Attention-Deficit/Hyperactivity Disorder

Frequently Asked Questions

What is attention deficit disorder (ADD)?

Attention deficit disorder is an illness characterized by profound disturbances in one's ability to concentrate, focus, organize, and stay on task. Although everyone suffers periods of distractibility or forgetfulness, the diagnosis of ADD should be reserved for those who meet strict diagnostic criteria. Just as everyone experiences shortness of breath or chest pain (such as when exercising) this obviously does not mean we are having a heart attack. It may, but it is the clustering of symptoms, their progression, and their severity that make a collection of signs and symptoms cross over a threshold into the realm of illness.

What is attention deficit hyperactivity disorder (ADHD) and how is it different from attention deficit disorder (ADD)?

As the name implies, attention deficit hyperactivity disorder is a pattern not only of inattentiveness, distractibility, disorganization, and forgetfulness, but also fidgetiness, an inability to sit still, and a sense of being "on the go" as if driven by a motor. It may or may not be accompanied by impulsivity, such as a decreased ability to inhibit the impulse to blurt out an answer or interrupt or intrude on others.

I heard that ADD/ADHD aren't real medical disorders. Aren't these illnesses just an attempt by society to medicate kids so they behave more to their parents' and teachers' liking?

Some people certainly have this belief. Some propagate it through talk shows. Almost all who have come to this conclusion have a poor understanding of what it means to have attention deficit disorder, and how this differs from the normal, age-appropriate inattentiveness and impulsivity of childhood.

Simply because we have all had some experience with chest pain does not make us experts in the appropriate diagnosis and treatment of a myocardial infarction (heart attack). In psychiatric disorders, which I view as medical disorders whose primary manifestation is behavioral and cognitive, our day-to-day experience with minor symptoms that do not constitute a full-blown disorder do not necessarily give us insight into or invalidate the idea of the existence of the disorder and the necessity of treatment.

We have all experienced sadness. Not all of us have experienced the full-blown constellation of extreme sadness, tearfulness, decreased concentration, appetite, sleep, and energy, along with rumination about suicide that represents a full-blown major depressive disorder.

Similarly, the fact that we may have had relative success using simple behavioral interventions to help our own bouts of distractibility does not mean that for a minority of children and adults, such techniques will be insufficient.

This does not mean that some children who receive medication for attention deficit disorder/attention deficit hyperactivity disorder should not be, and are indeed being treated for the convenience of their parents or teachers, but the decision to treat is not made in a vacuum. A well-done psychiatric history, mental status exam, including input from multiple observers, such as a Copeland checklist distributed to teachers and other care-givers, followed by a frank discussion of risks, benefits, and alternate treatments will make the probability of inappropriate diagnosis and treatment much less likely. A good psychiatrist should be able to detect if the behavioral expectations of the parents are unrealistic or if other, non-medical interventions should suffice.

At any rate, the appropriateness or inappropriateness of the treatment of your neighbor in no way influences the presence or absence of an illness in yourself or your children. Decisions to diagnose and treat should be made on an individual, not a societal basis.

Isn't is wrong to drug your kids to change their behavior?

The term "drugging" has a negative connotation. Few would disagree that if our child has a life-threatening bacterial infection, that aggressive antibiotic should be initiated. We would not call this drugging our child. If our child has epilepsy, or Tourette's, or diabetes, we would also medicate without using disparaging terms. Why should we make a distinction when the cluster of signs and symptoms is predominantly behavioral and cognitive?

"Drugging" is usually reserved for what torturers do to those being interrogated, or someone would do to control the behavior of an unruly animal. In broader parlance, recreational drug use refers to an attempt to alter oneself in an attempt to experience euphoria or some pleasurable state. Such a pejorative term seems inappropriate to apply to the actions of a loving parent attempting to help treat the negative consequences of a disorder.

How common is ADD/ADHD?

Studies suggest that about 3-5% of all school-age children have the disorder. This seems to be true across different cultures, although it tends to be recognized and treated more commonly in the United States. So although most kids have difficulty with ¯ attention, distractibility, forgetfulness, etc., only a minority have the full-blown constellation of symptoms that represents the disorder.

Do boys and girls both get ADD/ADHD?

Yes, but boys are about 3 times more likely to be recognized and diagnosed than girls. Girls are more likely to have the inattentive type (without hyperactivity), which is less likely to be noticed.

I thought ADD/ADHD was only diagnosed in children.

Not at all. About 50-80% of children continue to have symptoms persisting into adolescence, two thirds into adulthood. There is thought to be a genetic component to the disorder; many parents discover they have the disorder or many traits after bringing their children in for evaluation.

So how is it diagnosed?

It should be a team effort with a comprehensive review of all factors that can lead to the cluster of symptoms. For example, chaos at home, abuse, neglect, parental fighting, separation, or divorce, financial insecurity, geographical instability, bullying and teasing can all lead to symptoms that look like attention deficit disorder.

Symptoms MUST cause problems and most younger children have some inattentiveness that improves with age, so be careful with this label. I tend to be hesitant to make the diagnosis until all information is gathered. Several sources, including both parents, if applicable, several teachers or other observers, should be tapped. Distribution and completion of Copeland surveys or other behavioral checklists are invaluable.

There must be multiple symptoms in 3 clusters: inattention, hyperactivity, and impulsivity for at least 6 months.

The symptoms must be present by age 7.

INATTENTION Symptoms (must be present for 6 months to a degree that is maladaptive and inconsistent with developmental level)::

Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities:

Difficulty sustaining attention in tasks or play activities:

Often does not seem to listen when spoken to directly:

Often not follow through on instructions, finish homework or work assignments:

Difficulty organizing tasks and activities:

Avoids, dislikes, or is reluctant to do tasks that require sustained concentration such as schoolwork or homework:

Often loses things such as toys, assignments, tools:

Easily distractible by extraneous stimuli:

Often forgetful in daily activities:

HYPERACTIVITY Symtoms (requires 6 of the Hyperactivity and Impulsivity Symptoms for ADHD diagnosis) :

Often fidgets with hands or feet or squirms in seat:

Often leaves seat in classroom or other situations in which being seated is expected:

Often runs about or climbs excessively in inappropriate or has a feeling of restlessness:

Often has difficulty playing in or engaging in leisure activities quietly:

Often "on the go" as if driven by a motor:

Often talks excessively:


Often blurts out answers before questions have been completed:

Often has difficulty awaiting turn:

Often interrupts or intrudes on others:


Time criteria:

Symptoms present before 7 years old:

Some symptoms present in 2 or more settings:

Significant impairment in social, academic, or occupational functioning:

Not because of another disorder:

- source: DSM-4; see also:

Note that the child may have difficulty following commands (not due to conduct disorder), and this may be particularly true with multiple commands, e.g., "get a loaf of bread, a can of peas, and some corn" is much more challenging than "get a loaf of bread."

It is also imperative to rule out learning disabilities and medical causes of inattentiveness as well.

What difference does it make if my (or my child's) ADD/ADHD is treated?

The cost of not treating ADD/ADHD can be surprisingly high. A hyperactive child may miss critical cognitive and social milestones because of the disorder. 

Most commonly, ADD/ADHD leads to academic underachievement with subsequent under-education and under-occupation, meaning a person is held back by factors other than raw academic ability. Discouraged, children suffering from ADD/ADHD often have very poor self image and low self-esteem. They may start to see themselves as "slow" or "spastic" or "spacey." Their symptoms often impair their ability to form and maintain friendships. They may be socially "out of synch," engaging in so called "butt-insky" behavior.

They may be the class clown, the magnet for trouble, and frequently in the hot seat. Teachers may start to view them as problem children, and this may become a self-fulfilling prophecy (which may persist for some time even after successful treatment).

Those with ADD/ADHD are much more likely to abuse alcohol or other drugs and are about twice as likely to commit suicide as those who do not have the disorder. Their relationships, both intimate and occupational, can be disrupted by the illness, which can lead to high rates of divorce and spotty employment histories. If impulsivity is present, the cumulative effect of job-hopping and failing to stick with a given path can be devastating.

Financially, those with ADD/ADHD suffer a double whammy; their incomes may be lower on average than those with similar talents who do not have the disorder, and they are more likely to get into debt because of impulsivity and fail to pay bills on time because of distractibility and forgetfulness, leading to a poor credit history.

Isn't treating ADD/ADHD really a luxury problem, an artifact of Western culture?

This is one of those "if a tree falls in a forest" types of questions. It is highly likely that because the current classification of illnesses and disorders is in flux, in a hundred years people will look back on our current attempts to understand cognitive and behavioral phenomena with a derisive smile. Those of us who live in the West are obviously products of it, so stripping away reality from the filter through which it is viewed is about as difficult as separating white from rice.

It may be that industrialization, indoor lighting (which abolished the normal light-dark, sleep-wake cycle), 24-hour access through pagers, cell phones, and email, as well as a flood of information through television, radio, the Internet, mass media, etc., has disrupted a more "natural" agrarian rhythm of life that our great grandparents knew. But although these are contributing factors, it is unlikely that the collection of symptoms we currently label as ADD/ADHD is entirely explained by them.

At any rate, such questions are more appropriate for philosophers than for clinicians. It is faint consolation for someone suffering from carpal tunnel syndrome to be told that their illness is a result of modern technology; the suffering is real, and independent of its cultural or historical roots.

Although the United States is probably more comfortable with the idea that ADD/ADHD is a disorder that merits intervention, often pharmacological, the lower prevalence of treatment in some other cultures does not argue against its existence. Indeed, structured clinical interviews with carefully randomized, representative populations indicate that ADD/ADHD exists in most if not all cultures, and at about the same prevalence as in the United States.

My child is able to sit for long periods of time doing something she is interested in, but has trouble paying attention in school, and struggles with her homework. How can she have ADD/ADHD if she is able to play a video game for hours?

It is not uncommon for children with ADD/ADHD to have certain activities that attract and maintain their attention for long periods of time. Indeed, video games and television, with their flickering images and immediate gratification are magnets for kids with ADD/ADHD (which is one reason why they should be avoided). ADD/ADHD is more a disorder of inflexibility of attention, of an inability to shift attention voluntarily from one topic to another, than a true lack of attention per se.

A child who is quiet and attentive during the interview may still suffer from ADHD. This is why multiple sources of information from multiple settings are critical. Remember, ADHD must be present in multiple settings (but not all).

Isn't ADD/ADHD just a matter of bad parenting?

No. Many psychodynamic theories (authored by men) operated on the principle, when in doubt, blame Mom. The thinking today is that many factors lead to most of the disorders that we see and treat.

Certainly neglect, abuse, psychosocial chaos, and inconsistent parenting or disciplining can worsen ADHD, but none of these factors alone causes it. If there is a link, it is most likely that parents with untreated ADHD, with attendant impulsivity, difficulty deferring gratification, and disorganization, may be at somewhat higher risk of providing their children with a somewhat less stable environment.

Disciplining should be immediate, proportional, and consistent. It should focus on the behavior, not the child. It should communicate hope that things can improve. Corporal punishment is generally ineffective and counterproductive. At the extreme end, physically abusing a child can lead to posttraumatic stress disorder, emotional lability, and difficulty in the child's modulating her mood and behavior.

One cannot "beat ADHD out of" a child. It may be possible to terrify a child into a few moments or even hours of silence, but it is unlikely that a child who suffers from true ADD/ADHD will be able to be shamed into overcoming his neurobiological make-up.

What evidence is there that ADD/ADHD runs in families?

There is an increased incidence in first degree relatives. Patients who have family histories of ADHD and conduct disorder are at increased risk of having ADD/ADHD.

Is ADD/ADHD a behavioral disorder or a brain disorder?

Probably a mixture of both. Neuroimaging shows changes in frontal lobe function.

Several biological insults are associated with an increased risk of ADD/ADHD:

If a child has ADD/ADHD, does this mean he/she cannot have another psychiatric disorder?

This may be a function of how we lump or split diagnoses, but comorbidity is the rule in child psychiatry. About half of those diagnosed with ADHD also have Oppositional Defiant Disorder. 20% have Conduct Disorder. Mood and anxiety disorders, often secondary to the self-esteem and image problems cited above, are common. About 20-40% of children with ADHD have learning disabilities. As mentioned above, substance abuse is much more likely in those with ADHD.

Although it was once thought that children should take a "drug holiday" during the summer, that is no longer standard practice, since even the summer months when the child is out of school are crucial for social development.

What types of treatment are available for ADHD/ADD?

Treatments can be divided into behavioral and phamacological.

What are the behavioral treatments of ADHD/ADD?

Behavioral treatments alone can be effective in some cases, especially when there are significant family issues. Parents can learn new techniques to "shape" behavior, linking rewards with desired behavior (or absence of undesired behavior), and being more creative in their approach to problematic behaviors.

One of the most important behavioral principles in ADD/ADHD, adult or child, is to CLEAR THE DECKS. Decreasing clutter, turning off the television or radio, focusing on one activity at a time, and putting things away instead of putting them down can lead to tremendous pay-off. Avoiding the impulse to multi-task, over-schedule, or over-commit can help greatly. In children, cultivating "quiet time" activities such as arts and crafts, can help tremendously.

As with all children, those with ADD/ADHD should eat a well-balanced, healthy diet, with plenty of fresh fruits and vegetables. Snacks, especially those rich in sugar and low in nutritional value, should be avoided. Sodas, especially those containing caffeine (don't forget about the caffeine in chocolate and iced tea also) should be avoided.

Also, exercise is critically important. Walk as a family, encourage getting outside for a few hours a day, and discourage your child from becoming a couch potato.

Limit exposure to television, video games, and other attention black holes. Television makes children less interested in other things, more hyperactive, and more violent even if they are not watching a violent program. Link television to finishing homework, completing chores. Watch television with your child, talk about what you've seen afterwards, what people were feeling, etc.

A trained therapist who specializes in children with ADD/ADHD can be invaluable in helping to work out a detailed behavioral plan.

What medication treatments are available?

The most commonly used treatments are as follows:


Atomoxetine (Strattera) is an exciting new treatment that, unlike Ritalin, Adderall, or the other amphetamine products, is not controlled, does not require a new written prescription each month, and can be called into a pharmacy. Unlike the other products, however, it takes 2 weeks to work.

Other treatments include antidepressants, such as Wellbutrin or an selective serotonin reuptake inhibitor (SSRI), although their efficacy in children is less well established. Some atypical treatments also include anti-hypertensives. Newer agents such as Provigil are being explored for ADD/ADHD.

Aren't medications dangerous?

There is a risk of treatment and a risk of not treating.

Most medications are well-tolerated. The most common side effects with the stimulants are insomnia and ¯ appetite. Some kids experience worsening of mood swings. The stimulants have a paradoxical calming effect on those with ADHD (normal volunteers who do not have this diagnosis are more likely to experience the opposite - a feeling of being jittery or wired).

Rarely, the amphetamines can cause tics, but prompt discontinuation almost always leads to resolution of this.

In fact, all of the side effects are self-limited and will pass upon discontinuation of the medications, so if a medication does not work or is not tolerated, stop it and try something else.

Does everyone respond to medication?

No, but the stimulants and Strattera are each about 60-70% effective. Unfortunately, some work in some patients, but not in others, so trial and error is the rule.

What can I expect from treatment?

Medications alone can lead to dramatic improvement, but this is the exception rather than the rule. A 50% reduction in symptoms is usually achievable with medications; the best improvement comes from a combination of medications and behavioral modifications and/or therapy. Small changes in the environment and in parenting techniques, if applicable, can go a long way in concert with appropriate medication intervention, if warranted.

Do I have to take the medications for the rest of my life?

See above for the natural course of ADD/ADHD. The question might better be asked, If the medications are helpful, may I take them indefinitely?

Probably. The long-term side effects of the older agents are negligible; we have decades of experience with no appreciable differences in body weight, development, etc., between those who take the medications and those who don't. The newer agents, particularly Strattera, as with any new medication, may have rare side effects over the very long-term, but it is currently thought to be safe and effective indefinitely.

Isn't there a risk of "getting hooked"?

The amphetamines are controlled substances, highly regulated, with a definite street value. However, most of those who abuse these medications are not suffering from ADD/ADHD. The experience of the vast majority of patients with ADD/ADHD is that once the appropriate agent and dose are found, that they tend not to become tolerant to the beneficial effects (meaning it does not take more and more of the medication to get the same effect). Dosage should be adjusted as a child matures, of course, but the medications seem to be effective in the long term.

Interestingly, some studies indicate that those with ADHD are as much as 85% less likely to abuse alcohol or other drugs if they treated with stimulants.

But isn't taking a drug to feel better wrong? I mean, how is it any better to take Adderall to feel better than it is to take cocaine to feel better?

The following answer is copied from frequently asked questions about antidepressant medication.

This is a very important question and one of the most frequently asked. I think there are significant differences between using a recreational drug to achieve a euphoric escape from reality and using a prescribed medication to feel less miserable and more in touch with reality. (See the modules on cocaine addiction or substance dependence for more information.) These differences fall into three main categories.

    1. Motivation: The cocaine-user's motivation is to elevate a normal mood into the euphoric range. Someone taking an antidepressant, on the other hand, is attempting to bring a depressed or anxious mood into the range of normal. Relieving a source or intense pain and anguish is quite different from chasing an emotional "high." The cocaine user is attempting to escape from reality; the person successfully treated with an antidepressant is more likely to be in a position to embrace and deal with reality.
    2. Immediate consequences: People who use cocaine tend to find the experience intensely pleasurable, so much so that they become willing to do almost anything to get it again. Someone taking an antidepressant, however, won't feel anything for a few weeks if at all. If they aren't depressed or anxious to begin with, they won't feel anything at all [1]. No one (to my knowledge) has ever robbed a liquor store to get more money for their antidepressant. Antidepressants, if taken properly, do not significantly impair your ability to work, drive, be in a relationship, or make decisions.
    3. Long-term consequences: Using cocaine greatly increases your probability of suffering adverse legal, financial, emotional, medical, and social consequences. Taking cocaine is a great way for a young person to experience a stroke or heart attack, for example. There is no legitimate, empirically-proven benefit, but there is plenty of risk. The long-term benefits of antidepressant medication, on the other hand, is improved functioning in multiple life areas, and the ability to get on with your life. There is empirical evidence from controlled medication trials to support their use. They have been shown to be safe and effective on average in large groups of people. Cocaine has never been demonstrated to be safe, and there is strong evidence that it is quite dangerous.



Oppositional Defiant Disorder: A chronic pattern of stubborn, negativistic, profvocative, hostile, defiant behavior that does NOT violate the rights of others or the basic rules of society.

Conduct Disorder: Repetitive and persistent patterns of behavior which violate the rights of others and the rules of society. (You can think of conduct disorder as a juvenile form of adult antisocial personality disorder; it has a negative, fatalistic connotation.)