Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition that affects millions of children and often continues into adulthood. It is characterized by a persistent pattern of inattention, hyperactivity, and impulsivity, which can interfere with a child’s ability to function effectively at school, at home, and in social settings.
Children with ADHD may struggle to stay focused on tasks, follow instructions, or complete assignments, often appearing forgetful or easily distracted. Additionally, they may exhibit excessive energy, fidgeting, or difficulty sitting still. Impulsivity can manifest as impatience, frequent interruptions, or acting without considering the consequences.
The exact cause of ADHD remains unknown, but it is believed to involve a combination of genetic, environmental, and neurological factors. Early diagnosis and intervention are crucial for helping children with ADHD succeed academically and socially. Treatment typically involves a multifaceted approach that may include behavioral therapy, educational support, and medication management.
As a child and adolescent psychiatrist, I am dedicated to working closely with families to develop personalized treatment plans that address each child’s unique needs. By incorporating evidence-based strategies and ongoing support, we can help children with ADHD reach their full potential and thrive in all aspects of their lives.
Understanding the Causes
While the exact cause of ADHD is not yet fully understood, research suggests that it is likely influenced by a combination of genetic, environmental, and neurological factors. Here is an overview of the factors involved:
- Genetic factors: ADHD tends to run in families, suggesting a strong genetic component. Studies have identified several genes associated with the disorder, which may affect brain function and neurotransmitter systems related to attention and impulse control. About 20-30% of children with ADHD had at least one additional affected family member. Studies show that ADHD has about a 75% estimated heritability, which means that the symptom variability is due to genetic rather than environmental causes. If you take a look at this bar graph below, you will see that ADHD is more heritable than IQ and height and is one of the most heritable psychiatric disorders.
- Environmental factors: Prenatal and early childhood exposures to certain environmental factors have been linked to an increased risk of ADHD. These may include maternal smoking or alcohol use during pregnancy, exposure to lead or other toxins, and premature birth or low birth weight.
- Neurological factors: Differences in brain structure and function have been observed in individuals with ADHD compared to those without the disorder. Research indicates that certain brain regions related to attention, impulse control, and executive function may be affected, as well as imbalances in neurotransmitter systems, such as dopamine and norepinephrine. Neuropsychological models emphasize deficits in executive function and reward pathways that likely represent dysfunction in multiple brain circuits. Longitudinal studies suggest that ADHD-affected groups have parallel but delayed patterns of brain development, with approximately 3-year delays in cortical maturation.
- Other contributing factors: While not direct causes of ADHD, certain factors may exacerbate symptoms or make the condition more challenging to manage. These can include co-occurring mental health conditions, learning disabilities, or stressful life events including trauma.
It is important to note that ADHD is not caused by poor parenting, excessive sugar intake, or lack of discipline. As our understanding of ADHD continues to evolve, ongoing research aims to uncover more about the complex interplay of factors that contribute to the development of the disorder. By understanding the potential causes of ADHD, healthcare professionals can better tailor treatment strategies to help individuals manage their symptoms and lead fulfilling lives.
Despite demonstrated biological difference in groups with and without ADHD, the disorder remains a behaviorally defined syndrome diagnosed by careful assessment of symptoms and clinical history, not by laboratory tests or brain imaging.
The diagnostic evaluation for ADHD is a comprehensive process designed to accurately identify the presence of ADHD symptoms and determine the most appropriate course of treatment. This thorough assessment is essential for ensuring that your child receives the right support and resources to help them thrive.
The evaluation process typically includes:
- Clinical interview: A detailed discussion with parents and the child to gather information about the child’s medical history, family background, developmental milestones, and overall functioning at home, school, and in social settings.
- Behavior rating scales: Parents, teachers, and sometimes the child themselves will be asked to complete standardized questionnaires that assess ADHD symptoms, as well as any potential co-occurring conditions such as anxiety, depression, or learning disorders.
- Observation: I will observe the child during the appointment and may observe the child in a school setting to gain insight into their behavior and interactions with others.
- Cognitive and educational assessments: These tests help to identify any learning difficulties, intellectual capabilities, or other cognitive factors that may be contributing to the child’s difficulties. However, these are not necessary to make the diagnosis and can delay treatment.
- Review of records: I will review academic records, previous assessments, and any other relevant documentation to gather further information about the child’s history and performance.
- Rule out other conditions: It’s essential to rule out other medical, psychological, or environmental factors that may mimic or contribute to ADHD symptoms. This may involve coordinating with other healthcare professionals or conducting additional tests as needed.
Once the diagnostic evaluation is complete, I will analyze the gathered information to determine if the child meets the diagnostic criteria for ADHD. If a diagnosis is confirmed, a personalized treatment plan will be developed in collaboration with the family, focusing on a combination of behavioral interventions, educational support, and, if necessary, medication management.
By undergoing a thorough diagnostic evaluation, you can ensure that your child receives the appropriate support and resources to overcome challenges and achieve success in all aspects of their life.
Effective treatment for ADHD involves a comprehensive and personalized approach, addressing each individual’s unique needs and challenges. The goal of ADHD treatment is to help manage symptoms, improve overall functioning, and enhance the quality of life for patients and their families. Here are the key components of a comprehensive plan I use in my practice for ADHD treatment:
- Medication management: Stimulant medications, such as methylphenidate (e.g., Ritalin, Concerta) and amphetamine (e.g., Adderall, Vyvanse), are often prescribed to help improve focus, attention, and impulse control. Non-stimulant medications, like atomoxetine (Strattera) and guanfacine (Intuniv), may also be considered for patients who do not respond well to stimulants or have specific concerns or contraindications. It is important to work closely with your healthcare provider to find the right medication and dosage for your individual needs.
- Behavioral therapy: Behavioral interventions can help patients develop coping strategies, improve organizational skills, and enhance social functioning. This may include cognitive-behavioral therapy (CBT), parent training, social skills training, or school-based interventions. Executive functioning coaches can help where medications cannot, such as with more complex tasks like time management skills, prioritizing tasks, learning how to use a schedule, and procrastination.
- Educational support: Collaboration between parents, teachers, and healthcare providers is vital to ensure that children with ADHD receive appropriate accommodations and support in the classroom. This may involve individualized educational plans (IEPs), 504 plans, or other tailored academic strategies. I can write a letter of support for those who require accommodations for their ADHD in school or at work.
- Family involvement: Family education and support play a crucial role in the successful management of ADHD. This may involve family therapy, parent training, or psychoeducation to help parents better understand and support their child’s needs.
- Lifestyle modifications: Encouraging healthy habits, such as a balanced diet such as the DASH diet for ADHD, regular exercise, and adequate sleep, can have a positive impact on ADHD symptoms and overall well-being. For example, artificial food colorings can cause ADHD symptoms in children and therefore, eliminating this from the diet can yield a small positive effect in children.
- Supplements: While supplements are not considered a first-line ADHD, some individuals may explore these options as complementary therapies or in cases where traditional treatments have been ineffective or poorly tolerated, particularly as most of them are low risk options. Most of these do not have rigorous clinical trial Supplemental options include omega-3 fatty acids which have a small to moderate effect size of 0.31 especially with higher EPA dose, broad spectrum micronutrients which helps more with emotional dysregulation in ADHD than core ADHD symptoms, L-Carnitine and Acetyl L-Carnitine, zinc, iron, ginseng, and pycnogenol.
- Non-medication FDA approved interventions:
External trigeminal nerve stimulation (eTNS) is a treatment for pediatric ADHD. It is a non-invasive, small, portable device that delivers mild electrical pulses to stimulate the trigeminal nerve, which is located just beneath the surface of the forehead. The benefit of the Monarch eTNS device is that for kids who respond, which about half of kids are super responders, it’s twice as effective as the most powerful medication for ADHD, but it is a minimal risk intervention. Headaches are the most common side effect and this typically goes away by itself, similar to a medication. The risk is much smaller than with stimulant medications, which is why it is a good option to try for your child if you’d like to avoid medications.
EndeavorRx is a novel, FDA-approved digital therapeutic designed to help improve attention and focus in children with Attention Deficit Hyperactivity Disorder (ADHD). Developed by Akili Interactive Labs, EndeavorRx is the first prescription video game-based treatment for pediatric ADHD. The game utilizes a series of engaging tasks that target cognitive functions such as attention, working memory, and processing speed. By adapting to the player’s performance, EndeavorRx provides a personalized and progressively challenging experience, aiming to improve attentional control and cognitive skills over time. Clinical trials have shown that EndeavorRx can lead to improvements in attention and focus in some children with ADHD, with minimal side effects. It is important to note that EndeavorRx is not intended to replace traditional ADHD treatments, such as medication or behavioral therapy, but rather to serve as a complementary tool within a comprehensive treatment plan.
By integrating these various treatment components, patients with ADHD can receive a well-rounded approach that addresses their individual needs and fosters long-term success. It is essential to maintain open communication with your healthcare provider and monitor progress over time, adjusting the treatment plan as necessary to ensure optimal outcomes.
Resources for Families
Hallowell EM, Ratey JJ. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder
Barkley RA. Taking Charge of ADHD, Third Edition: The Complete Authoritative Guide for Parents
Monastra VJ. Parenting Children With ADHD: 10 Lessons That Medicine Cannot Teach.
Pope L, Oswald HM. Colleges That Change Lives: 40 Schools That Will Change the Way You Think About Colleges
Wilens Te. Straight Talk About Psychiatric Medications for Kids, Third Edition
- Efficacy and tolerability were first described in an 8-week, open-label, pilot study of eTNS treatment of 24 children diagnosed with ADHD aged 7-14 years.
- Participants were assessed weekly with parent-and physician-completed measures of ADHD symptoms and executive functioning, treatment compliance, adverse events, and side effects.
- After four weeks of nightly use, 64% of the study group were rated as “improved” or “improved very much” on the Clinical Global Impression–Improvement (CGI-I) scale.
- After eight weeks, 71% had achieved that rating.
- ADHD Rating Scale-IV (ADHD-RS-IV) scores showed a 47% decrease, compliance was 100%, and no child withdrew from the study due to adverse events