They’re disruptive; they’re delightful. They’re enraging; they’re engaging. Children with ADHD can have a powerful impact on everyone around them.
Because these children have problems with self-regulation, they often have trouble accomplishing tasks and following directions. At school, children with ADHD (Attention-Deficit Hyperactivity Disorder) usually have problems focusing in the classroom and completing homework. Some have difficulty making and keeping friends. At home, their behavior can affect family harmony. As these issues accumulate, children with ADHD can feel terribly left out and alone. They often “self-medicate” deficits in neurotransmitter functioning by engaging in activities that provide immediate stimulation, which can include video game playing, breaking rules, and other types of sensation-seeking.
Of course, this spectrum of problems does a disservice to the overall character of kids with ADHD, who routinely demonstrate a number of strengths that may very well be unique to the condition. ADHD children are often very resourceful, creative, funny, and intuitive. They are usually remarkable truth-detectors, forever observing inconsistencies between people’s words and behaviors. It is the recognition and appreciation of these considerable strengths, combined with acceptance of the executive functioning weaknesses associated with the disorder, that often form the foundation of strong parent-child and teacher-child relationships.
You might be wondering, why an article about ADHD in this fourth in a series of articles presented by Chayeinu, a new organization dedicated to providing education and guidance to our community to address many facets of substance use disorder? It is simply that, if left untreated, the long-term disruption in the areas of behavior linked to ADHD forms pathways to future mental health concerns, which can include substance use disorder. In fact, Dr. Russell Barkley, perhaps the leading expert in this field, noted in his recent talk at Beth Tfiloh that adults with untreated ADHD can expect to live about 13 years less than those without the disorder.
A reasonable strategy for preventing substance use disorder is therefore to treat conditions that often precede problematic alcohol or drug use – and ADHD is a risk factor. Children with ADHD, compared to those without ADHD, are well over twice as likely to develop a substance use disorder in their lifetime. The good news is that there is evidence that treatment of ADHD offers children significant protection from developing a substance use disorder, especially when treatment is started earlier in the course of ADHD. This article will describe the primary symptoms of ADHD, as well as some disorders that commonly co-occur with ADHD, and consider the best treatment options for helping children and their families.
It’s in the Brain: Getting a Diagnosis
ADHD is a chronic neurobehavioral disorder that first emerges in early childhood, prevalent in approximately eight percent of children in the United States. It is characterized by attention problems (e.g., easily distracted, disorganized) and/or hyperactivity (e.g., fidgety, on the go) across at least two settings (usually at home and at school). These symptoms must occur for at least six months, be inconsistent with the child’s developmental level, and be significant enough to harm the child’s functioning at home, at school, or with peers.
Many of these symptoms appear to be due to delays in brain regions responsible for self-awareness and self-control, and include lower levels of neurotransmitters involved in focus and motivation. Variability in symptoms across children can be linked to differences in brain development.
For the sake of beleaguered parents, who must cope not only with their child’s symptoms but also with judgmental family, friends, and neighbors, it is important to emphasize that ADHD is not a parenting problem. It is a neurological problem that is often observed at birth.
Primary care physicians like pediatricians are trained to make a diagnosis of ADHD in children as early as the age of four or five. In complicated or borderline cases, they are likely to recommend referral to a psychiatrist, psychologist, or other health professional who specializes in childhood disorders. In addition to speaking with the parent and child about the predominant symptoms, the clinician will ask parents and teachers to complete behavior checklists to confirm that the symptoms are present across at least two settings. Because a misdiagnosis might create an unnecessary label and harm future treatment efforts, clinicians are ordinarily quite careful to ascertain that the child meets diagnostic criteria.
Boys are about three times more likely to be diagnosed with ADHD. However, most practitioners and researchers feel strongly that ADHD is significantly under-diagnosed in girls, perhaps because it presents somewhat differently. Girls with ADHD seem to exhibit more talking, crying, and daydreaming, and lower levels of hyperactivity and aggression. It turns out that more women than men are likely to seek treatment for ADHD in adulthood, probably because it was overlooked or misdiagnosed when they were younger.
Treating ADHD
While ADHD is a very treatable disorder, it often takes time for treatment to show optimal results. The two primary categories of treatment are pharmacological and psychological. The most effective pharmacological treatments use short-acting stimulant medications like Adderall and Vyvanse that must be administered daily. These medications can improve attention and behavior throughout the school day, and a smaller dose in the afternoon can help with homework and other responsibilities.
Non-stimulant drugs like atomoxetine, guanfacine, or clonidine are also FDA approved for treatment of ADHD symptoms but are generally not as effective as stimulant medications and are more likely prescribed as a supplement to provide additional symptom relief. In straightforward cases, these prescriptions can be managed by the primary care provider. When the medication is ineffective, however, or when there is a strong suspicion of other co-occurring psychiatric conditions, it is best to work with a psychiatrist who specializes in ADHD.
Psychological approaches for managing ADHD are typically the domain of child psychologists and other mental health specialists. These clinicians most often use cognitive-behavioral therapy approaches that combine reward programs and parent training, with an emphasis on establishing positive relationships and creating a home environment to support better self-regulation. A therapist can work individually with the child to help him or her appreciate the nuances of the disorder, develop better time management and coping skills, and basically become his or her own advocate.
A number of studies show that the combination of stimulant medication and cognitive-behavior therapy is more effective than either intervention alone. Coordination with schools is also important for success. Schools can offer academic support, such as tutoring, and implement behavioral programs or create situations that allow kids with ADHD to succeed, such as preferred class seating and providing more time during tests. Other important components to comprehensive care are helping children identify strengths to pursue in extracurricular activities as well as limiting screen time and increasing exercise.
ADHD May Come with Other Conditions
The primary complication in treating ADHD is that it often occurs together with other disorders. It is not unusual for children with ADHD to have at least one other co-occurring condition, which might include learning problems, disruptive behavior, anxiety, or depression. These other conditions are so common that many professionals believe that they form part of the overall ADHD syndrome. It almost goes without saying that the presence of co-occurring disorders is a sign that parents should seek out an ADHD specialist. While stimulant medications at times reduce symptoms of depression or anxiety and improve overall behavior, in most cases additional medications and therapy are required to see clinical improvement.
Starting Early
Since ADHD symptoms start presenting when the child is very young, parents have a wonderful opportunity to get an early start on treatment. There are at least two major benefits to starting treatment as soon as possible. The first is that effective treatment protects children from many of the negative consequences of the disorder, including academic and social difficulties and strained relationships with parents and teachers. Even at an early age, children can start to “self-medicate” neurological deficits through impulsive behaviors, becoming “addicted” to the rush of getting in trouble. Unfortunately, an accumulation of difficult childhood experiences is emotionally draining and can have long-term negative impact on mental health.
Second, the successful treatment of ADHD is probably an equal part art and science. There is no one protocol that clinicians can rely upon because each child presents differently, with his own unique strengths and weaknesses. It takes time to find the right combination of medications that maximize benefits and minimize adverse effects. It also takes time for kids to develop a relationship with their therapist and learn new skills, and for parents to adjust their parenting strategies and consider approaches to help children self-regulate. We should also keep in mind that while the optimal length of treatment is not known, ADHD is considered a chronic neurobehavioral disorder with symptoms that can last into adulthood, and parents and children should be prepared to continue some form of therapy for many years. While there is no cure, treatment can make ADHD less of a disorder and more of a personality temperament, with ADHD traits, such as creativity, sensitivity, and energy, driving success.
Parents’ Worries
All treatments, including medications and verbal therapies, have potential adverse consequences. Perhaps foremost, in helping out children with ADHD, parents must weigh the advantages and drawbacks of stimulant medications. There are generally three types of questions that parents consider when a doctor discusses the use of stimulants: What are the short-term adverse effects of stimulant medication? What are the long-term adverse effects? And what are the risks of prescribing stimulant medications, which have high abuse potential, to children who are already vulnerable to developing substance use disorder? These are all reasonable and serious concerns, and we will try to address them with what is known in the literature.
Short-term adverse effects: The most obvious immediate adverse effects of stimulant medications are appetite loss and sleep disturbance. Sleep disturbance is probably most pronounced when children take stimulant medications in the afternoon. There are also some children who become more agitated with stimulants, due either to the direct effects of the medication or withdrawal from the medication at the end of the day. Psychiatrists are extremely mindful of these effects in their prescribing practices, and are careful to weigh the potential benefits with the adverse symptoms, yet there are typically no perfect solutions.
Long term adverse effects: Another area of concern is the long-term impact of stimulant medications on physical and psychological development. Some studies show diminished physical growth after the child starts taking the medicine (around half an inch), perhaps due at least in part to reduced appetite, though this issue appears to resolve after three years on the medication. Because the length of most research studies is only one to two years, not enough is known about other issues that might arise with daily stimulant use. While long-term follow-ups fail to find any significant problems, more research is needed to draw definitive conclusions.
Risk of stimulant misuse: Despite the fact that stimulants are highly addictive, there are no studies that show that prescription of stimulants to children with ADHD increases their risk of substance dependence. In fact, the research supports the opposite conclusion: Children receiving stimulant medication are at reduced risk for developing substance use disorder. The combination of medication and therapy provides a more effective way to decrease the neurological imbalance than “self-medicating” behaviors, which as kids grow older might include alcohol and illicit substances.
Nevertheless, we should note that stimulants are often misused by teenagers, independent of diagnosis. A recent well-known epidemiological study showed that up to nine percent of high school students report using stimulants, usually for getting high or studying for tests. And because there is a market for stimulants, some teenagers might choose to sell stimulant medications. What all of this means is that clinicians have a responsibility to provide guidance to children and their parents on how to take the medicine, on the risks of misuse and diversion, and on how to successfully transition administration of the drug from parent to child.
Conclusions
Approximately eight percent of our children meet criteria for ADHD, and many of these children have co-occurring disorders. Almost every major organization, from the American Academy of Pediatrics to the American Academy of Child and Adolescent Psychiatry, recommends the combination of stimulant medication and therapy for the treatment of the disorder. This recommendation is made with full understanding that parents have reasonable worries about starting their child on stimulants. It is also made with the understanding that effective cognitive-behavioral therapy requires a considerable amount of cost and effort. There are simply too many downsides to non-treatment of a treatable problem.
While we emphatically side with the general research and professional consensus, parents who are reluctant to start their children on stimulants might consider non-stimulant medications and/or cognitive-behavioral therapy before moving to stimulant medications. Nutritional interventions could supplement this approach (e.g., elimination of sugar or additives and Omega 3-6-9 supplements), though to date there is little research to support specialized diets or supplements as a stand-alone treatment. Of course, parents with questions can speak with their pediatrician, personal doctor, or school psychologist. With so much data supporting the benefits of integrated pharmacological and psychological treatment, doing nothing at all feels like a poor choice.
For those who are interested in reading more about the treatment of ADHD and its connection to substance use disorder, here are two scientific reports that nicely summarize the literature:
- “ADHD: Clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents” (2011) Pediatrics, 128, 1007-1022
- “Attention-deficit/hyperactivity disorder and substance abuse” (2014) Pediatrics, 134, e293-e301
We also recommend seeking out articles and books by Dr. Russell Barkley, who provides many practical suggestions for helping children with the important tasks of self-regulation and problem-solving.
Dr. Kidorf is Associate Director of Addiction Treatment Services and Associate Professor, Psychiatry and Behavioral Sciences, at Johns Hopkins University School of Medicine.
