Squirming, fidgeting, impulsive behavior, interrupting, talking excessively, trouble focusing – most children exhibit some of these behaviors on occasion.
But some children display these behaviors to the point that their ability to function at school, home, and in social relationships with other children is impaired. Their difficulty controlling impulsive and disruptive behavior can cause trouble in the classroom, and their inability to focus can seriously affect their academic performance. In those children, a condition called attention deficit hyperactivity disorder (ADHD) may be the culprit.
What is ADHD?
ADHD is one of the most common neurodevelopmental disorders of childhood. It is characterized by behaviors including inattentiveness, impulsivity, restlessness, and hyperactivity. The symptoms differ from person to person. ADHD was formerly called ADD, or attention deficit disorder.
Both children and adults can have ADHD, but the symptoms always begin in childhood. Adults with ADHD may have trouble managing time, being organized, setting goals, and holding down a job.
World-renowned ADHD expert Dr. Ned Hallowell explains the condition:
Having ADHD is like having a powerful race car for a brain, but with bicycle brakes. Treating ADHD is like strengthening your brakes–so you start to win races in your life.
In my opinion, ADHD is a terrible term. As I see it, ADHD is neither a disorder, nor is there a deficit of attention. I see ADHD as a trait, not a disability. When it is managed properly, it can become a huge asset in one’s life.
There are three different types of ADHD, according to the CDC:
- Predominantly Inattentive Presentation: It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.
- Predominantly Hyperactive-Impulsive Presentation: The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.
- Combined Presentation: Symptoms of the above two types are equally present in the person.
Because symptoms can change over time, the presentation may change over time as well.
Symptoms in Children
In children, symptoms of ADHD are grouped into three categories.
- Is easily distracted
- Doesn’t follow directions or finish tasks
- Doesn’t appear to be listening
- Doesn’t pay attention and makes careless mistakes
- Forgets about daily activities
- Has problems organizing daily tasks
- Doesn’t like to do things that require sitting still
- Often loses things
- Tends to daydream
- Often squirms, fidgets, or bounces when sitting
- Doesn’t stay seated
- Has trouble playing quietly
- Is always moving, such as running or climbing on things (In teens and adults, this is more commonly described as restlessness.)
- Talks excessively
- Is always “on the go” as if “driven by a motor”
- Has trouble waiting for his or her turn
- Blurts out answers
- Interrupts others
Some believe that these symptoms are natural for all children. To an extent they are correct with one major exception; Children with ADHD don’t show these symptoms occasionally – it is a part of their everyday life.
Symptoms in Adults
Although ADHD is usually thought of as a children’s disorder, many adults have it too. While adults are usually able to handle ADHD better than children, ADHD can still have a large impact on an adult’s life.
Symptoms of ADHD in adults may change as a person gets older, and include the following:
- Chronic lateness and forgetfulness
- Low self-esteem
- Problems at work
- Difficulty getting organized
- Procrastination and trouble getting started
- Trouble with follow through
- Easily distracted; trouble focusing attention, tendency to tune out during conversation or when reading, inability to focus at times
- Often creative, intuitive, highly intelligent
- Trouble in going through established channels and following “proper” procedure
- Easily frustrated
- Chronic boredom
- Mood swings
- Trouble controlling anger
- Relationship problems
- Substance abuse or addiction
Causes of ADHD
The cause of ADHD is unknown, but researchers say several things may lead to it, including:
- Heredity. ADHD tends to run in families.
- Chemical imbalance. Brain chemicals in people with ADHD may be out of balance.
- Brain changes. Areas of the brain that control attention are less active in children with ADHD.
- Health during pregnancy. Poor nutrition, infections, smoking, drinking, and substance abuse during pregnancy can affect a baby’s brain development.
- Toxins, such as lead. They may affect a child’s brain development.
- A brain injury or a brain disorder. Damage to the front of the brain, called the frontal lobe, can cause problems with controlling impulses and emotions.
ADHD can’t be prevented or cured, but it can be managed with treatment and planning.
How is ADHD diagnosed?
Deciding if a person has ADHD is a several-step process. There is no single test to diagnose ADHD, and many other issues, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms.
The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM-5), is used by mental health professionals to assist in the diagnosis of ADHD. This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD. Using the same standard across communities will help determine how many people have ADHD, and how public health is impacted by this condition.
The diagnostic criteria for ADHD is complex and can be viewed here: DSM-5 Criteria for ADHD
ADHD Treatment Options
Treatment options for ADHD include the following:
- Behavioral therapy
- Lifestyle changes
- Parent education and support
- Alternative treatments
In most cases, the standard protocol for ADHD treatment is a combination of behavior therapy and medication (if desired). For preschool-aged children (4–5 years of age) with ADHD, the American Psychological Association recommends behavior therapy as the first line of treatment. Some experts say that children of any age should try behavioral therapy before medication. William Pelham, Ph.D., director of the Center for Children and Families at the State University of New York, told ADDitude, “There’s clear evidence that a behavioral approach will work for the majority of children with ADHD. The benefit of using behavior therapy first is that, if a child also needs medication, he can often get by with a smaller dose.”
Behavioral therapy teaches the child or adult with ADHD techniques to change their behavior. In adults, behavioral therapy might teach behaviors that will make living with ADHD easier, such as how to set a routine, the importance of scheduling, breaking down large projects into smaller tasks, and effective use of time.
According to the American Academy of Pediatrics, behavior therapy for children with ADHD has three basic principles:
- Set specific doable goals. Set clear and reasonable goals for your child, such as staying focused on homework for a certain amount of time or sharing toys with friends.
- Provide rewards and consequences. Give your child a specified reward (positive reinforcement) every time she shows the desired behavior. Give your child a consequence (unwanted result or punishment) consistently when she has inappropriate behaviors.
- Keep using the rewards and consequences. Using the rewards and consequences consistently for a long time will shape your child’s behavior in a positive way.
These tips from the CDC can help parents make life with ADHD a bit easier for them and their child:
- Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime.
- Get organized. Put schoolbags, clothing, and toys in the same place every day so your child will be less likely to lose them.
- Avoid distractions. Turn off the TV, radio, and computer, especially when your child is doing homework.
- Limit choices. Offer a choice between two things (this outfit, meal, toy, etc., or that one) so that your child isn’t overwhelmed and overstimulated.
- Change your interactions with your child. Instead of long-winded explanations and cajoling, use clear, brief directions to remind your child of responsibilities.
- Use goals and rewards. Use a chart to list goals and track positive behaviors, then reward your child’s efforts. Be sure the goals are realistic—baby steps are important!
- Discipline effectively. Instead of yelling or spanking, use timeouts or removal of privileges as consequences for inappropriate behavior.
- Help your child discover a talent. All kids need to experience success to feel good about themselves. Finding out what your child does well — whether it’s sports, art, or music — can boost social skills and self-esteem.
Parent Education and Support
If your child has ADHD, you’re an integral part of their support system. Counselors, training classes, and support groups are available to help you cope with the effects of your child’s ADHD and teach you how to help them learn to deal with their behaviors and thoughts.
Parents, teachers, and counselors also work together to create a school environment that helps the child with their educational experience. It is often ideal for the child to have a specific plan for learning, and certain adjustments to their schedule (i.e. more time to take tests, less distractions in their environment, and a plan for behavioral disruptions) might be made to make learning easier. Adults can also make similar changes to their environment that will help them complete necessary tasks more effectively.
The most common class of medications used to treat ADHD are stimulants. Methylphenidate (available as Ritalin and Concerta) and amphetamine (available as Dexedrine and Adderall) are used to help both children and adults with ADHD control their behavior and have better mental focus. These stimulants, rather than “speeding up” the individual with ADHD, have the opposite effect.
In some cases, side effects include stomachaches, sleep difficulty, decreased appetite, weight loss, and headaches. If you or your child decide to take stimulants to treat an attention deficit disorder, it’s important to monitor the effects of the medication.
In rare cases, stimulants can have more serious side effects. For instance, some are linked to a higher risk of heart problems and sudden death in children with preexisting heart disease. They may also worsen psychiatric conditions like depression or anxiety or cause a psychotic reaction in some individuals. Before your child starts taking an ADHD medicine, talk to your doctor about the risks and benefits.
Atomoxetine ( Strattera ) and clonidine ( Catapres and Kapvay) are two non-stimulant drugs used for ADHD. Another drug, approved for children aged 6 to 17, is guanfacine (Intuniv), which uses the same active ingredient as guanfacine hydrochloride (Tenex), a blood pressure medicine that has been used as an ADHD treatment. These drugs also have side effects and risks, and your doctor should watch for problems. In 2005, the FDA issued a public health advisory about rare reports of suicidal thinking in children and adolescents taking Strattera.
The evidence so far only supports the effectiveness of short-term use of medications for ADHD, and the long-term effects on the developing brain are not yet known.
Vitamins, Minerals, and Nutrition
- Omega-3 fatty acids: Besides being good for heart health, studies have shown that omega-3 fatty acids improve symptoms of ADHD. A comprehensive review of many studies showed that omega-3s are about 40 percent as effective as stimulants in relieving symptoms. Omega-3s are found in fish such as salmon, walnuts, flaxseeds, leafy greens, and in other foods. Ask your healthcare provider for dosage recommendations.
- Zinc: Some studies have shown that children with ADHD may have lower levels of zinc. Taking zinc supplements may reduce hyperactivity and impulsivity, but has not been shown to improve attentiveness. High levels of zinc may be dangerous, so ask your doctor before taking a supplement.
- Iron: Some experts believe that iron deficiencies may contribute to ADHD symptoms in children. A 2008 study showed that children who were not anemic but had low ferritin levels, a protein needed to store iron in the blood, showed improvement of symptoms after 12 weeks of iron supplements. But before taking an iron supplement, ask your doctor, because high iron levels can be dangerous.
- Magnesium: Healthy levels of magnesium can help relax children with ADHD. Some small studies have shown that magnesium supplements can reduce some symptoms of ADHD. Magnesium helps with sleep and relaxation, which are often big challenges for children and adults with ADHD.
- Vitamin C: This vitamin is important in modulating the neurotransmitter dopamine at the synapses in the brain. (ADHD stimulants are effective because they increase dopamine levels in the brain.) Vitamin C is found in citrus fruits, peppers, strawberries, pineapple, kiwi, and broccoli, and is also available in supplement form.
One caution: Don’t take vitamin C less than an hour before or after taking ADHD medication because it prevents the drug from being absorbed.
- Protein: Studies have shown that a high-protein diet can can prevent surges in blood sugar, which increase hyperactivity. Eating protein for breakfast will help the body produce brain-awakening neurotransmitters. It may help improve concentration and possibly make ADHD medications work longer. Beans, cheese, eggs, meat, poultry, and nuts are good sources of protein.
- B vitamins: Studies suggest that giving children who have low levels of B vitamins in a supplement improved IQ scores (by 16 points) and reduced aggression and antisocial behavior. Vitamin B-6 seems to increase the brain’s levels of dopamine, which improves alertness.
Some experts say that artificial colors, flavors, and preservatives might lead to hyperactivity, and the American Academy of Pediatrics says that eliminating preservatives and food colorings from the diet is a reasonable option for children with ADHD. Some experts recommend that people with ADHD avoid artificial colors (especially red and yellow) and food additives (such as aspartame, MSG, and nitrites). Several studies have linked hyperactivity to the preservative sodium benzoate.
A 1993 Cornell University study found that eliminating dairy products, wheat, corn, yeast, soy, citrus, eggs, chocolate, peanuts, artificial colors, and preservatives seemed to decrease ADHD symptoms.
For more on elimination diets, please see How to Test Food Sensitivities With an Elimination Diet and The Feingold Diet.
Some studies have shown that after about 30 minutes of exercise, kids with ADHD can focus and organize their thoughts better. During exercise, the brain releases several important chemicals, including endorphins, which are hormone-like compounds that regulate mood, pleasure, and pain. Physical activity also elevates the brain’s dopamine, norepinephrine, and serotonin levels. These brain chemicals affect focus and attention, which are often low in those with ADHD. Studies have also found that tae kwon do, ballet, and gymnastics, in which you have to pay close attention to body movements, tax the attention system. Exercise can also help adults with ADHD: it can ease stress and anxiety, improve impulse control, enhance working memory, improve executive function, and increase levels of brain-derived neurotrophic factor (a protein involved in learning and memory that is in short supply in people with ADHD).
ADHD is linked with a variety of sleep problems. For example, one study found that children with ADHD had higher rates of daytime sleepiness than children without ADHD. Another study found that 50% of children with ADHD had signs of sleep disordered breathing, compared to only 22% of children without ADHD. Research also suggests that restless legs syndrome and periodic leg movement syndrome are also common in children with ADHD. Sleep-deprived children may be moody, emotionally explosive, and/or aggressive. In a study involving 2,463 children aged 6-15, children with sleep problems were more likely to be inattentive, hyperactive, impulsive, and display oppositional behaviors. And, to make matters more challenging, medications commonly used to treat ADHD can reduce the quality and quantity of sleep, according to research. Lemon Balm, melatonin, and German chamomile are natural remedies that can help improve sleep, but check with your healthcare provider before using them.
There isn’t much research specifically connecting music with reducing ADHD symptoms, but scientists do know that when children play an instrument, they do much better on tests of executive function than children who don’t study music. Executive functioning is the ability of the brain to organize and easily switch between tasks. Even just listening to music can calm children down long enough to help them complete tasks: when you listen to music you like, your brain releases dopamine, a chemical that also helps with focus.
Neurofeedback is a safe, non-invasive, alternative option for the treatment of attention-deficit hyperactivity disorder (ADHD). In November 2012, the American Academy of Pediatrics approved biofeedback and neurofeedback as a Level 1 or “best support” treatment option for children suffering from ADHD.
Here’s a description from PsychCentral:
Neurofeedback trains children to become more aware of their physiological responses and how to gain control of the brain’s frontal lobe, which is the executive functioning center. Electroencephalography (EEG) neurofeedback is a specific technique under biofeedback therapy, and it is the recording of electrical activity within the cells of the scalp. EEG neurofeedback focuses on the central nervous system and the brain’s activity in order to give moment-to-moment information.
Children with ADHD have higher rates of EEG abnormalities compared to children without ADHD, such as higher theta wave rhythms (drowsiness), lower sensorimotor rhythms (movement control), and lower beta waves (attention and memory processes). Neurofeedback provides audio and visual interpretations of these brain waves, and children learn how to maintain the appropriate levels for functioning.
Dr. Hallowell provides more information on complementary and alternative treatment options and programs for ADHD here.