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Attention deficit hyperactivity disorder

IntroductionAttention deficit hyperactivity disorder (ADHD) is a developmental disorder characterized byinattention, hyperactivity, and impulsivity. It is the most commonly diagnosed behavioraldisorder of childhood, affecting 8 - 12% of school-aged children. Although many peoplesometimes have difficulty sitting still, paying attention, or controlling impulsive behavior,people with ADHD find that these symptoms greatly interfere with everyday life. Generally,these symptoms appear before age 7 and can lead to problems in school and in socialsettings. One- to two-thirds of all children with ADHD continue to have symptoms when theygrow up. A diagnosis can be controversial, since there are no lab tests for ADHD, and noobjective way to measure a child's behavior. There is no best way to treat ADHD, however,experts agree that taking action early can improve a child's educational and socialdevelopment.

Signs and SymptomsA person is diagnosed with ADHD if they have at least 6 symptoms from the followingcategories, lasting for at least 2 months. In diagnosing children, the symptoms must appearbefore age 7, and pose a significant challenge to everyday functioning in at least 2 areas oflife (usually home and school). Most children do not show all the symptoms, and they may

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be different in boys and girls (boys may be more hyperactive and girls more inattentive).

Inattention

Fails to pay close attention to details or makes careless mistakes

Has difficulty sustaining attention in tasks or play activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish tasks

Has difficulty organizing tasks and activities

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort(such as school work)

Loses things needed for tasks or activities

Is easily distracted

Is forgetful in daily activities

Hyperactivity and Impulsivity

Fidgets with hands or feet or squirms when seated

Does not remain seated when expected to

Runs or climbs excessively in inappropriate situations (in teens or adults, may befeelings of restlessness)

Has difficulty playing or engaging in leisure activities quietly

Acts as if "driven by a motor"

Talks excessively

Blurts out answers before questions are completed

Has difficulty waiting his or her turn

Interrupts or intrudes on others

What Causes It?No one is sure what causes ADHD. Although environmental factors may play a role,researchers are now looking to find answers in the structure of the brain.

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Altered brain function -- Brain scans have shown differences in the brains of childrenwith ADHD compared to those of non ADHD children. For example, many children withADHD tend to have altered brain activity in the prefrontal cortex, a part of thebrain known as the command center. This may affect their ability to control impulsiveand hyperactive behaviors. Researchers also believe hyperactive behavior in childrencan be caused by too much slow wave (or theta) activity in certain regions of the brain.

Genetics -- ADHD seems to run in families.

Maternal or childhood exposure to certain toxins -- Women who smoke, drink, and areexposed to PCBs during pregnancy are more likely to have children with ADHD.Children who are exposed to lead, PCBs, or phthalates are more likely to develop thedisorder.

re-term birth -- Up to 20% of babies who are born prematurely develop ADHD.

Risk FactorsRisk factors for ADHD include:

Heredity -- children with ADHD usually have at least one first-degree relative who alsohas the disorder.

Gender -- ADHD is 4 - 9 times more common in boys than in girls. Some expertsbelieve that the disorder is underdiagnosed in girls, however, and recent studies showno association between a child's sex and ADHD.

Prenatal and early postnatal health -- maternal drug, alcohol, and cigarette use;exposure of the fetus or infant to toxins, including lead and PCBs; nutritionaldeficiencies and imbalances; pre-term birth and low birth weight.

Low Apgar scores at birth.

Other behavioral disorders, especially those that involve too much aggression (suchas oppositional defiant or conduct disorder).

What to Expect at Your Provider's OfficeThere is no objective test for ADHD, so making a diagnosis can be hard. Doctors may usea number of tests and observations. For this reason, it is crucial to make sure the doctorwho evaluates you or your child is trained in diagnosing ADHD.

To evaluate a child, the doctor will take a complete medical history and do a thorough examto check for conditions that may mimic ADHD, such as hyperthyroidism or problems withvision, hearing, and sleeping. Many symptoms show up at home or school rather than thedoctor's office, so you may be asked to fill out questionnaires. Your child's teacher may be

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interviewed. Your doctor will try to determine not only how the child behaves but also wherethe behavior occurs and how long it lasts. Children with ADHD have long lasting symptomsthat usually show up during stressful situations or situations that require sustained attention(such as schoolwork).

Diagnosing an adult with ADHD can be even more challenging. Because your symptomswould have appeared when you were young, your doctor may try to find out as much aspossible about you when you were a child by getting information from your parents or formerteachers. (If your symptoms are recent, you are not considered to have adult ADHD.) Inaddition to ruling out the other conditions mentioned above, your doctor may also check fordepression and bipolar disorder, which can mimic ADHD.

Preventive CareSince the cause or causes of ADHD are not known, there is no way to prevent thecondition. However, pregnant women can avoid known risk factors, including cigarettesmoke and known toxins. It can be managed with medication, behavioral therapy, andlifestyle changes.

Treatment OptionsHow to treat ADHD, particularly in children, is a controversial subject. Current treatmentincludes therapy or medication, or a combination of both. Studies show that medication byitself, without some kind of therapy, is not likely to improve a child's outcome in the longterm. Family therapy, behavioral therapy, social skills training, and parent skills training areoften used. Many parents investigate nutritional therapies (such as elimination diets or high-dose vitamins), but so far there is no clear evidence that these approaches are effective.Preliminary evidence indicates that homeopathy and mind/body techniques, especiallybiofeedback, may help improve behavior in children with ADHD.

LifestyleParent skills training offered by specialized clinicians provides parents with tools andtechniques for managing their child's behavior. Behavior therapy rewards appropriatebehavior and discourages destructive behavior. It can be performed by parents and teachersworking together with therapists and doctors. For example, older children with ADHD may berewarded with points or tokens, or even written behavioral contracts with their parents.Creating charts with stars for good behavior may work for younger children. On the otherhand, timeouts may discourage undesirable behavior. Other techniques include:

Setting rules that are easily understood, developmentally appropriate, and not undulyharsh

Avoiding repeated commands once the child has been reminded of the consequences

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Disciplining the child before becoming too angry and frustrated

Following discipline with praise when the child follows the rules and behavesappropriately

In addition to behavioral intervention at home, changes in the classroom environment (orwork, in the case of adolescents or adults) are significant parts of the treatment plan.Hyperactive children do best in highly structured circumstances with a teacher experiencedin handling their disruptive behavior and capable of adapting to their distinctive cognitivestyle. Interactions with groups can be very challenging for a child with ADHD. Social skillstraining, appropriate classroom placement, and clear rules of engagement with peers areessential. Preliminary evidence suggests that computer-based attention training in schoolsis highly effective for students who have ADHD.

Adults with ADHD may benefit from behavioral therapies, including cognitive remediation,couple therapy, and family therapy.

Drug TherapiesStimulant medications are the most widely researched and commonly prescribed treatmentsfor ADHD. Although researchers do not fully understand how these drugs improve ADHDsymptoms, studies indicate they boost the amount of dopamine and serotonin in the brain.Dopamine is a chemical that is associated with activity; and serotonin is a chemicalassociated with mood and well being. Medications prescribed for ADHD include:

Stimulants

Methylphenidate (Ritalin, Concerta) -- a stimulant and most commonly usedmedication for ADHD; effective in 75 - 80% of people with the condition; notrecommended for children under 6 years of age

Dextroamphetamine (Dexadrine) -- a stimulant that is effective in 70 - 75% ofpeople with ADHD; not recommended for children under 3 years of age

Amphetamine/Dextroamphetamine (Adderall)

Lisdexamfetamine dimesylate (Vyvanse)

Atomoxetine (Strattera) -- the first nonstimulant medication approved to treat ADHD.Strattera increases the levels of both dopamine and norepinephrine in the brain.Strattera was first developed as an antidepressant and, as with all antidepressants,carries a "black box" warning that it may increase thoughts of suicide in young childrenand teenagers.

Antihypertensives (clonidine, guanfacone) -- These medications are not approved bythe Food and Drug Administration for the treatment of ADHD, however, they have beenused off label for several years. Antihypertensives aren't as effective as stimulants,

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however, they are commonly used with stimulants to treat stimulant-induced tics andinsomnia.

The most common side effects from these medications are trouble sleeping, decrease inappetite, and nervousness.

Complementary and Alternative TherapiesAccording to a recent survey, many parents use complementary and alternative treatmentsfor their children with ADHD, with nutritional therapies being the most common. Althoughstudies show conflicting results, if your child appears sensitive to certain foods, talk to yourdoctor about eliminating them for a brief period to see if his symptoms improve. Putting achild on any supplement or complementary or alternative therapy (CAM) diet should be doneonly under the supervision of your doctor.

Diets

The Feingold diet was developed in the 1970s by Benjamin Feingold. He believed thatartificial colors, flavors, and preservatives, as well as naturally-occurring salicylates(chemicals similar to aspirin that are found in many fruits and vegetables), were a majorcause of hyperactive behavior and learning disabilities in children. Studies examining thediet's effect have been mixed. Most show no benefit, although there is some evidence thatsalicylates may play a role in hyperactivity in a small number of children. Because theFeingold diet is difficult to follow and also involves changes in family lifestyle (children areencouraged to participate in creating meals, for example), you should talk with your doctorbefore trying it.

Other dietary therapies may concentrate on eating foods that are high in protein andcomplex carbohydrates, and eliminating sugar and artificial sweeteners from the diet. Onestudy found increased hyperactivity among children after eating foods with artificial foodcoloring and additives. However, studies show no relation between sugar and ADHD. In onestudy, children whose diets were high in sugar or artificial sweeteners behaved no differentlythan children whose diets were free of these substances. This was true even amongchildren whose parents described them as having a sensitivity to sugar. However, someresearchers believe that chronic excessive sugar intake leads to alterations in brainsignaling, which would contribute to the symptoms associated with ADHD.

Some doctors who focus on nutrition say they see positive results when testing for foodallergies and using an elimination diet. If you think your child might benefit from food allergytesting or an elimination diet, talk to a doctor who has experience in nutrition for childrenwith ADHD.

Vitamins and Minerals

Magnesium (200 mg per day) -- Symptoms of magnesium deficiency include irritability,decreased attention span, and mental confusion. Some experts believe that children

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with ADHD may be showing the effects of mild magnesium deficiency. In onepreliminary study of 75 magnesium-deficient children with ADHD, those who receivedmagnesium supplements showed an improvement in behavior compared to those whodid not receive the supplements. Too much magnesium can be dangerous andmagnesium can interfere with certain medications, including antibiotics and bloodpressure medications. Talk to your doctor.

Vitamin B6 -- Adequate levels of vitamin B6 are needed for the body to make and usebrain chemicals, including serotonin, dopamine, and norepinephrine, the chemicalsaffected in children with ADHD. One preliminary study found that B6 pyridoxine wasslightly more effective than Ritalin in improving behavior among hyperactive children.However, the study used a high dose of B6, which could cause nerve damage(although none occurred in the study). Other studies have shown that B6 has no effecton behavior. Because high doses can be dangerous, do not give your child B6, or takehigh doses yourself, without your doctor's supervision.

Zinc (35 mg per day) -- Zinc regulates the activity of brain chemicals, fatty acids, andmelatonin, all of which are related to behavior. Several studies show that zinc mayhelp improve behavior, slightly. Higher doses of zinc can be dangerous, so talk to yourdoctor before giving zinc to a child or taking it yourself.

Essential fatty acids -- Fatty acids, such as those found in fish and fish oil (omega-3fatty acids) and evening primrose oil (omega-6 fatty acids), are "good fats" that play akey role in normal brain function. The results of studies are mixed, but researchcontinues. Omega-3 fatty acids are also good for heart health in adults, but high dosesmay increase the risk of bleeding. If you want to try fish oil to see if it reduces ADHDsymptoms in you or your child, talk to your doctor about the best dose.

L-carnitine -- L-carnitine is formed from an amino acid and helps cells in the bodyproduce energy. One study found that 54% of a group of boys with ADHD showedimprovement in behavior when taking L-carnitine, but more research is needed toconfirm any benefit. Because L-carnitine has not been studied for safety in children,talk to your doctor before giving a child L-carnitine. L-carnitine may make symptoms ofhypothyroid worse, and may increase the risk of seizures in people who have hadseizures before. It can also interact with some medications. Talk to your doctor.

Herbs

Herbs may help strengthen and tone the body's systems. As with any therapy, you shouldwork with your health care provider before starting treatment. You may use herbs as driedextracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcoholextracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water.Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4cups per day. You may use tinctures alone or in combination as noted.

Several herbal remedies for ADHD are sold in the United States and Europe. But fewscientific studies have investigated whether these herbs improve symptoms of ADHD. One

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or more of the following calming herbs may be recommended for people with ADHD:

Roman chamomile (Chamaemelum nobile). Chamomile may cause an allergic reactionin people sensitive to Ragweed. Chamomile may have estrogen-like effects in thebody and therefore should be used with caution in people with hormone-relatedconditions, such as breast, uterine, or ovarian cancers, or endometriosis. Chamomilecan also interact with certain medications; speak with your doctor.

Valerian (Valerian officinalis). Valerian can potentially interact with certain medications.Since valerian can induce drowsiness, it may interact with sedative medications.

Lemon balm (Melissa officinalis). Lemon balm may interact with sedative medications.

Passionflower (Passiflora incarnata). Passionflower may interact with sedativemedications.

Other herbs commonly contained in botanical remedies for ADHD include:

Gingko (Gingko biloba) -- used to improve memory and mental sharpness. Gingkoneeds to be used with caution in patients with a history of diabetes, seizures,infertility, and bleeding disorders. Gingko can interact with many different medications,including but not limited to, blood-thinning medications.

American ginseng (Panax quinquefolium) and gingko -- One study suggests thatgingko in combination with ginseng may improve symptoms of ADHD. Americanginseng should be used with caution in patients with a history of diabetes, hormone-sensitive conditions, insomnia, or schizophrenia. It can interact with severalmedications, including but not limited to, blood-thinning medications.

Massage

Relaxation techniques and massage can reduce anxiety and activity levels in children andteens. In one study, teenage boys with ADHD who received 15 minutes of massage for 10consecutive school days showed significant improvement in behavior and concentrationcompared to those who were guided in progressive muscle relaxation for the same durationof time.

Homeopathy

Before prescribing a remedy, homeopaths take into account a person's constitutional type --your physical, emotional, and psychological makeup. An experienced homeopath assessesall of these factors when determining the most appropriate treatment for each individual.

In a study of 43 children with ADHD, those who received an individualized homeopathicremedy showed significant improvement in behavior compared to children who receivedplacebo. The homeopathic remedies found to be most effective included:

Stramonium -- for children who are fearful, especially at nightPDFmyURL - the best online web to pdf conversion service unblock Vudu

Cina -- for children who are irritable and dislike being touched; whose behavior isphysical and aggressive

Hyoscyamus niger -- for children who have poor impulse control, talk excessively, oract overly exuberant

Biofeedback

Mind/body techniques such as hypnotherapy, progressive relaxation, and biofeedback maybe useful in treating children and teens. Through these techniques, children are often able tolearn coping skills they can use for the rest of their lives. These treatments allow children togain a sense of control and mastery, increase self esteem, and decrease stress.

Biofeedback operates on the principle that children can be trained to modify brain activityassociated with ADHD and increase brain activity associated with attention. Several studieshave shown positive results.

Other Considerations

Prognosis and ComplicationsAs many as half of all children with ADHD who receive appropriate treatment learn to controlsymptoms and function well as adults. Research suggests that children who receivetreatment that combines therapies such as medication, behavioral therapy, and biofeedbackare less likely to have behavioral problems as they grow up. Nevertheless, studies showthat ADHD persists into adulthood in 60 - 70% of people diagnosed with ADHD inchildhood. In most cases, ADHD can be effectively managed throughout life.

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Daroff: Bradley's Neurology in Clinical Practice, 6th ed. Philadelphi, PA: Saunders, AnImprint of Elsevier. 2012.

Farone S, Mick E. Molecular Genetics of Attention Deficit Hyperactivity Disorder.Psychiatric Clinics of North America. 2010;33(1).

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Gutgesell H, Atkins D, Barst R, et al. Cardiovascular monitoring of children and adolescentsreceiving psychotropic drugs: a statement for healthcare professionals from the Committeeon Congenital Cardiac Defects, Council on Cardiovascular Disease in the Young, AmericanHeart Association. Circulation. 1999; 99(7):979-82.

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Kim BN et al. Phthalates exposure and attention-deficit/hyperactivity disorder in school-agechildren. Biol Psych. 2009;66(10):958-63.

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Alternative NamesADHD

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Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing incomplementary and alternative medicine, Phoenix, AZ. Review provided by VeriMedHealthcare Network.

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