It’s not uncommon for kids, at times, to have seemingly endless amounts of energy or have trouble paying attention in school. But when that is the norm rather than the exception, it’s natural for parents to wonder if their child has attention deficit hyperactivity disorder, also known as ADHD.
According to the Centers for Disease Control and Prevention, about 6 million children and adolescents in the U.S. have a diagnosis of ADHD, one of the most common neurodevelopmental disorders in children that can make it difficult for them to focus or control impulsive behaviors.
“ADHD is commonly diagnosed in childhood, starting between the ages of 3 and 6, and can continue into the teenage years and adulthood,” says Dr. Alma Spaniardi, a psychiatrist at NewYork-Presbyterian Westchester Behavioral Health and an assistant professor of clinical psychiatry at Weill Cornell Medicine. “Just because a kid is energetic or behaves differently than other kids in their class doesn’t mean they have ADHD, but catching it early, especially if it’s impairing, can really help a child across the board, in school and in their social lives and relationships.”
Dr. Spaniardi spoke with Health Matters about ADHD, how it presents in children, and what parents need to know about treatment options.
What are the signs and symptoms of ADHD? Dr. Spaniardi: There are three types of ADHD: hyperactive, inattentive, and a combination of both.
With hyperactivity, it’s almost as if a child has a motor attached to them. They are always on the go or have a hard time sitting still. They could be fidgety or impulsive; for example, they may have a hard time eating at the dinner table or waiting for their turn in a board game. The hyperactivity tends to calm down as kids grow into adolescence, but they may continue to have impulsivity or an internal feeling of restlessness.
A child with the inattentive kind of ADHD could appear to be daydreaming or may easily misplace things. They do their homework, for example, but could forget to turn it in. They may have a hard time focusing during their classes or completing their chores at home. The inattentive kids typically get diagnosed later because they fly under the radar; it is easier to identify hyperactive kids.
Most kids, however, have the combined type, showing signs of both hyperactiveness and inattentiveness.
Symptoms of ADHD
Fidgets or squirms
Trouble staying in seats
Runs and climbs in settings they shouldn’t
Difficulty playing quietly
Impatient; for example, they struggle to wait for their turn
Always on the go
Blurts out answers before a question is completed
Interrupts or intrudes on other people’s conversations or activities; takes others’ possessions
Makes mistakes without thought; overlooks details in schoolwork
Easily distracted or sidetracked
Difficulty following instructions
Doesn’t appear to listen when spoken to directly
Trouble organizing tasks and possessions
Struggles to finish schoolwork or chores
Avoids or resists tasks that require sustained mental effort
Often loses homework assignments or personal items
How is a child diagnosed with ADHD? ADHD is a clinical diagnosis. Typically, a child psychiatrist or a pediatrician will determine an ADHD diagnosis using criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and by obtaining information through rating scales from at least two other people, such as family members and teachers, who can give insight into the child’s behavior.
To be diagnosed with ADHD, symptoms must happen across more than one setting, such as at home and school, and must persist for more than six months. Six or more symptoms must also be present and, because neurodevelopmental disorders start in youth, a child would need to exhibit symptoms before age 12.
Children being evaluated for ADHD can undergo tests to check for medical causes that can look like ADHD, such as a thyroid condition, as well as a screen for psychiatric comorbidities of ADHD like depression, anxiety, obsessive compulsive disorder, or tic disorders.
Is there treatment for ADHD? We can absolutely treat ADHD. Medication and behavioral therapies can both be effective. Just because your child has ADHD doesn’t mean they have to take medication, but it can make a huge difference. If you’re concerned about your child taking medication, your doctor should be able to give you all the information you need, including the pros and cons. Deciding on treatment should be a thoughtful conversation, and remember that you’re on a team that includes your child, and your child’s doctor and teacher. Everyone can work together to figure out the best course of action.
What does treatment with medication look like? The typical medication options for ADHD include stimulants and non-stimulants. Stimulants are the main medications we use because they are very effective. There are two types of stimulants: amphetamine and methylphenidate. There are many medications on the market that fall under these two classes.
You might assume that you wouldn’t want to use a stimulant on an already stimulated child, but it helps quiet down the parts of the brain that are impacted by ADHD, including the prefrontal cortex. This is the area that controls behavior, judgment, emotional responses, and executive functioning, which includes skills like planning ahead, following directions, or meeting goals. It also helps you pay attention to things even if you’re not totally into the topic. People with ADHD can focus intently on something they’re really interested in. That’s why you might see a child with ADHD who can play video games for hours but can’t give the same attention to their math homework.
Medication helps level the playing field for kids with ADHD so that their brains are like everyone else’s and they can calm down and focus. One stimulant is not necessarily better than the other, but generally, methylphenidate tends to be better tolerated by younger kids and amphetamines tend to be better tolerated by adolescents. Stimulants take effect right away, so it’s easy to do a trial to see if they are working for a child. They also don’t necessarily need to be taken every day, so it’s not uncommon for kids to take a break from them, for instance on the weekends, on vacation, or over the summer.
If stimulants don’t appear to work or a child is experiencing difficult side effects, there are non-stimulant medications for ADHD, such as atomoxetine, guanfacine, and viloxazine. They take longer to start working, about three to six weeks, and kids have to take them daily.
What are the side effects of stimulants? The two that are the most bothersome and really don’t go away over time are problems sleeping and a decreased appetite. A doctor will be able to work with the child to help manage these side effects with behavioral techniques or specific timing of the medication. The good thing is that there are many different formulations for these medications, with differences in how long they last or are dispersed in the body, so treatment can be tailored for each child.
For the kids who do well on stimulants, I’ve had parents tell me many times that the change is like night and day. ADHD can lead to academic and emotional challenges, and difficulty making friends and picking up social cues, so the medication can really help in these areas. In these cases, I think it’s worth managing the side effects because the kids get so much benefit.
"Deciding on treatment should be a thoughtful conversation, and remember that you’re on a team that includes your child, and your child’s doctor and teacher."
— Dr. Alma Spaniardi
What are the non-medication treatments for ADHD? There are a lot of great therapies to help treat ADHD. For preschool-aged children, we always start with parent-child interaction therapy, a type of behavioral therapy that coaches parents on how to interact with children with behavioral or emotional issues. There are other types of parent management training (PMT) that can also work with older children, where parents and caregivers learn how to help kids improve behaviors and executive functioning skills; it also teaches techniques for providing structure, routine, and discipline. PMT is evidence-based, and a lot of parents really find it useful. At NewYork-Presbyterian, we offer parent management groups for parents and kids with ADHD. Children can also receive individual counseling and therapy to improve emotion regulation and social skills. Organizational skills are also important for kids with ADHD to learn and practice. The combination of medication and therapy helps produce the best efficacy overall.
Do ADHD symptoms persist into the teenage years and adulthood? Symptoms can change over time and usually do. They may look different when someone is young versus when they are an adolescent or adult. Some people grow out of ADHD altogether or learn to manage their symptoms effectively.
As people get older, it’s common to learn tips and tricks regarding executive functioning, like how to organize themselves, write lists, and or pack their bags before going somewhere, so that they don’t necessarily need to take medication forever. Others may feel medication continues to be helpful or they still need it to function at their best in the world.
That’s the good thing about working with a doctor or psychiatrist. Treatment isn’t a “set it and forget it” plan. There’s always evaluation and follow-up, and a doctor can work with someone to see what’s right for them at any stage of life.
Alma Spaniardi, M.D., is an assistant attending psychiatrist and the chief of the outpatient program in the Division of Child and Adolescent Psychiatry at NewYork-Presbyterian Westchester Behavioral Health. She is also an assistant professor of clinical psychiatry at Weill Cornell Medicine. Dr. Spaniardi works to increase access to child mental health services by developing innovative and integrated models of care and training with the Department of Pediatrics. In her faculty practice, she specializes in evaluating, diagnosing, and treating psychiatric disorders in children, adolescents, and adults.