Attention-deficit hyperactivity disorder (ADHD) is one of the most common mental health conditions in children. We give you the tools you need to recognize this disorder and understand how it's diagnosed and treated.

ADHD affects 3% to 5% of school-age children and up to 5% of adults. Since 1902, when Sir George Still suggested ADHD was due to genetic dysfunction rather than poor parenting or behavioral problems, it has been the most researched and studied of all childhood psychiatric disorders. In ADHD, the cardinal symptoms of inattention, hyperactivity, and impulsivity start early in a child's life; often during the preschool years.

ADHD symptoms can differ in boys and girls: Boys are more likely to be hyperactive and impulsive, whereas the diagnosis in girls often gets missed because they're quieter and have more symptoms of inattention. However, because many children experience varying degrees of the three characteristics of ADHD and the symptoms can be caused by other medical and psychological problems, it's important for the child to undergo thorough examination and diagnostic evaluation by qualified professionals.

Three signposts

The criteria and symptoms associated with ADHD are listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, which can assist the clinician in accurate diagnosis and treatment. ADHD has three types:

* predominantly hyperactive-impulsive

* predominantly inattentive

* combined (both inattention and hyperactive-impulsive).

Children who are inattentive have difficulty staying on task, finishing homework, and listening in class. If they're engaged in an activity they like, they have no trouble paying attention, but focusing or learning something new is difficult. Homework is very hard for these children; they may forget what the assignment is or leave the assignment at school because they're easily distracted by other activities around them. They have difficulty attending to details, make frequent errors, and may lose needed items such as books, toys, tools, or pencils. Often found daydreaming, they struggle to follow instructions and frequently skip from one activity or task to another.

Hyperactivity

Hyperactive children appear always on the go; they talk a lot, move a lot, and touch a lot. They have trouble sitting still at dinner or when watching TV, squirming, fidgeting, wiggling, tapping pencils, or engaging in many other kinds of motion. Touching and playing with everything in sight, they run or climb excessively and have difficulty participating in quiet activities, often leaving their seat in the classroom or other places where staying seated is expected.

Impulsivity

Children who are impulsive don't think before they act. They can blurt out inappropriate comments, show uncensored emotions, and act without weighing the consequences of their behaviors. Often interrupting other people's conversations, making friends can be hard because they can't wait in turn for games and may grab toys from others without asking or hit others when upset.

How it happens

There are several theories regarding the etiology of ADHD, including brain injury, genetics, and environmental factors.

Altered brain anatomy

Brain scans in children with ADHD often show less activity in the areas of the brain that are responsible for concentration and attention. Some children with ADHD have thinner brain tissue in areas of the brain associated with attention. National Institute of Mental Health (NIMH) research has demonstrated that this difference isn't permanent; as children grow, the thickness of the tissue may increase to normal levels, improving concentration and attention skills. Using a variety of methods to visualize the brain, the NIMH found that these children had 3% to 4% smaller brain volumes in the parts of the brain that regulate impulsivity, motor skills, attention, and emotion.

Altered brain chemistry

Neurons, the basic structure of the nervous system, generate electrochemical impulses and transmit information. Neurotransmitters are the vehicles that allow these impulse transmissions to occur smoothly, traveling over a space, or synapse, between two neurons. The neurotransmitters norepinephrine and dopamine are produced in the neuron and stored in the synaptic vesicles until release. After release, any neurotransmitters not used during the transmission of the impulse are sent back to storage through a reuptake mechanism. Normally, in a stressful situation, the release of norepinephrine floods the neuronal synapse to increase pulse, BP, respiration, and alertness to help the body deal with the perceived stressor.

In ADHD, this mechanism is dysfunctional and causes increased unorganized activity in the neurons or disjointed transmission of impulses. In addition, dopamine is involved in regulation of emotions, concentration, reasoning, and coordinated movement. In ADHD, a low level of dopamine can cause the symptoms of inattention, hyperactivity, and impulsivity.

Genetics

ADHD often runs in families, with studies indicating that 25% of close relatives in the family of a child with ADHD also have the disorder. In addition, studies of twins demonstrate that there's a strong genetic component to ADHD. Current research is focusing on how the dysfunction in the ability to utilize the neurotransmitter dopamine is genetically based. Also, the effectiveness of stimulants may be directly related to a particular form of the neurotransmitter deficit, which could explain why some medications work for one child and not another.

Environmental factors

Studies have shown a link between cigarette smoking and alcohol use during pregnancy and ADHD in children. It's thought that use of alcohol or cigarettes may decrease the activity of neurons, thus decreasing the availability of neurotransmitters in utero. This dysfunction then continues when the child is born. Exposure to lead and other toxins has been shown to increase the risk of ADHD symptoms, especially disruptive and violent behaviors.

Contrary to popular belief, increased intake of sugar doesn't cause ADHD or worsen symptoms. According to research, children who received more sugar demonstrated no difference in behavior or learning capability than those who received a sugar substitute. In another study, children who were labeled as sugar-sensitive by their mothers were given sugar substitute containing aspartame. The mothers of these children were told that they had received sugar. The mothers who thought their children received sugar rated them as more hyperactive and were more critical of their behavior compared with the mothers who were told their children received aspartame.

Determining the diagnosis

In younger children, symptoms of inattention, hyperactivity, and impulsivity may be seen by parents, but it usually isn't until the child enters the school system and the behaviors interfere with learning that parents become concerned. Teachers may be the first to identify ADHD because they work with many different kinds of children and get to know how the average child acts. The hyperactive and impulsive symptoms of ADHD are disruptive in the classroom and demand a response from the teacher. The inattentive child may be more passive and quiet, so these symptoms don't immediately alert the teacher to a possible diagnosis of ADHD.

If ADHD is suspected, a psychiatric professional with experience and training with ADHD children is preferred to make a diagnosis. Other conditions, such as undetected seizures, medical disorders that affect brain functioning, anxiety, depression, neurologic disorders, and learning disabilities, may present with symptoms of inattention, hyperactivity, and impulsivity, so it's important to include a medical evaluation, neurologic evaluation, and learning assessment in the diagnosis.

The parents and teachers are also included in the diagnosis process. Both are asked to rate observations of the child's behavior on standardized evaluation forms or behavioral rating scales, such as the National Initiative for Children's Healthcare Quality Vanderbilt Assessment Scale, to compare the child with the behaviors of other children of the same age. The psychiatric professional usually interviews the parents and teachers, and may also contact other people involved with the child, such as coaches or babysitters, for input.

The results of all these methods of assessment are then examined by the psychiatric professional to formulate the diagnosis. A correct diagnosis often relieves the parents' concerns because reasons for the problem are identified and can be treated. It's also important to have a correct diagnosis because ADHD children are more likely to have coexisting conditions, such as depression, anxiety disorders, Tourette syndrome, and learning disabilities, which require different treatment interventions.

Pharmacologic therapy

Medications can be utilized to address the symptoms of ADHD and provide a way to improve the child's self-esteem, target learning problems, and enhance socialization skills (see Common medications used to treat ADHD). The majority of children who use medication report having increased self-esteem, fewer disruptive behaviors, and improved relationships with parents, siblings, and teachers.

Stimulants

Stimulants are the most common medications used to treat ADHD. Stimulants increase the levels of norepinephrine and dopamine, two neurotransmitters that aid in concentrating and focusing. Norepinephrine is the chemical involved in a person's fight or flight response, increasing the ability to maintain alertness and focus and sustaining motivation. When this neurotransmitter's level is altered, the child's ability to focus and concentrate is affected. In addition, the regulation of emotion and impulses is affected by dopamine, with the decreased levels seen in ADHD resulting in problems in these areas.

Stimulant medications come in different forms, such as pills, capsules, liquid, and a skin patch. They can be delivered in short-acting, long-acting, or extended-release varieties. The long-acting and extended-release types allow a child to take the medication just once daily. This decreases or eliminates visits to a school nurse for medication.

Adverse reactions include dry mouth, difficulty sleeping, loss of appetite, weight loss, racing heart, tics, and headaches. Because norepinephrine prepares a person to run or fight, it increases the heart rate and blood flow to vital organs, thus increasing BP. These sympathomimetic properties and the potential effects on the cardiovascular system may warrant monitoring the child's BP and pulse during treatment. Stimulants have been linked to sudden death in children with heart conditions. The American Heart Association recommends that a child undergo a cardiac evaluation before starting a stimulant medication.

In children taking stimulants, it's particularly important to monitor growth and weight. Stimulants can decrease appetite in a child who developmentally needs more calories for growth. The parents should see a healthcare provider to establish a starting weight, and continue monthly visits so weight loss or growth problems can be monitored and the medication adjusted if needed (see Tips for decreasing weight loss in children taking stimulants for ADHD). Parents can be taught to "front load" the child with a high-caloric, protein-rich breakfast before the morning dose of medication is given to compensate for appetite problems later in the day. In addition, making snacks nutritious is important. If a child continues to lose weight, the medications may need to be changed.

Although highly monitored through a controlled substance classification, there's also a large potential for abuse of stimulants. Older children in the household may take the younger child's medications to trade or sell to peers at school. Stimulants are popular with college students who use them to stay awake for study or to improve their ability to focus for exam taking. Other peers may use them for weight loss. It's important to monitor the child's use of stimulants to make sure he or she is taking them as prescribed rather than sharing them with others.

Table Common medications used to treat ADHD

Selective norepinephrine reuptake inhibitors

Atomoxetine is the first medication approved to specifically treat ADHD in children and adults, and it isn't a controlled medication. It works by increasing the neurotransmitters of norepinephrine and dopamine. However, it can take up to 8 weeks to fully see the effects of the medication. It's readily absorbed and food doesn't affect its absorption.

The most common adverse reactions include dry mouth, insomnia, nausea, decreased appetite, constipation, and decreased libido. Because it increases norepinephrine, it also has some cardiac effects such as increased pulse or BP. There have also been rare reports of hepatotoxicity, which resolved when the medication was stopped.

Similar to antidepressants, atomoxetine can increase the risk of becoming suicidal; it has a black box warning for this risk factor. It's important that you educate the parents about the signs of increased suicide risk and the actions to be taken.

Centrally acting alpha-agonist hypotensive agents

Clonidine and guanfacine are adrenergic agonist medications approved by the FDA for the treatment of ADHD. They can be used to effectively treat severe hyperactivity with aggression. These medications actually do the opposite of stimulants in that they lower BP and pulse. Although BP is lowered, the medication may activate certain areas of the brain in the prefrontal cortex that improve focus and attention. In addition, some of the adverse reactions from stimulants, such as headache and irritability, may be resolved when adding clonidine to the regimen.

These medications have a potentially dangerous adverse reaction: As BP is lowered, it may contribute to fainting. It's important for you to educate the family and child about this possible adverse reaction. These medications also have a potential for abuse, including snorting for recreational use.

Antidepressants

Bupropion is an antidepressant that also works to increase norepinephrine and dopamine levels to some degree. It's converted in the body to a form of amphetamine, which may explain why it has modest success in treating ADHD symptoms. Adverse reactions include headache, extreme anxiety, and decreased seizure threshold. Bupropion also has the potential to be abused and should be monitored appropriately.

Behavioral therapy

There are different kinds of therapy that may benefit a child diagnosed with ADHD by assisting him or her to modulate feelings, control unwanted behavior, and increase concentration.

Psychotherapy

In this form of treatment, the child talks about feelings and issues that are bothering him or her. The child can explore any negative behavior patterns and learn ways to deal with symptoms. Because many children with ADHD have difficulty with self-esteem, psychotherapy can assist them to feel better about themselves by building on personal strengths, increasing coping skills, improving attention, and controlling aggression. Homework assignments may be part of this therapy. The therapist may teach the child how to develop routines and organize tasks with calendars, lists, or notes. Learning how to break down large tasks into simple, achievable small steps can help increase self-esteem by letting the child feel a sense of accomplishment. Developing a skill set can assist in long-term recovery rather than just targeting the disruptive behavior.

Behavior therapy

Behavior therapy refers to a wide range of specific interventions with the goal of modifying the environment to change behaviors. Parents are often involved in this type of therapy to shape their child's behavior and improve the child's ability to regulate his or her own behavior. The behavior modification principles can be implemented in the home, school, or peer group setting. In the home, behavior techniques can improve the child's compliance with parental rules and increase the parents' understanding of how behavior can be shaped. In the classroom, the behavior techniques can increase attention, decrease disruptive behavior, and improve work productivity. Peer-to-peer groups focus on developing the social skills necessary for healthy peer relationships.

Helping parents adjust

Parenting skills training can help parents understand their child's behavior and learn to guide behavior into a more positive form (see Teaching parents of children with ADHD). Parents of a child with ADHD need new skills to assist them in developing a system of behavior and consequences that help shape the child's behavior. Immediate and frequent feedback helps the child learn what behavior promotes or hampers learning and socialization.

With some behaviors, time-outs can be used. This is a short time period given to the child to remove him or her from the upsetting situation and allow for regrouping. A time-out can also help the parent regroup.

Don't forget there are support groups available to help both the child and family by providing a network of support, information, and education.

Your support is needed

In all settings, from schools to hospitals to medical clinics, the nurse is a key member of the team who can help identify children that may be experiencing symptoms of ADHD. You can be an advocate for the child and family by ensuring the proper diagnosis is obtained before any medications are prescribed. Support the family and child by listening to the fears and challenges they may be experiencing and helping them with the behavior scales that are often part of the diagnostic process.

After diagnosis, teach parents how to effectively deal with the symptoms of ADHD by educating them on support groups in the community, ways to address the symptoms of ADHD, and how to keep their child on a mentally healthy developmental track. Children with ADHD and their families often encounter nurses. This makes it crucial for you to understand ADHD, the route to a proper diagnosis, and the best-available treatment modalities.

A brighter tomorrow

The optimal course of treatment for the child with ADHD is usually a combination of behavioral therapies and medication. By intervening early in the diagnosis, low self-esteem, learning difficulties, and depression can be decreased or avoided, thus improving the life experience of the child.

cheat sheet

Keys of action

* The primary care provider, such as a pediatrician, pediatric NP, or family provider, should screen all children ages 4 to 18 for ADHD.

* In diagnosing ADHD, an evaluation for developmental disorders, neurologic disorders, and physical disorders that may have similar symptoms should be conducted.

* Behavioral observations from parents, teachers, and other significant caregivers should be included in the formulation of an ADHD diagnosis.

* The child should be monitored for weight loss, growth, or adverse reactions of the prescribed medications on a regular basis.

* Because ADHD is a chronic disorder, consider the child as having special healthcare needs and manage his or her care following principles of chronic care and medical home models.

Tips for decreasing weight loss in children taking stimulants for ADHD

* Because appetite can decrease within 30 minutes (or longer if extended release) of taking the medication, have the child eat first.

* Make snacks count with high-protein and high-calorie food items.

* Use flexible eating schedules, allowing the child to eat when he or she is hungry.

* Change the timing of the stimulant dose according to appetite patterns.

* Feed the child nutrient dense foods to get maximum value in a meal.

* If weight loss continues, talk to the healthcare provider about changing the dosage or medication.

Teaching parents of children with ADHD

* Help parents show affection. Often, children with ADHD receive a lot of negative feedback about their behavior and may think that their parents don't love them.

* Help parents develop patience. Parents may find it difficult to deal with the behavior of a child with ADHD on a daily basis.

* Encourage parents to keep a regular schedule. Children with ADHD do better with a consistent and expected schedule; transitions and changes are particularly hard for these children. Help parents plan activities ahead of time, marking them on a calendar so the child can adjust.

* Teach parents to have a quiet space available for studying and to work on organizational skills with the child, such as keeping his or her room clean and uncluttered.

* Encourage parents to use simple, short sentences when giving the child direction. The child should face the parent and make eye contact when directions are being given. Parents should be specific and give one direction at a time.

* Help parents focus on the positive. Each child with ADHD has special skills or talents. Make sure there are opportunities for the child to utilize these skills and talents so his or her self-esteem will increase.

* Teach parents to use time-outs or loss of privileges to discipline the child. Often, children with ADHD need stimuli-free time away from an activity to regroup and focus.

On the web

Abikoff H, Hechtman L, Klein RG, et al. Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. J Am Acad Child Adolesc Psychiatry. 2004;43(7):802-811.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

Biederman J, Petty CR, Monuteaux MC, et al. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry. 2010;167(4):409-417.

Braun JM, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to environmental toxicants and attention deficit hyperactivity disorder in U.S. children. Environ Health Perspect. 2006;114(12):1904-1909.

Gonzalez S, Rangel-Barajas C, Peper M, et al. Dopamine D(4) receptor, but not the ADHD-associated D(4.7) variant, forms functional heteromers with the dopamine D(2S) receptor in the brain. Mol Psychiatry. 2011 Aug 16. doi: 10.1038/mp.2011.93. [Epub ahead of print]

Hechtman L, Abikoff H, Klein RG, et al. Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. J Am Acad Child Adolesc Psychiatry. 2004;43(7):812-819.

Linnet KM, Dalsgaard S, Obel C, et al. Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associate behaviors: review of the current evidence. Am J Psychiatry. 2003;160(6):1028-1040.

Mick E, Biederman J, Farone SV, Sayer J, Kleinman S. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. J Am Acad Child Adolesc Psychiatry. 2002;41(4):378-385.

Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164(6):942-948.

Rapport MD, Moffitt C. Attention deficit/hyperactivity disorder and methylphenidate: a review of height/weight, cardiovascular, and somatic complaint side effects. Clin Psychol Rev. 2002;22(8):1107-1131.

Reimherr FW, Marchant BK, Strong RE, et al. Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry. 2005;58(2):125-131.

Rucklidge JJ. Gender differences in attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2010;33(2):357-373.

Shaw P, Gornick M, Lerch J, et al. Polymorphisms of the dopamine D4 receptor, clinical outcome, and cortical structure in attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2007;64(8):921-931.

Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1020.

Wilens TE, Biederman J, Faraone SV, Martelon M, Westerberg D, Spencer TJ. Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically referred adults with ADHD. J Clin Psychiatry. 2009;70(11):1557-1562.

Wilens TE, Hammerness PG, Biederman J, et al. Blood pressure changes associated with medication treatment of adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2005;66(2):253-259.