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.