Pediatric Attention-Deficit / Hyperactivity Disorder (ADHD)

There are three different presentations of ADHD, including:

• ADHD Inattentive. Children and teens who have difficulty paying attention. This presentation of ADHD used to be called attention-deficit disorder or ADD. 
• ADHD Hyperactive/Impulsive. Children who are very hyperactive and have problems acting without thinking first. This is the least common type of ADHD, usually seen in younger children.
• ADHD Combined. Children who have difficulties paying attention, being hyper and acting without thinking first.

ADHD is a brain-based biological disorder that is one of the most researched areas in child and adolescent mental health. Current research suggests ADHD may be caused by interactions between genes and environment or non-genetic factors. Like many other illnesses, a number of factors may contribute to ADHD such as:

• Genes, because ADHD sometimes runs in families
• Smoking and drinking alcohol during pregnancy 
• Exposure to lead in old paint and plumbing parts
• Certain brain injuries

Diet does not cause ADHD. Food additives like sugar or artificial dyes and preservatives might cause a slight increase in hyperactivity for any child (with or without ADHD), but they do not cause ADHD.

Although the cause of ADHD is not certain, family stress, such as divorce, does not cause ADHD.

Environmental factors such as the structure of the classroom or parenting styles do not cause ADHD, but they do influence your child’s behaviors.

Although the precise cause of the disorder is unknown, low levels of dopamine (a brain chemical), are found in children with ADHD. Brain imaging studies using PET scanners (positron emission tomography; a form of brain imaging that makes it possible to observe the human brain at work) show that brain metabolism in children with ADHD is lower in the areas of the brain that control attention, social judgment and movement.

Children of all backgrounds can have ADHD. Teens and adults can have ADHD too. ADHD is the most common mental health problem of childhood, affecting 5% to 9% of children and 4% of adults.

It is normal for all children to have problems paying attention, being hyper or acting without thinking sometimes. But for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with ADHD, a child must have more symptoms than other children their age for at least six months. While each child may experience symptoms differently, the following are the most common symptoms of ADHD.

Children, teens and adults who have difficulties paying attention may:

• Be easily distracted, miss details and forget things
• Have a short attention span for their age 
• Often switch from one activity to the next
• Have a hard time focusing on one thing
• Not seem to listen when spoken to 
• Have a hard time planning and completing task 
• Have trouble completing or turning in homework
• Often lose things (e.g., pencils, toys, homework) needed to complete tasks or activities
• Daydream, become easily confused and move slowly
• Struggle to follow instructions

Children and teens with hyperactivity may:

• Fidget and squirm in their seat 
• Talk nonstop
• Have difficulty sitting still during dinner, school and story time
• Be constantly moving or feel restless
• Run around, climb on things, touch or play with everything in sight
• Have trouble doing quiet tasks or activities

Children and teens who experience impulsivity may:

• Be very impatient
• Show their emotions without restraint
• Often interrupt others
• Have difficulty waiting for things they want or waiting their turn
• Blurt out answers instead of waiting to be called upon
• Act without regard for consequences

Children do not have to have all of these symptoms, nor do they have to show the same symptoms in all settings for a diagnosis to be made. For example, most children with ADHD can pay attention in situations in which they are very interested (e.g., a favorite television show), or in a one-to-one setting such as a testing session with a psychologist. 

Since all children show some of these behaviors some of the time, it is important that the behaviors be present to a significant degree compared to other children of the same age and that they be causing significant disruption to the child’s daily life before the child is diagnosed with ADHD. The symptoms of ADHD may also resemble other medical conditions or behavior problems. If you are concerned about whether your child might have ADHD, the first step is to talk with a healthcare professional. The diagnosis can be made by a mental health professional, like a clinical psychologist or psychiatrist, primary care provider or pediatrician.

Deciding if a child or teen has ADHD is based on how they act. For a diagnosis of ADHD, behavior must be seen at home and at school. Assessment may include:

• Parent and teacher questionnaires
• Psychological testing of the child and family (e.g., IQ testing and psychological testing)
• Observations of the child in natural settings
• Evaluation of a child’s growth and development

There is no blood test, computer test or imaging test (like an MRI) that can reliably diagnose ADHD. To make a diagnosis, doctors need information from parents and teachers about these behaviors listed above. They ask parents and children questions and examine the children to make sure there aren’t other problems. Standardized rating scales and interviews should be used. 

A diagnosis is not as important as a good assessment of the problems that a child or teen is experiencing in daily functioning and identifying what can be done to improve the problems.

Many people think of ADHD as a childhood problem. However, ADHD can continue through the teen years and into adulthood. Symptoms of ADHD do change over time. Key points to remember as a child grows include:

• Hyperactivity is often seen in very young children. The hyperactive symptoms often lessen over time, and for teens and adults these behaviors are experienced more often as restlessness or fidgeting.
• Inattention, restlessness and impulsivity tend to persist into adulthood.
• Trouble paying attention may not get noticed until demands at school increase. These problems often continue in the teen and adult years. Using routines, organization skills and coping strategies can help people with these problems.

Every child and teen is different, and you know your child best. As a parent, trust your thoughts and feelings when deciding on treatments. Discuss treatment options with your child’s doctor. Gather as much information as you need to make a decision that is right for you and your child.

Some things to consider when deciding on treatments:

• Balancing possible benefits with side effects, cost and time
• Your child's age, overall health and medical history
• Extent of your child's symptoms
• Your opinion or preference
• Track and monitor your child’s progress. Your decisions may change over time as your child’s needs change.
• It is impossible to predict how your child will respond because every child is unique. The only way to find out if a treatment will help your child for sure is by trying it. 

Every effort should be made to manage symptoms and direct your child to helpful paths. There are three treatment options to consider:

• Behavioral treatment
• Medication
• Combined treatment (both behavioral treatment and medication)

Preventive measures to reduce the incidence of ADHD in children are not known at this time. Early detection and intervention, however, can reduce the severity of symptoms, decrease the interference of behavioral symptoms on school functioning, enhance the child's normal growth and development and improve the quality of life experienced by children or adolescents with ADHD.