Many FAQs about ADHD copied together as one large article

During the diagnostic process other possible causes of hyperactivity, attention deficits or distractibility or problems of impulse control have to be excluded. Important other causes of these symptoms could be:

• organic disorders
• recent trauma (but also early sexual abuse or other traumatic experiences)
• substance abuse
• onset of an other psychiatric disorder (depression, anxiety disorder)
• social problems or severe interpersonal problems at home

Some parents or teachers try to make a diagnosis after reading a book with ADHD-checklists. Simply knowing the symptoms of ADHD or having problems in distinct areas of behaviour or school performance is not enough to consider a clinical diagnosis. You need to refer to an expert to rule out other possible disorders and find the best help for your child.

This is one of the reasons why many parents do not want their children to be changed by psychopharmacotherapy or behavioural treatment. Some positive aspects of ADHD can be:

• creativity
• charming personality, warmheartedness
• good judge of character
• sense of humor
• quick to grasp essentials
• flexibility
• intuitiveness
• sensitive to surrounding environment
• enthusiastic, passionate
• forgives mistakes
• tries to do better next time
• willing to take risks

Wrong! All paediatric and psychological or psychiatric organisations accept ADHD. In fact, it is the most common mental disorder of children and adolescents.

Some people say, ADHD is not a real disorder because scientists cannot identify a cause of ADHD. The hyperactive behaviour of the children should be more or less "normal" like "ants in the pant" or signs of bad parenting or lack of motivation at school. These children could be stimuli driven due to a change of the environment like too much TV or a lack of attention of their parents.

One of these opponents is Thomas Armstrong. He says: "ADHD is a disorder that cannot be identified in the same way as polio, heart disease or other legitimate illnesses." But the diagnosis or psychological problems or psychiatric diseases like depression, anxiety disorders or dementia is not based on lab tests. Dr. Russel Barkley, a famous ADHD expert, explains that we do not have such tests for headaches, multiple sclerosis or Alzheimer. We would eliminate nearly all mental disorders, if we would only diagnose or treat "diseases" with a single lab test for diagnosis.

However, there is convincing evidence for a biological vulnerability of ADHD. Epidemiological evidence indicates that ADHD has a powerful genetic component. University of Colorado researchers have found that a child whose identical twin has the disorder is between eleven and 18 times more likely to also have it than is a non-twin sibling. Genetics is a special area of interest in the area of ADHD research. Scientists have identified several possible genes that influence the symptoms and severity of the disorder. Additional functional anatomy with SPECT or PET diagnosis can show distinct changes in the blood flow of ADHD adults and changes in the dopamine system (Dopamine transporter DAT) which are typical for ADHD. But this of course is not a method to diagnose ADHD in a clinical setting due to extreme high costs and possible adverse effects of the diagnostic tools (low radiation) for children.

There is ongoing research in the area of driving performance and ADHD. Up to now most scientist have no doubt that you will show a better driving performance if you take medicine. But you should also consider that your attention and awareness can differ extrem. If you are not used to the "new" perceptions of your enviroment (at the very beginning of a psychopharmacological treatment) you should not drive a car.

• Titration of the right dose

  The medication needs to be monitored and adapted to the personal needs. So the child might need a higher dose of the medication or might be very sensitive to psychostimulants. This should be evaluated!

• Rebound

  Normal methylphenidate pills work for about 3 to 4 hours. After that time a "rebound" of the old symptoms can occur. The patients feel very uncomfortable with this. Adaption of the right dose and intervall is necessary or you might try long-acting psychostimulants instead.

• Change stimulant preparation

  Some children do not respond to methylphenidate but do fine with amphetamines.

• Evaluate comorbid disorders like depression or anxiety disorders!!!
• Assess sleep.

  Many adhd children have severe problems at night. If they cannot sleep they might feel irritable and dysphoric.

So it is very important to make sure your child (and you) gets enough sleep!

How much sleep is enough?

• infancy/toddler: 17-18 hours
• 4 year old: 10-12 hours
• 10 year old: 9-10 hours
• 18 year old: 8-9 hours
• 30 year old: 7-8 hours
• 60 year old: less than 6-7 hours

ADHD children usually show some delay of the personal development, including a different growth pattern. The neurotransmitter Dopamine plays an important role in the regulation of the growth hormones and prolactine. Recommended doses of stimulants do not influence the hormone levels, but due to loss of appetite a slight delay of weight gain could occur.

The optimal medication dose should be adapted on a regular schedule at least every 6 months. Very often older children need LOWER stimulant doses.

Usually children with ADHD will reach a normal growth and weight in late puberty, sometime 1 or 2 years later than their classmates. Only a very small number of children will remain a little bit smaller than expected. This will not be caused by the medication but could be a result of additional hormonal disturbances.

Typical side effects of psychopharmacotherapy with stimulants like methylphenidate (Ritalin, Concerta) or amphetamines are usally mild and restricted to the first days or weeks of therapy. Typical adverse effects can be explained by the stimulation of the autonomic nervous system (sympathetic and parasympathecic).

The activation of the sympathetic nervous system can cause a mild increase of the pulse. But some patients report palpitations or tachycardia (trembling or fast, irregular heartbeat). Usally this will not cause any severe problems. The blood pressure might increase a little bit, usally not more than 5 mm Hg. This is relevant for patients with hypertension problems.

Sometimes this can also cause symptoms of dizziness. The most common side effect due to the activation of the sympathetic nervous system are sleep problems (insomnia). So usally stimulants will not be given in the late afternoon or evening. (But some patients have less sleeping problems if they take a low dose of stimulants in the late afternoon because their brain calms down). Typical reaction on the parasympathic system are:

• low appetite and stomach problems
• sometimes headaches Severe or long-lasting side effects are extremly rare! However every medication could cause an allergic reaction. Usally these are not caused by the stimulant but by additional substances of the tablet
• Severe toxic effects of methylphendiate have not been described in literature. An older other psychostimulant called Pemolin (Cylert) has rare liver complications, so that a special monitoring is required if the doctors uses this stimulant. However methlphenidate causes no damages or alterations of this kind.
• Neurotoxicity Some people are afraid of possible alterations of nerve cell groth or brain development using methylphenidate. Actually a German neurobiologist tried to get attention in the media saying methylphenidate might cause Parkinsonism. Yes, dopamine is of special importance for ADHD. Yes, psychostimulants act on the dopamine transporter in the brain. But NO: There is no connection between ADHD and Parkinson. There is not a single case where any ADHD child developed symptoms of Parkinson in later life.
• Growth Supression

Any medicine could cause allergic reactions or sometimes alterations of the number of red or white blood cells. However, this is extremely rare. The doctors usually make some blood tests at routine visits once or twice a year.

One older psychostimulant (Pemolin) had rare toxic effects on the liver, so a close monitoring of the liver enzyme was necessary.

Methylphenidate (Ritalin, Concerta) does not cause these alterations!

Psychostimulant medication can cause insomnia in some patients. However there is a significant group of patients that will even benefit from low dose psychostimulant in the afternoon or before bedtime to calm down!

To find out whether the psychostimulant medication is responsible for the sleeping problem you could try to administer the medication earlier and to reduce or avoid medication after 2 pm.

If you administer sustained release medication (e.g. Concerta) with a very long duration you might consider to change the tablet or dose.

Sometimes comedication with sedating antihistamine medication or Clonidine can be helpful.

However, it is important to establish sleeping routines and stick to defined times to go to bed. Try to reduce TV times or too much computer games in the late afternoon or evening because this can be a source of overstimulation of the brain.

Targets of Psychostimulant Pharmacotherapy

Psychostimulants like Methylphenidate (Ritalin, Concerta) are known for treating "hyperactivity". However, this is only one symptom of ADHD that can be altered by this medication. In a multimodal treatment approach of ADHD stimulants positively affect not only the core symptoms of ADHD (hyperactivity, attention deficits and impulsivity) but proved to have lasting effects on:

• Specific cognitive functions of learning, working memory and other attention functions.
• Improved social functioning with better peer interactions, more friends and prosocial behaviours.
• Better classroom behaviour and academic functioning with reduction of off-task behaviour, disruptive behaviour and following directions of the teachers.
• Relationships with the parents and siblings improves. Fewer anger outbursts or off-task behaviour.
• Mood improvement with less aggressive and disruptive behaviours.

This can have a big influence on the development of self-esteem and social interaction. While children with ADHD have a higher risk for substance abuse or addiction the treatment with psychostimulants prevents this bad outcome for them.

For children with additional Oppositional Defiant Disorder or Conduct Disorder psychostimulants proved to have a benefit as well. Aggression, lying, stealing or other conflicts with the law are influenced. Usually these kids are less prone to severe accidents if they are treated with psychostimulants within a good medical and psychosocial setting.

A typical problem for adhd children are "boring" tasks like doing homework or cleaning up their room. Usally any other stimuli (e.g. a bird outside the window, a dog barking next door, or a toy) will distract the child. Now the attention focus has complety changed, the old task is "off mind".

No. ADHD is a neurobiological based disorder. We know that at least 60 % of all children with severe ADHD will continue to show severe symptoms as adults. But symptoms might change: Hyperactive movements or impulsive behaviours might be reduced. So some children do no longer meet the diagnostic criteria for the hyperactive-impulsive type. But normally they will still have attentional problems and even more problems due to deficits of their executive functions and self-organisation.

So they might "outgrow" diagnostic criteria, but will still have the neurobiological vulnerability of ADHD.

This can cause different kinds of problems in later life due to maladaption at work, partnership or secondary problems of substance abuse or impulsive behaviours.

Many ADHD-adolescents are especially prone to substance abuse problems or problems with discipline at school or work due to their deficits in impulse control and self-organisation. However, many adolescents or adults develop positive traits and can use positive aspects of this "disorder". They learn to adapt in every day life and will no longer feel handicapped by ADHD-symptoms. But the biological vulnerability is still present.

ADHD characteristics in the Infancy, Toddler and Preschool Stages

It is very difficult to make a proper diagnosis for very young children. Normal development has to be carefully evaluated. Most of the research has focused on children with conduct problems and is mostly retrospective. But if a genetic predisposition or siblings with ADHD are present, the following symptoms might also be related to ADHD-traits:

• Excessive crying
• Difficulties to be soothed
• Hypersensitivity for touching or certain clothes
• Feeding problems, irregular eating
• Sleep disturbances
• colics

Theses symptoms can cause severe mother-child difficulties with stress and lower self-esteem of the parents. Especially excessive crying and sleeping problems can cause additional psychological problems for the mother. Very often they try every tip of friends of relatives, but they do not work! So the mother thinks, the symptoms might be due to bad parenting.

ADHD is a genetically based disorder. So the mother or father (and often both) might also be affected by ADHD. So they might have additional problems with organizing and impulse-regulation. Up to now there is very little help for these families. The best thing is to seek professional help by a doctor or psychotherapist. Psychostimulants are not recommended for very young children before preschool.

Many parents say that their children have less problems to complete their tasks (homework), if someone is in the room to supervise them. This could help the children to focus and reduce the risk of daydreaming.

Some children need rather specific situations, like background music, or have less problems if they get help from a friend who takes notes of the school day.

Controversially those with ADHD manifest more problems in group settings because they have problems to track conversations. Any boring work will not be completed in a reasonable time span if not supervised and rewarded in an appropriate way.

• Dietary Intervention. The changing of a child's diet to prevent ADHD. Conclusion: No scientific evidence of effectiveness
• Megavitamin and Mineral Supplements. The use of very high does of vitamins and/or minerals to treat ADHD. Conclusion: No scientific evidence of effectiveness.
• Anti-Motion Sickness Medication. Conclusion: No scientific evidence of effectiveness.
• Candida Yeast. Those who support this model believe that toxins created by the yeast overgrow and weaken the immune system making the individual susceptible to many illnesses including ADHD. Conclusion: No scientific evidence of effectiveness.
• Algae. Those who support this treatment believe blue-green algae to be a nutritional supplement for ADHD. Potential liver damage and no proof for effectiveness.
• Applied Kinesiology (Chiropratic approach). This theory believes that Learning Disabilities are caused by 2 specific bones in the skull. Conclusion: No scientific evidence of effectiveness.
• Optometric Vision Training. This proposes that reading related Learning Disabilities are caused by visual problems. Conclusion: No scientific evidence of effectiveness.
• EEG Biofeedback. Proponents of this approach believe that ADHD children can be trained to increase the type of brain-wave activity associated with sustained attention. Conclusion: No scientific evidence of effectiveness.

Possible causes are:

• hearing problems / tinnitus / hyperacusis
• lack of concentration due to sleep problems
• chronic worrying about problems (e.g. work related problems)
• depressive symptoms
• daydreaming
• low interest in the topic of conversation

Try to find out what might contribute to your problem. Some people have severe problems in group settings due to social anxiety or fears. This might cause high tension and reduced ability to focus on conversation.

If you have a history of attentional problems, distractibility and / or hyperactive symptoms (or children with these problems) you should also consider an residual form of ADHD (Attention Deficit Hyperactivity Disorder).

ADHD has to be considered as a chronic conditition, that might interfere with the further development and quality of life of the children. Studies indicate that persistence of ADHD into adolescence and adulthood will affect at least 60 to 80% of the ADHD children. It is important to develop an ongoing partnership among clinicians, parents, teachers or any other person who is relevant for the child and the further development.

Therefore special efforts for a long-term management of ADHD are recommended:

• Appropriate information about the condition and possible individual problems.
• Focus on individual strengths and resources of the child and the family!!!!
• Update and monitoring of the family knowledge and understanding of ADHD and any treatment options. Also alternative treatment methods should be considered, because more than 60% of all parents will at least try one or more methods.
• Counselling about the possible reactions of the family, friends, teachers...
• Developmentally appropriate education of the child about ADHD. Again: Consider resources and strengths of the child!
• Availability to any kind of questions, problems or crisis intervention.
• Offer additional support for coaching or explain the ADHD symptoms at school.
• Connect to other ADHD-families (self-help-groups, internet).
• Monitoring of any positive or negative changes and adjustment of the treatment plan/medication.