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Clinical Trials

Attention Deficit Hyperactivity Disorder (ADHD, ADD)

Featured Studies

Featured studies include only those currently recruiting participants. They are listed according
to the date they were added to the registry, with the most recent studies
appearing first.

Comparing the Effectiveness of New Versus Older Treatments for Attention

Deficit Hyperactivity Disorder (NOTA).
Interventional study. This study will determine whether two new
psychostimulant medications are more effective, tolerable, and acceptable
than two older medications for treating attention deficit hyperactivity
disorder. Ages 6-17. Location in Durham, NC.

Effectiveness of a Behavioral Treatment Program for Attention Deficit

Hyperactivity Disorder, Inattentive Type.
Interventional study. This study will test the effectiveness of a new behavioral
treatment, called the Child Life and Attention Skills Program, for children with
attention deficit hyperactivity disorder, inattentive type. Ages 7-11. Locations
in Berkeley, CA; San Francisco, CA.

Effects of Using Betahistine to Treat Adults With Attention Deficit

Hyperactivity Disorder.
Interventional study. This study will determine whether the drug betahistine
increases focus and causes side effects in people with attention deficit
hyperactivity disorder. Ages 22-55. Location in Cincinnati, OH.

Treatment of Severe Childhood Aggression (The TOSCA Study).

Interventional study. This study will determine the safety and effectiveness of
two medications for treating aggression in children with attention deficit
hyperactivity disorder (ADHD). Ages 6-12. Locations in Stony Brook, NY;
Cleveland, OH; Columbus, OH; Pittsburgh, PA.

Effectiveness of Combined Medication Treatment for Aggression in Children

With Attention Deficit With Hyperactivity Disorder (The SPICY Study).
Interventional study. This study will determine the advantages and
disadvantages of adding one of two different types of drugs to stimulant
treatment for reducing aggressive behavior in children with attention deficit
with hyperactivity disorder (ADHD). Ages 6-12. Locations in Glen Oaks, NY;
Stony Brook, NY; San Antonio, TX.

A Controlled Trial of Serotonin Reuptake Inhibitors Added to Stimulant

Medication in Youth With Severe Mood Dysregulation.
Interventional study. Severe mood dysregulation (SMD) is a very common
syndrome in children. Ages 7-17. Location in Bethesda, MD.

Effectiveness of an Extended Release Stimulant Medication in Treating

Preschool Children With Attention Deficit Hyperactivity Disorder (The APS
Interventional study. This study will evaluate the safety and effectiveness of
extended release mixed amphetamine salts in treating preschool children
with attention deficit hyperactivity disorder. Ages 36 Months-66 Months.
Location in Springfield, MA.

Atomoxetine and Parent Management Training in Treating Children With

Autism and Symptoms of Attention Deficit Disorder With Hyperactivity.
Interventional study. This study will evaluate the effectiveness of the
medication atomoxetine, with and without parent management training, in
treating children with autism or pervasive developmental disorder not
otherwise specified who have symptoms of attention deficit hyperactivity
disorder. Ages 5-14. Locations in Rochester, NY; Columbus, OH; Pittsburgh,

Effectiveness of Lobeline in Treating Symptoms of ADHD in Adult Patients.

Interventional study. The study will evaluate the effectiveness of the
nonstimulant medication lobeline in improving symptoms of attention deficit
hyperactivity disorder in adults. Ages 21-45. Location in Lexington, KY.

Group-Based Behavioral Therapy Combined With Stimulant Medication for

Treating Children With Attention Deficit Hyperactivity Disorder and Impaired
Interventional study. This study will evaluate the effectiveness of an
integrative group psychosocial therapy combined with stimulant medication
in treating children with attention deficit hyperactivity disorder plus
impairments in mood. Ages 7-11. Location in Buffalo, NY.

Effectiveness of School- and Home-Based Mental Health Services in Improving

Learning and Behavior in Children in Urban Schools.
Interventional study. This study will evaluate the effectiveness of school- and
home-based mental health services and training modules in supporting
learning and behavior in financially disadvantaged children who live in urban
areas. Ages 5-12. Location in Chicago, IL.

Effectiveness of Collaborative Services in Primary Care for Treating Children

With Behavior Disorders.
Interventional study. This study will evaluate the effectiveness of a doctoroffice collaborative care approach in treating children with disruptive
behavior problems in the pediatric primary care setting. Ages 5-12. Location
in Pittsburgh, PA.

Single Versus Combination Medication Treatment for Children With Attention

Deficit Hyperactivity Disorder.
Interventional study. This study will evaluate the effectiveness of a single
drug versus a combination of drugs in treating attention deficit hyperactivity
disorder in children. Ages 7-14. Location in Los Angeles, CA.

Parent Training to Promote Early Identification and Treatment of Childhood

Behavioral Disorders.
Interventional study. This study will evaluate the effectiveness of a parent
training program in improving parenting skills and reducing behavioral
symptoms in young children who are at risk for developing childhood
behavior disorders. Ages 22 Months-38 Months. Locations in Chelsea, MA;
Dorchester, MA; Jamaica Plain, MA; Leominster, MA; Southboro, MA; Westford,
MA; Westwood, MA; Wilmington, MA; Woburn, MA.

PET Scanning of Adults With Attention Deficit Hyperactivity Disorder (ADHD).

Evaluation study. This study will explore the brain in men with and without
attention deficit hyperactivity disorder (ADHD). Ages 18-55. Location in
Bethesda, MD.

Organizational Skills Training for Children With Attention Deficit Hyperactivity

Interventional study. This study will evaluate the effectiveness of
organizational skills training in improving organizational, time management,
and planning difficulties in children with attention deficit hyperactivity
disorder. Ages 8-11. Locations in Durham, NC; New York, NY.

Stimulant Versus Nonstimulant Medication for Attention Deficit Hyperactivity

Disorder in Children.
Interventional study. This study will determine the effectiveness of stimulant
and nonstimulant medication in treating the symptoms of attention deficit
hyperactivity disorder (ADHD) in children and adolescents. Ages 6-17.
Locations in Chicago, IL; New York City, NY.

Methylphenidate for Attention Deficit Hyperactivity Disorder and Autism in

Interventional study. This study will first examine the cognitive and
behavioral differences in children who have an autism spectrum disorder
(ASD) and who do and do not have additional symptoms of attention deficit
hyperactivity disorder (ADHD). Ages 7-12. Location in Houston, TX.

Improving Attention Deficit Hyperactivity Disorder Treatment Adherence and

Outcome in Primary Care Settings.
Interventional study. This study will determine the effectiveness of educating
pediatricians about attention deficit hyperactivity disorder treatment
guidelines in improving child behavior and pediatricians' adherence to
medication guidelines. Ages 6-11. Location in Chicago, IL.

A Clinic-Based Prevention Program for Families of Depressed Mothers.

Interventional study. This study will assess the effectiveness of the "Keeping
Families Strong" program (KFS) in avoiding or delaying the onset of
psychiatric disorders among children with depressed mothers. Ages 8 and
over. Location in Baltimore, MD.

Brain Changes in Children and Adolescents With Behavioral Problems.

Evaluation study. This study will examine brain changes in children and
adolescents with behavioral problems and compare them to children and
adolescents without behavioral problems. Ages 8-17. Location in Bethesda,

Search for other NIH studies on Attention Deficit Hyperactivity Disorder
Related Information
Learn more about Attention Deficit Hyperactivity Disorder (ADHD, ADD)
Attention Deficit Hyperactivity Disorder, ADHD, is one of the most common
mental disorders that develop in children. Children with ADHD have impaired
functioning in multiple settings, including home, school, and in relationships
with peers. If untreated, the disorder can have long-term adverse effects into
adolescence and adulthood.

Clinical Research at NIMH

For opportunities to participate in NIMH research on the NIH campus, visit the
patient recruitment Website. Travel and lodging assistance available.


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This page last reviewed: February 26, 2009
Comparing the Effectiveness of New Versus Older Treatments for Attention Deficit
Hyperactivity Disorder (NOTA)
This study is currently recruiting participants.
Verified by National Institute of Mental Health (NIMH), May 2009
First Received: April 27, 2009 Last Updated: May 11, 2009 History of Changes
Sponsored by:

National Institute of
Mental Health (NIMH)

Information National Institute of

provided by: Mental Health (NIMH)

ov Identifier:
This study will determine whether two new psychostimulant medications are more effective,
tolerable, and acceptable than two older medications for treating attention deficit hyperactivity

Attention Deficit Disorder
With Hyperactivity

Drug: Methylphenidate transdermal
Drug: Lisdexamfetamine dimesylate
Drug: Osmotic-release oral system
methylphenidate (OROS MPH)
Drug: Mixed amphetamine salts
extended release

e IV

Study Type:



Treatment, Randomized, Open Label, Active Control, Parallel Assignment,

Safety/Efficacy Study

Official Title:

A Randomized Controlled Trial of Methylphenidate Transdermal System

(Daytrana), Lisdexamfetamine Dimesylate (Vyvanse), OROS MPH (Concerta),
and Mixed Amphetamine Salts Extended Release (Adderall XR) in Children and
Adolescents With ADHD

Resource links provided by NLM:

MedlinePlus related topics: Attention Deficit Hyperactivity Disorder Child Mental Health
Dietary Sodium Methamphetamine
Drug Information available for: Methamphetamine hydrochloride Amphetamine sulfate
Methylphenidate Lisdexamfetamine Lisdexamfetamine dimesylate
Methylphenidate hydrochloride Amphetamine Methamphetamine Sodium chloride
U.S. FDA Resources

Further study details as provided by National Institute of Mental Health (NIMH):

Primary Outcome Measures:

Dichotomized Clinical Global Impression-Effectiveness (CGI-E) scale

[ Time Frame: Measured at each participant's last visit, which can occur at or before
Week 6 ] [ Designated as safety issue: No ]

Secondary Outcome Measures:

Clinical Global Impressions-Improvement (CGI-I) scale [ Time Frame: Measured at each

participant's last visit, which can occur at or before Week 6 ]
[ Designated as safety issue: No ]

Clinical Global Improvements-Acceptability (CGI-A) scale [ Time Frame: Measured at

each participant's last visit, which can occur at or before Week 6 ]
[ Designated as safety issue: No ]

Estimated Enrollment:


Study Start Date:

April 2009

Estimated Study Completion Date:

September 2009

Estimated Primary Completion Date:

September 2009 (Final data collection date for primary

outcome measure)


Assigned Interventions

1: Active Comparator
Participants will receive methylphenidate
transdermal system.

Drug: Methylphenidate transdermal

Not specified in protocol; determined by
local standard of care.

2: Active Comparator
Participants will receive lisdexamfetamine

Drug: Lisdexamfetamine dimesylate

Not specified in protocol; determined by
local standard of care.

3: Active Comparator
Participants will receive osmotic-release oral
system methylphenidate (OROS MPH).

Drug: Osmotic-release oral system

methylphenidate (OROS MPH)
Not specified in protocol; determined by
local standard of care.

4: Active Comparator
Participants will receive mixed amphetamine salts
extended release.

Drug: Mixed amphetamine salts extended

Not specified in protocol; determined by
local standard of care.

Detailed Description:
Attention deficit hyperactivity disorder (ADHD) is characterized by impulsiveness,
hyperactivity, and inattention. It is seen primarily in children and adolescents and is often treated
with psychostimulant medications. Osmotic-release oral system (OROS) methylphenidate, brand
name Concerta, and mixed amphetamine salts extended release, brand name Adderall XR, are
psychostimulant medications that have shown both efficacy (that they can have therapeutic
benefits) and effectiveness (that they typically have therapeutic benefits in practice). Two newer
psychostimulant medicationslisdexamfetamine dimesylate, brand name Vyvanse, and
methylphenidate transdermal system, brand name Daytranahave shown efficacy but have not
been tested for effectiveness, nor have they been tested head-to-head against the older
psychostimulants. This study will test the effectiveness, tolerability (lack of side effects), and
acceptability (ease of use for patients) of the two newer psychostimulant medications and
compare them to each other and to the two older psychostimulants.
Participation in this study will last 6 weeks, although some treatments may continue past the end
of the study. At enrollment, participants will undergo a series of baseline evaluations. These will
include interviews and assessments of ADHD symptoms, concurrent psychiatric disorders,
medical and psychiatric history, family history of mental illness, risk and protective factors, other
treatments, treatment expectancy of both the youth and parent, and vital signs. In consultation
with their doctors, participants will be allowed to exclude zero, one, or two of the study
medications; if they choose to exclude both of the new ADHD medications, they will not able to
participate in the study. Participants will then be randomly assigned to one of the treatments they
choose to include. They will receive a prescription for the medication and instructions for how to
use it from their doctors; the study protocol does not specify a particular treatment regimen.
Participants will undergo a second set of evaluations after 6 weeks of treatment or before, if the
treatment ends earlier. This will include interviews and assessments similar to those administered
at baseline as well as evaluation of any medication side effects.
Ages Eligible for Study:
Genders Eligible for Study:
Accepts Healthy Volunteers:

6 Years to 17 Years

Inclusion Criteria:

Meets DSM-IV diagnostic criteria for ADHD combined, hyperactive/impulsive, or

inattentive subtype

Outpatient at study entry

Speaks English

Willing to be randomly assigned to one of the study treatment options as outlined in the

No known significant history of cardiovascular disorders, including pre-existing

congenital heart disease, structural heart disease, known clinically significant
electrocardiogram (ECG) abnormality, or other clinically significant cardiac disorder

Willing to initiate study medication for ADHD within 7 days of the study baseline visit

May be receiving stable treatment with other drug for a comorbid disorder, defined as no
changes in dose or form of drug treatment for at least 2 weeks prior to the study
enrollment visit

May be receiving psychosocial interventions for ADHD or a comorbid disorder, defined

as no changes in form of psychosocial treatment for at least 4 weeks prior to the study
enrollment visit

Exclusion Criteria:

Hypersensitivity to study medication

Inpatient status at study entry

Currently taking another medication for ADHD, including another psychostimulant,

atomoxetine, or bupropion

Receiving treatment with a tricyclic antidepressant at study enrollment, with the

exception of low-dose imipramine for enuresis or amitriptyline for chronic pain

Received treatment with a monoamine oxidase inhibitor (MAOI) within the past 30 days

Psychostimulant drug dependence, bipolar disorder, or schizophrenia

Presence of psychosis

Severe mental retardation

Autism or Asperger's syndrome

Active suicidal ideation

Unable or unwilling to comply with the protocol

Demonstrates a lack of benefit from, an intolerance to, or contraindication to

psychostimulant medicine

Presence of other clinically significant medical conditions, including hyperthyroidism,

epilepsy or other seizure disorder, any condition for which an increase in blood pressure
or heart rate would be problematic, glaucoma or other significant eye disease for which a
psychostimulant would be problematic, or pre-existing gastrointestinal obstruction with
gastrointestinal narrowing

Pregnant or positive result of pregnancy test

Contacts and Locations

Please refer to this study by its identifier: NCT00889915


Contact: Jerry Kirchner, BS CCRP


Contact: Alice Petersen, RN MSN



United States, North Carolina
Child and Adolescent Psychiatry Trials Network (CAPTN)
Durham, North Carolina, United States, 27710
Contact: Jerry Kirchner, BS CCRP


Contact: Alice Petersen, RN MSN CCRA


Sponsors and Collaborators

National Institute of Mental Health (NIMH)
Principal Investigator:
More Information

John S. March, MD, MPH

Duke University School of Medicine

Additional Information:
Click here for the Child and Adolescent Psychiatry Trials Network (CAPTN) Web site
Click here for the Duke Clinical Research Institute Web site
Click here for the American Academy of Child and Adolescent Psychiatry Web site
No publications provided
Responsible Party:

Duke University Medical Center ( John S. March, MD, MPH )

Study ID Numbers:

P30 MH066386-02, DSIR CTM 4571; Pro00014075

Study First Received:

April 27, 2009

Last Updated:

May 11, 2009 Identifier:


Health Authority:

United States: Federal Government

History of Changes

Keywords provided by National Institute of Mental Health (NIMH):

Study placed in the following topic categories:
Dopamine Uptake Inhibitors
Neurotransmitter Agents
Adrenergic Agents
Attention Deficit and Disruptive Behavior
Central Nervous System Stimulants
Signs and Symptoms
Additional relevant MeSH terms:
Dopamine Uptake Inhibitors

Attention Deficit Disorder with Hyperactivity
Mental Disorders
Mental Disorders Diagnosed in Childhood
Neurologic Manifestations
Dopamine Agents
Peripheral Nervous System Agents


Neurotransmitter Uptake Inhibitors

Neurotransmitter Agents
Adrenergic Agents
Molecular Mechanisms of Pharmacological
Adrenergic Uptake Inhibitors
Physiological Effects of Drugs
Signs and Symptoms
Pathologic Processes
Attention Deficit Disorder with Hyperactivity
Mental Disorders
Therapeutic Uses
Mental Disorders Diagnosed in Childhood

Nervous System Diseases
Attention Deficit and Disruptive Behavior
Central Nervous System Stimulants
Pharmacologic Actions
Autonomic Agents
Neurologic Manifestations
Dopamine Agents
Peripheral Nervous System Agents
Central Nervous System Agents processed this record on June 30, 2009

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The impact of early behavior disturbances on academic

achievement in high school.
Breslau J, Miller E, Breslau N, Bohnert K, Lucia V, Schweitzer J.
Department of Internal Medicine, University of California, Davis, California, USA.
BACKGROUND: Previous research has indicated that childhood behavioral disturbances predict
lower scores on academic tests and curtail educational attainment. It is unknown which types of
childhood behavioral problems are most likely to predict these outcomes. METHODS: An
ethnically diverse cohort was assessed at 6 years of age for behavioral problems and IQ and at 17
years of age for academic achievement in math and reading. Of the original cohort of 823
children, 693 (84%) had complete data. Multiple regressions were used to estimate associations
of attention and internalizing and externalizing problems at age 6 and with math and reading
achievement at age 17, adjusting for IQ and indicators of family socioeconomic status.
RESULTS: Adjusting for IQ, inner-city community, and maternal education and marital status,
teacher ratings of attention, internalizing behavior, and externalizing problems at age 6
significantly predict math and reading achievement at age 17. When types of problems are
examined simultaneously, attention problems predict math and reading achievement with little
attenuation, whereas the influence of externalizing and internalizing problems is materially

reduced and not significant. CONCLUSIONS: Interventions that target attention problems at
school entry should be tested as a potential avenue for improving educational achievement.

Academic and educational outcomes of children with

Loe IM, Feldman HM.
Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine,
Pittsburgh, PA, USA.
Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor
reading and math standardized test scores, and increased grade retention. ADHD is also
associated with increased use of school-based services, increased rates of detention and
expulsion, and ultimately with relatively low rates of high school graduation and
postsecondary education. Children in community samples who show symptoms of
inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD
also show poor academic and educational outcomes. Pharmacologic treatment and
behavior management are associated with reduction of the core symptoms of ADHD and
increased academic productivity, but not with improved standardized test scores or
ultimate educational attainment. Future research must use conceptually based outcome
measures in prospective, longitudinal, and community-based studies to determine which
pharmacologic, behavioral, and educational interventions can improve academic and
educational outcomes of children with ADHD.
PMID: 17261487 [PubMed - indexed for MEDLINE]

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ReviewAcademic and educational outcomes of children with ADHD.

J Pediatr Psychol. 2007 Jul; 32(6):643-54. Epub 2007 Jun 14.
[J Pediatr Psychol. 2007]

Inattention, hyperactivity and impulsiveness: their impact on academic

achievement and progress.
Br J Educ Psychol. 2001 Mar; 71(Pt 1):43-56.

[Br J Educ Psychol. 2001]

Mathematical learning disorder in school-age children with attention-deficit

hyperactivity disorder.
Can J Psychiatry. 2008 Jun; 53(6):392-9.
[Can J Psychiatry. 2008]

Child and familial pathways to academic achievement and behavioral adjustment:

a prospective six-year study of children with and without ADHD.
J Atten Disord. 2003 Nov; 7(2):101-16.
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See reviews... | See all...

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Academic and educational outcomes of children with ADHD.Academic and

educational outcomes of children with ADHD.

The impact of early behavior disturbances on academic achievement in high


Adult ADHD: Evaluation and Treatment in Family Medicine

Family Medicine of St. Louis Residency Program, St.
Louis, Missouri

A patient
information handout
on attention-deficit/
hyperactivity disorder
in adults, written by
the authors of this
article, is provided on
page 2091.

Attention-deficit/hyperactivity disorder (ADHD) affects 30 to 50 percent of adults who had ADHD in

childhood. Accurate diagnosis of ADHD in adults is challenging and requires attention to early
development and symptoms of inattention, distractibility, impulsivity and emotional lability. Diagnosis is
further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other
common psychiatric conditions such as depression and substance abuse. While stimulants are a common
treatment for adult patients with ADHD, antidepressants may also be effective. Cognitive-behavioral skills
training and psychotherapy are useful adjuncts to pharmacotherapy. (Am Fam Physician 2000;62:207786,2091-2.)

See editorial
on page 1983.

Attention-deficit/hyperactivity disorder (ADHD) receives considerable attention in both

medical literature and the lay media. Historically, ADHD was considered to be primarily a
childhood condition. However, recent data suggest that symptoms of ADHD continue into
adulthood in up to 50 percent of persons with childhood ADHD.1,2(pp41-75) Because ADHD is such a
well-known disorder, adults with both objective and subjective symptoms of poor concentration
and inattention are likely to present to family physicians for evaluation. While the symptoms of
ADHD have been extended developmentally upward to adults, most of the information about the
etiology, symptoms and treatment of this disorder comes from observations of and studies in
children. Research on adult ADHD is in an early stage. The criteria for ADHD emphasize a
childhood presentation, and there is growing evidence that the diagnostic features of ADHD take
a different form in adults.
For several reasons, family physicians may be uncomfortable evaluating and treating patients
with symptoms of ADHD, particularly adults without a previously established ADHD diagnosis.
First, the criteria for ADHD are not objectively verifiable and require reliance on the patient's
subjective report of symptoms. Second, the criteria for ADHD do not describe the subtle

cognitive-behavioral symptoms that may affect adults more than children. Third, the most
effective treatment is long-term use of a schedule II drug with potential for abuse.3
The family physician's role as diagnostician is further complicated by the high rates of selfdiagnosis of ADHD in adults. Many of these persons are influenced by the popular press. Studies
of self-referral suggest that only one third to one half of adults who believe they have ADHD
actually meet formal diagnostic criteria.4 While family physicians are knowledgeable about
childhood ADHD, there is a noticeable absence of guidelines for primary care evaluation and
treatment of adults with symptoms of the disorder.

Diagnostic Criteria and Symptoms

The criteria for ADHD as specified in the Diagnostic and Statistical Manual of Mental Disorders,
4th ed. (DSM-IV), are described in Table 1.5 DSM-IV describes three subtypes of the disorder:
predominantly hyperactive, predominantly inattentive and a mixed type with symptoms of the
other two forms. Symptoms should be persistently present since age seven. While a longstanding
symptom history is often difficult to elicit clearly in adults, it is a key feature of the disorder.

DSM-IV Diagnostic Criteria for ADHD

A. Either (1) or (2):

1. Six (or more) of the following symptoms of inattention have persisted for at least six
months to a degree that is maladaptive and inconsistent with developmental level:

a. Often fails to give close attention to details or makes careless mistakes in

schoolwork, work or other activities

b. Often has difficulty sustaining attention in tasks or play activities

c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and fails to finish schoolwork,
chores or duties in the workplace (not due to oppositional behavior or failure
to understand instructions)

e. Often has difficulty organizing tasks and activities


Often avoids, dislikes or is reluctant to engage in tasks that require sustained

mental effort (such as schoolwork or homework)

g. Often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books or tools)

h. Is often easily distracted by extraneous stimuli


Is often forgetful in daily activities

2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for
at least six months to a degree that is maladaptive and inconsistent with
developmental level:

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

b. Often leaves seat in classroom or in other situations in which remaining
seated is expected

c. Often runs about or climbs excessively in situations in which it is

inappropriate (in adolescents or adults, may be limited to subjective feelings
of restlessness)

d. Often has difficulty playing or engaging in leisure activities quietly

e. Is often "on the go" or often acts as if "driven by a motor"

Often talks excessively


a. Often blurts out answers before questions have been completed

b. Often has difficulty awaiting turn
c. Often interrupts or intrudes on others (e.g., butts into conversations or

B Some hyperactive-impulsive or inattentive symptoms that caused impairment were present

before age 7 years.

C Some impairment from the symptoms is present in two or more settings (e.g., at school [or
work] and at home).

D There must be clear evidence of clinically significant impairment in social, academic or

occupational functioning.

ADHD = attention-deficit/hyperactivity disorder.

Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:83-4. Copyright 1994.

Adults who have retained some, but not all, of the symptoms of childhood ADHD may be best
diagnosed as having ADHD in partial remission.5,6 While the DSM-IV criteria for ADHD may be
applied to adults, these dimensions tend to reflect presentations in children. The subtlety of
ADHD symptoms among adults has led to several modifications of existing criteria. Rather than
requiring six DSM-IV symptoms of inattention or hyperactivity, some investigators propose
requiring only five such behaviors for older patients.7 In addition, the symptoms take different
forms in adults.
There is growing consensus that the central feature of ADHD is disinhibition.8 Patients are
unable to stop themselves from immediately responding, and they have deficits in their capacity
for monitoring their own behavior. Hyperactivity, while a common feature among children, is
likely to be less overt in adults. The "on the go" drivenness seen in many ADHD children is
replaced in adults with restlessness, difficulty relaxing and a feeling of being chronically "on
Deficits in sustained attention and concentration are likely
to remain and may become more apparent in late
Evaluating ADHD requires the
adolescence and early adulthood as responsibilities
physician to weigh and integrate a
increase. Appointments, social commitments and
range of data, including the patient's
deadlines are frequently forgotten. Impulsivity often takes
history, self-reported symptoms and
the form of socially inappropriate behavior, such as
mental status testing.
blurting out thoughts that are rude or insulting. While
many of the symptoms are reported by others in the
patient's life, the problem often expressed by adults with
ADHD is frustration over the inability to be organized.1 Prioritizing is another common source of
frustration. Important tasks are not completed while trivial distractions receive inordinate time
and attention.

Utah Criteria for ADHD in Adults
Wender developed a set of ADHD criteria, referred
to as the Utah criteria, that reflect the distinct
features of the disorder in adults (Table 2).2(pp122-43)
The diagnosis of ADHD in an adult requires a
longstanding history of ADHD symptoms, dating
back to at least age seven. In the absence of
treatment, such symptoms should have been
consistently present without remission. In addition,
hyperactivity and poor concentration should be
present in adulthood, along with two of five
additional symptoms: affective lability; hot temper;
inability to complete tasks and disorganization;
stress intolerance; and impulsivity.
The Utah criteria include the emotional aspects of
the syndrome. The episodes of hot temper, typified
by frequent angry eruptions out of proportion to the
precipitants, often "blow over" more quickly for the
patient than for coworkers and family members.
Affective lability is characterized by brief, intense
affective outbursts ranging from euphoria to despair
to anger, and is experienced by the ADHD adult as
being out of control. Under conditions of increased
emotional arousal from external demands, the
patient becomes more disorganized and

I. Childhood history consistent with ADHD

II. Adult symptoms
Hyperactivity and poor
Two of the following:
Affective lability
Hot temper
Inability to complete tasks and
Stress intolerance

ADHD = attention-deficit/hyperactivity
Adapted from Wender PH. Attention-deficit
hyperactivity disorder in adults. New York:
Oxford University Press, 1995:122-43.

Another model of adult ADHD diverges from DSM-IV but overlaps with Wender's criteria and
includes five areas.9 In this model, the five core ADHD dimensions include the following:
activation and organization; sustained attention; sustained energy and effort; managing affective
interference; and working memory and accessing recall. Activation refers to difficulties initiating
and organizing daily tasks. Sustained attention includes such aspects as distractibility,
daydreaming and having to reread material to understand it. Sustained energy and effort refers to
drowsiness, inconsistent performance and poor task completion. Managing affective interference
includes difficulty managing criticism as well as being easily frustrated, irritable and poorly
motivated. Memory difficulties encompass recent and remote memory for daily activities and
task-related materials.9
Another model, which serves as the basis for the Copeland symptom checklist for ADHD in
adults, includes eight dimensions: inattention and distractibility; impulsivity; activity level

problems; noncompliance; underachievement, disorganization and learning problems; emotional

difficulties; poor peer relations; and impaired family relationships.10

The subtlety and subjectivity of ADHD symptoms
in adults, together with the absence of a single "gold
standard" for confirming the diagnosis, make
assessment particularly challenging. Evaluation of
adults with symptoms of ADHD requires weighing
and integrating a range of data, including the
patient's history, the patient's self-report of
symptoms and mental status testing (Table 3). A
thorough history should include an emphasis on past
school performance and conduct, previous and
current psychiatric therapies, and reports of specific
symptoms of inattention, distractibility and
disorganization. ADHD is currently understood as a
neurobehavioral condition that is typically apparent
in preschool years and becomes more pronounced in
the early elementary grades.
An extended, consistent pattern of ADHD
symptoms, dating back to early childhood, should
be uncovered during history taking. Patients with
ADHD may have difficulty accurately recalling
relevant history.11Adult patients should be asked to
provide any available school records and gather
information from parents and other adults who
knew them as children. Because adults with ADHD
may not appreciate their symptoms, the patient's
spouse or another significant person in the patient's
life should ideally be included in the interview. The
recent onset of symptoms or sporadic episodes of
symptoms should raise concern about the
appropriateness of the diagnosis of ADHD.

Process of Assessment for
ADHD in Adults

Obtain a developmental history. Attempt to

corroborate information with other sources,
such as parents, spouse and school report
cards. Symptoms should be consistently
present since early childhood.
Inquire about impact of core ADHD
symptoms on current occupational, school
and relationship functioning.
Assess attention, concentration,
distractibility and short-term memory by
having patient perform screening tasks in
the office setting.
Assess for the presence of other psychiatric
disorders and substance abuse.
If results are equivocal, refer patient for
psychologic evaluation.

ADHD = attention-deficit/hyperactivity

The three most commonly used self-report measures for ADHD are the Wender rating scale,12 the
Copeland symptom checklist and the Brown scale (Table 4). While self-report instruments may
be useful for initial screening, they should not be used alone to diagnose adult ADHD. High
scores are likely in a variety of psychiatric conditions. Problems with attention, concentration,

affective lability, impulsivity and task completion are nonspecific and can be associated with
many forms of psychopathology.
Mental status testing is often useful when evaluating the patient's cognitive functioning in the
office, but impaired performance on mental status testing may result from numerous psychiatric
and medical conditions. Cognitive tasks include recitation of serial 7s for assessment of
concentration, digit span forward and backward for assessment of attention, and immediate recall
for assessment of short-term memory. Short-term memory can be evaluated by asking patients to
verbally recall a short paragraph that was read to them. The patient's ability to attend to relevant
stimuli while ignoring distractions can be assessed through vigilance tasks in which the patient is
read a string of letters and told to tap a finger when a target letter is spoken. Verbally
administered mathematic problems are more demanding tasks that require concentration and
problem solving.
The medical evaluation should include a neurologic examination. There are suggestions that
patients with ADHD exhibit a greater incidence of "soft neurologic signs," including problems
with right-left discrimination, motor overflow movements and sequencing difficulties.13
Laboratory tests may include a serum lead level and thyroid function tests.13,14

Features of Self-Report Scales for Adults with ADHD


Number of


Copeland Symptom
Checklist for Adult


3-point severity
rating scale

Broad range of cognitive, emotional and

social symptoms

Wender Utah Rating



5-point severity
rating scale

Retrospective rating of childhood ADHD


Brown Adult Attention

Deficit Disorder Scale


4-point frequency Cognitive symptoms associated with

rating scale
difficulty initiating and maintaining optimal
arousal level

ADHD = attention-deficit/hyperactivity disorder.

Differential Diagnosis
Patients with a range of psychiatric conditions may emphasize difficulty with concentration,
attention or short-term memory when they describe their problems to the physician.14 It is
important to exclude other psychiatric conditions, most of which are actually more prevalent than
ADHD among adults (Table 5). Major depression and substance abuse, in particular, commonly
accompany adult ADHD.

Psychiatric Disorders to Consider in the Differential Diagnosis of ADHD in

Psychiatric disorder

Features shared with ADHD Distinctive features

Major depression

Subjective report of poor

concentration, attention and
memory; difficulty with task

Enduring dysphoric mood or anhedonia;

sleep and appetite disturbance

Bipolar disorder

Hyperactivity, difficulty with

maintaining attention and
focus; mood swings

Enduring dysphoric or euphoric mood;

insomnia; delusions

Generalized anxiety

Fidgetiness; difficulty

Exaggerated apprehension and worry;

somatic symptoms of anxiety

Substance abuse or

Difficulties with attention,

concentration and memory;
mood swings

Pathologic pattern of substance use with

social consequences; physiologic and
psychologic tolerance and withdrawal

Personality disorders,
particularly borderline
and antisocial

Impulsivity; affective lability

Arrest history (antisocial personality);

repeated self-injurious or suicidal behavior
(borderline personality); lack of recognition
that behavior is self-defeating

ADHD = attention-deficit/hyperactivity disorder.

Importantly, most adults with ADHD do not have a "pure" form of the disorder. Comorbidity is
more likely to be the rule than the exception. It is not clear whether these comorbid psychiatric
conditions are a psychologic effect of preexisting ADHD or are simply associated with ADHD.2
For example, substance abuse may have developed as a way to reduce the frustration arising
from distractibility, inattention and impulsivity. If a comorbid psychiatric disorder exists in a
patient with ADHD, the patient should be educated about the ADHD symptoms that will resolve
with stimulant therapy and the symptoms of the other psychiatric condition that may warrant
additional treatment.
In addition to the physical examination and laboratory findings, a thorough history is valuable in
the differential diagnosis. Medical conditions that may mimic adult ADHD include
hyperthyroidism, petit mal and partial complex seizures, hearing deficits, hepatic disease and
lead toxicity.13 In addition, sleep apnea and drug interactions should be considered as possible
causes of inattention and hyperactivity.13,15 Patients with a history of head injury may also have
problems with attention, concentration and memory.16

The pathophysiologic basis of ADHD centers on an imbalance in catecholamine metabolism in
the cerebral cortex, and the agents used to treat this disorder in adults, as in children, enhance the
availability of dopamine and norepinephrine.17,18 Pharmacotherapy options are summarized in
Table 6. As with children, stimulants are the most commonly used category of medications in
adults with ADHD.

Pharmacotherapy of ADHD in Adults




Target daily Cost



Methylphenidate (Ritalin, Ritalin5-, 10-, 20-mg tablets


$ 50 to 76 (43
to 67)

5 to 10 mg

40 to 90 mg

18 mg

36 to 54 mg **

37.5 mg

75 mg

5 to 10 mg

20 to 45 mg 46 (27)

5 to 10 mg

20 to 45 mg 92

20 to 45 mg 37

20-mg (slow-release)
18-, 36-mg controlledrelease tablets
Pemoline (Cylert)

18.75-, 37.5-, 75-mg


95 to 103 (79
to 82)

37.5-mg chewable tablets

Dextroamphetamine (Dexedrine) 5-, 10-, 15-mg SR
5 mg per 5 mL (elixir)
Methamphetamine (Desoxyn)

5-mg tablets
5-, 10-, 15-mg longacting tablets

Mixture of amphetamine and

dextroamphetamine (Adderall)

5-, 10-, 20-mg tablets

5 to 10 mg

Desipramine (Norpramin)

10-, 35-, 50-, 75,- 100-,

150-mg tablets

10 to 25 mg 100 to 150

81 (32 to 38)

Imipramine (Tofranil)

10-, 25-, 50-mg tablets

10 to 25 mg 100 to 150

58 (41 to 44)

Nortriptyline (Pamelor)

10-, 25-, 50-, 75-mg


10 to 25 mg 100 to 150

136 (89 to 97)

Bupropion (Wellbutrin)

75-, 100-mg tablets

37.5 mg


300 to 450

ADHD = attention-deficit/hyperactivity disorder.

*--Estimated cost to the pharmacist based on average wholesale prices for one month of therapy at the lowest
target daily dosage taken twice daily (rounded to the nearest dollar), in Red book. Montvale, N.J.: Medical

Economics Data, 2000. Cost to the patient will be higher, depending on prescription filling fee.
**--Cost figures not available at press time.

Methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) are effective in improving

attention and concentration, and in reducing impulsivity in adults with ADHD.18 Although
chemically distinct from the other two agents, pemoline (Cylert) has a mechanism of action that
is similar to that of methylphenidate and dextroamphetamine. These agents stimulate the release
of catecholamines from storage sites at the synapses of the central nervous system. Because
catecholamine receptors are pervasive throughout the central nervous system, the exact focus of
the pharmacologic effect is unclear. Increased norepinephrine and dopamine concentrations in
the brain stem, midbrain or frontal cortex have been postulated to be responsible for the
increased attention span and concentrating ability that occurs with the use of stimulants. Because
stimulants may produce these effects in patients without ADHD and because not all patients with
ADHD improve with such therapy, the patient's response cannot be used to confirm or exclude
the diagnosis of ADHD.3
Each of the currently available stimulants appears to be equally effective in the management of
symptoms of ADHD, but they differ in their time course of action. Stimulants are usually well
tolerated and are associated with only mild side effects. A common initial side effect is sleep
disturbance, characterized by the delayed onset of sleep. While initial insomnia can be a side
effect of stimulant medication, it is also a common complaint of adults with untreated ADHD.
Therefore, if sleep problems develop after initiation of therapy, it may be helpful to assess the
patient's sleep patterns for several weeks before altering the dosage or the timing of
administration. Another side effect of stimulants may be a decrease in appetite, resulting in
weight loss.
The cardiovascular effects of stimulants are of
potentially greater concern in adults than in children.
Mild increases in heart rate and blood pressure may
occur but are not usually clinically significant.19 Because
the effects of stimulants on blood pressure may be
variable, blood pressure should be controlled and closely
monitored when initiating treatment with stimulants in
patients with hypertension.20

Psychiatric conditions that can mimic

ADHD include depression, bipolar
disorder, generalized anxiety
disorder, substance abuse and
personality disorders.

Because of the risk of hepatitis with pemoline, the use of this agent is recommended only in
patients who have failed to respond to other stimulants.18 A baseline serum alanine
aminotransferase (ALT) determination should be obtained before initiating therapy with

pemoline and every two weeks during therapy. According to the manufacturer, pemoline therapy
should be discontinued if the ALT level exceeds two times the upper limits of normal or if
symptoms of liver disease develop. The manufacturer of pemoline has developed a consent form
that describes the risks associated with this drug and recommends that patients sign the form
before initiation of therapy.
Some prescribing issues surround the use of controlled substances such as stimulants. Caution
should be exercised not only in making the diagnosis of ADHD but also in avoiding the use of
stimulants in patients with a history of substance abuse. On the other hand, adult patients may
require larger dosages than those usually prescribed to children. Therefore, it is important to
document the patient's symptoms and the patient's response to each dosage as the amount is
titrated upward. Because methylphenidate and dextroamphetamine are C-II controlled
substances, most states limit prescriptions to a 30-day supply and do not authorize refills. In
addition, written copies of the prescription are usually required. Such requirements necessitate
frequent contact between the patient and physician for reevaluation and prescription renewal.
Pemoline is classified as a C-IV controlled substance, which can usually be refilled up to five
times over the six months following the initial prescription.
As a means of increasing the concentration of catecholamines in the central nervous system,
antidepressants that inhibit reuptake of norepinephrine have been evaluated for the treatment of
ADHD.17 Tricyclic antidepressants (TCAs), which inhibit the uptake of norepinephrine and
serotonin, may be effective, while the response to selective serotonin reuptake inhibitors (SSRIs)
has been less promising in adults with ADHD.18,21 The secondary amine TCAs, such as
desipramine (Norpramin) and nortriptyline (Pamelor), may be preferred because of greater
effects on norepinephrine than on serotonin and a better side effect profile.17 Bupropion
(Wellbutrin), an atypical antidepressant with more stimulant properties than the TCAs, may be
effective as well.17 Therapy with monoamine oxidase (MAO) inhibitors has produced variable
responses in patients with ADHD, but may be tried in patients who have responded poorly to
other therapies.
Antidepressant therapy in adults with ADHD may be
particularly helpful in reducing affective instability and
Because the effects of stimulants on controlling a coexistent mood disturbance. Because of the
blood pressure may be variable,
different effects of stimulants and antidepressants, some
hypertension should be controlled
patients may benefit from the combination of a stimulant
and closely monitored when
and an antidepressant.
beginning therapy with stimulants for
adult ADHD.

Adverse effects of antidepressants often limit the ability

to titrate the dose to an effective level. Because of the
possibility of cardiac conduction abnormalities, an

electrocardiogram should be obtained before initiating TCA therapy and after the dosage is
stabilized. Drowsiness is common but may be minimized by taking the antidepressant at bedtime
and slowly titrating to the target dosage. Anticholinergic effects such as dry mouth, constipation
and urinary retention may also be troublesome. Weight gain and postural hypotension may be
problematic. Sexual dysfunction is more common with the agents that affect serotonin reuptake,
so it may be less common with secondary amine TCAs. If sedation is problematic, bupropion
may be an alternative agent. However, the use of bupropion is contraindicated in patients with a
history of seizures. If an antidepressant is tolerated at an effective dosage, it may be a reasonable
alternative in patients with coexisting depression or an alternative to a controlled substance.
Other Medications
Sympatholytics have also been used in the management of ADHD. Clonidine (Catapres) is a
centrally acting alpha2 agonist that decreases sympathetic outflow from the central nervous
system. While this agent may be beneficial in children and adolescents, particularly those with
significant hyperactivity and aggressive behavior, the benefits in adults are less clear. Sedation is
the most common adverse effect of clonidine. The antihypertensive effects of clonidine may be
beneficial in a patient with hypertension but may limit its usefulness in other patients.

Self-Management Strategies
Adults with ADHD benefit considerably from direct education about the disorder. They can use
information about their deficits to develop compensatory strategies. Planning and organization
can be improved by encouraging patients to make lists and use computerized schedules. Placing
a large calendar with important dates and deadlines in a central location in the home or
workplace is a valuable memory aid.20 Ways to reduce distractions may include having a clutterfree desk, a carrel-style desk or a windowless office. ADHD adults may benefit from going to
work early to accomplish tasks before coworkers arrive and phones begin ringing. Most adults
are aware of their "personal clock" and know their prime times for completing intellectually
demanding tasks. Task completion can be improved by systematically breaking down large
projects into manageable "chunks," each with its own deadline.20
Adults with ADHD should be educated about their elevated risk for drug and alcohol dependence
and should be encouraged to drink in moderation or practice abstinence.

Marital and individual counseling and self-help groups are often valuable adjuncts to
pharmacotherapy and skill training. Among newly diagnosed adults in particular there may be an
extended psychologic history of low self-esteem, failure, frequent job changes and relationship
problems. Individual psychotherapy that focuses on core issues of self-worth along with ways to
improve the patient's ability to monitor work and social skills can be invaluable.

Married patients often have significant relationship conflicts stemming from forgotten
commitments, impulsive decisions and emotional outbursts. Working with the couple to enhance
communication skills, conflict resolution and problem solving, and educating the patient's spouse
about ADHD can dramatically improve the relationship.20 Finally, self-help organizations such as
Children and Adults with Attention Deficit Disorder (CHADD;

) provide didactic information about the disorder.

The Authors
is director of behavioral medicine at the Family Medicine of St. Louis Residency Program. Dr.
Searight is also adjunct associate professor of community and family medicine at Saint Louis
University School of Medicine and adjunct professor of psychology at Saint Louis University.
He received a doctorate in clinical psychology from Saint Louis University.
is a clinical pharmacist on the faculty with the Family Medicine of St. Louis Residency Program
and associate professor of pharmacy practice at the Saint Louis College of Pharmacy. Dr. Burke
received a doctorate in pharmacology from the University of Texas and completed a clinical
pharmacy residency at Truman Medical Center, Kansas City, Mo. He is board certified as a
pharmaceutical care specialist.
is currently director of community services at the Institute for Research and Education in Family
Medicine, St. Louis. He formerly was medical director and community medicine coordinator at
the Family Medicine of St. Louis Residency Program. A graduate of Saint Louis University
School of Medicine, he completed a residency at Family Medicine of St. Louis. He also
completed a fellowship in faculty development at the University of North Carolina, Chapel Hill.
Address correspondence to H. Russell Searight, Ph.D., Family Medicine of St. Louis Residency Program,
6125 Clayton Ave., St. Louis, MO 63139. Reprints are not available from the authors.

1. Vollmer S. AD/HD: it's not just in children. Family Pract Recertif 1998;20:45-6.
2. Wender PH. Attention-deficit hyperactivity disorder in adults. New York: Oxford
University Press, 1995.

3. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attentiondeficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs,
American Medical Association. JAMA 1998;279:1100-7.

4. Roy-Byrne P, Scheele L, Brinkley J, Ward N, Wiatrak C, Russo J, et al. Adult attentiondeficit hyperactivity disorder: assessment guidelines based on clinical presentation to
a specialty clinic. Compr Psychiatry 1997;38:133-40.

5. American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 4th ed. Washington D.C.: American Psychiatric Association, 1994:78-85.

6. Spencer T, Biederman J, Wilens T, Faraone SV. Is attention-deficit hyperactivity

disorder in adults a valid disorder? Harv Rev Psychiatry 1994;1:326-35.

7. Barkley RA. Attention-deficit hyperactivity disorder: a handbook for diagnosis and

treatment. New York: Guilford, 1990.

8. Barkley RA. ADHD and the nature of self-control. New York: Guilford, 1997:10-1.
9. Brown TE. Brown ADD scales. San Antonio, Tex.: Psychological Corp., 1996:5-6.
10. Copeland ED. Medications for attention disorders (ADHD/ADD) and related medical
problems. (Tourette's syndrome, sleep apnea, seizure disorders). Atlanta: SPI Press,

11. Tzelepis A, Schubiner H, Warbasse LH. Differential diagnosis and psychiatric

comorbidity patterns in adult attention deficit disorder. In: Nadeau KG, ed. A
comprehensive guide to attention deficit disorder in adults: research, diagnosis and
treatment. New York: Brunner/Mazel, 1995:35-57.

12. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the
retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J
Psychiatry 1993;150:885-90 [Published erratum appears in Am J Psychiatry 1993;

13. Fargason RE, Ford CV. Attention deficit hyperactivity disorder in adults: diagnosis,
treatment, and prognosis. South Med J 1994;87:302-9.

14. Nahlik JE, Searight HR. Diagnosis and treatment of attention deficit hyperactivity
disorder. Prim Care Rep 1996;2:65-74.

15. Ball JD, Wooten V, Crowell TA. Adult ADHD and/or sleep apnea? Differential diagnostic
considerations with six case studies. J Clin Psychol Med Settings 1999;6(3):259-71.

16. Lavenstein B. Neurological comorbidity patterns/differential diagnosis in adult

attention deficit disorder. In: KG Nadeau, ed. A comprehensive guide to attention
deficit disorder in adults: research, diagnosis, and treatment. New York:
Brunner/Mazel, 1995:74-92.

17. Wilens TE, Biederman J, Prince J, Spencer TJ, Faraone SV, Warburton R, et al. Sixweek, double-blind, placebo-controlled study of desipramine for adult attention deficit
hyperactivity disorder. Am J Psychiatry 1996;153:1147-53.

18. Wilen TE, Spencer TJ, Biederman J. Pharmacotherapy of adult ADHD: In: Barkley RA,
ed. Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment.
2d ed. New York: Guilford, 1998:592-606.

19. Elia J, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit/hyperactivity disorder.

N Engl J Med 1999;340:780-8.

20. Wender PH. Pharmacotherapy of attention-deficit/hyperactivity disorder in adults. J

Clin Psychiatry 1998;59(suppl 7):76-9.

21. Spencer TJ, Biederman J, Wilen T. Pharmacotherapy of ADHD with antidepressants. In:
Barkley RS, ed. Attention deficit hyperactivity disorder: a handbook for diagnosis and
treatment. 2d ed. New York: Guilford, 1998:552-63.
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Copyright 2000 by the American Academy of Family Physicians.
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Attention deficit hyperactivity disorder


Drug Approval
In 2007, the Food and Drug Administration (FDA) approved lisdexamfetamine (Vysvanse), a
new stimulant drug for the treatment of attention-deficit/hyperactivity disorder (ADHD). The
active ingredient in lisdexamfetamine is similar to dextroamphetamine, the drug used in
Dexedrine and Adderall.
Drug Warning

In 2007, the FDA instructed the manufacturers of all ADHD drugs to include drug warning labels
describing the risks for heart and psychiatric side effects. Doctors should carefully evaluate
patients for any risk factors. Reports have linked ADHD drugs to sudden death in patients with
serious heart problems. There is also a slightly increased risk for auditory hallucinations,
paranoia, and manic behavior even in patients with no history of psychiatric problems. The FDA
warning applies to all stimulant ADHD drugs and to the non-stimulant drug atomoxetine
Ritalin Can Stunt Growth
After 3 years of methylphenidate (Ritalin) treatment, children are about an inch shorter and 6
pounds lighter than their peers who do not take this drug, according to a 2007 study in the
Journal of the American Academy of Child and Adolescent Psychiatry.
ADHD Improves Over Time
ADHD symptoms may improve over time regardless of the treatment approach, indicates a 2007
study in the Journal of the American Academy of Child and Adolescent Psychiatry. Researchers
found that medication, behavioral therapy, or a combination of the two all helped produce
improvement after 3 years. There appeared to be no significant difference between children who
took medication and those who did not.
Neurofeedback May Help ADHD
Neurofeedback (also known as biofeedback) is a non-drug treatment that may help improve
attention and behavior problems associated with ADHD. This treatment approach involves
teaching children to control their brain wave activity.

According to the U.S. National Institute of Mental Health, attention deficit hyperactivity disorder
(ADHD) is a legitimate psychologic condition.
ADHD is a syndrome generally characterized by the following symptoms:




Some experts categorize ADHD into three subtypes:

Behavior marked by hyperactivity and impulsivity, but not inattentiveness

Behavior marked by inattentiveness, but not hyperactivity and impulsivity

A combination of the above two

There is some debate over these criteria. Some argue the condition is over-diagnosed. Others say
it's underdiagnosed. (See Difficulties in Identifying Children with ADHD later in this article.)
One-third of cases are accompanied by learning disabilities and other neurologic or emotional
problems, making an ADHD diagnosis particularly difficult. It is likely that the term attentiondeficit hyperactivity disorder will eventually give way to subgroups of problems that include
some of these general symptoms.
General Description of a Child with ADHD

In the United States, about 4.7 million children ages 3 - 17 have been diagnosed at some point
with ADHD. This accounts for 7.4% of all American children in this age range.
ADHD is a genuine disorder, but it is telling that the U.S. accounts for 90% of worldwide
prescriptions for stimulants for ADHD. It is not known whether this reflects a real increase in
ADHD, or a better ability to recognize it. Some say it may be an indication of a culture that
places excessive value on normalcy and academic achievement at the expense of more frequent
Symptoms of ADHD usually occur before the age of 7. Studies indicate that ADHD symptoms in
preschool children with ADHD do not differ significantly from older children.
The classic ADHD symptoms do not always adequately describe the child's behavior, nor do they
describe what is actually happening in the child's mind. Some experts are focusing on deficits in
"executive functions" of the brain to understand and describe all ADHD behaviors. Such
impaired executive functions in ADHD children can cause the following problems:

Inability to hold information in short-term memory

Impaired organization and planning skills

Difficulty in establishing and using goals to guide behavior, such as selecting

strategies and monitoring tasks

Inability to keep emotions from becoming overpowering

Inability to shift efficiently from one mental activity to another

Hyperactivity. The term hyperactive is often confusing since, for some, it suggests a child racing
around non-stop. A boy with ADHD playing a game, for instance, may have the same level of

activity as another child without the syndrome. But when a high demand is placed on the ADHD
child's attention, his brain motor activity intensifies beyond the levels of the other children. In a
busy environment, such as a classroom or a crowded store, ADHD children often become
distracted and react by pulling items off the shelves, hitting people, or spinning out of control
into erratic, silly, or strange behavior.
Impulsivity and Temper Explosions. Even before the "terrible twos," impulsive behavior is often
apparent. The toddler may gleefully make erratic and aggressive gestures, such as hair pulling,
pinching, and hitting. Temper tantrums, normal in children after age 2, are usually exaggerated
and not necessarily linked to a specific negative event in the life of an ADHD child. One of the
most painful events a parent may experience is an abrupt and aggressive attack that may occur
after cuddling a young ADHD child. Often this reaction seems to be caused not by anger, but by
the child's apparent inability to endure overstimulation or displays of physical affection.
Attention and Concentration. ADHD children are usually distracted and made inattentive by an
overstimulating environment (such as a large classroom). They are also inattentive when a
situation is low-key or dull. Some experts believe that certain parts of the brain in ADHD
children may be underactive, so the children fail to be aroused by nonstimulating activities. In
contrast, they may exhibit a kind of "super concentration" to a highly stimulating activity (such
as a video game or a highly specific interest). Such children may even become over-attentive -so absorbed in a project that they cannot modify or change the direction of their attention.
Impaired Short-Term Memory. Many experts now believe that an essential feature in ADHD, as
well as in learning disabilities, is an impaired working (also called short-term) memory. People
with ADHD can't hold groups of sentences and images in their mind long enough to extract
organized thoughts. They are not necessarily inattentive. Instead, a patient with ADHD may be
unable to remember a full explanation (such as a homework assignment), or unable to complete
processes that require remembering sequences, such as model building. In general, children with
ADHD are often attracted to activities (television, computer games, or active individual sports)
that do not tax the working memory, or produce distractions. Children with ADHD have no
differences in long-term memory compared with other children.
Inability to Manage Time. Studies suggest that children with ADHD have difficulties being on
time and planning the correct amount of time to complete tasks. (This may coincide with shortterm memory problems.) In one study, although children with probable ADHD were able to selfreport many ADHD symptoms, they tended to believe they used their time wisely, in contrast to
reports by their teacher.
Lack of Adaptability. ADHD children have a very difficult time adapting to even minor changes
in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to
bed. Any shift in a situation can precipitate a strong and noisy negative response. Even when

they are in a good mood, they may suddenly shift into a tantrum if met with an unexpected
change or frustration. In one experiment, ADHD children could closely focus their attention
when directly cued to a specific location, but they had difficulty shifting their attention to an
alternative location.
Hypersensitivity and Sleep Problems. ADHD children are often hypersensitive to sights, sounds,
and touch. They usually complain excessively about stimuli that seem low key or bland to others.
Sleeping problems usually occur well after the point when most small children sleep through the
night. In one study, 63% of children with ADHD had trouble sleeping.
Diagnostic Criteria for ADHD in Children

A. Either 1 or 2 should be present:

1. Should have 6 or more of the following symptoms of inattention, persisting for at least 6
months to a degree that is maladaptive and inconsistent with developmental level:
Often fails to give close attention to detail, makes careless mistakes

Often has difficulty sustaining attention in tasks or play

Often does not seem to listen when spoken to directly

Often does not follow through and fails to finish tasks

Has difficulty organizing tasks and activities

Avoids or dislikes tasks requiring sustained mental effort

Often loses things necessary for tasks or activities

Is often easily distracted by extraneous stimuli

Is often forgetful in daily activities

2. Should have 6 or more of the following symptoms of hyperactivity-impulsivity that lasts for at
least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Often fidgets or squirms when sitting

Has difficulty remaining seated when required to do so

Often runs about or climbs excessively in inappropriate situations

Has difficulty playing quietly

Is often "on the go"

Often talks excessively

Often blurts out answers to questions before they have been completed

Has difficulty waiting for his or her turn

Often interrupts or intrudes on others

Note: Patients with A1 symptoms are diagnosed with ADHD, predominantly inattentive type.
Those with A2 are diagnosed with ADHD, predominantly hyperactive-impulsive type. Those
with both A1 and A2 are diagnosed as ADHD, combined-type.
B. Onset of some symptoms before the age of 7. However, children with the inattentive subtype
are not often diagnosed until they are above 7 years of age.
C. Symptoms occur in two or more settings. For example, at home and at school.
D. Clear evidence of significant impairment in social or academic functioning.
E. Not caused by a pervasive developmental disorder, schizophrenia, or any other psychotic
disorder, and is not better accounted for by another mental disorder, including anxiety or
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th Ed. (Text Revision). Washington, DC: 2000.
Risk Factors
Gender and ADHD

ADHD is most often diagnosed in boys. However, there is some evidence that it is
underdiagnosed in girls. Until recently, all major studies were conducted using boys as subjects.
Important studies on girls with ADHD are now underway. A major study reported that girls with
the condition experience the same multiple impairments as boys do.
Adults with ADHD

Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit

disorder in adults are on the rise. Methylphenidate (Ritalin) was prescribed for nearly 800,000
adults in the U.S. in 1997, nearly three times the number in 1992. As of 2005, experts estimated
that ADHD affects about 4.1% of adults ages 18 - 44 years in a given year.
Attention Deficit Hyperactivity Disorder In Adults

How Is ADHD Identified in Adults?

Research suggests that ADHD affects 2 - 6% of the adult population, assuming that one- to twothirds of cases persist into adulthood. ADHD in adults always occurs as a continuum of the
childhood condition. Adult-onset symptoms are likely due to other factors. Diagnosing adult
ADHD can be a difficult problem since hyperactivity typically wanes as children get older, while
attention and organizational problems may develop in older people. Some experts believe, then,
that the number of adults with ADHD is underestimated.
A rating scale using four factors may be useful in identifying adults with ADHD:

Inattention and memory problems. (Examples: losing or forgetting things,

being absent-minded, not finishing things, misjudging time, depending on
others for order, having trouble getting started, changing jobs or projects in
the middle.)
Hyperactivity and restlessness. (Examples: always being on the go, fidgety,
easily bored, taking risks, liking active and fast paced jobs and activities,
such as being a sales representative or stockbroker.)
Impulsivity and emotional instability. (Examples: saying things without
thinking first, interrupting others, being annoying to others, easily frustrated,
easily angered, having unpredictable moods, driving recklessly, having high
relationship and job turnover.)

Problems with self worth. (Examples: Avoids new challenges, appears

confident to others but not to oneself.)

Doctors use adult reports of their childhood behaviors and experiences when searching for clues
for a diagnosis. Interestingly, the disorder seems to be distributed equally between adult women
and men.
How Serious Is Attention Deficit Disorder in Adults?
Accompanying Emotional, Personality, and Learning Disorders. Between 19 - 37% of adults
with ADHD have depression or bipolar disorder. Between 25 - 50% have an anxiety disorder.
Bipolar disorder plus ADHD, in fact, may be very difficult to differentiate from ADHD alone in
Accompanying Learning Disorders. About 20% of adults with ADHD have learning disorders,
usually dyslexia and auditory processing problems. These problems should be considered in any
treatment plan.
Effect on Work. Compared to adults without ADHD, those with the condition tend to reach lower
educational levels, earn less money, and be fired more often. In fact, one article reported that by
the time they are in their 30s, about 35% of ADHD adults are self-employed.

Substance Abuse. About 1 in 5 adults with ADHD also contend with substance abuse. Studies
indicate that adolescents with ADHD are twice as likely to smoke cigarettes as their peers who
do not have ADHD. Cigarette smoking during adolescence is a risk factor for the development of
substance abuse in adulthood.
Sleep Disorders. Sleep disorders, especially restless legs syndrome and sleep apnea, are common
in adults and children with ADHD. Sleep apnea is a disorder in which a person temporarily stops
breathing during sleep, perhaps hundreds of times. In most cases the person is unaware of it,
although sometimes they awaken and gasp for breath. It is usually accompanied by snoring. One
report suggested that treating sleep apnea in adults with both conditions may help reduce ADHD
symptoms. [For more information, see In-Depth Report #65: Sleep apnea.]

Brain Structures. Research using advanced imaging techniques shows there is a difference in the
size of certain parts of the brain in children with ADHD compared to children who do not have
ADHD. The areas showing change include the prefrontal cortex, the caudate nucleus and globus
pallidus, and the cerebellum:

The prefrontal cortex is located in the front of the brain. It is thought to be the
brain's command center. It regulates the brains ability to block certain
responses. Numerous imaging studies have indicated that the prefrontal
cortex of the brain in people with ADHD may be less active than in those
without the disorder.
The caudate nucleus and globus pallidus, located near the center of the
brain, speed up or stop orders coming from the prefrontal cortex. In some
reports, these areas have been smaller than average in young children with
ADHD, but tended to become normal as the children got older. Abnormalities
in these areas may impair a person's ability to stop certain actions, resulting
in the impulsivity typical of people with ADHD.

The cerebellum is the area above the brain stem. This area helps control
muscle tone and balance, and synchronizes muscle activity. This has been
found to be smaller in children with ADHD compared to those without the

Brain Chemicals. Abnormal activity of certain brain chemicals in the prefrontal cortex may
contribute to ADHD. The chemicals dopamine and norepinephrine are of special interest.
Dopamine and norepinephrine are neurotransmitters, or chemical messengers, that affect both
mental and emotional functioning. They also play a role in the "reward response." This response
occurs when a person experiences pleasure in response to certain stimuli (such as food or love).
Studies suggest that increased levels of the brain chemicals glutamate, glutamine, and GABA -collectively called Glx -- interact with the pathways that transport dopamine and norepinephrine.

Nerve Pathways. Another area of interest is a network of nerves called the basal-ganglia
thalamocortical pathways. Abnormalities along this neural route have been associated with
ADHD, Tourette syndrome, and obsessive-compulsive disorders, all of which share certain
Genetic Factors

Genetic factors may play the most important role in ADHD. The relatives of ADHD children
(both boys and girls) have much higher rates of ADHD, antisocial, mood, anxiety, and substance
abuse disorders than the families of non-ADHD children. A study reported that 90% of children
with a diagnosis of ADHD shared it with their twin.
Genetic Factors Regulating Dopamine and Advantages in Early Man. Most of the research on
the underlying genetic mechanisms targets the neurotransmitter dopamine. Variations in genes
that regulate specific dopamine receptors have been identified in a high proportion of people
with addictions and ADHD. Such genes have been associated with novelty seeking and
extroversion. Some experts theorize that the genetic variants may have first appeared thousands
of years ago, and affect as many as half of ADHD children. Furthermore, the genetic variations
may have offered some benefits to their early carriers. In such people, a genetic predilection for
novelty-seeking and risk-taking may have supplied an advantage in reproduction, mating,
hunting, and achieving dominance.
Genetic Resistance to Thyroid Hormone. About 50% of adults and 70% of children with a
genetic resistance to thyroid hormone, essential for normal brain development, have ADHD.
People who have this condition appear to have a more severe form of ADHD. The thyroid
disorder is not a common cause of ADHD. Only those with a family history of thyroid disease
are at risk.
Dietary Factors

Infant malnutrition is a strong risk indicator of ADHD. Even if children receive enough food
later on, infants who suffer from malnutrition may develop behavior problems, the most
prevalent being attention-deficit disorder.
Deficiencies in Zinc and Essential Fatty Acids. Several dietary factors have been researched in
association with ADHD, including sensitivities to certain food chemicals, deficiencies in fatty
acids (compounds that make up fats and oils) and zinc, and sensitivity to sugar.
Some studies have found an association between deficiencies in certain fatty acids and ADHD.
Other research reports an association between zinc deficiencies and ADHD. Zinc aids in the
breakdown of fatty acids, which affects dopamine, the neurotransmitter likely to be involved
with ADHD.

No clear evidence has emerged, however, that implicates any of these nutritional factors in
Environmental Factors

Research suggests that prenatal exposure to tobacco, alcohol, environmental lead, and other
toxins may increase the risk for ADHD and conduct disorders.

Important factors for making a diagnosis of attention-deficit hyperactivity disorder (ADHD)

Children between ages 6 - 12 should first be evaluated for ADHD if they show
symptoms of inattention, hyperactivity, impulsivity, academic
underachievement, or behavior problems in at least two settings. Such
behaviors should have been harmful for the child academically or socially for
at least 6 months.

The child should meet the official symptom guidelines.

A diagnosis requires detailed reports by parents or caregivers. It should be

noted that a mother's description of her child's behavior is a very accurate
and reliable guide for diagnosing ADHD. Parents should not be shy about
insisting on further evaluation if their experience does not match a doctor's
single observation of their child.

Guidelines for primary care doctors emphasize the importance of obtaining

direct evidence from the classroom teacher or other school-based
professionals about the child's symptoms and their duration, and evidence of
functional impairment in the school setting.

The child should be assessed for accompanying conditions (such as learning

Difficulties in Identifying Children with ADHD

No laboratory or imaging tests exist to reliably diagnose ADHD. A diagnosis relies only on
behavioral symptoms and ruling out other disorders. Many experts believe that the disorder is
both over- and underdiagnosed. Diagnosis of attention-deficit hyperactivity disorder is difficult
for some of the following reasons:
Factors Leading to the Over-Diagnosis of ADHD:

The popularity methylphenidate (Ritalin) has encouraged some parents and

teachers to pressure doctors into prescribing this standard ADHD drug for
children who are aggressive or who have poor grades. Often with careful
testing many of these children do not meet the criteria for the illness.

Children may have other diagnoses, other behavioral or emotional problems,

or no problems at all.

Other factors that may contribute to misdiagnosis include children who are
young for their grade and therefore socially and intellectually immature, and
social and economic problems such as single parent households.

Factors Leading to the Under-Diagnosis of ADHD:

Some evidence suggests that many girls with ADHD may go underdiagnosed.
Research indicates that girls with ADHD are often inattentive but not
hyperactive or impulsive. In fact, older girls with ADHD tend to have social
problems due to withdrawal and internalized emotions, showing symptoms of
anxiety and depression. The inattentive subtype, in any case, may first show
up in older children and adolescents.

Doctors may fail to diagnose children with ADHD because they often behave
normally in the quiet doctor's office where there are no distractions to trigger
symptoms. In addition, doctors may be unfamiliar with how to diagnose the
In spite of the fact that there seems to be no differences in response to
treatment among population groups, African-American, Hispanic, and Asian
children with ADHD are half as likely to be diagnosed and treated as
Caucasian children. By high school, the racial disparity increases to the level
that the medication rate for blacks is one-fifth of that for whites.

History of Behavior

The doctor will first require a detailed history of the child's behavior. Doctors will match this
against a standardized checklist to define the disorder.
The parents should describe the following:

Specific problems, beginning as early as possible, they have encountered

during the child's development -- school reports are very helpful

Sibling relationships

Recent life changes

A family history of ADHD

Eating habits
Sleep patterns

Speech and language development

Any problems during the mother's pregnancy or during delivery

Any history of medical or physical problems, particularly allergies, chronic ear

infections, and hearing difficulties

The health professional will want to know how the parents handle different situations, and may
want to observe them interacting with the child.
Physical Examination

The child should also be given a general physical examination to determine if any medical
conditions are present. The child should be given a hearing test to rule out hearing abnormalities
as a source of behavioral problems.
Screening Tests

Various tests are available to test neurologic, intellectual, and emotional development problems.
Most involve learning and problem solving tasks that help define the particular areas that are
most disabling. Blood or other laboratory tests are currently recommended only if the doctor
suspects lead toxicity or other medical problems.
Drug Trial

Although some doctors use a trial of a psychostimulant (usually Ritalin) to facilitate diagnosis,
most experts strongly recommend against this method of diagnosis, because it is not always
accurate. An improvement in symptoms is considered suggestive of ADHD, while in non-ADHD
children the stimulant often increases agitation and hyperactivity. Many children and adults
without the disorder have a similar response, and such a diagnostic trial may lead to unnecessary
prescriptions of this drug.
Other Disorders Associated with ADHD

Several disorders may mimic or accompany attention-deficit disorder. ADHD exists alone in
only about one-third of children. Many professionals object to the use of the single term
"attention-deficit hyperactivity disorder" to encompass such a wide spectrum of behaviors, which
they believe should be categorized into subgroups. Many of these problems require other modes
of treatment and should be diagnosed separately, even if they accompany ADHD.
Attention-Deficit Disorder without Hyperactivity

Attention-deficit disorder can appear without hyperactivity, in which case the child's primary
symptoms are distractibility and an inability to persist in tasks.
Oppositional-Defiant Disorder

About 14% of children diagnosed with ADHD also have oppositional-defiant disorder (ODD).
The most common symptom for this disorder is a pattern of negative, defiant, and hostile
behavior toward authority figures that lasts more than 6 months. In addition to displaying

inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper
tantrums, and display antisocial behavior. A significant number of children with ODD also have
anxiety disorders and depression, which should be treated separately. Many children who
develop ODD at an early age go on to develop conduct disorder.
Conduct Disorder

Some children with ADHD also have conduct disorder, which describes a complex group of
behavioral and emotional disturbances seen in children. It includes aggression towards people
and animals, destruction of property, deceitfulness, lying, or stealing, and general violation of
Pervasive Developmental Disorder

Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behavior,
hand-flapping, repetitive statements, slow social development, and speech and motor problems.
If a child who has been diagnosed with ADHD does not respond to treatment, the parents might
inquire about PDD, which often responds to antidepressants. Some children with PDD may also
benefit from stimulants.
Central Auditory Processing Disorder and Hearing Problems

Children with ADHD often have difficulties with tasks that involve listening or hearing.
Research is indicating that symptoms of the two disorders often overlap but may actually be two
distinct disorders. Hearing problems themselves may cause ADHD symptoms.
Bipolar Disorder (Manic Depression)

Children diagnosed with attention-deficit disorder may also have bipolar disorder, commonly
called manic depression. Indications of this problem include episodes of depression and mania
(with symptoms of irritability, rapid speech, and disconnected thoughts), sometimes occurring at
the same time. [For more information, see In-Depth Report #66: Bipolar disorder.] Both
disorders often cause inattention and distractibility and may be difficult to distinguish,
particularly in children. Children with mania and ADHD may have more aggression, behavioral
problems, and emotional disorders than those with ADHD alone. In some cases, ADHD in
children or adolescents can even be a marker for an emerging bipolar disorder. The primary way
to differentiate bipolar disorder from ADHD is by the presence of a manic or hypomanic episode,
which occurs in patients with bipolar disorder but not with ADHD. Most children with bipolar
will also respond to the drug valproate, which does not typically work for ADHD in children.
Anxiety Disorders

Anxiety disorders commonly accompany ADHD. Obsessive-compulsive disorder is a specific

anxiety disorder that shares many characteristics with ADHD and may share a genetic
component. Young children who have experienced traumatic events, including sexual or physical

abuse or neglect, exhibit characteristics of ADHD, including impulsivity, emotional outbursts,

and oppositional behavior.
Sleep Disorders

Sleep disorders or disturbances are very common with ADHD patients. Insomnia is common. In
addition, specific sleep disorders -- restless legs syndrome and sleep-disordered breathing -- have
been identified with hyperactivity and conduct disorder.
Restless Legs Syndrome (RLS). Some experts believe RLS and periodic limb movement disorder
are strongly associated with ADHD in some children. One theory is that the two are linked by a
common mechanism. The disorders have much in common, including poor sleep habits,
twitching, and the need to get up suddenly and walk about frequently. They may even be
genetically linked. For example, both have been associated with lower levels of dopamine in the
brain, which is associated with faulty motor control, a common problem in both disorders.
Sleep-Disorder Breathing and Sleep Apnea. Some research has shown an association between
mild symptoms of ADHD and sleep-disordered breathing, including snoring and obstructive
sleep apnea in children and adults. Treating the sleep-related breathing disorders may improve
the attention disorder in some children. (One study indicated that such problems are unlikely to
be associated with children with moderate to severe ADHD.) [For more information, see InDepth Report #65: Sleep apnea.]
Other Diagnoses

Tourette Syndrome and Other Genetic Disorders. Several genetic disorders cause symptoms
resembling ADHD, including fragile X and Tourette syndrome. About 50% of those with
Tourette syndrome also have ADHD, and some of the treatments are similar.
Other Medical Conditions. A number of medical conditions, including hyperthyroidism and
vision problems, can produce ADHD-like symptoms.
Lead. Children who ingest even low amounts of lead may manifest symptoms similar to those of
ADHD. A child may be easily distractible, disorganized, and have trouble thinking logically. The
major cause of lead toxicity is exposure to leaded paint, particularly in homes that are old and in
poor repair.
Emotional Disorders

More than half of children with attention-deficit disorder have accompanying disorders,
including anxiety, depression, and conduct disorders. Children with ADHD who experience
anxiety or depression are also more likely to suffer from low self-esteem.

Social Problems

Anti-Social Behavior. Even if these emotional disorders are absent in childhood, the ADHD
child's relationship with others is volatile, and they are often unhappy from a very young age.
Research indicates that any boy or girl with ADHD, particularly an aggressive child, has trouble
getting along with others, and is less liked by his or her peers.
Children with the inattentive subtype of ADHD are more likely to be picked on
and to spend time alone.

Children with the combined subtypes tend to have different problems. Boys
with ADHD are less likely than others to empathize with people in difficult
circumstances. A best friend can turn into an enemy overnight when, for
example, a boy with ADHD does not perceive his friend's fearful response to
over-aggressive roughhousing and fails to let up. The next day the child with
ADHD has forgotten the event; the ex-friend hasn't. When a child with ADHD
hurts someone, the child either may go into a state of denial or blame himself
excessively. As ostracism, fear, and ridicule from peers persist from year to
year, the unstable behavior, originally neurologic, becomes emotionally
based. Unless this cycle is broken, serious adult problems can evolve.

Substance Abuse in Young People. Studies consistently report that young people with ADHD -in particular those with conduct or mood disorders -- have a higher than average risk for
substance abuse and that it starts in younger ages. In one study, for example, by age 11 nearly
20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. Biologic
factors associated with ADHD may make these individuals susceptible to substance abuse. Many
of these young people are self-medicating their condition. In fact, according to a major analysis,
Ritalin or other stimulants used to treat ADHD may help protect such patients against substance
abuse. (Boys with ADHD and conduct disorder, however, still face a high risk for substance
abuse. Girls with ADHD and emotional disorders may also still have a higher risk.)
High-Risk Behavior. Impulsivity in young people with ADHD can certainly cause them to take
chances before thinking them through, putting them in situations where the consequences
become clear only after the action has been taken. Children with ADHD and high levels of
aggression are at higher risk for delinquent behavior in adolescents and criminal activity in
adulthood. However, children with ADHD who are not aggressive have a lower and even normal
risk for dangerous activities. Even in aggressive children with ADHD, close parental attention
and early treatment can limit the risk considerably.
Learning Problems

Although speech and learning disorders are common in children with ADHD, the disorder does
not affect intelligence. People with ADHD span the same IQ range as the general population.
Many children with ADHD are underachievers, and half are held back in school at least once.
Some evidence suggests that inattention may be a major factor in low academic performance in

these children. About 20% also have reading difficulties, and 60% have serious handwriting
problems. Adults with ADHD are also at very high risk for these conditions.
Persistence of ADHD into Adulthood

Some research suggests that ADHD persists in one- to two-thirds of those diagnosed with the
condition in childhood. Many researchers describe the pattern of ADHD as they would a chronic
illness, with remission and periods of worsening.
Effect on Family

The time and attention needed to deal with a child with ADHD can change internal family
relationships and have devastating effects on parents and siblings.
Effect on Parents. Studies indicate that any intervention for the child must include the parents.
Parents who are responsive to their child in a positive way can help reduce the chances for
oppositional behaviors. But it can be very difficult. A child with ADHD is wonderful one day and
terrible the next, for no apparent reason. The parent can feel betrayed and hurt, and believe they
have no control over their child. Parents must protect themselves and their child by establishing
tough but kind rules about where their space ends and the child's begins. The are many effects on

Mothers generally get the brunt of the emotional and physical abuse that a
child with ADHD can produce.

Parents may have to give up on the idea of an immaculate house and a hot
meal every night. Parents must learn that striving for perfection is among the
most counterproductive goals to pursue in raising a child with ADHD, or any

Parents must face the hostility and anger of other parents and see their own
child rejected. It is very easy to fall into an emotional black hole, and feel
alone, inadequate, and helpless.
Marriages are often stressed to the breaking point because of exhaustion and
disagreements between the husband and wife on how to respond to the child.

Effect on Siblings. Siblings of children with ADHD have particular difficulties, and are also at
risk for psychologic impairment, depression, drug abuse, and language disorders. The nonADHD sibling does not have the control a parent does in the management of the ADHD child's
behavior and is very likely to feel alienated and alone. Children without ADHD are often
victimized by siblings with ADHD who may be demanding or bullying.
A sibling who does not receive attention in their own right may begin to imitate undesirable
behaviors or to act out negatively in other ways. It is very important to make the brothers and

sisters equally vital to the family's functioning. However, they should never be made to feel that
their value in the family is as caregivers of the ADHD sibling.

A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitivebehavioral therapy is proving to be the best option for treatment of children with ADHD.
Although medication can be helpful during the initial years of treatment, some research indicates
that the benefits of medication eventually wear off. It appears that for ADHD symptoms may
improve naturally over time, regardless of the treatment approach.
Signs that ADHD may be easing include not having to adjust medication dosages during growth
spurts, no deterioration when a drug dose is missed, or new abilities to concentrate during drug
holidays. (School vacation times are a good period to test the effectiveness of temporarily
stopping medication.) The American Academy of Child and Adolescent Psychiatry suggests that
parents evaluate whether medication can safely be withdrawn when children with ADHD have
been free of symptoms for at least 1 year. If a childs condition worsens after medication
withdrawal, the drug should be resumed.
Developing a Treatment Approach. The following guidelines may be useful in determining a
treatment approach for children with ADHD:
Behavioral techniques, possibly including dietary changes, should be tried
first, if possible.

If the symptoms are severe or do not respond, a trial using medication

(usually psychostimulants), in conjunction with behavior modification
therapy, is advisable.

Cognitive behavioral therapy (CBT) is often administered by mental health providers, with both
primary care physicians and psychiatrists prescribing medications. Unfortunately, many children
do not have access to behavioral therapies, either because of lack of time or available resources.
Specific Patient Populations. Unfortunately, such guidelines do not address the following
specific patient groups:

There are no definite guidelines for treating preschool children with severe
ADHD. Some parents have reported very good long-term results with
behavioral interventions at this age.

There are no reliable guidelines on how to treat the inattentive subtype of

ADHD, which might be more common in girls.

There are no defined treatments for ADHD patients with accompanying

conditions, including impaired working memory and deficits in language

There are no defined treatments for children with ADHD and accompanying
emotional problems, such as bipolar or anxiety disorders. (There is some
evidence, for example, that children with ADHD plus anxiety disorders do
worse on psychostimulants.)

Determining a Medication Regimen. Doctors still have a difficult time predicting which
medications will produce beneficial results, so treatment is individualized and performed on a
trial and error basis, which requires close observation and cooperation between all participants.
In developing an effective medication plan, the following steps may be helpful:

Both the doctor and the parents should be very clear about the specific
behaviors they hope the medication will target.

Before any drug is administered, a child should be given a thorough

examination for any medical problems to be sure there are no medical
conditions that interfere with the medication.

The goal is to use the lowest possible dosage that produces improved
If an initial regimen doesn't work, changing the dosage, or changing to a
different medication often brings improvement.

Frequent follow-up visits should be scheduled to assess the response and to

detect possible side effects.

Arguments For and Against Psychostimulants. Many parents are very disturbed by the idea of
putting their children on intensive stimulant drug regimens, possibly for years, particularly given
the uncertainties in diagnosis and the negative publicity surrounding the use of these drugs.
Although the decision to use these drugs should not be made lightly, the negative social and
emotional effects of the disorder itself for many children with ADHD are far more severe and
long-lasting than the use of these drugs. For some parents and children, medication seems like a
miracle and can provide desperate families with a quality of life for which they had almost given
up hope. Whether or not psychostimulants are used, children and families should understand that
ongoing efforts around behavior control will be necessary.
Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool
children. Although low doses of methylphenidate (Ritalin) may help preschoolers (ages 3 - 5
years) with ADHD, the drug can cause considerable side effects in many children. These side
effects include insomnia, nervousness, anxiety, loss of appetite and weight, and slowed growth.
Children in one large study grew about an inch less and weighed about 6 pounds less than normal

after 3 years of methylphenidate treatment. Doctors must carefully consider the risks versus
benefits when prescribing ADHD drugs to preschoolers. Children who do receive these drugs
need to be carefully monitored by their doctors.
Treatment for Adult ADHD. As with children, adults with ADHD are treated with a combination
of medication and psychotherapy. For medication, stimulant drugs or the non-stimulant drug
atomoxetine (Strattera) are usually first-line treatments, with antidepressants a secondary option.
Atomoxetine is approved specifically for adults with ADHD. Adults who have heart problems or
heart condition risk factors should be aware of the cardiovascular risks associated with ADHD
medication. There have been ADHD medication-associated incidents of sudden death in patients
with underlying serious heart problems, and reports of stroke and heart attack in adults with
cardiac risk factors.
Help for Families and Teachers

Research increasingly supports the view that interventions for the ADHD child must also include
the parents if they are to be successful. Teachers and school officials should also be educated and
involved in the process.
Parents who feel they have the most control over their child's situation experience the least
psychological stress and depression. Parents who are responsive in a positive way also help
reduce the chances for their child developing oppositional behaviors. But it can be very difficult,
particularly for parents who have ADHD themselves. In fact, parents who have severe ADHD
symptoms are less likely to respond to parent training programs unless they get help for
In addition to behavioral therapy for the child, family therapy may help ADHD children and their
parents and siblings cope with the emotional conflicts that nearly always arise in the lifelong
process of managing the condition. Separate psychological therapies for specific family members
might be needed, particularly in light of the high incidence of psychiatric and other emotional
problems in families with ADHD children.

Several types of medication are available to treat ADHD.

Psychostimulants: Methylphenidate (Ritalin) and Similar Drugs

Psychostimulants are the primary drugs used to treat ADHD. Although these drugs stimulate the
central nervous system, they have a calming effect on people with ADHD.
These drugs include:

Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)

Dexmethylphenidate (Focalin)

Amphetamine-Dextroamphetamine (Adderall)

Dextroamphetamine (Dexedrine, Dextrostat)

Lisdexamfetamine (Vyvanse)

Pemoline (Cylert), another stimulant drug, was withdrawn from the U.S. market in 2005 after
several reports of liver failure.
Methylphenidate and Dexmethylphenidate. Methylphenidate drugs (Ritalin, Metadate, Concerta,
Daytrana) are the most commonly used psychostimulants for treating ADHD in both children
and adults. Dexmethylphenidate (Focalin) is a similar drug. These drugs increase dopamine, a
neurotransmitter important for cognitive functions such as attention and focus.
With the exception of Daytrana, all of these drugs are pills taken by mouth. Daytrana, approved
in 2006, is the first skin patch drug for ADHD. A patch is applied to the hip each day and delivers
a 9-hour dose of methylphenidate.
These drugs are available in short-acting and long-acting dosage forms. The short-acting forms
need to be taken several times a day, including during school hours. As the drug wears off, a
rebound effect can occur, and ADHD symptoms can intensify. For this reason, the long-acting
dosage forms have become popular.
Amphetamine, Dextroamphetamine, and Lisdexamfetamine. Amphetamine-dextroamphetamine
(Adderall), dextroamphetamine (Dexedrine, Dextrostat), and lisdexamfetamine (Vyvanse) work
by blocking the reabsorption of the brain chemicals dopamine and norepinephrine. Side effects
can include stomach problems and mood changes, including sadness, anxiety, and irritability.
Risks of Stimulants

Psychostimulant medications are associated with some significant risks. All ADHD stimulant
drugs carry warnings that they should not be used by patients with structural heart problems or
pre-existing heart conditions (high blood pressure, heart failure, or heart rhythm disturbances).
These drugs have been associated with sudden death in children with heart problems. They have
also been associated with sudden death, stroke, and heart attack in adults with a history of heart
disease. In addition, these drugs may slightly increase the risk for auditory hallucinations,
paranoia, and manic behavior even in patients who do not have a history of psychiatric problems.
The FDA has directed manufacturers of ADHD medications to warn all patients taking these
medicines of their potential cardiovascular and psychiatric risks.
Stimulant drugs may also:

Worsen behavior and thought disturbance in patients with a pre-existing

psychotic disorder.

Cause a mixed or manic episode in patients who have both ADHD and bipolar

Increase aggressive behavior or hostility. Patients beginning stimulant drug

treatment should be monitored for worsening of these behaviors.

Slow growth and weight gain in children. Children who take stimulant drugs
should have their growth monitored. If they do not gain height or weight at a
normal rate, they may need to stop taking the drug.

Side Effects. All stimulants have a number of side effects:

The most common side effects of any stimulant are nervousness and
sleeplessness, although some parents have reported improved sleep patterns
in their children after taking stimulants.

Tics or jerky, disordered movements occur in about 9% of children.

Other side effects include irritability, stomach pain, headache, depression,

hair loss, and lack of spontaneity.

Symptoms of Overdose. Symptoms of overdose include changes in heart rhythm and rate,
hypertension, confusion, breathing difficulties, sweating, vomiting, and muscle twitches. If they
occur, parents should call the doctor immediately. Even among young people who abuse Ritalin,
however, less than 1% experience severe side effects (rapid heart rate, hypertension), and
outcomes are generally good. Side effects may be very severe, however, if Ritalin is overused
and taken with other drugs. A 2006 study reported that over 3,000 people are treated in hospital
emergency rooms due to side effects from ADHD drugs. Sixty-one percent of these visits
involved accidental ingestion or overdose.
Concerns for Abuse. Studies on both animals and humans suggest that Ritalin lacks the
properties that create addiction, particularly in doses used for treating ADHD. Although
methylphenidates have properties similar to amphetamines, their drug levels rise very slowly in
the brain at the oral doses given for ADHD. This slow rise prevents a so-called "high" and
subsequent addiction to the drug. Some stimulant drugs, such as lisdexamfetamine, may pose a
lower risk for abuse than others.
The primary danger for drug abuse from stimulants appears to occur in non-ADHD young people
who purchase these drugs illegally. In one study, for instance, 16% of children with ADHD
reported pressure from their fellow students to sell or give them their medication. While people
ages 18 - 25 are more likely to use ADHD drugs for non-medical uses, children ages 12 - 17 are

more likely to suffer adverse effects from medication misuse and to require treatment at an
emergency room. If a child abuses another drug (alcohol, prescription medication) along with the
ADHD medication, the chance for serious side effects is even greater.
Non-Stimulant: Atomoxetine

Atomoxetine (Strattera) was the first non-stimulant approved for ADHD in children and the first
treatment approved for adult ADHD. The drug works by increasing levels of both norepinephrine
and dopamine, which are generally lower than normal in ADHD. The most common side effect is
decreased appetite. A few cases of atomoxetine-associated liver injury have been reported, and
the FDA has warned doctors that the drug should be discontinued at the first signs of jaundice or
liver problems. Long-term effects, such as any impact on growth, are still unknown. Atomoxetine
may cause suicidal thinking in children and adolescents, especially during the first few months of
treatment. Parents should monitor children taking atomoxetine for any changes in mood or
behavior, and immediately contact their doctor if changes occur.

Antidepressants are not FDA-approved for ADHD treatment, but may be helpful in certain
circumstances. Because antidepressants appear to work about as well as behavioral therapy,
doctors recommend that patients first try psychotherapy before using antidepressants.
Bupropion (Wellbutrin) and tricyclics are the types of antidepressants used for ADHD.
Bupropion affects the reuptake of the serotonin, norepinephrine, and dopamine
neurotransmitters. Side effects include restlessness, agitation, sleeplessness, headache, and
stomach problems. Bupropion should not be used by patients who have a seizure disorder.
Tricyclics are an older type of antidepressant that are effective but have many side effects.
Imipramine (Tofranil) and nortriptyline (Pamelor, Aventil) are the tricyclics most commonly
prescribed for ADHD. A third tricyclic, desipramine (Norpramin) should only be used if patients
are not helped by other tricyclics. (Desipramine has caused sudden death in some children and
Tricyclic antidepressants can cause disturbances in heart rhythm. Children should have an
electrocardiogram when they first begin to take this drug, and after any dose increase.
[For more information, see In-Depth Report #8: Depression ].
Alpha-2 Agonists (Clonidine)

Alpha-2 agonists stimulate the neurotransmitter norepinephrine, which appears to be important

for concentration. They include clonidine (Catapres) and guanfacine (Tenex). They are used for
Tourette syndrome and may be beneficial when other drugs have failed for ADHD children with
tics or those whose primary symptoms are severe impulsivity and aggression. These drugs are
mainly prescribed in combination with a stimulant.

These drugs have a number of side effects. Sedation is the most common. A clonidine skin patch,
which gradually releases the medication, helps reduce the sedative effect. Because clonidine
slows the heart down, it can have adverse effects in some children. Going off too quickly or
missing doses can cause rapid heartbeats and other symptoms that may lead to severe problems.
Doctors strongly recommend that no child be given this medication without a preliminary
examination for heart problems, and no child with existing heart, kidney, or circulatory problems
should take it.
Behavioral Management

Behavioral techniques for managing the child with ADHD are not intuitive for most parents and
teachers. To learn them, caregivers may need help from qualified health care professionals or
from ADHD support groups. At first, the idea of changing the behavior of a highly energetic,
obstinate child is daunting. It is futile and damaging to try to force a child with ADHD to be like
most children. It is possible, however, to limit destructive behavior and to instill a sense of selfworth that will help overcome negativity toward life, which is one of the great dangers of the
Behavioral Techniques at Home

Bringing up a child with ADHD, like bringing up any child, is a process. No single point is ever
reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to
do anything more." The child's self worth will evolve with an increasing ability to step back and
consider the consequences of an action and then to control that action before taking it. But this
does not happen overnight. A growing child with ADHD is different from other children in very
specific ways, presenting challenges at every age.
Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some
parents are easygoing and can accept a wide range of behaviors, while others cannot. To help a
child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some
tips to help the parents include:

Parents should prepare a list giving priority to those behaviors they think are
the most negative, such as fighting with other children or refusing to get up
in the morning. The least negative behaviors on the bottom of the list should
be ignored temporarily or even permanently (refusing to wear anything but
red T-shirts).

Certain odd behaviors that are not hurtful to the child or to others may be an
indication of creative or humorous attempts to adapt (making up silly songs
or drawing violent pictures). These should be accepted as part of the child's
unique and positive development, even if they seem peculiar to the parent.

It is important to keep in mind that no one is a saint. Loving parents who

occasionally lose their tempers will not damage their children forever. In fact,

non-abusive open disapproval or dismay is far less destructive to both parent

and child than harboring resentment beneath a false calm.

Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their
approach to the child, which should reward good behavior and discourage destructive behavior.
Rules should be well-defined but flexible enough to incorporate harmless idiosyncrasies. It is
very important to understand that children with ADHD have much more difficulty adapting to
change than do children without the condition. (For example, the child should do homework
every day but might choose to start it after a TV show or computer game.)
Managing Aggression. Some useful tips for managing aggression include:
Parents should try to give little attention to mildly disruptive behaviors that
allow this energetic child to let off some harmless steam. The parent will also
be wasting energy that will be needed when the negative behavior becomes
destructive, abusive, or intentional.

The use of "time-out," isolating the child immediately for a short period of
time, is an effective measure for allowing both the caregiver and the child to
cool down. The child should immediately (and without emotion) be removed
from a situation in which they are endangered or endangering others. The
child should view time out as a way of cooling off and getting a distance on
their behavior, not as isolation from others.

To channel physical aggression and impulsivity in the ADHD toddler, the

parents must teach them to use verbal responses. (A parent may need to
allow verbal responses that would be unacceptable in another child.)
When the ADHD child becomes older and if the verbal responses become
intentionally abusive and socially undesirable, the parent must redirect this
form of aggression into more acceptable activities, such as competitive oneon-one sports, energetic music, video games, or big colorful paintings.
Competitive video games, such as sports games, may also be an option.

Sometimes a parent can anticipate situations when an ADHD child is likely to

misbehave, but all too often the child explodes for no apparent reason. If the
blow-up occurs in public, the parents should complete their activities and
leave as quickly as possible.

Establishing a Reward System. Children with ADHD respond particularly well to reward
systems. One study reported that they performed equally well when encouraged either by a direct
reward for a correct response or with the use of a system called response-cost. With this system,
the child is given the reward first and allowed to keep it if their behavior remains appropriate.
Some suggested tips for rewarding the ADHD child are:

Create charts with points or stars for good behavior or for completed tasks. It
is important to give points for even simple positive behaviors, which may be
taken for granted in other children (responding happily to a change in plans,
changing an obscenity to a more acceptable expletive).

Rewards for any child can include playing a favorite game with the child,
extending bedtime by an hour, or allowing an extra half-hour of TV.

Rewards of food or gifts should be used infrequently, if at all. They can create
other problems, such as being overweight, having a bad diet, or making
continuous demands for objects.

A reward system should rotate different types of rewards, because such

children are easily bored.

Children with ADHD respond better with small rewards promised in the shortterm than large rewards offered in the future. One approach that employs
both short- and long-term rewards uses a system that gives the child points
for specific positive behaviors. As the children accumulate points, they can
use them for larger tangible rewards, such as a favorite video game or CD.

Rewards should be promised only when caregivers are fairly certain they can
follow through. ADHD children respond with much greater frustration than
non-ADHD children to disappointment, and are likely to have a strong (and
noisy) negative reaction. A parent must remember that this response is part
of the ADHD child's make-up and not necessarily in their control.

Improving Concentration and Attention. Research indicates that ADHD children perform
significantly better when their interest is engaged. Parents should be on the lookout for activities
that hold the child's concentration. Some options that may help an ADHD child to focus include:

Many ADHD children are particularly lured by the computer, which is a very
promising tool. A number of non-violent computer games are available that
offer problem-solving techniques using characters, narrative, and humor.

Swimming, tennis, and other sports that focus attention and limit peripheral
stimuli are often appealing. ADHD children often do not do well with team
sports, although they are interested. Children with ADHD are less likely to
become distracted in sports that require constant alertness, such as football
or basketball. In baseball, positions such as pitching or catching are
preferable to the outfield, where attention easily wanders. Finding a coach
that understands the childs difficulties is very helpful.
Some experts are enthusiastic about martial arts, such as Tae Kwon Do,
which can offer an appropriate and controlled emotional outlet, help to focus
attention, and teach self-restraint, self-discipline, and tolerance. Care should
be taken to select an instructor who makes such goals a priority.

Learning an instrument may be one of the best ways for an ADHD child to
develop a more rhythmic and balanced sense of self. Music, even simply
listening to it, is often very important for these children. (Parents may have to
tolerate music that does not please them.)
Management at School

Even if a parent is successful in managing the child at home, difficulties often arise at school.
The ultimate goal for any educational process should be the happy and healthy social integration
of the ADHD child with their peers.
Preparing the Teacher. Although teachers can expect at least one student in every classroom to
have ADHD, there is currently little training that prepares them for managing these children. The
teacher should be prepared for the certain behaviors in the child with ADHD:

Students with ADHD are often demanding, talkative, and highly visible.

Inattention is a major factor in low academic performance. It causes them to

frequently forget homework or miss assignments. Children with ADHD often
require frequent reminders or visual cues (such as posters) for rules and
regulations. Having the child sit in the front of the classroom may be helpful
for both increasing attention and reducing noisy activity.

Lack of fine motor control makes taking notes very difficult, and handwriting
is often poor. Using a typewriter or computer can compensate for this. One
useful skill that has helped some children is learning to type at an early age,
around the third or fourth grade.
Rote memorization and math computation, which require following a set of
ordered steps, are often difficult. (Children with ADHD may do better with
math concepts.)

Many children with ADHD respond well to school tasks that are rapid, intense,
novel, or of short duration (such as spelling bees or competitive educational
games), but they almost always have problems with long-term projects where
there is no direct supervision.

The Role of the Parent in the School Setting. The parent can help the child by talking to the
teacher before the school year starts about their child's situation:

The first priority for the parent is to develop a positive, not adversarial,
relationship with the child's teacher.

The parent must acknowledge the teacher's situation, for the teacher must
deal not only with the ADHD child's behavior but also with the needs of all the
other children.

Frequent brief and sympathetic conversations with the teacher can be helpful
and can lead to coordination of efforts, particularly if they provide reciprocal
information about progress or setbacks.

Finding a tutor to help after school may be helpful. It is not clear, however, if
tutoring offers significant benefits for children whose academic problems
stem from inattention unless it is structured specifically to address this

Special Education Programs. The Individuals with Disabilities Education Act (IDEA) requires
the school to identify and evaluate children who may need help and to provide special services.
However, parents sometimes report pressure by the school to put their children on medication or
force them into special classrooms without clear educational justification. The schools, in these
cases, may be acting illegally.
High-quality special education can be extremely helpful in improving learning and developing a
child's sense of self worth. Many families, however, may not have appropriate programs
available for them. Programs vary widely in their ability to provide quality education. Parents
must be aware of certain limitations and problems with special education:

Special education programs within the normal school setting often increase
the child's feelings of social alienation.

If the educational strategy focuses only on abnormal behavior, it will fail to

take advantage of the creative, competitive, and dynamic energy that often
accompanies ADHD behavior.

There is no federally funded special education category specifically targeted

to ADHD.

If, in fact, ADHD is as common as studies are indicating, the best approach may be to treat the
syndrome as a variant of the norm and train teachers to manage these children within the context
of a normal classroom.
Special programs are also required under the Rehabilitation Act and by the Americans with
Disabilities Act (ADA) for students at institutions of higher learning. It is the student's
responsibility, however, to inform the administration at their college or university that they need
such services. Unfortunately, many college students are reluctant to do this, although such
programs can provide important and beneficial assistance in improving their academic

Other Treatments
Dietary Approaches

A number of diets have been suggested for people with ADHD. Several well-conducted studies
have failed to support dietary effects of sugar and food additives on behavior, except possibly in
a very small percentage of children. Still various studies have reported behavioral improvement
with diets that restrict possible allergens in the diet. Parents may want to discuss with their doctor
implementing an elimination diet of certain foods that would not be harmful and that might help.
Food Allergies. Evidence suggests that children with behavioral difficulties may be sensitive to
certain chemicals in foods. Studies vary widely, however, on how many cases of ADHD may be
associated with sensitivities or allergies to food chemicals or additives, with results ranging
widely from 5 - 62%. Among the suspected additives and foods that parents and studies report as
inciting behavioral changes are the following:
Any artificial colorings (particularly yellow, red, or green)

Other chemical additives -- for example, BHT or BHA




Foods containing salicylates, including all berries, chili powder, apples and
cider, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes,

In one small study, 62% of children who were given only rice, turkey, pears, and lettuce to eat for
2 weeks experienced at least a 50% improvement in symptoms. Nevertheless, about a quarter of
the children pulled out because they could not stick with the diet or they became ill.
Feingold Diet. The most well-known diet for ADHD is the Feingold diet, a salicylate- and
additive-free diet, which requires rigorous vigilance over a child's eating habits. This diet also
prohibits aspirin, which contains salicylates. Some parents report great success with this diet,
although it may be difficult to impose. One study that reported the diets efficacy suggested that it
might not provide enough nutritive value, although the diet provides a wide range of healthy
foods to select from. It is certainly wise, in any case, to avoid food with artificial colors and
flavors and to provide a healthy balance of fresh, natural foods.

Essential Fatty Acids. Omega-3 fatty acids, found in fatty fish and certain vegetable oils, are
important for normal brain function and may have some benefits for people with ADHD. It is not
clear if supplements of fatty acid compounds, such as docosahexaenoic acid (DHA) and
eicosapentaneoic acid (EPA), provide any advantages.
Zinc. Zinc is important for the metabolism of certain neurotransmitters that play a role in ADHD,
and deficiencies have been associated with some cases of ADHD. Long-term use of zinc,
however, can cause anemia and other side effects in people without deficiencies and it has no
effect on ADHD in these patients. In any case, testing for trace minerals, such as zinc, is not
standard procedure when evaluating children suspected to have ADHD.
Sugar. Although parents often blame sugar for causing children to become impulsive or
hyperactive, a number of studies strongly indicate that sugar plays no role in hyperactivity. One
study reported, in fact, that ADHD children had fewer problems after a high-carbohydrate
breakfast than after a high-protein one. Another reported that children actually moved more
slowly after a high-sugar meal, suggesting the carbohydrates may have a sedative effect. (Still,
it's probably always wise for any child to cut down on sugar.)
Feedback Approaches

Techniques that use biologic or auditory feedback are proving to be effective tools for increasing
children's attention -- a primary factor in low academic performance.
Neurofeedback. Neurofeedback is an approach that uses electronic devices to help the child
control their own brain wave activity. Electrodes are pasted to the child's head and pick up
signals from the brain. The child watches images, such as moving graphs, on a computer monitor
that reflect the child's brain wave activity. Children are then taught certain high-level mental
activities at the point when feedback information on the screen indicates that they are fully
concentrating. Children usually attend forty 50-minute sessions, usually twice a week. Small
studies have reported significant improvement in inattention, impulsivity, and response time.
Interactive Metronome and Musical Therapy. Interactive metronome uses feedback from sound
to improve attention, motor control, and certain academic skills. In this technique study, children
wear headphones and sensors on their hands and feet. They perform a number of exercises to a
rhythmic computer-beat. Training sessions are completed in 3 - 5 weeks. Some small studies
have reported improvement in attention, motor control, language processing, and behavior. (In
support of this, some parents report that learning a musical instrument helped their children
Other Alternative Remedies

Procedures and Non-Drug Therapies. A number of alternative approaches are used for children
and adults with mild ADHD symptoms. For example, daily massage therapy may help people

with ADHD feel happier, fidget less, be less hyperactive, and focus on tasks. Other alternative
approaches that may be helpful include relaxation training, meditation, and music therapy. Based
on existing evidence, these treatments may be helpful for symptom management but are not
proven to benefit the underlying disorder.
Natural Remedies. A number of parents resort to alternative remedies as an alternative to
psychostimulants and other drugs. Small trials have found some herbs and supplements -- such
as oral flower essence, ginkgo biloba, panax ginseng, melatonin, and pine bark extract
(Pycnogenol) --may possibly have benefits for ADHD. Based on existing evidence, however,
none can be recommended, particularly for children.
Herbs and Supplements

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval
to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and
therefore have the potential to produce side effects that may be harmful. There have been a
number of reported cases of serious and even lethal side effects from herbal products. Always
check with your doctor before using any herbal remedies or dietary supplements.
The following are special concerns for people taking natural remedies for attention-deficit

Melatonin. High doses of melatonin have been associated with an increased

risk for seizures in children with existing neurologic disorders.

Gingko. The risk for side effects from gingko appear to be low, but there is an
increased risk for bleeding and interaction with anti-clotting medications at
high doses.

Ginseng. There have been contaminated forms of imported ginseng. Ginseng

also has been associated with low blood sugar and a higher risk for bleeding.
In addition, a great number of ginseng products have been found to contain
little or no ginseng.
Resources -- National Institute of Mental Health -- Children and Adults with Attention-Deficit Disorder -- American Academy of Pediatrics -- Attention Deficit Disorder Association -- Association for Behavioral and Cognitive Therapies -- American Psychiatric Association -- Medication Guide for Treating ADHD -- American Academy of Child and Adolescent Psychiatry -- National Dissemination Center for Children with Disabilities -- National Center for Learning Disabilities -- Learning Disabilities Association of America


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2007 Jan 2.

Review Date: 12/27/2007

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Figure 3-2. Grading The Level of Evidence

for Efficacy of Psychotropic Drugs in

Click to enlarge

As its name implies, attentiondeficit/hyperactivity disorder (ADHD) is

characterized by two distinct sets of symptoms:
inattention and hyperactivity-impulsivity (see
Table 3-3). Although these problems usually
occur together, one may be present without the
other to qualify for a diagnosis (DSM-IV).
Inattention or attention deficit may not become
apparent until a child enters the challenging
environment of elementary school. Such children
then have difficulty paying attention to details and
are easily distracted by other events that are
occurring at the same time; they find it difficult
and unpleasant to finish their schoolwork; they
put off anything that requires a sustained mental
effort; they are prone to make careless mistakes,
and are disorganized, losing their school books
and assignments; they appear not to listen when
spoken to and often fail to follow through on
tasks (DSM-IV; Waslick & Greenhill, 1997).
The symptoms of hyperactivity may be apparent
in very young preschoolers and are nearly always
present before the age of 7 (Halperin et al., 1993;

Waslick & Greenhill, 1997). Such symptoms

include fidgeting, squirming around when seated,
and having to get up frequently to walk or run
around. Hyperactive children have difficulty
playing quietly, and they may talk excessively.
They often behave in an inappropriate and
uninhibited way, blurting out answers in class
before the teachers question has been completed,
not waiting their turn, and interrupting often or
intruding on others conversations or games
(Waslick & Greenhill, 1997).
Many of these symptoms occur from time to time
in normal children. However, in children with
ADHD they occur very frequently and in several
settings, at home and at school, or when visiting
with friends, and they interfere with the childs
functioning. Children suffering from ADHD may
perform poorly at school; they may be unpopular
with their peers, if other children perceive them as
being unusual or a nuisance; and their behavior
can present significant challenges for parents,
leading some to be overly harsh (DSM-IV).
Inattention tends to persist through childhood and
adolescence into adulthood, while the symptoms
of motor hyperactivity and impulsivity tend to
diminish with age. Many children with ADHD
develop learning difficulties that may not improve
with treatment (Mannuzza et al., 1993).
Hyperactive behavior is often associated with the
development of other disruptive disorders,
particularly conduct and oppositional-defiant
disorder (see Disruptive Disorders). The reason
for the relationship is not known. Some believe
that the impulsivity and heedlessness associated
with ADHD interfere with social learning or with
close social bonds with parents in a way that
predisposes to the development of behavior
disorders (Barkley, 1998).

Even though a great many children with this

disorder ultimately adjust (Mannuzza et al.,
1998), someespecially those with an associated
conduct or oppositional-defiant disorderare
more likely to drop out of school and fare more
poorly in their later careers than children without
ADHD. As they grow older, some teens who have
had severe ADHD since middle childhood
experience periods of anxiety or depression. This
seems to be especially common in children whose
predominant symptom is inattention (Morgan et
al., 1996). Excellent reviews of ADHD can be
found in DSM-IV and other sources5.
Table 3-3. DSM-IV criteria for AttentionDeficit/Hyperactivity Disorder
A. Either (1) or (2):
1. six (or more) of the
following symptoms of
inattention have
persisted for at least 6
months to a degree that is
maladaptive and
inconsistent with
developmental level:

1. often fails to give

close attention to
details or makes
careless mistakes in
schoolwork, work, or
other activities

2. often has difficulty

sustaining attention
in tasks or play

3. often does not seem

to listen when
spoken to directly

4. often does not

follow through on

instructions and
fails to finish
schoolwork, chores,
or duties in the
workplace (not due
to oppositional
behavior or failure
to understand

5. often has difficulty

organizing tasks and

6. often avoids,
dislikes, or is
reluctant to engage
in tasks that require
sustained mental
effort (such as
schoolwork or

7. often loses things

necessary for tasks
or activities (e.g.,
toys, school
pencils, books, or

8. is often easily
distracted by
extraneous stimuli

9. is often forgetful in
daily activities

b. six (or more) of the

following symptoms of
hyperactivityimpulsivity have persisted
for at least 6 months to a
degree that is maladaptive
and inconsistent with
developmental level:


often fidgets with

hands or feet or squirms in


2. often leaves seat in

classroom or in
other situations in
which remaining
seated is expected

3. often runs about or

climbs excessively
in situations in
which it is
inappropriate (in
adolescents or
adults, may be
limited to subjective
feelings of

4. often has difficulty

playing or engaging
in leisure activities

5. is often on the go
or often acts as if
driven by a motor

6. often talks

7. often blurts out

answers before
questions have
been completed

8. often has difficulty

awaiting turn

9. often interrupts or
intrudes on others
(e.g., butts into
conversations or

B. Some hyperactiveimpulsive or

symptoms that
cause impairment
were present before
age 7 years.

C. Some impairment from the

symptoms is present in two or
more settings (e.g., at school [or
work] and at home).

D. There must be clear evidence of

clinically significant impairment in
social, academic, or occupational

E. The symptoms do not occur

exclusively during the course of a
pervasive developmental disorder,
schizophrenia, or other psychotic
disorder and are not better
accounted for by another mental
disorder (e.g., mood disorder,
anxiety disorder, dissociative
disorder, or a personality

ADHD, which is the most commonly diagnosed
behavioral disorder of childhood, occurs in 3 to 5
percent of school-age children in a 6-month
period (Anderson et al., 1987; Bird et al., 1988;
Esser et al., 1990; Pelham et al., 1992; Shaffer et
al., 1996c; Wolraich et al., 1996). Pediatricians
report that approximately 4 percent of their
patients have ADHD (Wolraich et al., 1990), but
in practice the diagnosis is often made in children
who meet some, but not all, of the criteria
recommended in DSM-IV (Wolraich et al., 1990)
(see also Treatment later in this section). Boys are
four times more likely to have the illness than
girls are (Ross & Ross, 1982). The disorder is
found in all cultures, although prevalences differ;
differences are thought to stem more from
differences in diagnostic criteria than from

differences in presentation (DSM-IV).

The exact etiology of ADHD is unknown,
although neurotransmitter deficits, genetics, and
perinatal complications have been implicated. In
the early post-World War II years, a number of
pediatricians, neurologists, and child psychiatrists
noted that brain-damaged children were often
hyperactive (Strauss & Lehtinen, 1947;
Eisenberg, 1957; Laufer & Denhoff, 1957). These
observations led to the diagnostic concept
ofminimal brain damage (Wender, 1971), which
was thought to be characterized by hyperactivity,
inattention, learning difficulties, and a wide
variety of behavior problems. However, large
epidemiological studies (Rutter & Quinton, 1977)
of grossly brain-damaged children with cerebral
palsy, epilepsy, and so forth, did not find an
excess of hyperactivity, and more recent imaging
studies have found no evidence of gross brain
damage in children with ADHD (Swanson et al.,
1998). The past view that ADHD is a form of
minimal brain damage has therefore been
abandoned by experts. Many brain-damaged
children are, if anything, significantly
In the late 1970s, it was postulated that the core
problem in hyperkinetic children was one of
inattention (Douglas & Peters, 1979). This view
led, in 1980, to the adoption, in the official DSMIII (American Psychiatric Association, 1980)
nomenclature, of the new diagnostic label
attention-deficit disorder.
Because the symptoms of ADHD respond well to
treatment with stimulants, and because stimulants
increase the availability of the neurotransmitter
dopamine, thedopamine hypothesis has gained
a wide following. The dopamine hypothesis posits

that ADHD is due to inadequate availability of

dopamine in the central nervous system. The
neurotransmitter dopamine plays a key role in
initiating purposive movement, increasing
motivation and alertness, reducing appetite, and
inducing insomnia, effects that are often seen
when a child responds well to methylphenidate.
The dopamine hypothesis has thus driven much of
the recent research into the causes of ADHD.
The fact that ADHD runs in families suggests that
inheritance is an important risk factor. Between
10 and 35 percent of children with ADHD have a
first-degree relative with past or present ADHD.
Approximately one-half of parents who had
ADHD have a child with the disorder (Biederman
et al., 1995). Over the past decade, a large number
of twin studies have shown that, when ADHD is
present in one twin, it is significantly more likely
also to be present in an identical twin than in a
fraternal twin (Goodman & Stevenson, 1989).
These findings have led geneticists to estimate
that genes are important in a high proportion of
children with ADHD.
Research to pinpoint abnormal genes is honing in
on two genes: a dopamine-receptor (DRD) gene
on chromosome 11 and the dopamine-transporter
gene (DAT1) on chromosome 5 (Cook et al.,
1995; Smalley et al., 1998). Several studies have
found evidence that children with ADHD have
genetic variations in one of the dopamine-receptor
genes (DRD4), although the largest of these
studies suggests that the presence of such a
variation is associated with only a modest
increase in the risk of developing ADHD
(Smalley et al., 1998). Several other studies have
found evidence for abnormalities of the
dopamine-transporter gene (DAT1) in children
with very severe forms of ADHD (Cook et al.,

1995; Gill et al., 1997; Waldman et al., 1998).

Yet for most children with ADHD, the overall
effects of these gene abnormalities appear small,
suggesting that nongenetic factors also are
important. Although none of the many imaging
studies have found evidence of gross brain
damage, some investigators have suggested that
exposure to toxins, such as lead, or episodes of
oxygen deprivation for the fetus, as may occur
during some complications of pregnancy, may
adversely affect dopamine-rich areas of the brain.
These theories support observations that
hyperactivity and inattention are more common in
children whose mothers smoked during
pregnancy (Nichols & Chen, 1981), in children
who have been exposed to high quantities of lead
(Needleman et al., 1990), and in children who had
a lack of oxygen in the neonatal period (Whittaker
et al., 1997).
Some investigators have noted that the parents of
hyperactive children are often overintrusive and
overcontrolling (Carlson et al., 1995). It has
therefore been suggested that such parental
behavior is another possible risk factor for
ADHD. However, others have noted that, when
children are treated with methylphenidate, there is
a reduction in parental negativity and
intrusiveness. This suggests that the observed
overintrusive and overcontrolling behavior of the
parent is a response to the childs behavior rather
than the cause (Barkley et al., 1985).

The American Academy of Child and Adolescent

Psychiatry (AACAP) published practice
parameters (i.e., guidelines for clinical practice)
on the diagnosis and treatment of ADHD. The
AACAP parameters include an extensive
literature review, detailed descriptions of the

clinical presentation of the disorder, and

recommendations for treatment. The practice
parameters state thatthe cornerstones of
treatment are support and education of parents,
appropriate school placement, and pharmacology
(AACAP, 1991). These practice parameters
evolved out of research relating to two major
types of treatment: pharmacological treatment and
psychosocial treatment, particularly behavioral
modification, as well as multimodal treatment, the
combination of psychosocial and pharmacological
Pharmacological Treatment
Pharmacological treatment with psychostimulants
is the most widely studied treatment for ADHD.
Stimulant treatment has been used for childhood
behavioral disorders since the 1930s (Bradley,
1937). Psychostimulants are highly effective for
75 to 90 percent of children with ADHD. At least
four separate psychostimulant medications
consistently reduce the core features of ADHD in
literally hundreds of randomized controlled trials:
methylphenidate, dextroamphetamine, pemoline,
and a mixture of amphetamine salts (Spencer et
al., 1995; Greenhill, 1998a, 1998b; Greenhill et
al., 1998).
These medications are metabolized, leave the
body fairly quickly, and work for 1 to 4 hours.
Administration is timed to meet the childs school
schedule, to help the child pay attention and meet
his or her academic demands, and to mitigate side
effects. These medications have their greatest
effects on symptoms of hyperactivity, impulsivity,
and inattention and the associated features of
defiance, aggression, and oppositionality. They
also improve classroom performance and
behavior and promote increased interaction with
teachers, parents, and peers. Small effects were

found on learning and school achievement (see

reviews by Barkley, 1990; Pelham, 1993;
Swanson et al.,1993, 1995b; Greenhill et al.,
1998; Cantwell, 1996a; Spencer et al., 1996.)
However, psychostimulants do not appear to
achieve long-term changes in outcomes such as
peer relationships, social or academic skills, or
school achievement (Pelham et al., 1998).
Children who do not respond to one stimulant
may respond to another (Elia et al., 1991; Elia &
Rapoport, 1991). Children should be reevaluated
without the medication to see if stimulant
treatment is still indicated. Many families choose
to have their child take adrug holiday on
weekends and vacations to reduce overall
exposure, but the utility of this strategy has not
been demonstrated (AACAP, 1991).
Stimulants are usually started at a low dose and
adjusted weekly (AACAP, 1991). A recent study
demonstrated that the practice of dosing
methylphenidate on the basis of body weight fails
to predict the optimal dose of medication
(Rapport & Denney, 1997). One of the goals of
the recently completed NIMH Multimodal
Treatment Study of ADHD (described more fully
below) was to develop medication strategies to
guidebest dose, dose changes, management of
side effects, and integration with other treatments
(Greenhill et al., 1996).
Side Effects
Common stimulant side effects include insomnia,
decreased appetite, stomach aches, headaches,
and jitteriness. Some children may develop tics,
but a recent study suggests that they disappear
with continued treatment (Gadow et al., 1995).
Rebound activation (i.e., a sudden increase in
attention deficit and hyperactivity) has been noted

anecdotally after the childs last dose of

medication wears off (Johnston et al., 1988). Most
of the side effects are mild, recede over time, and
respond to dose changes. Children rarely
experience cognitive impairment, which, if it does
occur, can be resolved with reduction or cessation
of the drug (Cantwell, 1996). A few cases of
psychosis have been reported. Pemoline has been
associated with hepatotoxicity, so monitoring of
liver function is necessary. Two studies have
shown no long-term effects of stimulants on later
height or weight (Klein & Mannuzza, 1988;
Vincent et al., 1990). Nonetheless, regular
precautionary monitoring of weight and height for
children on stimulants is recommended.
Other Medications
For children with ADHD who do not respond to
stimulants (10 to 30 percent) or cannot tolerate
the side effects, there are other useful
medications. The antidepressant bupropion has
been found to be superior to placebo, although the
response is not as strong as that found with
stimulants (Cantwell, 1998). Bupropion can also
be used as an adjunct to augment stimulant
treatment. Well-controlled trials have shown
tricyclic antidepressants to be superior to placebo
but less effective than stimulants (Elia et al.,
1991; Elia & Rapoport, 1991). Reports of sudden
death of a few children in the early 1990s on the
tricyclic compound desipramine led to great
caution with the use of tricyclics in children
(Riddle et al., 1991).
Considerable controversy surrounds the use of
central alpha-adrenergic blocking drugs, such as
clonidine and guanfacine, to treat ADHD. There is
some evidence that clonidine is effective for
ADHD when it occurs with a tic disorder (Hunt,
1987; Hunt et al., 1990, 1995). Caution is
warranted in view of the four cases of sudden

death that have been reported in children taking

methylphenidate and clonidine together and of a
number of reports of nonfatal cardiac side effects
in children taking clonidine alone or in
combination (Swanson et al., 1995a).
Neuroleptics have been found to be occasionally
effective (Green, 1995), yet the risk of
movements disorders, such as tardive dyskinesia,
makes their use problematic. Lithium,
fenfluramine, or benzodiazapines have not been
found to be effective treatments for ADHD
(Cantwell, 1996a; Green, 1995), nor have SSRIs,
such as fluoxetine (Goldman et al., 1998).
Furthermore, more than 20 studies have shown
that dietary manipulation (e.g., the Feingold diet)
is not efficacious (Mattes & Gittelman, 1981), and
controlled studies failed to demonstrate that sugar
exacerbates the symptoms of children with
ADHD (Milich & Pelham, 1986).
Psychosocial Treatment
Important options for the management of ADHD
are psychosocial treatments, particularly in the
form of training in behavioral techniques for
parents and teachers. Behavioral techniques,
which are described more fully below, typically
employtime-out, point systems and contingent
attention (adults reinforcing appropriate behavior
by paying attention to it). Psychosocial treatments
are useful for the child who does not respond to
medication at all or for whom the therapeutic
benefits of the medication have worn off and for
the child who responds only partially to
medication or cannot tolerate medication. In
addition, some families express a strong
preference not to use medication. Even children
who are receiving medication may continue to
have residual ADHD symptoms or symptoms
from other disorders, such as oppositional defiant
disorder or depression, which make specialized

child management skills necessary and helpful

(see next section, Multimodal Treatments).
Furthermore, children with ADHD can present a
challenge that puts significant stress on the
family. Skills training for parents can help reduce
this stress on parents and siblings.
Behavioral Approaches
The main psychosocial treatments for ADHD are
behavioral training for parent and teacher, as well
as systematic programs of contingency
management (this behavioral technique is
described in more detail in the Treatment section
later in this chapter). Of these options, systematic
programs of intensive contingency management
conducted in specialized classrooms or summer
camps with the setting controlled by highly
trained individuals is the most effective
(Abramowitz et al., 1992; Carlson et al., 1992;
Pelham & Hoza, 1996). The efficacy of
behavioral training of teachers is well-established,
while the evidence for parent training is less solid,
according to the criteria, noted earlier,
promulgated by the American Psychological
Association Task Force (Pelham et al., 1998).
There is, however, indirect support for the
effectiveness of parent training in the literature,
demonstrating the efficacy of parent training for
children with oppositional defiant disorder who
share many characteristics with children who
have ADHD (see section on Disruptive
A number of studies have compared parent
training (Gittelman et al., 1980; Firestone et al.,
1986; Horn et al., 1987, 1990, 1991; Pelham et
al., 1988) or school-based behavioral
modification (Gittelman et al., 1980; Pelham et
al., 1988) with the use of stimulants. Most of the
studies are of outpatient behavioral therapy
programs in which parents meet in groups and are

taught behavioral techniques such as time out,

point systems, and contingent attention. Teachers
are taught similar classroom strategies, as well as
the use of a daily report card for parents that
evaluates the childs in-school behavior. The
improvements in the symptoms of ADHD
achieved with psychosocial treatments are not as
large as those found with psychostimulants
(Pelham et al., 1998). Behavioral interventions
tend to improve targeted behaviors or skills but
are not as helpful in reducing the core symptoms
of inattention, hyperactivity, or impulsivity.
Questions remain about the effectiveness of these
treatments in other settings. To be fully effective,
treatments for ADHD need to be conducted across
settings (school, home, community) and by
different people (e.g., parents, teachers,
therapists)a consistency and
comprehensiveness that can be hard to achieve.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT), primarily
training in problem solving and social skills, has
not been shown to provide clinically important
changes in behavior and academic performance of
children with ADHD (Pelham et al., 1998).
However, CBT might be helpful in treating
symptoms of accompanying disorders such as
oppositional defiant disorder, depression, or
anxiety disorders (Abikoff, 1985; Hinshaw &
Ehardt, 1991; Lochman, 1992).
Although there are no studies evaluating the
efficacy of psychoeducation as a treatment
modality for ADHD, providing information to
parents, children, and teachers about ADHD and
treatment options is considered critical in the
development of a comprehensive treatment plan
(AACAP, 1991). Educational accommodations for
children with ADHD are federally mandated, and

mental health providers are required to ensure that

patients and families have access to adequate and
appropriate educational resources. Organizations
such as Children and Adults with Attention
Deficit Disorder (CHADD) and the National
Attention Deficit Disorder Association can be
helpful sources of information and support for
Multimodal Treatments
Many researchers and families have long
suspected that multimodal treatmentmedication
used together with multiple psychosocial
interventions in multiple settingsshould be
more effective than medication alone. Multimodal
treatment has thus been used in the absence of
empirical support (Hechtman, 1993). To
determine whether multimodal treatment is indeed
effective, the recent NIMH Multimodal Treatment
Study of ADHD (called the MTA Study)
examined three experimental conditions:
medication management alone, behavioral
treatment alone, or a combination of medication
and behavioral treatments. The study compared
the effectiveness of these three treatment modes
with each other and with standard care provided
in the community (the control group). The
behavioral treatment condition consisted of parent
training, a school intervention, and a summer
treatment program. The MTA Study was also
designed to determine the relative benefits of
these treatments over time (Richters et al., 1995).
All subjects were treated for 14 months and then
followed for an additional 22 months.
Results of the MTA Study comparing the 14month outcomes of 579 children randomly
assigned to one of the four treatment conditions
were presented in the fall of 1998 (MTA
Cooperative Group, 1998). At 14 months,
medication and the combination treatment were

generally more effective than the behavioral

treatment alone or the control treatment. Notably,
the combined treatment resulted in significant
improvement over the control condition in six
outcome areassocial skills, parent child
relations, internalizing (e.g., anxiety) symptoms,
reading achievement, oppositional and/or
aggressive symptoms, and parent and/or
consumer satisfactionwhereas the single forms
of treatment (medication or behavior therapy)
were each superior to the control condition in
only one to two of these domains. The
conclusions from this major study are that
carefully managed and monitored stimulant
medication, alone or combined with behavioral
treatment, is effective for ADHD over a period of
14 months. Addition of behavioral treatment
yields no additional benefits for core ADHD
symptoms but appears to provide some additional
benefits for non-ADHD-symptom outcomes.
Treatment Controversies
Overprescription of Stimulants
Concerns have been raised that children,
particularly active boys, are being overdiagnosed
with ADHD and thus are receiving
psychostimulants unnecessarily. However, recent
reports found little evidence of overdiagnosis of
ADHD or overprescription of stimulant
medications (Goldman et al., 1998; Jensen et al.,
1999). Indeed, fewer children (2 to 3 percent of
school-aged children) are being treated for ADHD
than suffer from it. Treatment rates are much
lower for selected groups such as girls, minorities,
and children receiving care though public service
systems (Bussing et al., 1998a, 1998b). However,
there have been major increases in the number of
stimulant prescriptions since 1989 (Hoagwood et
al., 1998), and methylphenidate is being
manufactured at 2.5 times the rate of a decade ago

(Goldman et al., 1998). Most researchers believe

that much of the increased use of stimulants
reflects better diagnosis and more effective
treatment of a prevalent disorder. Medical and
public awareness of the problem of ADHD has
grown considerably, leading to longer treatment,
fewer interruptions in treatment, and increased
treatment of adults. Adolescents and younger girls
with ADHD, who were underdiagnosed in the
past, are being identified and treated.
Nonetheless, some of the increase in use may
reflect inappropriate diagnosis and treatment. In
one study, the rate of stimulant treatment was
twice the rate of parent-reported ADHD, based on
a standardized psychiatric interview (Angold &
Costello, 1998). While many children who do
meet the full criteria for ADHD are not being
treated, the majority of children and adolescents
who are receiving stimulants did not fully meet
the criteria. These findings may reflect a failure of
proper, comprehensive evaluation and diagnosis
rather than a failure of the diagnostic criteria,
which are clear and validated by research (Angold
& Costello, 1998). A diagnosis of ADHD requires
the presence of impairing ADHD symptoms in
multiple settings for at least 6 months. Although
fidgeting and not paying attention are normal,
common childhood behaviors, DSM-IV criteria
reserve a diagnosis of ADHD for children in
whom such frequent behavior produces persistent
and pervasive dysfunction. An adequate
diagnostic evaluation requires histories to be
taken from multiple sources (parents, child,
teachers), a medical evaluation of general and
neurological health, a full cognitive assessment
including school history, use of parent and teacher
rating scales, and all necessary adjunct evaluation
(such as assessment of speech, language). These
evaluations take time and require multiple clinical
skills. Regrettably, there is a dearth of

appropriately trained professionals.

Family practitioners are more likely than either
pediatricians or psychiatrists to prescribe
stimulants and less likely to use diagnostic
services, provide mental health counseling, or
provide followup care (Hoagwood et al., 1998).
The American Academy of Pediatrics published a
policy statement in 1996 on the use of medication
for children with attentional disorders, concluding
that use of medication should not be considered
the complete treatment program for children with
ADHD and should be prescribed only after a
careful evaluation (American Academy of
Pediatrics Committee on Children With
Disabilities and Committee on Drugs, 1996).
Safety of Long-Term Stimulant Use
Even though the MTA Study found no safety
issues over a 14-month period (Greenhill et al.,
1998), concerns have been raised about the longer
term safety of stimulant treatment. Since ADHD
has an early onset and requires an extended
course of treatment, research is needed to
examine the long-term safety of treatment and to
investigate whether other forms of treatment
could be combined with psychostimulants to
lower their dose as well as to reduce other
problem behaviors found with ADHD. Such
combined treatments could be targeted for
symptoms of disorders that often accompany
ADHD, such as conduct disorder, substance
abuse, and learning disabilities, and could be
targeted to improve overall functioning (Laufer,
1971; Gittelman et al., 1985).
Because stimulants are also drugs of abuse and
because children with ADHD are at increased risk
for a substance abuse disorder, concerns have also
been raised about the potential for abuse of
stimulants by children taking the medication or

diversion of the drug to others. While stimulants

clearly have abuse potential, the rate of lifetime
nonmedical methylphenidate use has not
significantly increased since methylphenidate was
introduced as a treatment for ADHD, suggesting
that abuse is not a major problem (Goldman et al.,
1998). Case reports describing abuse by children
prescribed stimulants for ADHD are rare
(Hechtman, 1985).

Taylor, 1994; Cantwell, 1996; Waslick &

Greenhill, 1997; Barkley, 1998; and NIH
Consensus Statement 110, 1998.

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Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
A non-profit organization serving individuals with AD/HD through advocacy, research,
education, and support.
AD/HD research studies identified through the U.S. National Library of Medicine's link to
federally and privately funded studies worldwide.

National Institute of Mental Health

Information from the NIH institute on AD/HD.

Attention deficit hyperactivity disorder


Attention deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by

inattention, hyperactivity, and impulsivity. It is the most commonly diagnosed behavioral
disorder of childhood, affecting between 3 - 5% of school-aged children. Although many people
sometimes have difficulty sitting still, paying attention, or controlling impulsive behavior, people
with ADHD find that these symptoms greatly interfere with everyday life. Generally, these
symptoms appear before age 7 and can lead to problems in school and in social settings. One- to
two-thirds of all children with ADHD continue to have symptoms when they grow up. A
diagnosis can be controversial, since there are no lab tests for ADHD and no objective way to
measure a child's behavior. Some experts also disagree about the best way to treat ADHD, but
taking action early can improve a child's educational and social development.
Signs and Symptoms:

A person is considered to have ADHD if they have at least 6 symptoms from the following
categories, lasting for at least 2 months. In diagnosing children, the symptoms must appear
before age 7 and pose a significant challenge to everyday functioning in at least two areas of life
(usually home and school). Most children do not show all the symptoms, and they may be
different in boys and girls (boys may be more hyperactive and girls more inattentive).

Fails to pay close attention to details or makes careless mistakes

Has difficulty sustaining attention in tasks or play activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish tasks

Has difficulty organizing tasks and activities

Avoids, dislikes, or is reluctant to engage in tasks that require sustained

mental effort (such as school work, homework)

Loses things needed for tasks or activities

Is easily distracted

Is forgetful in daily activities

Hyperactivity and Impulsivity

Fidgets with hands or feet or squirms in seat

Does not remain seated when expected to

Runs or climbs excessively in inappropriate situations (in teens or adults, may

be feelings of restlessness)

Has difficulty playing or engaging in leisure activities quietly

Acts as if "driven by a motor"

Talks excessively

Blurts out answers before questions are completed

Has difficulty waiting his or her turn

Interrupts or intrudes on others

What Causes It?:

No one is sure what causes ADHD. Although environment may play a role, researchers are now
looking to find answers in the structure of the brain.

Altered brain function -- Brain scans have shown differences in the brains of
ADHD children compared to those of non-ADHD children. For example, many
children with ADHD tend to have altered brain activity in the prefrontal
cortex, a part of the brain thought to be the command center. This may affect
their ability to control impulsive and hyperactive behaviors. Researchers also
believe hyperactive behavior in children can be caused by too much slowwave (or theta) activity in certain regions of the brain.

Genetics -- ADHD seems to run in families.

Maternal or childhood exposure to certain toxins -- Women who smoke, drink,

and are exposed to PCBs during pregnancy are more likely to have children
with ADHD. Children who are exposed to lead or PCBs are more likely to
develop the disorder.

Risk Factors:

Risk factors for ADHD include:

Heredity -- children with ADHD usually have at least one first-degree relative
who also has the disorder.

Gender -- ADHD is four to nine times more common in boys than in girls.
Some experts believe that the disorder is underdiagnosed in girls, however.

Prenatal and early postnatal health -- maternal drug, alcohol, and cigarette
use; exposure of the fetus or infant to toxins, including lead and PCBs;
nutritional deficiencies and imbalances.

Other behavioral disorders, especially those that involve too much aggression
(such as oppositional defiant or conduct disorder).

What to Expect at Your Provider's Office:

Because there is no objective test for ADHD, making a diagnosis can be hard. A number of tests
and observations may be used. For this reason, it is crucial to make sure the doctor who evaluates
you or your child has training in diagnosing ADHD.
To evaluate a child, the doctor will take a complete medical history and do a thorough exam to
check for conditions that may mimic ADHD, such as hyperthyroidism or problems with vision,
hearing, and sleeping. Because many symptoms show up at home or school rather than the
doctor's office, you may be asked to fill out questionnaires. Your child's teacher may be
interviewed. Your doctor will try to determine not only how the child behaves but also where the
behavior occurs and how long it lasts. Children with ADHD have long-lasting symptoms that
usually show up during stressful situations or situations that require sustained attention (such as
Diagnosing an adult with ADHD can be even more challenging. Because your symptoms would
have appeared when you were young, your doctor may try to find out as much as possible about
you when you were a child by getting information from your parents or former teachers. (If your
symptoms are recent, you are not considered to have adult ADHD.) In addition to ruling out the
other conditions mentioned above, your doctor may also check for depression and bipolar
disorder, which can mimic ADHD.
Preventive Care:

Because the cause or causes of ADHD are not known, there is no way to prevent the condition. It
can be managed with medication, behavioral therapy, and lifestyle changes.
Treatment Options:

How to treat ADHD, particularly in children, is a controversial subject. Current treatment

includes therapy or medication, or a combination of both. In fact, studies show that medication
by itself, without some kind of therapy, is not likely to improve a child's outcome in the longterm. Family therapy, behavioral therapy, social skills training, and parent skills training are often
used. Many parents investigate nutritional therapies (such as elimination diets or high-dose
vitamins), but so far there is no clear evidence that they are effective. Preliminary evidence
indicates that homeopathy and mind-body techniques, especially biofeedback, may help improve
behavior in children with ADHD.

Parent skills training offered by skilled clinicians provides parents with tools and techniques for
managing their child's behavior. Behavior therapy rewards appropriate behavior and discourages
destructive behavior. It can be performed by parents and teachers working together with
therapists and doctors. For example, older children with ADHD may be rewarded with points or
tokens, or even written behavioral contracts with their parents. Creating charts with stars for
good behavior may work for younger children. On the other hand, timeouts may discourage
undesirable behavior. Other techniques include:

Setting rules that are easily understood, developmentally appropriate, and

not unduly harsh

Avoiding repeated commands once the child has been reminded of the

Disciplining the child before becoming too angry and frustrated

Following discipline with praise when the child follows the rules and behaves

In addition to behavioral intervention at home, changes in the classroom environment (or work,
in the case of adolescents or adults) are significant parts of the treatment plan. Hyperactive
children do best in highly structured circumstances with a teacher experienced in handling their
disruptive behavior and capable of adapting to their distinctive cognitive style. Interactions with
groups are often very challenging for a child with ADHD. Social skills training, appropriate
classroom placement, and clear rules of engagement with peers are essential.
Adults with ADHD may benefit from behavioral therapies, including cognitive remediation,
couple therapy, and family therapy.
Drug Therapies

Stimulant medications are the most widely researched and commonly prescribed treatments for
ADHD. Although researchers do not fully understand how these drugs improve ADHD
symptoms, studies indicate they boost the amount of dopamine and serotonin in the brain.
Dopamine is a chemical that is associated with activity; and serotonin is a chemical associated
with mood and well-being. Medications prescribed for ADHD include:

Stimulants -- most often prescribed for ADHD.


Methylphenidate (Ritalin, Concerta) -- a stimulant and most commonly

used medication for ADHD; effective in 75 - 80% of people with the
condition; not recommended for children under 6 years of age

Dextroamphetamine (Dexadrine) -- a stimulant that is effective in 70 75% of people with ADHD; not recommended for children under 3
years of age

Amphetamine/Dextroamphetamine (Adderall)

Lisdexamfetamine dimesylate (Vyvanse)

Atomoxetine (Strattera) -- the first nonstimulant medication approved to treat

ADHD. Strattera increases the levels of both dopamine and norepinephrine in
the brain. Strattera was first developed as an antidepressant and, as with all
antidepressants, carries a "black box" warning that it may increase thoughts
of suicide in young children and teenagers.

The most common side effects from these medications are trouble sleeping, decrease in appetite,
and nervousness.
Complementary and Alternative Therapies

According to a recent survey, many parents use complementary and alternative treatments for
their children with ADHD, with nutritional therapies being the most common. Although studies
show conflicting results, if your child appears sensitive to certain foods, talk to your doctor about
eliminating them for a brief period to see if his symptoms improve. Putting a child on any diet
should be done only under the supervision of your doctor.
The Feingold diet was developed in the 1970s by Benjamin Feingold. He believed that artificial
colors, flavors, and preservatives, as well as naturally occurring salicylates (chemicals similar to
aspirin that are found in many fruits and vegetables), were a major cause of hyperactive behavior
and learning disabilities in children. Studies examining the diet's effect have been mixed. Most
show no benefit, although there is some evidence that salicylates may play a role in hyperactivity
in a small number of children. Because the Feingold diet is difficult to follow and also involves
changes in family lifestyle (children are encouraged to participate in creating meals, for
example), you should talk with your doctor before trying it.
Other dietary therapies may concentrate on eating foods that are high in protein and complex
carbohydrates, and eliminating sugar and artificial sweeteners from the diet. However, studies
show no relation between sugar and ADHD. In one study, children whose diets were high in
sugar or artificial sweeteners behaved no differently than children whose diets were free of these
substances. This was true even among children whose parents described them as having a
sensitivity to sugar.

Some doctors who focus on nutrition say they see positive results when testing for food allergies
and using an elimination diet. If you think your child might benefit from food allergy testing or
an elimination diet, talk to a doctor who has experience in nutrition for children with ADHD.
Vitamins and Minerals

Magnesium (200 mg per day) -- Symptoms of magnesium deficiency include

irritability, decreased attention span, and mental confusion. Some experts
believe that children with ADHD may be showing the effects of mild
magnesium deficiency. In one preliminary study of 75 magnesium-deficient
children with ADHD, those who received magnesium supplements showed an
improvement in behavior compared to those who did not receive the

Vitamin B6 -- Adequate levels of vitamin B6 are needed for the body to make
and use brain chemicals, including serotonin, dopamine, and norepinephrine,
the chemicals affected in children with ADHD. One preliminary study found
that B6 pyridoxine was slightly more effective than Ritalin in improving
behavior among hyperactive children. However, the study used a high dose
of B6, which could cause nerve damage (although none occurred in the
study). Other studies have shown that B6 has no effect on behavior. Because
high doses can be dangerous, do not give your child B6 without your doctor's

Zinc (35 mg per day) -- Zinc regulates the activity of brain chemicals, fatty
acids, and melatonin, all of which are related behavior. Several studies have
found that zinc may help improve behavior, but only slightly. Higher doses of
zinc can be dangerous, so talk to your doctor before giving zinc to a child or
taking it yourself.

Essential fatty acids -- Fatty acids, such as those found in fish and fish oil
(omega-3 fatty acids) and evening primrose oil (omega-6 fatty acids), are
"good fats" that play a key role in normal brain function. Experts have
suggested them as a treatment for ADHD. The results of studies are mixed,
but research continues. Omega-3 fatty acids are also good for heart health in
adults, but high doses may increase the risk of bleeding. If you want to try
fish oil to see if it reduces ADHD symptoms in you or your child, talk to your
doctor about the best dose.

L-carnitine -- L-carnitine is formed from an amino acid and helps cells in the
body produce energy. One study found that 54% of a group of boys with
ADHD showed improvement in behavior when taking L-carnitine, but more
research is needed to confirm any benefit. Because L-carnitine has not been
studied for safety in children, talk to your doctor before giving a child Lcarnitine.


Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy,
you should work with your health care provider to get your problem diagnosed before starting
any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites
(glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make
teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and
10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in
combination as noted.
Several herbal remedies for ADHD are sold in the United States and Europe. But few scientific
studies have been done to see whether these herbs improve symptoms of ADHD. One or more of
the following calming herbs may be recommended for people with ADHD:

Roman chamomile (Chamaemelum nobile)

Valerian (Valerian officinalis)

Lemon balm (Melissa officinalis)

Passionflower (Passiflora incarnata)

Other herbs commonly contained in botanical remedies for ADHD include:

Gingko (Gingko biloba) -- used to improve memory and mental sharpness.

American ginseng (Panax quinquefolium ) and gingko -- One study suggests

that gingko in combination with ginseng may improve symptoms of ADHD.

Relaxation techniques and massage can reduce anxiety and activity levels in children and teens.
In one study, teenage boys with ADHD who received 15 minutes of massage for 10 consecutive
school days showed significant improvement in behavior and concentration compared to those
who were guided in progressive muscle relaxation for the same duration of time.
Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your
physical, emotional, and psychological makeup. An experienced homeopath assesses all of these
factors when determining the most appropriate treatment for each individual.
In a study of 43 children with ADHD, those who received an individualized homeopathic remedy
showed a significant improvement in behavior compared to children who received placebo. The
homeopathic remedies found to be most effective included:

Stramonium -- for children who are fearful, especially at night

Cina -- for children who are irritable and dislike being touched; whose
behavior is physical and aggressive

Hyoscyamus niger -- for children who have poor impulse control, talk
excessively or act overly exuberant

Mind-body techniques such as hypnotherapy, progressive relaxation, and biofeedback may be
useful in treating children and teens. Through these techniques, children are often able to learn
coping skills they can use for the rest of their lives. These treatments allow children to gain a
sense of control and mastery, increase self-esteem, and decrease stress.
Biofeedback operates on the principle that children can be trained to modify brain activity
associated with ADHD and increase brain activity associated with attention. Several studies have
shown positive results.
Other Considerations:
Prognosis and Complications

As many as half of all children with ADHD who receive appropriate treatment learn to control
symptoms and function well as adults. Research suggests that children who receive treatment
that combines therapies such as medication, behavioral therapy, and biofeedback are less likely
to have behavioral problems as they grow up. In most cases, ADHD can be effectively managed
throughout life.
Alternative Names:


Reviewed last on: 12/7/2008

Steven D. Ehrlich, NMD, private practice specializing in complementary and

alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare

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