Introduction
Attention Deficit Hyperactivity Disorder (ADHD) is a
condition that becomes apparent in some children in the
preschool and early school years. It is hard for these
children to control their behavior and/or pay attention.
It is estimated that between 3 and 5 percent of children
have ADHD, or approximately 2 million children in the
United States. This means that in a classroom of 25 to
30 children, it is likely that at least one will have
ADHD.
ADHD was first described by Dr. Heinrich Hoffman in
1845. A physician who wrote books on medicine and
psychiatry, Dr. Hoffman was also a poet who became
interested in writing for children when he couldn't find
suitable materials to read to his 3-year-old son. The
result was a book of poems, complete with illustrations,
about children and their characteristics. "The Story of
Fidgety Philip" was an accurate description of a little
boy who had attention deficit hyperactivity disorder.
Yet it was not until 1902 that Sir George F. Still
published a series of lectures to the Royal College of
Physicians in England in which he described a group of
impulsive children with significant behavioral problems,
caused by a genetic dysfunction and not by poor child
rearing—children who today would be easily recognized as
having ADHD.1 Since
then, several thousand scientific papers on the disorder
have been published, providing information on its
nature, course, causes, impairments, and treatments.
A child with ADHD faces a difficult but not
insurmountable task ahead. In order to achieve his or
her full potential, he or she should receive help,
guidance, and understanding from parents, guidance
counselors, and the public education system. This
document offers information on ADHD and its management,
including research on medications and behavioral
interventions, as well as helpful resources on
educational options.
Because ADHD often continues into adulthood, this
document contains a section on the diagnosis and
treatment of ADHD in adults.
Symptoms
The principal characteristics of ADHD are
inattention, hyperactivity,
and impulsivity. These symptoms appear
early in a child’s life. Because many normal children
may have these symptoms, but at a low level, or the
symptoms may be caused by another disorder, it is
important that the child receive a thorough examination
and appropriate diagnosis by a well-qualified
professional.
Symptoms of ADHD will appear over the course of many
months, often with the symptoms of impulsiveness and
hyperactivity preceding those of inattention, which may
not emerge for a year or more. Different symptoms may
appear in different settings, depending on the demands
the situation may pose for the child’s self-control. A
child who “can’t sit still” or is otherwise disruptive
will be noticeable in school, but the inattentive
daydreamer may be overlooked. The impulsive child who
acts before thinking may be considered just a
“discipline problem,” while the child who is passive or
sluggish may be viewed as merely unmotivated. Yet both
may have different types of ADHD. All children are
sometimes restless, sometimes act without thinking,
sometimes daydream the time away. When the child’s
hyperactivity, distractibility, poor concentration, or
impulsivity begin to affect performance in school,
social relationships with other children, or behavior at
home, ADHD may be suspected. But because the symptoms
vary so much across settings, ADHD is not easy to
diagnose. This is especially true when inattentiveness
is the primary symptom.
According to the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders2
(DSM-IV-TR), there are three patterns of behavior that
indicate ADHD. People with ADHD may show several signs
of being consistently inattentive. They may have a
pattern of being hyperactive and impulsive far more than
others of their age. Or they may show all three types of
behavior. This means that there are three subtypes of
ADHD recognized by professionals. These are the
predominantly hyperactive-impulsive type (that
does not show significant inattention); the
predominantly inattentive type (that does not
show significant hyperactive-impulsive behavior)
sometimes called ADD—an outdated term for this entire
disorder; and the combined type (that
displays both inattentive and hyperactive-impulsive
symptoms).
Hyperactivity-Impulsivity
Hyperactive children always seem to
be “on the go” or constantly in motion. They dash around
touching or playing with whatever is in sight, or talk
incessantly. Sitting still at dinner or during a school
lesson or story can be a difficult task. They squirm and
fidget in their seats or roam around the room. Or they
may wiggle their feet, touch everything, or noisily tap
their pencil. Hyperactive teenagers or adults may feel
internally restless. They often report needing to stay
busy and may try to do several things at once.
Impulsive children seem unable to
curb their immediate reactions or think before they act.
They will often blurt out inappropriate comments,
display their emotions without restraint, and act
without regard for the later consequences of their
conduct. Their impulsivity may make it hard for them to
wait for things they want or to take their turn in
games. They may grab a toy from another child or hit
when they’re upset. Even as teenagers or adults, they
may impulsively choose to do things that have an
immediate but small payoff rather than engage in
activities that may take more effort yet provide much
greater but delayed rewards.
Some signs of hyperactivity-impulsivity
are:
- Feeling restless, often fidgeting with hands or
feet, or squirming while seated
- Running, climbing, or leaving a seat in
situations where sitting or quiet behavior is
expected
- Blurting out answers before hearing the whole
question
- Having difficulty waiting in line or taking
turns.
Inattention
Children who are inattentive have a hard time keeping
their minds on any one thing and may get bored with a
task after only a few minutes. If they are doing
something they really enjoy, they have no trouble paying
attention. But focusing deliberate, conscious attention
to organizing and completing a task or learning
something new is difficult.
Homework is particularly hard for these children.
They will forget to write down an assignment, or leave
it at school. They will forget to bring a book home, or
bring the wrong one. The homework, if finally finished,
is full of errors and erasures. Homework is often
accompanied by frustration for both parent and child.
The DSM-IV-TR gives these signs of
inattention:
- Often becoming easily distracted by irrelevant
sights and sounds
- Often failing to pay attention to details and
making careless mistakes
- Rarely following instructions carefully and
completely losing or forgetting things like toys, or
pencils, books, and tools needed for a task
- Often skipping from one uncompleted activity to
another.
Children diagnosed with the Predominantly Inattentive
Type of ADHD are seldom impulsive or hyperactive, yet
they have significant problems paying attention. They
appear to be daydreaming, “spacey,” easily confused,
slow moving, and lethargic. They may have difficulty
processing information as quickly and accurately as
other children. When the teacher gives oral or even
written instructions, this child has a hard time
understanding what he or she is supposed to do and makes
frequent mistakes. Yet the child may sit quietly,
unobtrusively, and even appear to be working but not
fully attending to or understanding the task and the
instructions.
These children don’t show significant problems with
impulsivity and overactivity in the classroom, on the
school ground, or at home. They may get along better
with other children than the more impulsive and
hyperactive types of ADHD, and they may not have the
same sorts of social problems so common with the
combined type of ADHD. So often their problems with
inattention are overlooked. But they need help just as
much as children with other types of ADHD, who cause
more obvious problems in the classroom.
Is It Really ADHD?
Not everyone who is overly hyperactive, inattentive,
or impulsive has ADHD. Since most people sometimes blurt
out things they didn’t mean to say, or jump from one
task to another, or become disorganized and forgetful,
how can specialists tell if the problem is ADHD?
Because everyone shows some of these behaviors at
times, the diagnosis requires that such behavior be
demonstrated to a degree that is inappropriate for the
person’s age. The diagnostic guidelines also contain
specific requirements for determining when the symptoms
indicate ADHD. The behaviors must appear early in life,
before age 7, and continue for at least 6 months. Above
all, the behaviors must create a real handicap in at
least two areas of a person’s life such as in the
schoolroom, on the playground, at home, in the
community, or in social settings. So someone who shows
some symptoms but whose schoolwork or friendships are
not impaired by these behaviors would not be diagnosed
with ADHD. Nor would a child who seems overly active on
the playground but functions well elsewhere receive an
ADHD diagnosis.
To assess whether a child has ADHD, specialists
consider several critical questions: Are these behaviors
excessive, long-term, and pervasive? That is, do they
occur more often than in other children the same age?
Are they a continuous problem, not just a response to a
temporary situation? Do the behaviors occur in several
settings or only in one specific place like the
playground or in the schoolroom? The person’s pattern of
behavior is compared against a set of criteria and
characteristics of the disorder as listed in the DSM-IV-TR.
Diagnosis
Some parents see signs of inattention, hyperactivity,
and impulsivity in their toddler long before the child
enters school. The child may lose interest in playing a
game or watching a TV show, or may run around completely
out of control. But because children mature at different
rates and are very different in personality,
temperament, and energy levels, it’s useful to get an
expert’s opinion of whether the behavior is appropriate
for the child’s age. Parents can ask their child’s
pediatrician, or a child psychologist or psychiatrist,
to assess whether their toddler has an attention deficit
hyperactivity disorder or is, more likely at this age,
just immature or unusually exuberant.
ADHD may be suspected by a parent or caretaker or may
go unnoticed until the child runs into problems at
school. Given that ADHD tends to affect functioning most
strongly in school, sometimes the teacher is the first
to recognize that a child is hyperactive or inattentive
and may point it out to the parents and/or consult with
the school psychologist. Because teachers work with many
children, they come to know how “average” children
behave in learning situations that require attention and
self-control. However, teachers sometimes fail to notice
the needs of children who may be more inattentive and
passive yet who are quiet and cooperative, such as those
with the predominantly inattentive form of ADHD.
Professionals Who Make the Diagnosis
If ADHD is suspected, to whom can the family
turn? What kinds of specialists do they need?
Ideally, the diagnosis should be made by a
professional in your area with training in ADHD or in
the diagnosis of mental disorders. Child psychiatrists
and psychologists, developmental/behavioral
pediatricians, or behavioral neurologists are those most
often trained in differential diagnosis. Clinical social
workers may also have such training.
The family can start by talking with the child’s
pediatrician or their family doctor. Some pediatricians
may do the assessment themselves, but often they refer
the family to an appropriate mental health specialist
they know and trust. In addition, state and local
agencies that serve families and children, as well as
some of the volunteer organizations listed at the end of
this document, can help identify appropriate
specialists.
Specialty |
Can Diagnose ADHD |
Can prescribe
medication, if needed |
Provides counseling
or training |
Psychiatrists |
yes |
yes |
yes |
Psychologists |
yes |
yes* |
yes |
Pediatricians or
Family Physicians |
yes |
yes |
no |
Neurologists |
yes |
yes |
no |
Clinical Social
workers |
yes |
no |
yes |
* As of October 2006, Louisiana and New Mexico laws
and regulations allow psychologists who have completed
specific training and meet other requirements to
prescribe psychotropic medications. The other 48 states
and the District of Columbia allow only physicians to
prescribe medications.
Knowing the differences in qualifications and
services can help the family choose someone who can best
meet their needs. There are several types of specialists
qualified to diagnose and treat ADHD. Child
psychiatrists are doctors who specialize in diagnosing
and treating childhood mental and behavioral disorders.
A psychiatrist can provide therapy and prescribe any
needed medications. Child psychologists are also
qualified to diagnose and treat ADHD. They can provide
therapy for the child and help the family develop ways
to deal with the disorder. But psychologists are not
medical doctors and must rely on the child’s physician
to do medical exams and prescribe medication.
Neurologists, doctors who work with disorders of the
brain and nervous system, can also diagnose ADHD and
prescribe medicines. But unlike psychiatrists and
psychologists, neurologists usually do not provide
therapy for the emotional aspects of the disorder.
Within each specialty, individual doctors and mental
health professionals differ in their experiences with
ADHD. So in selecting a specialist, it’s important to
find someone with specific training and experience in
diagnosing and treating the disorder.
Whatever the specialist’s expertise, his or her first
task is to gather information that will rule out other
possible reasons for the child’s behavior. Among
possible causes of ADHD-like behavior are the following:
- A sudden change in the child’s life—the death of
a parent or grandparent; parents’ divorce; a
parent’s job loss
- Undetected seizures, such as in petit mal or
temporal lobe seizures
- A middle ear infection that causes intermittent
hearing problems
- Medical disorders that may affect brain
functioning
- Underachievement caused by learning disability
- Anxiety or depression.
Ideally, in ruling out other causes, the specialist
checks the child’s school and medical records. There may
be a school record of hearing or vision problems, since
most schools automatically screen for these. The
specialist tries to determine whether the home and
classroom environments are unusually stressful or
chaotic, and how the child’s parents and teachers deal
with the child.
Next the specialist gathers information on the
child’s ongoing behavior in order to compare these
behaviors to the symptoms and diagnostic criteria listed
in the DSM-IV-TR. This also involves talking with the
child and, if possible, observing the child in class and
other settings.
The child’s teachers, past and present, are asked to
rate their observations of the child’s behavior on
standardized evaluation forms, known as behavior rating
scales, to compare the child’s behavior to that of other
children the same age. While rating scales might seem
overly subjective, teachers often get to know so many
children that their judgment of how a child compares to
others is usually a reliable and valid measure.
The specialist interviews the child’s teachers and
parents, and may contact other people who know the child
well, such as coaches or baby-sitters. Parents are asked
to describe their child’s behavior in a variety of
situations. They may also fill out a rating scale to
indicate how severe and frequent the behaviors seem to
be.
In most cases, the child will be evaluated for social
adjustment and mental health. Tests of intelligence and
learning achievement may be given to see if the child
has a learning disability and whether the disability is
in one or more subjects.
In looking at the results of these various sources of
information, the specialist pays special attention to
the child’s behavior during situations that are the most
demanding of self-control, as well as noisy or
unstructured situations such as parties, or during tasks
that require sustained attention, like reading, working
math problems, or playing a board game. Behavior during
free play or while getting individual attention is given
less importance in the evaluation. In such situations,
most children with ADHD are able to control their
behavior and perform better than in more restrictive
situations.
The specialist then pieces together a profile of the
child’s behavior. Which ADHD-like behaviors listed in
the most recent DSM does the child show? How often? In
what situations? How long has the child been doing them?
How old was the child when the problem started? Are the
behavior problems relatively chronic or enduring or are
they periodic in nature? Are the behaviors seriously
interfering with the child’s friendships, school
activities, home life, or participation in community
activities? Does the child have any other related
problems? The answers to these questions help identify
whether the child’s hyperactivity, impulsivity, and
inattention are significant and long-standing. If so,
the child may be diagnosed with ADHD.
A correct diagnosis often resolves confusion about
the reasons for the child’s problems that lets parents
and child move forward in their lives with more accurate
information on what is wrong and what can be done to
help. Once the disorder is diagnosed, the child and
family can begin to receive whatever combination of
educational, medical, and emotional help they need. This
may include providing recommendations to school staff,
seeking out a more appropriate classroom setting,
selecting the right medication, and helping parents to
manage their child’s behavior.
What Causes ADHD?
One of the first questions a parent will have is
“Why? What went wrong?” “Did I do something to cause
this?” There is little compelling evidence at this time
that ADHD can arise purely from social factors or
child-rearing methods. Most substantiated causes appear
to fall in the realm of neurobiology and genetics. This
is not to say that environmental factors may not
influence the severity of the disorder, and especially
the degree of impairment and suffering the child may
experience, but that such factors do not seem to give
rise to the condition by themselves.
The parents’ focus should be on looking forward and
finding the best possible way to help their child.
Scientists are studying causes in an effort to identify
better ways to treat, and perhaps someday, to prevent
ADHD. They are finding more and more evidence that ADHD
does not stem from the home environment, but from
biological causes. Knowing this can remove a huge burden
of guilt from parents who might blame themselves for
their child’s behavior.
Over the last few decades, scientists have come up
with possible theories about what causes ADHD. Some of
these theories have led to dead ends, some to exciting
new avenues of investigation.
Environmental Agents
Studies have shown a possible correlation between the
use of cigarettes and alcohol during pregnancy and risk
for ADHD in the offspring of that pregnancy. As a
precaution, it is best during pregnancy to refrain from
both cigarette and alcohol use.
Another environmental agent that may be associated
with a higher risk of ADHD is high levels of lead in the
bodies of young preschool children. Since lead is no
longer allowed in paint and is usually found only in
older buildings, exposure to toxic levels is not as
prevalent as it once was. Children who live in old
buildings in which lead still exists in the plumbing or
in lead paint that has been painted over may be at risk.
Brain Injury
One early theory was that attention disorders were
caused by brain injury. Some children who have suffered
accidents leading to brain injury may show some signs of
behavior similar to that of ADHD, but only a small
percentage of children with ADHD have been found to have
suffered a traumatic brain injury.
Food Additives and Sugar
It has been suggested that attention disorders are
caused by refined sugar or food additives, or that
symptoms of ADHD are exacerbated by sugar or food
additives. In 1982, the National Institutes of Health
held a scientific consensus conference to discuss this
issue. It was found that diet restrictions helped about
5 percent of children with ADHD, mostly young children
who had food allergies.3 A more recent study
on the effect of sugar on children, using sugar one day
and a sugar substitute on alternate days, without
parents, staff, or children knowing which substance was
being used, showed no significant effects of the sugar
on behavior or learning.4
In another study, children whose mothers felt they
were sugar-sensitive were given aspartame as a
substitute for sugar. Half the mothers were told their
children were given sugar, half that their children were
given aspartame. The mothers who thought their children
had received sugar rated them as more hyperactive than
the other children and were more critical of their
behavior.5
Genetics
Attention disorders often run in families, so there
are likely to be genetic influences. Studies indicate
that 25 percent of the close relatives in the families
of ADHD children also have ADHD, whereas the rate is
about 5 percent in the general population.6
Many studies of twins now show that a strong genetic
influence exists in the disorder.7
Researchers continue to study the genetic
contribution to ADHD and to identify the genes that
cause a person to be susceptible to ADHD. Since its
inception in 1999, the Attention-Deficit Hyperactivity
Disorder Molecular Genetics Network has served as a way
for researchers to share findings regarding possible
genetic influences on ADHD.8
Recent Studies on Causes of ADHD
Some knowledge of the structure of the brain is
helpful in understanding the research scientists are
doing in searching for a physical basis for attention
deficit hyperactivity disorder. One part of the brain
that scientists have focused on in their search is the
frontal lobes of the cerebrum. The frontal
lobes allow us to solve problems, plan ahead, understand
the behavior of others, and restrain our impulses. The
two frontal lobes, the right and the left, communicate
with each other through the corpus callosum,
(nerve fibers that connect the right and left frontal
lobes).
The basal ganglia are the interconnected
gray masses deep in the cerebral hemisphere that serve
as the connection between the cerebrum and the
cerebellum and, with the cerebellum, are
responsible for motor coordination. The cerebellum is
divided into three parts. The middle part is called the
vermis.
All of these parts of the brain have been studied
through the use of various methods for seeing into or
imaging the brain. These methods include functional
magnetic resonance imaging (fMRI) positron emission
tomography (PET), and single photon emission computed
tomography (SPECT). The main or central psychological
deficits in those with ADHD have been linked through
these studies. By 2002 the researchers in the NIMH Child
Psychiatry Branch had studied 152 boys and girls with
ADHD, matched with 139 age- and gender-matched controls
without ADHD. The children were scanned at least twice,
some as many as four times over a decade. As a group,
the ADHD children showed 3-4 percent smaller brain
volumes in all regions—the frontal lobes, temporal gray
matter, caudate nucleus, and cerebellum.
This study also showed that the ADHD children who
were on medication had a white matter volume that did
not differ from that of controls. Those never-medicated
patients had an abnormally small volume of white matter.
The white matter consists of fibers that establish
long-distance connections between brain regions. It
normally thickens as a child grows older and the brain
matures.9
Although this long-term study used MRI to scan the
children’s brains, the researchers stressed that MRI
remains a research tool and cannot be used to diagnose
ADHD in any given child. This is true for other
neurological methods of evaluating the brain, such as
PET and SPECT.
Disorders that
Sometimes Accompany ADHD
Learning Disabilities
Many children with ADHD—approximately 20 to 30
percent—also have a specific learning disability (LD).10
In preschool years, these disabilities include
difficulty in understanding certain sounds or words
and/or difficulty in expressing oneself in words. In
school age children, reading or spelling disabilities,
writing disorders, and arithmetic disorders may appear.
A type of reading disorder, dyslexia, is quite
widespread. Reading disabilities affect up to 8 percent
of elementary school children.
Tourette Syndrome
A very small proportion of people with ADHD have a
neurological disorder called Tourette syndrome. People
with Tourette syndrome have various nervous tics and
repetitive mannerisms, such as eye blinks, facial
twitches, or grimacing. Others may clear their throats
frequently, snort, sniff, or bark out words. These
behaviors can be controlled with medication. While very
few children have this syndrome, many of the cases of
Tourette syndrome have associated ADHD. In such cases,
both disorders often require treatment that may include
medications.
Oppositional Defiant Disorder
As many as one-third to one-half of all children with
ADHD—mostly boys—have another condition, known as
oppositional defiant disorder (ODD). These children are
often defiant, stubborn, non-compliant, have outbursts
of temper, or become belligerent. They argue with adults
and refuse to obey.
Conduct Disorder
About 20 to 40 percent of ADHD children may
eventually develop conduct disorder (CD), a more serious
pattern of antisocial behavior. These children
frequently lie or steal, fight with or bully others, and
are at a real risk of getting into trouble at school or
with the police. They violate the basic rights of other
people, are aggressive toward people and/or animals,
destroy property, break into people’s homes, commit
thefts, carry or use weapons, or engage in vandalism.
These children or teens are at greater risk for
substance use experimentation, and later dependence and
abuse. They need immediate help.
Anxiety and Depression
Some children with ADHD often have co-occurring
anxiety or depression. If the anxiety or depression is
recognized and treated, the child will be better able to
handle the problems that accompany ADHD. Conversely,
effective treatment of ADHD can have a positive impact
on anxiety as the child is better able to master
academic tasks.
Bipolar Disorder
There are no accurate statistics on how many children
with ADHD also have bipolar disorder. Differentiating
between ADHD and bipolar disorder in childhood can be
difficult. In its classic form, bipolar disorder is
characterized by mood cycling between periods of intense
highs and lows. But in children, bipolar disorder often
seems to be a rather chronic mood dysregulation with a
mixture of elation, depression, and irritability.
Furthermore, there are some symptoms that can be present
both in ADHD and bipolar disorder, such as a high level
of energy and a reduced need for sleep. Of the symptoms
differentiating children with ADHD from those with
bipolar disorder, elated mood and grandiosity of the
bipolar child are distinguishing characteristics.11
The Treatment of ADHD
Every family wants to determine what treatment will
be most effective for their child. This question needs
to be answered by each family in consultation with their
health care professional. To help families make this
important decision, the National Institute of Mental
Health (NIMH) has funded many studies of treatments for
ADHD and has conducted the most intensive study ever
undertaken for evaluating the treatment of this
disorder. This study is known as the Multimodal
Treatment Study of Children with Attention Deficit
Hyperactivity Disorder (MTA).12 The NIMH is
now conducting a clinical trial for younger children
ages 3 to 5.5 years (Treatment of ADHD in Preschool-Age
Children).
The Multimodal Treatment Study of Children with
Attention Deficit Hyperactivity Disorder
The MTA study included 579 (95-98 at each of 6
treatment sites) elementary school boys and girls with
ADHD, who were randomly assigned to one of four
treatment programs: (1) medication management alone; (2)
behavioral treatment alone; (3) a combination of both;
or (4) routine community care. In each of the study
sites, three groups were treated for the first 14 months
in a specified protocol and the fourth group was
referred for community treatment of the parents’
choosing. All of the children were reassessed regularly
throughout the study period. An essential part of the
program was the cooperation of the schools, including
principals and teachers. Both teachers and parents rated
the children on hyperactivity, impulsivity, and
inattention, and symptoms of anxiety and depression, as
well as social skills.
The children in two groups (medication management
alone and the combination treatment) were seen monthly
for one-half hour at each medication visit. During the
treatment visits, the prescribing physician spoke with
the parent, met with the child, and sought to determine
any concerns that the family might have regarding the
medication or the child’s ADHD-related difficulties. The
physicians, in addition, sought input from the teachers
on a monthly basis. The physicians in the
medication-only group did not provide behavioral therapy
but did advise the parents when necessary concerning any
problems the child might have.
In the behavior treatment-only group, families met up
to 35 times with a behavior therapist, mostly in group
sessions. These therapists also made repeated visits to
schools to consult with children’s teachers and to
supervise a special aide assigned to each child in the
group. In addition, children attended a special 8-week
summer treatment program where they worked on academic,
social, and sports skills, and where intensive
behavioral therapy was delivered to assist children in
improving their behavior.
Children in the combined therapy group received both
treatments, that is, all the same assistance that the
medication-only received, as well as all of the behavior
therapy treatments.
In routine community care, the children saw the
community-treatment doctor of their parents’ choice one
to two times per year for short periods of time. Also,
the community-treatment doctor did not have any
interaction with the teachers.
The results of the study indicated that long-term
combination treatments and the medication-management
alone were superior to intensive behavioral treatment
and routine community treatment. And in some
areas—anxiety, academic performance, oppositionality,
parent-child relations, and social skills—the combined
treatment was usually superior. Another advantage of
combined treatment was that children could be
successfully treated with lower doses of medicine,
compared with the medication-only group.
Treatment of Attention Deficit Hyperactivity
Disorder in Preschool-Age Children (PATS)
Because many children in the preschool years are
diagnosed with ADHD and are given medication, it is
important to know the safety and efficacy of such
treatment. The NIMH is sponsoring an ongoing multi-site
study, “Preschool ADHD Treatment Study” (PATS). It is
the first major effort to examine the safety and
efficacy of a stimulant, methylphenidate, for ADHD in
this age group. The PATS study uses a randomized,
placebo-controlled, double-blind design. Children ages 3
to 5 who have severe and persistent symptoms of ADHD
that impair their functioning are eligible for this
study. To avoid using medications at such an early age,
all children who enter the study are first treated with
behavioral therapy. Only children who do not show
sufficient improvement with behavior therapy are
considered for the medication part of the study. The
study is being conducted at New York State Psychiatric
Institute, Duke University, Johns Hopkins University,
New York University, the University of California at Los
Angeles, and the University of California at Irvine.
Enrollment in the study will total 165 children.
Which Treatment Should My Child Have?
For children with ADHD, no single treatment is the
answer for every child. A child may sometimes have
undesirable side effects to a medication that would make
that particular treatment unacceptable. And if a child
with ADHD also has anxiety or depression, a treatment
combining medication and behavioral therapy might be
best. Each child’s needs and personal history must be
carefully considered.
Medications
For decades, medications have been used to treat the
symptoms of ADHD.
The medications that seem to be the most effective
are a class of drugs known as stimulants. Following is a
list of the stimulants, their trade (or brand) names,
and their generic names. “Approved age” means that the
drug has been tested and found safe and effective in
children of that age.
Trade Name |
Generic Name |
Approved Age |
Adderall |
amphetamine |
3 and older |
Concerta |
methylphenidate
(long acting) |
6 and older |
Cylert* |
pemoline |
6 and older |
Dexedrine |
dextroamphetamine |
3 and older |
Dextrostat |
dextroamphetamine |
3 and older |
Focalin |
dexmethylphenidate |
6 and older |
Metadate ER |
methylphenidate
(extended release) |
6 and older |
Metadate CD |
methylphenidate
(extended release) |
6 and older |
Ritalin |
methylphenidate |
6 and older |
Ritalin SR |
methylphenidate
(extended release) |
6 and older |
Ritalin LA |
methylphenidate
(long acting) |
6 and older |
*Because of its potential
for serious side effects affecting the
liver, Cylert should not ordinarily be
considered as first-line drug therapy for
ADHD. |
The U.S. Food and Drug Administration (FDA) recently
approved a medication for ADHD that is not a
stimulant. The medication, Strattera®, or
atomoxetine, works on the neurotransmitter
norepinephrine, whereas the stimulants primarily
work on dopamine. Both of theses neurotransmitters
are believed to play a role in ADHD. More studies
will need to be done to contrast Strattera with the
medications already available, but the evidence to
date indicates that over 70 percent of children with
ADHD given Strattera manifest significant
improvement in their symptoms.
Some people get better results from one medication,
some from another. It is important to work with the
prescribing physician to find the right medication and
the right dosage. For many people, the stimulants
dramatically reduce their hyperactivity and impulsivity
and improve their ability to focus, work, and learn. The
medications may also improve physical coordination, such
as that needed in handwriting and in sports.
The stimulant drugs, when used with medical
supervision, are usually considered quite safe.
Stimulants do not make the child feel “high,” although
some children say they feel different or funny. Such
changes are usually very minor. Although some parents
worry that their child may become addicted to the
medication, to date there is no convincing evidence that
stimulant medications, when used for treatment of ADHD,
cause drug abuse or dependence. A review of all
long-term studies on stimulant medication and substance
abuse, conducted by researchers at Massachusetts General
Hospital and Harvard Medical School, found that
teenagers with ADHD who remained on their medication
during the teen years had a lower likelihood of
substance use or abuse than did ADHD adolescents who
were not taking medications.13
The stimulant drugs come in long- and short-term
forms. The newer sustained-release stimulants can be
taken before school and are long-lasting so that the
child does not need to go to the school nurse every day
for a pill. The doctor can discuss with the parents the
child’s needs and decide which preparation to use and
whether the child needs to take the medicine during
school hours only or in the evening and on weekends too.
If the child does not show symptom improvement after
taking a medication for a week, the doctor may try
adjusting the dosage. If there is still no improvement,
the child may be switched to another medication. About
one out of ten children is not helped by a stimulant
medication. Other types of medication may be used if
stimulants don’t work or if the ADHD occurs with another
disorder. Antidepressants and other medications can help
control accompanying depression or anxiety.
Sometimes the doctor may prescribe for a young child
a medication that has been approved by the FDA for use
in adults or older children. This use of the medication
is called “off label.” Many of the newer medications
that are proving helpful for child mental disorders are
prescribed off label because only a few of them have
been systematically studied for safety and efficacy in
children. Medications that have not undergone such
testing are dispensed with the statement that “safety
and efficacy have not been established in pediatric
patients.”
Side Effects of the Medications
Most side effects of the stimulant medications are
minor and are usually related to the dosage of the
medication being taken. Higher doses produce more side
effects. The most common side effects are decreased
appetite, insomnia, increased anxiety, and/or
irritability. Some children report mild stomach aches or
headaches.
Appetite seems to fluctuate, usually being low during
the middle of the day and more normal by suppertime.
Adequate amounts of food that is nutritional should be
available for the child, especially at peak appetite
times.
If the child has difficulty falling asleep, several
options may be tried—a lower dosage of the stimulant,
giving the stimulant earlier in the day, discontinuing
the afternoon or evening dosage, or giving an adjunct
medication such as a low-dosage antidepressant or
clonidine. A few children develop tics during treatment.
These can often be lessened by changing the medication
dosage. A very few children cannot tolerate any
stimulant, no matter how low the dosage. In such cases,
the child is often given an antidepressant instead of
the stimulant.
When a child’s schoolwork and behavior improve soon
after starting medication, the child, parents, and
teachers tend to applaud the drug for causing the sudden
changes. Unfortunately, when people see such immediate
improvement, they often think medication is all that’s
needed. But medications don’t cure ADHD; they only
control the symptoms on the day they are taken. Although
the medications help the child pay better attention and
complete school work, they can’t increase knowledge or
improve academic skills. The medications help the child
to use those skills he or she already possesses.
Behavioral therapy, emotional counseling, and
practical support will help ADHD children cope with
everyday problems and feel better about themselves.
Facts to Remember About Medication for ADHD
- Medications for ADHD help many children focus
and be more successful at school, home, and play.
Avoiding negative experiences now may actually help
prevent addictions and other emotional problems
later.
- About 80 percent of children who need medication
for ADHD still need it as teenagers. Over 50 percent
need medication as adults.
Medication for the Child with Both ADHD and Bipolar
Disorder
Since a child with bipolar disorder will probably be
prescribed a mood stabilizer such as lithium or Depakote®,
the doctor will carefully consider whether the child
should take one of the medications usually prescribed
for ADHD. If a stimulant medication is prescribed, it
may be given in a lower dosage than usual.
The Family and the ADHD
Child
Medication can help the ADHD child in everyday life.
He or she may be better able to control some of the
behavior problems that have led to trouble with parents
and siblings. But it takes time to undo the frustration,
blame, and anger that may have gone on for so long. Both
parents and children may need special help to develop
techniques for managing the patterns of behavior. In
such cases, mental health professionals can counsel the
child and the family, helping them to develop new
skills, attitudes, and ways of relating to each other.
In individual counseling, the therapist helps children
with ADHD learn to feel better about themselves. The
therapist can also help them to identify and build on
their strengths, cope with daily problems, and control
their attention and aggression. Sometimes only the child
with ADHD needs counseling support. But in many cases,
because the problem affects the family as a whole, the
entire family may need help. The therapist assists the
family in finding better ways to handle the disruptive
behaviors and promote change. If the child is young,
most of the therapist’s work is with the parents,
teaching them techniques for coping with and improving
their child’s behavior.
Several intervention approaches are available.
Knowing something about the various types of
interventions makes it easier for families to choose a
therapist that is right for their needs.
Psychotherapy works to help people
with ADHD to like and accept themselves despite their
disorder. It does not address the symptoms or underlying
causes of the disorder. In psychotherapy, patients talk
with the therapist about upsetting thoughts and
feelings, explore self-defeating patterns of behavior,
and learn alternative ways to handle their emotions. As
they talk, the therapist tries to help them understand
how they can change or better cope with their disorder.
Behavioral therapy (BT) helps people
develop more effective ways to work on immediate issues.
Rather than helping the child understand his or her
feelings and actions, it helps directly in changing
their thinking and coping and thus may lead to changes
in behavior. The support might be practical assistance,
like help in organizing tasks or schoolwork or dealing
with emotionally charged events. Or the support might be
in self-monitoring one’s own behavior and giving
self-praise or rewards for acting in a desired way such
as controlling anger or thinking before acting.
Social skills training can also help
children learn new behaviors. In social skills training,
the therapist discusses and models appropriate behaviors
important in developing and maintaining social
relationships, like waiting for a turn, sharing toys,
asking for help, or responding to teasing, then gives
children a chance to practice. For example, a child
might learn to “read” other people’s facial expression
and tone of voice in order to respond appropriately.
Social skills training helps the child to develop better
ways to play and work with other children.
Support groups help parents connect
with other people who have similar problems and concerns
with their ADHD children. Members of support groups
often meet on a regular basis (such as monthly) to hear
lectures from experts on ADHD, share frustrations and
successes, and obtain referrals to qualified specialists
and information about what works. There is strength in
numbers, and sharing experiences with others who have
similar problems helps people know that they aren’t
alone. National organizations are listed at the end of
this document.
Parenting skills training, offered
by therapists or in special classes, gives parents tools
and techniques for managing their child’s behavior. One
such technique is the use of token or point systems for
immediately rewarding good behavior or work. Another is
the use of “time-out” or isolation to a chair or bedroom
when the child becomes too unruly or out of control.
During time-outs, the child is removed from the
agitating situation and sits alone quietly for a short
time to calm down. Parents may also be taught to give
the child “quality time” each day, in which they share a
pleasurable or relaxing activity. During this time
together, the parent looks for opportunities to notice
and point out what the child does well, and praise his
or her strengths and abilities.
This system of rewards and penalties can be an
effective way to modify a child’s behavior. The parents
(or teacher) identify a few desirable behaviors that
they want to encourage in the child—such as asking for a
toy instead of grabbing it, or completing a simple task.
The child is told exactly what is expected in order to
earn the reward. The child receives the reward when he
performs the desired behavior and a mild penalty when he
doesn’t. A reward can be small, perhaps a token that can
be exchanged for special privileges, but it should be
something the child wants and is eager to earn. The
penalty might be removal of a token or a brief time-out.
Make an effort to find your child being good.
The goal, over time, is to help children learn to
control their own behavior and to choose the more
desired behavior. The technique works well with all
children, although children with ADHD may need more
frequent rewards.
In addition, parents may learn to structure
situations in ways that will allow their child to
succeed. This may include allowing only one or two
playmates at a time, so that their child doesn’t get
overstimulated. Or if their child has trouble completing
tasks, they may learn to help the child divide a large
task into small steps, then praise the child as each
step is completed. Regardless of the specific technique
parents may use to modify their child’s behavior, some
general principles appear to be useful for most children
with ADHD. These include providing more frequent and
immediate feedback (including rewards and punishment),
setting up more structure in advance of potential
problem situations, and providing greater supervision
and encouragement to children with ADHD in relatively
unrewarding or tedious situations.
Parents may also learn to use stress management
methods, such as meditation, relaxation techniques, and
exercise, to increase their own tolerance for
frustration so that they can respond more calmly to
their child’s behavior.
Some Simple Behavioral Interventions
Children with ADHD may need help in organizing.
Therefore:
- Schedule. Have the same routine
every day, from wake-up time to bedtime. The
schedule should include homework time and playtime
(including outdoor recreation and indoor activities
such as computer games). Have the schedule on the
refrigerator or a bulletin board in the kitchen. If
a schedule change must be made, make it as far in
advance as possible.
- Organize needed everyday items.
Have a place for everything and keep everything in
its place. This includes clothing, backpacks, and
school supplies.
- Use homework and notebook organizers.
Stress the importance of writing down assignments
and bringing home needed books.
Children with ADHD need consistent rules that they
can understand and follow. If rules are followed, give
small rewards. Children with ADHD often receive, and
expect, criticism. Look for good behavior and praise it.
Your ADHD Child and School
You are your child’s best
advocate. To be a good advocate for your child,
learn as much as you can about ADHD and how it affects
your child at home, in school, and in social situations.
If your child has shown symptoms of ADHD from an
early age and has been evaluated, diagnosed, and treated
with either behavior modification or medication or a
combination of both, when your child enters the school
system, let his or her teachers know. They will be
better prepared to help the child come into this new
world away from home.
If your child enters school and experiences
difficulties that lead you to suspect that he or she has
ADHD, you can either seek the services of an outside
professional or you can ask the local school district to
conduct an evaluation. Some parents prefer to go to a
professional of their own choice. But it is the school’s
obligation to evaluate children that they suspect have
ADHD or some other disability that is affecting not only
their academic work but their interactions with
classmates and teachers.
If you feel that your child has ADHD and isn’t
learning in school as he or she should, you should find
out just who in the school system you should contact.
Your child’s teacher should be able to help you with
this information. Then you can request—in writing—that
the school system evaluate your child. The letter should
include the date, your and your child’s names, and the
reason for requesting an evaluation. Keep a copy of the
letter in your own files.
Until the last few years, many school systems were
reluctant to evaluate a child with ADHD. But recent laws
have made clear the school’s obligation to the child
suspected of having ADHD that is affecting adversely his
or her performance in school. If the school persists in
refusing to evaluate your child, you can either get a
private evaluation or enlist some help in negotiating
with the school. Help is often as close as a local
parent group. Each state has a Parent Training and
Information (PTI) center as well as a Protection and
Advocacy (P&A) agency. (For information on the law and
on the PTI and P&A, see the section on support groups
and organizations at the end of this document.)
Once your child has been diagnosed with ADHD and
qualifies for special education services, the school,
working with you, must assess the child’s strengths and
weaknesses and design an Individualized Educational
Program (IEP). You should be able periodically to review
and approve your child’s IEP. Each school year brings a
new teacher and new schoolwork, a transition that can be
quite difficult for the child with ADHD. Your child
needs lots of support and encouragement at this time.
Never forget the cardinal rule—you are your
child’s best advocate.
Your Teenager with ADHD
Your child with ADHD has successfully navigated the
early school years and is beginning his or her journey
through middle school and high school. Although your
child has been periodically evaluated through the years,
this is a good time to have a complete re-evaluation of
your child’s health.
The teen years are challenging for most children; for
the child with ADHD these years are doubly hard. All the
adolescent problems—peer pressure, the fear of failure
in both school and socially, low self-esteem—are harder
for the ADHD child to handle. The desire to be
independent, to try new and forbidden things—alcohol,
drugs, and sexual activity—can lead to unforeseen
consequences. The rules that once were, for the most
part, followed, are often now flaunted. Parents may not
agree with each other on how the teenager’s behavior
should be handled.
Now, more than ever, rules should be straightforward
and easy to understand. Communication between the
adolescent and parents can help the teenager to know the
reasons for each rule. When a rule is set, it should be
clear why the rule is set. Sometimes it helps
to have a chart, posted usually in the kitchen, that
lists all household rules and all rules for outside the
home (social and school). Another chart could list
household chores with space to check off a chore once it
is done.
When rules are broken—and they will be—respond to
this inappropriate behavior as calmly and
matter-of-factly as possible. Use punishment sparingly.
Even with teens, a time-out can work. Impulsivity and
hot temper often accompany ADHD. A short time alone can
help.
As the teenager spends more time away from home,
there will be demands for a later curfew and the use of
the car. Listen to your child’s request, give reasons
for your opinion and listen to his or her opinion, and
negotiate. Communication, negotiation, and
compromise will prove helpful.
Your Teenager and the Car.
Teenagers, especially boys, begin talking about
driving by the time they are 15. In some states, a
learner’s permit is available at 15 and a driver’s
license at 16. Statistics show that 16-year-old drivers
have more accidents per driving mile than any other age.
In the year 2000, 18 percent of those who died in
speed-related crashes were youth ages 15 to 19.
Sixty-six percent of these youth were not wearing safety
belts. Youth with ADHD, in their first 2 to 5 years of
driving, have nearly four times as many automobile
accidents, are more likely to cause bodily injury in
accidents, and have three times as many citations for
speeding as the young drivers without ADHD.14
Most states, after looking at the statistics for
automobile accidents involving teenage drivers, have
begun to use a graduated driver licensing system (GDL).
This system eases young drivers onto the roads by a slow
progression of exposure to more difficult driving
experiences. The program, as developed by the National
Highway Traffic Safety Administration and the American
Association of Motor Vehicle Administrators, consists of
three stages: learner’s permit, intermediate
(provisional) license, and full licensure. Drivers must
demonstrate responsible driving behavior at each stage
before advancing to the next level. During the learner’s
permit stage, a licensed adult must be in the car at all
times.15 This period of time will give the
learner a chance to practice, practice, practice. The
more your child drives, the more efficient he or she
will become. The sense of accomplishment the teenager
with ADHD will feel when the coveted license is finally
in his or her hands will make all the time and effort
involved worthwhile.
Note: The State Legislative Fact Sheets—Graduated
Driver Licensing System can be found at web site
http://www.nhtsa.dot.gov/people/outreach/
safesobr/21qp/html/fact_sheets/Graduated_Driver.html,
or it can be ordered from NHTSA Headquarters, Traffic
Safety Programs, ATTN: NTS-32, 400 Seventh Street, S.W.,
Washington, DC 20590; telephone 202-366-6948.
Attention Deficit
Hyperactivity Disorder in Adults
Attention deficit hyperactivity disorder is a highly
publicized childhood disorder that affects approximately
3 percent to 5 percent of all children. What is much
less well known is the probability that, of children who
have ADHD, many will still have it as adults. Several
studies done in recent years estimate that between 30
percent and 70 percent of children with ADHD continue to
exhibit symptoms in the adult years.16
The first studies on adults who were never diagnosed
as children as having ADHD, but showed symptoms as
adults, were done in the late 1970s by Drs. Paul Wender,
Frederick Reimherr, and David Wood. These symptomatic
adults were retrospectively diagnosed with ADHD after
the researchers’ interviews with their parents. The
researchers developed clinical criteria for the
diagnosis of adult ADHD (the Utah Criteria), which
combined past history of ADHD with current evidence of
ADHD behaviors.17 Other diagnostic
assessments are now available; among them are the widely
used Conners Rating Scale and the Brown Attention
Deficit Disorder Scale.
Typically, adults with ADHD are unaware that they
have this disorder—they often just feel that it’s
impossible to get organized, to stick to a job, to keep
an appointment. The everyday tasks of getting up,
getting dressed and ready for the day’s work, getting to
work on time, and being productive on the job can be
major challenges for the ADHD adult.
Diagnosing ADHD in an Adult
Diagnosing an adult with ADHD is not easy. Many
times, when a child is diagnosed with the disorder, a
parent will recognize that he or she has many of the
same symptoms the child has and, for the first time,
will begin to understand some of the traits that have
given him or her trouble for years—distractibility,
impulsivity, restlessness. Other adults will seek
professional help for depression or anxiety and will
find out that the root cause of some of their emotional
problems is ADHD. They may have a history of school
failures or problems at work. Often they have been
involved in frequent automobile accidents.
To be diagnosed with ADHD, an adult must have
childhood-onset, persistent, and current symptoms.18
The accuracy of the diagnosis of adult ADHD is of utmost
importance and should be made by a clinician with
expertise in the area of attention dysfunction. For an
accurate diagnosis, a history of the patient’s childhood
behavior, together with an interview with his life
partner, a parent, close friend, or other close
associate, will be needed. A physical examination and
psychological tests should also be given. Comorbidity
with other conditions may exist such as specific
learning disabilities, anxiety, or affective disorders.
A correct diagnosis of ADHD can bring a sense of
relief. The individual has brought into adulthood many
negative perceptions of himself that may have led to low
esteem. Now he can begin to understand why he has some
of his problems and can begin to face them. This may
mean, not only treatment for ADHD but also psychotherapy
that can help him cope with the anger he feels about the
failure to diagnose the disorder when he was younger.
Treatment of ADHD in an Adult
Medications. As with children, if
adults take a medication for ADHD, they often start with
a stimulant medication. The stimulant medications affect
the regulation of two neurotransmitters, norepinephrine
and dopamine. The newest medication approved for ADHD by
the FDA, atomoxetine (Strattera®), has been tested in
controlled studies in both children and adults and has
been found to be effective.19
Antidepressants are considered a second choice for
treatment of adults with ADHD. The older
antidepressants, the tricyclics, are sometimes used
because they, like the stimulants, affect norepinephrine
and dopamine. Venlafaxine (Effexor®), a newer
antidepressant, is also used for its effect on
norepinephrine. Bupropion (Wellbutrin®), an
antidepressant with an indirect effect on the
neurotransmitter dopamine, has been useful in clinical
trials on the treatment of ADHD in both children and
adults. It has the added attraction of being useful in
reducing cigarette smoking.
In prescribing for an adult, special considerations
are made. The adult may need less of the medication for
his weight. A medication may have a longer “half-life”
in an adult. The adult may take other medications for
physical problems such as diabetes or high blood
pressure. Often the adult is also taking a medication
for anxiety or depression. All of these variables must
be taken into account before a medication is prescribed.
Education and psychotherapy.
Although medication gives needed support, the individual
must succeed on his own. To help in this struggle, both
“psychoeducation” and individual psychotherapy can be
helpful. A professional coach can help the ADHD adult
learn how to organize his life by using “props”—a large
calendar posted where it will be seen in the morning,
date books, lists, reminder notes, and have a special
place for keys, bills, and the paperwork of everyday
life. Tasks can be organized into sections, so that
completion of each part can give a sense of
accomplishment. Above all, ADHD adults should learn as
much as they can about their disorder.
Psychotherapy can be a useful adjunct to medication
and education. First, just remembering to keep an
appointment with the therapist is a step toward keeping
to a routine. Therapy can help change a long-standing
poor self-image by examining the experiences that
produced it. The therapist can encourage the ADHD
patient to adjust to changes brought into his life by
treatment—the perceived loss of impulsivity and love of
risk-taking, the new sensation of thinking before
acting. As the patient begins to have small successes in
his new ability to bring organization out of the
complexities of his or her life, he or she can begin to
appreciate the characteristics of ADHD that are
positive—boundless energy, warmth, and enthusiasm.
References and Resource
Books
References
1. Still GF. Some abnormal psychical conditions in
children: the Goulstonian lectures. Lancet,
1902;1:1008-1012.
2. DSM-IV-TR workgroup. The Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC: American
Psychiatric Association.
3. Consensus Development Panel. Defined Diets
and Childhood Hyperactivity. National Institutes
of Health Consensus Development Conference Summary,
Volume 4, Number 3, 1982.
4. Wolraich M, Milich R, Stumbo P, Schultz F. The
effects of sucrose ingestion on the behavior of
hyperactive boys. Pediatrics, 1985; 106;
657-682.
5. Hoover DW, Milich R. Effects of sugar ingestion
expectancies on mother-child interaction. Journal
of Abnormal Child Psychology, 1994; 22; 501-515.
6. Biederman J, Faraone SV, Keenan K, Knee D, Tsuang
MF. Family-genetic and psychosocial risk factors in
DSM-III attention deficit disorder. Journal of the
American Academy of Child and Adolescent Psychiatry,
1990; 29(4): 526-533.
7. Faraone SV, Biederman J. Neurobiology of
attention-deficit hyperactivity disorder.
Biological Psychiatry, 1998; 44; 951-958.
8. The ADHD Molecular Genetics Network. Report from
the third international meeting of the attention-deficit
hyperactivity disorder molecular genetics network.
American Journal of Medical Genetics, 2002,
114:272-277.
9. Castellanos FX, Lee PP, Sharp W, Jeffries NO,
Greenstein DK, Clasen LS, Blumenthal JD, James RS, Ebens
CI, Walter JM, Zijdenbos A, Evans AC, Giedd JN, Rapoport
JL. Developmental trajectories of brain volume
abnormalities in children and adolescents with
attention-deficit/hyperactivity disorder. Journal
of the American Medical Association, 2002,
288:14:1740-1748.
10. Wender PH. ADHD: Attention-Deficit
Hyperactivity Disorder in Children and Adults.
Oxford University Press, 2002, p. 9.
11. Geller B, Williams M, Zimerman B, Frazier J,
Beringer L, Warner KL. Prepubertal and early adolescent
bipolarity differentiate from ADHD by manic symptoms,
grandiose delusions, ultra-rapid or ultradian cycling.
Journal of Affective Disorders, 1998,
51:81-91.
12. The MTA Cooperative Group. A 14-month randomized
clinical trial of treatment strategies for
attention-deficit hyperactivity disorder (ADHD).
Archives of General Psychiatry,
1999;56:1073-1086.
13. Wilens TC, Faraone, SV, Biederman J, Gunawardene
S. Does stimulant therapy of
attention-deficit/hyperactivity disorder beget later
substance abuse? A meta-analytic review of the
literature. Pediatrics, 2003,
111:1:179-185.
14. Barkley RA. Taking Charge of ADHD.
New York: The Guilford Press, 2000, p. 21.
15. U.S. Department of Transportation, National
Highway Traffic Safety Administration. State
Legislative Fact Sheet, April 2002.
16. Silver LB. Attention-deficit hyperactivity
disorder in adult life. Child and Adolescent
Psychiatric Clinics of North America, 2000:9:3:
411-523.
17. Wender PH. Pharmacotherapy of
attention-deficit/hyperactivity in adults. Journal
of Clinical Psychiatry, 1998; 59 (supplement
7):76-79.
18. Wilens TE, Biederman J, Spencer TJ. Attention
deficit/hyperactivity disorder across the lifespan.
Annual Review of Medicine, 2002:53:113-131.
19. Attention Deficit Disorder in Adults.
Harvard Mental Health Letter, 2002:19;5:3-6.
Resource Books
The following books were helpful resources in the
writing of this document. Many other informative books
can be found at any good bookstore, on a website that
offers books for sale, or from the ADD Warehouse
catalog.
Taking Charge of ADHD, by Russell A.
Barkley, PhD. New York: The Guilford Press, 2000.
ADHD: Attention-Deficit Hyperactivity Disorder
in Children and Adults, by Paul H. Wender, MD.
Oxford University Press, 2002.
Straight Talk about Psychiatric Medications for
Kids, by Timothy E. Wilens, MD. New York: The
Guilford Press, 1999.
For More Information
Attention Deficit Hyperactivity Disorder Information and
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