Attention Deficit Hyperactivity Disorder

ADHD is one of the most common neurodevelopmental disorders, affecting millions of children and adults. While symptoms like difficulty focusing, hyperactivity, and impulsive behaviors can create challenges at home, school, and work, effective treatments combining medication and behavioral approaches can help people manage their symptoms and thrive.

Table of contents

• What is ADHD?
• Types of ADHD
• Signs and Symptoms
• Causes and Risk Factors
• How ADHD is Diagnosed
• Treatment Approaches
• Living With ADHD

What is ADHD?

ADHD stands for attention-deficit/hyperactivity disorder. It is a neurodevelopmental disorder, which means it affects how the brain grows and develops^[2]. Despite its name, ADHD doesn’t mean that you lack attention. Instead, it means that it’s harder to control your attention or direct it to certain tasks^[3].

ADHD is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood^[2]. Symptoms typically begin before age 12, commonly between ages 3 and 6^[3]. Millions of children in the United States have an ADHD diagnosis, with around 1 in 10 kids age 3 to 17 affected^[3]. ADHD occurs in 5 to 8 percent of school-age children and about 2 to 4 percent of adults^[5].

Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active^[2]. These symptoms continue, can be severe, and can cause difficulty at school, at home, or with friends^[2]. If not adequately treated, ADHD can lead to impaired quality of life and negative outcomes in academic, family, occupational and social settings, as well as increased risk for substance abuse disorders^[11].

ADHD can last into adulthood. Some adults have ADHD but have never been diagnosed. The symptoms can cause difficulty at work, at home, or with relationships. Symptoms may look different at older ages – for example, hyperactivity may appear as extreme restlessness^[2].

Types of ADHD

There are three different ways ADHD presents itself, depending on which types of symptoms are strongest in the individual at the time of diagnosis^[2]:

• Predominantly inattentive presentation: This involves difficulty focusing, finishing tasks and staying organized. People with this type have few or no hyperactivity symptoms and may have trouble paying attention and are easily distracted^[3][6].
• Predominantly hyperactive-impulsive presentation: This involves difficulty sitting still or having “quiet time.” People have excess energy and are extremely talkative. They may also interrupt others and act without thinking it through first. They may show less obvious trouble with paying attention^[3][6].
• Combined presentation: This is a combination of inattentive and hyperactive-impulsive symptoms. People with this type have a mix of inattention and hyperactivity-impulsivity symptoms. This is the most common type of ADHD, and it’s what most people associate with the condition^[2][3][6].

Healthcare providers also use the terms mild, moderate and severe to describe how much symptoms affect daily life^[3]. There is also an unspecified presentation, which is when symptoms are severe enough to interfere with daily life but don’t meet the official criteria for the types listed above^[3].

Overall, ADHD is approximately twice as common in boys. However, the ratios vary by type. The predominantly hyperactive/impulsive type occurs more frequently in boys, while the predominantly inattentive type occurs with approximately equal frequency in both sexes^[7].

Signs and Symptoms

It is normal for children to have trouble focusing and behaving at one time or another. However, for children with ADHD the symptoms continue, can be severe, and can cause difficulty at school, at home, or with friends^[2]. ADHD symptoms can change over time and might increase when the demands of daily life increase^[2].

ADHD symptoms fall into two big groups: inattention symptoms and hyperactivity/impulsivity symptoms^[3].

Inattention Symptoms

Inattention symptoms affect the ability to focus on a task and complete it from start to finish. People may put off tasks that require focusing and may seem distracted when someone’s talking to them^[3]. People with symptoms of attention problems may often^[3][6]:

• Not pay attention to details or make seemingly careless mistakes in schoolwork, at work, or in other activities
• Have trouble staying focused on play activities or work tasks
• Not seem to listen when spoken to directly
• Find it hard to follow instructions or finish tasks, or may start but get easily sidetracked
• Have trouble being organized, keeping belongings in order, and managing time
• Avoid doing tasks that require long periods of mental effort
• Lose important items, such as books, wallets, keys, eyeglasses, and cellphones
• Get easily distracted by things going on around them, or sometimes their own thoughts
• Forget about doing daily activities

Hyperactivity and Impulsivity Symptoms

Hyperactivity and impulsivity symptoms affect the ability to sit still or feel comfortable staying in one place. People may also have trouble waiting for their turn to speak or do something^[3]. With hyperactivity, people feel a need to always be moving. They have trouble sitting still and may fidget and/or talk too much. With impulsivity, people have trouble controlling their actions and words. They tend to act on sudden ideas or feelings without thinking about the possible results^[6].

People with symptoms of hyperactivity-impulsivity may often^[3][6]:

• Fidget and squirm while seated
• Get up when staying seated is expected, such as at school or work
• Run around or climb when it’s not appropriate (children) or feel restless (teens and adults)
• Have trouble doing quiet activities
• Be constantly moving or “on the go”
• Talk much more than is normal
• Blurt out answers before questions are completed
• Have trouble waiting for their turn
• Interrupt others, for example during conversations or games

While children with ADHD are more likely to struggle with impulsivity and hyperactivity, adults with ADHD are more likely to experience memory problems, restlessness and lack of mental focus^[15].

Causes and Risk Factors

The exact cause of ADHD is unknown. ADHD probably results from a combination of factors, such as genetics and your environment^[6]. The causes of ADHD are complex, and there are many possible causes. However, research shows that ADHD tends to run in families^[5].

ADHD is among the most heritable of psychiatric disorders with a mean heritability estimate of 76%. Children with parents or siblings of children with ADHD have two- to eight-fold increased risk for being diagnosed with ADHD^[11]. Studies indicate that there is generally a strong genetic contribution to ADHD^[5].

Even though the exact cause and mechanisms underlying ADHD are not yet completely understood, evidence implicates differences in brain chemical systems. Specifically, there are differences in dopaminergic and noradrenergic systems (systems involving the brain chemicals dopamine and noradrenaline) with decreased activity or stimulation in upper brain stem and frontal-midbrain tracts^[7].

Scientists have identified some possible risk factors that may contribute to ADHD^[2]:

• Genetics
• Exposure to environmental risks (for example, lead) during pregnancy or at a young age
• Alcohol and tobacco use during pregnancy and other pregnancy-related factors
• Child health conditions, including head injuries
• Parental mental health and family environment

Other factors that may contribute to ADHD include low birth weight, smoking during pregnancy, and some severe illnesses in infancy^[5]. Some risk factors also include birth weight less than 1500 grams, head trauma, iron deficiency, obstructive sleep apnea, and lead exposure, as well as prenatal exposure to alcohol, tobacco, and possibly cocaine^[7]. ADHD is also associated with adverse childhood experiences^[7].

Researchers are looking at possible environmental factors that might raise the risk of developing ADHD. These factors include brain injuries, nutrition, and social environments^[6].

ADHD is not caused by poor parenting, but a child’s home environment can affect whether the ADHD behaviors get better^[5].

How ADHD is Diagnosed

If you are concerned about whether your child might have ADHD, the first step is to talk with a healthcare provider to find out if the symptoms fit an ADHD diagnosis^[2]. Deciding if someone has ADHD is a process with several steps. There is no single test to diagnose ADHD^[2][6].

Many other problems, such as anxiety, depression, sleep problems, and certain types of learning disabilities, can have similar symptoms^[2]. One step of the process involves having a medical exam, including hearing and vision tests (for children and adults), to rule out other problems with symptoms like ADHD^[2][6].

Diagnosing ADHD usually includes a checklist for rating ADHD symptoms and taking a history of the child from parents, teachers, and sometimes, the child^[2]. The diagnosis process may also include information gathering, such as asking questions about any current medical issues, personal and family medical history, and the history of symptoms^[9].

For adults, signs and symptoms of ADHD can be hard to spot. However, core symptoms start early in life — before age 12 — and continue into adulthood, creating major problems^[9]. Healthcare providers may use ADHD rating scales or psychological tests to help collect and evaluate information about symptoms^[9].

Treatment Approaches

ADHD can often be managed with the right treatment. While treatment won’t cure ADHD, it can help a great deal with symptoms^[4]. There is no cure for ADHD, but treatments like medications and behavioral therapies can help manage symptoms^[3].

Treating ADHD often requires medical, educational, behavioral and psychological intervention. This comprehensive approach to treatment is sometimes called “multimodal”^[12]. Working closely with health care providers and other professionals, treatment should be tailored to the unique needs of each individual and family to help control symptoms, cope with the disorder, improve overall psychological well-being and manage social relationships^[12].

There are many treatment options, and what works best can depend on the person, their family, and their environment. To find the best options for children, it is recommended that parents work closely with others involved in their child’s life — teachers, coaches, and other family members^[8].

Treatment by Age Group

Treatment recommendations vary by age group. For children with ADHD younger than 6 years of age, the American Academy of Pediatrics recommends parent training in behavior management as the first line of treatment, before medication is tried^[8].

For children 6 years of age and older, the recommendations include medication and behavior therapy together — parent training in behavior management for children up to age 12 and other types of behavior therapy and training for adolescents^[8]. Schools can be part of the treatment as well, including adding behavioral classroom intervention and school supports^[8].

Good treatment plans will include close monitoring of whether and how much the treatment helps behavior, as well as making changes as needed along the way^[8].

Behavior Therapy

Behavior therapy is a treatment option that can help reduce disruptive behaviors and can help increase self-regulation skills. It is often helpful to start behavior therapy as soon as a diagnosis is made^[8]. ADHD affects not only a child’s ability to pay attention or sit still at school, but it also affects relationships with family and other children^[8].

The goals of behavior therapy are to learn or strengthen positive behaviors and eliminate unwanted or problem behaviors^[8]. Behavior therapy for ADHD can include^[8]:

• Parent training in behavior management
• Behavior therapy with children
• Behavioral interventions in the classroom

These approaches can also be used together. For children who attend early childhood programs, it is usually most effective if parents and educators work together to help the child^[8].

Some helpful behavior management suggestions for parents include^[8]:

• Create a routine – for tasks that happen every day, try to follow the same schedule every day, from wake-up time to bedtime
• Get organized – encourage your child to put schoolbags, clothing, and toys in the same place every day so that they will be less likely to lose them
• Manage distractions – turn off the TV and social media, limit noise, and provide a clean workspace when your child is doing homework
• Limit choices – to help your child not feel overwhelmed or overstimulated

Medications

ADHD medications work by increasing the levels of important chemicals (neurotransmitters) in the brain. These neurotransmitters include dopamine and norepinephrine^[10]. Increasing the amount of these neurotransmitters helps improve the symptoms of ADHD, including increasing attention span, reducing hyperactivity, controlling impulsive behavior, and managing executive dysfunction^[10].

ADHD medications include stimulants and non-stimulants. Healthcare providers often prescribe antidepressants as well^[10].

Stimulants are the most common type of prescription medication healthcare providers use to treat ADHD. Despite their name, stimulants don’t work by increasing stimulation. Rather, they work by increasing levels of certain chemicals in the brain. Studies have shown that stimulants are effective for treating ADHD^[10]. Stimulants, such as products that include methylphenidate or amphetamine, are typically the most commonly prescribed medications^[9].

There is ample evidence for the efficacy and safety of both stimulants and non-stimulants in the treatment of ADHD^[11].

ADHD medications affect each person differently. What works for one person may not be effective for another. The first ADHD medication tried may not be the right one – it may not be effective, or it may cause bothersome side effects. Or the correct medication may be prescribed but a higher dose may be needed^[10].

Healthcare providers may need to try different medications and doses to find what works best. They will observe the individual and adjust the dose of the medication to find the right balance between the benefits and side effects^[10]. It may take some time to determine what works best^[9].

Once the right medication and dose are found, most people find ADHD medication helps their symptoms. The symptoms involved with hyperactivity, attention span and impulsive behaviors improve^[10]. For many people, medications help them focus their thoughts, ignore distractions, pay attention and control their behavior. Medication doesn’t cure ADHD, but it can help ease the symptoms while taking it so people can function more effectively^[10].

Complementary Treatments

Treatment may also include skills training, counseling, educational supports, and education regarding ADHD^[12]. A combination of medication, education, skills training and psychological counseling is often the most effective treatment^[9].

Living With ADHD

While there is no cure for ADHD, individuals with ADHD can experience mental health recovery. For these individuals, recovery can best be understood as the ongoing management of ADHD symptoms^[12].

Even though evidence-based treatments like medication and psychotherapy go a long way to help manage the condition, learning effective behavioral strategies can give people the power to control ADHD symptoms in the moment^[15].

Strategies for Managing ADHD

Several practical strategies can help people with ADHD manage their daily lives more effectively:

Organization: If daily tasks feel overwhelming, a new organizational approach might help. Organization helps manage activities and time efficiently, removing distractions and potential frustration from the day^[15]. One strategy is to write down a schedule every night for the following day. Beginning each morning knowing what to expect gives control over responsibilities and activities. The act of crossing out completed tasks boosts a positive sense of accomplishment^[15].

To maximize chances of success, cluster similar tasks together under the same time umbrella. For example, answer emails and return phone calls once in the morning and once in the afternoon, instead of throughout the day. Also, make sure to create a bit of space in the day to allow for unexpected obstacles^[15].

Organizational tools: Tools can include a pen and paper to make lists, or computer or smartphone apps to set appointment reminders, highlight important days on the calendar, mark deadlines, and keep lists and other information handy^[19]. Set aside time each day to update lists and schedules. Don’t let the task become a chore in itself; think of it like a routine task and do it daily so it becomes an established habit^[19].

Reduce distractions: Declutter the home and office. Give yourself an appealing work environment and keep important items easily accessible. This could mean changing a workstation so it doesn’t face a window, moving to a quieter space, or just silencing smartphone and email alerts^[19].

Focus strategies: Jot down ideas as they come. You may have an “aha” moment for one task while in the middle of another. That’s okay; just write down that thought and get back to it later, after more pressing work is finished^[19].

Managing deadlines: Put off procrastinating by putting procrastination on a to-do list — like a chore — and fool yourself into actually starting work. Deal with emails, phone calls, or other matters as soon as possible. That way there will be fewer things hanging overhead and overwhelming later on^[19].

Time management: Get a watch and get in the habit of using it. The more aware of time, the more likely to avoid spending too long on a task^[19]. Be realistic about time, which can mean having to say no to new projects or other commitments^[19].

Single-tasking: Take one thing at a time. Multitasking is overrated for everyone — and it’s a nightmare for people with adult ADHD. Focus on completing one task, then move on to the next^[19].

Take breaks: Encourage time for short breaks during tasks that require sustained attention to help prevent burnout^[17].

Supporting Someone With ADHD

If someone in your life has ADHD, there are ways to offer support^[17]:

• Educate yourself: Learn about ADHD to better understand its symptoms, causes, and challenges
• Offer practical help: There are many practical ways to help someone with ADHD, such as giving them a hand with tasks like cleaning and organizing or simply being present and engaged while they work. This technique, known as “body doubling,” can give individuals with ADHD a sense of accountability and motivation, helping them stay focused and on track
• Be patient and understanding: ADHD can be frustrating both for those who have it and for the people in their lives. Be patient, flexible, and empathetic
• Encourage breaks: Help prevent burnout by encouraging time for short breaks during tasks that require sustained attention

It’s important to remember that people with ADHD are dealing with a neurodevelopmental condition. This means their brain works differently than others, and they may struggle with certain tasks or behaviors and use different strategies to succeed^[17]. Instead of assuming what someone with ADHD is going through, learn about their individual challenges by listening to them and asking questions. Everyone experiences this condition differently and uses different strategies to manage it^[17].

Building Self-Esteem

Managing ADHD symptoms is important, but thriving with ADHD starts with something more elemental: rethinking the core concept of the condition. In essence, living a happy, healthy life with ADHD comes down to eliminating shame, understanding the unique workings of the mind, and following strategies that focus on and nurture strengths^[18].

The more people understand ADHD and its unique challenges, the better they can support those who have it. ADHD is a lifelong journey, and understanding and acceptance can make a world of difference^[17].