ADHD SymptomsADHD (Attention Deficit Hyperactivity Disorder) is defined as a persistent inability to maintain age appropriate concentration, attention and/or activity levels. The symptoms are typically present before the age of 7, are more often seen in boys than in girls, and cause some degree of impairment in at least 2 significant settings.
The symptoms must have been present for at least 6 months to be considered a true diagnosis. Children with ADHD have difficulties learning, due to impaired concentration. These difficulties often result in behavior problems at school related to high activity levels, impulsivity, intermittent or persistent inability to demonstrate age appropriate academic progress and to appropriately interpret social cues. Several studies have supported the findings that 3-5% of school-age children meet the criteria for ADHD. The condition is not associated with intelligence levels.
Cause of ADHD
Studies comparing brains of ADHD and non-ADHD children have found differences in brain chemistry in the frontal lobes, the area of the brain that is responsible for attention, planning, problem solving and reasoning. This provides the basis for the success of many medications in the treatment of ADHD.
ADHD clearly runs in families, therebyestablishing a genetic component to the condition. Studies have shown that if one parent meets the criteria for ADHD, there is a 50% chance that there child will also have ADHD. Fathers with ADHD have a 60-80% chance of having a son that displays symptoms of ADHD by age 7. In addition, a sibling of a child with ADHD has a 33% chance of being diagnosed. Many studies have shown, through adoption and twin studies, that the genetics of the biological parents have a significantly greater impact on the diagnosis of ADHD than the environmental setting the child is living in.
Environmental factors have been shown to potentially exacerbate symptoms of ADHD in children. Lack of structure, disorganization, poor eating and sleeping habits will exacerbate ADHD symptoms. By the same token calm, well structure and organized environemt that provide consistent daily routines along with heathly eating and sleeping habits tend to minimize symptoms of ADHD.
ADHD is a medical diagnosis given to a child after an evaluation by a mental health professional or a medical doctor. For most schools aged children the diagnostic process begins at school. Since children spend the majority day at school, the teachers and other education staff are usually the first to become aware of the child’s attentional difficulties. They may start the process of diagnosis by suggesting a child study team evaluation. The child study team may recommend further evaluation by a medical or mental health professional to corroborate their conclusions. There are three subtypes of ADHD; Inattentive, Hyperactive-Impulsive and Mixed types. See the list of symptoms for each subtype below.
1) Fails to pay close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2) Has difficulty sustaining attention in tasks or play activities.
3) Does not seem to listen when spoken to directly.
4) Does not follow through on instructions and fails to finish school work
and household chores.
5) Has difficulty organizing tasks and activities.
6) Avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (such as schoolwork or homework).
7) Loses things necessary for tasks or activities (toys, keys, school
assignments, pencils, or books).
8) Is easily distracted by extraneous stimuli.
9) Is often forgetful in daily activities.
1) Fidgets with hands or feet, squirms in seat.
2) Leaves seat in classroom or in other situations in which remaining
seated is expected.
3) Runs around or climbs excessively in situations in which it is inappropriate.
4) Has difficulty playing or engaging in leisure activities quietly.
5) Is “on the go” or often acts as if “driven by a motor”.
6) Talks excessively.
7) Blurts out answers before questions have been completed.
8) Has difficulty waiting turn.
9) Interrupts or intrudes on others (e.g. at school or work, or at home).
ADHD-Inattentive Type (ADD) requires the presence of at least 6 symptoms from the inattention list and fewer than 6 symptoms in the Hyperactive-Impulsive list.
ADHD-Hyperactive-Impulsive Type requires at least 6 symptoms from the Hyperactive/Impulsive list and fewer than 6 symptoms in the Inattention list.
ADHD-Mixed Type is the diagnosis when there are 6 or more symptoms of Inattention and 6 or more symptoms of Hyperactivity-Impulsivity.
The diagnosis of childhood ADHD can be made by a child psychologist, pediatrician, family practice doctor, pediatric neurologist or a child psychiatrist. Although psychologist are adept in analyzing behavior, it is important that a medical doctor perform a physical examination to rule out the possibility of a medical condition contributing to inattentive, hyperactivity and impulsive behavior. The doctor may need to order tests if there are findings on examination or medical history that warrant further examination. For example, hyperactivity is also a symptom of hyperthyroidism. The findings on physical examination would be elevated heart rate, blood pressure and findings of an enlarged thyroid.
A parent or guardian needs to be able to give a detailed history to the clinician in order to establish a true diagnosis. There is no single test used to daignose ADHD. Rather a combination of different tools are used to determine whether or not a child has ADHD, if so, what type. The behaviors need to be present in at least 2 settings. This critera is usually established by getting a through history from caretakers, teachers and any other adults who have regular interaction with the child. The parents or caretakers can give a history of attention and focus abilities during homework time and tasks that required sustained attention (not including games). The teacher’s feedback is crucial in assessing these behaviors at school. The parents have likely discussed these issues with the child’s teacher by the time this has reached the doctor’s office. To help quantify a child’s behaviors in the classroom, the Conner’s Rating Scales are very helpful. This is a series of approximately 30 statements that the teacher uses to rank the child behavior. The form is brought back to the doctor and it is scored for age appropriateness.
Some form of academic, perceptual or psychological testing may be helpful in making the diagnosis of ADHD. This is important for 2 reasons. First it is important to rule out learning disabilities as a cause of difficulty remaining focused and staying on task. Secondly, there are several testing situations that measure tasks that require a higher degree of attention. In addition to a through history and resting, the clinician’s observations are crucial in helping establish a diagnosis.
The areas of intervention include behavioral, academic and emotional/social. A program can be developed with the parents to educate them to organize an all inclusive approach. Not all children will need intervention in all 3 areas and some will require extentive assistance in specific areas. The interventions depend on the symptoms and behaviors that are most problematic for the child. All children benefit from an appropriate sleep pattern, healthy diet and daily excersize.
Behavioral interventions are most common required. There are two types of behavioral interventions. The first is the use of Behavioral Modification techniques. For youger children a star chart for desired behaviors id=s frequently used. A strong reward should be used to motivate the child. For example, in class a child can earn a star for remaining in there seat and not calling out for an entire lesson. If the child receives 5 stars (during 6 lessions) he/she can earn free time on an activity that they enjoy.
Psychological therapy is another behavior intervention. This should be pursued if the child with ADHD is experiencing social difficulties associated with his/her symptoms. The child may have difficulty socially because they are not paying attention to social cues or noticing important social rules in groups.
Medication is considered after the educational and behavioral methods are in place. It is important to first teach the child with ADHD how to begin to deal with their attention and activity related behaviors. If these interventions are not suffiecent to allow the child to learn or behave at age appropriate levels, medication should be strongly considered.
The following is a presentaion of medications approved for the treatment of ADHD. There have not been studies that show one is overall more effective than the other, but individual medications may work better under cirtain circumstances. The child may only be having diifculty paying attention in school, but in a quiet home environment with no distractions has no problem remaining focused. In this case, a short acting medication may be sufficient. Anither child may have difficulty all through the day and in the late afternoon sports practice. A long-acting medication would be beneficial in this situation.
Ritalin (Methylphenadate) was the first drug to be approved for ADHd over 30 years ago. This is a short-acting (approximately 4 hours) medication. Commonly a second dose will be required at lunchtime for benefit in the afternoon.There are several more recent formulations of short-acting methylphenadate, including Methylin and Metadate.
Methylin is avalble in short-acting tablet, a chewable tablet and is now available in an oral solution. The oral solution and chewable tablet are beneficial for child that has problems swallowing tablets. Using the solution also allows for a lower dose to be administered to younger children and smaller increases can be made. The solution strength is 5mg/ml. Therefore 1 mg ( 1 ml) can easily be administered as a starting dose in a smaller child. The lowest dose formulation of the other methylphenadate tablets is 5 mg. Even if the tablets are divided in half, that is a dose of 2.5 mg.
Ritalin SR (sustained release) was introduced in an attempt have a medication last longer . Ritalin SR workes for about 5-6 hours.
Metadate ER (extended release) works on the same principle as Ritalin SR.
Ritalin LA (long acting) uses a new form of methylphenadate to provide an 8 hour effect. It is a capsule that contains “beads” of the medicine. About half are coated and are released and absorbed gradually though out the day. The benefit of the capsule formulation is that the contents can be sprinkled on yogert or pudding for those who have trouble swallowing pills/
Metadate CD works on the same principle as Ritalin LA.
Concerta uses a breakthrough technology drug delivery system that allows a measured amount of methylphenadate to be released over a 12 period. There is a lower amount of medication released in the morning and is gradually increased in the afternoon and works through homework time for most children.
Focalin (dexmethylphenidate) is a short-acting medication that uses a modified methylphenadate molecule. It has been shown to be as effective as methylphenadate with fewer side effects.
Focalin XR (extended release) is a capsule with some of the “beads “ are coated and are absorbed after 4-5 hours to provide a beneficial effect over 12 hours. Again, the capsule can be opened and sprinkled on a spoonful of yogurt or pudding.
Daytrana is the first and only methylphenadate transdermal patch available for the treatment of ADHD. The patch is applied to the hip region about 2 hours before the medication will begin to work. The patch slowly releases the medication from a gelatinous material in the patch. The medication is absorbed thought he skin and gradually enters the blood stream. Therefore when the patch is removed there is still medication in the layers of skin to be absorbed. The patch can be worn a maximum of 9 hours. The patch is beneficial for those children with difficulty swallowing and lasts up to 12 hours. This patch may be able to be used in children with gastrointestinal problems since it is not taken orally.
Dexedrine (dextroamphetamine) was the first non-methylphenadate ADHD medication approved. It is a short-acting medication with a similar effectiveness as methylphenadate.
Dexedrine Spansule is a capsule for and lasts up to hours,
Adderall (mixed salt amphetamine) is also a short-acting medication, but typically will last up to 6 hours.
Adderall XR (extended release) is in capsule form and is effective for up to 10 -12 hours. This formulation can also be sprinkled on a spoon of yogurt or pudding.
Strattera (atomoxetine) is the first non-stimulant approved for ADHD. The medication works on a different pathway in the brain than the stimulant medication. There are no significant problems with appetite suppression or sleep. This medication can take up to a week to begin working. There are several benefits to Strattera. It has been shown to be effective throughout the day and even into the evening.
In the last 10 years there has been significant progress in understanding the areas of the brain responsible for ADHD symptoms and the genetics responsible for inheriting the characteristic symptoms. In addition to helping us understand this condition, the knowledge gained by decades of research has also made us aware of the complexity of the biological factors associated with ADHD and research that has yet to be done to more completely understand and more effective address the educational, social and behavioral needs of children with ADHD.