Among the most commonly diagnosed neurodevelopmental disorders, Attention-Deficit/Hyperactivity Disorder features a pattern of inattention and/or hyperactivity that interferes with functioning or development. Typically identified in childhood, symptoms of ADHD need to be evident across multiple settings and caregivers in order for the diagnosis to be confirmed.1 While individuals with ADHD are often impacted throughout their lives, symptoms can be managed with behavior therapy and/or medication.
Signs of ADHD
Although not specific ADHD exclusively, children with ADHD can also present with mild delays in language, motor, or social development.1 Many parents first report excessive motor activity when their child is a toddler, but these symptoms can often be difficult to distinguish from typical development before age 4. Most commonly, ADHD is diagnosed during elementary school years (ages 5-7) where symptoms of inattention become more impairing.
Symptoms of impulsivity, excessive activity levels, and poor focus tend to be stable throughout early adolescence. For many individuals, hyperactive behaviors tend to lessen as they age and give way to fidgeting, impatience, and/or general restlessness. Adolescents with ADHD tend to demonstrate more educational difficulties, including more failing grades and higher school drop outs, than their neurotypical peers. They also have more difficulty in their relationships with peers, teachers, siblings, and parents.3
As adolescents develop into adulthood, research suggests a reduction in core symptoms of ADHD.4 In adults, qualities of poor planning and inattention tend to persist throughout their lifetime. Older individuals who continue to meet criteria for ADHD tend to have more problems with adjustment and poorer mental health than comparison groups. These adults also continue to have difficulty with impulsivity, which can lead to financial and/or legal problems (i.e. these individuals are more likely to switch jobs, get speeding tickets, and have driving accidents).4
However, some research has demonstrated that adults who were hyperactive youngsters use their energy more adaptively; many may work multiple jobs, may choose jobs that are more active, and/or may work longer hours. In this way, the aimlessness of childhood restlessness has given way to more purposeful activity-seeking in adulthood.
As some adults who present to physicians and other mental health professionals have not previously been diagnosed in childhood, additional criteria beyond medical history have been suggested. It should be noted that each criterion is only met if the behavior occurs more frequently and is more impairing than individuals with the same developmental age.
These criteria include:4
- Sense of underachievement/low self-esteem
- Difficulty getting organized
- Chronic procrastination
- Trouble with follow-through on tasks
- Tendency to speak one’s mind, with little insight into the timing or appropriateness of the remark
- Frequent search for high stimulation
- Intolerance for boredom
- High distractibility
- Often creative, intuitive, and highly intelligent
- Difficulty following “proper” procedure
- Low tolerance for frustration
- Impulsive
- Tendency to work endlessly
- Sense of insecurity or worry
- Mood swings
- Restlessness
- Tendency toward addictive behavior
Current research suggests that attention-deficit/hyperactivity disorders is a chronic condition, with approximately half of children continuing to exhibit symptoms and impairment into adulthood. ADHD is also associated with other types of psychiatric disorders, including oppositional defiant disorder (ODD), conduct disorder, mood and anxiety disorders, and substance use disorders.5
Symptoms of ADHD
Symptoms of ADHD are first observed in childhood (i.e. before age 12). These children often display difficulties with persistence in the face of challenging tasks, excessive motor activity (hyperactivity), and in thinking through the consequences of their actions (impulsivity).
With regard to impulsive behaviors, individuals with ADHD are best described as having “ready, fire, aim” behaviors; they often act without thinking about the impact of their behaviors, demonstrating poor foresight and planning. These behaviors may be the product of an underlying inability or intolerance to delay gratification, which will be discussed further in subsequent sections.
Signs & Symptoms of Each Type of ADHD
There are three types of ADHD: ADHD with predominantly inattentive presentation, ADHD with predominantly hyperactive/impulsive presentation, and ADHD with combined presentation.
ADHD With Predominantly Inattentive Presentation1
Individuals meeting diagnostic criteria for this subtype of ADHD present with fewer symptoms of hyperactivity.
Inattentive symptoms typically manifest in some or all of the following ways:
- Difficulty with close attention to detail across multiple contexts, resulting in frequent mistakes and creating a negative impact on work productivity (e.g., at school, work, or during non-preferred leisure activities).
- Difficulty maintaining attention in non-preferred tasks or activities. Examples include challenges remaining on-task during reading tasks or lengthy conversations.
- Demonstrates “wandering attention” even without the presence of clear distractions in the environment.
- Difficulty following through with tasks (preferred or nonpreferred). These individuals may often start projects with relative ease but fail to complete them.
- Challenges related to organization; including completing multiple-step actions, time management, and keeping things in order.
- Avoidance of tasks that require persistence of mental effort (e.g., completion of homework, lengthy forms, or monotonous review of information).
- Difficulty holding onto things necessary for task completion (e.g., eyeglasses, car keys, cellphone, wallet, etc.)
- Easily distracted by stimuli in the environment (includes fleeting, unrelated thoughts).
- Forgetful during activities of daily living (e.g., routine chores, errands, returning calls, keeping appointments).
ADHD With Predominantly Hyperactive/Impulsive Presentation1
Individuals meeting diagnostic criteria for this subtype of ADHD have significant difficulty with behavioral excess (i.e. behaviors that are more overt, and at times, socially stigmatizing).
Hyperactive and/or Impulsive symptoms typically manifest in some or all of the following ways:
- Frequent fidgeting or tapping with hands or feet; squirming in seat
- Inability to remain seated during times when doing so is expected (e.g., while working in a classroom or office).
- Excessive motor activity (e.g., running, climbing, restlessness) in situations where it may be inappropriate.
- Difficulty engaging in quiet leisure activities (e.g. private reading in a library).
- Behavior characterized as being “driven by a motor” (e.g., unable to remain still for an extended period of time).
- Excessive talking
- Inability to inhibit one’s own communicative behavior (e.g., blurts out answers to questions, difficulty waiting for one’s turn in conversation).
- Interrupts or intrudes on others (e.g., takes over others’ activities, uses others’ things or invades others’ space without asking).
ADHD With Combined Presentation1
Individuals meeting diagnostic criteria for this subtype demonstrate significant symptomology in both Inattentive and Hyperactive/Impulsive categories.
Treatment of ADHD
Behavior therapy has been identified over the last 20 years as being an evidence-based treatment for the symptoms of ADHD.10 Behavioral strategies, grounded in learning theory, includes a focus on procedures wherein parents and/or caregivers (i.e. behavioral parent training) are trained to use specific strategies to increase desired behaviors (e.g., compliance, organization) and decrease undesirable behaviors (e.g., noncompliance, disruptions).
Several meta-analyses over the last decade have established that behavioral treatments result in moderate to substantial improvement for children who engage in a variety of disruptive and noncompliant behaviors.10 These types of therapies can be provided by licensed psychologists, social workers, and/counselors with the appropriate educational background and training.
Numerous systematic reviews show that up to 70% of children respond well to stimulant medications, with short-term improvement in ADHD symptoms related to inattention and hyperactivity/impulsivity.11 Stimulant medications typically used to treat these symptoms include Methylphenidate (brand names: Ritalin, Quillivant, QuilliChew, Metadate, Concerta), Dextroamphetamine + Amphetamine (brand name: Adderall) and Dextroamphetamine (brand name: Dexedrine).
Additional types of pharmacotherapy for ADHD symptoms include atomoxetine (brand name: Strattera), an FDA-approved alternative to stimulant medication which replaces certain neurotransmitters in the brain, and guanfacine (brand name: Tenex), which is a blood pressure medication that is often prescribed off-label to treat ADHD.
These medications are associated with side effects, which include nervousness, insomnia, dry mouth, loss of appetite, constipation, and tachycardia. While a pediatrician is qualified to prescribe these medications, many will refer families to a specialist (i.e. developmental pediatricians and/or psychiatrists) for ongoing medication management.
10 Strategies for Dealing With Symptoms of ADHD
The following list can help guide teachers, parents, and other caregivers to support children, teens, and young adults who are struggling with the ADHD diagnosis.
1. Personalize Tasks and Assignments
Make assignments personally meaningful for individuals with ADHD and allow them to complete things having to do with their interests. This will help them rely less on rote memorization and make more meaningful and relevant connections with the material.
2. Set Smaller, More Realistic Goals
Given poor frustration tolerance when faced with challenging tasks that is common for individuals with ADHD, it is important that teachers understand what these students currently are and are not capable of, so that they can develop challenging, yet realistic goals that are attainable based on their abilities. Individuals with ADHD can often develop a sense of learned helplessness over the years. For these students, achieving even the smallest goals are predictive of increased achievement and self-esteem.
3. Let Them Move
Many individuals with ADHD are able to attend most effectively on tasks that require sensory-motor manipulation. Thus, these individuals should be given as many opportunities as possible within an academic schedule to be involved in classes that allow movement, building, and construction (i.e. wood shop, culinary, art, etc.).
4. Provide Visual Resources
Students with ADHD benefit from the use of a word bank on tests and quizzes. In addition, they benefit from graphic organizers in helping them formulate and structure their thoughts on written assignments.
5. Give Preferential Seating
To help students with ADHD maintain attention, specifically activation/arousal needs, preferential seating may be beneficial in helping them stay on task. These students should be placed at a desk in front of the room, away from both the windows and the classroom entrance, but near the teacher at the point of instruction.
6. Give Breaks
Given the difficulty individuals with ADHD have sustaining attention for extended periods of time, opportunities for short, frequent breaks should be provided throughout the school and work day.
7. Provide Notes
Students with ADHD often benefit from having copies of classroom notes so they can direct their attention to the teacher’s lesson in real time.
8. Link Information & Use Mnemonic Devices
Individuals with ADHD may benefit from using associative linkages when encoding information. By linking new information to what has been previously learned, these individuals may be able to gain a more global understanding of the information and improve recall.
Mnemonic Devices
When learning new information, individuals with ADHD may benefit from using mnemonic devices and repeating them aloud frequently in order to capitalize on his strength in auditory memory. These strategies include mental pictures (using imagery and visualizations) and first-letter cues (to remember the words in a series or statement). An example of the latter would be Every good boy deserves fudge to remember the notes on the music staff. These devices are most meaningful when the individual creates the key words.
Repetition & Association
Individuals with ADHD often have difficulties remembering people’s names. The following strategy may be useful to aid in encoding new information: Pay attention and listen to the name when the person is introduced. Repeat the name to the person being introduced, “Hello, John Smith, it is a pleasure to meet you,” and say it several times to yourself. Make the name meaningful and concrete by using substitute words for names that are long or hard to remember.
For example, Woitazewski may become What a zoo ski. Focus on distinctive features of the person’s face or appearance. Review the association and the person’s name periodically. Motor cuing where an action is associated with a person’s name may be helpful. For example, Skip can be paired with thinking about skipping rope.
“Chunking”
Individuals with ADHD may benefit from “chunking” information; that is, grouping pieces of information together into larger chunks so that fewer “bits” need to be remembered. For example, the seven digits of a telephone number can be grouped into four numbers: 285-5678 becomes two, eighty-five, fifty-six, seventy-eight.
Writing It Down
Individuals with ADHD may compensate for limited memory capacity by writing down important information as quickly as possible after it is presented. Recording orally presented information in writing not only makes the information visual but also requires the integration of modalities.
Categorize
Individuals with ADHD may benefit from clustering information semantically (by meaning). Using cues to cluster information into categories to help improve recall. Learning to organize information and material in meaningful ways may help these individuals better remember where to locate personal belongings and work materials. For example, canned goods might be organized into meaningful categories such as fruits, vegetables, and soups.
9. Set Boundaries
Parents and family members should develop clear schedules, rules, and guidelines for children with ADHD. Young adults should be encouraged to keep a daily planner that includes all upcoming events and activities.
More advanced students with ADHD benefit from setting feasible timelines for completion of work and/or school-related activities. By establishing clear priorities for completing tasks, they can more likely complete the most important tasks first. Setting aside a specific study area at home and keeping all necessary materials organized and available in that area will help students with ADHD concentrate on and complete work and/or school-related activities.
10. Self-Monitor & Listen
Individuals should be encouraged to increase self-monitoring by asking themselves, “Did I get everything this person said?” and by double-checking with the speaker. Encourage children and young adults with ADHD to listen to others but also not to be afraid to tell others that they must get their attention when they have something important to communicate.
How to Get Help for ADHD
Children and young adults who are struggling with symptoms of ADHD can often feel incompetent, frustrated, and misunderstood. Getting them the support they need, whether in the form of medication or behavior therapy, is the start of a process that can take time before significant gains are observed. The first point of contact is often a teacher or daycare provider, who can provide some context about whether a child is falling behind academically, behaviorally, or socially. Pediatricians are typically the first in medical assessment who can discuss a potential diagnosis and/or provide information about developmental expectations.
While some may prescribe medication, many will refer patients seeking treatment to specialists such as developmental pediatricians, psychiatrists or pediatric psychologists. It is not uncommon for multiple professionals to be involved in the management of ADHD symptoms, as many individuals benefit from both medication and behavioral therapy.
Living With ADHD Long-Term
As ADHD is a chronic condition, many individuals with the diagnosis have ongoing difficulties throughout their lifetime, including a risk of depression.3 For those taking medication, it may become clear that symptoms shift with changes in the environment requiring ongoing management of dosages and types. Younger children may require educational and/or behavioral supports at school, including an IEP or 504 plans. Adolescents and adults may consider informing administrators or employers about an ADHD diagnosis for accommodations to increase productivity.
Aside from more formal accommodations, individuals with ADHD can take measures on their own to support skills deficits. Common strategies to manage symptoms include note taking to address working memory deficits, structured scheduling to avoid procrastination, and use of technology and planners to support difficulty with organization. There are some games and exercises that purport to improve memory and attention, ranging from crossword puzzles and Sudoku to more expensive options (e.g., Lumosity© or BrainHQ©, though these activities do not claim to treat specific diagnoses.
Additional Resources for ADHD
While only a professional can diagnose and treat Attention-Deficit/Hyperactivity Disorder, there are several organizations that can provide support and guidance, including:
