more likely to be self-employed.

Substance Abuse. About 1 in 5 adults with ADHD also contend with substance abuse. Studies indicate that adolescents with ADHD are twice as likely to smoke cigarettes as their peers who do not have ADHD. Cigarette smoking during adolescence is a risk factor for the development of substance abuse in adulthood.

Causes

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 in the prefrontal cortex may contribute to ADHD. The chemicals dopamine and norepinephrine are of special interest. Dopamine and norepinephrine are neurotransmitters (chemical messengers in the brain) that affect both mental and emotional functioning. They also play a role in the "reward response." This response occurs when a person experiences pleasure in response to certain stimuli (such as food or love). Studies suggest that increased levels of the brain chemicals glutamate, glutamine, and GABA -- collectively called Glx -- interact with the pathways that transport dopamine and norepinephrine.

Genetic Factors

Genetic factors most likely play a role in ADHD. The relatives of ADHD children (both boys and girls) have much higher rates of ADHD, antisocial, mood, anxiety, and substance abuse disorders than the families of non-ADHD children. Some twin studies report that up to 90% of children with a diagnosis of ADHD shared it with their twin.

Most of the research on the underlying genetic mechanisms targets the neurotransmitter dopamine. Variations in genes that regulate specific dopamine receptors have been identified in a high proportion of people with addictions and 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

Some 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 been possibly linked to ADHD. Environmental lead exposure before age 6 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.

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.

History of Behavior. 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.

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

Diagnostic Criteria. The American Psychiatric Association (APA) has specific criteria that must be met for a diagnosis of ADHD. These symptoms should have occurred in two or more settings (home and school) and not be due to a learning disability or another mental health disorder (such as bipolar disorder, depression, anxiety, and schizophrenia). 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 diagnosis of ADHD, at least six of the following symptoms should have been present for at least 6 months (or 9 months in preschoolers).

Symptoms of Inattention (at least six must be present):

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

Has difficulty organizing tasks and activities

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 (at least six must be present):

Often fidgets or squirms when sitting

Has difficulty remaining seated when required to do so

Often runs about or climbs excessively in inappropriate situations

Has difficulty playing quietly

Is often "on the go"

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.

Diagnosing ADHD in Adults

Childhood ADHD can affect children ages 4 - 18. 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 patient may be asked to provide school records or information from parents or former teachers. The doctor will ask the patients about these types of symptoms:

Inattention and memory problems. (Losing or forgetting things, being absent-minded, not finishing things, misjudging time, depending on others for order, having trouble getting started, changing jobs or projects midway)

Problems with self-worth. (Avoids new challenges, appears confident to others but not to self)

Complications

ADHD can pose challenges for children and their families.

Emotional Problems

Children with ADHD, especially those who also have anxiety or depression disorders, are likely to suffer from low self-esteem.

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. Children with ADHD and high levels of aggression may be at higher risk for delinquent behavior in adolescence and criminal activity in adulthood.

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 while bicycling or may engage in high-risk physical activities.

Substance Abuse

Studies consistently report that young people with ADHD -- in particular those with conduct or mood disorders -- have a higher than average risk for substance abuse and that it starts in younger ages. In one study, by age 11 nearly 20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. 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

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.

Many children with ADHD are underachievers, and half are held back in school at least once. Some evidence suggests that inattention may be a major factor in low academic performance in these children. Reading difficulties and handwriting problems can also pose challenges.

Low academic achievement can affect a child’s self-esteem and self-confidence, and contribute to teasing and other social problems with peers.

Effect on Family

The time and attention needed to deal with a child with ADHD can change internal family relationships and create conflicts with parents and siblings.

Problems in Adulthood

ADHD is very often a chronic condition. According to the American Academy of Child and Adolescent Psychiatry, about 30 – 65 percent 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.

Other Disorders Associated with ADHD

Several disorders may mimic or accompany ADHD. Many of these conditions require other modes of treatment and should be diagnosed separately, even if they accompany ADHD.

Oppositional-Defiant Disorder

Oppositional-defiant disorder (ODD) is often associated with ADHD. The most common symptom for this disorder is a pattern of negative, defiant, and hostile behavior toward authority figures that lasts more than 6 months. In addition to displaying inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper tantrums, and display antisocial behavior. A significant number of children with ODD also have anxiety disorders and depression, which should be treated separately. Many children who develop ODD at an early age go on to develop conduct disorder.

Conduct Disorder

Some children with ADHD also have conduct disorder, which describes a complex group of behavioral and emotional disturbances. It includes aggression towards people and animals, destruction of property, deceitfulness and lying, stealing, and general violation of rules.

Pervasive Developmental Disorder

Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behavior, hand-flapping, repetitive statements, slow social development, and speech and motor problems. If a child who has been diagnosed with ADHD does not respond to treatment, the parents might inquire about PDD, which often responds to antidepressants. Some children with PDD may also benefit from stimulant medications.

Auditory Processing Disorder and Hearing Problems

Hearing problems may mimic ADHD symptoms and should be evaluated during diagnosis. Auditory processing disorder (APD) is another condition that can affect children’s ability to process spoken information. Children with ADP have normal hearing, but something in their brain prevents them from filtering out background noise and distinguishing between similar sounds. APD may be misdiagnosed as ADHD and the two conditions can also occur together.

Bipolar Disorder

Children diagnosed with attention-deficit disorder may also have bipolar disorder. Bipolar disorder is marked by episodes of depression and mania (with symptoms of irritability, rapid speech, and disconnected thoughts). Both disorders often cause inattention and distractibility and may be difficult to distinguish from one another, particularly in children. In some cases, ADHD in children or adolescents may be a marker for an emerging bipolar disorder. [For more information, see In-Depth Report #66: Bipolar disorder.]

Anxiety Disorders

Anxiety disorders often accompany ADHD. Obsessive-compulsive disorder is a specific anxiety disorder that shares many characteristics with ADHD and may share a genetic component. Young children who have experienced traumatic events (including sexual or physical abuse or neglect) may exhibit characteristics of ADHD including impulsivity, emotional outbursts, and oppositional behavior. [For more information, see In-Depth Report #28: Anxiety Disorders.]

Other Conditions

Tourette Syndrome and Other Genetic Disorders. Several genetic disorders cause symptoms resembling ADHD, including fragile X and Tourette syndrome. Many patients with Tourette syndrome also have ADHD, and some of the treatments are similar.

Lead Poisoning. Children who ingest even small amounts of lead may manifest symptoms similar to those of ADHD. A child may be easily distractible, disorganized, and have trouble thinking logically. The major cause of lead toxicity is exposure to leaded paint, particularly in homes that are old and in poor repair.

Treatment

ADHD is considered to be 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.” Patients 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 a psychostimulant medication, most commonly methylphenidate (Ritalin, generic), and behavioral therapy. (For older children and adults, other drugs may also be used.) Treatment often involves a team approach that includes the child’s pediatrician, other health professionals, parents, and teachers.

Guidelines by Age. The American Academy of Pediatrics recommends that children with ADHD be treated according to the following age groups:

Preschool children (ages 4 -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, etc.)

Elementary school-aged children (ages 6 - 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 - 18 years old) should be treated with medication, and behavior therapy if necessary. Some patients 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.

Treatment for Adult ADHD. As with children, adults with ADHD are treated with a combination of medication and psychotherapy. 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 patients 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, Metadate, Daytrana, generic)

Dexmethylphenidate (Focalin, generic)

Amphetamine-Dextroamphetamine (Adderall, generic)

Dextroamphetamine (Dexedrine, Dextrostat, generic)

Lisdexamfetamine (Vyvanse)

Methylphenidate and Dexmethylphenidate. Methylphenidate drugs (Ritalin, Metadate, Concerta, Daytrana, Quillivant XR) are the most commonly used psychostimulants for treating ADHD in both children and adults. Dexmethylphenidate (Focalin) 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 patients age 6 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, and Lisdexamfetamine. Amphetamine-dextroamphetamine (Adderall), dextroamphetamine (Dexedrine, Dextrostat), and lisdexamfetamine (Vyvanse) work by blocking the reabsorption of the brain chemicals dopamine and norepinephrine.

Side Effects. 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 patients 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 patients who do not have a history of psychiatric problems.

Cause a mixed or manic episode in patients who have both ADHD and bipolar disorder.

Increase aggressive behavior or hostility. Patients beginning stimulant drug treatment should be monitored for worsening of these behaviors.

Reduce growth and weight gain in children. 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.

Cardiovascular Risks. All ADHD stimulant drugs carry warnings that they should not be used by patients 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. Symptoms of overdose include changes in heart rhythm and rate, hypertension, confusion, breathing difficulties, sweating, vomiting, and muscle twitches. If they occur, parents should call the doctor immediately.

Concerns for Abuse. Stimulant drugs can be habit forming, but they are not considered especially addictive, particularly 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 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.

Atomoxetine may cause suicidal thinking in children and adolescents, especially 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, generic) and clonidine (Catapres, generic). In 2009, Intuniv (a long-acting form of Tenex) was approved for the treatment of ADHD in children and adolescents ages 6 - 17 years.

Alpha-2 agonists are used for Tourette syndrome and may be beneficial when other drugs have failed for ADHD children with tics or those whose primary symptoms are severe impulsivity and aggression. These drugs may be prescribed in combination with a stimulant.

These drugs have a number of side effects. Sleepiness and dry mouth are the most common, followed by headache and fatigue. A clonidine skin patch, which gradually releases the medication, helps reduce the sedative effect. 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 patients first try psychotherapy before using antidepressants.

Bupropion (Wellbutrin, generic) and tricyclics are the types of antidepressants 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 patients 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 patients are not helped by other tricyclics. Desipramine has caused sudden death in some children and adolescents and is especially dangerous for patients 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 self esteem will evolve 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.

Setting Priorities for the Parent. 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 (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.

Establishing Consistent Rules for the Child. 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.) Parents should establish a predictable routine, and provide a neat, stable home environment (particularly in the child’s room).

Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional.

The use of "time-out," isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which they are endangered or endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others.

To channel physical aggression and impulsivity in a toddler with ADHD, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.)

When the child becomes older and if the verbal responses become intentionally abusive and socially undesirable, the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Competitive video games, such as sports games, may also be an option.

Sometimes a parent can anticipate situations when a child with ADHD is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible.

Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.

Some suggested tips for rewarding the ADHD child 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 in 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 than children without ADHD to disappointment, 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.

Improving Concentration and Attention. Children with ADHD perform significantly better when their interest is engaged. 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 an instrument can help a child to develop a more rhythmic and balanced sense of self.

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.

Preparing the Teacher. 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 Role of the Parent in the School Setting. 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

Special Education Programs. 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. However, programs vary widely in their ability to provide quality education. Parents must be aware of certain limitations and problems with special education:

Special education programs within the normal school setting often increase the child's feelings of social alienation.

If the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior.

There is no federally funded special education category specifically targeted to ADHD.

The best approach may be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom.

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.

Other Treatments

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:

Feingold Diet. 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. 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. .

Essential Fatty Acids. 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. There is no evidence that supplements of fatty acids, such as docosahexaenoic acid (DHA) and eicosapentaneoic acid (EPA) fish oils, provide any advantages.

Zinc. Zinc is important for the metabolism of certain neurotransmitters that play a role in ADHD, and deficiencies may be associated with some cases of ADHD. Long-term use of zinc, however, can cause anemia and other side effects in people without deficiencies, and it has no effect on ADHD in these individuals. In any case, testing for trace minerals, such as zinc, is not standard procedure when evaluating children suspected to have ADHD.

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

Feedback Approaches

Techniques that use biologic or auditory feedback may be effective tools for improving children's attention.

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 relaxation training, meditation, and music therapy. Based on existing evidence, these treatments may be helpful for symptom management but are not proven to benefit the underlying disorder.

Herbs and Supplements. 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.

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.

Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894-921.