Attention for ADHD: 9 Key Facts

New guidelines make it easier for doctors to diagnose it in kids as young as 4, yet many parents feel the condition is overdiagnosed. It's time for a closer look at this misunderstood disorder.

Brian Maranan Pineda

The 4-year-old who talks incessantly and blurts out answers ahead of his classmates... the racing-on-all-cylinders 5-year-old who leaps before he looks... the overzealous 6-year-old who butts into games and then is surprised when he's rejected... the spacey 8-year-old who can never find her homework folder, shifts from one unfinished task to another, and has trouble following directions. They're all very different children, but they all could have attention deficit hyperactivity disorder.

"ADHD is the most common and yet one of the most misunderstood of all childhood psychiatric illnesses," says Steven Kurtz, Ph.D., senior director of the ADHD and Disruptive Behavior Disorders Center at New York City's Child Mind Institute. It's also a disorder that never fails to trigger controversy and leave overwhelmed parents feeling guilty about their disruptive, daydreamy, disorganized child. A 2010 report from the Centers for Disease Control and Prevention was a reminder of ADHD's prevalence: Roughly 7 percent of 4- to 17-year-olds have the disorder, according to their parents. This represents a 22 percent jump in just four years.

"It's good news that more kids are being identified instead of falling through the cracks," says Dr. Kurtz. "The fact that parents and teachers are aware of the condition means that some of the shame that held parents back from seeking treatment for their children is now lifting."

Late last year, the American Academy of Pediatrics released new guidelines for diagnosing and managing ADHD in children as young as 4 (previous guidelines started at age 6). Meanwhile, in a recent survey Parents conducted with the Child Mind Institute, 63 percent of people believed that too many kids are being diagnosed with ADHD when they really just have behavioral issues. But a youngster with ADHD has problems that show up more often, last longer, and are more intense than the average child's, explains Mark Wolraich, M.D., professor of pediatrics at the University of Oklahoma's College of Medicine, in Norman. "If his behavior is frequently out of control and that's causing him to get into trouble not only at home but also in preschool or day care, then it's important to find out why--and the earlier the better.

"There remains a great deal of confusion and public debate about where to draw the line between typical childhood behaviors and those that signal a clinical condition that should be treated," continues Dr. Wolraich, lead author of the AAP guidelines. We shed light on nine essential facts.

The brains of kids with ADHD are different.

ADHD is a neurobehavioral disorder with two key components: impulsivity/hyperactivity and inattention/distractibility. Some children are predominantly impulsive and hyperactive; others are mostly easily distracted. Most are a combination.

"These children have a Ferrari brain with bicycle brakes," explains Edward M. Hallowell, M.D., director of the Hallowell Centers for Cognitive and Emotional Health in Sudbury, Massachusetts, and New York City and author of several books on ADHD. "Their mind is racing, but they can't slow down when they need to."

Scans show that when a child has ADHD, the part of her brain that helps control behavior, maintain focus, and prioritize what she needs to do and then do it is slightly smaller. What's more, neurotransmitters--chemicals such as serotonin, dopamine, and norepinephrine that send messages from one part of the brain to another--get used up more quickly. So if a teacher gives a set of five instructions, the child may only be able to get through the first two steps before losing track of what she should do next.

Symptoms range from mild to severe and may be noticeable as early as age 2 or 3. But in most cases, they're not apparent until a child starts school and needs to pay attention and sit quietly. Bright kids who have mild symptoms may squeak by for years until the academic demands for planning, organization, and time management become too overwhelming.

We still don't know the exact causes of ADHD.

Studies consistently suggest that ADHD is inherited. But in the last few years, research has also linked ADHD to prenatal exposure to environmental toxins such as bisphenol A and phthalates (key ingredients in a wide range of products from cosmetics to plastic shower curtains), as well as lead (found in old paint) and pesticides (used in homes and schools and on farms). "The science is still very new and the studies, though strong, must be repeated by other researchers," says pediatrician and epidemiologist Philip Landrigan, M.D., director of the Children's Environmental Health Center, in New York City, and a member of the Parents Board of Advisors. "But children are especially sensitive to environmental toxins and we need to pay much more attention to how and when they are exposed."

A theory has persisted that food dyes contribute to ADHD, and some parents insist that once their kids are on a diet that eliminates dyes and preservatives, their ADHD symptoms improve dramatically. But the mainstream medical community is unconvinced. In 2011, after reviewing 50-plus studies linking food additives and ADHD, the FDA's Food Advisory Committee concluded there is not enough solid data to definitively say that artificial food dyes can trigger hyperactivity in kids. Adds Dr. Kurtz, "At this time, we have no reliable evidence showing that avoiding products with sugars, dyes, or additives will lessen problematic symptoms."

ADHD often looks different in girls.

Boys are three times more likely than girls to be diagnosed with the condition, and girls are typically diagnosed five years later than boys. The disorganized, quiet girl is often overlooked, even though her ADHD may be just as severe as that of the boy bouncing out of his seat beside her. In elementary school, girls with ADHD tend to be less attentive and have trouble finishing projects, but they're not usually disruptive. By the time they reach middle school, though, their self-esteem takes a big hit.

"Girls aren't 'supposed' to leave their backpack at soccer or have a messy notebook. They're supposed to get along well with others. So when they struggle, they may feel stupid, lazy, and unlovable," says Deborah Pearson, Ph.D., professor of child and adolescent psychiatry at The University of Texas-Houston Medical School.

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