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Attention Deficit/Hyperactivity Disorder
   
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Retrieved on March 13, 2006, from http://www.nimh.nih.gov/publicat/adhd.cfm

Attention Deficit/Hyperactivity Disorder

National Institute of Mental Health
2004

Attention Deficit/Hyperactivity Disorder

 

Attention deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood, estimated to affect between 3% and 5% of school-aged children. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity. Although many people occasionally have difficulty sitting still, paying attention, or controlling impulsive behavior, these behaviors are so persistent in people with ADHD that they interfere with daily life. Generally, these symptoms appear before the age of 7 years and cause significant functional problems at home, in school, and in various social settings. One- to two-thirds of all children with ADHD (somewhere between 1% and 6% of the general population) continue to exhibit ADHD symptoms into adult life. Diagnosis is difficult (usually requiring more than one visit) but essential, as early treatment can substantially alter the course of a child's educational and social development.


 

Signs and Symptoms

 

A person is considered to have ADHD if he or she demonstrates symptoms of inattention, hyperactivity, and impulsivity for at least 6 months in at least two settings (such as at home and in school). The signs and symptoms listed below are typically seen in children with ADHD and usually appear before age seven. (In order to diagnose ADHD in adults, psychiatrists must determine how the adult patient behaved as a child.)

Symptoms of 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 schoolwork, chores, or duties in the workplace 
  • Has difficulty organizing tasks and activities 
  • Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort 
  • Loses things necessary for tasks or activities 
  • Is easily distracted by extraneous stimuli 
  • Is forgetful in daily activities 

Symptoms of Hyperactivity and Impulsivity

  • Fidgets with hands or feet or squirms in seat 
  • Leaves seat in situations where remaining seated is expected 
  • Runs or climbs excessively in inappropriate situations (in adolescents or adults, may be limited to subjective feelings 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 awaiting turn 
  • Interrupts or intrudes on others 

 

Causes

 

Like most complex neurobehavioral disorders, the cause of ADHD is unknown. Genetic factors as well as those affecting brain development during prenatal and postnatal life are likely involved. Brain scans have revealed a number of differences in the brains of ADHD children compared to those of non-ADHD children. For example, many children with ADHD tend to have altered brain activity in the prefrontal cortex, a region thought to be the brain's command center. Irregularities in this area may impair an individual's ability to control impulsive and hyperactive behaviors. Researchers also believe that hyperactive behavior in children results from excessive slow-wave (or theta) activity in certain regions of the brain. Other studies indicate that ADHD may be caused by abnormally low levels of dopamine, a neurotransmitter involved with mental and emotional functioning.


 

Risk Factors

 

  • Heredity: children with ADHD usually have at least one first-degree relative who also has ADHD and one-third of all fathers who had ADHD in their youth have children with ADHD 
  • Gender: ADHD is four to nine times more common in boys than in girls (some experts believe that the disorder is underdiagnosed in girls, however) 
  • Prenatal and early postnatal health: maternal drug, alcohol, and cigarette use; exposure of the fetus to toxins, including lead and polychlorinated biphenyls (PCBs); nutritional deficiencies and imbalances
  • Learning disabilities, communication disorders, and tic disorders such as Tourette's sydrome 
  • Other behavioral disorders, particularly those that involve excessive aggression (such as oppositional defiant or conduct disorder) 
  • Nutritional factors (controversial): allergies or intolerances to food, food coloring, or additives (see Nutrition and Dietary Supplements) 

 

Diagnosis

 

The names and symptoms for ADHD have changed frequently since the turn of the century. What is now referred to as ADHD has been described in the past as Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, and Attention Deficit Disorder (ADD) With or Without Hyperactivity. The name ADHD was adopted in 1987 by the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).

Diagnosis is largely dependent on specific observed behaviors. The first step in establishing the diagnosis of ADHD is to determine whether the individual meets the diagnostic criteria as defined in the DSM-IV. The DSM-IV's symptomatic criteria were developed for children; there are no specific criteria for ADHD in adults. In these cases, physicians will often determine the psychiatric status of the adult patient as a child and make a retroactive diagnosis of childhood ADHD. Since most of the characteristic behaviors of childhood ADHD occur at home and in the school setting, parents and teachers play an important role in providing information to establish the diagnosis.

DSM-IV Diagnostic Criteria:

  • Either (1) or (2)
    1.Six (or more) symptoms of inattention that persist for at least 6 months to a maladaptive degree inconsistent with the child's developmental level
    2.Six (or more) symptoms of hyperactivity-impulsivity that persist for at least 6 months to a maladaptive degree inconsistent with the child's developmental level 
  • Some inattentive or hyperactive-impulsive symptoms that caused impairment were present before the age of 7 years 
  • Some impairment from symptoms present in two or more settings (such as at school/work and home) 
  • Clear evidence of significant impairment in functioning 
  • Symptoms not secondary to another pyschological disorder (such as mood disorder, anxiety disorder) 

Although most children with ADHD have symptoms of both inattention and hyperactivity-impulsivity, some tend to demonstrate symptoms from one cluster or the other. These specific subtypes of ADHD are based on the predominant symptom pattern exhibited for the past 6 months:

  • ADHD, Combined Type: if both A1 and A2 criteria are met 
  • ADHD, Predominantly Inattentive Type: if A1 is met but A2 is not 
  • ADHD, Predominantly Hyperactive-Impulsive Type: if A2 is met but A1 is not 

 

Preventive Care

 

There are no targeted prevention programs for ADHD. Nevertheless, the following steps may be taken to help reduce the risk of neurobehavioral disorders including ADHD:

  • Minimizing exposures to potential neurotoxins (such as lead, heavy metals, pesticides, herbicides) in the environment 
  • Screening children for high levels of lead in the blood and treating this immediately 
  • Obtaining comprehensive healthcare during and immediately following pregnancy 
  • Addressing psychosocial stressors in the lives of all children

 

Treatment Approach

 

Despite the effectiveness of stimulant medications, multiple strategies are required to effectively manage ADHD over the long-term. A combination of prescription drugs and lifestyle changes, including behavioral therapies, is proving to be the best option for many children. Currently, the most accepted treatments include individual and family education, behavioral therapy, school remediation, and social skills training. Although nutritional management (such as elimination diets and high-dose vitamin supplementation) is among the most frequently explored alternative therapy among parents, relatively few studies support its effectiveness for ADHD. A growing number of studies suggest an association between essential fatty acid (EFA) deficiencies and hyperactivity in children, yet intervention studies using EFAs to treat behavioral problems have reported varying results. Preliminary evidence also indicates that homeopathy and mind/body techniques, particularly biofeedback, may significantly improve behavior among children with ADHD.


 

Lifestyle

 

There are two basic ways to manage hyperactive children: change the child's environment or change the child. The former can be accomplished by actively modifying a child's social and family interactions, a process that usually begins with parental training. The latter involves stimulant medication and other interventions discussed in the sections that follow. Notably, a recent study sponsored by the National Institute of Mental Health (NIMH) indicated that a comprehensive treatment regimen that combines medication with intensive behavioral interventions (such as parental training) is among the most effective treatments for elementary school children with ADHD.

Parental training offered by skilled clinicians provides parents with tools and techniques for managing their child's behavior. Behavior modification is accomplished by rewarding appropriate behavior and discouraging destructive behavior. Parents are taught to be as consistent as possible in their discipline and to deliver praise and punishment that is appropriate to their child's developmental level. For example, older children with ADHD may be rewarded with points or tokens, or even written behavioral contracts with their parents. Creating charts with stars for good behavior may be more effective for younger children. Positive reinforcement must also be counterbalanced by swift and consistent consequences for undesirable behavior. The following disciplinary strategies have been shown to effectively distinguish undesirable behavior:

  • Establish rules that are easily understood, developmentally appropriate, and not unduly harsh
  • Avoid repeated commands once the child has been reminded of the consequences
  • Discipline the child before becoming too angry and frustrated 
  • Follow disciplinary actions with praise when the child adheres to the rules and behaves appropriately

In addition to behavioral intervention at home, modifications in the classroom environment (and/or work, in the case of adolescents or adults) are significant aspects of the treatment plan. Hyperactive children do best in highly structured circumstances under the direction of a teacher experienced in handling their disruptive behavior and capable of adapting to their distinctive cognitive style. Since group interactions are often particularly challenging, social skills training, appropriate classroom placement, and explicit rules of engagement with peers are essential.

Adults with ADHD may benefit from a variety of behavioral interventions including cognitive remediation, couple therapy, and family therapy.


 

Medications

 

According to the NIMH, stimulant medications are the most widely researched and commonly prescribed treatments for ADHD. Although researchers do not fully understand how these medications improve ADHD symptoms, studies indicate that methylphenidate (the most commonly prescribed stimulant) significantly increases dopamine levels in the brain. People with ADHD are believed to have abnormally low levels of dopamine in the brain. Approximately 70% of people with ADHD benefit from the first stimulant prescribed (usually methylphenidate), and an additional 20% may respond to one of the other two drugs in this class if the first did not work. The NIMH reports that the two most effective treatments for children with ADHD are a closely monitored medication treatment and a treatment that combines medication with intensive behavioral interventions.

Stimulant medications prescribed for ADHD include:

  • Methylphenidate: most commonly used medication for ADHD; effective in 75% to 80% of patients; not recommended for children under 6 years of age 
  • Dextroamphetamine: effective in 70% to 75% of patients; not recommended for children under 3 years of age 
  • Pemoline: effective in 65% to 70% of children; not recommended for children under 6 years of age; should not be considered the first-choice medication for ADHD because its use has been associated with liver failure

The following medications are recommended for those who do not improve from stimulants:

  • Alpha2-agonists (such as clonidine, guanfacine): helpful in individuals who are particularly aggressive or oppositional; may cause low blood pressure in some individuals
  • Antidepressants: bupropion for children who also have mood disorders such as depression; tricyclics (such as imipramine) for individuals who also have tic disorders or significant symptoms of anxiety and depression 

 

Nutrition and Dietary Supplements

 

According to a recent survey, nutritional therapies are the most commonly used alternative treatment among American children with ADHD. Dietary management of ADHD takes two basic forms: restriction and supplementation.

Dietary Restrictions

Additives and allergies

In 1975, Benjamin Feingold, a practicing allergist, proposed that artificial colors, flavors, and preservatives, as well as naturally occurring salicylates (found in many fruits and vegetables), were a major cause of hyperactive behavior and learning disabilities in children. According to his observations, eliminating all of these substances dramatically improved ADHD symptoms in 50% of children, and reintroducing them one at a time caused the symptoms to recur. Feingold's hypothesis, however, was based solely on experience and speculation rather than scientific validation. A 1986 review of studies assessing the Feingold diet determined that only 1% of children consistently improved on the elimination diet and only 10% developed symptoms when challenged with artificial dyes specifically.

Although the original Feingold diet has shown no consistent benefit for ADHD children, a number of well-designed studies have found an association between certain dietary constituents and poor behavior in children.

One such study assessed the effects of food coloring on behavior in 34 hyperactive children and 20 children with no behavioral problems. All children were maintained on a color-free diet and were randomly given one colorless capsule containing either lactose (placebo) or tartrazine (yellow food coloring) at varying doses each morning for 21 days. Twenty-four of the 54 children became more irritable and restless after taking tartrazine, whereas all of the children behaved normally when given placebo. In a similar study of 26 children with ADHD, behavior improved on days when certain foods (corn, wheat, milk, soy, oranges, and food coloring) were eliminated from the diet. Behavior worsened on days when these same foods were re-introduced to the diet. Notably, most of the children who demonstrated an improvement in behavior with these restrictive diets in both of the studies described also had a history of allergies (such as asthma and allergic rhinitis). Eggs, peanuts, and fish are foods believed to carry a high risk of causing an allergic reaction. Some researchers speculate that eliminating these foods from the diet may improve symptoms of ADHD in certain children. Elimination diets, however, should only be used under the guidance and direction of a registered dietician because of the potential risk of malnourishment.

Sugar and Artificial Sweeteners

There are virtually no scientific studies supporting the widespread belief that sugar consumption causes or worsens ADHD behavior. In one study, children who consumed diets high in sugar or high in artificial sweeteners behaved no differently than children who consumed diets free of these substances. This was true even among children whose parents described them as having a sensitivity to sugar. A review of 12 studies also failed to find any evidence that ingestion of sugar (including candy and chocolate) worsens behavior among children with ADHD.

Dietary supplements

A well-balanced diet rich in micronutrients is essential for normal brain development, particular in young children. In fact, many children with nutrient deficiencies have significant cognitive and behavioral problems. These conditions, however, are extremely rare in children living in industrialized countries like the United States. Nevertheless, children with ADHD tend to have irregular eating habits and are therefore at slightly increased risk for becoming mildly deficient in certain nutrients.

Megavitamin therapy

Using high-dose vitamin treatment (up to 10 times the recommended daily allowance) has been advocated as a treatment for many chronic conditions, including ADHD. However, there is no consistent evidence that megavitamin therapy is of benefit in hyperactive children, and, in some cases such therapy may actually have toxic effects.

Magnesium

Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion. Mild magnesium deficiency is not uncommon in normally nourished children, and some experts believe that children with ADHD may be exhibiting the effects of mild magnesium deficiency. In one study of 116 children with ADHD, 95% were magnesium deficient. In a separate study, 75 magnesium-deficient children with ADHD were randomly assigned to receive magnesium supplements in addition to standard treatment or standard treatment alone for 6 months. Those who received magnesium demonstrated a significant improvement in behavior, whereas the control group exhibited worsening behavior.

Vitamin B6

Adequate levels of vitamin B6 (pyridoxine) are required for normal brain development and are essential for the synthesis of essential brain chemicals including serotonin, dopamine and norepinephrine. A preliminary study found that pyridoxine was slightly more effective than methylphenidate (the most commonly used stimulant) in improving behavior among hyperactive children. The results, however, were not significant and no other studies have been able to confirm these findings. Therefore, supplementation with vitamin B6 is not considered a standard treatment for ADHD.

Iron

Iron deficiency is common among children and adolescents, particularly in lower socioeconomic groups where it affects half of all infants. Normal levels of iron in the blood are necessary for optimal brain function. Symptoms of iron deficiency include decreased attention, arousal, and social responsiveness. There is little scientific evidence, however, that iron supplementation in those who are deficient improves behavior in children with ADHD. Since iron can be toxic in children who are not deficient, there is little justification for its supplementation as treatment for ADHD in those with normal levels of this mineral. If iron levels are low, a healthcare provider can determine whether replacement is needed.

Zinc

Zinc regulates the activity of neurotransmitters, fatty acids, and melatonin, all of which are related to the biology of behavior. Two separate studies found that children with ADHD have significantly lower blood zinc levels than children without ADHD. Another study indicated that ADHD children with mild zinc deficiency may be less likely to improve from a commonly prescribed stimulant than children with adequate zinc levels. To date, however, no studies have been conducted to evaluate whether zinc supplementation improves behavior in children with ADHD who are deficient in this mineral.

Melatonin

Although melatonin supplementation probably has no direct effect on the primary symptoms of ADHD, it may be effective in managing sleep cycle disturbances in children with a variety of developmental disorders, including ADHD.

Essential Fatty Acids

Fatty acids play a key role in normal brain function. Since the body cannot synthesize essential fatty acids (EFA), they must be provided in the diet. There are two major types of EFAs: omega-3 fatty acids (found in cold-water fish such as salmon, mackerel, halibut, and herring) and omega-6 fatty acids (found in commonly used cooking oils, such as sunflower oil, safflower oil, corn oil, and soybean oil). Omega-3 fatty acids are highly concentrated in the brain and appear to play a particularly important role in cognitive and behavioral function. Specific enzymes convert EFAs (such as alpha linolenic acid [ALA]) into other substances known as long-chain polyunsaturated fatty acids (PUFAs). PUFAs, including eicosapentaenoic acid (EPA) and docosahexanoic (DHA), are also essential for normal brain function. Some researchers believe that individuals with ADHD may have difficulty converting EFAs to PUFAs and may be deficient in both of these substances. In a recent study, researchers reported the following findings in hyperactive boys compared to boys of the same age who were not hyperactive:

  • Lower blood levels of PUFAs and omega-3 fatty acids 
  • More allergies and other health problems associated with EFA deficiencies 
  • Less likelihood of having been breastfed (breast milk contains PUFAs) 

Another study found that boys with lower levels of omega-3 fatty acids had more learning and behavioral problems (such as temper tantrums and sleep disturbances) than boys with normal omega-3 fatty acid levels. Despite the accumulation of evidence suggesting a link between PUFA deficiency and ADHD, however, further studies are necessary before EFA supplementation can be recommended for children with ADHD.


 

Herbs

 

Several herbal remedies for ADHD are sold in the United States and Europe but few scientific studies have investigated whether these herbs improve symptoms of ADHD. Herbs, like other medications, may have side effects or interact with other medications. They should therefore be used with caution and under the guidance of a professionally trained and qualified herbalist. One or more of the following calming herbs may be recommended for people with ADHD:

  • Roman chamomile (Chamaemelum nobile)
  • Kava kava (Piper methysticum)
  • Valerian (Valerian officinalis)
  • Lemon balm (Melissa officinalis)
  • Passionflower (Passiflora incarnata)

Other herbs commonly contained in botanical remedies for ADHD include:

  • Pycnogenol: a bioflavonoid antioxidant extracted from pine bark (Pinus)
  • Gingko (Gingko biloba): this herb has been used clinically in Europe for circulatory and memory disorders.
  • American ginseng (Panax quinquefolium) and gingko: One recent study suggests that gingko in combination with ginseng may improve symptoms of ADHD.

 

Massage and Physical Therapy

 

Relaxation and massage techniques have been shown to reduce anxiety and activity levels in children and adolescents with a variety of psychiatric illnesses. In one study of 28 teenage boys with ADHD, those who received 15 minutes of massage for 10 consecutive school days demonstrated significant improvement in measures of behavior and concentration compared to those who were guided in progressive muscle relaxation for the same duration of time.


 

Homeopathy

 

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

  • Stramonium 
  • Cina 
  • Hyoscyamus niger 

 

Mind/Body Medicine

 

Mind/body techniques such as hypnotherapy, progressive relaxation, and biofeedback are particularly well suited to children and adolescents. Children tend to readily accept hypnotic suggestion and the visual process of biofeedback works well for children of this generation because many are accustomed to computerized graphics. Through these techniques, children are often able to learn coping skills that will stay with them for the rest of their lives. These treatments allow children to gain a sense of control and mastery, increase self-esteem, and decrease stress.

Many researchers believe that hyperactive behavior in children results from excessive slow-wave (or theta) activity in certain regions of the brain. In EEG biofeedback, or neurofeedback, an individual is provided with information regarding his or her brain activity. The subject is then trained to suppress slow wave activities while enhancing faster brain waves, over a period of usually 40 or more sessions. The belief is that these children can be trained to consciously modify and permanently change this underlying abnormal electrical brain activity associated with ADHD.

In one study of 23 hyperactive children and teenagers, those who successfully decreased their theta activity after 2 to 3 months of intensive neurofeedback training showed significant improvements in behavior and attention. In a similar study of 18 children and adolescents with ADHD, those who attended 40 neurofeedback sessions over a 6-month period demonstrated a significant improvement in IQ scores and a substantial reduction in inattentive behavior compared to those who did not attend the neurofeedback sessions.

A larger, more recent study found that a combination of 40 behavioral treatments (neurofeedback and metacognitive strategies, a technique designed to help individuals consciously monitor how they learn and remember things), significantly improved ADHD symptoms, academic performance, and IQ scores among children and adults with ADHD. The combined treatment also dramatically reduced the need for medications; 30% of the participants were taking stimulant medication at the beginning of the study compared to only 6% at the end of the study. To be most effective for ADHD, however, these mind/body techniques should be incorporated into an overall comprehensive treatment plan that is tailored to the particular individual.


 

Traditional Chinese Medicine

 

Qi Gong

Although no published studies have evaluated qi gong as a treatment for ADHD, preliminary evidence from unpublished research suggests that weekly qi gong breathing techniques may improve attention and reduce disruptive behaviors in school-age children.


 

Other Considerations

 

 

Pregnancy

 

To prevent ADHD in their unborn children, pregnant women should obtain high quality prenatal medical care, abstain from cigarette, alcohol, and drug use, and should avoid exposure to toxic substances, including lead.


 

Prognosis and Complications

 

As many as half of all children with ADHD who receive appropriate treatment learn to control symptoms and function well in adulthood, while the remaining continue to exhibit symptoms of inattention and impulsivity throughout life. As many as 50% to 80% of those who do not seek treatment for ADHD may demonstrate delinquent and antisocial behavior into adulthood. Research suggests that children who receive sustained comprehensive treatment (such as medication, behavioral therapy, and biofeedback) are less likely to have behavioral problems in adolescence. In most cases, ADHD can be effectively managed throughout life, particularly when multiple treatment strategies are combined.


 

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Review Date: December 2001

Richard Glickman-Simon, MD, Department of Family Medicine, New England Medical Center, Tufts University, Boston, MA; Jacqueline A. Hart, MD, Department of Internal Medicine, Newton-Wellesley Hospital, Harvard University and Senior Medical Editor Integrative Medicine, Boston, MA; James Lake, MD, Psychiatry, Community Hospital of the Monterey Peninsula, Pacific Grove, CA.

Copyright © 2004 A.D.A.M., Inc

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