Attention-Deficit/Hyperactivity Disorder (ADHD)
What is Attention-Deficit/Hyperactivity Disorder (ADHD)?
Does your child fail to sustain attention, behave within appropriate limits at home and in public, or sit quietly when they’re expected to do so? Not being able to stay within limits or sit quietly is normal childhood behavior if it happens at different ages and from time to time, but if this behavior occurs frequently and interferes with your child’s daily life, they may have ADHD.
ADHD is a neurodevelopmental condition that can affect family life. The word “neurodevelopmental” refers to the nervous system, which includes the brain as it develops across the lifespan. ADHD behavior usually appears by age 7, though difficult behavior may show up before this. With ADHD, children can have trouble with impulsivity, hyperactivity, distractedness, following instructions and completing tasks. But ADHD is treatable.
When symptoms of Attention-Deficit Hyperactivity Disorder occur in childhood, they tend to persist into adulthood in about half of all cases. Adults with ADHD often find it difficult to follow directions, remember information, and concentrate on or organize tasks. Without proper acknowledgement and management of these behaviors, ADHD can result in behavioral, emotional, academic, vocational and social problems that decrease the quality of life.
What is the difference between ADHD and ADD (Attention-Deficit Disorder)?
ADHD is the only term assigned to this diagnosis but there are different presentations of ADHD — ADHD Inattentive Presentation, ADHD Hyperactive/Impulsive Presentation, ADHD Combined Presentation (both inattention and H/I behavior) and a fourth type called Unspecified ADHD, a diagnosis used when symptoms are unclear.
How common is ADHD?
About 11% of children between the ages of four and 17 have ADHD. Symptoms of ADHD typically first appear between the ages of three and six years old. The average age of ADHD diagnosis is seven years old. In children, it’s three times more common in young boys than girls.
ADHD isn’t just a childhood disorder. About 4% of American adults over the age of 18 contend with ADHD behaviors on a daily basis. In adulthood, it’s diagnosed equally between males and females.
Is ADHD a mental illness?
By definition, ADHD is better referred to as a neurodevelopmental disorder, not a “mental illness.” The term “mental illness” is a very broad term for any type of condition that affects mood, behavior or thinking. ADHD is better described as a pattern of behavior — something different in the way a person does things — rather than describing it as something “wrong” with people. Evidence indicates that ADHD is associated with neural pathways in brain functioning (the default mode and the task positive mode). This functioning yields problematic behavioral at certain ages (stages of development) — thus the term neurodevelopmental disorder is a better broad category name for the problem of ADHD.
Is ADHD a form of autism?
No, although they are both neurodevelopmental disorders. Except, many children with autism have ADHD. But the two conditions are by expression and definition quite different.
Is ADHD a learning disability?
ADHD is not a learning disability, though it certainly can impair learning. About 30% to 40% of children with ADHD also have a learning disability. Like those with a learning disability, children with ADHD are eligible to receive special education services.
Symptoms and Causes
What are the symptoms of ADHD?
Children, teenagers and adults with ADHD have an ongoing pattern of three types of core behaviors:
- Inattentiveness: Difficulty sustaining attention to tasks.
- Impulsivity: Doing things on sudden urges, without thinking such as talking out in class, throwing a toy, or interrupting someone in conversation. In adults, the impulses may be irresponsible such as spending too much money.
- Hyperactivity: Restlessness such as fidgeting, inability to stay seated when sitting is expected such as in church or school, moving or climbing when it’s inappropriate to do so.
Children, teens and adults with ADHD are diagnosed by the behavior pattern that is most actively present. The three most common ADHD presentations are Predominantly Inattentive, Predominantly Hyperactive/Impulsive and the combination of these types.
ADHD Predominantly Inattentive Presentation is defined by the following nine behaviors:
- Fails to pay close attention to details or makes careless mistakes in schoolwork, at work or during other activities.
- Has trouble paying attention during tasks or play.
- Appears to not listen even when spoken to directly.
- Has difficulty following through on instructions (for example, often fails to finish schoolwork, chores or other duties in the workplace).
- Often has difficulty organizing tasks or activities.
- Avoids or dislikes tasks that require continuous mental effort, such as schoolwork, homework or preparing reports, completing forms and reviewing lengthy papers.
- Frequently loses needed items, such as books, pencils, tools, wallets/purses, keys, paperwork, phone and eyeglasses.
- Can be easily distracted by actions or thoughts unrelated to the current task.
- Is often forgetful in daily activities (such as doing chores, running errands, returning phone calls, paying bills and keeping appointments).
Behaviors of the ADHD Predominantly Hyperactivity/Impulsive type include:
- Fidgets with or taps hands or feet or squirms frequently.
- Leaves seat in the classroom or in the workplace when remaining seated is expected.
- Runs or climbs excessively when it's not appropriate; constantly feels restless (if an adolescent or adult).
- Has trouble playing or engaging in leisure activities 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 risk factors of ADHD?
ADHD is largely a hereditary condition. If one or both parents have been diagnosed with ADHD, their children are more likely to have it as well. Although the exact etiology (i.e., origins) of ADHD are ill-defined, healthcare providers report other associated risk factors:
- Biological: ADHD is associated with the way certain neurotransmitters (chemicals in the brain that help control behavior) work, especially dopamine and norepinephrine, and this difference causes changes in two different attentional networks of the brain — the default network, associated with automatic attention and the task positive network, associated with directed or effortful attention.
- Environment: Exposure to toxins (poisons) in the environment (lead, for example) has been linked to ADHD in children.
- Prenatal substance exposure (during pregnancy): Smoking and/or drug and alcohol use during pregnancy is associated with ADHD in children.
What makes ADHD symptoms worse?
Certain behaviors are expected depending on the age of a person. Because the brain doesn’t develop at the same rate in everyone, cognitive functions may be poor in some people and not in others. A child 10 years old, for example, might only have the abilities of a younger child 8 years old rather than his or her same age peers. Therefore, as you or your child get older, the problem is not that ADHD gets worse, it’s that the child’s abilities are not developing synchronized with age.
Although ADHD doesn’t get “worse,” the tasks expected of the person become more complicated with age and circumstances, such as increased demands in school, therefore, the problematic behaviors (such as completing things on time) become more problematic. For example, as the child may get a lower grade for turning in late work. Examples of other complications include:
- Undertaking new challenges without sufficient support: New and more complex challenges frequently arise in school. As a child advances in grade level, academic tasks become more complex, such as having to write lengthy reports or studying numerous chapters of a history book. Task complexity in reading, spelling, math and interacting with classmates pose problems to the child who has limited ability to meet demand. The student with ADHD may struggle even more without additional collateral support from parents and teachers.
- Often, children are punished for actions they cannot control: Children with ADHD may be criticized and punished by parents and teachers, they may be looked down on by peers because of their inability to finish tasks or remember their schoolwork, and some may not know how to play appropriately with their friends. Adults can be penalized by supervisors at their jobs for forgetting to do work and, at times, even by family members for failing to stay organized, or stay focused on tasks to completion.
- Additional problems with thinking, emotions and behaviors: Psychiatric disorders like depression and anxiety are common in people with ADHD. Children are 62% more likely to have at least one disorder. Adults with ADHD are six times more likely to have a disorder. People with ADHD are also more likely to abuse drugs and alcohol.
- Stress: So many things can cause additional stress in the life of someone with ADHD. Examples include serious medical illnesses, domestic violence, divorce, loss of employment or the death of a friend or family member.
- No treatment: According to recent data, 17.5% of children ages four to 17 in the United States received no treatment — behavioral or pharmacological — for ADHD. Treatment is vital for managing ADHD symptoms.
Diagnosis and Tests
How is ADHD diagnosed in children, teens and adults?
To diagnose a child, the healthcare provider must perform three tasks. The healthcare provider must: 1) identify the presence of ADHD symptom criteria, 2) rule out alternative causes of symptoms, and 3) identify comorbid conditions (other conditions such as depression or anxiety).
But, the job is not yet done. Certain conditions must also be met. First, the symptom behaviors must be present in two or more settings such as at home and in school. Second, the symptoms must be impairing. It’s not just that they occur as everyone engages in these behaviors sometimes. Third, symptom behaviors must have been present in childhood, typically before the age of 12 years. Last, the symptoms cannot be corollaries to another disorder that is not ADHD. For example, sometimes, when a person is depressed or anxious, inattentive behaviors may occur. The clinician will identify ADHD symptoms by asking you questions about your child’s behavior s at home and school (that is, behaviors your child’s teachers shared with you). Next, your provider will rule out other possible conditions that share some similar symptoms. These conditions include:
- Learning disabilities.
- Undetected seizures.
- Medical disorders that affect the functioning of the brain.
- Thyroid disorders.
- Lead toxicity (poisoning).
- Sleep problems.
A sudden life change (such as divorce, death in the family, or moving to a new home) may also result in behaviors that could be confused with ADHD).
Sometimes, an adult will recognize the behaviors of ADHD in himself or herself when a son or daughter is diagnosed. Other times, adults will seek professional help for themselves and find that their depression or anxiety is related to ADHD.
The American Psychological Association has guidelines to help healthcare providers make the diagnosis. To be diagnosed with ADHD, children must have six or more symptoms in one of the two (or both) main categories — 1) inattention and/or 2) hyperactivity/impulsivity (see the symptom section) — of ADHD over the last six months. To be diagnosed with ADHD as an adult, you must have five or more of the established ADHD behaviors in either of these categories for at least six months and there must be evidence such as recall of school experiences that indicates symptoms were present in childhood.
To reiterate, in addition to having ADHD behaviors, children, teens and adults must meet the following criteria:
- The symptoms must interfere with school, home or work life.
- The symptoms must be present in two or more settings (such as home, church, school, work, with friends, or social groups/activities).
- The symptoms were present before the age of 12.
Based on review of the collected information, your healthcare provider may diagnose an adult or child with one of types of ADHD:
- Predominately hyperactive/impulsive type: You or your child must have behaviors of hyperactive/impulsive behavior for the past six months, but not meet the criteria for inattention.
- Predominately inattentive type (formerly known as attention deficit disorder, or ADD): You or your child must have behaviors of inattention present for six months, but do not meet the criteria for hyperactive/impulsive.
- Combined type (inattentive and hyperactive/impulsive): Symptoms from both types of ADHD must be present for the past six months. This is the most common form of ADHD in children.
- Other specified/unspecified ADHD: Children, teens or adults have inattentive type behaviors but do not meet the above conditions for diagnosis.
Keep in mind that symptoms can change over time and therefore so can the diagnosis of the type of ADHD.
How should I prepare for my child’s appointment to discuss ADHD?
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, your next step is to see your pediatrician.
If the symptoms are affecting your child’s schoolwork, contact the school and request an evaluation. 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 (ages three to 21) if there’s evidence of 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). Get a copy of the school’s report and bring it with you to the appointment with the pediatrician.
If necessary, the family provider may suggest you take your child to a professional who specializes in ADHD and other developmental, behavioral or mental health concerns.
Management and Treatment
How is pharmacotherapy used to treat ADHD?
A group of drugs called psychostimulants are an effective treatment for ADHD. The two most commonly used medicines in this class are methylphenidates (often known as Ritalin) and dextroamphetamines (similar to Adderall). These medicines help people with ADHD focus their thoughts and ignore distractions. Stimulant medicines are effective in 70% to 90% of patients with ADHD. New medicines are also being developed.
Examples of short-acting (immediate-release), intermediate-acting and long-acting forms of these medications include:
- 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) Jornay.
- Short-acting: Dextrostat®, Dexedrine Tabs®, Evekeo®, Zenzedi®, Adderall®, ProCentra®.
- Long-acting intermediate release: Adderall®, Dexedrine Spansule®.
- Long-acting extended-release: Vyvanse®, Adderall XR®, Dyanavel® XR, Adzenys® XR-ODT.
Non-stimulant medicines include atomoxetine (Strattera®,) guanfacine (Intuniv®), and clonidine (Kapvay®). They are often used as additional treatment, or can be used on their own if the healthcare provider approves. New nonstimulant formulations are in the pipeline of several pharmaceutical companies.
There’s no way to really know which medicine(s) and dosage level(s) will work best for you or your child until you try it out. Your healthcare provider may need to prescribe several different formulations and see how you your or your child react. Typically the physician will “start low (in dose) and go slow.”
The most common side effects of ADHD medications include decreased appetite, trouble sleeping and irritability. Fortunately, side effects are often mild and short-lived and usually happen early in treatment. If they continue or interfere with you or your child’s daily life, your provider will probably change your medication or lower the dose. The most important question to ask is, “Does the benefit of the medicine outweigh the side effect?” The most effective treatment is medicine combined with behavioral therapy.
What behavioral treatments are used to treat childhood and adult ADHD?
The best prevention for ADHD, supported by substantial research, is to use a combined approach of both behavioral intervention and pharmacotherapy. Medicines are not enough to treat you or your child’s ADHD. The old adage — pills don’t teach skills — is certainly appropriate here. Thus it’s best to combine medical treatments with behavioral treatments.
Behavioral treatments for childhood ADHD include:
- Behavior modification: With this treatment, your child’s behavior is analyzed, and strategies are designed to increase appropriate behaviors and decrease inappropriate behaviors. One model program for children with ADHD is called the Summer Treatment Program developed by Dr. William Pelham of Florida International University.
- Behavioral parent training: This training helps parents 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. A good parent training program is 1-2-3 Magic by Thomas Phelan.
- Social skills training: This training teaches social skills that will improve the child’s ability to act positively and effectively with peers and adults in school and at home. It also provides a setting to practice the skills in a safe, accepting atmosphere.
- School interventions: A specialist may work with your child’s educational team to conduct a multi-factored evaluation, or MFE, as noted above to create an individualized education plan (IEP), 504 plan or other classroom-based intervention.
- Organizational skills training: This training teaches older children skills to help them improve time management, organizational skills and effectively use executive functions to increase efficiency and work completion at home and school.
Behavioral treatments in adults help you navigate the demand of jobs, relationships and educational opportunities. ADHD coaches are trained and certified to assist adults with ADHD to manage the various difficulties of their lives.
Behavioral treatments for adults with ADHD include:
- Individual cognitive behavioral treatment (“talk therapy”) to enhance a person’s sense of self-efficacy.
- Relaxation training and stress management to reduce anxiety and stress.
- Behavioral coaching 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 to ensure that everyone in the family understands ADHD and its symptoms.
What happens if ADHD is left untreated?
Symptoms will continue if ADHD is left untreated and people are left to manage them on their own. Children may struggle at school, home and in social situations, and adults may struggle with work, education, interactions with friends and family and more. Untreated ADHD makes life harder than it has to be.
How can I prevent ADHD?
There are certain risk factor categories for the development of ADHD, some of which can be changed, some that can’t. They are:
- Prenatal exposure to toxic substances.
If you or your parents have ADHD, there is a higher probability that your children will, too. Unfortunately, there’s nothing that can be done to prevent the genetics from ADHD expression. The same goes for biologic factors. People can be born with chemical imbalances or they can have adequately functioning neurotransmitters.
Environmental toxins have been linked to ADHD in children. Parents may have their home tested for lead, for example, to prevent lead poisoning which increases the risk of ADHD. Another way to help reduce the risk of ADHD is to avoid smoking, alcohol and drugs while pregnant with your child.
Outlook / Prognosis
What can I expect if I or my child has ADHD?
ADHD is a complicated condition with various symptom expressions. If you or your child have ADHD, educate yourself as much as possible about the behaviors that make life difficult. Consider medicines and behavioral treatments. Your healthcare provider will help you with these. He or she will sum up the results of the ADHD evaluation and will recommend appropriate treatment. A combination of pharmacotherapy and behavioral treatment, is generally recommended. A trained behavioral health clinician can give general guidelines for managing your own or your child’s ADHD and these can be tailored to your family’s needs and your child’s strengths and weaknesses.
Also, it is always useful to have appropriate expectations for yourself and your child. Don’t expect your child to get out of bed the first time you wake them up, and don’t be too hard on yourself if making progress is difficult. It is always best to have your partner and friends help with tasks like organizing and time management. Stay in contact with your healthcare provider, especially if there is a change in you or your child’s behaviors, or there is a reaction to prescribed medications.
Two important questions to ask yourself are: 1) "Am I moving forward in the world of action or am I living in my head? 2) "Am I moving closer to my values or am I moving away from what I value?"
How long will I have ADHD?
ADHD does not go away but many people learn to manage it successfully in their adult lives. ADHD is a lifelong condition, and behaviors are often successfully managed with medicine and behavioral treatment.
A child with ADHD typically may become hyper focused with activities of interest. 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 schoolwork at home.
Your child uses a certain kind of attention — called automatic attention — when doing something that is of interest to them. However, things that require effort, such as homework, require a different type of attention — called directed or effortful attention — which is harder to use and requires much more effort.
What are some additional strategies for managing my child’s ADHD at home?
You 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 them what not to do. Recognizing and acknowledging positive behaviors is an effective way to teach your child what to do. This increases the expression of appropriate behavior.
- Set up an effective behavior system: Create a consistent system to reward appropriate behavior and respond to misbehavior with alternatives such as a "time out" or loss of privileges. Corporal punishment (spanking) is not effective. A common practice is to use "marbles-in-a-jar" wherein the child earns one marble for a specified appropriate behavior in the household. When a certain number of marbles are earned, they can be exchanged for a privilege.
- 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 the child can see: 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 a home workstation for school work 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 timeframe 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 from many classes.
- Praise effort and completion: Reward the child’s completed work instead of punishing incomplete work. Refrain from telling your child how smart he or she is. When children think they are "smart," the next time they confront work that is difficult for them, they quit because they don’t want to present themselves as incapable of completing the work (i.e., not being smart).
What strategies can parents with ADHD use to resolve conflicts with children with ADHD?
- Be aware: Accept the fact that you are angry, frustrated and fearful. So is your child or teen. You can’t help your child through tough times if you can’t control your own emotions. You may find it helpful to seek the help of a healthcare provider.
- Be honest and positive: Admit to your child that having ADHD is not easy, that it takes a lot of effort to stay on track. Tell him/her about some of the challenges you yourself faced, and the ways you successfully managed them. Use humor to deflect anxiety or anger. Make it a habit to reinforce your child’s strengths.
- Practice healthy confrontation: If you are about to lose your temper, use these techniques: Avoid accusation and focus on the behavior. Focus on solutions to the problem and teach your child or teen to find alternatives that work. Make it clear that your child is not only his or her behaviors, and that he or she, within reason, can control them. If you or your child starts to shout, break the pattern by speaking softly.
- Avoid the guilt trip: You may have challenges like those of your child, but they are their own person. ADHD is an explanation of behaviors, not an excuse for them. Your failures don’t mean you shouldn’t have reasonable expectations for your child.
- Humor works: Parents who have a sense of humor during tense, stressful situations may make their child or teen feel more accepted, less anxious, and better able to manage their emotions.
- Model behavior you want your child to emulate. Don’t let the perception that you’ve failed as a parent because of your child’s challenges affect your interactions with him or her. You are a role model for your child, imperfections and all. Your child is constantly watching you. Model behavior that you would like your child to imitate.
In addition to the formal symptoms used to diagnose ADHD in children and adults, are there other easy to identify behaviors and problems that indicate an adult may have ADHD?
Yes. The following behaviors and problems might stem directly from ADHD or might be the result of related adjustment difficulties in adults:
- Chronic lateness and forgetfulness.
- Lack of organizational skills.
- Low self-esteem and self-inefficacy.
- Employment problems.
- Difficulty controlling anger.
- Perception of laziness (Very few people are lazy. What we call laziness is most likely avoidance behavior.)
What strategies can help an adult with ADHD succeed in the workplace?
If you struggle at your job, it may be because your job requires strong organization, focus and decision-making skills—the very skills that people with ADHD struggle with. Your healthcare provider can help. Ask your provider for referral to other professionals, such as a professional ADHD Coach, who can offer the following tactics that can help you thrive at your job:
- Time-management training to help get to work on time, handle tasks and attend meetings at designated times and meet deadlines.
- Relaxation and stress management training to help cope with new and difficult situations and people.
- 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.
What questions should I ask my child’s healthcare provider about ADHD?
- Does my child have a learning disability in addition to ADHD?
- What type of ADHD does my child have?
- Does my child have a psychiatric illness in addition to ADHD?
- How do I explain to my child what ADHD is?
- What’s the best medicine for my child? (Please remember that you won’t know until you try.)
- How do I improve my child’s self-esteem and self-efficacy?
- How do I talk to my child’s teachers about his/her ADHD?
- How do I judge if a medication is worth the side effects that come with it?
- What are the side effects of the prescribed medications?
- What are my child’s strengths? What are my child’s weaknesses?
What questions should I ask my healthcare provider about ADHD?
- If my child has ADHD, does that mean that I have it, too?
- How do I know when to discipline my child and when to let the behavior go?
- Do I have a learning disability in addition to ADHD?
- What type of ADHD do I have?
- Should I have a conversation with my supervisor at work regarding my disorder?
- Do I have a psychiatric illness as well as ADHD?
- Why do I have ADHD? Is it environmental? Biological?
- Should I have my home tested for poisons such as lead?
- Are there any foods I should eat, or any foods I should avoid?
- How do I judge if a medication is worth the side effects that come with it?
- What are the side effects of the prescribed medications?
A note from Cleveland Clinic
Attention-deficit hyperactivity disorder (ADHD) is a common, lifelong condition that affects children, teens and adults. Although it can negatively affect behavior, thinking, and attention, it is nevertheless treatable with behavior therapy and medication. Behavioral treatments and support from friends, family and teachers are always helpful. Stay in contact with your healthcare provider. Be open and honest about all of the behavior you find problematic. Together, come up with a plan.
There may seem like there’s a lot to do for your child between dealing with school and healthcare providers and monitoring homework. If you also have ADHD, there’s even more to do like attending therapy sessions, taking your own medicines and monitoring your children. There are long to-do lists, and they are especially complicated if you have ADHD and may give a sense of feeling overwhelmed like your child often feels. However, it is possible to have things work far better than they are and it is helpful to follow the tips in this article. And so doing you can drastically improve your child’s life and your own. Never hesitate to contact your healthcare providers with any questions or concerns about you or your child’s ADHD. They are there to help you!
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