Answers to questions families often have about caring for their child with attention deficit hyperactivity disorder (ADHD)

ADHD is a condition that involves some combination of hyperactivity, impulsivity, and/or inattention that interfere with someone’s ability to function. Symptoms begin in childhood, and ADHD is usually identified between 4 and 18 years of age. Three types of ADHD have been defined: predominantly inattentive, predominantly hyperactive/impulsive, and a combination of those two.

While ADHD tends to run in families, and studies of twins and adopted children support a strong genetic component, the genetics are not well understood. A child's environment also plays a role in some cases of ADHD. Many other things can cause ADHD-like symptoms, such as stress, lack of sleep, anxiety, depression, poor nutrition, a history of trauma, medication side effects, and other medical problems.

Toddlers with the hyperactive/impulsive type of ADHD may constantly be physically active, running in circles, and climbing on furniture, while adolescents with this type may engage in risky behaviors and sports. Preschoolers with the inattentive type may have difficulty paying attention while reading a picture book, while adolescents may find it hard to finish homework and perform required tasks.

Many children with ADHD will be able to concentrate or even hyperfocus on their favorite activities for long periods, such as playing video games for hours, but have a hard time concentrating on tasks they need to do, such as homework. Teachers are often a good resource to help families recognize if the child is struggling with activity level, impulse control, or distractibility more than peers.

Most children with ADHD are diagnosed and managed by the child’s pediatrician or family doctor. Children with problematic levels of inattention, hyperactivity, or impulsivity, low school achievement for the child's IQ, and/or behavior problems should be evaluated. This will generally take a few visits and require gathering information about school performance, school/daycare behavior, functioning within the family and with friends, and other medical or mental health concerns. Evidence of functional problems in at least 2 settings (usually at home and at school) is needed to make the diagnosis. If the child only struggles in 1 setting, it likely isn’t ADHD. Developmental delays, low IQ, or other chronic problems such as sensory deficits (such as vision or hearing problems), other behavioral health or psychosocial problems, and/or features of autism make it harder to diagnose ADHD. Sometimes specialized educational testing or a neuropsychological evaluation may be needed to help understand if someone has ADHD and/or other conditions that can overlap.

More information about diagnosing ADHD can be found at Symptoms and Diagnosis of ADHD (CDC) and The ADHD Diagnostic Process. Guidelines for diagnosis, published by the American Academy of Pediatrics (AAP), can be found at [Wolraich: 2019].

ADHD is a life-long condition. However, most children learn skills to help manage their symptoms and play to their strengths. Not all children or adults will need medication to manage ADHD.

ADHD tends to run in families; the parents and the primary care doctor should be aware of this possibility in siblings. Sometimes during their child’s ADHD evaluation, parents realize that they have had lifelong symptoms, and then they can work with their doctor to get an adult evaluation.

Stimulant medications are medications that increase attention and focus. They are currently considered the most effective treatment for ADHD symptoms. They are controlled substances because some people abuse stimulant medications to get more energy and focus even though they don’t have a diagnosis of ADHD. A variety of other medications may be considered, especially if stimulants have too many side effects or don’t work well enough. Long-term medication use may be needed to help manage the symptoms of ADHD because it is a chronic condition.

Behavior therapy (also called behavior modification or psychosocial treatment) is the most effective non-medication therapy for children. Behavior therapy may include helping parents and teachers improve structure and communication. Parent-training therapy, a specific kind of therapy that works well for many kids with ADHD, coaches parents on how to structure the child’s environment and manage expectations so that the child can develop better self-regulation and adaptive skills.

Occupational therapy can help children manage executive function skills, like organizing and planning, that will help them be more successful at school and home. An occupational therapist may be found through the school system, or the child can be referred to private occupational therapy. There are some newer treatments, including games and virtual reality available for certain children. These are rarely covered by insurance or Medicaid.

While a child’s ADHD may greatly affect the family, there are many treatments available. ADHD symptoms and related behaviors can be managed to help the child lead a normal and productive life. Effective management of ADHD can really improve the quality of life for the child and family. Getting a diagnosis and good treatment plan with regular follow-up can make a huge difference in the quality of life and long-term success for the child and, therefore, the family too.

Children with ADHD rarely get addicted to (or dependent upon) stimulants. In fact, the evidence suggests that careful use of stimulants in the early years decreases the risk of adolescent drug use and cigarette smoking. The reasons are not well understood, but one study found that reduced self-esteem due to school problems and impulsivity may contribute to drug use among children who are not treated for their ADHD. [Wilens: 2008] Another study suggests that stimulant use for ADHD does not affect later illicit substance abuse. [Shaw: 2012]

Research to date has not clearly shown a higher risk of serious heart problems in children using stimulant medication. [Wolraich: 2019] Behavioral therapy is an important part of the management of ADHD, but for many children, it is not enough to manage their symptoms. The risk of heart problems with stimulants, which are the most common class of medication used to treat ADHD, is very small. The medical home doctor should talk with you about specific concerns based on your child and family’s health history.

ADHD medications do not cure ADHD; they help manage the symptoms of ADHD. Those symptoms will improve over time in most people, but some will continue to benefit from medication even in adulthood. The length of treatment will depend on the child and whether she has associated learning problems. Your primary care doctor will regularly check progress to determine with you and your child when to consider stopping medication.

You, your child, and your primary care doctor can discuss if there are times that stimulants are not needed (such as prolonged school holidays or even weekends). This would not apply to children on atomoxetine (Strattera) or extended-release preparations of guanfacine and clonidine.

Common side effects are decreased appetite, insomnia, anxiety or nervousness, stomachache or headache, increased heart rate and blood pressure, and irritability (most often as the medication wears off in the afternoon/evening). Often, raising the dose slowly over time can avoid many of these side effects. Adding a small dose in the afternoon can sometimes get rid of irritability. Since one stimulant may work better than another for your child, try a different kind before giving up.

While stimulants can lead to weight loss in some children, this doesn’t happen in all children (some even gain weight). Stimulants may slow height growth for a while, but then kids generally catch up over time. Some studies have shown a slight decrease in projected height with long-term stimulant use, but more research is needed to confirm this finding. [Harstad: 2014] [Troksa: 2019] Your primary care doctor will track weight and height before, during, and after stimulant use to identify any concerns about growth while your child is growing.

Many insurers don’t cover behavior therapy for ADHD because they prefer to cover some stimulant medications, which are often considered the most effective treatment for ADHD symptoms. Insurers may cover behavior therapy for related conditions such as depression, substance abuse, or anger management, so if any of those concerns exist, the behavior therapy should list those as the primary focus of treatment. Some behavioral approaches can be provided through the public school system, such as social skills training, depending on the availability of skilled staff and the needs of the child. Insurers may cover occupational therapy to work on executive function skills, organization, and fine motor skills like writing.