What is Attention-Deficit/Hyperactivity Disorder (ADHD)?
Attention-Deficit/Hyperactivity Disorder (ADHD) is a treatable condition that affects about 11% of children between the ages of four and 17 in the United States. Symptoms of ADHD usually appear by age seven (they may appear before this age), and are seen in boys three times more often than in girls; in adulthood, symptoms are found in men and women equally.
What are the symptoms of ADHD?
The “core,” or main, symptoms of ADHD include:
- Inattentiveness (trouble paying attention)
- Distractibility (easily distracted)
- Impulsivity (doing things on sudden urges)
- Hyperactivity (restlessness)
Some children may have ADHD without hyperactivity. This condition is more difficult to discover early because these children do not "act up" in class or at home. They are often bright and manage their workload in the early grades with little effort, not drawing attention to themselves. They may seem bored and fail to complete work, or they may show signs of confusion, forgetfulness, daydreaming, and disorganization.
At times, children seem to be “overfocused” in areas they are interested in. As a result, they do not appear disobedient or defiant, but simply don’t do their assigned chores or self-care routines when their parents ask them to, since they are so absorbed in their interests.
ADHD has two main classes of symptoms: inattention and hyperactivity/impulsivity.
The child with inattention has the following signs and symptoms:
- Fails to pay close attention to details or makes careless mistakes in schoolwork or other activities.
- Has trouble paying attention during tasks or play.
- Seems not to listen even when spoken to directly.
- Has difficulty following through on instructions (for example, often fails to finish schoolwork, chores, or other tasks).
- Often has difficulty organizing tasks or activities.
- Avoids or dislikes tasks that require continuous mental effort, such as schoolwork or homework.
- Frequently loses needed items, such as books, pencils, toys, or tools.
- Can be easily distracted by surrounding activity or noise.
- Is often forgetful.
The child with hyperactive and impulsive behavior has these signs and symptoms:
- Fidgets or squirms frequently.
- Leaves his/her seat in the classroom or in other situations when he/she is expected to remain seated.
- Runs or climbs excessively when it's not appropriate.
- May constantly feel restless (if an adolescent).
- Has trouble playing quietly.
- Always seems on the go or “driven by a motor.”
- Talks too much.
- Blurts out the answers before questions have been completely asked; older children may often finish sentences for others who are talking.
- Frequently has trouble waiting for his or her turn.
- Often interrupts or intrudes on others' conversations or games.
What are the causes and risk factors of ADHD?
Research has shown that ADHD is caused by neurological (nervous system) and biological (related to the body) factors, though the exact causes are not yet known.
Risk factors for ADHD include the following:
- Hereditary: If one or both parents have been diagnosed with ADHD, their children are more likely to show signs of it, as well.
- Biological: Studies suggest that ADHD comes from a chemical imbalance or problem with the way certain neurotransmitters (chemicals in the brain that help control behavior) work, especially dopamine.
- Environment: Exposure to toxins (poisons) in the environment (for example, lead) is linked to ADHD in children.
- Prenatal (during pregnancy) exposure: Smoking and/or drug and alcohol use during pregnancy are associated with ADHD in children.
Although the following factors may contribute to ADHD or make it worse, they are not causes:
- Everyday things in the child’s life, such as the home or school setting
- Poor parenting or poor teaching (such as too much punishment)
- Food additives*
*Note: A small number of children with ADHD may be sensitive to food dyes, artificial flavors, preservatives, or other food additives. Children with specific sensitivities and/or allergies may have fewer ADHD symptoms on a diet without food additives. Generally, food additives are not considered a cause of ADHD.
How is ADHD diagnosed?
Though all children show behaviors similar to ADHD from time to time, the child with ADHD has symptom “clusters”—six symptoms of inattention and/or six symptoms of hyperactivity/impulsivity. Before a diagnosis of ADHD can be made, however, it is not enough for the child to have these symptoms—he or she must also meet these conditions:
- The symptoms must cause problems.
- The symptoms must cause problems in more than two settings (such as home and school).
- The symptoms must be present in some form before the child is 12 years old.
If a child shows symptom clusters and also meets these conditions, the doctor may diagnose the following types of ADHD:
- Combined type (inattentive/hyperactive/impulsive): Children with this type of ADHD have all three groups of symptoms. This is the most common form of ADHD.
- Predominately hyperactive/impulsive type: Children have both hyperactive and impulsive behavior, but do not have problems with attention.
- Predominately inattentive type (formerly known as attention deficit disorder, or ADD): Children have difficulties with attention, but are not overly active or impulsive.
- Other specified/unspecified ADHD: Children have symptoms but do not meet the above conditions for diagnosis.
It is very important to follow three steps when diagnosing ADHD:
- Identify the symptoms or behaviors that occur in the natural environment.
- Rule out other possible causes of the symptoms.
- Identify comorbid conditions (those occurring at the same time as the main symptoms).
A child who has symptoms of ADHD may be able to pay attention in a focused way to activities that he or she finds interesting. For example, children can spend hours in front of a screen playing video games, but they may have trouble finishing even simple homework assignments, or they may throw tantrums and refuse to do chores or school work at home. This affects parent behavior as well, causing parents to yell more often or have to give repeated reminders to prompt the child to do simple tasks (like get ready for school). At such times, parents may know the child is not being oppositional—they just do not follow directions immediately.
Fascination or automatic attention (the kind of attention one uses when doing something interesting) is not a problem for children with ADHD; in fact, it may be very strong in some cases. However, “directed attention” (also known as effortful attention or top-down attention) is far more difficult for a child with ADHD. Tasks that require directed attention are harder to do and require much more effort. This kind of attention is much more readily used up. Because of these conditions, the caregiver must carefully observe the child in a number of different situations to make sure the evaluation is thorough.
Preparing for your ADHD appointment
If you think your child has a problem with attention, hyperactivity, or impulsivity, and it seems that his or her behavior at home and performance at school are being affected, the next step is to have an examination and evaluation.
If the symptoms are affecting your child’s school work, you should request that the school evaluate him or her. When making this request, be as specific as possible about the type of educational or behavioral difficulties your child is having.
Schools are required to evaluate children (age 3 to 21) if they are believed to have a disability that affects their learning. This evaluation is free and must, by law, include appropriate standardized tests.
School testing can lead to accommodations in the classroom. The school will not diagnose ADHD, but will take note of the symptoms and will often assign a designation of “Other Health Impaired” (OHI).
If your child is not yet school age, or if his or her problems occur mostly at home, make an appointment with your family doctor or pediatrician (or a caregiver who is familiar with diagnosing ADHD) to discuss the possibility of ADHD. Be sure to give the caregiver or doctor background information about your concerns and the concerns of school personnel or other caregivers. If necessary, the family doctor may suggest you take your child to a professional who specializes in ADHD and other developmental, behavioral, or mental health concerns.
Before the ADHD appointment, parents should fill out and return all the rating scales or medical information forms they received, both broad band (which cover a variety of conditions) and narrow band (which include symptoms associated with ADHD alone). Because there is no one single test for ADHD, information about family history, the child’s medical history, and behavior concerns are important for the doctor or specialist to know in order to complete a full evaluation.
If your child already receives school services from an IEP or 504 Accommodations plan, bring a copy of the IEP/504 to your appointment. This will let the physician or specialist know about the child’s difficulties at school and any testing the school has completed, and will give a picture of the strategies the school already has in place for your child.
The ADHD evaluation
The diagnosis of ADHD will probably be made by a pediatric psychologist or physician (a pediatrician, psychiatrist, or neurologist), with the help of standard guidelines from the American Academy of Pediatrics.
A comprehensive ADHD evaluation includes the following:
- Broad band and narrow band behavior rating scales completed by at least two observers (for example, parents, teachers, and other caregivers)
- A medical and family history
- A physical examination (often included by medical doctors)
- A detailed interview with the parents and the child
- Observation of the child
- Psychological tests to measure the child’s intellectual strengths and weaknesses
If a child is diagnosed with ADHD, it means that not only is he or she easily distracted, but that the distraction is much more noticeable than it is in other children of the same age. Specialists will consider the following when diagnosing ADHD:
- Are the behaviors more frequent or excessive than in other children of the same age?
- Did the behaviors begin early in life (before age 12)?
- Have the behaviors been present for more than six months?
- Are the behaviors a continuous problem, and not just a response to a temporary situation?
- Do the behaviors occur in several settings or only in one specific place?
- Do the behaviors cause problems in at least two areas of a person's life (such as home, school, work, or social settings)?
The specialists will also check to see if other things might be causing behavior that is similar to ADHD. This behavior can often show up in other disorders and situations, such as the following:
- A sudden life change (such as divorce, death in the family, or moving to a new home)
- Learning disabilities
- Undetected seizures
- Medical disorders that affect the functioning of the brain
- Thyroid disorders
- Lead toxicity (poisoning)
- Sleep problems
Understanding the diagnosis of ADHD
After the first appointment, your child’s healthcare provider will collect all the information from the evaluation process, make a diagnosis, and complete a report. The report will sum up the results and give treatment recommendations, including general guidelines for managing your child’s ADHD, and specific strategies and resources tailored to your family’s needs and your child’s strengths and weaknesses.
After diagnosis, recommendations for both behavior therapy and pharmacotherapy (medication) should be discussed with the healthcare provider.
Medications and behavioral treatments for ADHD
What medications are used to treat ADHD?
A group of drugs called psychostimulants has been found to be the most effective treatment for childhood ADHD. The two most commonly used medicines in this class are methylphenidate (Ritalin®, Concerta®, Focalin XR®, Ritalin LA®, Daytrana®, Quillivant XRTM, Metadate CD) and dextroamphetamine (Adderall XR®, Vyvanse®). These medicines help children to focus their thoughts and ignore distractions. Stimulant medicines are effective in 70% to 80% of patients.
Non-stimulant medicines include atomoxetine (Strattera®,) guanfacine (Intuniv®), and clonidine (Kapvay®). They are often used as additional therapy, or can be used on their own if the doctor decides.
Here is a current list of ADHD medications:
- Short-acting: Ritalin, Focalin, Methylin Chewable, Methylin Solution
- Long-acting intermediate release: Ritalin SR, Methylin, Metadate ER
- Long-acting extended release: Concerta, Aptensio® XR, Metadate CD, Metadate ER, Ritalin LA, Focalin XR, Daytrana, Quillivant XR (liquid)
- Short-acting: Dextrostat®, Dexedrine Tabs, Evekeo®, Zenzedi®, Adderall, ProCentra®
- Long-acting intermediate release: Adderall, Dexedrine Spansule
- Long-acting extended release: Vynase, Adderall XR, Dyanavel® XR, Adzenys® XR-ODT
- Atomoxetine (Strattera)
- Guanfacine (Intuniv)
- Clonidine (Kapvay)
ADHD medicines are available in short-acting (immediate-release), intermediate-acting, and long-acting forms. It might take some time for a doctor to find the most effective medicine, dosage, and schedule for a person who has ADHD.
There is no reliable way to predict which medicine(s) will work. The only way to know that a medication will be helpful for a child with ADHD is to prescribe it.
ADHD drugs sometimes have side effects, including appetite suppression, trouble sleeping, or irritability. Side effects are often mild and short-lived, and usually happen early in treatment. If side effects continue or interfere with the child’s life, the doctor will probably change the medication or lower the dose of the medicine used. A good rule is to compare the benefit of medicine to the side effect—if the benefit outweighs the side effect, it is often helpful to manage the side effect.
What behavioral treatments are used to treat ADHD?
Behavioral treatments for ADHD include the following:
- Behavior modification: The child’s behavior is analyzed, and strategies are designed to increase appropriate behaviors and decrease inappropriate behaviors.
- Behavioral parent training: This trains parents to respond to a child’s behaviors in ways that will strengthen growth and development and encourage a positive parent-child relationship. Parent training often occurs at the same time as behavior modification or social skills training for the child.
- Social skills training: This teaches social skills that will improve the child’s ability to act positively and effectively in school, at home, and with peers. It also provides a setting to practice the skills in a safe, accepting atmosphere.
- School interventions: A specialist can work with your child’s educational team to conduct an evaluation (multi-factored evaluation, or MFE) to create an IEP, 504 plan, or classroom-based interventions.
- Organizational skills training: It’s often helpful to teach older children skills that will help them improve time management and organization skills and increase efficiency at home and at school.
What alternative treatments for ADHD are available?
Parents should use caution when considering alternative treatments. Very few alternative or complementary treatments have been shown to be helpful for ADHD.
The program Cogmed® is effective in training working memory, which is often a problem with children who have ADHD. Other studies have shown mild benefits for omega-3 supplements, massage therapy, and mindfulness training. Mindfulness training is proving to be a real asset in many therapies, including ADHD.
Other alternative treatments for ADHD that have not been proven useful in controlled scientific studies, or may even be harmful, are:
- Allergy treatment
- Herbal supplements
- Restricted diets
- Movement therapy
- Anti-motion sickness treatment
- Eye movement training
Though many claims are made for other complementary and alternative treatments for ADHD, such as Brain Gym® and Lumosity®, few have been found to be effective.
Strategies for Managing ADHD
Parenting a child with ADHD: Tips for success
Families must understand that children will adapt their behavior to their parents’ behavior. Children can learn rules, follow them, cooperate with siblings, and complete homework and chores more often when effective family strategies are put to use in the home.
Such positive changes don’t come easily—changes in behavior often take time and focused effort. Excellent behavior management strategies for the home can be found in the book 1-2-3 Magic by Dr. Thomas Phelan.
Parents may find the following strategies helpful for managing ADHD in the home:
- Give clear and specific directions and limits. Children with ADHD need to know exactly what others expect from them.
- “Catch” your child being good. Punishing a child only teaches what not to do. Recognizing and acknowledging positive behaviors is an effective way to teach and increase appropriate behavior.
- Set up an effective behavior system. Create a consistent system to reward appropriate behavior and respond to misbehavior with alternatives such as "time out" or loss of privileges. Corporal punishment (spanking) is not advised, as it is not effective.
- Stick to a schedule. Follow the same routine every day, from wake-up time to bedtime. The schedule should include time for homework and play.
- Use a calendar or planner. Create a place to write down important reminders, responsibilities, and events. These tools may be especially helpful for adolescents and young adults who struggle with time management.
- Organize items that are needed every day. Have a place for everything and keep everything in its place. This includes clothing, backpacks, and school supplies. An organization checklist may be helpful.
- Pick out a homework area. Set up in a quiet area without clutter or distractions.
- Use less verbal prompting. Give clear and brief instructions. Find ways to silently redirect a child to tasks, such as a gesture, a special sign, or brief “instruction lists” taped to a mirror the child uses.
- Set a timer. Have a time frame for working on homework. If the child does not finish, take a break and set a new time to finish.
- Allow breaks. Allow time to rest and recharge, especially if a child has long assignments or homework in many classes.
- Praise effort and completion. Reward the child’s completed work instead of punishing incomplete work.
Teaching a child with ADHD: Tips for the classroom
Teachers may want to use these strategies for managing a child with ADHD in school:
- Use consistent classroom rules. Create a system to reward the child for following classroom rules. Respond to breaking of classroom rules in a consistent way, with alternatives such as "time out" or loss of privileges.
- Seat the child to succeed. Placing the child at the front of the class or near good peer role models can cut down on distraction and set the child up for success.
- Clearly state instructions and expectations. Children with ADHD need to know exactly what others expect from them. Give brief and specific instructions for activities or assignments. Combine verbal instructions with written instructions.
- Provide immediate feedback whenever possible. Children with ADHD respond best to feedback that is timely and specific. Positive or negative feedback is best when it is given right after the child’s behavior.
- Use less verbal prompting. If the child is frequently “off-task,” find ways to silently redirect him or her, such as a gesture or special sign.
- “Catch” the child being good. Praise the child for appropriate behaviors, such as following classroom rules, completing an assignment, or contributing to a classroom discussion. Timely praise is an effective way to teach and emphasize appropriate classroom behaviors.
- Use a daily report card. Research has shown that daily report cards are an effective tool to manage behaviors for children with ADHD. The Electronic Daily Report Card (https://e-drc.com/) is a free online resource to help teachers and parents set up and use a daily report card.
Living with ADHD
For more than 60% of children with ADHD, troublesome symptoms continue through adolescence and into adulthood. The following behaviors and problems might stem directly from ADHD, or might be caused by problems with adjustment:
- Chronic (long-term) lateness and forgetfulness
- Lack of organizational skills
- Low self-efficacy (poor self-confidence or the feeling of being ineffective in getting things done)
- School and employment problems
- Trouble managing anger
If these issues are not managed appropriately, they may cause emotional, social, work, and educational difficulties for adults with ADHD. However, with the right combination of resources, family support, social support, and treatment programs, problems related to ADHD can be effectively managed.
ADHD and its difficulties may be treated or managed with the help of these strategies:
- Individual cognitive and behavior therapy (the Summer Treatment Program, social skills training, parent training)
- Acceptance Commitment Therapy (ACT)
- Relaxation, stress management, or mindfulness training to reduce anxiety and stress
- Behavioral coaching or occupational therapy to teach strategies for organizing home and work activities
- Job coaching or mentoring to support better working relationships and improve on-the-job performance
- Family education and therapy
- Time management training
In addition, some adults with ADHD may benefit from medication to address symptoms and difficulties with inattention, distractibility, hyperactivity, and impulsive behavior.
Helpful information for adults living with ADHD can be found at the following websites:
- Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD): www.chadd.org
- Attention Deficit Disorder Association (ADDA): add.org
Additional information about ADHD and its management can be found at the following websites:
- ADDitude: Strategies and Support for ADHD & LD: www.additudemag.com
- American Academy of Child and Adolescent Psychiatry: www.aacap.org
© Copyright 1995-2017 The Cleveland Clinic Foundation. All rights reserved.
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 10/18/2016…#4784