Attention Deficit Hyperactivity Disorder (ADHD) is a neurobehavioral disorder affecting 3-5% of children and adolescents between the ages of 4 and 17 in the United States. It is a disorder that impacts not only the child, but other family members as well. Children with Attention Deficit Hyperactivity Disorder have a difficult time, both socially and academically. This article will explore the etiology and impact of Attention Deficit Hyperactivity Disorder on children. It will also outline treatment options available for children with ADHD.
Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological disorder that is characterized by hyperactivity/impulsivity and/or persistent inattention. ADHD is categorized into 3 types: predominantly hyperactive-impulsive, predominantly inattentive, and combined. It is estimated that 3-5% of children in the United States between the ages of 4 and 17 have been diagnosed with this disorder. ADHD is more prevalent in boys. The ratio of boys to girls who are diagnosed with ADHD is 3:1. ADHD often becomes noticeable during preschool and early school age. The hyperactive-impulsive type usually materializes during the preschool years. The combined type is more often seen between the ages of 5 and 8 and the inattentive type is more often noticeable between 8 and 12 years old (Kerig & Wenar).
A child with the predominantly hyperactive-impulsive type of ADHD is constantly on the go and full of energy. They are restless, talk excessively and have difficulty sitting still for long periods of time. They also act very impulsively, such as interrupting when others are speaking and talking out at inappropriate times. They have difficulty with quiet activities, such as reading. It is not easy for them to wait for their turn or listen and follow directions (Raulin).
A child with the predominantly inattentive type of ADHD has a difficult time staying on task and finishing a task. They also have a hard time keeping themselves and their belongings organized. It is a challenge for these children to follow both directions and conversations. They become easily distracted and often forget the steps necessary to perform daily routines. Children with the combined type of ADHD have an equivalent amount of symptoms from both of the other types. Most children diagnosed with this disorder fall into this category (Raulin).
Many of the behaviors associated with ADHD, such as hyperactivity and impulsivity, are typically found in young children, so for a proper diagnosis to be made, the child must exhibit these behaviors at a level that is not appropriate for their age. According to the DSM-IV-TR, symptoms should be present for 12 months in preschoolers before a diagnosis of ADHD is made. The criterion used to identify children with ADHD is more pertinent to boys’ behavior than to girls, which raises the question about the gender differences found in this disorder. The diagnosis is based on how many of the symptoms listed in the DSM-IV-TR are present. Persistence and history of ADHD behaviors are also considered when a child is being evaluated. The degree to which the symptoms interfere and disrupt the child’s performance in at least 2 settings, such as school and home, are also taken into account (Kerig and Wenar).
There does not appear to be a single cause for ADHD. Heredity seems to be the most common denominator in ADHD. Adults with ADHD have a 35% chance of having a child with ADHD. Researchers have been studying the genetic factors that may affect how a brain develops and functions. Much of this research has been focused on the frontal lobes in the cerebellum. The function of the frontal lobes is to aid in problem solving, organization, and control of impulses. Magnetic Resonance Imaging, Positron Emission Topography and Single Photon Emission Computed Tomography have been used to study the brains of individuals with ADHD. Researchers have found the brains of those with ADHD are 3-4% smaller than the brains of individuals who do not have this disorder (Strock).
Researchers have also been exploring the possibility that the central nervous system plays a role in ADHD. The neurotransmitters norepinephrine and dopamine are of special interest to researchers; since the medication used to treat ADHD increase both norepinephrine and dopamine in the brain (Strock).
Children with ADHD have many developmental problems, such as learning difficulties, coordination of both fine and gross motor skills and trouble with socialization. These children often have negative transactions with others due to their behavior, which puts them at risk for developing comorbid psychopathology (Kerig and Wenar). A child with ADHD may have a difficult time making and keeping friends. Children with the inattentive type of ADHD may be viewed by their peers as introverted and withdrawn, while children with the hyperactivity-impulsivity type often exhibit aggressive behavior, so other children tend to steer away from them.
ADHD affects a child’s life in many ways. They often have a low self-esteem and immature behavior (Strock). Their behavior can affect the whole family. Parents and caregivers often feel angry and frustrated when dealing with the child’s ADHD behaviors. Living with a child with ADHD can make family life chaotic for everyone in the home. The family’s stress level can be quite high, especially with the combined or hyperactive-impulsive types of ADHD. Siblings may feel neglected and resentful of the attention the child with ADHD receives. Parents may feel guilty that they are not giving their other children the attention they need.
There are different treatment options available for ADHD. There is not one treatment that works best for all children. Each child is different, so the treatment must be adjusted to fit a child’s individual needs. The National Institute of Mental Health (NIMH) has conducted several studies on the treatments for ADHD. One study, called the Multimodal Treatment Study of Children with ADHD (MTA), included 579 elementary school boys and girls (aged 7-9.9 years old) who were diagnosed with the combined type of ADHD. They divided the children into 4 groups: Group 1 children only received medication. Group 2 children only received behavioral treatment. Group 3 children received a combination of medication and behavioral treatment. Group 4 children received routine community care by a private physician chosen by their parents. The groups received treatment for 14 months (Strock).
The first 3 groups were designed to have a team approach to treatment. Physicians, parents and teachers kept in contact and recorded the child’s progress. The private physicians for the children in Group 4 did not have any communication with the child’s teacher. The results of the study showed that in most cases, medication along or a combination of medication and Behavioral Therapy was most successful. In specific areas (parent/child interactions, academics, oppositional behavior and social skills) Group 3 (combination of medication and Behavioral Therapy) was much more effective (Strock).
The most common treatment option is stimulant medications. 70-96% of children taking stimulants to treat their ADHD show some improvement. This type of medication has been shown to improve the interactions of the child with his/her family and peers by decreasing aggressiveness and hyperactivity (Kerig & Wenar). The stimulants most often prescribed for ADHD are Ritalin, Adderall and Concerta. These drugs work on the neurotransmitter, dopamine. There are some side effects associated with stimulants, such as insomnia, irritability, anxiety and lack of appetite. The medication must be closely monitored by a physician and the dosage adjusted or medication changed as needed. Often parents and teachers notice immediate improvements, but sometimes these improvements are short-lived. Stimulant medications do not always have long-term effects on academic and social areas (Whalen).
Strattera, which is not a stimulant, has also been approved by the United States Food and Drug Administration to treat ADHD. Strattera works on the neurotransmitter, norepinephrine. So far, studies on children taking Strattera have been promising. More than 70% of the children taking Strattera showed marked improvement. Many parents worry about having their child take a drug every day for fear their child will become addicted to these drugs. No evidence has been found that supports this worry (Strock).
Children who do not show improvement with stimulant medication or who develop harsh side effects or depression are sometimes given tricyclic antidepressants to treat their ADHD. Tricyclic antidepressants do not help the cognitive problems associated with ADHD and the effectiveness of these drugs tends to decline over time. These drugs also have side effects that can be very dangerous, such as cardiac arrest (Kerig and Wenar).
Behavior Therapy lessons a child’s behavioral problems and increases behaviors that help a child both socially and academically. This type of therapy helps a child learn ways to change the way they think and act and to learn new behavioral techniques to help them in their daily lives. Behavioral Therapy teaches a child how to monitor their own behavior. It also shows them ways to organize their schoolwork and improve their relationships with their peers. This type of therapy aids a child in building a better self-image of themselves (Strock). Cognitive Behavioral Therapy helps a child take what they learn and apply it to their everyday life. Cognitive Behavioral Therapy often teaches anger management skills to decrease aggressive behavior (Kerig and Wenar).
In 2001, The American Academy of Pediatrics, provided guidelines for both diagnosing and treating school-aged children who have ADHD. Their recommendation was to use the DSM-IV diagnostic criteria along with collecting and examining information from parents and teachers and using scales to ascertain the level of appropriateness of the child’s ADHD symptoms. The American Academy of Pediatrics also noted that ADHD is a chronic disorder which needs to be treated with both medication and behavioral psychosocial treatment on an ongoing basis (Resnick & Root).
It is best for psychosocial treatment to be tried first in cases where a child’s ADHD symptoms are mild. This approach should also be applied first in preschoolers, when comorbid social skills deficits or internalizing disorders are present. Most experts are in agreement that a combination of medication and psychosocial treatments should be used for children who exhibit severe symptoms of ADHD. The combination approach is also best when the child shows aggression or has severe problems at school or at home. This approach should also be used when external comorbid disorders, such as mental retardation or central nervous system problems are present (Resnick & Root).
A long term plan is important because Attention Deficit Hyperactivity Disorder is a chronic condition that lasts a long time. The treatment plan that is set up for the child should be positive and set the child up for success, not failure. A treatment plan for a child with ADHD should include a behavior management plan with target goals. Target goals are important to help the child’s symptoms improve. Some examples of target goals are improving relationships with parents and siblings, improving schoolwork and improving behavior to be less disruptive and safer. Target goals should be realistic and the goals should be attainable for the child. The goals should contain behaviors that can be observed and measured. It is crucial that the plan created for the child have a team approach with parents, teachers, and physicians working to make choices that are in the best interest of the child (Reiff & Tippins).
The prognosis of ADHD if left untreated is not good. As the child with ADHD reaches adulthood, those who have not received treatment have a greater chance of developing a comorbid disorder. Approximately 60% will be prescribed psychiatric medication during their lives and about 50% will have substance abuse problems as adults (Feldman, Olds & Papalia).