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ADHD

  • ADHD_infograph

    Infographics courtesy of CDC

    ADHD stands for Attention-Deficit/Hyperactivity Disorder. It is one of the most common neurobehavioral disorders that typically begins in childhood and can continue into adolescence and adulthood. In the United States, the percentage of children with an ADHD diagnosis continues to increase, from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 20111. Approximately 6.4 million children 4-17 years of age have been diagnosed with ADHD as of 20111.

    ADHD consists of a group of syndromes characterized by persistent pattern of inattention and/or hyperactivity/impulsivity. People with ADHD may have difficulty sustaining attention, may be hyperactive or restless, and may act impulsively. The onset is typically by the age of 3 to 7 years, although professional attention may not be sought until the child enters school.

    ADHD can only be diagnosed by a healthcare professional, and is treatable with ongoing medication and behavioral interventions. Because ADHD and its treatments are often misperceived and misunderstood, it is especially important to use reliable sources while seeking information. To better assist you, we have compiled a list of frequently asked questions, myths and truths, and validated resources.

    1. Centers for Disease Control and Prevention. Key findings: trends in the parent-report of health care provider-diagnosis and medication treatment for ADHD: United States, 2003—2011. http://www.cdc.gov/ncbddd/adhd/features/key-findings-adhd72013.html (accessed 2014).


  • What is ADHD?

    ADHD stands for Attention-Deficit/Hyperactivity Disorder. It is a common medical condition involving biologically active substances in the brain involved in problem solving, planning ahead, understanding, and impulse control.

    ADHD is characterized by a persistent pattern of inattention and/or hyperactivity/impulsivity that occurs more often and is more severe than is usually seen in one’s peers. There are three subtypes of ADHD.

    1. Inattentive Type
      This subtype is defined by only having inattention and difficulty with organization.
    2. Hyperactive Type
      This subtype is defined by only having the hyperactive and impulsive symptoms.
    3. Combined Type
      This is the most common subtype of ADHD and is defined by having difficulties with both attention and hyperactivity.

    ADHD is usually diagnosed in childhood, although the condition typically continues. In some instances, ADHD may be diagnosed for the first time in adulthood.


    What are the differences between ADD and ADHD?

    ADHD used to be called ADD (attention-deficit disorder). Now, the official medical term is ADHD. Many people still use ADD interchangeably with ADHD, while some may use ADD to refer to the Inattentive Type of ADHD (aka ADHD without hyperactivity).


    What are the symptoms of ADHD?

    ADHD is characterized by inattention, hyperactivity and/or impulsivity. There are three subtypes of ADHD, categorized according to the presence and extent of specific symptoms.

    1. Inattentive Type
      This subtype is defined by only having inattention and difficulty with organization.
    2. Hyperactive Type
      This subtype is defined by only having the hyperactive and impulsive symptoms.
    3. Combined Type
      This is the most common subtype of ADHD and is defined by having difficulties with both attention and hyperactivity.

    Some common signs of ADHD include:

    • Difficulties with attention
      • Trouble paying attention
      • Easily distracted
      • Difficulty organizing tasks and activities
      • Forgetful of daily activities
      • Having trouble responding to details
      • Trouble following multiple commands
    • Hyperactivity
      • Fidgeting with hands and feet
      • Inability to stay seated
    • Impulsivity
      • Talks too much and interrupts on others
      • Impatience

    ADHD symptoms usually appear over many months, often with impulsiveness and hyperactivity preceding inattention. Different symptoms may also appear in different settings.


    What causes ADHD?

    The exact cause of ADHD remains unknown and is under ongoing research. It has been observed that in people with ADHD, alterations in the brain are present due to imbalance of neurotransmitters (chemical messengers).

    To date, researchers believe ADHD may be related to one or more of the following factors1:

    • Genetic predisposition
    • Premature delivery or low birth weight
    • History of environmental exposures (e.g. lead)
    • History of brain injury
    • Maternal smoking or alcohol use during pregnancy

    1. Biederman, J. ADHD: A selective overview. Biol Psychiatry 2005; 57: 1215-1220.


    How do I tell if I have/my child has ADHD? Is there a test?

    ADHD is defined by a group of symptoms and must be carefully evaluated by an experienced professional. You may use this interactive checklist provided by CDC as a guide to help you discuss your or your child’s symptoms with the doctor.


    What do I do if I think I have/my child has ADHD?

    Talk to your healthcare professional if you think you have or your child has ADHD. Your healthcare professional may refer you to an ADHD specialist. The specialist will evaluate the symptoms and talk with multiple people involved in your or your child’s life to determine whether the diagnosis should be made.

    If the ADHD is diagnosed, your healthcare team will work with you to determine an appropriate management plan.


    Can ADHD be treated?

    Yes. ADHD symptoms can be controlled with an effective management plan, and this may include education, medication and/or behavioral therapy. Ongoing assessment and treatment is also necessary.


    What are the consequences of untreated ADHD?

    Current evidence suggests that ADHD is a disorder with serious consequences if left untreated.

    Without treatment, a child or adolescent with ADHD may fall behind in school and have trouble with friendships. Untreated ADHD may also lead to stressful family life.

    Adolescent with untreated ADHD are more likely to drop out of school, to have fewer friends, to participate in antisocial activities, and to be influenced by recreational drug use1, 2.

    1. Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 2003; 111(1): 179-85.
    2. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1990; 29(4): 546-57.


    What medication can be used to treat ADHD?

    Several medications have been approved by the US Food and Drug Administration (FDA) to treat ADHD. These medications are thought to help the areas of the brain that control attention and behavior. Since the doctor needs work with you to find out which medication works best, treatment plan may differ among individuals with ADHD.

    As with all medications, ADHD medications must be used properly and taken exactly as prescribed. Exchanging of medication is unacceptable.

    ADHD medication can be classified into two categories: stimulants and non-stimulants.

    Stimulants

    Stimulants are considered first-line therapy in most cases of ADHD when no contraindication is present and when side effects are tolerated. How these drugs affect the primary symptoms of ADHD is unclear, but they are thought to stimulate the area of the brain that controls focus and attention.Examples of stimulants include:

    • Dextroamphetamine (Dexedrine®)
    • Dexmethylphenidate (Focalin®)
    • Methylphenidate (Concerta®, Ritalin®, Metadate®)
    • Methylphenidate patch (Daytrana®)
    • Mixed amphetamine salts (Adderall®)

    Non-Stimulants

    Non-stimulants are an alternative to stimulants when one is contraindicated to the latter, cannot tolerate the side effects, or remains unresponsive despite treatment. Depending on the doctor’s professional judgement, they may also be used in combination with a stimulant when necessary to control specific symptoms.Non-stimulants consist of a variety of chemical classes and each has unique mechanisms.Examples of non-stimulants include but are not limited to:

    • Atomoxetine (Strattera®)
    • Bupropion (Wellbutrin®)
    • Clonidine (Catapres®)
    • Guanfacine (Tenex®, Intuniv®)

    Suggested reading:

    1. What We Know#3: Managing Medications for Children and Teenagers with AD/HD by National Resource Center on AD/HD


    What side effects are associated with ADHD medication and how can I manage them?

    Common side effects of stimulants include headache, reduced appetite, stomach ache, insomnia, and rebound symptoms between doses. These can be managed using the following measures.

    • To reduce headache, take the medication with food. If this persists, discuss with your doctor to assess if dividing the dose into smaller doses is appropriate.
    • To offset negative effect of reduced appetite, have high-calorie meals when stimulant effects are low (e.g. breakfast or bedtime).
    • To reduce stomach ache, take the medication on a full stomach. If this persists, discuss with your doctor to assess if dividing the dose into smaller doses is appropriate.
    • To avoid insomnia, take the medication early in the day and take the last dose of the medication earlier. Discuss with your doctor first if you would like to get medication for sleep aid.
    • To prevent rebound symptoms, discuss with your doctor to assess if a trial of longer-acting stimulant is appropriate.

    Conversely, side effects of non-stimulants vary among agents.

    • Atomoxetine (Strattera®) can cause nausea, reduced appetite, insomnia or sedation, fatigue, increased blood pressure
    • Bupropion (Wellbutrin®) can cause nausea, insomnia
    • Clonidine (Catapres®) can cause sedation, dizziness, constipation
    • Guanfacine (Tenex®, Intuniv®) can cause sedation, dizziness, constipation


    What other treatments are there for ADHD?

    Multimodal treatment individualized to the specific needs of the child and family is crucial for overall positive therapeutic outcome. Behavior therapy, combined with medication, is often part of an ADHD management plan.

    Examples of behavior therapy cognitive behavioral therapy (CBT), classroom interventions, and contingency management (e.g. rewards for good behavior). Family therapy and parent training may also provide important benefits in providing parents with a better understanding of ADHD and useful coping strategies.

    Suggested reading:

    1. What We Know#7: Behavioral Treatment for Children and Teenagers with AD/HD by National Resource Center on AD/HD
    2. What We Know#21: Cognitive-Behavioral Therapy for Adults with ADHD by National Resource Center on AD/HD


    How often should the symptoms be reassessed?

    Follow-up appointments several times a year will help your healthcare team assess progress and adjust the management plan accordingly.


    When is it okay to stop taking ADHD medication?

    Each individual with ADHD has different circumstances. Many with ADHD will continue to have problems with some symptoms later in life. Others will learn to compensate for their behavioral symptoms. If you have questions about stopping ADHD medication, consult the doctor.

    If you are a parent and would like to know whether your child can stop taking ADHD medication, the choice should be discussed with the doctor, teachers, family members, and your child. Your child may be ready to reduce or stop ADHD medication if he or she is:

    • Symptom-free for more than a year while on medication
    • Doing better and better without dosage increase
    • Well-behaved despite missing a dose or two


    I have ADHD. What coping strategies are there to help me manage this?

    The following strategies may be helpful.

    1. Educate yourself about ADHD
    2. Establish a daily routine of waking up eating, and going to sleep at the same time each day; a planned quiet time before bedtime is often helpful
    3. Follow healthy exercise and diet habits (e.g. avoid too much caffeine and alcohol) and get plenty of rest
    4. Use reminders such as daily planners, timers, and self-notes
    5. Get your workspace organized (e.g. using labeled containers) and away from distractions (e.g. TV sounds); playing white noise may help concentrate
    6. Don’t put things off if you can do them right now to prevent confusion
    7. Take a moment to stop and evaluate situations before you make decisions
    8. Take your medication exactly as directly
    9. Tell your doctor if you don’t think your medication is helping
    10. Schedule regular appointments with healthcare professionals
    11. Join a support group
    12. Don’t hesitate to ask or help


    My loved one has ADHD. What coping strategies are there to help me manage this?

    The following strategies may be helpful. While some of these strategies are more appropriate for children with ADHD, some also may be useful for adults.

    1. Educate yourself about ADHD
    2. Establish a daily routine for chores and other household responsibilities
    3. Make sure your loved one gets plenty of rest
    4. Provide an outlet for excess energy such as sports or long walks
    5. Set realistic goals; be clear and consistent about your expectations
    6. Encourage positive behaviors by praising for every success
    7. Arrange a workspace away from distractions (e.g. TV sounds)
    8. Encourage your loved one to do tasks in short blocks of time with breaks in between
    9. Even if your loved one seems out of control, try to stay patient and calm
    10. Help manage medication and use as directed
    11. Schedule regular appointments with healthcare professionals
    12. Join a support group
    13. Take breaks to cut down on your own stress
    14. Don’t hesitate to ask for help

    Suggested reading:

    1. What We Know#2: Parenting a Child with ADHD by National Resource Center on AD/HD
    2. What We Know#20: AD/HD and Teens: Information for Parents by National Resource Center on AD/HD



  • ADHD is not a real medical disorder

    Like most mental disorders, ADHD has a strong biological component. Studies have identified several genes associated with ADHD1. In addition, brain parts involved in facilitating attention (e.g. prefrontal cortex, basal ganglia, caudate nucleus) are consistently reported as smaller than average in individuals with ADHD2.

    1. Gilbert DL, Wang Z, Sallee FR, Ridel KR, Merhar S, Zhang J, et al.. Dopamine transporter genotype influences the physiological response to medication in ADHD. Brain 2006; 129(8): 2038-46.
    2. Castellanos FX, Sharp WS, Gottesman RF, Greenstein DK, Giedd JN, Rapoport JL. Anatomic brain abnormalities in monozygotic twins discordant for attention deficit hyperactivity disorder. Am J Psychol 2003; 160: 1693-1696.


    ADHD is not a serious condition

    Children and adolescents with ADHD can have more frequent and severe injuries than peers without ADHD. These include major injuries (59% vs. 49%), hospital inpatient (26% vs. 18%), hospital outpatient (41% vs. 33%), or emergency department admission (81% vs. 74%) 1.

    Data from international samples also suggest that young people with high levels of attentional difficulties are at greater risk of involvement in a motor vehicle crash, drinking and driving, and traffic violations2. ADHD also poses at least a twofold greater risk of adolescent and adult substance abuse3.

    People with diagnosed ADHD may also be more prone to coexisting condition(s), such as conduct disorder, mood disorders, anxiety disorders, and learning disabilities3.

    1. Leibson CL, Katusic SK, Barbaresi WJ, Ransom J, O’Brien PC. Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder. JAMA 2001; 285(1): 60-6.
    2. Woodward LJ, Fergusson DM, Horwood LJ. Driving outcomes of young people with attentional difficulties in adolescence. J Am Acad Child Adolesc Psychiatry 2000; 39(5): 627-34.
    3. Barkley RA. Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2002; 63 (Suppl 12): 10-5.


    ADHD only occurs in children

    Many people tend to think of ADHD as a childhood disorder when it may actually affect one lifelong. The symptoms may change or diminish when one learns to cope with difficulties, but for many the disorder can continue to create difficulty when left untreated. In some instances, an adult can still be diagnosed with ADHD if it was overlooked during childhood. In fact, a 2005 study estimated that approximately 4.1% of U.S. adult population was affected by the disorder in that given year1.

    1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry 2005; 62(6): 617-27.


    ADHD is a result of bad parenting

    There is little evidence that ADHD arises from social factors or parenting methods. Instead, ADHD is a disorder that involves physiological abnormalities with neurotransmitters (chemical messengers) in the brain.

    To date, researchers believe ADHD may be related to one or more of the following factors1:

    • Genetic predisposition
    • Premature delivery or low birth weight
    • History of environmental exposures (e.g. lead)
    • History of brain injury
    • Maternal smoking or alcohol use during pregnancy

    1. Biederman, J. ADHD: A selective overview. Biol Psychiatry 2005; 57: 1215-1220.


    ADHD is a result of eating too much sugar and food additives

    Scientific literature provides very limited support for a causal relationship. In fact, research has shown that the simple elimination of sugar or candy does not affect AD/HD symptoms1.

    It is possible, however, that a small subset of children are more sensitive to artificial food colors which may aggravate existing symptoms2. Parents who are concerned about diet sensitivity should have their children examined by a medical doctor for food allergies.

    1. Wolraich ML, Wilson DB, White JW. The Effect of Sugar on Behavior or Cognition in Children. JAMA 1995; 274(20): 1617-1621.
    2. Sobotka TJ. Proposed association between artificial food colors and attention deficit hyperactivity disorders (ADHD) and problem behaviors in children. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/FoodAdvisoryCommittee/UCM248113.pdf (accessed 2014).


    ADHD stimulant medication leads to addiction

    Stimulant therapy does not increase the risk of substance abuse1, and effective treatment of ADHD can facilitate functioning and reduce substance abuse2.

    1. Molina BS, Flory K, Hinshaw SP, Greiner AR, Arnold LE, Swanson JM, et al. Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. J Am Acad Child Adolesc Psychiatry 2007; 46: 1028–1040
    2. Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 2003; 111(1): 179-85.


    ADHD stimulant medication lead to stunted growth

    Research shows that no long-term impact on height was noted. Although temporary deficits in growth in height was observed in children (in the range of 1 to 2 cm), this effect was not seen after the first two years of therapy1.

    1. Subcommittee on Attention-Deficit/Hyperactivity Disorder. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011; 128(5): 1007-22.


    ADHD can be treated with herbs, vitamins, or other non-medicinal treatment

    Many treatments for ADHD reported by media do not have scientifically robust evidence to prove their effectiveness. Some examples include but are not limited to:

    • Megadose vitamins and minerals
    • Amino acid supplements
    • Herbal supplements
    • Antimotion sickness medication
    • Antifungal treatment
    • Thyroid treatment
    • Chiropractic
    • Vision therapy
    • EEG biofeedback

    Always be very cautious when you hear or read about a non-conventional treatment from a non-scientific source. Using therapy with unproven effectiveness can be dangerous as they may contain harmful ingredients and/or may delay proper treatment.

    Suggested reading:

    1. Complementary and Alternative Treatments for AD/HD by National Resource Center on AD/HD


  • The websites listed below are excellent resources if you would like to learn more about ADHD.

    Attention Deficit Disorder Association
    http://www.add.org/

     

    CHADD: Children and Adults with ADHD
    http://www.chadd.org/

     

    National Resource Center on AD/HD
    http://www.help4adhd.org/

     

    Centers for Disease Control and Prevention: ADHD Topics
    http://www.cdc.gov/ncbddd/ADHD/

     

    AACAP: ADHD Resource Center
    http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/ADHD_Resource_Center/Home.aspx

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