Attention deficit hyperactivity disorder (ADHD) is a commonly diagnosed childhood problem. ADHD is characterized by consistent demonstration of the following traits: decreased attention span, impulsive behavior and excessive fidgeting or other non-directed motor activity. All children, including children with Down syndrome, display these traits from time to time. But a child with Down syndrome may exhibit these traits more often than other children his or her age.

How Common is ADHD in Children with Down Syndrome?

The frequency of ADHD in children with Down syndrome is not known with certainty. However, ADHD-like symptoms are more common in young children with Down syndrome than they are in children from the general population. Compounding symptoms such as stereotypy (repetitiveness), anxiety or extreme irritability in the presence of ADHD-like symptoms may indicate another disorder such as autism, bipolar disorder or obsessive compulsive disorder.

Uncomplicated ADHD is common in younger children with Down syndrome. However, many school age children with ADHD frequently have other behavioral conditions including oppositional defiant disorder, disruptive behavior disorder or obsessive compulsive traits.
 

What are Medical Problems that can look like ADHD?

Hearing and Vision Issues

In order for a child to pay attention to classroom material, he or she has to be able to hear and see it. Both hearing and vision problems are common in children with Down syndrome. Ear infections are overwhelmingly common, and even if treated, can cause hearing loss for weeks. People with Down syndrome have middle ear structural abnormalities that can cause lifetime mild to moderate hearing loss.

Both near and far sightedness are common in individuals with Down syndrome, as are cataracts and “lazy eye.”

Rule out Significant Hearing and/or Visual Loss as a Cause of Attention Problems 

To monitor hearing, an auditory brainstem response test (ABR) or otoacoustic emission (OAE) should be performed early in the child’s life (by three months of age at the latest) as a baseline. Hearing screens should be performed annually until three years of age, and every other year thereafter. Children with abnormal hearing evaluations should be seen by an ear-nose-throat physician (otolaryngologist) to manage treatable causes of hearing loss.

A child with Down syndrome should be evaluated by an eye doctor during the first year of his of her life, and yearly thereafter. Some children may need more frequent follow-ups depending on their visual diagnosis.
 

Gastrointestinal Issues

People with Down syndrome are at increased risk for an intestinal condition called celiac disease, which is a condition in which the body cannot process a protein found in wheat and certain other grains. While typical symptoms of celiac disease include loose stools, diarrhea and poor weight gain, the condition often presents only with subtle effects on energy and behavior. People with Down syndrome are also predisposed to significant constipation, which can cause abdominal pain, lack of appetite and restlessness IF severe.

Current recommendations for gastrointestinal monitoring include screening for celiac disease between two and three years of age. This screening should include measurement of IgA antiendomysium antibodies as well as total IgA. There should also be a review of the child’s bowel status at each visit.
 

Thyroid Issues

About 30% of people with Down syndrome have thyroid disease at some point in their lives. Most have hypothyroidism or an underactive thyroid gland. A few have Graves disease or an overactive thyroid gland. Hypothyroidism can make a child very tired and apathetic among other things while Graves disease can cause agitation and restlessness. Therefore, both conditions can look like poor attention and behavior.

Because thyroid disease is so prevalent in this population, an annual blood test for thyroid hormone is recommended by the Down Syndrome Health Care Guidelines.
 

Sleep Issues

Sleep disorders are extremely common in Down syndrome. These disorders are a group of conditions with many different causes but one thing in common - they all interfere with getting a good night’s sleep. Tired children can behave very differently from tired adults. They can become restless, whiny and difficult to calm. And people of all ages have difficulty focusing and learning new information when they are sleep deprived.

Sleep apnea, or short periods of not breathing during sleep, is especially common. People with Down syndrome have small, often “floppy” airways, which can sometimes be completely or partially blocked during sleep by large tonsils and adenoids or by the floppy walls of the airway collapsing as air is exhaled. Regardless of the cause of obstruction, the sleeper must awaken briefly to resume breathing. Some patients with sleep apnea awaken hundreds of times per night.

Symptoms associated with, but not specific to, sleep apnea include snoring, lots of “thrashing” while asleep, excessive daytime sleepiness, mouth breathing, and unusual sleep positions such as sleeping in a seated or hunched forward position.

Children suspected of having a sleep disorder should undergo a sleep study evaluation at an accredited sleep center.
 

What Types of Communication Difficulties can look like ADHD?

People with Down syndrome may have many barriers to effective communication. The receptive language skills of children with Down syndrome (how well they understand what is being said) are often much stronger than their expressive language skills (how well they can say it). Parents often comment, “He knows what he wants to tell us, he just can’t seem to put the words together or we can’t make out what he is saying.” Classroom participation is thus more difficult. A child may express his or her frustration by acting out or by inattention.
 

What Types of Educational Problems can look like ADHD?

Children with Down syndrome have a wide range of learning styles. A child’s educational team may need to try more than one method of presenting material before finding the one that works best for the child. If material is presented in a way that is not compatible with a child’s learning style (e.g. oral lectures for a student who needs visual aids and prompts), that child may appear bored, fidgety and hyperactive.

The level of the material may also be a problem. If a child is presented with concepts that are too difficult for his or her cognitive level, he or she might “tune” out and appear inattentive. A child who is bored with overly easy material may also act out.
 

What Types of Emotional Issues can look like ADHD?

Because of the communication problems discussed above, people with Down syndrome may have difficulty talking about things that make them sad or angry. Major life changes such as loss or separation may prompt decreases in appropriate behavior at school or at work.
 

What are the Next Steps?

If a parent is concerned about decreased attention span, impulsive behavior and excessive fidgeting or other non-directed motor activity in their child, a pediatrician and child psychiatrist should conduct a thorough analysis and rule out masking conditions before arriving at a diagnosis of ADHD and initiating treatment.