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