The Centers for Disease Control and Prevention (CDC) estimates that 11% of children between the ages of four and 17 have attention deficit/hyperactivity disorder (ADHD)—leaving many parents with the difficult decision of whether to treat their child with powerful (and potentially risky) drugs.
The decision is particularly fraught because ADHD has a low threshold for diagnosis—that is, there aren’t any definitive physical tests to identify the condition. It’s usually diagnosed by a primary-care physician (probably a pediatrician), who runs through a checklist of possible behavioral—and subjective—symptoms, such as inattention, excessive talking, not paying attention, etc. If a child is found to have a certain number of these symptoms, he/she could be diagnosed with ADHD.
Problem: Many other conditions, including anxiety, sleep problems and learning disabilities (such as difficulty with language processing or dyslexia), can cause similar symptoms. But despite this inherent uncertainty, children in the US are about 14 times more likely to be given a prescription for ADHD medication than children in the UK.
My take: Children who display such behaviors often need emotional support more than a prescription drug. It’s possible that your child might be an exception—and really does need medication for ADHD. To find out, ask these questions of any health-care provider who believes your child has ADHD…
How can you be sure it’s ADHD and not a behavioral problem? A doctor will evaluate your child by running down a list of 18 possible symptoms. These include “does not seem to listen”…“often fidgets”…and/or “talks excessively.” A child who is found to have six or more symptoms for both inattention and hyperactivity/impulsivity—in addition to other factors, such as the appearance of symptoms before the age of 12—may be diagnosed with ADHD.
The problem is that every child has some degree of these behaviors. Maybe your child drops things just to hear the noise…fidgets in his seat…or always forgets to take out the trash. Most children will outgrow the behaviors—or learn to control them—as they get older.
Important: ADHD rarely develops after the age of 12. If your child didn’t exhibit problems in elementary school but is starting to struggle with issues in eighth grade, he probably doesn’t have ADHD. (In adults who have ADHD, the condition would have been present in childhood regardless of whether it was diagnosed at that time.)
To help diagnose ADHD, the FDA has approved a device that uses an electroencephalogram (EEG), a test that detects abnormalities in brain waves, to measure theta and beta brain waves. Children with ADHD tend to have a higher theta-to-beta ratio between the waves than children without ADHD. The test isn’t conclusive, but it can help doctors feel more confident that an ADHD diagnosis is correct.
Why are you suggesting drug therapy? Even if your doctor is unsure about the diagnosis, he/she might say something such as, “Let’s try medications and see if they help.”
But for the majority of children, the nondrug treatments discussed below can be equally effective—and safer. For example, neurofeedback (see below) is recognized as being as effective as medication for ADHD.
That said, drugs can be a smart choice in some cases. Drugs can quickly change behavior (and make life easier for parents) and may be essential for children with extreme impulsivity. Example: A child who keeps reaching toward the flames on a gas stove, despite getting burned in the past. This type of risky behavior is a clear indication for drug therapy.
What’s the difference between methylphenidate (Ritalin) and amphetamine/dextroamphetamine (Adderall)? They’re the two most widely used prescription drug treatments for ADHD. Both are stimulants that increase levels of dopamine and norepinephrine, neurotransmitters that speed up brain activity and increase attention and reduce impulsivity.
Both drugs have about a 70% success rate, but there are some important differences. Ritalin targets the parts of the brain that control focus and attention—but not the parts that control arousal. So it is less likely than Adderall to be misused or cause addiction.
Both drugs can improve attention and performance (even in children who don’t have ADHD), but they can also cause sleep problems, reduced appetite and other side effects. Serious side effects (Adderall sometimes causes an increase in blood pressure and heart rate, while Ritalin can cause numbness/tingling in the fingers, hands and face, etc.) are rare, but I worry that children who depend on drugs won’t develop the skills to deal with normal variations in their personality and temperament.
Are there any better drug treatments? Ritalin and Adderall are the most common treatments because they work almost immediately and are unlikely to cause serious or long-lasting side effects. But your child’s doctor might recommend staring treatment with the antidepressant bupropion (Wellbutrin), for example, atomoxetine (Strattera), which affects norepinephrine levels, or other nonstimulant drugs.
They’re less likely to dampen the motivational part of the brain (a possible side effect of Ritalin/Adderall) but can take weeks or months to fully kick in.
What are the best nondrug drug treatments? Therapies including neurofeedback (which teaches children to produce brain-wave patterns that are associated with focus) and mindfulness meditation (to train attention and reduce anxiety) can be as effective as drugs. The downside is that they’re more work for already-busy parents and can be challenging for focus-challenged children.
Neurofeedback. The American Academy of Pediatrics ranks it a “Level 1 Best Support” treatment for ADHD. During regular sessions, a child will wear an electrode-studded cap that maps brain activity while he plays a computer or video game. The game stops when brain activity shows that the child is losing focus and resumes when he uses the focus-centered part of the brain.
A meta-analysis of research published in Clinical EEG and Neuroscience found that neurofeedback caused large-scale improvements in inattention and impulsivity, along with more modest improvements in hyperactivity. One drawback is that a series of brief sessions (about 30 minutes each) can cost more than $2,000 and is probably not covered by your insurance.
Mindfulness meditation. Children attend weekly classes in which they learn to focus their attention on objects or activities (such as their breathing rhythms)…acknowledge the presence of distracting thoughts…and learn to prevent distractions from interfering with their thoughts. A study published in the Journal of Attention Disorders found that 78% of participants in a mediation program had an average reduction in ADHD symptoms of 30%.
Nutritional supplements. They’re not effective for everyone, but there’s some evidence that omega-3 fatty acids and other supplements (see below) can help in some cases.
Examples: Children given fish-oil supplements (high in omega-3s) for three months showed improvements in behavior as well as reading and spelling, according to a study in Pediatrics. (A typical dose might be 2.5 g daily). Meanwhile, research published in The British Journal of Psychiatry found that patients given a mix of vitamin B-12, vitamin D, folate and other nutrients had more improvements in inattention and hyperactivity/impulsivity than those who were taking placebos.
Can drugs/behavioral approaches be combined? They’re often used together. Research has shown that children who take a stimulant drug can focus more effectively when learning new behavioral skills (like talking less and listening more). A study published in Journal of Clinical Child & Adolescent Psychology found that a combined approach allowed children to take much lower doses of medication.
Are there any groups that offer support to kids with ADHD? Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) has a nationwide network of affiliates and provides evidence-based information on the condition.
