Attention Deficit Hyperactivity Disorder (ADHD) in Children

What is ADHD?

Attention deficit hyperactivity disorder or ADHD is one of the most common behavioral disorders in children. Inattention, over-activity, impulsive behavior, or a combination of these symptoms are often to be found in normal children, but when these features continue over a longer period of time and occur in different settings, ADHD should be suspected. Previously known as attention deficit disorder or ADD, the term ADHD is now preferred since it includes all features of the disorder. Childhood hyperkinesis is another term that is often used synonymously, although it does not embrace all aspects of the disorder.

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ADHD can impair a child’s ability to perform well in school, as well as hamper normal functioning at home, in school, and with in social settings. Although it cannot be cured, appropriate treatment can help children with ADHD to adjust to their problems and carry on normal activities sufficiently well. The symptoms of ADHD may continue into adulthood, but many children outgrow their problem, especially when proper treatment has been instituted in childhood. Adults who do retain the symptoms may be better able to manage it more effectively than children and thus it may only minimally hamper normal functioning.

Causes and Risk Factors of ADHD

The exact cause of ADHD is not known. There may be some alteration in brain structure and functioning in children with ADHD. It commonly affects young children but may continue into adolescence and even adulthood.

  • Boys are more often affected than girls.
  • The problem usually starts in early life when the brain is developing.
  • There may be a genetic predisposition to ADHD.
  • A family history may be present.
  • ADHD is likely to co-exist with other developmental and behavioral problems.
  • It is more common in learning-disabled children.
  • Prenatal cannabis exposure (marijuana) may contribute to ADHD.
  • Psychiatric problems such as depression or bipolar disorder may be co-existing.
  • Smoking and alcohol use during pregnancy has been linked to ADHD in the child.
  • Premature delivery, low birth weight, and injury to the brain at birth may increase the risk of ADHD.
  • Exposure of pre-school children to environmental toxins, such as high levels of lead, may be a risk factor for ADHD.
  • Research suggests that food additives such as artificial colors and preservatives may be linked to hyperactivity.
  • Oppositional defiant disorder (ODD) and conduct disorder (CD) may co-exist with ADHD.
  • Poor parenting is not a cause for ADHD, neither is excessive glucose intake. ADHD is also not caused by vaccines.

Symptoms of ADHD

Not all children with ADHD are hyperactive. Children present with various symptoms. The typical features of ADHD may be divided into 3 groups – hyperactivity, inattentiveness and impulsivity.

Symptoms of Hyperactivity

  • The child does not sit still.
  • Always engaged in some activity, even though the setting may be inappropriate.
  • Squirming or fidgeting endlessly.
  • Cannot sit down and play quietly.
  • Talks excessively and rapidly.

Symptoms of Inattentiveness

  • The child has trouble focusing.
  • Cannot pay attention for long.
  • Easily distracted.
  • Serious lack of concentration.
  • Inability to pay attention to details.
  • Lags behind in school work.
  • Has difficulty in following instructions.
  • Dislikes tasks requiring mental effort.
  • Forgetfulness.
  • Often loses things necessary for daily activities.

Symptoms of Impulsivity

  • The child acts without thinking.
  • Is inconsiderate of others.
  • Interrupts continually.
  • Has difficulty awaiting his/her turn.
  • Blurts out answers.
  • Does not obey requests.
  • Disturbs during games or conversation.

Types of ADHD

ADHD is usually of 3 types – predominantly inattentive, predominantly hyperactive-impulsive and combination.

Predominantly Inattentive

These children usually have trouble focusing and paying attention to details but they are less likely to be disruptive. All or most of the symptoms of inattentiveness may be present. However, children with predominantly inattentive features are less likely to be diagnosed with ADHD.

Predominantly Hyperactive-Impulsive

These children show features of both hyperactivity and impulsivity hence are more likely to be disruptive. They are also more likely to have accidents and sustain injuries.

Combined Type

These children have features of both the above types. This is the most common type of ADHD.

Diagnosis of ADHD

Since there is no diagnostic test for ADHD, a complete evaluation is necessary in suspected cases so as to rule out other conditions that may be confused with ADHD. The guidelines for diagnosing ADHD are as follows :

  • The behavioral symptoms from any type of ADHD should be present from an early age (before the age of 7).
  • The symptoms should be present for at least 6 month and in 2 or more settings.
  • The severity of these features should be inappropriate for that age.
  • These patterns behavior are seen to affect at least 2 aspects of a child’s life, such as home, school, or daycare settings.
  • These behavioral symptoms should not arise due to any stress at home such as divorce or death of a parent, change in school or environment, or any other significant life event.

Conditions that may be mistaken for ADHD

A child may develop behavioral problems in certain situations which may be mistaken for ADHD. This may be related to abuse, discord in the home environment, neglect and lack of stability. It is important to rule out these situations before a diagnosis of ADHD is made. Often one or more of the following problems may co-exist with ADHD.

  • Severe anxiety.
  • Depression.
  • Extreme stress.
  • Lack of sleep.
  • Vision and hearing problems.
  • Behavioral problems.
  • Tic disorders.
  • Learning disabilities.
  • Seizure disorders.

Misdiagnosis of ADHD

There is no doubt that ADHD is overdiagnosed in developing countries. This is partly due to the misdiagnosis by practitioners with limited experience in behavioral disorders in children. It is also associated with impatient parents with poor parenting and coping skills who often pressurize the family doctor and at times even misrepresent the child’s behavior. The role of teachers, particularly those with large classes, is another factor that contributes to a misdiagnosis. It may be due to the incorrect reporting of symptoms during school hours by teachers and may be associated with boredom, poor teaching skills, bullying, negative company and other behavioral disorders. ADHD must be diagnosed by a mental health professional before considering any therapy. However, this should not detract from the existence and nature of ADHD and the necessity for proper diagnosis and management.

Treatment of ADHD

Although it may be difficult to handle children with ADHD, it may help to remember that their behavior is not intentional but is beyond their control unless treated with medication or behavioral therapy. There is no cure for ADHD but appropriate treatment can help children live with and control some of the symptoms. Medication and behavioral therapy is the mainstay of ADHD treatment. Close follow-up and monitoring is essential.

Medication

Stimulants (psychostimulants) are most often used to control symptoms of ADHD. These may include amphetamine-dextroamphetamine, dexmethylphenidate, dextroamphetamine, lisdexamfetamine, and methylphenidate. The common side effects of stimulants are abdominal pain, decreased appetite, irritability, and sleep difficulties.

A nonstimulant drug, such as atomoxetine may be used in some cases. Side effects are less likely than with stimulants.
Antidepressants are sometimes prescribed, especially in those children who do not respond to stimulants or atomoxetine, or those who also suffer from mood disorders. However, it should be used with caution as it may have several side effects and may increase risk of suicide.

Clonidine and guanfacine are high blood pressure medications that may be used to reduce tics or insomnia caused by other ADHD medication, or to treat aggressive behavior.

However, not all medication will be suitable for every patient. The dosage will need to be regulated too according to individual requirement.

Medication should not replace behavioral therapy and more time and attention from parents and other caregivers.

Behavioral Therapy

Behavioral therapy and counseling can go a long way in coping with ADHD. This is most effective when used in combination with medication. Occupational therapy and social skills training can help many children.

Parental Training Programs

It is important for parents to be actively involved in their child’s treatment plan. Parental training programs may help by educating parents to cope with these children.

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