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Institute of Mental Health
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
- Does not follow through on instructions
and fails to finish schoolwork, chores, or duties in the
- Has difficulty organizing tasks and
- Avoids, dislikes, or is reluctant to
engage in tasks that require sustained mental effort
- Loses things necessary for tasks or
- Is easily distracted by extraneous
- Is forgetful in daily activities
Symptoms of Hyperactivity
- Fidgets with hands or feet or squirms in
- 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
- Has difficulty awaiting turn
- Interrupts or intrudes on others
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
- 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)
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
- Some inattentive or hyperactive-impulsive
symptoms that caused impairment were present before the age of 7
- Some impairment from symptoms present in
two or more settings (such as at school/work and home)
- Clear evidence of significant impairment
- 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
There are no targeted
prevention programs for ADHD. Nevertheless, the following steps may be
taken to help reduce the risk of neurobehavioral disorders including
- Minimizing exposures to potential
neurotoxins (such as lead, heavy metals, pesticides, herbicides) in the
- 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
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.
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
- 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.
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.
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
- 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
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.
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
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.
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
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.
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.
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
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
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.
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
- 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.
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
- Roman chamomile (Chamaemelum
- 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.
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
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
- Hyoscyamus niger
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
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
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
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.
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.
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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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.
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