Attention Deficit Hyperactivity Disorder (ADHD) - Questions and Answers

Q. What is Attention Deficit Hyperactivity Disorder				treatments for alleviating the symptoms of
(ADHD)?				ADHD. NIMH research has indicated that the two
A. ADHD refers to a family of related chronic				most effective treatment modalities for
neurobiological disorders that interfere with an				elementary school children with ADHD are a
individual's capacity to regulate activity level				closely monitored medication treatment and a
(hyperactivity), inhibit behavior (impulsivity), and				treatment that combines medication with intensive
attend to tasks (inattention) in developmentally				behavioral interventions. In the NIMH Multimodal
appropriate ways. The core symptoms of ADHD				Treatment Study for Children with ADHD (MTA),
include an inability to sustain attention and				which included nearly 600 elementary school
concentration, developmentally inappropriate levels				children across multiple sites, nine out of ten
of activity, distractibility, and impulsivity. Children				children improved substantially on one of these
with ADHD have functional impairment across				treatments. Additionally, antidepressant
multiple settings including home, school, and peer				medications may also be used as a second line of
relationships. ADHD has also been shown to have				treatments for children who show poor response
long-term adverse effects on academic				to stimulants, who have unacceptable side
performance, vocational success, and				effects, or who have comorbid conditions (such
social-emotional development. Children with ADHD				as tics, anxiety, or mood disorders). Tricyclic
experience an inability to sit still and pay attention				antidepressants have shown clinical efficacy in
in class and the negative consequences of such				60-70% of children with ADHD. While the
behavior. They experience peer rejection and				medications were extremely beneficial to most
engage in a broad array of disruptive behaviors.				children, MTA findings indicated that medications
Their academic and social difficulties have				alone may not necessarily be the best strategy
far-reaching and long-term consequences. These				for many children. For example, children who had
children have higher injury rates. As they grow				accompanying problems (e.g., anxiety, stressful
older, children with untreated ADHD, in				home circumstances, social skills deficits, etc.),
combination with conduct disorders, experience				over and above the ADHD symptoms, appeared
drug abuse, antisocial behavior, and injuries of all				to obtain maximal benefit from the combined
sorts. For many individuals, the impact of ADHD				treatment.
continues into adulthood.				Q. Are there standard doses for these
Q. What are the symptoms of ADHD?				medications?
Inattention. People who are inattentive have a				A. Careful medication management is important in
hard time keeping their mind on one thing and				treating a child with ADHD. For methylphenidate
may get bored with a task after only a few				(Ritalin(R)), the usual dosage range is 5 to 20 mg
minutes. Focusing conscious, deliberate attention to				given two to three times a day. The dose for
organizing and completing routine tasks may be				amphetamines (Dexedrine(R) and Dextrostat(R)
difficult.				and Adderall(R)) is one-half the methylphenidate
Hyperactivity. People who are hyperactive always				dose. Dosage requirements do not always
seem to be in motion. They can't sit still; they				correlate with weight, age or severity of
may dash around or talk incessantly. Sitting still				symptoms in an individual patient. Dosages may
through a lesson can be an impossible task. They				need to be increased during childhood with
may roam around the room, squirm in their seats,				increased lean body weight and decreases may
wiggle their feet, touch everything, or noisily tap a				be necessary after puberty. Different doctors use
pencil. They may also feel intensely restless.				these medications in slightly different ways.
Impulsivity. People who are overly impulsive, seem				Q. How long are children on these medications?
unable to curb their immediate reactions or think				A. The expected duration of treatment has
before they act. As a result, they may blurt out				lengthened during this past decade as evidence
answers to questions or inappropriate comments,				has accumulated that benefits extend into
or run into the street without looking. Their				adolescence and adulthood. However, many
impulsivity may make it hard for them to wait for				factors work against continued treatment during
things they want or to take their turn in games.				adolescence including the partial resolution of the
They may grab a toy from another child or hit				most obvious symptoms, the short-lasting effects
when they are upset.				of medications that require multiple doses per
Q. How is ADHD diagnosed?				day, and the need for regular physician written
A. The diagnosis of ADHD can be made reliably				prescriptions. Additionally, parents often discontinue
using well-tested diagnostic interview methods.				medication even when benefit has been
Diagnosis is based on history and observable				demonstrated or because they see the child
behaviors in the child's usual settings. Ideally, a				improve and don't think the medication is
health care practitioner making a diagnosis should				necessary any longer.
include input from parents and teachers. The key				Q. How often are stimulant prescriptions used?
elements include a thorough history covering the				A. Data from 1995 show that physicians treating
presenting symptoms, differential diagnosis,				children and adolescents wrote six million
possible comorbid conditions, as well as medical,				prescriptions for stimulant
developmental, school, psychosocial, and family				medications-methylphenidate (Ritalin(R)) and
histories. It is helpful to determine what				dextroamphetamine (Dexedrine(R)). Of all the
precipitated the request for evaluation and what				drugs used to treat psychiatric disorders in
approaches had been used in the past. As of yet,				children, stimulant medications are the most
there is no independent test for ADHD. This is not				thoroughly studied.
unique to ADHD, but applies as well to most				Q. Isn't stimulant use on the increase?
psychiatric disorders, including other disabling				A. Stimulant use in the United States has
disorders such as schizophrenia and autism.				increased substantially over the last 25 years. A
Q. How many children are diagnosed with ADHD?				recent study saw a 2.5-fold increase in
A. ADHD is the most commonly diagnosed				methylphenidate between 1990 and 1995. This
disorder of childhood, estimated to affect 3 to 5				increase appears to be largely related to an
percent of school-age children, and occurring three				increased duration of treatment, and more girls,
times more often in boys than in girls. On				adolescents, adults, and inattentive individuals (in
average, about one child in every classroom in the				addition to those individuals with both hyperactivity
United States needs help for this disorder.				and inattentiveness/attention deficit) receiving
Q. Aren't there various types of ADHD?				treatment.
A. According to DSM-IV, the fourth and most				Q. Are there differences in stimulant use across
recent edition of the DSM, while most individuals				racial and ethnic groups?
have symptoms of both inattention and				A. There are significant differences in access to
hyperactivity-impulsivity, there are some				mental health services between children of
individuals in whom one or another pattern is				different racial groups; and, consequently, there
predominant (for at least the past 6 months).				are differences in medication use. In particular,
Q. How are schools involved in diagnosing,				African American children are much less likely than
assessing, and treating ADHD?				Caucasian children to receive psychotropic
A. Physicians and parents should be aware that				medications, including stimulants, for treatment of
schools are federally mandated to perform an				mental disorders.
appropriate evaluation if a child is suspected of				Q. Why are stimulants used when the problem is
having a disability that impairs academic				overactivity?
functioning. This policy was recently strengthened				A. The answer to this question is not well
by regulations implementing the 1997				established, but one theory suggests that ADHD
reauthorization of the Individuals with Disabilities				is related to difficulties in inhibiting responses to
Act (IDEA), which guarantees appropriate				internal and external stimuli. Evidence to date
services and a public education to children with				suggests that those areas of the brain thought to
disabilities from ages 3 to 21. For the first time,				be involved in planning, foresight, weighing of
IDEA specifically lists ADHD as a qualifying				alternative responses, and inhibiting actions when
condition for special education services. If the				alternative solutions might be considered, are
assessment performed by the school is				underaroused in persons with ADHD. Stimulant
inadequate or inappropriate, parents may request				medication may work on these same areas of
that an independent evaluation be conducted at				the brain, increasing neural activity to more normal
the school's expense. Furthermore, some children				levels. More research is needed, however, to
with ADHD qualify for special education services				firmly establish the mechanisms of action of the
within the public schools, under the category of				stimulants.
"Other Health Impaired." In these cases, the				Q. What are the risks of the use of stimulant
special education teacher, school psychologist,				medication and other treatments?
school administrators, classroom teachers, along				A. Stimulant drugs, when used with medical
with parents, must assess the child's strengths				supervision, are usually considered quite safe.
and weaknesses and design an Individualized				Although they can be addictive when abused by
Education Program. These special education				teenagers and adults, when taken as prescribed
services for children with ADHD are available				for ADHD these medications have not been
though IDEA.				shown to be addictive nor to lead to substance
Q. Is ADHD inherited?				abuse problems. They seldom make children "high"
A. Research shows that ADHD tends to run in				or jittery, nor do they sedate the child. Although
families, so there are likely to be genetic				little information exists concerning the long-term
influences. Children who have ADHD usually have				effects of psychostimulants, there is no evidence
at least one close relative who also has ADHD.				that careful therapeutic use is harmful. When
And at least one-third of all fathers who had				adverse drug reactions do occur, they are usually
ADHD in their youth have children with ADHD.				related to dosage and are always reversible.
Even more convincing of a possible genetic link is				Effects associated with moderate doses are
that when one twin of an identical twin pair has				decreased appetite and insomniA. These effects
the disorder, the other is likely to have it too.				occur early in treatment and may decrease with
Q. Is ADHD on the increase? If so, why?				time. There may be negative effects on growth
A. No one knows for sure whether the				rate, but ultimate height appears not to be
prevalence of ADHD per se has risen, but it is				affected.
very clear that the number of children identified				Q. Will children taking these medications for ADHD
with the disorder who obtain treatment has risen				become drug addicts?
over the past decade. Some of this increased				A. Actually, it appears to be just the opposite.
identification and increased treatment seeking is				Although an increased risk of drug abuse and
due in part to greater media interest, heightened				cigarette smoking is associated with childhood
consumer awareness, and the availability of				ADHD, this risk appears mostly due to the ADHD
effective treatments. A similar pattern is now				condition itself, rather than its treatment. In a
being observed in other countries. Whether the				study jointly funded by the NIMH and the National
frequency of the disorder itself has risen remains				Institute on Drug Abuse, boys with ADHD who
unknown, and needs to be studied.				were treated with stimulants were significantly
Q. Can ADHD be seen in brain scans of children				less likely to abuse drugs and alcohol when they
with the disorder?				got older. Caution is warranted, nonetheless, as
A. Neuroimaging research has shown that the				the overall evidence suggests that persons with
brains of children with ADHD differ fairly				ADHD (particularly untreated ADHD) are indeed at
consistently from those of children without the				greater risk for later alcohol or substance abuse.
disorder in that several brain regions and				Because some studies have come to conflicting
structures (pre-frontal cortex, striatum, basal				conclusions, more research is needed to
ganglia, and cerebellum) tend to be smaller. Overall				understand these phenomenA. Regardless, in view
brain size is generally 5% smaller in affected				of the substantial, well-established findings of the
children than children without ADHD. While this				harmful effects of inadequate or no treatment
average difference is observed consistently, it is				for a child with ADHD, parents should not be
too small to be useful in making the diagnosis of				dissuaded from seeking effective treatments
ADHD in a particular individual. In addition, there				because of misconstrued or exaggerated claims
appears to be a link between a person's ability to				about substance abuse risks.
pay continued attention and measures that reflect				Q. Wasn't there a large conference held at NIH on
brain activity. In people with ADHD, the brain				ADHD recently?
areas that control attention appear to be less				A. In 1998, the NIH held a two-day Consensus
active, suggesting that a lower level of activity in				Conference on ADHD, bringing together national
some parts of the brain may be related to				and international experts, as well as
difficulties sustaining attention.				representatives from the public. The Consensus
Q. Can a preschool child be diagnosed with ADHD?				statement is now available at .
A. The diagnosis of ADHD in the preschool child is				Q. What is the relationship between ADHD and
possible, but can be difficult and should be made				other disorders, such as learning disabilities, anxiety
cautiously by experts well trained in childhood				disorders, bipolar disorder, or depression?
neurobehavioral disorders. Developmental				A. Comorbidity occurs in most children clinically
problems, especially language delays, and				treated for ADHD. ADHD can co-occur with
adjustment problems can sometimes imitate				learning disabilities (15-25%), language disorders
ADHD. Treatment should focus on placement in a				(30-35%), conduct disorder (15-20%), oppositional
structured preschool with parent training and				defiant disorder (up to 40%), mood disorders
support. Stimulants can reduce oppositional				(15-20%), and anxiety disorders (20-25%). Up to
behavior and improve mother-child interactions,				60 percent of children with tic disorders also have
but they are usually reserved for severe cases				ADHD. Impairments in memory, cognitive
or when a child is unresponsive to environmental				processing, sequencing, motor skills, social skills,
or behavioral interventions.				modulation of emotional response, and response
Q. What is the impact of ADHD on children and				to discipline are common. Sleep disorders are also
their families?				more prevalent.
A. Life can be hard for children with ADHD.				Q. What is the history of ADHD? How is it related
They're the ones who are so often in trouble at				to ADD?
school, can't finish a game, and have trouble				A. ADHD has assumed many aliases over time
making friends. They may spend agonizing hours				from hyperkinesis (the Latin derivative for
each night struggling to keep their mind on their				"superactive") to hyperactivity in the early 1970s.
homework, then forget to bring it to school. It is				In the 1980s, DSM-III dubbed the syndrome
not easy coping with these frustrations day after				Attention Deficit Disorder, or ADD, which could be
day for children or their families. Family conflict				diagnosed with or without hyperactivity. This
can increase. In addition, problems with peers and				definition was created to underline the importance
friendships are often present in children with				of the inattentiveness or attention deficit that is
ADHD. In adolescence, these children are at				often but not always accompanied by
increased risk for motor vehicle accidents,				hyperactivity. The revised edition of DSM-III, the
tobacco use, early pregnancy, and lower				DSM-III-R, published in 1987, returned the
educational attainment. When a child receives a				emphasis back to the inclusion of hyperactivity
diagnosis of ADHD, parents need to think carefully				within the diagnosis, with the official name of
about treatment choices. And when they pursue				ADHD. With the publication of DSM-IV, the name
treatment for their children, families face high				ADHD still stands, but there are varying types
out-of-pocket expenses because treatment for				within this classification, to include symptoms of
ADHD and other mental illnesses is often not				both inattention and hyperactivity-impulsivity,
covered by insurance policies. School programs to				signifying that there are some individuals in whom
help children with problems often connected to				one or another pattern is predominant (for at
ADHD (social skills and behavior training) are not				least the past 6 months). In the International
available in many schools. In addition, not all				Classification of Diseases (used predominantly in
children with ADHD qualify for special education				other Western countries), the term "Hyperkinetic
services. All of this leads to children who do not				Disorder" is used, but the criteria are the same as
receive proper and adequate treatment. To				for ADHD/combined type.
overcome these barriers, parents may want to				Q. What are the future research directions for
look for school-based programs that have a team				ADHD?
approach involving parents, teachers, school				A. Continued research on ADHD is needed from
psychologists, other mental health specialists, and				many perspectives. The societal impact of ADHD
physicians.				needs to be determined. Studies in this regard
Q. Aren't there nutritional treatments for ADHD?				include (1) strategies for implementing effective
A. Many parents have exhausted nutritional				medication management or combination therapies
approaches, such as eliminating sugar from the				in different schools and pediatric healthcare
diet, before they seek medical attention.				systems; (2) the nature and severity of the
However, there are no well-established nutritional				impact on adults with ADHD beyond the age of
interventions that have been consistently				20, as well as their families; and (3) determination
demonstrated to be efficacious for assisting the				of the use of mental health services related to
great majority of children with ADHD. A small				diagnosis and care of persons with ADHD.
body of research has suggested that some				Additional studies are needed to improve
children may benefit from these interventions, but				communication across educational and health care
delaying the implementation of well-established,				settings to ensure more systematized treatment
effective interventions while engaged in the				strategies. Basic research is also needed to better
search for unknown, generally unproven allergens,				define the behavioral and cognitive components
is likely to be harmful for many children.				that underpin ADHD, not just in children with
Q. What are behavioral treatments?				ADHD, but also in unaffected individuals. This
A. There are various forms of behavioral				research should include (1) studies on cognitive
interventions used for children with ADHD,				development, cognitive and attentional processing,
including psychotherapy, cognitive-behavioral				impulse control, and attention/inattention; (2)
therapy, social skills training, support groups, and				studies of prevention/early intervention strategies
parent and educator skills training. An example of				that target known risk factors that may lead to
very intensive behavior therapy was used in the				later ADHD; and (3) brain imaging studies before
NIMH Multimodal Treatment Study of Children with				the initiation of medication and following the
ADHD (MTA), which involved the child's teacher,				individual through young adulthood and middle age.
the family, and participation in an all-day, 8-week				Finally, further research should be conducted on
summer camp. The consulting therapist worked				the comorbid (coexisting) conditions present in
with teachers to develop behavior management				both childhood and adult ADHD, and treatment
strategies that address behavioral problems				implications.
interfering with classroom behavior and academic				For More Information on Mental Disorders in
performance. A trained classroom aide worked				Children, Contact:
with the child for 12 weeks in his or her				Office of Communications and Public Liaison, NIMH
classroom, to provide support and reinforcement				Information Resources and Inquiries Branch
for appropriate, on-task behavior. Parents met				6001 Executive Blvd., Room 8184, MSC 9663
with the therapist alone and in small groups to				Bethesda, MD 20892-9663
learn approaches for handling problems at home				Phone: 301-443-4513
and school. The summer day camp was aimed at				TTY: 301-443-8431
improving social behavior, academic work, and				FAX: 301-443-4279
sports skills.				Mental Health FAX 4U: 301-443-5158
Q. What medications are currently being used to				E-mail:
treat ADHD?				NIMH home page address:
A. Psychostimulant medications, including				Listen to Arthur Buchanan on the Mike Litman
methylphenidate (Ritalin(R)) and amphetamines				Show! THIS LINK WORKS, LISTEN TODAY!
(Dexedrine(R), Dextrostat(R), and Adderall(R)),				With Much Love,
are by far the most widely researched and				Arthur Buchanan
commonly prescribed treatments for ADHD.				President/CEO
Numerous short-term studies have established the				Out of Darkness & Into the Light
safety and efficacy of stimulants and psychosocial				43 Oakwood Ave.

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Attention Deficit Hyperactivity Disorder (ADHD) - Questions and Answers