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Attention deficit hyperactivity disorder
Highlights
Heart Testing Before Starting Stimulant Drugs
In 2008, the American Heart Association issued a scientific statement recommending that children with ADHD should receive careful heart evaluation and monitoring, including having an electrocardiogram (ECG, also called EKG), before beginning stimulant drug therapy. The American Academy of Pediatrics issued a response, stating that routine ECG testing prior to initiating stimulant drug therapy is not necessary.
In addition to ECG, the American Heart Association recommends that doctors:
- Obtain a complete patient and family history
- Conduct a physical exam to check for heart problems, including heart murmurs and high blood pressure
- Arrange a consultation with a pediatric cardiologist if necessary
- Consider ordering an electrocardiogram (ECG) to check for heart abnormalities (in contrast, the American Academy of Pediatrics does not recommend routine use of ECGs before starting stimulant therapy)
- Monitor patients on stimulant drugs for emergence of cardiac symptoms
The AHA notes that stimulant drugs remain a reasonable option for children with stable heart disease or those who are currently receiving care from a pediatric cardiologist.
Stimulant drugs for ADHD include:
- Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
- Dexmethylphenidate (Focalin)
- Amphetamine-Dextroamphetamine (Adderall)
- Dextroamphetamine (Dexedrine, Dextrostat)
- Lisdexamfetamine (Vyvanse)
St. John’s wort Not Effective for ADHD
The herbal remedy St. John’s wort does not work any better than placebo in improving ADHD symptoms in children and teens, according to a 2008 study in the Journal of the American Medical Association. To date, no scientific evidence has demonstrated the effectiveness of any herbal or dietary supplement in helping relieve ADHD symptoms.
Introduction
According to the U.S. National Institute of Mental Health, attention deficit hyperactivity disorder (ADHD) is a legitimate psychologic condition.
ADHD is a syndrome generally characterized by the following symptoms:
- Inattention
- Distractibility
- Impulsivity
- Hyperactivity
Some doctors categorize ADHD into three subtypes:
- Behavior marked by hyperactivity and impulsivity, but not inattentiveness
- Behavior marked by inattentiveness, but not hyperactivity and impulsivity
- A combination of the above two
There is some debate over these criteria. Some argue the condition is overdiagnosed. Others say it's underdiagnosed. (See Difficulties in Identifying Children with ADHD section in this report.) One-third of cases are accompanied by learning disabilities and other neurologic or emotional problems, making an ADHD diagnosis particularly difficult. It is likely that the term attention-deficit hyperactivity disorder will eventually give way to subgroups of problems that include some of these general symptoms.
Childhood ADHD
In the United States, about 4.7 million children ages 3 - 17 have been diagnosed at some point with ADHD. This accounts for 7.4% of all American children in this age range.
ADHD is a genuine disorder, but it is telling that the U.S. accounts for 90% of worldwide prescriptions for stimulants for ADHD. It is not known whether this reflects a real increase in ADHD, or a better ability to recognize it. Some say it may be an indication of a culture that places excessive value on normalcy and academic achievement at the expense of more frequent diagnoses.
Symptoms of ADHD usually occur around the age of 7. Studies indicate that ADHD symptoms in preschool children with ADHD do not differ significantly from older children.
The classic ADHD symptoms do not always adequately describe the child's behavior, nor do they describe what is actually happening in the child's mind. Some researchers focused on deficits in "executive functions" of the brain to understand and describe all ADHD behaviors. Such impaired executive functions in ADHD children can cause the following problems:
- Inability to hold information in short-term memory
- Impaired organization and planning skills
- Difficulty in establishing and using goals to guide behavior, such as selecting strategies and monitoring tasks
- Inability to keep emotions from becoming overpowering
- Inability to shift efficiently from one mental activity to another
Hyperactivity. The term hyperactive is often confusing since, for some, it suggests a child racing around non-stop. A boy with ADHD playing a game, for instance, may have the same level of activity as another child without the syndrome. But when a high demand is placed on the child's attention, his brain motor activity intensifies beyond the levels of the other children. In a busy environment, such as a classroom or a crowded store, children with ADHD often become distracted and react by pulling items off the shelves, hitting people, or spinning out of control into erratic, silly, or strange behavior.
Impulsivity and Temper Explosions. Even before the "terrible twos," impulsive behavior is often apparent. The toddler may gleefully make erratic and aggressive gestures, such as hair pulling, pinching, and hitting. Temper tantrums, normal in children after age 2, are usually exaggerated and not necessarily linked to a specific negative event in the life of a child with ADHD. One of the most painful events a parent may experience is an abrupt and aggressive attack that may occur after cuddling a young child with ADHD. Often this reaction seems to be caused not by anger, but by the child's apparent inability to endure overstimulation or displays of physical affection.
Attention and Concentration. Children with ADHD are usually distracted and made inattentive by an overstimulating environment (such as a large classroom). They are also inattentive when a situation is low-key or dull. Some researchers theorize that certain parts of the brain in ADHD children may be underactive, so the children fail to be aroused by nonstimulating activities. In contrast, they may exhibit a kind of "super concentration" to a highly stimulating activity (such as a video game or a highly specific interest). Such children may even become over-attentive -- so absorbed in a project that they cannot modify or change the direction of their attention.
Impaired Short-Term Memory. Many doctors now believe that an essential feature in ADHD, as well as in learning disabilities, is an impaired working (also called short-term) memory. People with ADHD can't hold groups of sentences and images in their mind long enough to extract organized thoughts. They are not necessarily inattentive. Instead, a patient with ADHD may be unable to remember a full explanation (such as a homework assignment), or unable to complete processes that require remembering sequences, such as model building. In general, children with ADHD are often attracted to activities (television, computer games, or active individual sports) that do not tax the working memory, or produce distractions. Children with ADHD have no differences in long-term memory compared with other children.
Inability to Manage Time. Studies suggest that children with ADHD have difficulties being on time and planning the correct amount of time to complete tasks. (This may coincide with short-term memory problems.)
Lack of Adaptability. Children with ADHD have a very difficult time adapting to even minor changes in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to bed. Any shift in a situation can precipitate a strong and noisy negative response. Even when they are in a good mood, they may suddenly shift into a tantrum if met with an unexpected change or frustration. In one experiment, These children can closely focus their attention when directly cued to a specific location, but they have difficulty shifting their attention to an alternative location.
Hypersensitivity and Sleep Problems.. Children with ADHD are often hypersensitive to sights, sounds, and touch. They may complain excessively about stimuli that seem low key or bland to others. Sleeping problems usually occur well after the point when most small children sleep through the night. In one study, 63% of children with ADHD had trouble sleeping.
Adult ADHD
Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit disorder in adults are on the rise. Methylphenidate (Ritalin) was prescribed for nearly 800,000 adults in the U.S. in 1997, nearly three times the number in 1992. It is estimated that ADHD affects about 4.1% of adults ages 18 - 44 years in a given year. The disorder appears to be distributed equally between adult women and men.
Accompanying Mental Health Disorders. About 20 % of adults with ADHD also have major depression or bipolar disorder. Up to 50 % have an anxiety disorder. Bipolar disorder plus ADHD, in fact, may be very difficult to differentiate from ADHD alone in adults.
Accompanying Learning Disorders. About 20% of adults with ADHD have learning disorders, usually dyslexia and auditory processing problems. These problems should be considered in any treatment plan.
Effect on Work. Compared to adults without ADHD, those with the condition tend to reach lower educational levels, earn less money, and be fired more often. In fact, one study reported that by the time they are in their 30s, about 35% of ADHD adults are self-employed.
Substance Abuse. About 1 in 5 adults with ADHD also contend with substance abuse. Studies indicate that adolescents with ADHD are twice as likely to smoke cigarettes as their peers who do not have ADHD. Cigarette smoking during adolescence is a risk factor for the development of substance abuse in adulthood.
Causes
Brain Structure
Research using advanced imaging techniques shows there is a difference in the size of certain parts of the brain in children with ADHD compared to children who do not have ADHD. The areas showing change include the prefrontal cortex, the caudate nucleus and globus pallidus, and the cerebellum.
Brain Chemicals
Abnormal activity of certain brain chemicals in the prefrontal cortex may contribute to ADHD. The chemicals dopamine and norepinephrine are of special interest. Dopamine and norepinephrine are neurotransmitters, or chemical messengers, that affect both mental and emotional functioning. They also play a role in the "reward response." This response occurs when a person experiences pleasure in response to certain stimuli (such as food or love). Studies suggest that increased levels of the brain chemicals glutamate, glutamine, and GABA -- collectively called Glx -- interact with the pathways that transport dopamine and norepinephrine.
Nerve Pathways
Another area of interest is a network of nerves called the basal-ganglia thalamocortical pathways. Abnormalities along this neural route have been associated with ADHD, Tourette syndrome, and obsessive-compulsive disorders, all of which share certain symptoms.
Genetic Factors
Genetic factors may play the most important role in ADHD. The relatives of ADHD children (both boys and girls) have much higher rates of ADHD, antisocial, mood, anxiety, and substance abuse disorders than the families of non-ADHD children. Some twin studies report that up to 90% of children with a diagnosis of ADHD shared it with their twin.
Most of the research on the underlying genetic mechanisms targets the neurotransmitter dopamine. Variations in genes that regulate specific dopamine receptors have been identified in a high proportion of people with addictions and ADHD.
Risk Factors
Gender and ADHD
ADHD is most often diagnosed in boys. However, there is some evidence that it is underdiagnosed in girls. Until recently, all major studies were conducted using boys as subjects. More studies on girls with ADHD are now underway. A major study reported that girls with the condition experience the same multiple impairments as boys do.
Family History
ADHD tends to run in families. A child who has a parent or sibling with ADHD has an increased risk of also developing ADHD.
Environmental Factors
Some research suggests that prenatal exposure to tobacco and alcohol may increase the risk for ADHD. Environmental lead exposure before age 6 may also raise the risk for ADHD.
Dietary Factors
Several dietary factors have been researched in association with ADHD, including sensitivities to certain food chemicals, deficiencies in fatty acids (compounds that make up fats and oils) and zinc, and sensitivity to sugar. No clear evidence has emerged, however, that implicates any of these nutritional factors as risk factors for developing ADHD.
Diagnosis
Diagnostic Criteria for ADHD in Children
A. Either 1 or 2 should be present:
1. Should have 6 or more of the following symptoms of inattention, persisting for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
- Often fails to give close attention to detail, makes careless mistakes
- Often has difficulty sustaining attention in tasks or play
- Often does not seem to listen when spoken to directly
- Often does not follow through and fails to finish tasks
- Has difficulty organizing tasks and activities
- Avoids or dislikes tasks requiring sustained mental effort
- Often loses things necessary for tasks or activities
- Is often easily distracted by extraneous stimuli
- Is often forgetful in daily activities
2. Should have 6 or more of the following symptoms of hyperactivity-impulsivity that lasts for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
- Often fidgets or squirms when sitting
- Has difficulty remaining seated when required to do so
- Often runs about or climbs excessively in inappropriate situations
- Has difficulty playing quietly
- Is often "on the go"
- Often talks excessively
- Often blurts out answers to questions before they have been completed
- Has difficulty waiting for his or her turn
- Often interrupts or intrudes on others
Note: Patients with A1 symptoms are diagnosed with ADHD, predominantly inattentive type. Those with A2 are diagnosed with ADHD, predominantly hyperactive-impulsive type. Those with both A1 and A2 are diagnosed as ADHD, combined-type.
B. Onset of some symptoms before the age of 7. However, children with the inattentive subtype are not often diagnosed until they are above 7 years of age.
C. Symptoms occur in two or more settings. For example, at home and at school.
D. Clear evidence of significant impairment in social or academic functioning.
E. Not caused by a pervasive developmental disorder, schizophrenia, or any other psychotic disorder, and is not better accounted for by another mental disorder, including anxiety or depression.
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. (Text Revision). Washington, DC: 2000.
Factors for Making a Diagnosis
Important factors for making a diagnosis of attention-deficit hyperactivity disorder (ADHD) include:
- Children between ages 6 - 12 should first be evaluated for ADHD if they show symptoms of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems in at least two settings. Such behaviors should have been harmful for the child academically or socially for at least 6 months.
- The child should meet the official symptom guidelines.
- A diagnosis requires detailed reports by parents or caregivers. Parents should not be shy about insisting on further evaluation if their experience does not match a doctor's single observation of their child.
- Guidelines for primary care doctors emphasize the importance of obtaining direct evidence from the classroom teacher or other school-based professionals about the child's symptoms and their duration, and evidence of functional impairment in the school setting.
- The child should be assessed for accompanying conditions (such as learning difficulties).
Difficulties in Identifying Children with ADHD
No laboratory or imaging tests exist to reliably diagnose ADHD. A diagnosis relies only on behavioral symptoms and ruling out other disorders. Many doctors believe that the disorder is both over- and underdiagnosed. Diagnosis is difficult for some of the following reasons:
Factors Leading to the Over-Diagnosis of ADHD:
- The popularity of methylphenidate (Ritalin) has encouraged some parents and teachers to pressure doctors into prescribing this standard ADHD drug for children who are aggressive or who have poor grades. Often with careful evaluation many of these children do not meet the criteria for the illness. Children may have other diagnoses, other behavioral or emotional problems, or no problems at all.
- Other factors that may contribute to misdiagnosis include children who are young for their grade and therefore socially and intellectually immature, and social and economic problems such as single parent households.
Factors Leading to the Under-Diagnosis of ADHD:
- Some evidence suggests that girls with ADHD are underdiagnosed. Research indicates that girls with ADHD are often inattentive but not hyperactive or impulsive. In fact, older girls with ADHD tend to have social problems due to withdrawal and internalized emotions, showing symptoms of anxiety and depression.
- Doctors may fail to diagnose children with ADHD because they often behave normally in the quiet doctor's office where there are no distractions to trigger symptoms. In addition, doctors may be unfamiliar with how to diagnose the condition.
History of Behavior
The doctor will first require a detailed history of the child's behavior. Doctors will match this against a standardized checklist to define the disorder.
The parents should describe:
- Specific problems, beginning as early as possible, they have encountered during the child's development -- school reports are very helpful
- Sibling relationships
- Recent life changes
- A family history of ADHD
- Eating habits
- Sleep patterns
- Speech and language development
- Any problems during the mother's pregnancy or during delivery
- Any history of medical or physical problems, particularly allergies, chronic ear infections, and hearing difficulties
The health professional will want to know how the parents handle different situations, and may want to observe them interacting with the child.
Physical Examination
The child should also be given a general physical examination to determine if any medical conditions are present. The child should be given a hearing test to rule out hearing abnormalities as a source of behavioral problems.
Screening Tests
Various tests are available to test neurologic, intellectual, and emotional development problems. Most involve learning and problem solving tasks that help define the particular areas that are most disabling. Blood or other laboratory tests are currently recommended only if the doctor suspects lead toxicity or other medical problems.
Drug Trial
Although some doctors use a trial of a psychostimulant (usually Ritalin) to facilitate diagnosis, most doctors strongly recommend against this method of diagnosis, because it is not always accurate. An improvement in symptoms is considered suggestive of ADHD, while in non-ADHD children the stimulant often increases agitation and hyperactivity. Many children and adults without the disorder have a similar response, and such a diagnostic trial may lead to unnecessary prescriptions of this drug.
Diagnosing ADHD in Adults
ADHD in adults always occurs as a continuation of the childhood condition. Adult-onset symptoms are likely due to other factors. Diagnosing adult ADHD can be a difficult problem since hyperactivity typically wanes as children get older, while attention and organizational problems may develop in older people.
A rating scale using four factors may be useful in identifying adults with ADHD:
- Inattention and memory problems. (Examples: losing or forgetting things, being absent-minded, not finishing things, misjudging time, depending on others for order, having trouble getting started, changing jobs or projects in the middle.)
- Hyperactivity and restlessness. (Examples: always being on the go, fidgety, easily bored, taking risks, liking active and fast paced jobs and activities, such as being a sales representative or stockbroker.)
- Impulsivity and emotional instability. (Examples: saying things without thinking first, interrupting others, being annoying to others, easily frustrated, easily angered, having unpredictable moods, driving recklessly, having high relationship and job turnover.)
- Problems with self worth. (Examples: avoids new challenges, appears confident to others but not to oneself.)
Doctors use adult reports of childhood behaviors and experiences when searching for clues for a diagnosis.
Other Disorders Associated with ADHD
Several disorders may mimic or accompany attention-deficit disorder. ADHD exists alone in only about one-third of children. Many professionals object to the use of the single term "attention-deficit hyperactivity disorder" to encompass such a wide spectrum of behaviors, which they believe should be categorized into subgroups. Many of these problems require other modes of treatment and should be diagnosed separately, even if they accompany ADHD.
Attention-Deficit Disorder without Hyperactivity
Attention-deficit disorder can appear without hyperactivity, in which case the child's primary symptoms are distractibility and an inability to persist in tasks.
Oppositional-Defiant Disorder
About 14% of children diagnosed with ADHD also have oppositional-defiant disorder (ODD). The most common symptom for this disorder is a pattern of negative, defiant, and hostile behavior toward authority figures that lasts more than 6 months. In addition to displaying inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper tantrums, and display antisocial behavior. A significant number of children with ODD also have anxiety disorders and depression, which should be treated separately. Many children who develop ODD at an early age go on to develop conduct disorder.
Conduct Disorder
Some children with ADHD also have conduct disorder, which describes a complex group of behavioral and emotional disturbances seen in children. It includes aggression towards people and animals, destruction of property, deceitfulness, lying, or stealing, and general violation of rules.
Pervasive Developmental Disorder
Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behavior, hand-flapping, repetitive statements, slow social development, and speech and motor problems. If a child who has been diagnosed with ADHD does not respond to treatment, the parents might inquire about PDD, which often responds to antidepressants. Some children with PDD may also benefit from stimulants.
Central Auditory Processing Disorder and Hearing Problems
Children with ADHD often have difficulties with tasks that involve listening or hearing. Research is indicating that symptoms of the two disorders often overlap but may actually be two distinct disorders. Hearing problems themselves may cause ADHD symptoms.
Bipolar Disorder (Manic Depression)
Children diagnosed with attention-deficit disorder may also have bipolar disorder, formerly called manic depression. Indications of this problem include episodes of depression and mania (with symptoms of irritability, rapid speech, and disconnected thoughts), sometimes occurring at the same time. [For more information, see In-Depth Report #66: Bipolar disorder. ] Both disorders often cause inattention and distractibility and may be difficult to distinguish, particularly in children. Children with mania and ADHD may have more aggression, behavioral problems, and emotional disorders than those with ADHD alone. In some cases, ADHD in children or adolescents can be a marker for an emerging bipolar disorder. The primary way to differentiate bipolar disorder from ADHD is by the presence of a manic or hypomanic episode, which occurs in patients with bipolar disorder but not with ADHD. Most children with bipolar will also respond to the drug valproate, which does not typically work for ADHD in children.
Anxiety Disorders
Anxiety disorders commonly accompany ADHD. Obsessive-compulsive disorder is a specific anxiety disorder that shares many characteristics with ADHD and may share a genetic component. Young children who have experienced traumatic events, (including sexual or physical abuse or neglect), may exhibit characteristics of ADHD including impulsivity, emotional outbursts, and oppositional behavior.
Sleep Disorders
Sleep disorders or disturbances are often associated with ADHD. Insomnia is common. In addition, specific sleep disorders -- restless legs syndrome and sleep apnea (sleep-disordered breathing) -- have been identified with hyperactivity and conduct disorder. [For more information, see In-Depth Reports #27: Insomnia; #95: Restless legs syndrome; #65: Sleep apnea.
Other Conditions
Tourette Syndrome and Other Genetic Disorders. Several genetic disorders cause symptoms resembling ADHD, including fragile X and Tourette syndrome. Many patients with Tourette syndrome also have ADHD, and some of the treatments are similar.
Lead Poisoning. Children who ingest even small amounts of lead may manifest symptoms similar to those of ADHD. A child may be easily distractible, disorganized, and have trouble thinking logically. The major cause of lead toxicity is exposure to leaded paint, particularly in homes that are old and in poor repair.
Complications
Emotional Problems
Children with ADHD, especially those who also have anxiety or depression disorders, are likely to suffer from low self-esteem.
Social Problems
Anti-Social Behavior. A child with ADHD oftentimes has volatile relationships with others and these children are often unhappy from a very young age. Research indicates that any boy or girl with ADHD, particularly an aggressive child, has trouble getting along with others, and is less liked by his or her peers.
- Children with the inattentive subtype of ADHD are more likely to be picked on and to spend time alone.
- Children with the combined subtypes tend to have different problems. Boys with ADHD are less likely than others to empathize with people in difficult circumstances. A best friend can turn into an enemy overnight when, for example, a boy with ADHD does not perceive his friend's fearful response to over-aggressive roughhousing and fails to let up. The next day the child with ADHD has forgotten the event; the ex-friend hasn't.
- When children with ADHD hurt someone, they may either go into a state of denial or blame themselves excessively. As ostracism, fear, and ridicule from peers persist from year to year, the unstable behavior, originally neurologic, becomes emotionally based. Unless this cycle is broken, serious adult problems can evolve.
High-Risk Behavior. Impulsivity in young people with ADHD can cause them to take chances before thinking them through, putting them in situations where the consequences become clear only after the action has been taken. Children with ADHD and high levels of aggression are at higher risk for delinquent behavior in adolescence and criminal activity in adulthood. Close parental attention and early treatment can limit the risk considerably.
Substance Abuse
Studies consistently report that young people with ADHD -- in particular those with conduct or mood disorders -- have a higher than average risk for substance abuse and that it starts in younger ages. In one study, by age 11 nearly 20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. Biologic factors associated with ADHD may make these individuals susceptible to substance abuse. Many of these young people are actually self-medicating their condition.
Learning Problems
Although speech and learning disorders are common in children with ADHD, the disorder does not affect intelligence. People with ADHD span the same IQ range as the general population.
Many children with ADHD are underachievers, and half are held back in school at least once. Some evidence suggests that inattention may be a major factor in low academic performance in these children. About 20% also have reading difficulties, and 60% have serious handwriting problems. Adults with ADHD are also at very high risk for these conditions.
Persistence of ADHD into Adulthood
Some research suggests that ADHD persists in one- to two-thirds of those diagnosed with the condition in childhood. Many researchers describe the pattern of ADHD as they would a chronic illness, with remission and periods of worsening.
Effect on Family
The time and attention needed to deal with a child with ADHD can change internal family relationships and have devastating effects on parents and siblings.
Effect on Parents. Any intervention for the child must include the parents. Parents who are responsive to their child in a positive way can help reduce the chances for oppositional behaviors. But it can be very difficult. A child with ADHD is wonderful one day and terrible the next, for no apparent reason. The parent can feel betrayed and hurt, and believe they have no control over their child. Parents must protect themselves and their child by establishing tough but kind rules about where their space ends and the child's begins. There are many effects on parents:
- Mothers generally get the brunt of the emotional and physical abuse that a child with ADHD can produce.
- Parents may have to give up on the idea of an immaculate house and a hot meal every night. Parents must learn that striving for perfection is among the most counterproductive goals to pursue in raising a child with ADHD, or any child.
- Parents must face the hostility and anger of other parents and see their own child rejected. It is very easy to fall into an emotional black hole, and feel alone, inadequate, and helpless.
- Marriages are often stressed to the breaking point because of exhaustion and disagreements between the husband and wife on how to respond to the child.
Effect on Siblings. Siblings of children with ADHD have particular difficulties, and are also at risk for psychologic impairment, depression, drug abuse, and language disorders. A sibling without ADHD does not have the control a parent does in the management of the ADHD child's behavior and is very likely to feel alienated and alone. Children without ADHD are often victimized by siblings with ADHD who may be demanding or bullying.
Siblings who do not receive attention in their own right may begin to imitate undesirable behaviors or to act out negatively in other ways. It is very important to make the brothers and sisters equally vital to the family's functioning. However, they should never be made to feel that their value in the family is as caregivers of the sibling with ADHD.
Treatment
A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitive-behavioral therapy is proving to be the best option for treatment of children with ADHD. Although medication can be helpful during the initial years of treatment, some research indicates that the benefits of medication eventually wear off. It appears that for ADHD symptoms may improve naturally over time, regardless of the treatment approach.
Signs that ADHD may be easing include not having to adjust medication dosages during growth spurts, no deterioration when a drug dose is missed, or new abilities to concentrate during “drug holidays.” (School vacation times are a good period to test the effectiveness of temporarily stopping medication.) The American Academy of Child and Adolescent Psychiatry suggests that parents evaluate whether medication can safely be withdrawn when children with ADHD have been free of symptoms for at least 1 year. If a child’s condition worsens after medication withdrawal, the drug should be resumed.
Developing a Treatment Approach. The following guidelines may be useful in determining a treatment approach for children with ADHD:
- Behavioral techniques, possibly including dietary changes, should be tried first, if possible.
- If the symptoms are severe or do not respond, a trial using medication (usually psychostimulants), in conjunction with behavior modification therapy, is advisable.
Cognitive behavioral therapy (CBT) is often administered by mental health providers, with both primary care physicians and psychiatrists prescribing medications. Unfortunately, many children do not have access to behavioral therapies, either because of lack of time or available resources.
Specific Patient Populations. Unfortunately, such guidelines do not address the following specific patient groups:
- There are no definite guidelines for treating preschool children with severe ADHD. Some parents have reported very good long-term results with behavioral interventions at this age.
- There are no reliable guidelines on how to treat the inattentive subtype of ADHD, which might be more common in girls.
- There are no defined treatments for ADHD patients with accompanying conditions, including impaired working memory and deficits in language processing.
- There are no defined treatments for children with ADHD and accompanying emotional problems, such as bipolar or anxiety disorders. (There is some evidence, for example, that children with ADHD plus anxiety disorders do worse on psychostimulants.)
Determining a Medication Regimen. Doctors still have a difficult time predicting which medications will produce beneficial results, so treatment is individualized and performed on a trial and error basis, which requires close observation and cooperation between all participants. In developing an effective medication plan, the following steps may be helpful:
- Before any drug is administered, a child should be given a thorough examination for any medical problems to be sure there are no medical conditions that interfere with the medication. It is especially important that children be checked for heart problems prior to initiating stimulant medication. (See “Risks of Stimulants” in the Medications section of this report.)
- Both the doctor and the parents should be very clear about the specific behaviors they hope the medication will target.
- The goal is to use the lowest possible dosage that produces improved behavior.
- If an initial regimen doesn't work, changing the dosage, or changing to a different medication often brings improvement.
- Frequent follow-up visits should be scheduled to assess the response and to detect possible side effects.
Arguments For and Against Psychostimulants. Many parents are very disturbed by the idea of putting their children on intensive stimulant drug regimens, possibly for years, particularly given the uncertainties in diagnosis and the negative publicity surrounding the use of these drugs. Although the decision to use these drugs should not be made lightly, the negative social and emotional effects of the disorder itself for many children with ADHD are far more severe and long-lasting than the use of these drugs. For some parents and children, medication seems like a miracle and can provide desperate families with a quality of life for which they had almost given up hope. Whether or not psychostimulants are used, children and families should understand that ongoing efforts around behavior control will be necessary.
Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children. Although low doses of methylphenidate (Ritalin) may help preschoolers (ages 3 - 5 years) with ADHD, the drug can cause considerable side effects in many children. These side effects include insomnia, nervousness, anxiety, loss of appetite and weight, and slowed growth. Children in one large study grew about an inch less and weighed about 6 pounds less than normal after 3 years of methylphenidate treatment. Doctors must carefully consider the risks versus benefits when prescribing ADHD drugs to preschoolers. Children who do receive these drugs need to be carefully monitored by their doctors.
Treatment for Adult ADHD. As with children, adults with ADHD are treated with a combination of medication and psychotherapy. For medication, stimulant drugs or the non-stimulant drug atomoxetine (Strattera) are usually first-line treatments, with antidepressants a secondary option. Most stimulant drugs, as well as atomoxetine, are approved for adults with ADHD. Adults who have heart problems or heart condition risk factors should be aware of the cardiovascular risks associated with ADHD medication. There have been ADHD medication-associated incidents of sudden death in patients with underlying serious heart problems, and reports of stroke and heart attack in adults with cardiac risk factors.
Help for Families and Teachers
Research increasingly supports the view that interventions for the ADHD child must also include the parents if they are to be successful. Teachers and school officials should also be educated and involved in the process.
Parents who feel they have the most control over their child's situation experience the least psychological stress and depression. Parents who are responsive in a positive way also help reduce the chances for their child developing oppositional behaviors. But it can be very difficult, particularly for parents who have ADHD themselves. In fact, parents who have severe ADHD symptoms are less likely to respond to parent training programs unless they get help for themselves.
In addition to behavioral therapy for the child, family therapy may help children with ADHD and their parents and siblings cope with the emotional conflicts that nearly always arise in the lifelong process of managing the condition. Separate psychological therapies for specific family members might be needed, particularly in light of the high incidence of psychiatric and other emotional problems in families with ADHD children.
Medications
Several types of medication are available to treat ADHD.
Psychostimulants: Methylphenidate (Ritalin) and Similar Drugs
Psychostimulants are the primary drugs used to treat ADHD. Although these drugs stimulate the central nervous system, they have a calming effect on people with ADHD.
These drugs include:
- Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
- Dexmethylphenidate (Focalin)
- Amphetamine-Dextroamphetamine (Adderall)
- Dextroamphetamine (Dexedrine, Dextrostat)
- Lisdexamfetamine (Vyvanse)
Pemoline (Cylert), another stimulant drug, was withdrawn from the U.S. market in 2005 after several reports of liver failure.
Methylphenidate and Dexmethylphenidate. Methylphenidate drugs (Ritalin, Metadate, Concerta, Daytrana) are the most commonly used psychostimulants for treating ADHD in both children and adults. Dexmethylphenidate (Focalin) is a similar drug. These drugs increase dopamine, a neurotransmitter important for cognitive functions such as attention and focus.
With the exception of Daytrana, all of these drugs are pills taken by mouth. Daytrana, approved in 2006, is the first skin patch drug for ADHD. A patch is applied to the hip each day and delivers a 9-hour dose of methylphenidate.
These drugs are available in short-acting and long-acting dosage forms. The short-acting forms need to be taken several times a day, including during school hours. As the drug wears off, a rebound effect can occur, and ADHD symptoms can intensify. For this reason, the long-acting dosage forms have become popular.
Amphetamine, Dextroamphetamine, and Lisdexamfetamine. Amphetamine-dextroamphetamine (Adderall), dextroamphetamine (Dexedrine, Dextrostat), and lisdexamfetamine (Vyvanse) work by blocking the reabsorption of the brain chemicals dopamine and norepinephrine. Side effects can include stomach problems and mood changes, including sadness, anxiety, and irritability.
Risks of Stimulants
Psychostimulant medications are associated with some significant risks. All ADHD stimulant drugs carry warnings that they should not be used by patients with structural heart problems or pre-existing heart conditions (high blood pressure, heart failure, heart rhythm disturbances, or congenital heart disease). These drugs have been associated with sudden death in children with heart problems. They have also been associated with sudden death, stroke, and heart attack in adults with a history of heart disease.
The American Heart Association (AHA) currently recommends cardiac testing prior to prescribing stimulant drugs for children. The AHA recommends that doctors:
- Get a complete patient and family history
- Conduct a physical exam to check for heart problems, including heart murmurs and high blood pressure
- Arrange a consultation with a pediatric cardiologist if necessary
- Consider ordering an electrocardiogram (ECG) to check for heart abnormalities (in contrast, the American Academy of Pediatrics does not recommend routine use of ECGs before starting stimulant therapy)
- Monitor patients on stimulant drugs for emergence of cardiac symptoms
The AHA notes that stimulant drugs remain a reasonable option for children with stable heart disease or those who are currently receiving care from a pediatric cardiologist.
Stimulant drugs may also:
- Worsen behavior and thought disturbance in patients with a pre-existing psychotic disorder. These drugs may also slightly increase the risk for auditory hallucinations, paranoia, and manic behavior even in patients who do not have a history of psychiatric problems.
- Cause a mixed or manic episode in patients who have both ADHD and bipolar disorder.
- Increase aggressive behavior or hostility. Patients beginning stimulant drug treatment should be monitored for worsening of these behaviors.
- Slow growth and weight gain in children. Children who take stimulant drugs should have their growth monitored. If they do not gain height or weight at a normal rate, they may need to stop taking the drug.
The FDA has directed manufacturers of ADHD medications to warn all patients taking these medicines of their potential cardiovascular and psychiatric risks.
Side Effects. All stimulants have a number of side effects:
- The most common side effects of any stimulant are nervousness and sleeplessness, although some parents have reported improved sleep patterns in their children after taking stimulants.
- Tics or jerky, disordered movements occur in about 9% of children.
- Other side effects include irritability, stomach pain, headache, depression, hair loss, and lack of spontaneity.
Symptoms of Overdose. Symptoms of overdose include changes in heart rhythm and rate, hypertension, confusion, breathing difficulties, sweating, vomiting, and muscle twitches. If they occur, parents should call the doctor immediately. Even among young people who abuse Ritalin, however, less than 1% experience severe side effects (rapid heart rate, hypertension), and outcomes are generally good. Side effects may be very severe, however, if Ritalin is overused and taken with other drugs.
Concerns for Abuse. Studies on both animals and humans suggest that Ritalin lacks the properties that create addiction, particularly in doses used for treating ADHD. Although methylphenidates have properties similar to amphetamines, their drug levels rise very slowly in the brain at the oral doses given for ADHD. This slow rise prevents a so-called "high" and subsequent addiction to the drug. Some stimulant drugs, such as lisdexamfetamine, may pose a lower risk for abuse than others.
The primary danger for drug abuse from stimulants appears to occur in young people without ADHD who purchase these drugs illegally. In one study, 16% of children with ADHD reported pressure from their fellow students to sell or give them their medication. While people ages 18 - 25 are more likely to use ADHD drugs for non-medical uses, children ages 12 - 17 are more likely to suffer adverse effects from medication misuse and to require treatment at an emergency room. If a child abuses another drug (alcohol, prescription medication) along with the ADHD medication, the chance for serious side effects is even greater.
Non-Stimulant: Atomoxetine
Atomoxetine (Strattera) was the first non-stimulant approved for ADHD in children and the first treatment approved for adult ADHD. The drug works by increasing levels of both norepinephrine and dopamine, which are generally lower than normal in ADHD. The most common side effect is decreased appetite. A few cases of atomoxetine-associated liver injury have been reported, and the FDA has warned doctors that the drug should be discontinued at the first signs of jaundice (yellowing of skin and eyes) and liver problems. Long-term effects, such as any impact on growth, are still unknown. Atomoxetine may cause suicidal thinking in children and adolescents, especially during the first few months of treatment. Parents should monitor children taking atomoxetine for any changes in mood or behavior, and immediately contact their doctor if changes occur.
Antidepressants
Antidepressants are not FDA-approved for ADHD treatment, but may be helpful in certain circumstances. Because antidepressants appear to work about as well as behavioral therapy, doctors recommend that patients first try psychotherapy before using antidepressants.
Bupropion (Wellbutrin) and tricyclics are the types of antidepressants used for ADHD. Bupropion affects the reuptake of the serotonin, norepinephrine, and dopamine neurotransmitters. Side effects include restlessness, agitation, sleeplessness, headache, and stomach problems. Bupropion should not be used by patients who have a seizure disorder.
Tricyclics are an older type of antidepressant that can be beneficial but have many side effects. Imipramine (Tofranil) and nortriptyline (Pamelor, Aventil) are the tricyclics most commonly prescribed for ADHD. A third tricyclic, desipramine (Norpramin) should only be used if patients are not helped by other tricyclics. (Desipramine has caused sudden death in some children and adolescents.)
Tricyclic antidepressants can cause disturbances in heart rhythm. Children should have an electrocardiogram when they first begin to take this drug, and after any dose increase.
[For more information, see In-Depth Report #8: Depression ].
Alpha-2 Agonists (Clonidine)
Alpha-2 agonists stimulate the neurotransmitter norepinephrine, which appears to be important for concentration. They include clonidine (Catapres) and guanfacine (Tenex). They are used for Tourette syndrome and may be beneficial when other drugs have failed for ADHD children with tics or those whose primary symptoms are severe impulsivity and aggression. These drugs are mainly prescribed in combination with a stimulant.
These drugs have a number of side effects. Sedation is the most common. A clonidine skin patch, which gradually releases the medication, helps reduce the sedative effect. Because clonidine slows the heart down, it can have adverse effects in some children. Going off too quickly or missing doses can cause rapid heartbeats and other symptoms that may lead to severe problems. Doctors strongly recommend that no child be given this medication without a preliminary examination for heart problems, and no child with existing heart, kidney, or circulatory problems should take it.
Behavioral Management
Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers. To learn them, caregivers may need help from qualified health care professionals or from ADHD support groups. At first, the idea of changing the behavior of a highly energetic, obstinate child is daunting. It is futile and damaging to try to force a child with ADHD to be like most children. It is possible, however, to limit destructive behavior and to instill a sense of self-worth that will help overcome negativity toward life, which is one of the great dangers of the disorder.
Behavioral Techniques at Home
Bringing up a child with ADHD, like bringing up any child, is a process. No single point is ever reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to do anything more." The child's self esteem will evolve with an increasing ability to step back and consider the consequences of an action and then to control that action before taking it. But this does not happen overnight. A growing child with ADHD is different from other children in very specific ways, presenting challenges at every age.
Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some parents are easygoing and can accept a wide range of behaviors, while others cannot. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some tips to help parents include:
- Parents should prepare a list giving priority to those behaviors they think are the most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (refusing to wear anything but red T-shirts).
- Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (making up silly songs or drawing violent pictures). These should be accepted as part of the child's unique and positive development, even if they seem peculiar to the parent.
- It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm.
Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their approach to the child, which should reward good behavior and discourage destructive behavior. Rules should be well-defined but flexible enough to incorporate harmless idiosyncrasies. It is very important to understand that children with ADHD have much more difficulty adapting to change than do children without the condition. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.) Parents should establish a predictable routine, and provide a neat, stable home environment (particularly in the child’s room).
Managing Aggression. Some useful tips for managing aggression include:
- Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional.
- The use of "time-out," isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which they are endangered or endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others.
- To channel physical aggression and impulsivity in a toddler with ADHD, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.)
- When the child becomes older and if the verbal responses become intentionally abusive and socially undesirable, the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Competitive video games, such as sports games, may also be an option.
- Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible.
Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.
Some suggested tips for rewarding the ADHD child are:
- Create charts with points or stars for good behavior or for completed tasks. It is important to give points for even simple positive behaviors, which may be taken for granted in other children (responding happily to a change in plans, changing an obscenity to a more acceptable expletive).
- Rewards for any child can include playing a favorite game with the child, extending bedtime by an hour, or allowing an extra half-hour of TV.
- Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects.
- A reward system should rotate different types of rewards, because such children are easily bored.
- Children with ADHD respond better with small rewards promised in the short-term than large rewards offered in the future. One approach that employs both short- and long-term rewards uses a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game or CD.
- Rewards should be promised only when caregivers are fairly certain they can follow through. Children with ADHD respond with much greater frustration than non-ADHD children to disappointment, and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the child's make-up and not necessarily in their control.
Improving Concentration and Attention. Research indicates that children with ADHD perform significantly better when their interest is engaged. Parents should be on the lookout for activities that hold the child's concentration. Options include swimming, tennis, and other sports that focus attention and limit peripheral stimuli. (Children with ADHD may have difficulty with team sports require constant alertness, such as football or basketball.)
Martial arts, such as Tae Kwon Do, which can also offer an appropriate and controlled emotional outlet, and help to focus attention, and teach self-restraint, self-discipline, and tolerance. Learning an instrument can help a child to develop a more rhythmic and balanced sense of self.
Management at School
Even if a parent is successful in managing the child at home, difficulties often arise at school. The ultimate goal for any educational process should be the happy and healthy social integration of the ADHD child with their peers.
Preparing the Teacher. Although teachers can expect at least one student in every classroom to have ADHD, there is currently little training that prepares them for managing these children. The teacher should be prepared for the certain behaviors in the child with ADHD:
- Students with ADHD are often demanding, talkative, and highly visible.
- Inattention is a major factor in low academic performance and can cause children to frequently forget homework or miss assignments. Children with ADHD often require frequent reminders or visual cues (such as posters) for rules and regulations. Having the child sit in the front of the classroom may be helpful for both increasing attention and reducing noisy activity.
- Lack of fine motor control makes taking notes very difficult, and handwriting is often poor. Using a computer can compensate for this.
- Rote memorization and math computation, which require following a set of ordered steps, are often difficult. (Children with ADHD may do better with math concepts.)
- Many children with ADHD respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision.
The Role of the Parent in the School Setting. The parent can help the child by talking to the teacher before the school year starts about their child's situation. The first priority for the parent is to develop a positive, not adversarial, relationship with the child's teacher. Finding a tutor to help after school may also be helpful
Special Education Programs. The Individuals with Disabilities Education Act (IDEA) requires the school to identify and evaluate children who may need help and to provide special services. However, parents sometimes report pressure by the school to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally.
High-quality special education can be extremely helpful in improving learning and developing a child's sense of self worth. However, programs vary widely in their ability to provide quality education. Parents must be aware of certain limitations and problems with special education:
- Special education programs within the normal school setting often increase the child's feelings of social alienation.
- If the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior.
- There is no federally funded special education category specifically targeted to ADHD.
If, in fact, ADHD is as common as studies are indicating, the best approach may be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom.
Special programs are also required under the Rehabilitation Act and by the Americans with Disabilities Act (ADA) for students at institutions of higher learning. It is the student's responsibility, however, to inform the administration at their college or university that they need such services.
Other Treatments
Dietary Approaches
A number of diets have been suggested for people with ADHD. Several well-conducted studies have failed to support dietary effects of sugar and food additives on behavior, except possibly in a very small percentage of children. Still various studies have reported behavioral improvement with diets that restrict possible allergens in the diet. Parents may want to discuss with their doctor implementing an elimination diet of certain foods that would not be harmful and that might help.
Among the suspected additives and foods that parents and studies report as inciting behavioral changes are:
- Any artificial colorings (particularly yellow, red, or green)
- Other chemical additives -- for example, BHT or BHA
- Milk
- Chocolate
- Eggs
- Wheat
- Foods containing salicylates, including all berries, chili powder, apples and cider, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes, tomatoes
Feingold Diet. The most well-known diet for ADHD is the Feingold diet, a salicylate- and additive-free diet, which requires rigorous vigilance over a child's eating habits. This diet also prohibits aspirin, which contains salicylates. Some parents report great success with this diet, although it may be difficult to impose. It is certainly wise, in any case, to avoid food with artificial colors and flavors and to provide a healthy balance of fresh, natural foods.
Essential Fatty Acids. Omega-3 fatty acids, found in fatty fish and certain vegetable oils, are important for normal brain function and may have some benefits for people with ADHD. It is not clear if supplements of fatty acid compounds, such as docosahexaenoic acid (DHA) and eicosapentaneoic acid (EPA), provide any advantages.
Zinc. Zinc is important for the metabolism of certain neurotransmitters that play a role in ADHD, and deficiencies have been associated with some cases of ADHD. Long-term use of zinc, however, can cause anemia and other side effects in people without deficiencies and it has no effect on ADHD in these patients. In any case, testing for trace minerals, such as zinc, is not standard procedure when evaluating children suspected to have ADHD.
Sugar. Although parents often blame sugar for causing children to become impulsive or hyperactive, a number of studies strongly indicate that sugar plays no role in hyperactivity.
Feedback Approaches
Techniques that use biologic or auditory feedback are proving to be effective tools for increasing children's attention -- a primary factor in low academic performance.
Neurofeedback. Neurofeedback is an approach that uses electronic devices to help the child control their own brain wave activity. Electrodes are pasted to the child's head and pick up signals from the brain. The child watches images, such as moving graphs, on a computer monitor that reflect the child's brain wave activity. Children are then taught certain high-level mental activities at the point when feedback information on the screen indicates that they are fully concentrating. Children usually attend forty 50-minute sessions, usually twice a week. Small studies have reported significant improvement in inattention, impulsivity, and response time.
Interactive Metronome and Musical Therapy. Interactive metronome uses feedback from sound to improve attention, motor control, and certain academic skills. In this technique study, children wear headphones and sensors on their hands and feet. They perform a number of exercises to a rhythmic computer-beat. Training sessions are completed in 3 - 5 weeks. Some small studies have reported improvement in attention, motor control, language processing, and behavior. (In support of this, some parents report that learning a musical instrument helped their children significantly.)
Other Non-Drug Therapies
A number of alternative approaches are tried by children and adults with mild ADHD symptoms. For example, daily massage therapy may help some people with ADHD feel happier, fidget less, be less hyperactive, and focus on tasks. Other alternative approaches that may be helpful include relaxation training, meditation, and music therapy. Based on existing evidence, these treatments may be helpful for symptom management but are not proven to benefit the underlying disorder.
Herbs and Supplements. A number of parents resort to alternative remedies as an alternative to psychostimulants and other drugs. These products include- as St. John’s wort, ginkgo biloba, panax ginseng, melatonin, and pine bark extract. Based on existing evidence, however, none can be recommended, particularly for children.
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.
Resources
- www.aap.org -- American Academy of Pediatrics
- www.nimh.nih.gov -- National Institute of Mental Health
- www.chadd.org -- Children and Adults with Attention-Deficit Disorder
- www.add.org -- Attention Deficit Disorder Association
- www.psych.org -- American Psychiatric Association
- www.parentsmedguide.org -- Medication Guide for Treating ADHD
- www.aacap.org -- American Academy of Child and Adolescent Psychiatry
- www.nichcy.org -- National Dissemination Center for Children with Disabilities
- www.ncld.org -- National Center for Learning Disabilities
- www.ldaamerica.org -- Learning Disabilities Association of America
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
