From time immemorial adults have envied the energy, passion and spontaneity of children. For the same amount of time, adults have complained about those same qualities. It wasn’t until the late 1800’s that physicians attempted to define excessive activity and impulsivity as a clinical syndrome. And it wasn’t until 1980 that the term Attention Deficit Disorder (ADD) was officially adopted by the American Psychiatric Association. 
This article will examine the basics of ADHD including symptoms, some look alike conditions, possible treatments & side effects, and prognosis. Finally, it will discuss why the diagnosis remains controversial.
Table of Contents
 There are three main symptoms of ADHD:
- Inattention (inability to maintain attention),
- Hyperactivity (excessive, often purposeless, physical activity),
- Impulsivity (acting without considering consequences to self or others).
For a formal diagnosis these symptoms must:
- Occur before the age of 12,
- Have lasted for more than six months and
- Interfere significantly with ability to function in at least two settings (e.g. home, school, church, etc.)
- The symptoms must also be out of the ordinary for a child of that age and not be better explained by some other medical or psychological condition.
Finally for children under 16 they must have at least 6 criteria for either inattention or hyperactivity/impulsivity. The criteria are listed below.
The nine criteria for inattention
- Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities (e.g. overlooks or misses details, work is inaccurate).
- 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 school work, 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., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- Often avoids or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework; for older adolescents and adults, 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 (e.g., for older adolescents and adults may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
The nine criteria for hyperactivity/impulsivity
- Often fidgets with or taps hands 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 office or other workplace, or in other situations that require remaining in place).
- Often runs about or climbs in situations where it is inappropriate (e.g., in adolescents or adults, may be limited to 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 be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- Often talks excessively;
- Often blurts out answers before questions have been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
- Often has difficulty awaiting turn (e.g., while waiting in line).
- 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).
* For children and adults over the age of 16 at least five of the above criteria must be met, instead of six.
When a child is diagnosed with ADHD they are put into one of three categories:
- Inattentive ( meets 6 or more criteria for inattention, but less than 6 for hyperactivity/impulsivity),
- Hyperactive/impulsive (meets 6 or more criteria for hyperactivity/impulsivity, but less than 6 for inattentiveness) or
- Combined (meet at least 6 criteria for both inattentiveness and hyperactivity/impulsivity)
Severity of symptoms is also specified:
- Mild. Mild severity means that only the minimal number of criteria are met for diagnosis and that there are fewer difficulties with functioning day to day.
- Moderate. Moderate is in the middle of the two extremes.
- Severe. Severe means that most of the diagnostic criteria are met and that day to day functioning is severely impaired.
Researchers have conducted numerous studies on those, who have ADHD, and found that the percentage of population with ADHD truly depends on the diagnostic criteria. In the United States, the criteria most commonly used are listed above. According to these criteria, the percentage of Americans with ADHD is approximately 7%. (3) However, when stricter criteria are used, the percent is approximately 5%. (3)
Therefore, the prevalence is approximately 6% for American adults. (3)
Causes and Risk Factors
The only known cause for ADHD is genetic. That said, not everyone with family with a history of ADHD will have ADHD themselves and vice versa. Researchers believe that at least two genes are involved in the development of ADHD and it is likely other medical and environmental conditions affect the presence and expression of the disorder (e.g. specific symptoms and severity).
In addition to genetics there are many environmental factors which are correlated with ADHD, however it is unclear if they actually cause ADHD. Some of these are:
- Nutritional deficiencies (magnesium, zinc, polyunsaturated fats such as omega 3 and 6 oils)
- Maternal factors (stress, substance abuse/use including alcohol and tobacco)
- Prematurity and low birth weight
- Exposure to lead, some pesticides and polychlorinated biphenyls(PCBs)
- Poverty, severe deprivation and extreme family conflict.
Research into the causes of ADHD is ongoing.
Summary: Causes and Risk Factors
- There is a genetic component to ADHD. It does tend to “run in families”.
- Nutritional deficiencies, prenatal stress, prematurity, environmental stress and toxins may also affect the developing brain and may contribute to ADHD symptoms.
If you are concerned about your child’s behavior the first place to start is with your child’s pediatrician. Most pediatricians are experienced with treatment and evaluation of ADHD. However if they feel your child’s condition is complicated, they may refer you to a child or family therapist or a psychiatrist for further evaluation and treatment.
A good history is the best way to diagnose ADHD. A physical exam and family history are essential to help rule out other causes of behavioral problems. Typically a psychiatrist will ask for medical records from the child’s pediatrician for review and will do only a focused neurological exam, as well as observing the child’s behavior closely during the appointment. Because they have evaluated hundreds of children with behavioral issues it is easier for them to notice behaviors which may be more typical of other problems than ADHD, and to assess any of those further.
There are some tests for attention and impulse control that are administered by computer. These are very accurate for detecting inattention and poor impulse control, but they are not able to identify the cause of inattention, which can be present for many reasons. That is why observing the child and getting a good history from parents, caregivers and teachers areis vital.
- Your pediatrician can diagnose simple ADHD.
- More complex problems will be referred to a specialist.
- Other conditions must be considered before a diagnosis is made.
- History and observation are vital for making a diagnosis.
The major treatments for ADHD include education, medication, assessment and treatment of any other conditions that interfere with attention, and educational accommodations as needed.
Education about the disorder for parents, the child and others involved in care of the child is the first part of treatment. Parents often must adjust expectations, family routines and disciplinary styles to suit the child’s strengths and weaknesses. A child with ADHD may have fewer symptoms with:
- A predictable routine
- Attention to ensure they are not too hungry or fatigued.
- Parents and caregivers who try to anticipate troublesome behaviors before they happen.
- Avoid a reactive parenting style ( providing direction or guidance only after child is in trouble).
The calmer the parents are able to stay, generally speaking, the calmer the child will be. An ADHD child may often feel out of control, so greater structure and adult calmness can help reassure the child. When a child feels the world is in control it helps keep them be better able to pay attention and to cooperate with adults.
- Stimulants: ADHD is often treated with stimulants like methylphenidate (Ritalin and others) and amphetamines/dextroamphetamines (Adderall and others). Stimulants work quickly but also wear off quickly, similar to the effects of aspirin. A benefit of these medications is that, for some, they only need to be taken on school days. A disadvantage of stimulants is that they can cause poor appetite and be addictive. Stimulants are considered controlled-substances, so be cautious when giving your child these medications.
- Atomoxetine: Atomoxetine, also referred to by its brand name Strattera, is another drug used to treat ADHD. This medication must be taken every day for maximum effectiveness. Note: It may take a few weeks before you will notice a change in your child’s behavior. A benefit of atomoxetine is that it is not habit-forming, while a disadvantage is that it can cause stomach upset.
- Clonidine & Guanfacine: This ADHD medication is especially effective for children who are hyperactive and impulsive. A benefit of this medication is that it is not habit-forming, while a disadvantage is that it can cause drowsiness and increased appetite.
Other medications are sometimes effective for ADHD, but have not been approved by the FDA. Usually they are prescribed by a child psychiatrist or neurologist.
A summary detailing these medications can be found at this site, maintained by the American Academy of Child and Adolescent Psychiatry.
Sometimes basic education about managing ADHD is not enough. Play therapy for children and family therapy can be very helpful. In addition, support groups for parents and other caregivers can also be important tools for coping and learning.
Most children learn organizational, social and sequencing skills through normal family and school life, but some children benefit from extra exposure, which can often be through chores and games. Some of these can be focused on organizational skills, such as packing lunch or school supplies, playing memory games and repeating steps in order (dance routines, reciting songs or poems). Charts helping children identify emotions in themselves and others can be a good starting point for social skills.
In other cases a child may have a diagnosable learning disorder and may require more formal treatment. Often an occupational therapist can help with this, but a reading specialist or even an optometrist specializing in low vision or visual processing can help with this. These services are only sometimes provided through the schools and often can present a financial strain for families.
The frustration a child experiences from a learning disability can aggravate other emotional and behavioral issues the child has. Parents and siblings may also become frustrated. When these learning difficulties are addressed appropriately it may help the entire family.
Whether or not a learning disorder is present, a child with severe and poorly controlled ADHD (about 10% of children diagnosed and treated for ADHD) may require an individualized educational plan (or IEP). This type of plan can be very valuable as it allows the child to stay in a regular classroom with special limits on what is expected of the child and extra resources provided if necessary. At other times accommodations may be negotiated with the child’s teacher on a case -by -case basis. For example, a child who has great difficulty writing, might do his or her spelling word sentences by dictating them to a parent who writes them down for the child. This should generally be a temporary arrangement which prevents the child from falling behind in learning while the learning disability is being addressed.
Herbal Remedies and Biofeedback
Unfortunately, to date there is no reliable evidence for the usefulness of herbal remedies or biofeedback in the treatment of ADHD.
- Education about ADHD can help children and parents understand how to cope with symptoms and reduce tension at home.
- Medications are the mainstay of treatment for ADHD. There are several types available which are effective and generally safe when taken as prescribed.
- Therapy can be invaluable for families and children with severe ADHD or who have other coexisting disorders.
- Treatment of learning disorders and school accommodations may be needed.
- Many herbal and alternative treatments are available, but scientific and clinical data have not shown them to be effective as of March 2018.
Outlook and Prognosis
Most children (and adults) have an excellent response to treatment for ADHD. Stimulants are effective in between 60 to 90% of cases. In the remaining cases there are often co-occuring conditions which complicate treatment, meaning that there are actually two or more conditions to be treated.
Up to one-third of children treated for ADHD may find that their symptoms diminish greatly in early adolescence and that they are able to discontinue medications altogether.
The remaining two thirds find they do much better on medication, at least while they are in a formal education setting.
And one third of children will become adults and find that they benefit from taking medication indefinitely. They will continue to struggle with impulsivity, interpretation of social cues and focusing unless the material is highly interesting to them. Fortunately, side effects of the medications are usually mild. Nonetheless it is vital for those who are on medication for ADHD long term to find and develop a good relationship with a psychiatrist for those who are on medications for ADHD for long term.. [pullquote align=”normal”]
- Treatment is effective in 60-90% of patients.
- The other 10-40% have other conditions which also require treatment, or very severe symptoms.
- One third of patients seem to “grow out” of ADHD in early adolescence.
- One third may do better staying on medications while in a formal learning setting, but may not require medication long term.
- One third may do better remaining on medications indefinitely, depending on career and lifestyle choices.
Q&A on Overdiagnosis and Other Causes of Inattention
1. Is ADHD a real disorder?
Yes, ADHD is a real disorder that affects all age groups, ethnicities, races, cultures, genders, economic groups, and sexual orientations.
2. Are all attention problems caused by ADHD?
No, in fact, ADHD is just one of many causes of inattention. Therefore, it is important to consider other factors that may be contributing to your child’s learning and discipline problems.
3. What are some nutritional deficiencies that can cause symptoms similar to ADHD?
The nutritional deficiencies that can cause symptoms similar to ADHD are:
In addition, essential fatty acid supplements and phosphatidylserine supplements may assist in brain and nervous system health ( Vayarin by prescription and various over the counter supplements).
4. Can exposure to toxins cause ADHD?
Yes, environmental toxins can impair attention and cause behavioral disturbances.
The most common and serious toxins are:
- Lead Exposure
- Organophosphate Pesticides
- PCB’s (Polychlorinated Biphenyls)
5. What learning disabilities and sensory-processing disorders mimic ADHD?
There are a variety of conditions that can mimic ADHD.
These conditions are listed below:
- Visual Processing Problems (sometimes appears as not being able to tell right from left, seeing things blurry although doesn’t need glasses, and other signs)
- Over or under sensitivity to tactile sensation (can cause child to be excessively fearful if over-sensitive or to be physically too intense when affectionate such as “tackling” hugs)
- Learning Disabilities can cause frustration leading to poor motivation and misbehavior.
6. Can some mood and psychiatric disorders mimic ADHD?
Yes, some mood and psychiatric disorders can mimic ADHD, such as:
- Anxiety Disorders such as Panic Disorder, Post Traumatic Stress Disorder and Obsessive Compulsive Disorder.
- Depression and Bipolar Disorder
- Childhood onset schizophrenia
7. Are there any other neurological disorders that could be mistaken for ADHD?
Yes, there are other neurological disorders that could be mistaken for ADHD.
Some of these disorders are listed below:
- Traumatic Brain Injuries (TBI)
- Some seizure disorders, in particular Absence seizures and Temporal lobe seizures
- Sleep Apnea can cause daytime drowsiness (usually snoring is a sign)
8. What about allergies – are there any allergies that could be linked to or mistaken for ADHD?
Yes, some allergies have been linked to or mistaken for ADHD.
These allergies are listed below:
- Pollen, Dust, Mold & Animal Dander Allergies (these allergies can cause cold symptoms and poor concentration)
- Food Allergies (food allergies can impair attention and cause behavioral issues)
9. Is ADHD Overdiagnosed?
The rate of diagnosis with ADHD has increased dramatically since 1980. However some states have a rate of 14% of children who are diagnosed with ADHD, other states have closer to 4% diagnosed with ADHD.[4,5,6] It is clear that in some places ADHD is underdiagnosed and in some places it is overdiagnosed.
This could be because:
- There is no definitive test for ADHD
- Other conditions have similar symptoms
- Diagnosis depends on a good clinical history, which is not always available.
- Factors that increase referrals for ADHD, such as school funding policies, may increase referrals by schools for evaluations.
- Areas which have little access to medical care generally have a lower rate of diagnosis for ADHD.
- Since the 1990’s there have been more medications available to treat ADHD and much direct-to-patient advertising, which could lead to an increase in diagnosis.
The main symptoms of ADHD are: inattention, hyperactivity, and impulsivity. This condition can occur at any age, but it is usually diagnosed during childhood. In most cases, ADHD persists through adolescence and into adulthood. It typically affects approximately 9% of the general population and has been observed worldwide. ADHD can affect an individual’s self-esteem, romantic relationships, friendships, and academic and career success.
In fact, approximately 80% of those diagnosed with and treated for ADHD experience a reduction in symptoms (i.e. improved academic performance and better family and social relationships, along with decreased impulsivity and dangerous behaviors). However, approximately 20% of those diagnosed with ADHD do not receive satisfactory results from treatment.
For these individuals, additional problems – i.e. medical, developmental, and/or environmental in nature – should be addressed to help the child attain the best possible results. To be diagnosed with the condition, individuals must meet specific criteria. And, with early diagnosis and proper treatment, individuals with ADHD can go on to have happy and successful lives.
Lange, K. W., Reichl, S., Lange, K.M., Tucha, L., Tucha, O. (2010). The history of attention deficit hyperactivity disorder. Attn Defic Hyperact Disord, 2(4), 241-255. Retrieved from https://www.ncbi.nlm.gov/pme/articles/PMC3000907/#
2. American Psychiatric Association (APA). (2013). DSM-V. Diagnostic and Statistical Manual of Mental Disorders.
3. Thomas, R., Sanders, S., Doust, J., Beller, E., Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Pediatrics, 135(4), 1-10. Retrieved from http://pediatrics.aappublications.org/content/early/2015/02/24/peds.2014-3482
4. McDonald, D. C., & Jalbert, S. K. (2013). Geographic variation and disparity in stimulant treatment of adults and children in the United States in 2008. Psych Services, 64(11), 1079-1086.
5. Visser, S. N., Blumberg, S. J., Danielson, M. L., Bitsko, R. H., & Kogan, M. D. (2013). State-based and demographic variation in parent-reported medication rates for attention-deficit/hyperactivity disorder, 2007-2008. Prev Chronic Disorders,10(9).
6. Visser, S., Danielson, M., Bitsko, R., et al. (2014). Trends in the parent-report of health care provider-diagnosis and medication treatment for ADHD disorder: United States, 2003–2011. J Am Acad Child Adolesc Psychiatry, 53(1), 34–46. Retrieved from https://www.cdc.gov/ncbddd/adhd/prevalence.htm
7. Thaper, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner review: What have we learnt about the causes of ADHD? J. Child Psychol. Psychiatry, 54(1), 3-16. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-7610.2012.02611.x
8. Conrad, P., & Bergey, M. R., (2014). The impending globalization of ADHD: Notes on the expansion and growth of a medicalized disorder. Soc. Sci. & Medicine, 122, 31-43. Retrieved from https://www.sciencedirect.com/science/article/pii/S0277953614006650