ADHD in Children: Symptoms, Evaluations, Treatments
Children who exhibit these symptoms of inattentive or hyperactive/impulsive ADHD may warrant a qualified diagnosis and appropriate treatment such as medication and behavior therapy. Learn more about common signs of ADHD, and what to do if your child shows them.
ADHD diagnoses have skyrocketed nearly 50 percent since 2003, bringing the total number of American children with ADHD to nearly 6 million, according to 2015 statistics from the Center for Disease Control and Prevention (CDC).1
The CDC reports that 11 percent of all children in the U.S. aged 4-17 had been diagnosed with ADHD by 2011. Boys are nearly three times more likely to be diagnosed with ADHD (13.2 percent) than are girls (5.6 percent),2 although the largest surge in rising ADHD diagnosis rates is currently attributed to girls and women.
The stereotypical ADHD patient is a 9-year-old boy who loves to jump off dangerously high things and never remembers to raise his hand in class. In reality, only a fraction of people with ADHD fit this description. Children with hyperactive ADHD symptoms are difficult to ignore — they are the ones bouncing out of their chairs or clowning behind the teacher’s back, and are the first to be evaluated for and diagnosed with ADHD.
Meanwhile, the students with inattentive ADHD (predominantly girls) are quietly staring out the window at a bird while their work lays unfinished. According to the National Institute of Mental Health (NIMH), inattentive symptoms are far less likely to be recognized by parents, teachers, and medical professionals. As a result, individuals with inattentive ADHD rarely get the treatment they need. This leads to academic frustration, apathy, and undue shame that can last a lifetime.
Symptoms of ADHD
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) lists nine symptoms that suggest ADHD Primarily Inattentive, and nine that suggest ADHD Primarily Hyperactive-Impulsive. A child may be diagnosed with ADHD only if he or she exhibits at least six of the symptoms from one of the lists below, and if the symptoms have been noticeable for at least six months in two or more settings — for example, at home and at school. What’s more, the symptoms must interfere with the child’s functioning or development, and at least some of the symptoms must have been apparent before age 123. Older teens may need to demonstrate just five of these symptoms in multiple settings.
ADHD – Primarily Inattentive Type
A person with this type of ADHD will fit six of the nine descriptions below:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, turns in inaccurate work).
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organizing tasks and activities (e.g., struggle to manage sequential tasks, keep materials and belongings in order, organize work, manage time, and meet deadlines).
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, this may include preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, this may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, this may include returning calls, paying bills, keeping appointments).
ADHD – Primarily Hyperactive-Impulsive Type
A person with this type of ADHD will fit six of the nine descriptions below:
- Often fidgets with or taps hands or feet or squirms in seat.
- Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the workplace, or in other situations that require remaining in place).
- Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, this may manifest as feeling restless.)
- Often unable to play or engage in leisure activities quietly.
- Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to remain still — in restaurants or meetings, for example — for any extended time without significant discomfort; others may say the patient is restless, fidgety, or difficult to keep up with).
- Often talks excessively.
- Often blurts out an answer before a question has been completed (e.g., completes people’s sentences).
- Often has difficulty waiting his or her turn (e.g., while waiting in line, while speaking in conversations).
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).”4
ADHD – Combined Type
To have ADHD Combined Type, an individual must meet the guidelines of both ADHD Primarily Inattentive and ADHD Primarily Hyperactive-Impulsive – that is, they must exhibit six of the nine symptoms listed for each sub-type.
No ADHD test alone can diagnose ADHD. ADHD is a nuanced condition with three distinct sub-types (as detailed above), symptoms that appear along a spectrum of severity, and overlapping comorbid conditions that often complicate diagnosis and treatment.
An evaluation for ADHD may start with a routine visit to the pediatrician, but chances are it won’t end it there. As a rule, most general practitioners are not trained in the idiosyncrasies of ADHD and its overlapping conditions, or not equipped to perform the in-depth evaluation needed.
Any ADHD evaluation worth its weight will begin by critically analyzing many aspects of the patient’s daily life, such as learning, memory, cognitive functioning, executive functioning, reasoning, social functioning, verbal and non-verbal communication. For children, the testing should include an intelligence test (IQ), and may also gauge math, reading, and writing skills.
This information is gathered through a clinical interview, plus a thorough review of the child’s and the family’s medical history, various parent and/or teacher rating scales, and neuropsychological testing. An in-depth evaluation offers greater insight into strengths and weaknesses, and helps identify comorbid conditions, such as learning disabilities, depression, anxiety disorder, or autism spectrum disorder.
When performed thoroughly and effectively, a formal assessment should offer therapy, treatment, and educational strategies to address the specific needs it reveals or confirms.
Stimulant medication is the most recommended form of ADHD treatment for one simple reason: studies show it to be most effective. According to the American Academy of Pediatrics (AAP), 80 percent of the children who use stimulant medications, either alone or combined with behavior therapy, increase focus and decrease impulsivity. What’s more, the majority of children who use medication report having increased self-esteem, fewer disruptive behaviors, and improved relationships with parents, siblings, and teachers.
The clinical practice guidelines for ADHD, developed by the American Academy of Child and Adolescent Psychiatry (AACAP), recommend medication as the first-line treatment for ADHD in school-age children, citing a formal review of 78 studies on the treatment of ADHD, which “consistently supported the superiority of stimulant over the non-drug treatment.”5
Even the widely-cited Multi-Modal MTA Cooperative Group Study, which concluded that medication combined with behavior therapy is the optimal treatment of ADHD in children, conceded that “a pharmacological intervention for ADHD is more effective than a behavioral treatment alone.”
Stimulant medication might be the most recommended treatment for ADHD, but it certainly isn’t the only option for parents to consider.
Non-stimulant medications are a viable alternative for children who can’t tolerate or don’t experience the desired effects of stimulant medications. These medications do target neurotransmitters, but not dopamine specifically, like the stimulants do. While non-stimulants don’t carry the same side-effect risks as stimulants, they do have their own possible side effects.
Straterra, Intuniv, Kapvay are non-stimulant medications specifically recommended for ADHD. The classification also includes medications often prescribed off-label for ADHD — tricyclic antidepressants, and Wellbutrin, for example.
While medication works on a neurological level to regulate the brain, behavior therapy addresses specific problem behaviors by structuring time at home, establishing predictability and routines, and increasing positive attention. Behavior therapy operates on a simple premise: Parents and other adults in a child’s life set clear expectations for their child’s behavior — they praise and reward positive behavior and discourage negative behavior. Behavior therapy requires participation from parents and teachers.
Diet and Nutrition
Poor diet and eating habits do not cause ADHD. However, parents of children with ADHD are finding that, while whole foods may not be a cure-all, diet changes can make a big difference for some kids with ADHD.
Research shows that diet and nutrition impact cognition, attention, sleep, and mood. According to the Harvard Health Blog, studies show that people who eat “clean” or “whole” diets high in vegetables, fruits, unprocessed grains, and lean meats, are more likely to experience better emotional health and 25 to 35 percent less likely to experience depression.6
Studies by Massachusetts Institute of Technology neuroscientist Richard Wurtman Ph.D., and others have shown that protein triggers alertness-inducing neurotransmitters, while carbohydrates trigger drowsiness. These findings support the popular belief that people with ADHD do better after eating a protein-rich breakfast and lunch.
For optimal brain performance, children should eat more unprocessed foods, complex carbohydrates, proteins, vegetables, and fruits. That means avoiding artificial colors and flavors, chemical preservatives, and over-processed foods — all shown to exacerbate ADHD symptoms in some individuals.
It’s true that not everyone eats the right foods to achieve beneficial levels of certain nutrients, especially picky kids. But it’s also true that our bodies don’t always produce the nutrients we need, so we have to get some of them from supplements. There are many vitamins, herbs, and supplements that may diminish ADHD symptoms or address medication side effects in some individuals: Omega-3s, Zinc, Iron, Magnesium, Vitamin C, Valerian, Melatonin, Ginkgo, and Ginseng.
However, “all natural” is not synonymous with “safe.” Many herbs and supplements have side effects, may cause or worsen health problems, or interfere with prescription medications. Talk to your child’s doctor before starting any supplements. When your doctor asks if your child is taking any medications, be sure to tell him about all vitamins and supplements he takes on a daily basis.
“Think of exercise as medication,” says John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School and author of Spark: The Revolutionary New Science of Exercise and the Brain. “Exercise turns on the attention system, the so-called executive functions — sequencing, working memory, prioritizing, inhibiting, and sustaining attention. On a practical level, it causes kids to be less impulsive, which makes them more primed to learn.”
Exercise causes the brain to release several important chemicals. Endorphins, for one — hormone-like compounds that regulate mood, pleasure, and pain. That same burst of activity also elevates the brain’s dopamine, norepinephrine, and serotonin levels. These brain chemicals affect focus and attention, which are in short supply in children with ADHD. “When you increase dopamine levels, you increase the attention system’s ability to be regular and consistent, which has many good effects,” explains Ratey, like reducing the craving for new stimuli and increasing alertness.
A 2015 study published in the Journal of Abnormal Psychology found that 30 minutes of exercise before school can help kids with ADHD focus and manage moods. It can even decrease the need for stimulant medications used to treat symptoms.7
Kids with ADHD can’t always hold on to information because their attention gets hijacked. Improving working memory capacity with brain training enables an individual to pay attention, resist distractions, manage emotions better, and learn.
“Working memory is the ability to hold information in your mind for several seconds, manipulate it, and use it in your thinking,” says Ari Tuckman, Psy.D., a clinical psychologist in West Chester, Pennsylvania. “It is central to concentration, problem solving, and impulse control.”
Brain-training therapies like neurofeedback and Cogmed are making a serious promise: increased attention and working memory without medication. The scientific community, however, is not convinced and insists that more rigorous studies are needed.8
Another form of brain training with some encouraging but inconclusive studies, neurofeedback uses brain exercises to reduce impulsivity and increase attentiveness. The brain emits different types of waves, depending on whether we are in a focused state or daydreaming. The goal of neurofeedback is to teach a person to produce brain-wave patterns that reflect focus. The result: Some ADHD symptoms — namely, impulsivity and distractibility — diminish.
Mindfulness & Meditation
For many children with ADHD, two persistent daily challenges are paying attention and maintaining self-regulation. So it stands to reason that some kind of attention training that also hones self-control would be invaluable — and incredibly powerful. Indeed, a 2005 study at Arizona State University found that children who participated in mindfulness exercises had lower test anxiety and ADHD symptoms, and greater attention than kids who did not participate in the exercises.9
“Research suggests that anyone can improve attention by practicing mindfulness — cognitive fitness training aimed at building real-time and compassionate awareness of our lives rather than remaining lost in distraction, on autopilot,” explains Mark Bertin, M.D., in his book, Mindful Parenting for ADHD: A Guide to Cultivating Calm, Reducing Stress & Helping Children Thrive. “How does it work with the ADHD brain? ADHD is characterized by difficulties with executive function, not just attention, and mindfulness is an avenue to developing interrelated cognitive skills, many related to executive function, not just attention.”
More than two-thirds of children with ADHD have at least one other psychiatric, developmental, emotional, and/or neurological disorder sometime during their lifetime.10
Doctors used to view ADHD as a stand-alone disorder. But research now suggests that a majority of kids who have ADHD also suffer from depression, anxiety, obsessive-compulsive disorder (OCD), oppositional defiance disorder (ODD), a learning disorder, autism, sensory processing disorder, or some other psychological or neurological problem.
In some cases, these problems are “secondary” to ADHD — that is, they are triggered by the frustration of coping with symptoms of ADHD. For example, a girl’s chronic lack of focus may cause her to experience anxiety in school. Years of disapproval and negative feedback from friends, family members, and teachers may cause a boy to become depressed. Most of the time, secondary problems fade once ADHD symptoms are under control.
When secondary problems don’t resolve with effective ADHD treatment, it’s time to consider another possibility: Some problems are not secondary to ADHD, but distinct entities known as “comorbid” conditions. Like ADHD, comorbid conditions occur along what doctors call a “continuum of neurologically based disorders.”
Comorbid disorders may be caused by the same factors that trigger ADHD (heredity, exposure to environmental toxins, prenatal trauma, and so on). But unlike secondary problems, comorbid conditions do not go away on their own once ADHD has been treated. They require their own specific treatment in addition to any treatment given for ADHD itself.
School & Learning
The symptoms of inattention, impulsivity, and executive functioning deficits often mean kids with ADHD don’t perform well academically or have trouble focusing on schoolwork. What’s more, up to 1 in 4 students with ADHD has other serious learning disabilities in one or more of these areas: written expression, oral expression, listening skills, reading comprehension, and math.11
IDEA covers kids with very specific conditions, including intellectual disorders, emotional disturbances, hearing impairments, learning disabilities, and speech and language difficulties. Kids may qualify for coverage if they frequently have one of these problems in addition to attention deficit. Some qualify under another IDEA category: Other Health Impairments. If a child’s ADHD is so severe that he’s unable to learn in a regular classroom without special services, he may qualify.
Section 504 covers kids with ADHD who don’t qualify for special-education services under IDEA, but who need extra help in the classroom. The law prohibits schools from discriminating against students because of physical and mental impairments. Just as the school must provide ramps for kids in wheelchairs, it must make modifications (such as preferential seating, extra time on tests, or help with note taking) for kids with brain-based learning barriers.
Studies have shown that positive parenting approaches work best for kids with ADHD.12, 14 Instead of a strict system of punishment and consequences, kids with ADHD respond better to praise and a greater focus on strengths than on weaknesses. Positive parenting approaches result in greater behavior control for the child, and reduced stress and anxiety for the parents.
“Many parents use the terms ‘discipline’ and ‘punishment’ interchangeably,” says Sal Severe, Ph.D., the author of How to Behave So Your Preschooler Will Too! “In fact, they’re vastly different.” Discipline, he says, is preferable because it teaches the child how to behave. It includes an explanation of the inappropriate behavior and redirection to acceptable behavior — along with positive reinforcement each time the child makes a good behavior choice. Punishment, on the other hand, uses fear and shame to force the child to behave.
ADHD symptoms affect kids’ social skills in several ways — impulsivity and inattention cause them to miss necessary social cues; talkativeness and distractibility cause them to interrupt or stray off topic; and short attention spans or social immaturity usually don’t help.
1 “Data & Statistics.” Centers for Disease Control and Prevention. Ed. Center for Disease Control. Centers for Disease Control and Prevention, 14 Feb. 2017. Web. 15 Mar. 2017.
2 Visser, Susanna N., Melissa L. Danielson, Rebecca H. Bitsko, Joseph R. Holbrook, Michael D. Kogan, Reem M. Ghandour, Ruth Perou, and Stephen J. Blumberg. “Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003â2011.” Journal of the American Academy of Child & Adolescent Psychiatry 53.1 (2014): n. pag. Web.
3 Association, American Psychiatric, ed. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric, 2014.
4 Association, American Psychiatric, ed. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric, 2014.
5 Pliszka, Steven. “Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder.” Journal of the American Academy of Child & Adolescent Psychiatry 46.7 (2007): 894-921. Web.
6 MD, Eva Selhub. “Nutritional Psychiatry: Your Brain on Food.” Harvard Health Blog. Harvard University, 17 Nov. 2015. Web. 14 Mar. 2017.
7 Hoza, Betsy, Alan L. Smith, Erin K. Shoulberg, Kate S. Linnea, Travis E. Dorsch, Jordan A. Blazo, Caitlin M. Alerding, and George P. Mccabe. “A Randomized Trial Examining the Effects of Aerobic Physical Activity on Attention-Deficit/Hyperactivity Disorder Symptoms in Young Children.” Journal of Abnormal Child Psychology 43.4 (2014): 655-67. Web.
8 GeladÃ©, Katleen, Tieme W. P. Janssen, Marleen Bink, Rosa Van Mourik, Athanasios Maras, and Jaap Oosterlaan. “Behavioral Effects of Neurofeedback Compared to Stimulants and Physical Activity in Attention-Deficit/Hyperactivity Disorder.” The Journal of Clinical Psychiatry (2016): n. pag. Web.
9 Dr. Maria Napoli, Paul Rock Krech, and Lynn C. Holley. “Mindfulness Training for Elementary School Students.” Journal Of Applied School Psychology (2005).
10 A Program of Chadd, National Resource Center on ADHD:, ed. “About ADHD.” About ADHD (n.d.): n. pag. CHADD. CHADD, 2015. Web. 15 Mar. 2017.
11 Mayes, S. D., S. L. Calhoun, and E. W. Crowell. “Learning Disabilities and ADHD: Overlapping Spectrum Disorders.” Journal of Learning Disabilities 33.5 (2000): 417-24. Web.
12 Pfiffner, Linda J., and Lauren M. Haack. “Behavior Management for School-Aged Children with ADHD.” Child and Adolescent Psychiatric Clinics of North America 23.4 (2014): 731-46. Web.
13 Aghebati, Asma et al. “Triple P-Positive Parenting Program for Mothers of ADHD Children.” Iranian Journal of Psychiatry and Behavioral Sciences 8.1 (2014): 59–65. Print.