Attention Deficit/Hyperactivity Disorder
Attention deficit/hyperactivity disorder (ADHD) is poor or short attention span and impulsiveness inappropriate for the child's age; some children also manifest hyperactivity.
Although there is considerable controversy about incidence, it is estimated that ADHD affects 5 to 10% of school-aged children and is diagnosed 10 times more often in boys than in girls. Many features of ADHD are often noticed before age 4 and invariably before age 7, but they may not interfere significantly with academic performance and social functioning until the middle school years. ADHD was previously just called "attention deficit disorder"; however, the common occurrence of hyperactivity in affected children--which is really a physical extension of attention deficit--led to a change in the current terminology.
ADHD can be inherited. Recent research indicates that the disorder is caused by abnormalities in neurotransmitters (substances that transmit nerve impulses within the brain). The symptoms of ADHD range from mild to severe and can become exaggerated or become a problem in certain environments, such as in the child's home or at school. The constraints of school and organized lifestyles make ADHD a problem, whereas in prior generations, the symptoms may not have interfered significantly with children's functioning because such restraints were often much fewer. Although some of the symptoms of ADHD also occur in children without ADHD, they are more frequent and severe in children with ADHD.
Symptoms
ADHD is primarily a problem with sustained attention, concentration, and task persistence (ability to finish a task). The child may also be overactive and impulsive. Many preschool children are anxious, have problems communicating and interacting, and behave poorly. They seem inattentive. They may fidget and squirm. They may be impatient and answer out of turn. During later childhood, such children may move their legs restlessly, move and fidget their hands, talk impulsively, forget easily, and they may be disorganized. They are generally not aggressive.
About 20% of children with ADHD have learning disabilities and about 80% have academic problems. Work may be messy, with careless mistakes and an absence of considered thought. Affected children often behave as if their mind is elsewhere and they are not listening. They often do not follow through on requests or complete schoolwork, chores, or other duties. There may be frequent shifts from one incomplete task to another.
About 40% of affected children may have issues with self-esteem, depression, anxiety, or opposition to authority by the time they reach adolescence. About 60% of young children have such problems as temper tantrums, and most older children have a low tolerance for frustration.
 See the sidebar Signs of ADHD.
Diagnosis
The diagnosis is based on the number, frequency, and severity of symptoms. Symptoms must be present in at least two separate environments (typically, home and school)--occurrence of symptoms just at home or just at school and nowhere else does not qualify as ADHD. Often, diagnosis is difficult because it depends on the judgment of the observer. There is no laboratory test for ADHD. Questionnaires about various aspects of behavior can help the doctor make the diagnosis. Because learning disabilities are common, many children receive psychologic testing both to help determine if ADHD exists and to detect the presence of specific learning disabilities.
See the sidebar ADHD: Epidemic or Over-Diagnosis?
Treatment and Prognosis
To minimize the effects of ADHD, structures, routines, a school intervention plan, and modified parenting techniques are often needed. Some children who are not aggressive and who come from a stable and supportive home environment may benefit from drug treatment alone. Behavior therapy conducted by a child psychologist is sometimes combined with drug treatment. Psychostimulant drugs are the most effective drug treatment.
Methylphenidate is the psychostimulant drug most often prescribed. It is as effective as other psychostimulants (such as dextroamphetamine) and is probably safer. A number of slow-release (longer-acting) forms of methylphenidate are available in addition to the regular form and allow for one time per day dosing. Side effects of methylphenidate include sleep disturbances, such as insomnia, appetite suppression, depression or sadness, headaches, stomachaches, and high blood pressure. All of these side effects disappear if the drug is discontinued; however, most children have no side effects except perhaps a decreased appetite. However, if taken in large doses for a long time, methylphenidate can occasionally slow the child's growth; therefore, doctors monitor weight gain.
A number of other drugs can be used to treat inattentiveness and behavioral symptoms. These include clonidine, amphetamine-based drugs, antidepressants, and antianxiety drugs. Sometimes, combinations of drugs are used.
Children with ADHD generally do not outgrow their inattentiveness, although those with hyperactivity tend to become somewhat less impulsive and hyperactive with age. However, most adolescents and adults learn to adapt to their inattentiveness. Other problems that emerge or persist in adolescence and adulthood include poor academic achievement, low self-esteem, anxiety, depression, and difficulty in learning appropriate social behaviors. Importantly, the vast majority of children with ADHD become productive adults, and people who have ADHD seem to adjust better to work than to school situations. However, if the disorder is untreated in childhood, the risk of alcohol or substance abuse or suicide may increase.
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