AD/HD (attention deficit/hyperactivity disorder) is a very common condition, affecting millions of children and adults in the USA, resulting in difficulties involving attention span and hyperactive, impulsive behavior. This causes an impairment of function that may affect the academic abilities, behavior, social skills, one’s self-esteem, or vocation/occupation.
The prevalence of this disorder is about 10%. Different studies report prevalence rates of 1.7% to 17.8%. The difference in these frequency rates is related to recognition of the disorder and to issues of quality of life, since in some societies certain impairments such as learning impairments may be considered less important. A “significant degree of impairment” is required for the diagnosis, but may be considered differently. The higher the socioeconomic status, the more important the academic performance. The environment we live in may greatly influence the determination of “an impairment” and who meets criteria for the diagnosis and treatment for AD/HD.
The slash (“/”) in AD/HD, indicates that in order to qualify for the diagnosis, one may have attention deficit alone, hyperactivity alone, or any combination of the two. Other terms, such as ADD are outdated and no longer in use as an official medical diagnosis.
The diagnosis of AD/HD is based on the Diagnostic Statistical Manual 5th Edition (DSM V) diagnostic criteria. Some assessment scales, such as the Conner Scales, and others, may be helpful in the collection of the diagnostic behavioral features, required for or suggestive of the diagnosis of AD/HD.
In simple terms, all four of the following diagnostic criteria must be met for a diagnosis of AD/HD to be established:
A more detailed understanding of the above criteria is provided by reading and understanding the DSM V criteria.
All of the criteria from A to E must be met for AD/HD to be diagnosed.
Attention-deficit/hyperactivity disorder, combined type: if both criteria A1 and A2 are met for the past 6 months.
Attention-deficit/hyperactivity disorder, predominantly inattentive type: if criterion A1 is met but criterion A2 is not met for the past 6 months.
Attention-deficit/hyperactivity disorder, predominantly hyperactive-impulsive type: if criterion A2 is met but criterion A1 is not met for the past 6 months.
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “in partial remission” should be specified. Severity: mild, moderate, severe.
Other Specified AD/HD: Impairment in function is present, yet not all criteria for AD/HD were met. One must specify why the criteria weren’t fully met.
Unspecified AD/HD: Impairment in function is present, yet not all criteria for AD/HD were met. The clinician chooses not to specify why criteria weren’t used, for instance, when insufficient information is available.
AD/HD always presents before 7 years of age (according to the DSM V criteria). Usually children will be restless, up and on the go, unable to sit still, being squirmy on the chair and fidgeting frequently. They may be excitable, impulsive (doing things without thinking of the consequences, such as pushing, cursing, yelling or lying). They will also have a poor attention span and easy distractibility (looking out the window in class, jumping from one toy or occupation to another). Some kids may be so distracted that they will forget what was told to them while on the way to follow orders just given to them. For example, getting something from the refrigerator for mom, forgetting about it and ending up drinking a soda and heading away to do something else. Or trying to dress up and ending up playing with a sock for 10 minutes when the bus is due in 2 minutes. When a child has hyperactive symptoms with associated behavioral difficulties, the referral to get diagnosed is faster and the diagnosis is relatively easy. This scenario will more commonly occur in boys.
These are the ones who have AD/HD of the predominantly inattentive type, most commonly girls (but many boys fall under this category as well). These kids present with the cognitive impairment of AD/HD. They may do relatively well until schoolwork becomes more difficult. Some may present with academic difficulties only in Junior High, when the work becomes more complicated and the requirements complex with different teachers and the need to change classes. The impairment may begin later in life, some symptoms however must be present before 6 years of age (see DSM V criteria).
The cognitive dysfunctions of AD/HD include the procrastination, the inability to start work on a pre-set time, “forgetfulness,” poor organization skills, fluctuating grades (even in the same subject), taking a very long time to complete a relatively simple task. They may also have a difficult time maintaining “mental energy” focused on a task.
Reading may be a problem, since as they start reading, their mind may become distracted, leading to thinking about something else, so that by the end of the paragraph or a page, the individual has no idea what they were reading about. The same thing may happen when trying to monitor a conversation, a lecture, or copying the homework from the blackboard.
Others may be unable to complete a simple task, jumping from one thing to the other, starting many different assignments, unable to complete any of them. For example trying to clean the room knowing that mom will check it in one hour. As soon as the child is starting to clean up, he comes across a book, remembering that homework is not done, looking for the notebook but the homework assignment is not written down. The next logical thing is to call a friend who gives him the homework but also reminds him of the rock concert next week. This urges him to listen to the band’s CD, but it seems to be out of the box. “No problema!” he thinks to himself, I can load this music on the computer in one second. He goes online with AOL and guess what??? His best buddy is online. He chats a little with his friend remembering that he wanted to download some music, but on his way he clicks on a very appealing commercial for skateboards, his favorite hobby, checking out the latest models only to be “awaken” by his mother’s voice, yelling at him in a terrible screeching voice. “What’s wrong with you? You had an hour to clean up your room and nothing was done.” The child gets upset and starts crying, yelling back, “I can’t believe you are angry at me for trying to do my homework.”
The best way of understanding the cognitive dysfunctions of AD/HD is by trying to perform a very demanding academic task very late at night, being extremely tired, when all one really wants to do is sit comfortably and “veg out in front of the TV.” Doing the task under these circumstances may require reading and re-reading the same page several times until it “sinks in.” This is how a child with AD/HD operates under regular conditions. Similar difficulties will be present in undiagnosed adults with this condition.
What usually stands behind AD/HD is a genetic tendency to have a “mild chemical imbalance” in the brain, involving mostly the neurotransmitters dopamine, epinephrine, and norepinephrine. Decreased dopamine function in the brain results in slowed “dopaminergic” neurotransmission that leads to a poor utilization of some brain activities. This results in the AD/HD symptoms. Supplementing the brain with missing dopamine, as a result of the use of stimulant medications, may correct this situation.
Dr. Grossmann likes to use a graphic representation to help explain to families and patients the physiological basis of AD/HD.
This is a simplified understanding of the mechanism which is more complicated, involving other neurotransmitters as well, including norepinephrine and serotonin, as well as different areas of the brain which are more involved than others.
The best way of helping a child who has this condition, requires a serious multidisciplinary approach. This must include:
The degree of response to medication varies individually and some do not respond to stimulant medications. For a visual example of the effect of medication on one child, the links below are examples of one child’s handwriting:
Please note: This is only one child’s experience. Many children respond as well or better, but not all.
Adderall, Ritalin, Metadate, Methylin, Daytrana, Concerta, Dexedrine, Focalin, Quillivant XR and Vyvance are the stimulant medications currently on the market.
Stattera, or atomoxetine HCl has been available since January 2003. This is a non-stimulant, non-controlled substance medication. Straterra works on a different neurotransmitter compared to the stimulants that increase dopamin activity. Straterra is a selective norepinephrine reuptake inhibitor, meaning it increases the norepinephrine activity. Straterra is available in 5mg, 10mg, 18mg, 25mg, 40mg, 60mg, 80mg and 100mg capsules. The target dose is 1.2mg/kg in a single daily dose, but should be initiated at 0.5mg/kg to prevent side effects. In some patients (kids over 70kg body weight or adults), the dose was pushed up to a maximum of 100mg per day in a single daily dose or evenly distributed in a morning and late evening dose. If drowsiness occurs, the entire dose may be given at night.
Side effects may include allergic reactions (rare), weight loss, mild temporary growth retardation, hypertension and rapid heart rate, orthostatic hypotension (feeling dizzy when getting up from sitting due to a fall in blood pressure), urinary retention, dry mouth, abdominal pain3, irritability, constipation, nausea, sleeping difficulties, erectile and ejaculatory disturbances. Strattera is a milder medication with less dramatic effects compared to the fast acting stimulant medications. Yet, for some individuals who are unable to tolerate stimulant medications, Strattera may be an excellent alternative. These are, for the most part, individuals with anxiety disorders, nervous tic disorders, obsessive compulsive disorder or some patients with autism or other milder degrees of Pervasive Developmental Disorders (PDD’s) who are unable to tolerate stimulant medications. Strattera may take a longer time time to exert its functions, usually 1-2 weeks. On some occasions, Strattera may be added to stimulant medications in order to enhance their effect.
Adderall, an excellent first line medication for AD/HD. It is safe, effective, long acting (6-10 hours) and easily dosed. Unlike Ritalin, which is slow acting and comes in 20mg sustained release (SR) tablets that cannot be broken into smaller pieces, Adderall comes in 5, 7.5, 10, 12.5, 15, 20, and 30 mg tablets, all scorable to halves and quarters that make dosing much easier, enabling one to customize the dose specifically to the child’s needs, with great dosing flexibility.
Adderall XR or “extended release” stays in the system for 12 hours, covering the homeworks needs and some of the evening difficulties. The Adderall XR comes in a capsule form of 5mg, 10mg, 15mg, 20mg, 25mg, or 30mg. Another advantage is that this medication comes in sprinkle form that may be sprinkled on food, overcoming the need to swallow tablets or crush and ingest tablets that taste badly. A very effective course of action is to start with the short active Adderall, fine tune the dose based on the individual’s needs and then switch to the Adderal XR. Usually an additional 25-30% in total milligrams is required for this adjustment.
For example, a person who did best with 10mg of Adderall (short acting) will do very well with Adderall XR 15mg. This increases the duration of the same effect from 8-10 hours.
Concerta is a 12 hour (slow release) methylphenidate. This is the same substance as Ritalin, Meladate, Methylin, Daytrana and Quillivant XR. Concerta is an excellent alternative for Adderall, especially in the younger children who are irritable and cry easily as a side effect of Adderall or Dexedrine. Concerta must be swallowed and can’t be broken to small pieces since the mechanism of release is a small laser drilled hole at the pole of the capsule through which the medicine gets release during the course of the day.
Daytrana is the patch. It’s applied at the hip area and releases the same medicine as Concerta. The advantages include, no need to swallow, a full control on the duration of the activity (can be placed before the child wakes up or later during the day and may be taken off at any time.) Once taken off the effect continues for 3 hours. The disadvantages include a frequent rash, the child may take it off himself and some technical problems applying the patch reported by some people.
Quillivant XR is a liquid form of methylphenidate extended release that works well for 9-12 hours. It is an excellent first like medication since it provides the best available dosing flexibility with the measuring syringe, provided by the company.
Vyvance or Lisdexamfetamine, is a prodrug. Prodrug means that it has no effect at its given form, yet once ingested it converts into the active medication. In the Vyvance case, it converts to Dextroamphetamine and Amphetamine or Dexedrine. Dexedrine is a component of Adderall. Adderall is made of Dextroamphetamine and Amphetamine. The only difference between Vyvance and Dexedrine is the duration of action. Vyvance works 11-14 hours. Dexedrine works 4 hours and Dexedrine SR works 8 hours. Adderall is a more effective medication for most people and surprisingly, is very well tolerated.
Focalin is a component of Ritalin. The generic name is Detromethylphenidate (Dextro = Right) or the right side of the methylphenidate molecule. By splitting the Ritalin molecule and using just the right side of it, many of the side effects related to left side may be eliminated. This is an individual effect, but in some cases Focalin may eliminate the anxiety, tics, decreased appetite, OCD or sleeping problems that may occur in Ritalin.
To simplify the AD/HD stimulants medications understand: There are two groups. There are two groups. Ritalin-like and Adderall-like.
Group 1
These are all the same. The only difference is the mechanism of release. Focalin is a portion (isomer) of Ritalin.
Group 2
Adderall and Adderall XR are Dexroamphetamin + Amphetamine, therefore, they will all have a similar effect. It must be noted, however, that for some unclear reason, some people will respond well to a particular medication, yet less effectively or poorly to the same preparation with a slightly different system.
In all, there are 12 Ritalin like medications and 5 Adderall like medications on the market. It may be confusing, but not if you think of it as just 2 drugs.
The treatment with stimulant medications is the backbone of treating AD/HD and the most important and effective measure of it. Parents have to be prepared for the fact that treatment may be prolonged. I like to compare treatment with stimulants and AD/HD in general, with placing glasses on eyes “which are out of focus.” This approach and understanding helps the child deal with his condition on a more acceptable level, not as a mental or psychiatric disorder, but more as a physical disability. I tell them, “Your attention span is out of focus. Taking Adderall in the morning is doing for your attention span what my glasses do for my eyes.” They are also told that “Without my glasses, despite having the ability to do well, I will not be able to read and I will most likely fail.” The same applies to AD/HD and medication. The parents should understand that fluctuating grades, a common aspect of AD/HD, may be similarly explained. A child who needs glasses, without them may do poorly, but when a lot of pressure mounts on him he will give it a great effort, placing his face close to the books, trying very hard to satisfy his parents, eventually succeeding to get a good grade because he has the mental ability. This effort, however, will be very difficult to maintain and a relapse to the lower grades is expected. The same thing may happen to children with AD/HD, resulting in their parents blaming them for being lazy, “Because you can do it, you have done it before.” This leads to increased frustration and more friction within the family.
Stimulants correct the underlying physiological abnormality causing AD/HD by increasing dopamine concentrations in the brain. The effect usually starts 1/2 hour after taking the medication. And with Adderall preparations, this lasts for an average of 8 or 12 hours. The effects must be clearly noticeable; a “questionable” response is unacceptable. Stimulants work in 70-80% of children with AD/HD. The effect of the stimulants may completely or partially correct the AD/HD. Once AD/HD is corrected, comorbid disorders must also be addressed. These include ODD (oppositional defiant disorder), anxiety disorder, OCD (obsessive compulsive disorder), and PDD (pervasive developmental disorder). These will be discussed in the next section.
Dosing with the stimulant medication is not clearly formulated. This is more of an art than a science and requires sensitivity to improvements and side effects. Parents (rightfully) are most concerned with side effects. Even though side effects may exist, I like parents to regard AD/HD treatments with medications as a risk free proposition. “You like it, we will go ahead. You don’t like it, we can always decrease the dose or stop the medication.” I promise my patients’ parents that I will not let their children suffer any side effects. This however places a great responsibility upon the parents to watch, observe, and be sensitive to any undesirable changes that only they can detect, such as minor “changes in personality, mild irritability, etc.” Therefore, any changes of the doses of medications should be made over weekends and holidays, so that possible dose related side effects may be readily observed and corrected. About 80-90% of side effects are dos related and resolve as proper adjustments are made.
Dosing with short acting Adderall starts low and is gradually increased, as directed by the physician, until the best effect is obtained. Certain increases may be made on a weekly basis. And if side effects are observed, the dose should be decreased to the previous one that did not cause the side effects. This approach may minimize the side effects.
Some side effects of the stimulant medication include, most commonly, a decrease in appetite. An allergic reaction (rash), which is an indication to stop the medication and never use it again, is rare. Side effects that are dose related (too much medicine) include increased irritability, tiredness, and “zoning out” (being too focused on one thing). These respond to lowering of the dose. In about 2% of children, nervous tics may develop, eye twitches, facial grimacing, neck movement, or frequent throat clearing. This may require stopping the treatment or decreasing the dose. Other unusual side effects may include abdominal pain, headaches, sleeping difficulties (if dosing late in the afternoon), and increased heart rate. No fatality was directly related to stimulant medications if dosed appropriately.
Most children with AD/HD will not have a completely “pure” AD/HD situation. In the majority of cases the children will have different, yet related, behavioral comorbid (coexisting) disorders. These may affect the outcome of managing AD/HD (such as in a specific math or reading/dyslexia disorder), or may confuse the diagnosis, constituting a different baseline disorder that behaves like AD/HD yet is not AD/HD (such as manic depressive disorder or a pervasive developmental disorder/autism).
The most common comorbid disorders include:
One must also expect a different degree of the comorbid disorders. When it comes to the diagnosis of psychiatric conditions, the word “disorder” indicates that one meets clear clinical criteria for a certain diagnosis. However, an individual may have behavioral tendencies of one of the disorders without having the actual diagnosis. Usually the use of the word “disorder” implies that there is an associated, significant, functional impairment due to the difficulties related to the condition.
The diagnosis of ODD requires a period of at least 6 months of negative, hostile, and defiant behavior. These kids frequently lose their temper, argue with adults, refuse to comply with rules, deliberately annoy people, blame others for their mistakes, get easily annoyed, are angry, defiant and vindictive. This becomes a “disorder” if there is a significant associated impairment; academic, social, occupational or behavioral.
A conduct disorder is a more severe form of ODD. There is a pervasive pattern of aggression towards people or animals. Physical fights, use of weapons, cruelty, destruction of property, theft, and violation of rules.
These kids may try to hide their fears or rationalize them, but still may be afraid to stay home alone, go to the bath by themselves or to leave the house by themselves. They try to avoid certain situations such as social encounters and react with apparent irritability, unexplained crying or restless behaviors rather than admit or understand clearly that they have fears. This disorder is frequently associated with an obsessive-compulsive disorder and depression.
Individuals with this disorder will have repetitive, unpleasant thoughts (obsessions) that are relieved by an unusual, ritualistic type behavior (compulsions.) Some compulsions consist of touching themselves symmetrically, washing hands frequently, holding their breath in certain situations, arranging objects, checking things frequently, and opening and closing doors repetitively. These actions may relieve the stress of the obsessions temporarily. The compulsive behaviors are known to the children to be strange, yet despite being bothered by the behaviors, they cannot help it. OCD and anxiety may be associated with the development of some nervous twitches and in extreme situations a tic disorder such as Tourette’s disorder.
Tic disorders, such as Tourette’s, are disorders consisting of multiple daily motor tics of different kinds (eye blinking, facial grimacing, body jerking) and vocal tics (yelling, grunting, throat clearing) lasting for more than a year and causing a significant impairment. This disorder is important to recognize due to the fact that it may become worse as a result of treating the AD/HD symptoms with stimulant medication (Adderall and Ritalin.)
For more information, see our section devoted to tic disorders.
Depression is another condition frequently related to anxiety and OCD. Again, to qualify for major depression as a medical entity one must meet DSM V criteria. However, there may be milder degrees of depression associated with AD/HD. Moreover, frequently in children, depression will have an atypical presentation. In addition to the typical sense of worthlessness, guilt, or sadness, as well as decreased activity, some children may present with increased irritability and unusual behaviors. Depression may also develop due to the difficulties and impact on self esteem resulting from the frustration caused by AD/HD. Physicians and parents must also be sensitive to the possibility that depression results from a side effect of stimulant medication, usually caused by overdosing.
ASD typically presents with a language delay. All children with AD/HD who have a history or a language delay must be considered for the possibility of ASD. The child will typically have poor eye contact, pervasive ignoring of other people, may develop normally and present with a regression of speech and interaction abilities at about 18 months of age.
For more information, see our section devoted to ASD/autism.
Other features of a ASD may include severe temper tantrums, especially when changing between activities, lack of interest in toys or other children, toe walking, hand flapping or bizarre play habits, such as arranging toys in rows, spinning objects or themselves, fascination with spinning objects, being in their own world or being unable to understand simple things or communicate them. Some of these children, when they become verbal, may repeat heard words, say the same phrase or repeat TV commercials over and over again and have a very unusually remarkable memory for certain details, such as train routes, numbers, dates or any field of their interest.) As they grow, many of the above mentioned symptoms may tone down. The eye contact improves, the pervasive ignoring disappears, but they remain with a poor understanding for social skills and their communication is impaired. Some of these children may also have persisting AD/HD symptoms that may respond well to treatment with stimulant medication, yet Anxiety, OCD, irritability and temper tantrums with anger outbursts may persist and worsen with the use of AD/HD medication at times.
Some (very few) children with AD/HD may have mental retardation. AD/HD may occur at any IQ level. Mental retardation is defined as an IQ score below 70 (as scored on the IQ testing.) A normal IQ score is 100. The normal range is between 80 to 120. An IQ of 70 to 80 is considered a borderline IQ. 50-70 is mild mental retardation (MR) and below 50 is a moderate MR. An IQ test may be of value in the evaluation of AD/HD in the sense that if the academic impairment does not correspond to the IQ ability, the difference between the actual performance and the IQ ability may be attributed to AD/HD. For example, in a child who has an IQ of 130, yet fails most of the academic subjects, one would expect him to be an A student based on the IQ. If this child meets criteria for AD/HD, the difference between their actual grade and their ability to be an A student may be attributed to the dysfunction caused by AD/HD. This child would be an excellent candidate for stimulant medication treatment and should be expected to do exceptionally well unless he has a separate specific learning disorder.
These are disorders affecting specific learning skills despite a normal IQ ability. A reading disorder may be termed dyslexia, alexia or developmental word blindness. This occurs in about 4% of children. (See specific dyslexia section.)
Mathematical disorders occur in about 6% of the population and despite correction of AD/HD, these children will have a permanent degree of impairment understanding mathematical concepts.
These disorders are caused by a dysfunction of a specific region of the brain and may be evaluated with neuropsychiatric testing. The mathematical disorders are caused by a dysfunction of the right occipital lobe of the brain. Reading disorders may be localized in the temporal or parietal lobes.
Medications are indicated in any child who qualifies for the diagnosis of AD/HD. If properly diagnosed, this indicates that a significant impairment is present (as per the DSM V definition). Since no other aspect of treatment of AD/HD is as effective and rewarding, once a diagnosis is correctly established, treatment should be initiated.
To assist in assessing symptoms, a symptom questionnaire should be completed by parents and a different questionnaire should be completed by a teacher. English and Spanish versions are available for both questionnaires:
Instructions:
Please fill out the appropriate forms online and then print out the completed form. Bring all applicable printed forms to the child’s appointment.
Only those children who have learning difficulties associated with an apparent “lack of effort”. Best responders will be motivated children, who hardly invest any time in their work , have a good potential, but can’t seem to get themselves to sit and study effectively. These are children with a history of fluctuating grades. A motivated family is essential.
A predetermined period of about 1 hour per day, during which the child will sit and do his school related work. This is done during school days, not during week ends or holidays. A contract should be drawn and written in cooperation with the child. The details, such as the exact starting time, location, and the reward, are decided by the child with the parents guidance using the following guidelines. All of these should be agreed upon by parents. The location should be as free of distraction as possible. (TV, music, toys, siblings)
The location must be a chair by a table (not laying on the bed or floor). The learning period should be divided into sessions, individually designed for each child’s needs. For example, 15 minutes sessions during which the child does, #1 homework, #2 Math, #3 Reading, #4 Social studies. The extra work should include academic activity specifically customized for the child, according to his or her specific difficulties.
During the period of learning some restrictions apply: (These restrictions are meant to help overcome the cognitive dysfunctions of AD/HD.)
When writing the contract, all the above mentioned details must be specified (to prevent future arguments), the contract is then signed and brought into the Dr.’s office. The agreement must be carried out strictly with as little deviation from the contract as possible.
Many kids, even if not carrying the diagnosis of AD/HD spend very little time doing their school related work on a daily basis. Some spend a long time, but very ineffectively, daydreaming and taking too many breaks.
The brain tissue can be compared to the muscle tissue. If exercised, it will be able to perform tasks previously impossible. If a child is independently able to “change old habits” by “exercising the brain,” it may lead to improved academic results and this may serve as a “ticket off the Ritalin” for some of the children with AD/HD.
This may also be compared to biofeedback, only more effective, it is practiced more frequently, is more affordable and more specific for the AD/HD child.
The extra time actually sitting and performing the work will serve as a helpful academic advantage.
This will also improve responsibility and organization skills. The child is responsible for his own reward and helps decide upon it.
The child will feel somewhat in control of his own responsibilities, which may decrease the amount of arguments, “nagging,” and unnecessary friction related to the homework issues.
The program, if carried out properly, may decrease the actual time necessary to complete the daily homework assignment, rather then extending it for a very long and ineffective play / fidget / distraction / TV and other activity time.
The child is more likely to cooperate if earning a “reward.” This may develop good solid established learning habits and help to understand the concept of future employment, responsibility and accountability, which relates to the values of our society.
This is a suggested contract that must be individually adjusted to each child’s needs and abilities. This contract should be used as a guideline:
Date: ________ Child: _________________________
Date: ________ Parent: _________________________