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.

There are no tests for ADHD. Your child’s doctor may make a diagnosis. Sometimes the doctor may refer you to an expert to assist with diagnosis.

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.

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.

Behavioral treatment is an active treatment where parents and teachers learn methods and strategies to help children with ADHD. Teens and families may also work with a therapist to build certain strategies to help manage ADHD.  

Strategies for Parents to Use at Home

Parents learn how to manage their child’s behaviors problems caused by ADHD. For example, parents can learn to give better instructions, set small goals and use appropriate rewards and consequences. This shows parents how to help their child with ADHD to behave better. Because the focus is on the child’s behavior, these methods are also called “behavior therapy.” Unlike other therapies, this does not mean talking with the child about how they feel. Rather, therapists help parents learn practical ways to help their child behave better. 

What is usually involved?

In studies where this helped, parents learned these methods in groups with other parents. The groups met between 8 and 16 times. In addition to learning new skills, parents often get support from being in a group with other parents of children with ADHD. Some families benefit from working with a therapist individually.

What is available at Children’s National?

The ADHD & Learning Differences Program and the HALP Clinic offer behavior therapy options for children, teens and families led by clinical psychologists who specialize in ADHD. The ADHD & Learning Differences Program at Children’s National offers parent groups “Understanding and Managing ADHD: A Group Program for Parents of Children with ADHD.” The groups have 8 weekly sessions. Parents learn about ADHD, how to manage child behavior, and how to work with teachers and doctors to help their child. For more information, view our flyer.

Also, your child’s doctor may be able to refer you to a local psychologist. They are trained to help you learn ways to manage your child’s behavior. 

Strategies for Teachers and Parents to Use to Improve Performance at School

Teachers can use many of the same methods as parents to help children behave in school (e.g. set small goals, use time-outs, reward systems and point systems). Daily Report Cards are often used to change behavior in class. They provide a way for teachers and parents to better communicate about progress toward goals. School counselors, school mental health professionals, classroom aides or tutors help children with organization and study skills in school. 

What is usually involved?

In studies where this helped, teachers, school counselors, school mental health professionals, classroom aides and tutors received formal training on methods that are helpful for children with ADHD. This was important because many teachers receive no formal education about ADHD during their training. There are key differences in the types of methods that work best for children with ADHD compared to those without ADHD. 

What is available nearby?

The ADHD & Learning Differences Program  partners with local schools to deliver these programs in the context of ongoing research and community programming. The parent groups offered by the ADHD & Learning Differences Program also include advice about how to successfully work with your child’s teacher. This includes how to use a daily report card, how to tailor classroom methods for children with ADHD and how to request support for your child. 

Choosing Behavioral Treatment

The first step is learning strategies and methods to help your child manage his or her behavior. Next, you need to use these strategies regularly. These strategies will become part of your parenting skills. You may need to refresh these skills through reading and/or meeting with professionals. 

Certain strategies may work for a while and then stop working. You may need to learn different methods. It is very important for you and your child’s teacher to keep a close eye on how things are going. Contact your child’s doctor if any problems come up. 

To learn more about behavioral treatment on your own, review our ADHD resources for families.

Medication treatment uses drug therapy to control ADHD symptoms. Medication for ADHD works by helping the brain send messages to certain parts of the brain that helps children pay attention. 

Types of ADHD Medication

There are two types of medication that can be used: stimulants and nonstimulants. Treatment with a stimulant medication is highly effective in 75-90% of children with ADHD. Stimulant medications are often tried first. In studies, more children benefit from stimulant medications than non-stimulant medications. On average, stimulants reduce ADHD symptoms better than non-stimulant medicines.

Every child is unique. Currently, there is no way to predict which medication will work best for your child. Talk to your child’s doctor about the differences between medications. They can help you pick a medicine to try first, and work with you to find a dose that is best for your child. 

Stimulant medications commonly used to treat ADHD include the following:

• Methylphenidate (Ritalin, Metadate, Concerta)
• Dextroamphetamine (Dexedrine)
• Pemoline (Cylert)
• A mixture of amphetamine salts (Adderall)

Stimulants have been used to treat childhood behavior disorders since the 1930s. They have been studied widely. Stimulants take effect in the body quickly, work for one to four hours, and then leave the body quickly. Doses of stimulant medications need to be timed to match the child's school schedule – to help the child pay attention for a longer period of time and improve classroom performance. 

The most common side effects of stimulants are:

• Trouble falling asleep
• Decreased appetite
• Stomach aches
• Headaches
• Increased crabbiness or irritability
• Increased anxiety, jitteriness and/or crying over little things
• Rebound: Some children are more active or get in a bad mood for a short period of time when the effect of the stimulant wears off

Most side effects of stimulant use are mild, decrease with regular use, and respond to dose changes. Always discuss potential side effects with your child's physician. 

Choosing Medication

The first step is to work with your child’s doctor to find a medicine and dose that works. It should help your child without causing troubling side effects. Next, your child has to continue taking medicine for it to work. If your child is taking a stimulant medicine (e.g. methylphenidate, amphetamine), you will need to come to the doctor’s office every few months to pick up a refill. Let your child’s doctor know how things are going. It is important to have regular follow-up visits with your child’s doctor. They will check your child’s growth (i.e. height and weight). They will also check your child’s heart rate and blood pressure. They might make changes to the medicine. 

Even if you find a medicine and amount that works for your child, things can change over time. You and your child’s teacher need to keep a close eye on how things are going. Call your child’s doctor if problems arise. Sometimes the medicine stops working as well as it did before. Sometimes children start having side effects. 

Many children change the amount or type of medicine within 14 months of treatment. The average time to first medicine change is about five months. The average number of medicine changes is two per child. Keep in mind: 

• Some children stay on the same medicine and dose because the medicine is working well. 
• Some children change to a lower dose or a different medicine because they start having troubling side effects. 
• Many children change to higher dose because they original dose isn’t helping as much as before. 

Antidepressant medications may also be administered for children and adolescents with ADHD to help improve attention while decreasing aggression, anxiety and/or depression.

Medication and Your Child's Personality

While your child may stop and think before talking or acting, their personality should not change due to being on medication. If your child loses interest in the things they enjoy, they may be on a dose that is too high.

Medication Addiction Concerns

It is unlikely that children will become addicted to their ADHD medication, as children do not crave the medicine when it is not given. However, some children do notice that it is harder to focus on days that they don’t take their medicine.