Drugs Expert

Attention deficit/hyperactivity disorder (ADHD or AD/HD or ADD) is a neurobehavioral developmental disorder. It is primarily characterized by “the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone” and symptoms starting before seven years of age.

ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3% to 5% of children globally and diagnosed in about 2% to 16% of school aged children. It is a chronic disorder with 30% to 50% of those individuals diagnosed in childhood continuing to have symptoms into adulthood. Adolescents and adults with ADHD tend to develop coping mechanisms to compensate for some or all of their impairments. 4.7% of American adults are estimated to live with ADHD.

ADHD is diagnosed two to four times as frequently in boys as in girls, though studies suggest this discrepancy may be due to subjective bias of referring teachers. ADHD management usually involves some combination of medications, behavior modifications, lifestyle changes, and counseling. Its symptoms can be difficult to differentiate from other disorders, increasing the likelihood that the diagnosis of ADHD will be missed. Additionally, most clinicians have not received formal training in the assessment and treatment of ADHD, particularly in adult patients.

ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media. Topics include the actuality of the disorder, its causes, and the use of stimulant medications in its treatment. Most healthcare providers accept that ADHD is a genuine disorder with debate in the scientific community centering mainly around how it is diagnosed and treated. The American Medical Association concluded in 1998 that the diagnostic criteria for ADHD are based on extensive research and, if applied appropriately, lead to the diagnosis with high reliability.

Classification

ADHD may be seen as one or more continuous traits found normally throughout the general population. ADHD is a developmental disorder in which certain traits such as impulse control lag in development. Using magnetic resonance imaging of the prefrontal cortex, this developmental lag has been estimated to range from 3 to 5 years. These delays are considered to cause impairment.

ADHD is classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder and antisocial disorder.

Subtypes

ADHD has three subtypes:

• Predominantly hyperactive-impulsive
  • Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
  • Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
• Predominantly inattentive
  • The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
  • Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.
• Combined hyperactive-impulsive and inattentive
  • Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
  • Most children with ADHD have the combined type.

Childhood ADHD

Attention-deficit hyperactivity disorder or ADHD is a common childhood condition that can be treated. ADHD may affect certain areas of the brain that allow problem solving, planning ahead, understanding others’ actions, and impulse control.

The American Academy of Child Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child:

• The behaviors must appear before age 7.
• They must continue for at least six months.
• The symptoms must also create a real handicap in at least two of the following areas of the child’s life:
  • in the classroom,
  • on the playground,
  • at home,
  • in the community, or
  • in social settings.

If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.

Even if a child’s behavior seems like ADHD, it might not actually be ADHD; careful attention to the process of differential diagnosis is mandatory. Many other conditions and situations can trigger behavior that resembles ADHD. For example, a child might show ADHD symptoms when experiencing:

• A death or divorce in the family, a parent’s job loss, or other sudden change
• Undetected seizures
• An ear infection that causes temporary hearing problems
• Problems with schoolwork caused by a learning disability
• Anxiety or depression
• Insufficient or poor quality sleep
• Child abuse

Adult ADHD

Researchers found that 60% of the children diagnosed with ADHD continue having symptoms well into adulthood. Many adults, however, remain untreated. Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized and may rely on non-prescribed drugs and alcohol to get by. They often have such associated psychiatric comorbidities as depression, anxiety disorder, bipolar disorder, substance abuse, or a learning disability. A diagnosis of ADHD may offer adults insight into their behaviors and allow patients to become more aware and seek help with coping and treatment strategies. There is controversy amongst some experts on whether ADHD persists into adulthood. Recognized as occurring in adults in 1978, it is currently not addressed separately from ADHD in childhood. Obstacles that clinicians face when assessing adults who may have ADHD include developmentally inappropriate diagnostic criteria, age-related changes, comorbidities and the possibility that high intelligence or situational factors can mask ADHD.

What causes Attention-deficit/hyperactivity disorder (ADHD)?

A specific cause of ADHD is not known. There are, however, a number of factors that may contribute to, or exacerbate ADHD. They include genetics, diet and social and physical environments.

Genetics

Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75% of all cases. Hyperactivity also seems to be primarily a genetic condition; however, other causes do have an effect.

Researchers believe that a large majority of ADHD cases arise from a combination of various genes, many of which affect dopamine transporters. Candidate genes include α_2A adrenergic receptor, dopamine transporter, dopamine receptors D₂/D₃, dopamine beta-hydroxylase monoamine oxidase A, catecholamine-methyl transferase, serotonin transporter promoter (SLC6A4), 5HT_2A receptor, 5HT_1B receptor, the 10-repeat allele of the DAT1 gene, the 7-repeat allele of the DRD4 gene, and the dopamine beta hydroxylase gene (DBH TaqI).

The broad selection of targets indicates that ADHD does not follow the traditional model of “a genetic disease” and should therefore be viewed as a complex interaction among genetic and environmental factors. Even though all these genes might play a role, to date no single gene has been shown to make a major contribution to ADHD.

Evolutionary theories

The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of ADHD. The theory proposes that hyperactivity may be an adaptive behavior in pre-modern humans and that those with ADHD retain some of the older “hunter” characteristics associated with early pre-agricultural human society. According to this theory, individuals with ADHD may be more adept at searching and seeking and less adept at staying put and managing complex tasks over time. Further evidence showing hyperactivity may be evolutionarily beneficial was put forth in 2006 in a study which found it may carry specific benefits for certain forms of ancient society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk or competition (i.e. hunting, mating rituals, etc.).

Environmental

Twin studies to date have suggested that approximately 9% to 20% of the variance in hyperactive-impulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared environmental (nongenetic) factors. Environmental factors implicated include alcohol and tobacco smoke exposure during pregnancy and environmental exposure to lead in very early life. The relation of smoking to ADHD could be due to nicotine causing hypoxia (lack of oxygen) to the fetus in utero. It could also be that women with ADHD are more likely to smoke and therefore, due to the strong genetic component of ADHD, are more likely to have children with ADHD. Complications during pregnancy and birth—including premature birth—might also play a role. ADHD patients have been observed to have higher than average rates of head injuries; however, current evidence does not indicate that head injuries are the cause of ADHD in the patients observed. Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.

A 2007 study linked the organophosphate insecticide chlorpyrifos, which is used on some fruits and vegetables, with delays in learning rates, reduced physical coordination, and behavioral problems in children, especially ADHD.

A 2010 study found that pesticide exposure is strongly associated with an increased risk of ADHD in children. Researchers analyzed the levels of organophosphate residues in the urine of more than 1,100 children aged 8 to 15 years old, and found that those with the highest levels of dialkyl phosphates, which are the breakdown products of organophosphate pesticides, also had the highest incidence of ADHD. Overall, they found a 35% increase in the odds of developing ADHD with every 10-fold increase in urinary concentration of the pesticide residues. The effect was seen even at the low end of exposure: children who had any detectable, above-average level of pesticide metabolite in their urine were twice as likely as those with undetectable levels to record symptoms of ADHD.

Diet

A study conducted by researchers at Southampton University in the United Kingdom and published in The Lancet on November 3, 2007 found a link between children’s ingestion of many commonly used artificial food colors, the preservative sodium benzoate and hyperactivity. In response to these findings, the British government took prompt action. According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers are being encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009. Following the FSA’s actions, the European Commission ruled that any food products containing the “Southampton Six” (The contentious colourings are: sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124)) must display warning labels on their packaging by 2010. In the US, little has been done to curb food manufacturer’s use of specific food colors, despite the new evidence presented by the Southampton study. However, the existing US Food Drug and Cosmetic Act had already required that artificial food colors be approved for use, that they must be given FD&C numbers by the FDA, and the use of these colors must be indicated on the package. This is why food packaging in the USA may state something like: “Contains FD&C Red #40.”

Social

The World Health Organization states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology. Other researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD. Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse. Furthermore, Complex Post Traumatic Stress Disorder can result in attention problems that can look like ADHD. ADHD is also considered to be related to sensory integration dysfunction.

A 2010 article by CNN suggests that there is an increased risk for internationally adopted children to develop mental health disorders, such as ADHD and ODD. The risk may be related to the length of time the children spent in an orphanage, especially if they were neglected or abused. Many of these families who adopted the affected children feel overwhelmed and frustrated, since managing their children may entail more responsibilities than originally anticipated. The adoption agencies may be aware of the child’s behavioral history, but decide to withhold the information prior to the adoption. This in turn has resulted in some parents suing adoption agencies, the abuse of children, and even the relinquishment of the child.

Neurodiversity

Proponents of the neurodiversity theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected just like any other human difference. Social critics argue that while biological factors may play a large role in difficulties with sitting still in class and/or concentrating on schoolwork in some children, these children could have failed to integrate others’ social expectations of their behavior for a variety of other reasons. It has been said that ADHD has a link with creativity. As genetic research into ADHD proceeds, it may become possible to integrate this information with the neurobiology in order to distinguish disability from varieties of normal or even exceptional functioning in people along the same spectrum of attention differences.

Social construct theory of ADHD

Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Thus society members including physicians, parents, teachers, and others are the ones who determine which diagnostic criteria are applied and thus determine the number of people affected. This is exemplified in the fact that the DSM IV arrives at levels of ADHD three to four times higher than those obtained with use of the ICD 10. Thomas Szasz, an extreme proponent of this theory, has gone so far as to state that ADHD was “invented and not discovered.”

Low arousal theory

According to the low arousal theory, people with ADHD need excessive activity as self-stimulation because of their state of abnormally low arousal. The theory states that those with ADHD cannot self-moderate, and their attention can only be gained by means of environmental stimuli, which in turn results in disruption of attentional capacity and an increase in hyperactive behaviour.

Without enough stimulation coming from the environment, an ADHD child will create it him or herself by walking around, fidgeting, talking, etc. This theory also explains why stimulant medications have high success rates and can induce a calming effect at therapeutic dosages among children with ADHD. It establishes a strong link with scientific data that ADHD is connected to abnormalities with the neurochemical dopamine and a powerful link with low-stimulation PET scan results in ADHD subjects.

What are the Risk Factors?

Risk factors for ADHD include:

• Maternal exposure to toxins
• Smoking, drinking alcohol or using drugs during pregnancy
• A family history of ADHD or certain other behavioral and mood disorders
• Premature birth

ADHD frequently occurs along with certain other conditions, including:

• Hyperthyroidism
• Having a learning disability or being a gifted learner
• Oppositional defiant disorder

What are the Symptoms of Attention-deficit/hyperactivity disorder (ADHD)?

ADHD has been called attention-deficit disorder (ADD) and hyperactivity. But ADHD is the preferred term because it describes both primary aspects of the condition: inattention and hyperactive-impulsive behavior.

While many children who have ADHD tend more toward one category than the other, most children have some combination of inattention and hyperactive-impulsive behavior. Signs and symptoms of ADHD become more apparent during activities that require focused mental effort.

In most children diagnosed with ADHD, signs and symptoms appear before the age of 7. In some children, signs of ADHD are noticeable as early as infancy.

Signs and symptoms of inattention may include:

• Often fails to pay close attention to details or makes careless mistakes in schoolwork or other activities
• Often has trouble sustaining attention during tasks or play
• Seems not to listen even when spoken to directly
• Has difficulty following through on instructions and often fails to finish schoolwork, chores or other tasks
• Often has problems organizing tasks or activities
• Avoids or dislikes tasks that require sustained mental effort, such as schoolwork or homework
• Frequently loses needed items, such as books, pencils, toys or tools
• Can be easily distracted
• Often forgetful

Signs and symptoms of hyperactive and impulsive behavior may include:

• Fidgets or squirms frequently
• Often leaves his or her seat in the classroom or in other situations when remaining seated is expected
• Often runs or climbs excessively when it’s not appropriate or, if an adolescent, might constantly feel restless
• Frequently has difficulty playing quietly
• Always seems on the go
• Talks excessively
• Blurts out the answers before questions have been completely asked
• Frequently has difficulty waiting for his or her turn
• Often interrupts or intrudes on others’ conversations or games

ADHD behaviors can be different in boys and girls.

• Boys are more likely to be hyperactive, whereas girls tend to be inattentive.
• Girls who have trouble paying attention often daydream, but inattentive boys are more likely to play or fiddle aimlessly.
• Boys tend to be less compliant with teachers and other adults, so their behavior is often more conspicuous.

You may suspect your child’s behavior is caused by ADHD if you notice consistently inattentive or hyperactive, impulsive behavior that:

• Lasts more than six months
• Occurs in more than just one setting (typically at home and at school)
• Regularly disrupts school, play and other daily activities
• Causes problems in relationships with adults and other children

Normal behavior vs. ADHD

Most healthy children are inattentive, hyperactive or impulsive at one time or another. For instance, parents may worry that a 3-year-old who can’t listen to a story from beginning to end may have ADHD. But preschoolers normally have a short attention span and aren’t able to stick with one activity for long. Even in older children and adolescents, attention span often depends on the level of interest. Most teenagers can listen to music or talk to their friends for hours but may be a lot less focused about homework.

The same is true of hyperactivity. Young children are naturally energetic — they often wear their parents out long before they’re tired. And they may become even more active when they’re tired, hungry, anxious or in a new environment. In addition, some children just naturally have a higher activity level than do others. Children should never be classified as having ADHD just because they’re different from their friends or siblings.

Children who have problems in school but get along well at home or with friends are not considered to have ADHD. The same is true of children who are hyperactive or inattentive only at home but whose schoolwork and friendships aren’t affected by their behavior.

When to see a doctor

If your child has disruptive behaviors you think may be signs of ADHD, such as trouble concentrating, sitting still or controlling his or her behavior, see your pediatrician or family doctor. Your doctor may refer you to a specialist, but it’s important to have a medical evaluation first to check for likely causes of your child’s signs and symptoms.

If your child is already being treated for ADHD, he or she should see the doctor regularly — at least once during the month following diagnosis, and then at least every six months after that. Be sure to discuss how often your child should be seen for appointments with his or her doctor. Call the doctor if your child has any medication side effects, such as loss of appetite, trouble sleeping or increased irritability. Over time some children taking stimulant medications may also lose weight or grow more slowly, although these changes are usually temporary.

Diagnosis

ADHD is diagnosed via a psychiatric assessment; to rule out other potential causes or comorbidities, physical examination, radiological imaging, and laboratory tests may be used.

In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD-10. If the DSM-IV criteria are used, rather than the ICD-10, a diagnosis of ADHD is 3–4 times more likely. Factors other than those within the DSM or ICD however have been found to affect the diagnosis in clinical practice. A child’s social and school environment as well as academic pressures at school are likely to be of influence.

Many of the symptoms of ADHD occur from time to time in everyone; in patients with ADHD, the frequency of these symptoms is greater and patients’ lives are significantly impaired. Impairment must occur in multiple settings to be classified as ADHD. As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified:

1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
2. ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
3. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but criterion 1A is not met for the past six months.

The previously used term ADD expired with the most recent revision of the DSM. Consequently, ADHD is the current nomenclature used to describe the disorder as one distinct disorder which can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD, predominately hyperactive-impulsive type) or inattention (ADHD predominately inattentive type) or both (ADHD combined type).

DSM-IV criteria

IA. Six or more of the following signs of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

• Inattention:

1.     Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2.     Often has trouble keeping attention on tasks or play activities.

3.     Often does not seem to listen when spoken to directly.

4.     Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5.     Often has trouble organizing activities.

6.     Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7.     Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools).

8.     Is often easily distracted.

9.     Often forgetful in daily activities.

IB. Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

• Hyperactivity:

1.     Often fidgets with hands or feet or squirms in seat.

2.     Often gets up from seat when remaining in seat is expected.

3.     Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4.     Often has trouble playing or enjoying leisure activities quietly.

5.     Is often “on the go” or often acts as if “driven by a motor”.

6.     Often talks excessively.

• Impulsiveness:

1.     Often blurts out answers before questions have been finished.

2.     Often has trouble waiting one’s turn.

3.     Often interrupts or intrudes on others (example: butts into conversations or games).

II. Some signs that cause impairment were present before age 7 years.

III. Some impairment from the signs is present in two or more settings (such as at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a Personality Disorder).

ICD-10

In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name “Hyperkinetic disorders”. When a conduct disorder (as defined by ICD-10) is present, the condition is referred to as “Hyperkinetic conduct disorder”. Otherwise the disorder is classified as “Disturbance of Activity and Attention”, “Other Hyperkinetic Disorders” or “Hyperkinetic Disorders, Unspecified”. The latter is sometimes referred to as, “Hyperkinetic Syndrome”.

Other diagnostic guidelines

The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria:

• The use of explicit criteria for the diagnosis using the DSM-IV-TR.
• The importance of obtaining information about the child’s signs in more than one setting.
• The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

All three criteria are determined using the patient’s history given by the parents, teachers and/or the patient.

Adults often continue to be impaired by ADHD. Adults with ADHD are diagnosed under the same criteria, including the stipulation that their signs must have been present prior to the age of seven. Adults face some of their greatest challenges in the areas of self-control and self-motivation, as well as executive functioning, usually having more signs of inattention and fewer of hyperactivity or impulsiveness than children do.

Comorbid conditions

Common comorbid conditions include oppositional defiant disorder (ODD). About 20% to 25% of children with ODD meet criteria for a learning disorder. Learning disorders are more common when there are inattention signs.

Comorbid disorders or substance abuse can make the diagnosis and treatment of ADHD more difficult. Psychosocial therapy is useful in treating some comorbid conditions. ADHD is not, in boys, associated with increased substance misuse unless there is comorbid conduct disorder; but “research needs to examine the extent to which ADHD in adulthood increases the risk of substance use disorders.”

Depression may also coincide with ADHD, increasingly prevalent among girls and older children.

Epilepsy is a commonly found comorbid disorder in ADHD diagnosed individuals. Some forms of epilepsy can also cause ADHD like behaviour which can be misdiagnosed as ADHD.

Differential diagnoses

To make the diagnosis of ADHD, a number of other possible medical and psychological conditions must be excluded.

Medical conditions

Medical conditions that must be excluded include: hypothyroidism, anemia, lead poisoning, chronic illness, hearing or vision impairment, substance abuse, medication side effects, sleep impairment and child abuse, and cluttering (tachyphemia) among others.

Sleep conditions

As with other psychological and neurological issues, the relationship between ADHD and sleep is complex. In addition to clinical observations, there is substantial empirical evidence from a neuroanatomic standpoint to suggest that there is considerable overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal. Primary sleep disorders play a role in the clinical presentation of symptoms of inattention and behavioral dysregulation. There are multilevel and bidirectional relationships among sleep, neurobehavioral functioning and the clinical syndrome of ADHD.

Behavioral manifestations of sleepiness in children range from the classic ones (yawning, rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to mood lability and inattentiveness. Many sleep disorders are important causes of symptoms which may overlap with the cardinal symptoms of ADHD; children with ADHD should be regularly and systematically assessed for sleep problems.

From a clinical standpoint, mechanisms that account for the phenomenon of excessive daytime sleepiness include:

• Chronic sleep deprivation, that is insufficient sleep for physiologic sleep needs,
• Fragmented or disrupted sleep, caused by, for example, obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD),
• Primary clinical disorders of excessive daytime sleepiness, such as narcolepsy and
• Circadian rhythm disorders, such as delayed sleep phase syndrome (DSPS). A study in the Netherlands compared two groups of unmedicated 6-12-year-olds, all of them with “rigorously diagnosed ADHD”. 87 of them had problems getting to sleep, 33 had no sleep problems. The larger group had a significantly later dim light melatonin onset (DLMO) than did the children with no sleep problems.

Methods of Treatment

Standard treatments for ADHD in children include medications and counseling. Other treatments to ease ADHD symptoms include special accommodations in the classroom, and family and community support.

Medications

Currently, stimulant drugs (psychostimulants) and the nonstimulant medication atomoxetine (Strattera) are the most commonly prescribed medications for treating ADHD.

Stimulant medications for ADHD include:

• Methylphenidate (Ritalin, Concerta, Daytrana)
• Dextroamphetamine-amphetamine (Adderall)
• Dextroamphetamine (Dexedrine)

Although scientists don’t understand exactly why these drugs work, stimulants appear to boost and balance levels of the brain chemicals called neurotransmitters. These ADHD medications help improve the core signs and symptoms of inattention, impulsivity and hyperactivity — sometimes dramatically. However, effects of the drugs wear off quickly. Additionally, the right dose varies from child to child, so it may take some time in the beginning to find the correct dose.

Stimulant drugs are available in short-acting and long-acting forms.

• The short-acting forms last about four hours, while the long-acting preparations last between six and 12 hours.
• Methylphenidate is available in a long-acting patch that can be worn on the hip (Daytrana). It delivers medication for about nine hours and is approved for use in children between the ages of 6 and 12. While the long-lasting effects mean your child won’t need to take medication as often, it can take up to three hours to start working. For it to work in the morning, the patch needs to be put in place early while your child is still asleep.

Stimulant medication side effects

The most common side effects of stimulant medications in children include:

• Decreased appetite
• Weight loss
• Problems sleeping
• Irritability as the effect of the medication tapers off

A few children may develop jerky muscle movements, such as grimaces or twitches (tics), but these usually disappear when the dose of medication is lowered. Stimulant medications may also be associated with a slightly reduced growth rate in children, although in most cases growth isn’t permanently affected. There’s been some concern about using stimulants to treat preschoolers who have ADHD.

ADHD medications and heart problems

Although a rare occurrence, several heart-related deaths have occurred in children and adolescents taking stimulant medications. Your child’s doctor will want to be sure your child doesn’t have any signs of a heart condition before prescribing a stimulant. Experts disagree about whether children need an extensive evaluation before taking these medications. The American Heart Association has said that every child should have a heart test called an electrocardiogram (ECG) before getting stimulant medications for ADHD, while other organizations such as the American Academy of Pediatrics say that a thorough history and physical exam is enough to screen for heart problems.

Nonstimulant medication

Atomoxetine (Strattera) is generally given to children with ADHD when stimulant medications aren’t effective or cause side effects. In addition to reducing ADHD symptoms, atomoxetine may also reduce anxiety. Given one or two times a day, atomoxetine side effects can include nausea and sedation. It can also cause reduced appetite and weight loss.

Atomoxetine has been linked to rare side effects that include liver problems. If your child is taking atomoxetine and develops yellow skin (jaundice), dark-colored urine or unexplained flu symptoms, contact the doctor right away.

There’s been some concern that children and adolescents taking atomoxetine have an increased risk of suicidal thinking. Although atomoxetine has never been linked to an actual suicide, contact your child’s doctor if you notice any signs of suicidal thinking or other signs of depression.

Other medications used to treat ADHD include:

• Antidepressants. These medications are generally used in children who don’t respond to stimulants or atomoxetine or have a mood disorder as well as ADHD.
• Clonidine (Catapres) and guanfacine (Tenex). These are high blood pressure drugs shown to help with ADHD symptoms. They may be prescribed to reduce tics or insomnia caused by other ADHD medications, or to treat aggression caused by ADHD.

Giving medications safely

Making sure your child takes the right amount of the prescribed medication is very important. Parents are understandably concerned about stimulants — which are similar to amphetamines — and the risk of abuse and addiction. But dependence hasn’t been reported in children who take medications at the proper dose. That’s because drug levels in the brain rise too slowly to produce a “high.” On the other hand, there’s concern that siblings and classmates of children and teenagers with ADHD might abuse ADHD medications. To keep your child’s medications safe and to make sure your child is getting the right dose of medication at the right time:

• Administer medications carefully. Children and teens shouldn’t be in charge of their own ADHD medication.
• At home, keep medication locked in a childproof container. An overdose of stimulant drugs is serious and potentially fatal. Young children are especially sensitive to drug overdoses.
• Don’t send supplies of medication to school with your child. Deliver any medicine yourself to the school nurse or health office.

ADHD counseling and therapy

Children with ADHD often benefit from counseling or behavior therapy, which may be provided by a psychiatrist, psychologist, social worker or other mental health care professional. Some children with ADHD may also have other conditions such as anxiety disorder or depression. In these cases, counseling can help both ADHD and the coexisting problem.

Counseling types include:

• Psychotherapy. This allows older children with ADHD to talk about issues that bother them, explore negative behavioral patterns and learn ways to deal with their symptoms.
• Behavior therapy. Teachers and parents can learn behavior-changing strategies for dealing with difficult situations. These strategies may include token reward systems and timeouts.
• Family therapy. Family therapy can help parents and siblings deal with the stress of living with someone who has ADHD.
• Social skills training. This can help children learn appropriate social behaviors.
• Support groups. Support groups can offer children with ADHD and their parents a network of social support, information and education.
• Parenting skills training. This can help parents develop ways to understand and guide their child’s behavior.

The best results usually occur when a team approach is used, with teachers, parents, and therapists or physicians working together. You can help by making every effort to work with your child’s teachers and by referring them to reliable sources of information to support their efforts in the classroom.

Drugs rating:

	Title	Votes	Rating
1	ProCentra (Dextroamphetamine)	1		(10.0/10)
2	Dextrostat (Dextroamphetamine)	12		(9.3/10)
3	Desoxyn (Methamphetamine)	34		(8.6/10)
4	Daytrana (Methylphenidate)	107		(8.5/10)
5	Adderall XR (Amphetamine and Dextroamphetamine)	357		(8.3/10)
6	Dexedrine (Dextroamphetamine)	162		(8.2/10)
7	Vyvanse (Lisdexamfetamine)	714		(7.7/10)
8	Focalin XR (Dexmethylphenidate)	117		(7.7/10)
9	Adderall (Amphetamine and Dextroamphetamine)	932		(7.6/10)
10	Concerta (Methylphenidate)	399		(7.4/10)
11	Metadate CD (Methylphenidate)	63		(7.4/10)
12	Ritalin (Methylphenidate)	98		(7.3/10)
13	Focalin (Dexmethylphenidate)	116		(7.0/10)
14	Methylin (Methylphenidate)	17		(6.9/10)
15	Intuniv (Guanfacine)	48		(6.7/10)
16	Strattera (Atomoxetine)	462		(5.6/10)
17	Liquadd (Dextroamphetamine)	0		(0/10)

Prognosis

Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment.

In the United States, 37% of those with ADHD do not get a high school diploma even though many of them will receive special education services. A 1995 briefing citing a 1994 book review says the combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish high school. Also in the US, less than 5% of individuals with ADHD get a college degree compared to 28% of the general population. Those with ADHD as children are at increased risk of a number of adverse life outcomes once they become teenagers. These include a greater risk of auto crashes, injury and higher medical expenses, earlier sexual activity, and teen pregnancy.

Russell Barkley states that adult ADHD impairments affect “education, occupation, social relationships, sexual activities, dating and marriage, parenting and offspring psychological morbidity, crime and drug abuse, health and related lifestyles, financial management, or driving. ADHD can be found to produce diverse and serious impairments”.

The proportion of children meeting the diagnostic criteria for ADHD drops by about 50% over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD. ADHD persists into adulthood in about 30-50% of cases. Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.

Epidemiology

ADHD’s global prevalence is estimated at 3-5% in people under the age of 19. There is, however, both geographical and local variability among studies. Geographically, children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East, well published studies have found rates of ADHD as low as 2% and as high as 14% among school aged children. The rates of diagnosis and treatment of ADHD are also much higher on the East Coast of the USA than on the West Coast. The frequency of the diagnosis differs between male children (10%) and female children (4%) in the United States. This difference between genders may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.

Rates of ADHD diagnosis and treatment have increased in both the UK and the USA since the 1970s. In the UK an estimated 0.5 per 1,000 children had ADHD in the 1970s, while 3 per 1,000 received ADHD medications in the late 1990s. In the USA in the 1970s 12 per 1,000 children had the diagnosis, while in the late 1990s 34 per 1,000 had the diagnosis and the numbers continue to increase.

Adults are likely not to be diagnosed or treated for ADHD. This may result in a substantial underestimation of prevalence in most populations. Awareness about Hyperactivity and ADHD or its signs and symptoms has been rudimentary until early 1990 across Europe.

In the UK in 2003 a prevalence of 3.6% is reported in male children and less than 1% is reported in female children.

As of 2009, eight percent of all Major League Baseball players have been diagnosed with ADHD, making the disorder epidemic among this population. The increase coincided with the League’s 2006 ban on stimulants (q.v. Major League Baseball drug policy).