In many households, the start of a new school year is a cause for excitement. There are new books to read, friends to be made, pencils to sharpen.
But in the Gigliotti household in Benicia, Calif., the anticipation is mixed with apprehension. The family’s oldest son, Justin, has attention deficit hyperactivity disorder, which can be difficult to mesh with the routines and structure of the classroom.
“Every year at the beginning of the school year, it’s a new challenge,” says Heidi Gigliotti, a registered nurse and mother of three. “It’s a readjusting, a new teacher, how are we going to make this work.”
Plenty of parents have wondered whether their children are simply rambunctious, high-energy kids or if they have a behavioral disorder in need of treatment. As toddlers become preschoolers and preschoolers enter grade school, the question becomes easier to answer.
Attention deficit hyperactivity disorder is among the most common ailments of childhood, according to the National Institute of Mental Health. Kids with ADHD have trouble focusing on a task, following instructions, sitting still, listening to people who are talking to them, being patient, controlling their impulsive behavior and being quiet, among other symptoms.
Some children struggle primarily with hyperactive and impulsive behaviors, and others have more trouble being attentive; in most children, it’s a combination of both.
Christine Hammond had hoped that school would give her son more outlets for his energy and teach him how to interact appropriately with other kids his age. Instead, his acting out grew worse.
“By the second week of kindergarten, he was in the principal’s office,” says Hammond, a mental health counselor in Winter Garden, Fla. “He never got rewards, like stickers for good behavior.”
His IQ was high, but he was performing poorly in school. The school tested him for dyslexia and other learning disabilities, but counselors couldn’t pinpoint a problem. Finally, in second grade, they said he had ADHD. Hammond and her husband saw at least five doctors and counselors to confirm the diagnosis.
“My husband was adamantly opposed,” Hammond says. “He was upset that [our son] would have a label he’d carry for the rest of his life. … This will definitely be part of all college applications.”
Some studies show that between 5% and 8% of children are affected with ADHD, but estimates reach as high as 12%, depending on the criteria used for diagnosis. ADHD is about three times more common in boys than in girls, but the gap closes as children reach adolescence, according to a 2009 review in Current Attention Disorder Reports.
About 70% of children continue to meet the full criteria for ADHD as they enter their teen years, according to a 2010 study in the British Journal of Psychiatry. Experts believe that 4% to 5% of adults have ADHD.
Diagnosing ADHD is far from an exact science. Children with extreme symptoms are fairly straightforward to identify, but most fall somewhere in the middle, making the diagnosis fuzzier and prone to error. Evaluations often consist of subjective questionnaires for parents and teachers that have yes-or-no answers — if enough of the answers are yes, the child may be diagnosed with ADHD, says Dr. Lawrence H. Diller, a behavioral and developmental pediatrician in Walnut Creek, Calif.
Kids with ADHD are usually identified early in their elementary school careers. Key factors include whether they can function well in the classroom and progress in their development. ADHD children may be so disruptive that they get rejected by their friends and classmates or even expelled, says Dr. Benedetto Vitiello, chief of child and adolescent treatment at the National Institute of Mental Health in Bethesda, Md.
Researchers are starting to realize that in some cases, ADHD only becomes apparent in middle and high school, when student life gets more complicated and classes become more demanding. Hyperactivity often wanes as children reach adolescence, but teens are expected to deal with multiple teachers and be more independent and organized. Those who were able to muddle through elementary school may lack the attention skills needed to cope, Vitiello says.
The condition is also being recognized more often in preschoolers as teachers expect more discipline at a younger age. A decade ago, children were introduced to rules and educational goals in kindergarten, says Dr. Mark Riddle, a professor of psychiatry and pediatrics at Johns Hopkins University School of Medicine in Baltimore. Now “a larger proportion of youngsters are having those expectations at ages 3, 4, and 5 in daycare and nursery school settings.”
Brain imaging studies have found that neural circuitry in the prefrontal cortex — which controls functions such as planning, understanding and following rules, and figuring out what type of behavior is appropriate for a particular situation — and several other brain regions may be impaired in people with ADHD.
For example, in a 2005 study in the journal Biological Psychiatry, researchers gave a word recall test to 20 people with ADHD and 20 healthy controls while they were in a functional MRI scanner. The brain scans suggested that people with ADHD use the prefrontal cortex, the cerebellum (which plays a role in attention) and the occipital lobes (which process vision) less efficiently than others, says coauthor Stephen V. Faraone, director of child and adolescent psychiatry research at State University of New York Upstate Medical University.
A 2007 meta-analysis in the same journal examined 21 studies that compared f-MRI brain scans of people with ADHD and age-matched controls. Researchers concluded that several key regions were significantly smaller in people with ADHD, a sign that abnormal functioning of these brain regions may contribute to ADHD symptoms.
Several genes have also been implicated in the disorder, including ones that control the uptake and transport of dopamine and serotonin. Perhaps faulty regulation of these neurotransmitters may make people susceptible to ADHD, Faraone says.
Despite the recognition that ADHD is a neurological disorder that can have serious implications for children, the decision of whether or not to medicate can be very difficult for parents.
Vitiello recommends starting out with behavioral interventions, such as tutoring and coaching to help children learn to focus for longer periods. Drugs should be considered when “the kid is really suffering and falling behind,” he says.
When Hammond’s son was diagnosed, she and her husband argued for nearly a year about whether to treat him with medication, she recalls.
“He didn’t want to medicate because he felt like it was giving up on him,” Hammond says. “My point of view was, ‘He’s not going to graduate.’”
At first they tried specialized diets, vitamins and exercise, but the boy’s symptoms remained severe. Then their pediatrician warned them that their son was approaching an age when he might begin to self-medicate with drugs and alcohol. “That scared the daylights out of us,” Hammond says.
So when he was 9 years old, they tried Concerta and Focalin before settling on Vyvanse. They’ve had to experiment with different dosages along the way. Now, at 13, the young man is earning accolades in the Boy Scouts and excelling in school. He still takes medication, Hammond says, but only when he feels that he needs it.
For Gigliotti, the decision of whether to start Justin on medication was more straightforward, and he began taking the stimulant Adderall about seven years ago, when he was in first grade.
“He was up and down, around the chair, under the chair, on top of the desk,” Gigliotti says. Without drugs, “he couldn’t really focus and couldn’t really keep his hands to himself.”
Even with drugs, things haven’t been easy. As her son grew older, certain medications became less effective, and his doctors have had to try other medications, including Ritalin and Concerta. “It’s not like ‘OK, he’s diagnosed, life is now great,’” she says.