Expert Advice: ADHD and Adoption

Introduction

Attention Deficit/Hyperactivity Disorder, often referred to as ADHD or ADD, is one of the most prevalent pediatric neurodevelopmental disorders. Children with ADHD have significant difficulty with distractibility, impulsivity, and sometimes, hyperactivity. Although all children can display some of these behaviors at times, children with ADHD generally exhibit these symptoms repeatedly both at home and at school. Moreover, the formal diagnostic criteria for ADHD require that these symptoms must lead to "impairment of function." Thus, by definition, children with ADHD are unable to function well in school, at home, and/or with peers socially.

An estimated 5 to 9% of grade-school children have ADHD. Although concerns have been raised regarding over-diagnosis, this is not a widespread phenomenon. To the contrary, there are many children with ADHD who have not been diagnosed or received proper treatment. It is important to remember that not all children with ADHD are overactive; ADHD also refers to the child who simply has significant difficulty with inattention and distractibility.

What causes ADHD?

Although its cause has not been clearly established, we know that ADHD can be inherited. Forty percent of children with ADHD will have a parent with ADHD -- usually the father. Although ADHD appears to have a genetic basis, other factors influence who will actually develop symptoms and who won't. Even among pairs of genetically identical twins, one twin may have ADHD and the other not. The attention center in the brain appears to be the most vulnerable or sensitive psychological function. Thus a range of medical problems can result in an impaired attention span without any other apparent difficulties. Prenatal drug or alcohol exposure, prematurity, lead poisoning, and other similar conditions can put a child at risk for ADHD.

ADHD is most typically diagnosed in the early grade-school years, and teachers are often the first to identify the child's difficulties. Inattention may be noted if the child daydreams frequently or has trouble completing tasks. Impulsivity often leads to calling out in class or having difficulty waiting their turn in games or lines. Hyperactivity in children will likely be exhibited by restlessness, fidgetiness, and getting out of their seat at inappropriate times. Although boys are more likely to be identified as having ADHD with hyperactivity, girls are more likely to be identified as having the "inattentive type" of ADD.

Diagnosis of ADHD requires a careful evaluation by a physician or psychologist. A thorough diagnostic assessment is needed, because children with ADHD often have additional developmental problems, such as learning disabilities, auditory processing difficulties, or a mood disorder. Also, these same conditions can actually mimic or be confused for ADHD, yet each would require a different approach to treatment.

Adoption and ADHD

Prospective adoptive parents must remember that although several risk factors for ADHD have been identified, one cannot predict whether any specific child will develop it. Not all children born prematurely or to ADHD parents will have ADHD. One can assume that approximately 5 to 10% of healthy full-term infants adopted domestically will later be diagnosed with ADHD. Although an unplanned pregnancy may occasionally be a manifestation of poor impulse control owing to ADHD, one cannot infer that most biological parents placing their children up for adoption have ADHD.

Youngsters adopted from China, Russia, and other countries where waiting children live in an orphanage setting are likely to be at greater risk for ADHD. Apart from malnutrition and lack of adequate nurturing, these children often have other influencing factors for ADHD, including prematurity and prenatal alcohol exposure. Despite this increased risk, the diagnosis of ADHD should be deferred to school age whenever possible. Institutionalization and sensory integration disorders are all more common in these children, yet each can mimic some of the symptoms of ADHD. Therefore, one should not hastily presume the presence of ADHD.

Treatments

The three main types of treatment for children with ADHD are behavioral interventions, educational interventions, and medication. During the preschool years, ADHD is generally easily managed with behavioral interventions. Preschool children with significant developmental delays or behavior problems qualify for special education services. Children who are unable to function well in a regular preschool program may need to attend a special education preschool, where additional staffing with better training is available. These preschools are generally cost-free to eligible children; parents should contact their local school district for more information.

Although school-age children with ADHD also respond to behavioral interventions, treatment with medication has been shown to be the single most effective intervention in this population. Stimulants (including Ritalin, Concerta, and Adderall) are the most commonly prescribed medications, and their relative safety and efficacy have been recognized in many research studies. Occasionally, other types of medication need to be used either instead or in addition to the stimulants.

The Individuals with Disabilities Education Act mandates that children with ADHD may be eligible for part-time special education services, such as resource room. Occasionally, children with ADHD may need placement in a self-contained classroom - a smaller class with other students who likewise require more intensive services. Also, under the Americans with Disabilities Act, children with ADHD are entitled to educational accommodations -- such as additional time for written tests, abbreviated homework assignments, and preferential classroom seating (nearer the teacher).

Although many preschool children will respond to behavioral interventions and many school-age children will do well with medication management alone, it is most helpful to take a multi-modal approach -- combining behavioral, medical, and educational interventions.

Parents who feel concerned about ADHD symptoms in their child should consult with their pediatrician and, at the same time, gather additional information about its diagnosis and treatment. Remember: Most children who are adopted will not have ADHD, and there are many effective ways to help children who do.

For more information on ADHD or other issues in this article, call SPARK Child Development for Adoptive Families at 212-360-0259 or e-mail jcleary@spence-chapin.org.

Andrew Adesman, M.D. serves at the Schneider Children's Hospital Adoption Evaluation Center