ADHD

What Causes ADHD?

Scientists have not yet determined a definitive cause of ADHD. Because the disorder is often connected with family history, it may have an inherited genetic cause. However, environmental factors seem to play a role, too. The condition is most likely caused by a combination of genetic and environmental factors, and the precise cause probably varies from case to case.

Beyond the inherited risk, research has identified some environmental factors that increase a child’s risk of developing ADHD. These factors include:

• Tobacco, alcohol, or drug use by the mother during pregnancy
• Low birth weight
• Premature birth
• Exposure to toxins such as lead during pregnancy
• Exposure to toxins during early childhood
• Brain injury

Is ADHD Hereditary?

Research has shown that there is a relationship between ADHD and family history. Children whose parents, siblings, or other close relatives suffer ADHD are significantly more likely to have the disorder themselves. These findings suggest that at least some of the risk for developing the condition comes from inherited genetic traits. ADHD has an estimated heritability of about 74%, meaning that the disorder is strongly connected to genetic factors.

While scientists have identified several specific genes that might be a factor in developing ADHD, no single gene defect seems to be the primary cause. Instead, it is likely that changes in multiple genes, each of which has a small overall effect, combine to produce the disorder. It is also probable that external environmental factors work together with genetic tendencies in the development of ADHD.

How Is ADHD Detected?

Early detection of ADHD can be difficult because some of the disorder’s symptoms are not easily distinguishable from normal behavior in young children. High energy, excitability, and distractibility are all typical in preschool-age children. Impulse control and attention span typically improve as a child develops, and early limitations in these areas are not necessarily an indication of ADHD.

ADHD can also be hard to detect early on if hyperactivity and impulsivity are not the predominant symptoms. Difficulties with attention or focus may go unnoticed when a child is otherwise quiet and well-behaved.

ADHD is most commonly diagnosed later when a child enters elementary school. At this stage, symptoms are more likely to interfere with the child’s performance at school and in social interactions.

How Is ADHD Diagnosed?

Diagnosis of ADHD requires multiple steps. The first step is typically an examination by a pediatrician that will rule out other possible medical causes of the child’s symptoms. When other causes are ruled out, the child is likely to be referred to a psychologist, psychiatrist, or neurologist, who will look for the diagnostic criteria for ADHD.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (https://www.psychiatry.org/patients-families/adhd) lays out specific criteria that must be present for a clinical diagnosis of ADHD. The criteria include:

• Inattention. A child 16 years old or younger must exhibit six different symptoms of inappropriate inattention. The symptoms must have been present for at least six months.
• Hyperactivity and Impulsivity. The child must show at least six symptoms of inappropriate behavior that have been present for at least six months.
• Symptoms must have been present before the age of 12.
• Symptoms must be present in at least two different settings, such as school and home.
• Symptoms must interfere with the child’s functioning at school, in relationships, or in other contexts.
• Other medical or mental disorders do not explain symptoms.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is ADHD Treated?

ADHD can be effectively treated with behavioral therapy and/or medication to control symptoms. Different children respond differently to various therapies, and an effective treatment plan should be tailored to fit an individual child’s needs.

Common treatments for ADHD include:

• Behavioral therapies. These therapeutic approaches aim to teach children to manage their behaviors. Treatment can improve focus, organizational skills, and impulse control.
• Parent training. This approach teaches parents how to manage a child’s behavior. Parent training is the primary recommended treatment for children under age 6. Younger children are less likely to control their behavior, and doctors recommend against using medication to treat children younger than age 6.
• Medications. Several different therapeutics have been approved for the treatment of ADHD. Stimulants such as Adderall or Ritalin are most commonly prescribed; these medications are fast-acting and help improve attention. Non-stimulant drugs such as atomoxetine or clonidine tend to act more slowly, but they may be prescribed when stimulants are ineffective or cause side effects.

How Does ADHD Progress?

ADHD symptoms may first appear in preschool-age children, but the disorder is usually not diagnosed until later, when the signs begin to interfere with the child’s functioning in school and with peers.

Symptoms may change over time, with inattention, hyperactivity, and impulsivity each becoming more or less prevalent as the child gets older.

In many children, symptoms decrease in severity as the child enters adulthood. In about a third of cases, however, symptoms continue into adulthood.

Potential long-term consequences and complications of ADHD include:

• Poor performance in school
• Poor performance at work
• Low self-esteem
• Unstable relationships
• Criminal or legal trouble
• Financial problems
• Drug or alcohol abuse
• Other mental disorders such as anxiety, depression

ADHD often coexists with other mental or neurological disorders such as:

• Oppositional defiant disorder (ODD)
• Mood disorders such as bipolar disorder
• Tourette syndrome
• Autism spectrum disorder

How Is ADHD Prevented?

There is no guaranteed way to prevent ADHD, but avoiding known risk factors may reduce your child’s likelihood of developing the disorder.

• Do not smoke, drink alcohol, or use drugs during pregnancy.
• Do not expose your child to toxins such as tobacco smoke or lead.
• Limit young children’s access to electronic devices and television. Some research suggests that excessive screen time in children under age 5 increases the risk of ADHD.

ADHD Caregiver Tips

Especially when a child is young, the intervention of parents is the most effective treatment for ADHD. By building an environment for your child that minimizes the disorder’s effects and encourages appropriate behavior, you can help your child thrive.

• Provide a supportive environment. Develop a routine for your child’s daily activities and help the child to plan steps for getting tasks done. Do your part to limit distractions, and always be clear about your expectations.
• Take a positive approach to discipline. Help your child to set goals, and be generous with praise when they meet those goals. When discipline is necessary, concentrate on consequences that are logical responses to inappropriate behavior rather than arbitrary punishments. For example, use a time out when the child is misbehaving in a particular setting.
• Be an advocate for your child. Work with teachers and other people outside the home to help them understand how they can support your child.
• Encourage a healthy lifestyle. Poor wellness choices can make the effects of ADHD worse. Ensure your child is eating a healthy diet, getting plenty of exercise, and getting enough sleep.

ADHD often exists alongside other brain and mental health-related conditions, a situation called co-morbidity. Here are a few of the disorders commonly associated with ADHD:

• Depression and ADHD are often comorbid, and people with both disorders are likely to have other disorders as well. For example, as many as half of all people with ADHD also suffer from depression.
• Bipolar disorder and ADHD are comorbid in a substantial percentage of cases.
• People with ADHD often suffer from anxiety disorders.
• Some studies suggest that as many as half of people with ADHD also have borderline personality disorder or another personality disorder. In addition, about a quarter of people living with ADHD have two or more personality disorders.
• Obsessive-compulsive disorder (OCD) and ADHD are often associated with one another.
• Tobacco addiction, alcoholism, and other substance use disorders are twice as common in people with ADHD as they are in the general population.

ADHD often co-exists with Tourette syndrome and other tic disorders. For example, as many as 80 percent of people with Tourette syndrome also have ADHD.

ADHD Brain Science

ADHD develops as a response to a complex set of circumstances in a sufferer’s brain. Scientists do not yet fully understand the details of how the disorder emerges, but it seems to require a complicated interaction between a number of genes and environmental factors. Each of these components has a relatively small effect on its own, but the combined effects add up to create the symptoms of ADHD.

Researchers believe that a problem with a specific brain chemical’s production and/or function underlies the disorder. Norepinephrine is a neurotransmitter, a naturally occurring chemical that allows brain cells to communicate with one another. In an ADHD brain, deficiencies in norepinephrine appear to interfere with normal cell-to-cell communication in several different areas.

• Prefrontal cortex. This part of the brain control functions such as planning, organization, and attention.
• Basal ganglia. This area regulates communication between different parts of the brain. A problem here could impair the flow of information through the brain and affect functions such as attention.
• Limbic system. This part of the brain helps to regulate emotions. Impairment here could contribute to restlessness or volatility.
• Reticular activating system. This area controls the flow of information into and out of the brain. Deficiencies in this area could also contribute to hyperactivity, inattention, or impulsivity.

Research has shown that children with ADHD typically have smaller brains overall, suggesting that widespread problems with brain development could be to blame for the disorder.

ADHD Research

Title: Open Trial of a Program to Support Parents of Children With Attention-deficit/Hyperactivity Disorder (ADHD)

Stage: Recruiting

Principal Investigator: Gregory A Fabiano, Ph.D.

Center for Children and Families

Amherst, NY 

Behavioral parent training is an evidence-based treatment for ADHD. The intervention can be implemented individually or in groups. Currently, group-based parent training programs require considerable coordination, including ascertainment of a large physical space, the coordination of all families traveling to the same location simultaneously, and childcare provision requirements. Innovations in online connectivity and ease of implementation of online support applications (e.g., Zoom) may reduce these barriers. However, it is necessary to investigate the feasibility and promise of the online approach to effectively support parents.

This study will utilize a pre-post, open trial design as the primary aim is to investigate feasibility. Approximately sixty parents will complete pre-post ratings of parenting behaviors and measures of child functioning. They will also complete post-treatment measures of satisfaction and open-ended questions about feasibility and suggestions for future iterations of the approach. Process measures will include data collection related to attendance and engagement in the activities. Risks include breach of confidentiality and a lack of effectiveness of the intervention for the child’s presenting problems. Benefits include the parent receiving an effective intervention.

Title: Mindfulness-Based ADHD Treatment for Children: a Feasibility Study (MBAT-C)

Stage: Recruiting

Principal Investigator: Hedy Kober, PhD

Clinical & Affective Neuroscience Lab

New Haven, CT

Attention-Deficit/Hyperactivity Disorder (ADHD) affects 11% of American children. ADHD is a source of considerable psychosocial, educational, and neurocognitive impairment. It is co-morbid with multiple psychiatric disorders and poses an economic burden. Pharmacotherapy is often the first-line treatment for children with ADHD, but such medications are associated with adverse effects, including insomnia, loss of appetite, headaches, stomachaches, tics, moodiness, and irritability. Further, concerns about substance misuse and diversion and parental preference can limit medications’ use and utility. These limitations underscore the urgency of developing behavioral interventions that do not pose such concerns. However, at this time, behavioral treatments for ADHD are generally less effective than pharmacotherapy, emphasizing the need for better non-pharmacologic interventions.

Mindfulness, defined as nonjudgmentally paying attention to the present moment, is a promising behavioral approach to ADHD treatment. Evidence suggests that mindfulness improves attention in both healthy adults and those with ADHD. Mindfulness also enhances neurocognitive outcomes in children and adolescents, including executive function and attention, suggesting that mindfulness may effectively treat ADHD in young persons.

This is a feasibility study of a novel intervention: Mindfulness-Based ADHD Treatment for Children (MBAT-C). MBAT-C is derived from Mindfulness-Based Stress Reduction (MBSR), a well-known and extensively-studied mindfulness intervention. Unlike all other mindfulness-based interventions, however, MBAT-C is tailored to the needs, abilities, and vulnerabilities of children with ADHD through age-appropriate class length, homework assignments, contemplative practices, and discussion topics. Specifically, MBAT-C includes 16 twice-weekly 30-minute sessions over eight weeks. Each session includes two brief meditations, discussion, an exercise, and homework.

In this study, 45 children ages 7-13 with ADHD will be randomized into one of three treatment groups: MBAT-C, medication (MED), or a combined intervention (COM).

The aims of the study are as follows:

Aim 1: Evaluate the feasibility of MBAT-C

Aim 2. Measure within-group change from pre- to post-treatment on ADHD-relevant outcomes.

Title: Preschool ADHD Online Behavioral Treatment

Stage: Recruiting

Principal Investigator: Tanya Froehlich, MD, MS

Cincinnati Children’s Hospital Medical Center

Cincinnati, OH

Although behavioral interventions are the recommended first-line treatment for preschool children with Attention Deficit Hyperactivity Disorder (ADHD), the majority of preschool children receiving treatment for ADHD are treated with medication only. Barriers to preschool children receiving behavioral treatments include financial limitations, family logistical challenges, and the scarcity of trained providers. Web-based approaches may be one innovative way to address these obstacles. Thus, the proposed study’s goal is to pilot-test an online behavioral intervention integrated into the evidence-based mehealthTM for ADHD software (mehealth.com) to determine feasibility, acceptability, and preliminary efficacy. The investigators will enroll a community-based sample of caregivers and teachers/childcare providers of 20 preschool children with ADHD recruited from two DBPNet sites (Cincinnati and Boston) who will utilize the on-line behavioral tools to create and implement child behavior plans. The investigators will track system usage over a 9-month period to determine feasibility for mehealthTM‘s integrated behavioral tools intervention. Standardized measures and open-ended questions will be used to determine the intervention’s acceptability to parents and teachers/childcare providers. In addition, parent and teacher/childcare provider’s ratings of child ADHD symptoms and impairment collected at baseline and at the 3-month, 6-month, and 9-month time points will be examined to provide preliminary estimates of efficacy. Ultimately, the development of the mehealthTM for ADHD.com integrated behavioral tools may offer a cost-effective and convenient means of implementing behavioral plans for young children, thereby increasing access to behavioral treatments for preschoolers with ADHD. This scalable and disseminatable approach has great potential for use in clinical settings and in national Developmental-Behavioral Pediatrics Research Network multi-site research studies, which require standardized behavioral intervention packages for preschool ADHD.