Parents Guide

to ADHD
Frequently asked questions, treatment options,
helpful tips and online resources
Copyright 2014
Child Mind Institute
Parents Guide to ADHD
ADHD BASICS
What is ADHD?
Whats the difference between ADD and ADHD?
Can a child whos not hyperactive or impulsive still have ADHD?
Why can kids who have ADHD concentrate on some things,
but not others?
What is executive functioning and what does it have to do
with ADHD?
Does ADHD affect kids outside of school?
Why are kids with ADHD often defant and prone to tantrums?
Do children outgrow ADHD?
DIAGNOSIS
How is ADHD diagnosed?
Who can diagnose ADHD?
TREATMENT
What is the most effective treatment for ADHD?
What are the kinds of stimulant medications?
What about side effects of stimulant medications?
Are there non-stimulant medications for ADHD?
Should kids stop taking medication during the summer?
What are the behavioral treatments for ADHD?
What can we do to help kids strengthen executive functions?
Helpful links
TABLE OF CONTENTS
page 1
page 2
page 2
page 2
page 3
page 3
page 4
page 4
page 5
page 6
page 7
page 7
page 8
page 10
page 10
page 11
page 12
page 12
What is ADHD?
Attention-defcit hyperactivity disorder, or ADHD, is a condition that makes it unusually
diffcult for children to concentrate, to pay attention, to sit still, to follow directions, and to
control impulsive behavior. While all young children can be distractible, restless, and oblivious
to parents and teachers instructions, kids with ADHD behave this way much
more often than other children their age. And their inability to focus and settle down in
age-appropriate ways makes it very hard for them to do whats expected of them at
school and at home.
Symptoms of ADHD are divided into two groups: inattentive behaviors and hyperactive
and impulsive behaviors.
Some children exhibit only the frst group of symptoms, and some exhibit only the latter.
But the majority of those with an ADHD diagnosis have a combination of both, which can
make it very diffcult for them to function in school, and in other activities, and can create
a lot of confict at home.
page 1
ADHD BASICS
Hyperactive or impulsive
symptoms of ADHD:
Fidgeting or squirming, trouble staying
in one place or waiting his turn
Excessive running and climbing
Trouble playing quietly
Extreme impatience
Always seems to be on the go or
driven by a motor
Excessive talking or interrupting,
blurting out answers
Inattentive symptoms of
ADHD:
Makes careless mistakes
Is easily distracted
Doesnt seem to be listening when
spoken to directly
Has diffculty following instructions
Has trouble organizing
Avoids or dislikes sustained effort
Is forgetful, always losing things
Parents Guide to ADHD
page 2
Parents Guide to ADHD
Whats the difference between ADD and ADHD?
ADD, or attention-defcit disorder, is an older term for the disorder we now call ADHD,
or attention-defcit hyperactivity disorder. It was called ADD up until 1987, when the word
hyperactivity was added. Some people still use the old term, ADD, out of habit, or because its
a more familiar term than ADHD. Some use it to refer to kids with ADHD who arent hyperactive.
Can a child whos not hyperactive or impulsive still have ADHD?
Yes. Kids who have trouble focusing but are not unusually restless or impulsive have a
more inattentive form of ADHD. They tend to be diagnosed later because they are less prone
to disruptive or problematic behavior that comes to the attention of teachers and parents. But
kids who have inattentive symptoms may start to struggle in the middle of elementary school,
or even later, when it becomes diffcult for them to keep up.
Why can kids who have ADHD concentrate on some things,
like video games, but not others, like school?
While ADHD is called an attention defcit disorder, experts say whats really disordered is the
childs ability to control and direct what hes paying attention to. So many kids with ADHD
are perfectly capable of intense focus on things that are very exciting to them, but they cant
maintain that kind of focus on things that arent immediately rewarding, like schoolwork or
putting on their shoes or going to bed.
That intense concentration (sometimes called hyperfocus)
is also the reason kids with ADHD often get upset when asked
to stop doing something they are engaged in, like a favorite
activity at school or playing a video game. They have what
experts call an inability to attention switch, which can
cause a lot of conficts with adults.
For more information on hyperfocus
click here.
What is executive functioning and what does it have to do with ADHD?
Executive functions are the self-regulating skills that we all use to accomplish tasks,
from getting dressed to doing homework. They include:
Planning
Organizing time and materials
Making decisions
Shifting from one situation to another
Controlling emotions
Learning from past mistakes
Most kids with ADHD have defcits in some executive functions, though not all children with
weak executive functions have ADHD.
Does ADHD affect kids outside of school?
Yes. Their inattention and impulsivity also hurt their friendships, extra-curricular activities and
family life. They may have trouble making and keeping friends because they interrupt other
kids and blow up when they dont get their way. Its not uncommon for children with severe
ADHD to be blackballed from playdates because they cant appropriately behave. They may
have trouble playing on teams because they fnd it hard to focus and follow the rules.
Home life may be diffcult for themand their parents and siblings, toobecause its so hard
for them to follow instruction and control their impulses. By the time kids with ADHD reach
adolescence, their impulsivity can be dangerous, making them prone to car accidents, unsafe
sex, and other risky behaviors.
Parents Guide to ADHD
page 3
page 4
Why are some kids with ADHD prone to deance and tantrums?
Defance and emotional outbursts are not, themselves, symptoms of ADHD, but kids with
ADHD are at higher risk for developing these behaviors. Some kids who have ADHD tend
to become frustrated and overwhelmed by demands placed on them that they cannot
consistently fulfll, because of inherent defcits in paying attention, reining in impulses, and
controlling their activity level. Things like homework, going to bed, getting dressed, and
coming to dinner can trigger resistance, especially when they involve stopping some activity
thats more stimulatinglike playing a video game. Emotional outbursts may work for them in
the short-termto avoid whatever they fnd unpleasantbut they can cause chronic confict
with parents and authorities.
Do children outgrow ADHD?
ADHD symptoms change as children get older, and its estimated that about 70 percent of
children who are diagnosed with the disorder will no longer meet the criteria by the time
they reach young adulthood.
Hyperactivity often declines as kids move through elementary school, and inattention can
become the primary problem for them as the schoolwork they are expected to do becomes
more demanding and their parents and teachers are not so closely supervising their activities. In
adolescence, impulsivity becomes a larger concern, because it can increase the likelihood of car
accidents, unsafe sex, and other risky behavior.
Research shows that even those who outgrow many of the symptoms continue to have
problems with academics, work, and relationships.
For more information on adolescents with ADHD, click here.
Parents Guide to ADHD
How is ADHD diagnosed?
A child should be diagnosed with ADHD only if he exhibits a variety of inattentive or
impulsive behaviors
At a level that is more severe than typical children his age
Over an extended period
In more than one settingboth at home and at school, for instance
These behaviors must also be interfering signifcantly with schoolwork
or social interaction
A child should not be diagnosed with ADHD just based on a parents or teachers report
that he is overly active or distracted. To make an accurate diagnosis, a clinician should
collect information from several people who have observed your child, including you, other
caregivers, and teachers. A thorough history should be obtained in order to understand the
childs developmental patterns.
Parents and teachers should be asked to fll out a rating scale, to capture an accurate
assessment of the frequency of symptoms. Because inattention and impulsivity can also be
the result of other issues, such as anxiety, depression or trauma, a professional diagnosing
your child should carefully rule out other possible reasons for his behavior.
page 5
Parents Guide to ADHD
DIAGNOSIS
page 6
Parents Guide to ADHD
Who can diagnose ADHD?
ADHD can be diagnosed by any doctor or mental health professional, including:
Pediatricians
Psychiatrists
Clinical psychologists
Social workers
School psychologists
The overwhelming majority of ADHD diagnoses are made by pediatricians, though parents
should be aware that pediatricians often dont have advanced training in psychiatric
disorders. Developmental and behavioral pediatricians, as well as child and adolescent
psychiatrists, are specialists who do have advanced training in developmental, learning, and
behavioral problems of children and adolescents, including ADHD.
In most states, only medical doctors (including psychiatrists) can prescribe medication to
treat ADHD, though some states allow psychologists to prescribe, and nurse practitioners and
physicians assistants often can, as well.
For more information on how to be sure your child gets an accurate
diagnosis click here.
page 7
Parents Guide to ADHD
TREATMENT
What is the most effective treatment for ADHD?
Research shows that a combined approach of medication and behavioral therapy is the
most effective treatment.
For moderate to severe cases of ADHD the frst line of treatment is usually medication.
The most commonly used are psychostimulants, which help children focus and curb
impulsivity and hyperactivity.
Behavioral therapies help kids control impulsive behavior and be better organized. Behavioral
therapies are the starting point for most young children (i.e., preschoolers) with ADHD.
What are the most commonly used medications for ADHD?
If a child has ADHD, studies show theres an over 80% chance that he will respond to
stimulant medication with a signifcant reduction in symptoms.
There are two main classes of stimulant medications:
Methylphenidate-based medications
Ritalin, Methylin, Concerta, Metadate, Daytrana Patch, Ritalin LA
Dextroamphetamine-based medications
Adderall, Vyvanse, Dexedrine, Focalin
Of the children who respond to stimulants, half will
respond equally well to both groups of medications,
and the other half will respond better to one or the
other. There are many different release formulas for
stimulant medications, which make them effective
for different periods of time.
Immediate-release formulas
effective for about 4 to 6 hours
Extended-release formulas
last as long as 9 to 12 hours
Within the extended-release group, medications
vary in the doses they deliver during different parts
of the day; some deliver more in the frst half
and others more in the second half. The goal is to
fnd the formula that delivers an effective dose
over a desirable period of time for your child.
page 8
Parents Guide to ADHD
Finding the right dose
For stimulant medications, the dose cannot be determined by a childs age, weight or severity
of symptoms. Kids respond to the medication in very different ways, so getting the right
dosage for a particular child takes several weeks of trial. The clinician normally increases the
dosage gradually until it becomes effective. If your child experiences undesirable side effects,
it may mean that the dosage is too high, or the medication isnt right for her.
Its important to note that some children respond differently to the two different stimulants
used in these medicationsmethylphenidate and dextroamphetamine. Changing from one
to the other, or even to a different release formula of the same basic medicine, can help
reduce or eliminate side effects.
Once an effective dosage is established, your child should be monitored periodically to
make sure its still meeting her needs as she grows.
What about side effects of stimulant medications?
Stimulant medications can be very effective in reducing symptoms of ADHD, but some kids
do experience adverse side effects. They include:
Eating Issues
The most common side effect of stimulant medications is loss of appetite, which can cause kids to be
underweight. Some kids can compensate for this lack of appetite by eating a nutritious breakfast before the
medication kicks in, and eating well at the end of the day when the medicine is wearing off, at dinner and
perhaps again before bedtime.
Sleep Issues
Some kids on stimulants have trouble falling asleep, though sleep problems tend to get better over time, so
its worth giving kids four to six weeks to see if they adjust. If a child is taking a short-acting formula, trouble
sleeping may mean that she is taking a dose too late in the day, so the stimulant is still active at bedtime.
If shes taking an extended-release formula, it may help to try one thats not quite as long-acting. Some
children with ADHD who had sleep problems before taking stimulant medication are actually able to sleep
better on the medication.
page 9
Parents Guide to ADHD
Wear-off Effects
In some cases, as the medication wears off a child can become irritable. This effect (sometimes called
rebound) can be avoided, if its a problem, by adding a smaller dose a half hour before it usually happens, to
ease off the medication more gradually. Its also important to consider whether there might be an underlying
anxiety or mood issue that comes into play when the child comes off his ADHD medicine.
Tics
Some children who take stimulant medication temporarily develop tics, although some kids who already
have tics fnd them reduced by taking a stimulant. If tics are a problem, your doctor might try a different
stimulant or a non-stimulant medication, that affects the brain in a different way. Keep in mind that tic
disorders begin to appear in early elementary school, so onset could be unrelated to medication.
Mood Changes
When a stimulant dose is too high for a child he may become emotionally fat, or tearful and irritable. If this
happens the dose needs to be reduced. But there is also a small subset of kids with ADHD who get moody
or irritable when they take stimulant medications, even at the best possible dose. It usually happens as soon
as they start taking the medication, and goes away immediately when they stop taking it. If this happens,
your doctor can try switching to a different stimulant, or a non-stimulant medication.
Growth Issues
Some kids, particularly boys, grow a little more slowly when theyre taking stimulant medication, especially
in the frst year. But studies show that they catch up over time and by adulthood are no different from their
peers. Kids who take weekend and summer breaks from the medication dont show delays in growth.
Cardiovascular Irregularities
Stimulant medications increase the risk for cardiac irregularitiesadverse increases in blood pressure and pulse.
While these are very rare, doctors should monitor patients blood pressure and pulse before and during treatment.
Nausea and Headaches
Occasionally children report nausea and headaches, although these problems tend to dissipate within a few
weeks and may be caused by nervousness about the medication. If theyre a problem, they can be minimized
by taking the medication with food, and in some cases by changing the dosage or schedule.
page 10
Parents Guide to ADHD
Are there non-stimulant medications for ADHD?
There are several types of medications that arent stimulants that can help alleviate symptoms
of ADHD. They are useful for kids who dont respond to stimulant medications or who
experience adverse side effects from them. The most commonly used are:
Clonidine (Catapres, Nexicon) and guanfacine (Tenex) are called alpha-adrenergic agonists.
These medications were developed to lower high blood pressure. At the doses given to kids for ADHD they
usually dont affect blood pressure, but kids taking them should be monitored for this effect. Both clonidine
and guanfacine come in a 24-hour-release version (Kapvay and Intuniv), and they are sometimes used to
treat tics.
Atomoxetine (sold as Strattera) is in a class of drugs called norepinephrine reuptake inhibitors.
Norepinephrine is a chemical in the brain that helps control behavior and learning.
Should children stop taking ADHD medication during holidays
and the summer?
Since children with ADHD dont need to perform academically during the summer or on
extended holidays, parents sometimes take kids off their regular medication regimen. Other
parents avoid an interruption, fearing that their child is behavioral problems will worsen.
One reason to stay with treatment year-round is that ADHD doesnt only affect a childs
performance in school. During the
summer, children still have to get along
with family and friends and function
effectively in group activities like sports
and camp.
If a child is underweight due to
suppressed appetite, a summer
without medication can help her put
on some pounds.
For more on the pros and cons of a
drug holiday, click here.
page 11
Parents Guide to ADHD
What are the behavioral treatments for ADHD?
Behavior therapies do not eliminate the core symptoms of ADHD, but they can be very helpful
in teaching many children with ADHD to manage their symptoms. For example, children who
have trouble fnishing things and staying organized can learn techniques for completing tasks,
keeping track of assignments, and getting their schoolwork done.
Theres also a kind of behavior therapy called parent training that can help reduce behavior
problems that occur in some children with ADHD. Parent-child interaction therapy and
other forms of parent training teach parents how to work with their kids to cultivate good
behaviors while minimizing impulsive or inattentive ones. Stimulated by more positive
reinforcement, kids who have been out of control can learn to change their behavior and enjoy
more rewarding relationships with parents and teachers.
In school-based treatment, a clinician works with a childs teacher to establish positive
behavioral goals for him and a reward system to reinforce him when he meets those goals.
The desired behaviors might be to remain seated, to fnish schoolwork, to raise his hand
before speaking; rewards include praise and points towards a prize. This allows teachers to
focus on what the child is doing wellrather than what he isnt doing well. It can bolster his
self-esteem and help him feel positive about school. Parents receive a daily behavior report
card, enabling them to further to reinforce positive behavior in school.
As children get older, they often begin working more one-on-one with clinicians to strengthen
their organizational skills and develop effective behavioral plans. When a child is old enough,
cognitive behavioral therapy can help teach him to control his behaviors by understanding
how his thoughts and feelings infuence them.
What can we do to help kids strengthen executive functions?
To bolster kids with weak skills in these areas, learning specialists teach a mix of
specifc strategies and alternative learning styles that complement or enhance a childs
particular abilities.
With elementary school children, the educational specialist usually works with parents
and kids together, to establish routines and tools to use to get work done successfully and
with minimal confict. For instance:
Checklists can be useful for anything from getting out of the house on time in the morning to doing
homework after school to the bedtime routine. Since the steps necessary for completing a task often arent
obvious to kids with ADHD, defning them clearly ahead of time, and posting them prominently, makes
a task less daunting and more achievable.
Assigning a time limit for each step, particularly if it is a bigger, longer-term project, helps kids
manage their time and avoid underestimating how long it will take to do something.
Using a planner is essential for kids with ADHD who struggle to remember things
like homework assignments.
A rewards chart at home, as well as at school, can help motivate kids
who are easily distracted and struggle to acquire new skills.
Helpful Links
Parents Guide to Getting Good Care
http://www.childmind.org/en/parents-guide-getting-good-care/
Child Mind Institute ADHD and Disruptive Behavior
Disorders Center
http://www.childmind.org/en/clinics/centers/adhd-and-
disruptive-behavior-disorders-center
Find a Child and Adolescent Psychiatrist
http://www.aacap.org/AACAP/Families_and_Youth/
Resources/CAP_Finder.aspx
Find a CBT Therapist
http://www.abctcentral.org/xFAT/
Find an Educational Therapist
http://www.aetonline.org/fndET/index.html
page 12
Parents Guide to ADHD
445 Park Avenue
New York, NY 10022
212.308.3118
The Child Mind Institute is dedicated to transforming mental health
care for children everywhere. Founded by Dr. Harold S. Koplewicz
and Brooke Garber Neidich, our organization is committed to nding
more effective treatments for childhood psychiatric and learning
disorders, building the science of healthy brain development, and
empowering children and their families with the information they
need to get help, hope, and answers.
To learn more, visit childmind.org