Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD) is a mental health condition often diagnosed in children. ADHD can make it very hard for kids to pay attention, focus on schoolwork or other tasks, control their impulses, and sit still. Children with ADHD have a harder time controlling themselves than other kids their age, which can lead to challenges at school and home.

What are the symptoms of ADHD?

Symptoms of ADHD are divided into two groups: inattentive behaviors, and hyperactive and impulsive behaviors.

Symptoms of Inattention

– Not paying close attention, missing details, or making careless mistakes

– Having trouble staying focused during tasks or play

– Not listening when spoken to

– Not following instructions

– Difficulty organizing tasks and activities

– Avoiding or disliking tasks that need focus

– Losing things

– Easily distracted

– Forgetfulness

Symptoms of Hyperactivity/Impulsivity

– Fidgeting, tapping hands or feet, or squirming in seat

– Leaving seat when expected to stay seated

– Running or climbing when expected to be seated

– Inability to play or engage in activities quietly

– Being “on the go” or acting as if “driven by a motor”

– Talking too much

– Blurting out answers

– Difficulty waiting in lines or for a turn

– Interrupting or intruding on others

Associated Symptoms of ADHD may include issues with:

– Planning

– Making decisions

– Shifting from one situation to another

– Controlling emotions

– Learning from past mistakes

– Socializing

– Participating in games or team sports

– Poor school performance

How is ADHD diagnosed?

A child-adolescent psychiatrist may diagnose a child or teen with ADHD after determining if the symptoms meet the diagnostic criteria; have been present since before the child’s 12th birthday; several symptoms must be present in two or more settings (e.g., home, school, other activities); and the symptoms have lasted for at least six months and interfere with or reduce the quality of the child’s performance in daily activities (e.g., social, academic, occupational).

The psychiatrist may conduct interviews with caregivers, teachers, and the child, and use standardized assessments, as well as behavior and emotion rating forms to support the diagnosis. Because ADHD symptoms can also be caused by other issues, like anxiety, depression, or trauma, the professional will carefully rule out other possible reasons for the behavior.

ADHD facts

Worldwide frequency of the condition:

It is estimated that ADHD is present in approximately 5.9% of the world’s child and adolescent population, although estimates vary from 0.1% to 10.2%.

Impact of the condition in Brazil:

Despite limited data, the estimated prevalence of ADHD in Brazil is 4.1% in children (5-9 years) and 4.9% in adolescents (10-19 years).

Gender ratio:

Data indicate that boys are more likely to be diagnosed with ADHD than girls, with a ratio of approximately 2:1.

Peak age of onset:

The average age of diagnosis for ADHD is 9.5 years, which is later than for other neurodevelopmental disorders, whose average age of onset is 5.5 years.

Proportion of the condition that emerges before age 18:

According to recent data, 73% of people with ADHD will be diagnosed before the age of 18. This is lower than for other neurodevelopmental disorders, where the proportion is 83.2%.

What are the associated factors for ADHD?

Some common factors linked with ADHD are:

– Genetic and familial factors: Most likely a combination of multiple genes interacting with environmental factors. Having a close family member with ADHD increases risk.

– Preterm birth.

– Very low birth weight.

– Complications during pregnancy: These include maternal hypertensive disorders, preeclampsia, and hyperthyroidism; smoking or drinking alcohol by a pregnant mother; and some evidence suggests exposure to certain medications (e.g., acetaminophen, valproate) may increase risk for ADHD.

– Complications after birth and early in childhood: These include encephalitis and other early infections.

– Environmental factors: These include lead exposure, exposure to second-hand smoke, certain food dyes, and air pollution.

What other disorders co-occur with ADHD?

ADHD might be commonly found with specific learning disorders, anxiety disorders, ODD, Conduct Disorder, and DMDD.

How is ADHD treated?

ADHD is usually treated with medication. Psychotherapy or a combination of psychotherapy and medication can be helpful, especially when there are associated headstrong and rule-breaking behaviors.

Kids with ADHD are sometimes prescribed stimulant medication, which helps them be calm, focus, and control their impulses. The two most common medications are methylphenidate (e.g., methylphenidate, dexmethylphenidate) and amphetamines (e.g., amphetamine/dextroamphetamine, lisdexamfetamine), although amphetamines are not available in Greece. For children who cannot tolerate methylphenidate or have not responded after a six-week trial, atomoxetine (a serotonin and norepinephrine reuptake inhibitor, SNRI) may be prescribed. While these medications may have side effects, they are safe for kids to use with proper monitoring by their doctor and close supervision from their caregivers. A child or teen taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

For children with oppositional symptoms (e.g., headstrong behaviors and rule-breaking behavior), there are multiple therapies that effectively treat associated symptoms and behaviors of ADHD. Younger children and their caregivers are often referred for parent-child interaction therapy (PCIT), where the parent learns how to encourage good behavior. Caregivers of older children may also be referred for behavioral parent training (BPT), such as parent management training (PMT), where they learn skills to address their child’s symptoms.

There is also some evidence that cognitive-behavioral therapy (CBT) may help older children or teens with ADHD. CBT involves a therapist teaching a kid to control their behaviors, discussing how their thoughts and feelings are connected to their behavior, and practicing ways to improve self-control. Other treatments, including meditation, computer cognitive training, cognitive training for executive functioning, and neurofeedback have less supporting evidence.

The combination of therapy and medication should also be considered.

Where to find more information

Where to find more information

For more details on inattention, hyperactivity, and impulsivity and reasons for concerns, please visit our Short Guides webpage.

To learn more about the technical work behind this guide, please see our reference list here (link to content below).

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2022, May 2). Complete guide to ADHD. _https://childmind.org/guide/parents-guide-to-adhd/_

– Faraone, S. V., Banaschewski, T., Coghill, D., et al. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. _https://doi.org/10.1016/j.neubiorev.2021.01.022_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 6A05 Attention Deficit Hyperactivity Disorder. _https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f821852937_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Faraone, S. V., Banaschewski, T., Coghill, D., et al. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. _https://doi.org/10.1016/j.neubiorev.2021.01.022_

– Faraone, S. V., Asherson, P., Banaschewski, T., et al. (2015). Attention-deficit/hyperactivity disorder. Nature Reviews Disease Primers, 1(1), 15020. _https://doi.org/10.1038/nrdp.2015.20_

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

– Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A. (2014). ADHD prevalence estimates across three decades: An updated systematic review and meta-regression analysis. International Journal of Epidemiology, 43(2), 434–442. _https://doi.org/10.1093/ije/dyt261_

– Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: A systematic review and metaregression analysis. American Journal of Psychiatry.

– Rocco, I., Corso, B., Bonati, M., & Minicuci, N. (2021). Time of onset and/or diagnosis of ADHD in European children: A systematic review. BMC Psychiatry, 21(1), 575. _https://doi.org/10.1186/s12888-021-03547-x_

– Sacco, R., Camilleri, N., Eberhardt, J., Umla-Runge, K., & Newbury-Birch, D. (2022). A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. European Child & Adolescent Psychiatry. _https://doi.org/10.1007/s00787-022-02131-2_

– Solmi, M., Radua, J., Olivola, M., et al. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

– Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis. Pediatrics, 135(4), e994–e1001. _https://doi.org/10.1542/peds.2014-3482_

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Arango, C., Dragioti, E., Solmi, M., et al. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. _https://doi.org/10.1002/wps.20894_

– Bitsko, R. H., Holbrook, J. R., O’Masta, B., et al. (2023). A systematic review and meta-analysis of prenatal, birth, and postnatal factors associated with Attention-Deficit/Hyperactivity Disorder in children.

– Faraone, S. V., Banaschewski, T., Coghill, D., et al. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. _https://doi.org/10.1016/j.neubiorev.2021.01.022_

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Bishop, C., Mulraney, M., Rinehart, N., & Sciberras, E. (2019). An examination of the association between anxiety and social functioning in youth with ADHD: A systematic review. Psychiatry Research, 273, 402–421. _https://doi.org/10.1016/j.psychres.2019.01.039_

– Di Lorenzo, R., Balducci, J., Poppi, C., et al. (2021). Children and adolescents with ADHD followed up to adulthood: A systematic review of long-term outcomes. Acta Neuropsychiatrica, 33(6), 283–298. _https://doi.org/10.1017/neu.2021.23_

– Khodeir, M. S., El-Sady, S. R., & Mohammed, H. A. E.-R. (2020). The prevalence of psychiatric comorbid disorders among children with specific learning disorders: A systematic review. The Egyptian Journal of Otolaryngology, 36(1), 57. _https://doi.org/10.1186/s43163-020-00054-w_

– Solberg, B. S., Halmøy, A., Engeland, A., et al. (2018). Gender differences in psychiatric comorbidity: A population-based study of 40,000 adults with attention deficit hyperactivity disorder. Acta Psychiatrica Scandinavica, 137(3), 176–186. _https://doi.org/10.1111/acps.12845_

– Tung, I., Li, J. J., Meza, J. I., et al. (2016). Patterns of Comorbidity Among Girls With ADHD: A Meta-analysis. Pediatrics, 138(4), e20160430. _https://doi.org/10.1542/peds.2016-0430_

Interventions

– Battagliese, G., Caccetta, M., Luppino, O. I., et al. (2015). Cognitive-behavioral therapy for externalizing disorders: A meta-analysis of treatment effectiveness. Behaviour Research and Therapy, 75, 60–71. _https://doi.org/10.1016/j.brat.2015.10.008_

– Correll, C. U., Cortese, S., Croatto, G., et al. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. _https://doi.org/10.1002/wps.20881_

– Evans, S. W., Owens, J. S., Wymbs, B. T., & Ray, A. R. (2018). Evidence-Based Psychosocial Treatments for Children and Adolescents With Attention Deficit/Hyperactivity Disorder. Journal of Clinical Child & Adolescent Psychology, 47(2), 157–198. _https://doi.org/10.1080/15374416.2017.1390757_

– Faraone, S. V., Banaschewski, T., Coghill, D., et al. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. _https://doi.org/10.1016/j.neubiorev.2021.01.022_

– Faraone, S. V., Asherson, P., Banaschewski, T., et al. (2015). Attention-deficit/hyperactivity disorder. Nature Reviews Disease Primers, 1(1), 15020. _https://doi.org/10.1038/nrdp.2015.20_

– Khoodoruth, M. A. S., Ouanes, S., & Khan, Y. S. (2022). A systematic review of the use of atomoxetine for management of comorbid anxiety disorders in children and adolescents with attention-deficit hyperactivity disorder. Research in Developmental Disabilities, 128, 104275. _https://doi.org/10.1016/j.ridd.2022.104275_

– Park, J., Lee, D. Y., Kim, C., et al. (2022). Long-term methylphenidate use for children and adolescents with attention deficit hyperactivity disorder and risk for depression, conduct disorder, and psychotic disorder: A nationwide longitudinal cohort study in South Korea. Child and Adolescent Psychiatry and Mental Health, 16(1), 80. _https://doi.org/10.1186/s13034-022-00515-5_

– Pringsheim, T., Hirsch, L., Gardner, D., & Gorman, D. A. (2015). The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with Attention-Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder: A systematic review and meta-analysis. Part 1: Psychostimulants, alpha-2 agonists, and atomoxetine. The Canadian Journal of Psychiatry, 60(2), 42–51. _https://doi.org/10.1177/070674371506000202_

– Riise, E. N., Wergeland, G. J. H., Njardvik, U., & Öst, L.-G. (2021). Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis. Clinical Psychology Review, 83, 101954. _https://doi.org/10.1016/j.cpr.2020.101954_