Attention Deficit Hyperactivity Disorder (ADHD)
A diagnosis of attention deficit hyperactivity disorder (ADHD), can be overwhelming, but thorough evaluation and treatment tailored to your child can help your family manage this condition effectively. ADHD is a chronic condition that interferes with concentration, impulse control and the ability to sit still.
Approximately 11 percent of children in the United States between the ages of four and 17 have been diagnosed with ADHD, according to the Centers for Disease Control and Prevention. Usually diagnosed in childhood, this lifelong condition can profoundly affect how well a child functions at home, at school and socially.
“There has been a lot of controversy about ADHD over the years,” says Robert King, MD, a child psychiatrist and expert in ADHD at the Yale Medicine Child Study Center. “We psychiatrists tend to say that it is both overdiagnosed, in the sense that people see a restless child and make the automatic assumption that he or she has ADHD—and underdiagnosed, in that many children who could be helped by medication and treatment aren’t getting the services they need.”
What causes ADHD?
Brain researchers have found differences in the neurotransmitters of people with ADHD, which means that the condition is biological in nature. There is growing evidence that environmental factors—such as in utero (before birth) exposure to tobacco or alcohol, low birth weight or prematurity, or extreme neglect in infancy or early childhood—play a role in a child’s likelihood of having ADHD. The disorder occurs more often in people with a family history, but sometimes ADHD is found in children with no known risk factors.
What are the symptoms of ADHD in a child?
The core symptom of ADHD is difficulty concentrating, and most children with ADHD are also hyperactive and impulsive. Of course, all children act this way sometimes, making it tricky to pin down whether or not a particular child’s behavior actually reflects ADHD.
“To judge whether a child has inattention or hyperactivity, we have to look across the context of his or her life,” says Dr. King. Though the majority of children with ADHD are given the diagnosis in the early grade-school years, some show clear signs of the disorder early on. Others may not get the diagnosis until high school or even later.
“We have had moms tell us that even in utero their child was especially active,” Dr. King says. “Sometimes we see it in 3- or 4-year-olds who have difficulty sharing or can’t learn to wait their turn during circle time in preschool. Our suspicion is that the deficits are there from the very beginning but really come into focus when the child is in a situation, like the classroom, that requires concentration.”
How is ADHD diagnosed?
Experts in child development and psychiatry now agree that ADHD is a syndrome in its own right. However, according to Dr. King, part of the complexity and controversy is that children can be inattentive or restless or impulsive for a large variety of reasons. "The core of good care is a careful initial evaluation that can distinguish whether there are other reasons such as anxiety or learning difficulties that make it hard for a child to pay attention,” he says.
An effective evaluation gathers information from both parents and teachers to determine whether a child’s symptoms are significant enough to the criteria for a diagnosis of ADHD. Sometimes this phase provides enough information to warrant a medication trial, Dr. King says. But often a more comprehensive psychological assessment with detailed psycho-educational testing is recommended to look for challenges, such as with organizational and planning skills (called “executive function”) or learning disabilities.
How is ADHD treated?
When ADHD is properly diagnosed, medication can be very helpful, but it may take some trial and error to find the right drug and the right dose. Stimulants and amphetamines are most commonly prescribed, but some non-stimulant medications can also be effective.
“Some people have concerns that we’re simply drugging the child to achieve quiet, but that is not correct,” says Dr. King. “The medications we use to treat ADHD are among the most dramatically effective agents in the psycho-pharmaceutical world. The drug helps the child become more attuned to what is going on in the environment, not less so—and also brings self-control so the child can appropriately respond to the environment.”
Early on, you can expect many conversations and visits with your child’s doctor, Dr. King says. Once the dosing is stabilized, three-month checkups are required to track your child’s height and weight. This is important because a small percentage of children taking medication for ADHD experience a slowing of growth, in part because the drugs can suppress appetite. Other potential side effects include difficulty sleeping and stomach cramps.
But there is more to effective treatment of ADHD than just medication. Appropriate school placement is vital. Children may also need educational accommodations and supportive resources. Many also benefit from other psychotherapeutic treatments, including cognitive behavioral therapy, to help them learn effective techniques and achieve success at school and socially.
What can parents do to help a child with ADHD reach her full potential?
Children with ADHD require “industrial strength parenting,” according to Dr. King. By that he means parents should stay closely involved with schoolwork, maintaining ongoing contact with teachers. Children need help keeping track of assignments and projects and breaking them down into a step-by-step process.
Students with ADHD need a quiet place to study and do homework without distractions. For many, study halls and tutoring help, too. “Many children with ADHD are very bright,” Dr. King says. “But parenting them is a labor-intensive task.”
What makes Yale Medicine's approach to the diagnosis and treatment of children with ADHD unique?
We have been at the forefront of much of the research into the diagnosis and treatment of ADHD. Yale Medicine Child Study Center has been the birthplace of innovative treatments, including the development of non-stimulant medications as an alternative for children who don’t do well with the traditional ADHD drugs.
Dr. King and his colleagues, including Michael Howard Bloch, MD, MS, a child psychiatrist at the Yale Medicine Child Study Center, have also done many of the studies that inform the current practice in treating children with the disorder. The center's reputation for breakthrough research not only means that you can feel confident that your child’s care is in the hands of true experts, but that we may also provide access to groundbreaking treatments not available elsewhere.
Dr. King acknowledges that it is not difficult to find community doctors who can competently oversee the medication management for a child with uncomplicated ADHD. But he adds that the more comprehensive services available at Yale Medicine extend far beyond just prescribing drugs.
“We see a lot of children with ADHD,” he says. “Sometimes we end up prescribing medication and it’s very straightforward – but when we do that, it’s within the context of a comprehensive diagnostic assessment and regular, ongoing follow-up to ensure that the child is doing well in the various domains of his or her life.”