Attention-Deficit Hyperactivity Disorder - UMHS Approved Clinical Care Guideline

This information is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition.

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental health problem in children. Children with ADHD often have problems with attention span, hyperactivity, and impulsive behavior. It is often called by an older name, attention deficit disorder (ADD).

Between 8% and 12% of all school age children have ADHD. The disorder begins in the preschool years and may either continue or fade away during the teenage years. About one-third of children with ADHD also have learning problems such as a reading disability. About half of ADHD children and teenagers have behavior problems, which may include breaking rules, talking back, and hitting other children.

ADHD is more common in boys than girls. Girls are more likely to have troubles with attention and less likely to have hyperactivity.

In about 70% of cases, ADHD is inherited. It runs in families, especially through the males in the family line. Research continues in an effort to find out why it occurs in those without a family history.

Much research has looked at whether ADHD is caused by sugar or things added to foods such as preservatives and coloring. No sound evidence has connected these with ADHD. Allergies are also not a factor in causing ADHD.

People with ADHD have several small differences in their brain structure. These differences are in the front part of the brain (an area involved in self-control) and in some parts in the center of the brain.

The symptoms of ADHD, especially hyperactivity, usually appear by age 2 or 3 and by first grade at the latest. The main symptoms are:

Your health care provider will ask about the symptoms and will observe your child's behavior for signs of ADHD. To diagnose ADHD, it must be clear that the symptoms interfere in a major way with daily life. You and others, such as your child's teachers, may be asked to complete questionnaires or rating forms about ADHD symptoms. Your child may be asked to see a psychologist or other mental health professional for tests of attention and self-control.

There are no useful physical tests such as blood tests or brain scans for diagnosing ADHD.

Attention deficit disorder is a chronic condition that needs special parenting and school intervention. If your child seems to have a poor attention span and is over 3 years of age, these recommendations may assist you in helping your child. Your main obligations involve organizing your child's home life and improving discipline. Only after your child's behavior has improved will you know for certain if your child also has a short attention span. If he does, specific interventions to help him learn to listen and complete tasks ("stretch" his attention span) can be initiated. Even though you can't be sure about poor attention span until your child is 3 or 4 years of age, you can detect and improve behavior problems at any time after 8 months of age.

Accept the fact that your child is intrinsically active and energetic and possibly always will be. The hyperactivity is not intentional. Don't expect to eliminate the hyperactivity but merely to bring it under reasonable control. Any criticism or other attempt to change an energetic child into a quiet or model child will cause more harm than good. Nothing helps a hyperactive child more than having a tolerant, patient, low-keyed parent.

This energy can't be bottled up and stored. Daily outdoor activities such as running, sports, and long walks are good outlets. A fenced yard helps. In bad weather your child needs a recreational room where he can play as he pleases with minimal restrictions and supervision. If no large room is available, a garage will sometimes suffice. Your child should not have too many toys, for this can cause him to be more easily distracted from playing with any one toy. The toys should be safe and relatively unbreakable. Encourage your child to play with one toy at a time.

Although the expression of hyperactivity is allowed in these ways, it should not be needlessly encouraged. Don't initiate roughhousing with your child. Forbid siblings to say, "Chase me, chase me," or to instigate other noisy play. Encouraging hyperactive behavior can lead to its becoming your child's main style of interacting with people.

Household routines help the hyperactive child to accept order. Keep the times for wake-up, meals, snacks, chores, naps, and bed as regular as possible. Try to keep your environment relatively quiet because this encourages thinking, listening, and reading at home. In general, leave the radio and TV off. Predictable daily events help your child's responses become more predictable. ADHD symptoms are made worse by sleep deprivation and hunger. Be sure your child has an early bedtime and a big breakfast on school days.

When a hyperactive child becomes exhausted, his self-control often breaks down and the hyperactivity becomes worse. Try to have your child sleep or rest when he is fatigued. If he can't seem to "turn off his motor," hold and rock him in a rocking chair.

For children who have trouble slowing down at bedtime, night lights and background music are often helpful.

Except for special occasions, avoid places where hyperactivity would be extremely inappropriate and embarrassing (such as churches or restaurants). You also may wish to reduce the number of times your child goes with you to stores and supermarkets. After your child develops adequate self-control at home, he can gradually be introduced to these situations. Be sure to praise your child when he plays independently rather than interrupting you when you are talking to guests or are on the telephone.

These children are unquestionably difficult to manage. They need more carefully planned discipline than the average child. Rules should be formulated mainly to prevent harm to your child and to others. Aggressive behavior, such as biting, hitting, and pushing, should be no more accepted in the hyperactive child than in the normal child. Try to eliminate such aggressive behaviors, but avoid unnecessary or unattainable rules; that is, don't expect your child to keep his hands and feet still. Hyperactive children tolerate fewer rules than the normal child. Enforce a few clear, consistent, important rules and add other rules at your child's pace. Avoid constant negative comments like "Don't do this," and "Stop that." Develop a set of hand signals and use them rather than verbal reminders to tell your child to calm down or slow down.

Physical punishment suggests to your child that physically aggressive behavior is OK. We want to teach hyperactive children to be less aggressive. Your child needs adult models of control and calmness. Try to use a friendly, matter-of-fact tone of voice when you discipline your child. If you yell, your child will be quick to imitate you.

Punish your child for misbehavior immediately. When your child breaks a rule, isolate him in a chair or time-out room if a show of disapproval doesn't work. The time-out should last about 1 minute per year of your child's age. Without a time-out system, overall success is unlikely.

Encouraging attentive (nonhyperactive) behavior is the key to preparing your child for school. Increased attention span and persistence with tasks can be taught at home. Don't wait until your child is of school age and expect the teacher to change him. By age 5 he needs at least a 25-minute attention span to perform adequately in school. Simple behavior programs with charts and daily rewards can be good for teaching longer attention spans and sitting still.

Set aside several brief periods each day to teach your child listening skills by reading to him. Start with picture books, and gradually progress to reading stories. Coloring pictures can be encouraged and praised. Teach games to your child, gradually increasing the difficulty by starting with building blocks and progressing to puzzles, dominoes, card games, and dice games. Matching pictures is an excellent way to build your child's memory and concentration span. Later, consequence games such as checkers or tic-tac-toe can be introduced. When your child becomes restless, stop and return for another session later. Praise your child for attentive behavior. This process is slow but invaluable in preparing your child for school.

Plan to have your child do homework and other tasks that require concentration in short blocks of time with breaks in between. Try having your child study with low-level background sound such as white noise or instrumental music. Do homework and studying away from the sounds of television, radio, or others talking but where adults can supervise.

Ask neighbors with whom your child has contact to be helpers. If your child is labeled by some adults as a "bad" kid, it is important that this image of your child doesn't carry over into your home life. At home the attitude that must prevail is that your child is a good child with excess energy. It is extremely important that you not give up on him. Your child must always feel loved and accepted within the family. As long as a child has this acceptance, his self-esteem will survive. If your child has trouble doing well in school, help him gain a sense of success through a hobby in an area of strength.

Exposure to some of these children for 24 hours a day would make anyone a wreck. Periodic breaks help parents to tolerate hyperactive behavior. If just one parent works outside the home, they should try to look after the child when they come home, not only to give the other parent a deserved break but also to understand better what they must contend with during the day. A baby sitter one afternoon each week and an occasional evening out can provide much-needed breaks for an exhausted parent. Preschool is another helpful option. Parents need a chance to rejuvenate themselves so that they can continue to meet their child's extra needs.

Try to start your child in preschool by age 3 to help him learn to organize his thoughts and develop his ability to focus. However, you should consider enrolling your child in kindergarten a year late (that is, at age 6 rather than 5) because the added maturity may help him fit in better with his classmates.

Once your child enters grade school, the school is responsible for providing appropriate educational programs for your child's attention deficit disorder and any learning disability he might have. Some standard approaches that teachers use to help children with ADHD are smaller class size, isolated study space, spaced learning techniques, and inclusion of the child in tasks like erasing the blackboard or passing out books (as outlets for excessive energy). Many of these children spend part of their day with a teacher specializing in learning disabilities who helps improve their skills and confidence.

Seek a classroom for your child that has individual desks rather than one where students are seated in groups at tables or with clusters of desks.

If you think your child has ADHD and he has not been tested by the school's special education team, you can request an evaluation. Usually you can obtain the help your child needs with schoolwork by working closely with the school staff through parent-teacher conferences and special meetings. Your main job is to continue to help your child improve his attention span, self-discipline, and friendships at home.

Since the 1920s, medicines such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) have been used. They are stimulants, and appear to stimulate the self-control areas of the brain. Another medicine often used is dextroamphetamine/amphetamine (Adderall). These medicines do not slow you down, but rather increase self-regulation. About 70% of children with ADHD improve with these medicines. The most common side effects are loss of appetite and trouble getting to sleep. Your child's dosage will be gradually adjusted to reduce side effects. Sometimes, medicines are used only on school days. When these medicines are not effective, there are other medicines that can help with ADHD.

You may want to discuss the use of drugs with your child's physician. In general, medications should not be prescribed before school age. They should also not be prescribed until after your child has been evaluated by a doctor and a school psychologist or special education teacher, an individualized educational plan (I.E.P.) is in effect at school, and you have followed the suggestions in this handout. Medications without special education and home management programs have more limited long-term benefit. They should be part of a broader treatment program.

Treatments that have not been found effective include diets limiting sugar, food additives, or food colorings; and herbal supplements and health foods. Despite much research into this area since the 1970s, little has been found that relates diet to hyperactivity, impulsive behavior, or poor attention. It is clear that children who believe certain foods (such as sugar) will make them "hyper," do change behavior after eating that food.

Although there are claims that many health foods benefit children with ADHD, there are almost no data to back up or refute those claims.

The symptoms of ADHD almost always last from early childhood until puberty. Between puberty and the young adult years, about half of ADHD sufferers have a major reduction in symptoms. The other half show a slight change or no change in symptoms as they grow into adulthood. Being more patient and better able to sit still are the most common improvements between late childhood and young adulthood.

Your child shows unprovoked aggression and destructiveness.
Your child has repeated accidents.
Your child has been suspended or expelled from school.
Your child can't make or keep any friends.
You have "given up" hope of improving your child.
You can't stop using physical punishment on your child.
You are at your wit's end.

Written by B.D. Schmitt, M.D., author of "Your Child's Health," Bantam Books.

Published by McKesson Health Solutions LLC.

This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.

May 2005[an error occurred while processing this directive]