Attention Deficit Hyperactivity Disorder (ADHD) Information on eMedicineHealth

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Attention Deficit Hyperactivity Disorder (cont.)

Exams and Tests

The evaluation of a child for attention deficit hyperactivity disorder (ADHD) should begin with a thorough medical interview. The child's health care provider should ask detailed questions about the child's medical history. When not known from previous visits, this might include questions regarding the pregnancy and delivery, psychiatric history, family history, home and daycare conditions, school performance, work and legal problems (if appropriate), illnesses, current medications and supplements, diet, sleep, other habits, and social behaviors.

A thorough physical exam is rarely needed if a child has had regular checkups and has no significant physical problems. An important part of the evaluation, however, is careful observation of behavior, even though a child or teen with ADHD may exhibit few symptoms in the medical office.

At this time, no lab test, x-ray film, or procedure is known to suggest or confirm the diagnosis of ADHD. Specific tests may be ordered if indicated by specific symptoms.

Psychometric and educational testing is often important to the diagnosis of ADHD.

Testing can be instrumental in ruling out other conditions and specific learning disabilities.
It can highlight the weakest areas of attention and allowing counseling for the individual, parents, and teachers about how to use strengths to best advantage.
As useful as these tests can be, they do not diagnose ADHD. The diagnosis of ADHD can only be made by a qualified professional after reviewing all of the information.

Psychometric tests most widely used in the diagnosis of ADHD include the following:

The Conners' Parent and Teacher Rating Scale (for children) and the Brown Attention Deficit Disorder Scale (BADDS) for teens and adults may be useful in arriving at a diagnosis.
Impulsivity and inattention can be assessed with timed computer tests, such as the Conners Continuous Performance Test (CPT), the Integrated Visual and Auditory (IVA) CPT, or both.
The Nadeau/Quinn/Littman ADHD Self-Rating Scale for Girls should be part of the assessment for all girls.
Various neuropsychiatric tests can be used to identify strengths and weaknesses in executive function.

Evaluation of intellectual function (for example, intelligence quotient, or IQ) can be helpful in distinguishing between ADHD and intellectual impairment.

Educational testing can identify learning disabilities such as language or math weaknesses. It also evaluates intellectual ability and academic achievement and can suggest whether academic support such as tutoring is needed.

A baseline ECG may be performed to assess heart function before prescribing certain medications, such as tricyclic antidepressants.

ADHD Treatment

Medical Treatment

The 2 major components of treatment for children with attention deficit hyperactivity disorder (ADHD) are behaviorally focused psychotherapy and medication.

Usually, the primary care provider refers the person with ADHD to a psychotherapist. The more common components of psychotherapy are as follows. Not all components are necessary for every individual with ADHD.

School or education interventions: These interventions are aimed at improving the child's study skills and behavior in the classroom setting. The age of the child and the severity of the ADHD symptoms affect the extent to which the child benefits from working with education specialists. Teachers have an important function. Their periodic feedback on school performance through the use of standardized scales, narrative descriptions, and telephone follow-up is generally an indispensable component of ongoing care.
Psychotherapy: ADHD coaching, a support group, or both can help teens feel more normal and provide well-focused peer feedback and coping skills. Counselors such as psychologists, child and adolescent psychiatrists, behavioral/developmental pediatricians, clinical social workers, and advanced practice nurses, can be invaluable to both the children and families. Behavior modification and family therapy are usually necessary for the best possible outcome.

Medications

The medications used to treat ADHD are psychoactive. This means they affect the chemistry, and thus the functioning, of the brain.

Psychostimulants are by far the most widely used medications in ADHD. They work very well in most individuals with the disorder and, when used appropriately, have a good track record of relieving symptoms without causing major adverse effects.

These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.
The most common adverse effects are short term. They include loss of appetite, sleep disturbances, rebound (for example, agitation, anger, lethargy as the last dose starts to wear off), and mild anxiety.
Most individuals who take psychostimulants for ADHD build up tolerance to adverse effects within a few weeks, but growth rate needs to be followed closely in children throughout most of the time of their treatment, since any decrease in gaining height or weight may have long-term effects.
Individuals with certain coexistent psychiatric disorders (for example, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to adverse effects if they do not receive appropriate concurrent treatment for the coexistent condition.

The psychostimulants most often used in ADHD include the following. The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.

Dextroamphetamine (Dexedrine, Dexedrine Spansules, Dextrostat)
Methylphenidate (Ritalin, Concerta, Methylin, Metadate CD)
Dexmethylphenidate (Focalin, Folacin XR)
Dextroamphetamine and amphetamine mixture (Adderall)
Pemoline (Cylert) - Rarely used now because of side effects in the liver (Cylert [Abbott Laboratories] is being discontinued in the US market because of declining sales. Pemoline is not considered as first-choice therapy for ADHD because of reports of severe acute liver failure. Since pemoline was introduced on the market in 1975, 15 cases of liver failure were reported as of December 1998. Twelve of these cases resulted in death or liver transplantation, usually within 4 weeks of onset. Pemoline has previously been removed from the market in the United Kingdom and Canada. As of this date, it is not known if generic pemoline products will remain on the market.)

Atomoxetine (Strattera) is a new nonstimulant used to treat ADHD. This medication has been used for only a few years and less is known about its long-term side effects. This drug has several benefits over stimulants and its popularity is growing rapidly.

It is not a controlled substance and is not considered a drug of potential abuse by the US Food and Drug Administration (FDA).
It is usually taken only once a day for full 24-hour effectiveness.
It is much less likely than stimulants to disrupt eating or sleeping.
For some children, atomoxetine is not enough to control their ADHD symptoms. Many other children do very well on this medicine alone.

Some medications originally developed to treat depression (antidepressants) also have important roles in treating some individuals with ADHD. Since these medicines have been used for many years to treat other mental health conditions, their adverse effects are well understood.

Imipramine (Tofranil) - An antidepressant that increases levels of neurotransmitters norepinephrine and/or serotonin in the brain
Bupropion (Wellbutrin) - An antidepressant that increases levels of neurotransmitters in the brain, especially dopamine
Desipramine (Norpramin) - An antidepressant that increases level of the neurotransmitter norepinephrine in the brain

Other medicines that were originally developed to treat high blood pressure (alpha agonists) may also be useful in the treatment of those having ADHD. Again, due to widespread and long-term use, their side effects are well known to doctors.

Clonidine (Catapres) - An á₂ agonist that stimulates certain receptors in the brain stem; the overall effect is to "turn down the volume" of hyperactive movement and speech
Guanfacine (Tenex) - Another alpha agonist with an effect similar to that of clonidine

Warnings concerning psychostimulant use

The psychostimulants are controlled substances; prescriptions must follow strict federal and state guidelines.

Any psychostimulants found by legal authorities (for example, while writing a speeding ticket) can cause suspicion. Thus, if the medication must be carried away from home, it should be kept in the original pharmacy container. In some states, having the medication in any container is acceptable as long as the pills are accompanied by a doctor order on a prescription or letterhead that states that the person is under the doctor's care and takes the medication as directed by a doctor.

Although the stimulant abuse rate in ADHD specialty centers is remarkably low, it is not zero. Illicit practices include crushing the psychostimulant so that it can be snorted through the nose. Unfortunately, this is not uncommon on college campuses. Pills can also be crushed and diluted and injected intravenously. These practices, which are most widespread among adolescents, are potentially addicting and dangerous, and even fatal. Any person who knowingly supplies others with these drugs is considered partly responsible for any injury sustained by the abuser. Teens should be warned about the dangers.

ADHD is a controversial diagnosis for several reasons. Many well-meaning individuals have spoken out against making children behave according to a norm or take medications for the sake of improving grades. These individuals have expressed concern about addiction or drugging children. This kind of concern is valid; however, the following must also be considered:

The negative consequences of not using medication for children with ADHD have to be weighed against the known risks. Long-term outcome studies have now been conducted with large numbers of adults diagnosed with ADHD as children, and one clear finding is that those who received medication for their disorder in childhood are more functional and have a better quality of life as adults than those who had the symptoms of the disease but did not receive medicine.
Stimulants used for ADHD do not cause addiction. Although tolerance usually develops for the stimulant-associated effects of anorexia, insomnia, or mild euphoria, tolerance does not develop to the increased levels of neurotransmitters.
These medications should not be used just to improve grades or quiet down classrooms. School performance should be looked at as a sign of how well the child is doing, just like other areas of health. These medications often improve school performance dramatically, which is linked to better social skills and heightened self-esteem. But the grades should be a marker, not a goal.

The use of psychostimulants in children should be scrutinized carefully. Fortunately, methylphenidate (or Ritalin, historically the most widely prescribed medication for ADHD) has been available for more than 40 years. This long period of clinical experience has shown that this is one of the safest medications used in children.

Studies that have examined whether taking a psychostimulant for ADHD in childhood contributes to future substance abuse have shown this to not be the case. In one very large study, in fact, children who received stimulant medication for ADHD had half the risk of future substance abuse of similar children with ADHD who did not receive medication.

Other Therapy

Diet

No specific food or diet has been clearly shown to have a significant positive or negative effect on the symptoms or course of ADHD. People with ADHD should eat a healthy diet and probably avoid caffeine. That having been said, if the family's experience with a person having ADHD is that some sort of dietary change, such as decreased refined sugar intake, helps, then if the person is not deprived of necessary nutrients, there is certainly no harm in trying to follow such a plan. A good rule of thumb is to discuss the plan with the family doctor or whoever is providing the primary treatment for the ADHD symptoms.

Activity

Regular physical activity has been shown to play an important role in some of the common related conditions (for example, depression, anxiety) and to improve concentration. Regular exercise may be beneficial in people with ADHD.

Next Steps

Follow-up

The primary care provider, behavioral pediatrician, or child and adolescent psychiatrist will want to see the caregiver and the child often at first to monitor progress and response to therapy. Once the individual's condition is stabilized, follow-up visits will be regular but less frequent.

The frequency of follow-up visits is quite variable and is dictated by the person's characteristics and convenience, provider experience, and use of psychotherapy.
Follow-up visits every 4-12 weeks are often appropriate for the first year. After that, visits every 3-4 months for medication assessment may be adequate for a person whose condition is stable.
Behavioral therapy may need to be ongoing for months or years.

Federal and state laws grant special educational accommodations for children with ADHD and learning disabilities. Become familiar with these laws.

Prevention

No clear methods for preventing ADHD are currently known. While some people have suggested that certain diets, teaching or parenting methods, or other approaches may keep ADHD from happening, unfortunately, none of these approaches has stood up to rigorous scientific testing so far. On the other hand, once the symptoms have begun and careful assessment has produced an ADHD diagnosis, various specific behavioral and learning techniques can be used by teachers and family to help get symptoms under better control. These should be discussed with the treating doctor so that the right interventions can be applied for the specific person.

Outlook

The outlook for people with ADHD is excellent as long as the following conditions are met:

No major related conditions
Continued adherence to the therapy recommended by health care providers
Any and all coexisting learning disabilities are diagnosed and addressed
Any and all coexisting emotional problems are investigated and treated appropriately by a primary care physician or an appropriate mental health professional

The outlook for people with related conditions or who do not receive appropriate remediation and/or treatment for their disabilities is less promising. The actual outcome for any specific individual cannot be predicted accurately because of the many variables involved.

Support Groups and Counseling

Attention deficit hyperactivity disorder (ADHD), whether it is an adult or a child who is affected, brings many challenges. People with ADHD can learn, achieve, succeed, and create a happy life for themselves, but not without effort. The individual needs to change his or her expectations and get organized. Only then can he or she learn practical ways to cope with ADHD and put them into practice. But making changes is not always easy. Sometimes it helps to have someone to talk to.

This is the purpose of support groups. Support groups consist of people in the same situation. They come together to help each other and to help themselves. Support groups provide reassurance, motivation, and inspiration. They help individuals see that their situation is not unique and not hopeless, and that gives them power. They also provide practical tips on coping with ADHD and navigating the medical, educational, and social systems that people will rely on for help for themselves or their child. Being in an ADHD support group is strongly recommended by most mental health professionals.

Support groups meet in person, on the telephone, or on the Internet. To find a support group that works for you, contact the following organizations. You can also ask your health care provider, behavioral therapist, or education specialist, or go on the Internet. If you do not have access to the Internet, check with your child's teacher or go to the public library.