Attention-Deficit Hyperactivity Disorder (ADHD)

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People with Attention-Deficit Hyperactivity Disorder (ADHD) may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active. Although ADHD can’t be cured, it can be successfully managed and some symptoms may improve as the child ages.

Signs and Symptoms

It is normal for children to have trouble focusing and behaving at one time or another. However, children with ADHD do not just grow out of these behaviors. The symptoms continue and can cause difficulty at school, at home, or with friends.

A child with ADHD might:

  • daydream a lot;
  • forget or lose things a lot;
  • squirm or fidget;
  • talk too much;
  • make careless mistakes or take unnecessary risks;
  • have a hard time resisting temptation;
  • have trouble taking turns;
  • have difficulty getting along with others.

Deciding if a child has ADHD is a several-step process. There is no single test to diagnose ADHD, and many other problems, like sleep disorders, anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

If you are concerned about whether a child might have ADHD, the first step is to talk with a healthcare professional to find out if the symptoms fit the diagnosis. The diagnosis can be made by a mental health professional, like a psychologist or psychiatrist, or by a primary care provider, like a pediatrician.

The American Academy of Pediatrics (AAP) recommends that healthcare professionals ask parents, teachers, and other adults who care for the child about the child’s behavior in different settings, like at home, school, or with peers.

When evaluating a child for ADHD, the primary care clinician should assess whether other conditions are present that might coexist with ADHD, including emotional or behavioral (such as anxiety, depressive, oppositional defiant, and conduct disorders), developmental (such as learning and language disorders or other neurodevelopmental disorders), and physical conditions.

There are three different types of ADHD.

There are three different types of ADHD, depending on which types of symptoms are strongest in the individual:

  • Predominantly Inattentive Presentation: It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.
  • Predominantly Hyperactive-Impulsive Presentation: The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.
  • Combined Presentation: Symptoms of the above two types are equally present in the person.

Because symptoms can change over time, the presentation may change over time as well.

Causes of ADHD

Scientists are studying causes and risk factors in an effort to find better ways to manage and reduce the chances of a person having ADHD. The causes and risk factors for ADHD are unknown, but current research shows that genetics plays an important role. Recent studies of twins link genes with ADHD.

In addition to genetics, scientists are studying other possible causes and risk factors including:

  • Brain injury;
  • Exposure to environmental (e.g., lead) during pregnancy or at a young age;
  • Alcohol and tobacco use during pregnancy;
  • Premature delivery;
  • Low birth weight.

Research does not support the popularly held views that ADHD is caused by eating too much sugar, watching too much television, parenting, or social and environmental factors such as poverty or family chaos.

Of course, many things, including these, might make symptoms worse, especially in certain people. But the evidence is not strong enough to conclude that they are the main causes of ADHD.

Diagnosis

Deciding if a child has ADHD is a several step process. There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

One step of the process involves having a medical exam, including hearing and vision tests, to rule out other problems with symptoms like ADHD.

Another part of the process may include a checklist for rating ADHD symptoms and taking a history of the child from parents, teachers, and sometimes, the child.

Treatments

In most cases, ADHD is best treated with a combination of behavior therapy and medication. For preschool-aged children (4-5 years of age) with ADHD, behavior therapy is recommended as the first line of treatment.

No single treatment is the answer for every child and good treatment plans will include close monitoring, follow-ups and any changes needed along the way.

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with ADHD. In addition to behavioral therapy and medication, having a healthy lifestyle can make it easier for your child to deal with ADHD symptoms. Here are some healthy behaviors that may help:

  • Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds.
  • Participating in physical activity for at least 60 minutes each day.
  • Limiting the amount of daily screen time from TVs, computers, phones, etc.
  • Getting the recommended amount of sleep each night based on age.

ADHD in Adults

ADHD often lasts into adulthood. Approximately 10 million adults have attention-deficit/hyperactivity disorder (ADHD).

In early adulthood, ADHD may be associated with depression, mood or conduct disorders and substance abuse. Adults with ADHD often cope with difficulties at work and in their personal and family lives related to ADHD symptoms.  

Many have inconsistent performance at work or in their careers; have difficulties with day-to-day responsibilities; experience relationship problems; and may have chronic feelings of frustration, guilt or blame.

Individuals with ADHD may also have difficulties with maintaining attention, executive function and working memory.  

Recently, deficits in executive function have emerged as key factors affecting academic and career success. Executive function is the brain’s ability to prioritize and manage thoughts and actions.

This ability permits individuals to consider the long-term consequences of their actions and guide their behavior across time more effectively.  

Individuals who have issues with executive functioning may have difficulties completing tasks or may forget important things.  

Diagnosis of ADHD in Adult

Although there is no single medical, physical, or genetic test for ADHD, a diagnostic evaluation can be provided by a qualified mental health care professional or physician who gathers information from multiple sources.

These sources include ADHD symptom checklists, standardized behavior rating scales, a detailed history of past and current functioning, and information obtained from family members or significant others who know the person well.

Some practitioners will also conduct tests of cognitive ability and academic achievement in order to rule out a possible learning disability.

ADHD cannot be diagnosed accurately just from brief office observations or  simply by talking to the person.

The person may not always exhibit the symptoms of ADHD during the office visit, and the diagnostician needs to take a thorough history of the individual’s life. A diagnosis of ADHD must include consideration of the possible presence of co-occurring conditions.

Clinical guidelines for a diagnosis of ADHD are provided by the American Psychiatric Association in the diagnostic manual Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

These established guidelines are widely used in research and clinical practice. During an evaluation, the clinician will try to determine the extent to which these symptoms currently apply to the adult and if they have been present in childhood.

In making the diagnosis, adults should have at least five of the symptoms present. These symptoms can change over time, so adults may fit different presentations from when they were children.

The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The symptoms for each are adapted and summarized below.

ADHD predominantly inattentive presentation

  • Fails to give close attention to details or makes careless mistakes.
  • Has difficulty sustaining attention.
  • Does not appear to listen.
  • Struggles to follow through with instructions.
  • Has difficulty with organization.
  • Avoids or dislikes tasks requiring sustained mental effort.
  • Loses things.
  • Is easily distracted.
  • Is forgetful in daily activities. 

ADHD predominantly hyperactive-impulsive presentation

  • Fidgets with hands or feet or squirms in chair. 

  • Has difficulty remaining seated. 

  • Runs about or climbs excessively in children; extreme restlessness in adults.

  • Difficulty engaging in activities quietly. 

  • Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor.

  • Talks excessively. 

  • Blurts out answers before questions have been completed. 

  • Difficulty waiting or taking turns. 

  • Interrupts or intrudes upon others. 

ADHD combined presentation

  • The individual meets the criteria for both inattention and hyperactive-impulsive ADHD presentations.

These symptoms can change over time, so adults may fit different presentations from when they were children.

A diagnosis of ADHD is determined by the clinician based on the number and severity of symptoms, the duration of symptoms and the degree to which these symptoms cause impairment in various areas of life, such as home, school or work; with friends or relatives; or in other activities.

It is possible to meet diagnostic criteria for ADHD without any symptoms of hyperactivity and impulsivity. The clinician must further determine if these symptoms are caused by other conditions, or are influenced by co-existing conditions.

Several of the symptoms must have been present prior to age 12. This generally requires corroboration by a parent or some other informant.

It is important to note that the presence of significant impairment in at least two major settings of the person’s life is central to the diagnosis of ADHD. Impairment refers to how ADHD interferes with an individual’s life.

Examples of impairment include losing a job because of ADHD symptoms, experiencing excessive conflict and distress in a marriage, getting into financial trouble because of impulsive spending, failure to pay bills in a timely manner or being put on academic probation in college due to failing grades.

If the individual exhibits a number of ADHD symptoms but they do not cause significant impairment, s/he may not meet the criteria to be diagnosed with ADHD as a clinical disorder.

Internet self-rating scales

There are many Internet sites about ADHD that offer various types of questionnaires and lists of symptoms. Most of these questionnaires are not standardized or scientifically validated and should not be used to self-diagnose or to diagnose others with ADHD. A valid diagnosis can only be provided by a qualified, licensed professional.

Who is qualified to diagnose ADHD?

For adults, an ADHD diagnostic evaluation should be conducted by a licensed mental health professional or a physician. These professionals include clinical psychologists, physicians (psychiatrist, neurologist, family doctor or other type of physician) or clinical social workers.

Whichever type of professional is chosen, it is important to ask about their training and experience in working with adults with ADHD.

Many times the professional’s level of knowledge and expertise about adult ADHD is more important for obtaining an accurate diagnosis and effective treatment plan than the type of professional degree.

Qualified professionals are usually willing to provide information about their training and experience with adults with ADHD.

Reluctance to provide such information in response to reasonable requests should be regarded with suspicion and may be an indicator that the individual should seek out a different professional.

How do I find a professional qualified to diagnose ADHD?

Ask your personal physician for a referral to a health care professional in your community who is qualified to perform ADHD evaluations for adults. It may also be helpful to call a local university-based hospital, a medical school or a graduate school in psychology for recommendations.

If there is an ADHD support group in your area, it may be very helpful to go there and talk with the people attending the group. Chances are that many of them have worked with one or more professionals in your community and can provide information about them.

Most insurance plans list professionals by specialty and can assist those who participate in their plans to find a health care professional. Finally, there are many internet sites that list providers of ADHD services, including CHADD’s professional directory.

How do I know if I need an evaluation for ADHD?

Most adults who seek an evaluation for ADHD experience significant problems in one or more areas of living. The following are some of the most common problems:

  • Inconsistent performance in jobs or careers; losing or quitting jobs frequently.

  • History of academic and/or career underachievement.

  • Poor ability to manage day-to-day responsibilities, such as completing household chores, maintenance tasks, paying bills or organizing things.

  • Relationship problems due to not completing tasks.

  • Forgetting important things or getting upset easily over minor things.

  • Chronic stress and worry due to failure to accomplish goals and meet responsibilities.

  • Chronic and intense feelings of frustration, guilt or blame.

A qualified professional can determine if these problems are due to ADHD, some other cause or a combination of causes.

Although some ADHD symptoms are evident since early childhood, some individuals may not experience significant problems until later in life. Some very bright and talented individuals, for example, are able to compensate for their ADHD symptoms and do not experience significant problems until high school, college or in pursuit of their career.

In other cases, parents may have provided a highly protective, structured and supportive environment, minimizing the impact of ADHD symptoms until the individual has begun to live independently as a young adult. 

How should I prepare for the evaluation?

Most people are a little nervous and apprehensive about being evaluated for any type of condition such as ADHD. This is normal and should not stop anyone from seeking an evaluation if s/he is having significant problems in life and ADHD is suspected.

Unfortunately, some of the common misconceptions about ADHD, such as “it only occurs in children” or “the person is just looking for an excuse,” make many people reluctant to seek help.

Many professionals find it helpful to review old report cards and other school records dating back to kindergarten or even the preschool years. If such records are available, they should be brought to the first appointment.

Copies of reports from any previous psychological testing should also be brought to the appointment. For adults who experience problems in the workplace, job evaluations should be brought for review if available.

Many professionals will ask the individual to complete and return questionnaires before the evaluation and to identify a spouse or other family member who can also participate in parts of the evaluation. Timely completion and return of the questionnaires will expedite the evaluation.

What is a comprehensive evaluation?

Although different clinicians will vary somewhat in their procedures and testing materials, certain protocols are considered essential for a comprehensive evaluation.

These include a thorough diagnostic interview, information from independent sources such as the spouse or other family members, DSM-5 symptom checklists, standardized behavior rating scales for ADHD and other types of psychometric testing as deemed necessary by the clinician. These are discussed in more detail below.

The diagnostic interview: ADHD symptoms

The single most important part of a comprehensive ADHD evaluation is a structured or semi-structured interview, which provides a detailed history of the individual.

The interviewer asks a pre-determined, standardized set of questions in order to increase reliability and decrease the chances that a different interviewer would come up with different conclusions.

The clinician covers a broad range of topics, discusses relevant issues in detail and asks follow-up questions to ensure that all areas of interest are covered.

The examiner will review the diagnostic criteria for ADHD and determine how many of them apply to the individual, both at the present time and since childhood.

The interviewer will further determine the extent to which these ADHD symptoms are interfering with the individual’s life. 

The diagnostic interview: screening for other psychiatric disorders

The examiner will also conduct a detailed review to see if other psychiatric disorders that may resemble ADHD or commonly co-exist with ADHD are present. ADHD rarely occurs alone, and research has shown that more than two-thirds of people with ADHD have one or more co-existing conditions.

The most common include depression, anxiety disorders, learning disabilities and substance use disorders. Many of these conditions have symptoms that can mimic ADHD symptoms, and may, in fact, be mistaken for ADHD.

A comprehensive evaluation includes screening for co-existing conditions. When one or more co-existing conditions are present along with ADHD, it is essential that all are diagnosed and treated.

Failure to treat co-existing conditions often leads to failure in treating the ADHD. And, crucially, when the ADHD symptoms are a secondary consequence of depression, anxiety or some other psychiatric disorder, failure to detect this can result in incorrect treatment of the individual for ADHD.

Other times, treating the ADHD will eliminate the other disorder and the need to treat it independently of ADHD.

The examiner is also likely to ask questions about the person’s history of health, development going back to early childhood, academic and work experience, driving history, drug and alcohol abuse, family and/or marital life and social history.

The examiner will look for patterns that are typical in individuals with ADHD and also try to determine if factors other than ADHD may be causing symptoms that look like ADHD.

Participation of loved ones

It is also essential for the clinician to interview one or more independent sources, usually a significant other (spouse, family member, parent or partner) who knows the person well.

This procedure is not to question the person’s honesty, but rather to gather additional information. Many adults with ADHD have a spotty or poor memory of their past, particularly from childhood.

They may recall specific details but forget diagnoses they were given or problems they encountered.

Thus, the clinician may request that the individual being evaluated have his or her parents fill out a retrospective ADHD profile describing childhood behavior.

Many adults with ADHD may also have a limited awareness of how ADHD-related behaviors cause problems for them and have impact on others.

In the case of married or cohabitating couples, it is to the couple’s advantage for the clinician to interview them together when reviewing the ADHD symptoms.

This procedure helps the non-ADHD spouse or partner develop an accurate understanding and an empathetic attitude concerning the impact of ADHD symptoms on the relationship, setting the stage for improving the relationship after the diagnostic process has been completed.

If it is not possible to interview the loved ones, having them fill out checklists of symptoms is a good alternative.

Many adults with ADHD may feel deeply frustrated and embarrassed by the ongoing problems caused by the disorder.

It is very important that the person being evaluated discuss these problems openly and honestly and not hold back information due to feelings of shame or fear of criticism.

The quality of the evaluation and the accuracy of the diagnosis and treatment recommendations will be largely determined by the accuracy of the information provided to the examiner.

Standardized behavior rating scales

A comprehensive evaluation can include one or more standardized behavior rating scales. These questionnaires use research comparing behaviors of people with ADHD to those of people without ADHD.

Scores on the rating scales are not considered diagnostic by themselves but serve as an important source of objective information in the evaluation process.

Most clinicians ask the individual undergoing the evaluation and the individual’s significant other to complete these rating scales.

Additional testing

Depending on the individual and the problems being addressed, additional psychological, neuropsychological or learning disabilities testing may be used as needed.

These do not diagnose ADHD directly but can provide important information about ways in which ADHD affects the individual. The testing can also help determine the presence and effects of co-existing conditions.

For example, in order to determine whether the individual has a learning disability, the clinician will usually give a test of intellectual ability as well as a test of academic achievement.

Medical examination

If the individual being evaluated has not had a recent physical exam (within 6–12 months), a medical examination is recommended to rule out medical causes for symptoms.

Some medical conditions, such as thyroid problems and seizure disorders, can cause symptoms that resemble ADHD symptoms. A medical examination does not confirm ADHD but is extremely important in helping to rule out other conditions or problems.

Concluding the evaluation

Towards the end of the evaluation the clinician will integrate the information that has been collected through diverse sources, complete a written summary or report, and provide the individual and family with diagnostic opinions concerning ADHD as well as any other psychiatric disorders or learning disabilities that may have been identified during the course of the assessment.

The clinician will then review treatment options and assist the individual in planning a course of appropriate medical and psychosocial intervention. Afterward, the clinician will communicate with the individual’s primary care providers, as deemed necessary.

Get Help!

If you or your doctor has concerns about ADHD, you can take your child to a specialist such as a child psychologist or developmental pediatrician, or you can contact your local early intervention agency (for children under 3) or public school (for children 3 and older). You can fill out a symptoms checklist and take it to the child’s doctor.

The Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) website  has links to information for people with ADHD and their families. The National Resource Center operates a call center with trained staff to answer questions about ADHD. The number is 1-800-233-4050.

For more information on services for children with special needs, visit the Center for Parent Information and Resources. To find the Parent Center near you, you can visit this website.

In order to make sure your child reaches his or her full potential, it is very important to get help for ADHD as early as possible.