ADHD in Children: Symptoms, Evaluations & Treatments

ADHD in Children

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders, affecting between 5 and 11 percent of American children. ADHD in children may present through symptoms including inattentiveness, impulsivity, hyperactivity, fidgeting, excessive talking, trouble waiting turn, and difficulty following direction.

What Are Common Symptoms?

Your child is a wiggle worm. She can’t sit still and fidgets constantly. Does this mean she has attention deficit hyperactivity disorder (ADHD or ADD)?

Your child forgets to hand in his homework and typically writes down only half his assignments. Are these working memory glitches typical symptoms of ADHD in children?

Your student disrupts the classroom by blurting out answers, veering off topic, or getting up from his seat daily. Should he be evaluated for ADHD symptoms?

Or are these just typical childhood and adolescent behaviors that your kid with outgrow with time?

Only a qualified medical professional can evaluate and diagnose symptoms of ADHD in children. However, it’s critical for parents and educators to know the warning signs because early detection, ADHD treatment, and school accommodations can make a world of difference for a child with ADHD.

ADHD Symptoms in Kids

Although symptoms may differ depending on the type of ADHD diagnosed, some common symptoms of ADHD in kids are:

• Self-focused behavior
• Trouble waiting turn
• Emotional turmoil
• Fidgeting
• Problems playing quietly
• Trouble finishing tasks
• Lack of focus
• Forgetfulness

[Self-Test: Could Your Child Have ADHD?]

ADHD in Children: Hyperactive Vs. Inattentive Symptoms

The stereotypical ADHD patient is a 9-year-old boy who loves to jump off dangerously high things and hates to focus on school work. In reality, only a fraction of people with ADHD fit this description. Children with hyperactive ADHD symptoms are difficult to ignore — they are the ones bouncing out of their chairs or clowning behind the teacher’s back, and are the first to be evaluated for and diagnosed with ADHD.

Meanwhile, the students with inattentive ADHD are quietly staring out the window at a bird while their work lays unfinished. According to the National Institute of Mental Health (NIMH), inattentive symptoms are far less likely to be recognized by parents, teachers, and medical professionals.¹ As a result, individuals with inattentive ADHD rarely get the treatment they need. This leads to academic frustration, apathy, and undue shame that can last a lifetime.

ADHD in Children: Symptoms, Testing, and Diagnosis

ADHD is a genetic, brain-based condition, not just a deficit of executive functions. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) lists nine symptoms that suggest ADHD Primarily Inattentive, and nine that suggest ADHD Primarily Hyperactive-Impulsive. A child may be diagnosed with ADHD only if he or she exhibits at least six of the symptoms from one of the lists below, and if the symptoms have been noticeable for at least six months in two or more settings — for example, at home and at school. What’s more, the symptoms must interfere with the child’s functioning or development, and at least some of the symptoms must have been apparent before age 12². Older teens may need to demonstrate just five of these symptoms in multiple settings.

Primarily Inattentive Type (ADD) Symptoms

A person with this Inattentive ADHD (formerly called ADD) will exhibit six of these nine symptoms:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, turns in inaccurate work).
• Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
• Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
• Often has difficulty organizing tasks and activities (e.g., struggle to manage sequential tasks, keep materials and belongings in order, organize work, manage time, and meet deadlines).
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, this may include preparing reports, completing forms, reviewing lengthy papers).
• Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
• Is often easily distracted by extraneous stimuli (for older adolescents and adults, this may include unrelated thoughts).
• Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, this may include returning calls, paying bills, keeping appointments).

[Self-Test: Symptoms of Inattentive ADHD in Children]

Primarily Hyperactive-Impulsive Type Symptoms

A person with this Hyperactive/Impulsive ADHD will exhibit six of these nine symptoms:

• Often fidgets with or taps hands or feet or squirms in seat.
• Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the workplace, or in other situations that require remaining in place).
• Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, this may manifest as feeling restless.)
• Often unable to play or engage in leisure activities quietly.
• Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to remain still — in restaurants or meetings, for example — for any extended time without significant discomfort; others may say the patient is restless, fidgety, or difficult to keep up with).
• Often talks excessively.
• Often blurts out an answer before a question has been completed (e.g., completes people’s sentences).
• Often has difficulty waiting his or her turn (e.g., while waiting in line, while speaking in conversations).
• Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).”⁵

[Self-Test: Symptoms of Hyperactive Impulsive ADHD in Children]

Combined Type Symptoms

To have ADHD Combined Type, an individual must meet the guidelines of both ADHD Primarily Inattentive and ADHD Primarily Hyperactive-Impulsive – that is, they must exhibit six of the nine symptoms listed for each sub-type.

ADHD in Children: How a Diagnosis Is Made

No ADHD test alone can diagnose symptoms of ADHD. ADHD is a nuanced condition with three distinct sub-types (as detailed above), symptoms that appear along a spectrum of severity, and overlapping comorbid conditions (learning disabilities, oppositional defiant disorder, etc.) that often complicate diagnosis and treatment.

An evaluation for ADHD may start with a routine visit to the pediatrician, but chances are it won’t end it there. As a rule, most general practitioners are not trained in the idiosyncrasies of ADHD and its overlapping conditions, or not equipped to perform the in-depth evaluation needed.

Any ADHD evaluation worth its weight will begin by critically analyzing many aspects of the patient’s daily life, such as learning, memory, cognitive functioning, executive functioning, reasoning, social functioning, verbal and non-verbal communication. In cases where learning disabilities are suspected, the evaluation might include an intelligence test (IQ), and gauge math, reading, and writing skills. Full neuropsychological testing is not required, however, to diagnose ADHD.  Educational testing normally occurs several months after any diagnosed ADHD has been successfully treated⁷.

This information is gathered through a clinical interview, plus a thorough review of the child’s and the family’s medical history, various parent and/or teacher rating scales. An in-depth evaluation offers greater insight into strengths and weaknesses, and helps identify comorbid conditions, such as learning disabilities, depression, anxiety disorder, or autism spectrum disorder.

When performed thoroughly and effectively, a formal assessment should offer therapy, treatment, and educational strategies to address the specific needs it reveals or confirms.

Diagnoses Continue to Rise

Diagnoses of ADHD have skyrocketed nearly 50 percent since 2003, bringing the total number of American children with ADHD to nearly 6 million, according to 2015 statistics from the Center for Disease Control and Prevention (CDC).³

The CDC reports that 11 percent of all children in the U.S. aged 4-17 had an ADHD diagnosis by 2011. Boys are nearly three times more likely to be diagnosed with ADHD (13.2 percent) than are girls (5.6 percent),⁴ although the largest surge in rising ADHD diagnosis rates is currently attributed to girls and women.

ADHD Treatment Options for Children

Stimulant Medication for ADHD in Children

Stimulant medication is the most recommended form of ADHD treatment for one simple reason: studies show it to be most effective. According to the American Academy of Pediatrics (AAP), 80 percent of the children who use stimulant medications, either alone or combined with behavior therapy, increase focus and decrease impulsivity.⁶ What’s more, the majority of children who use medication report having increased self-esteem, fewer disruptive behaviors, and improved relationships with parents, siblings, and teachers.

The clinical practice guidelines for ADHD, developed by the American Academy of Child and Adolescent Psychiatry (AACAP), recommend medication as the first-line treatment for ADHD in school-age children, citing a formal review of 78 studies on the treatment of ADHD, which “consistently supported the superiority of stimulant over the non-drug treatment.”⁷

Even the widely-cited Multi-Modal MTA Cooperative Group Study, which concluded that medication combined with behavior therapy is the optimal treatment of ADHD in children, conceded that “a pharmacological intervention for ADHD is more effective than a behavioral treatment alone.”⁸

Non-Stimulant Medications for ADHD in Children

Non-stimulant medications are a viable alternative for children who can’t tolerate or don’t experience the desired effects of stimulant medications. These medications do target neurotransmitters, but not dopamine specifically, like the stimulants do. While non-stimulants don’t carry the same side-effect risks as stimulants, they do have their own possible side effects.

Strattera, Intuniv, Kapvay are non-stimulant medications specifically recommended for ADHD. The classification also includes  medications often prescribed off-label for ADHD — tricyclic antidepressants, and Wellbutrin, for example.

Therapy for ADHD in Children

While medication works on a neurological level to regulate the brain, behavior therapy addresses specific problem behaviors by structuring time at home, establishing predictability and routines, and increasing positive attention. Behavior therapy operates on a simple premise: Parents and other adults in a child’s life set clear expectations for their child’s behavior — they praise and reward positive behavior and discourage negative behavior. Behavior therapy requires participation from parents and teachers.

Diet and Nutrition for ADHD in Children

Poor diet and eating habits do not cause ADHD. However, parents of children with ADHD are finding that, while whole foods may not be a cure-all, diet changes can make a big difference for some kids with ADHD.

Research shows that diet and nutrition impact cognition, attention, sleep, and mood. According to the Harvard Health Blog, studies show that people who eat “clean” or “whole” diets high in vegetables, fruits, unprocessed grains, and lean meats, are more likely to experience better emotional health and 25 to 35 percent less likely to experience depression.⁹

Studies by Massachusetts Institute of Technology neuroscientist Richard Wurtman Ph.D., and others have shown that protein triggers alertness-inducing neurotransmitters, while carbohydrates trigger drowsiness. These findings support the popular belief that people with ADHD do better after eating a protein-rich breakfast and lunch.

For optimal brain performance, children should eat more unprocessed foods, complex carbohydrates, proteins, vegetables, and fruits. That means avoiding artificial colors and flavors, chemical preservatives, and over-processed foods — all shown to exacerbate ADHD symptoms in some individuals.

Natural Supplements and Vitamins for ADHD in Children

It’s true that not everyone eats the right foods to achieve beneficial levels of certain nutrients, especially picky kids. But it’s also true that our bodies don’t always produce the nutrients we need, so we have to get some of them from supplements. There are many vitamins, herbs, and supplements that may diminish ADHD symptoms or address medication side effects in some individuals: Omega-3s, Zinc, Iron, Magnesium, Vitamin C, Valerian, Melatonin, Ginkgo, and Ginseng.

However, “all natural” is not synonymous with “safe.” Many herbs and supplements have side effects, may cause or worsen health problems, or interfere with prescription medications. Talk to your child’s doctor before starting any supplements. When your doctor asks if your child is taking any medications, be sure to tell him about all vitamins and supplements he takes on a daily basis.

Exercise for ADHD in Children

“Think of exercise as medication,” says John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School and author of Spark: The Revolutionary New Science of Exercise and the Brain. “Exercise turns on the attention system, the so-called executive functions — sequencing, working memory, prioritizing, inhibiting, and sustaining attention. On a practical level, it causes kids to be less impulsive, which makes them more primed to learn.”

Exercise causes the brain to release several important chemicals. Endorphins, for one — hormone-like compounds that regulate mood, pleasure, and pain. That same burst of activity also elevates the brain’s dopamine, norepinephrine, and serotonin levels. These brain chemicals affect focus and attention, which are in short supply in children with ADHD. “When you increase dopamine levels, you increase the attention system’s ability to be regular and consistent, which has many good effects,” explains Ratey, like reducing the craving for new stimuli and increasing alertness.

A 2015 study published in the Journal of Abnormal Psychology found that 30 minutes of exercise before school can help kids with ADHD focus and manage moods. It can even decrease the need for stimulant medications used to treat symptoms.¹⁰

Brain Training for ADHD in Children

Kids with ADHD can’t always hold on to information because their attention gets hijacked. Improving working memory capacity with brain training enables an individual to pay attention, resist distractions, manage emotions better, and learn.

“Working memory is the ability to hold information in your mind for several seconds, manipulate it, and use it in your thinking,” says Ari Tuckman, Psy.D., a clinical psychologist in West Chester, Pennsylvania. “It is central to concentration, problem solving, and impulse control.”

Brain-training therapies like neurofeedback and Cogmed are making a serious promise: increased attention and working memory without medication. The scientific community, however, is not convinced and insists that more rigorous studies are needed.¹¹

Another form of brain training with some encouraging but inconclusive studies, neurofeedback uses brain exercises to reduce impulsivity and increase attentiveness. The brain emits different types of waves, depending on whether we are in a focused state or daydreaming. The goal of neurofeedback is to teach a person to produce brain-wave patterns that reflect focus. The result: Some ADHD symptoms — namely, impulsivity and distractibility — diminish.

Mindfulness and Meditation for ADHD in Children

For many children with ADHD, two persistent daily challenges are paying attention and maintaining self-regulation. So it stands to reason that some kind of attention training that also hones self-control would be invaluable — and incredibly powerful. Indeed, a 2005 study at Arizona State University found that children who participated in mindfulness exercises had lower test anxiety and ADHD symptoms, and greater attention than kids who did not participate in the exercises.¹²

“Research suggests that anyone can improve attention by practicing mindfulness — cognitive fitness training aimed at building real-time and compassionate awareness of our lives rather than remaining lost in distraction, on autopilot,” explains Mark Bertin, M.D., in his book, Mindful Parenting for ADHD: A Guide to Cultivating Calm, Reducing Stress & Helping Children Thrive. “How does it work with the ADHD brain? ADHD is characterized by difficulties with executive function, not just attention, and mindfulness is an avenue to developing interrelated cognitive skills, many related to executive function, not just attention.”

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