Attention-deficit/hyperactivity disorder (ADHD) in children

Symptoms

The main features of ADHD include not paying attention and being hyperactive and impulsive. ADHD symptoms usually start before age 12. In some children, they can be seen as early as 3 years of age. ADHD symptoms can be mild, moderate or severe. Symptoms need to be seen in two or more settings, such as at home and at school. The symptoms cause problems with development and daily life and may continue into adulthood.

ADHD occurs more often in boys than in girls. Behaviors can be different in boys and girls. For example, boys may be more hyperactive and girls may tend to quietly not pay attention.

There are three types of ADHD:

• Predominately inattentive. In this type, most symptoms fall under inattention. This means having trouble focusing and staying on a task. It also includes trouble getting and staying organized.
• Predominately hyperactive and impulsive. In this type, most symptoms involve being hyperactive and impulsive. Hyperactive means being too active and having too much energy. It may include disruptive behavior. Being impulsive means acting without thinking ahead about the results or effects of behavior.
• Combined. This type is a mix of inattentive symptoms and hyperactive and impulsive symptoms. The person meets the criteria for both predominately inattentive and predominately hyperactive and impulsive types of ADHD.

Inattentive symptoms

A child who shows a pattern of inattention may often:

• Fail to pay close attention to details or make careless mistakes in schoolwork.
• Have trouble staying focused in tasks or play.
• Seem not to listen, even when spoken to directly.
• Have a hard time following through on instructions and not finish schoolwork or chores.
• Have trouble organizing tasks and activities.
• Stay away from or not like tasks that need focused mental effort, such as homework.
• Lose items needed for tasks or activities, for example, toys, school assignments, pencils.
• Be easily distracted by other things, thoughts or activities rather than finishing a task.
• Forget to do some daily activities, such as forgetting to do chores.

Hyperactive and impulsive symptoms

A child who shows a pattern of hyperactive and impulsive symptoms may often:

• Fidget with or tap hands or feet, or squirm in the seat.
• Have a hard time staying seated in the classroom or in other situations.
• Be on the go, in constant motion.
• Run around or climb in situations when it's not proper.
• Have trouble playing or doing an activity quietly.
• Talk too much.
• Blurt out answers, interrupting the questioner.
• Have trouble waiting for a turn.
• Interrupt others' conversations, games or activities.

Typical development versus ADHD

Most healthy children are inattentive, hyperactive or impulsive at one time or another. It's typical for preschoolers to have short attention spans and not be able to stick with one activity for long. Even in older children and teenagers, attention span often depends on the level of interest.

The same is true of hyperactivity. Young children are naturally energetic. They often are still full of energy long after they've tired their parents. And some children just naturally have a higher activity level than others do. Children should never be classified as having ADHD just because they're different from their friends or siblings.

Children who have problems in school but get along well at home or with friends may likely have a concern other than ADHD. The same is true of children who are hyperactive or inattentive at home but whose schoolwork and friendships aren't affected.

When to see a doctor

If you're concerned that your child shows signs of ADHD, see your pediatrician or family healthcare professional. Your healthcare professional can do a medical evaluation to check for other causes of your child's symptoms. Then if needed, your child may be referred to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist.

Risk factors

Risk factors for ADHD may include:

• Having a blood relative, such as a parent or sibling, with ADHD or another mental health condition.
• Being around environmental toxins such as lead, which is found mainly in paint and pipes in older buildings.
• Being born to a parent who used recreational drugs, alcohol or tobacco during pregnancy.
• Being born too early, also called premature birth.

Although many people seem to believe that sugar causes hyperactivity, there's no proof of this. Many issues in childhood can lead to trouble paying attention, but that's not the same as ADHD.

Prevention

To help lower your child's risk of ADHD:

• During pregnancy, avoid anything that could harm your baby's development before birth. For example, don't drink alcohol, use drugs or smoke cigarettes.
• Protect your child from exposure to pollutants and toxins, including cigarette smoke and lead paint.
• Limit screen time. Although still not proved, it may be a good idea for young children to limit TV, video games and other screen time.

Treatment

Standard treatments for ADHD in children include medicines, behavior therapy, counseling and education services. These treatments can lessen many of the symptoms of ADHD, but they don't cure it. Treatment also can help prevent some complications caused by ADHD. It may take some time to find what works best for your child.

Stimulant medicines

Stimulant medicines, also called psychostimulants, are currently the most prescribed medicines for ADHD. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters. The medicines help lessen the symptoms of inattention and hyperactivity. They can sometimes help in a short period of time.

Examples of stimulant medicines include:

• Amphetamines. These include dextroamphetamine (Dexedrine Spansule), dextroamphetamine-amphetamine (Adderall XR, Mydayis) and lisdexamfetamine (Vyvanse).
• Methylphenidates. These include methylphenidate (Concerta, Ritalin, others), dexmethylphenidate (Focalin) and dexmethylphenidate-serdexmethylphenidate (Azstarys).

Stimulant medicines are available in short-acting and long-acting forms. Long-acting patches of methylphenidate (Daytrana) or dextroamphetamine (Xelstrym) are available. They can be worn on the hip.

The right dose varies from child to child, so it may take time to find what works for your child. And the dose may need to be adjusted if side effects occur or as your child matures. Ask your healthcare professional about possible side effects of stimulant medicines.

Stimulant medicines and certain health risks

Some research suggests that using ADHD stimulant medicines with certain heart problems may be a concern. Weight and growth may be affected. Also, the risk of certain mental health symptoms may be higher when using stimulant medicines.

• Heart conditions. Stimulant medicines may cause a rise in blood pressure or heart rate. But the higher risk of serious side effects or sudden death is still not proved. The healthcare professional evaluates your child for any heart condition or family history of heart disease before prescribing a stimulant medicine. The healthcare professional also monitors your child when stimulant medicines are used.
• Appetite changes, weight loss and slowed growth. Stimulant medicines can affect appetite and cause weigh loss. These medicines also can slightly affect height growth.
• Mental health conditions. Stimulant medicines may rarely raise the risk for agitation or irritability. Uncommonly, manic symptoms or losing touch with reality can happen. Contact your child's healthcare professional right away if your child has sudden new or worsening behavior or sees or hears things that aren't real while taking stimulant medicine.

Other medicines

Medicines that are sometimes called nonstimulants have been approved by the U.S. Food and Drug Administration, also called the FDA, to treat ADHD. These include:

• Atomoxetine (Strattera).
• Viloxazine (Qelbree).
• Guanfacine (Intuniv).
• Clonidine (Onyda XR).

Antidepressants, such as bupropion (Aplenzin, Wellbutrin XL, others), are not specifically approved by the FDA to treat ADHD. But they may be effective if other medicines haven't worked or have too many side effects.

Atomoxetine and antidepressants work slower than stimulant medicines do and may take several weeks to show a full effect. These may be good options if your child can't take stimulant medicine because of health conditions or severe side effects.

Suicide risk

Although not proved, concerns have been raised that there may be a slightly higher risk of suicidal thinking in children and teenagers taking atomoxetine, viloxazine or antidepressants. Contact your child's healthcare professional right away if you notice any signs of depression or suicidal thinking.

Give medicines safely

It's very important to make sure your child takes the right amount of the prescribed medicine. Parents may be concerned about stimulant medicines and the risk of misuse and addiction. Stimulant medicines are considered safe when your child takes the medicine as prescribed by the healthcare professional. Your child should see the healthcare professional regularly to decide if the dose of the medicine needs to be adjusted.

There is concern that other people might misuse stimulant medicines prescribed for children and teenagers with ADHD. To keep your child's medicine safe and to make sure your child is getting the right dose at the right time:

• Give medicines carefully. Supervise children and teens when they take ADHD medicines rather than letting them be in charge on their own.
• At home, keep medicine in a childproof container. Also store medicine out of the reach of children. An overdose of stimulant medicine is serious and could result in death.
• Don't send supplies of medicine to school with your child. Deliver any medicine yourself directly to the school nurse or health office.

ADHD behavior therapy

Children with ADHD often benefit from behavior therapy, social skills training, parent skills training and counseling. These may be provided by a psychiatrist, psychologist, social worker or other mental health professional. Some children with ADHD also may have other mental health conditions such as anxiety or depression. Counseling may help both ADHD and the other condition.

Examples of therapy include:

• Behavior therapy. Teachers and parents can learn behavior-changing strategies, such as token reward systems and timeouts, for dealing with difficult situations.
• Social skills training. This can help children learn proper social behaviors.
• Parenting skills training. This can help parents develop ways to understand and guide their child's behavior.
• Talk therapy. Also called psychotherapy, this allows older children with ADHD to talk about issues that bother them, explore negative behavior patterns and learn ways to deal with their symptoms.
• Family therapy. Family therapy can help people find ways to overcome challenges that may arise when a family member has ADHD.

The best results happen when a team approach is used. Your child's team may include teachers, parents, therapists and healthcare professionals working together. Learn about ADHD and available services. Work with your child's teachers and refer them to trusted sources of information to support their efforts in the classroom.

Medical devices

The FDA has approved two devices for ADHD. They both need a prescription.

• Monarch external trigeminal nerve stimulation (eTNS) system. This is a medical device to treat children with ADHD who are 7 to 12 years old and not taking ADHD prescription medicine. The device creates low-level electrical pulses that move through a wire to a small patch placed on the child's forehead. Signals are sent to areas of the brain that relate to attention, emotion and behavior.
• EndeavorRx. This is a game-based digital therapeutic device. The game is designed to improve attention in children with predominately inattentive- or combined-type ADHD who are 8 to 17 years old.

These devices have FDA approval, but they are new and have limited evidence and data to guide treatment. If you're considering these devices, it's important to talk with your healthcare professional about precautions, expectations and possible side effects. Get complete information and instructions from your healthcare professional.

Ongoing treatment

Your child should see a healthcare professional regularly while being treated for ADHD. If symptoms are much better and stable, visits usually take place every 3 to 6 months.

Contact the healthcare professional if your child has any medicine side effects, such as loss of appetite, trouble sleeping or worse irritability. Also contact the healthcare professional if your child's ADHD symptoms are not getting better with the current treatment.

Alternative medicine

Alternative medicine means using another approach instead of standard medical care. Complementary medicine means using alternative medicine along with standard medical care. This mix is sometimes called integrative medicine.

There's little research that shows that alternative or complementary medicine can lessen ADHD symptoms. If you're thinking about trying alternative medicine, talk with your child's healthcare professional first to decide if the therapy is safe and effective. Some alternative medicine treatments that have been tried but are not yet fully proved scientifically include:

• Yoga or meditation. Regular yoga or meditation and relaxation techniques may help children relax and learn discipline. This may help them manage their symptoms of ADHD.

• Special diets. Most diets promoted for ADHD involve not eating foods thought to worsen hyperactivity, such as sugar, and foods that are common allergens, such as wheat, milk and eggs. Some diets recommend staying away from artificial food colorings and additives. So far, studies haven't found a consistent link between diet and fewer symptoms of ADHD.

  Also, limiting foods may keep children from getting a healthy well-balanced diet. Some evidence based on individual reports or personal experience suggests diet changes might make a difference in children with specific food sensitivities. Using caffeine as a stimulant for children with ADHD can have risky effects and is not recommended.

• Vitamin or mineral supplements. While certain vitamins and minerals from foods are needed for good health, there's no evidence that supplemental vitamins or minerals can lessen symptoms of ADHD. "Megadoses" of vitamins, which are doses far above the Recommended Dietary Allowance can be harmful.
• Herbal supplements. There is no evidence to suggest that herbal remedies help with ADHD, and some may be harmful.
• Proprietary formulations. These are products made from vitamins, micronutrients and other ingredients that are sold as possible treatment supplements for children with ADHD. These products have had little or no research and are not monitored by the FDA, making them possibly not effective or harmful.
• Essential fatty acids. These fats, which include omega-3 fatty acids, are needed for the brain to work properly. Researchers are still studying whether these may lessen ADHD symptoms.
• Neurofeedback training. This also is called electroencephalographic biofeedback. During these sessions, a child focuses on certain tasks while using a machine that shows brain wave patterns. Using the feedback on the monitor, the child learns to control brain activity to help manage focus and behavior. More research is needed to see if this works.

Preparing for an appointment

You're likely to start by taking your child to a pediatrician or family healthcare professional. Depending on the results of the evaluation, your healthcare professional may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist.

What you can do

To prepare for your child's appointment:

• Make a list of any symptoms and troubles your child has at home or at school.
• Bring notes about important personal information, including any major stresses or recent life changes.
• Make a list of all medicines, vitamins, herbs and other supplements that your child is taking, and the doses.
• Bring any past evaluations and results of formal testing if you have them, and school report cards.
• Make a list of questions to ask your child's healthcare professional.

Questions to ask may include:

• Other than ADHD, what are possible causes for my child's symptoms?
• What kinds of tests does my child need?
• What treatments are available, and which do you recommend?
• What are options other than the main approach that you're suggesting?
• My child has other health conditions. How can I best manage these conditions together?
• Should my child see a specialist?
• Is there a generic option for the medicine you're prescribing for my child?
• What types of side effects can we expect from the medicine?
• Are there any printed materials that I can have? What websites do you suggest?

Feel free to ask other questions during your appointment.

What to expect from your doctor

Your healthcare professional may ask you questions, such as:

• When did you first notice your child's behavior issues?
• Do the troubling behaviors occur all the time or only in some situations?
• How big of a challenge are your child's behaviors at home and at school?
• What, if anything, appears to make your child's behavior worse?
• What, if anything, seems to make your child's behavior better?
• Does your child drink beverages with caffeine? How often?
• What are your child's sleep hours and patterns?
• How well has your child done in school in the past and how is your child doing now?
• Does your child read at home? Does your child have trouble reading?
• What do you do when your child doesn't behave well or doesn't follow the rules at home? Which methods of discipline work the best?
• Describe who lives at home and a typical daily routine.
• Describe your child's family and friend relationships at home and at school.

Be ready to answer questions so you have time to talk about what's most important to you.