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.
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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More Key ADHD Facts
ADHD can make learning difficult.
A child with the disorder needs to be taught other ways of getting information because he can have trouble staying focused long enough for the facts to sink in. His working memory--how much data he can hold at one time--may also be weak. So even though he can understand vocabulary words, he can have trouble recalling and writing them down fast enough on a test. (Kids with ADHD often get extra time to complete tests.)
Dr. Hallowell takes issue with the very name ADHD: "These kids don't have a deficit of attention; they have a wandering of attention. Like a toddler at a picnic, their brain goes wherever it wants to go." In fact, many can actually become hyper-focused on something they're interested in.
It's tricky to diagnose.
"There is still no test that tells us conclusively that a child has ADHD," says Dr. Pearson. This fuels skeptics' belief that children are misdiagnosed. But doctors rely on a comprehensive developmental history, detailed questionnaires, and rating scales that assess a child's behavior and level of impairment over the years. By talking to the child, parents, teachers--and, if necessary, grandparents, babysitters, and even coaches--doctors determine whether her symptoms are normal for a kid her age or whether they're causing serious problems at home or at school. They must also rule out other factors--such as anxiety, a learning disability, depression, or perhaps divorce or an ill family member--that might be triggering symptoms.
There's no cure--but there are effective treatments.
Medication is a critical element of treatment, research has consistently found. Stimulants are the gold standard, especially when combined with behavioral therapy; both help manage the disruptive and inattentive behaviors of ADHD.
Many people question why you'd give a stimulant to a child who is already unable to sit still. But medications such as Ritalin and Adderall stimulate the brain's ability to send signals back and forth in a way that promotes attention and impulse control. Doctors insist it's not just a valid treatment--it's vital. "To hold off on medication for a child who's been diagnosed with ADHD is like asking someone who is nearsighted to try squinting for a year instead of giving him glasses to correct his vision," explains Dr. Hallowell.
But a medicine that works for one child may not work for another. That's why doctors monitor kids closely, adjusting dosages or changing medications altogether until they find one, or a combination, that works.
If stimulants don't work or trigger too many side effects (such as agitation, sleeplessness, anxiety, and tics), which can happen in 20 percent of cases, doctors move to other drugs. These include antidepressants and antihypertensives, which also have a calming effect. However, they take longer to kick in and are not as effective in curbing ADHD behaviors.
"We're not sure why, but many children who can't tolerate a medicine at one age do better with the same medicine a few years later," says Dr. Kurtz. "The brain changes, so parents shouldn't rule out medication forever."
Teaching specific skills helps kids cope.
There's growing evidence that parents, working with their child's school, can help rein in behaviors that make life difficult academically and socially.
In a soon-to-be-released study from NYU Langone Medical Center and Duke Medical School, in Durham, North Carolina, research confirmed what experts had previously only suspected: Certain straightforward steps help kids stay organized, improve their concentration, and finish what they start. This includes dedicating a specific time and place for homework, creating centrally posted checklists every day, using a planner to track assignments, designating a file folder to bring papers to and from school, and taking time to review work at home.
Parents can be trained too.
One particular technique for parents and their children ages 2 to 7 has helped manage the disruptive behavior that comes with ADHD. It's called Parent Child Interaction Therapy (PCIT), and the basic premise is that by coaching parents to monitor and reinforce positive behaviors, ignore mild negative ones, and give commands with calm, consistent follow-through, therapists can help moms and dads manage their reactions and teach critical coping skills. During hour-long sessions each week over a period of months, a therapist advises parents on how to interact with their children. Wearing an earpiece, a parent plays with her child while the therapist watches behind a one-way mirror and suggests specific strategies. "The key is to 'catch' your child being good and applaud those strengths," says Dr. Kurtz. (For help finding a PCIT program near you, e-mail email@example.com.)
Most kids with ADHD still have it as an adult.
"Children outgrow it only in about one third of cases," says Dr. Pearson. "Another third have mild symptoms that may surface only during times of stress; and another third have significant issues into adulthood and need to be treated consistently."
While many kids struggle with inattention and disorganization through their teen years, long-term studies show that they become less hyperactive and impulsive. As they mature, they are also more aware of how they're acting and are better able to use strategies to curb negative behavior
More Information and Resources
Could Your Child Have ADHD?
Every child displays some of the following behaviors some of the time--but for kids with ADHD, the extent of these behaviors makes it difficult for them to function. Ask yourself:
- Does your child have trouble listening when you ask her to do something?
- Is he more easily excitable or fidgety than other kids?
- Is your home life filled with conflicts over mealtime, bedtime, and brushing teeth?
- Has your child's teacher raised concerns about his behavior?
- Is she easily distracted? Particularly forgetful?
- Does he blame others for his shortcomings?
- Does she have trouble getting along with friends?
If you answer yes to many of these questions, talk to your doctor. He may refer you to a mental-health professional specializing in ADHD, who can begin the diagnostic process. Once a child is diagnosed, it's time to meet with his teacher (or guidance counselor, or principal) to find out which accommodations he might qualify for, free of charge.
Speak Up for Kids!
To spread the word about the signs of ADHD and other common psychiatric and learning disorders, Child Mind Institute (CMI) is partnering with Parents and other mental-health organizations on a national campaign called Speak Up for Kids. During National Children's Mental Health Awareness Week (May 6 through 12), local child and adolescent mental-health professionals will hold talks in communities across the nation. Topics include bullying and managing difficult behavior. "The formula is simple: Mental-health experts plus parents and educators equals more help for our children," says CMI president and Parents advisor Harold Koplewicz, M.D. Find an event near you at childmind.org/speakupforkids.
Originally published in the May 2012 issue of Parents magazine.
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