Attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by inattention, hyperactivity, and impulsivity. It is the most commonly diagnosed behavioral disorder of childhood. Although many people sometimes have difficulty sitting still, paying attention, or controlling impulsive behavior, people with ADHD find that these symptoms greatly interfere with everyday life. Generally, symptoms appear before age 7 and lead to problems in school and in social settings. One- to two-thirds of all children with ADHD continue to have symptoms when they grow up. A diagnosis can be controversial, since there are no lab tests for ADHD, and no objective 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 social development.
Signs and Symptoms
A person is diagnosed with ADHD if they have at least 6 symptoms from the following categories, lasting for at least 2 months. In diagnosing children, the symptoms must appear before age 7, and pose a significant challenge to everyday functioning in at least two areas of life (usually home and school). Most children do not show all the symptoms, and they may be different in boys and girls (boys may be more hyperactive and girls more inattentive).
- 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 be 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 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.
- Altered brain function. Brain scans show differences in the brains of children with ADHD compared to those of non-ADHD children. For example, many children with ADHD tend to have altered brain activity in the prefrontal cortex, a part of the brain known as the command center. This may affect their ability to control impulsive and hyperactive behaviors. Researchers also believe hyperactive behavior in children can 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 are exposed 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 the disorder.
- Pre-term birth. Up to 20% of babies who are born prematurely develop ADHD.
Risk factors for ADHD include:
- Heredity. Children with ADHD usually have at least one first-degree relative who also has the disorder.
- Gender. ADHD is 4 to 9 times more common in boys than in girls. Some experts believe that the disorder is underdiagnosed in girls, however, and recent studies show no 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.
- Nutritional deficiencies and imbalances.
- Pre-term birth and low birth weight.
- Low Apgar scores at birth.
- Other behavioral disorders, especially those that involve too much aggression (such as oppositional defiant or conduct disorder).
What to Expect at Your Doctor's Office
There is no objective test for ADHD, so making a diagnosis can be difficult. Doctors may use a number of tests and observations. For this reason, it is crucial to make sure the doctor who 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 exam to check for conditions that may mimic ADHD, such as hyperthyroidism or problems with vision, hearing, and sleeping. Many symptoms show up at home or school rather than the doctor's office, so you may be asked to fill out questionnaires. Your child's teacher may be interviewed. Your doctor will try to determine not only how the child behaves but also where the behavior occurs and how long it lasts. Children with ADHD have long-lasting symptoms that usually show up during stressful situations or situations that require sustained attention (such as school work).
Diagnosing an adult with ADHD can be even more challenging. Because your symptoms would have appeared when you were young, your doctor may try to find out as much as possible about you when you were a child by getting information from your parents or former teachers. (If your symptoms are recent, you are not considered to have adult ADHD.) In addition to ruling out the other conditions mentioned above, your doctor may also check for depression and bipolar disorder, which can mimic ADHD.
Since the cause or causes of ADHD are not known, there is no way to prevent the condition. However, pregnant women can avoid known risk factors, including cigarette smoke and other known toxins. You can manage the condition with medication, behavioral therapy, and lifestyle changes.
How to treat ADHD, particularly in children, is a controversial subject. Current treatment includes therapy or medication, or a combination of both. Studies show that medication by itself, without some kind of therapy, is not likely to improve a child's outcome long term. Family therapy, behavioral therapy, social skills training, and parent skills training are often used. Many parents investigate nutritional therapies (such as elimination diets or high-dose vitamins), however, there is no clear evidence to support these these approaches. Preliminary evidence indicates that homeopathy and mind/body techniques, especially biofeedback, may help improve behavior in children with ADHD.
Parent skills training offered by specialized clinicians provides parents with tools and techniques for managing their child's behavior. Behavior therapy rewards appropriate behavior and discourages destructive behavior. It can be performed by parents and teachers working together with therapists and doctors. 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 work for younger children. On the other hand, time-outs may discourage undesirable behavior. Other techniques include:
- Setting rules that are easily understood, developmentally appropriate, and not unduly harsh
- Avoiding repeated commands once the child has been reminded of the consequences
- Disciplining the child before becoming too angry and frustrated
- Following discipline with praise when the child follows the rules and behaves appropriately
In addition to behavioral intervention at home, changes in the classroom environment (or work, 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 experienced in handling their disruptive behavior and capable of adapting to their distinctive cognitive style. Group interaction can be very challenging for a child with ADHD. Social skills training, appropriate classroom placement, and clear rules of engagement with peers are essential. Preliminary evidence suggests that computer-based attention training in schools is highly effective for students who have ADHD.
Adults with ADHD may benefit from behavioral therapies, including cognitive remediation, couples therapy, and family therapy.
Stimulant medications are the most widely-researched and commonly-prescribed treatments for ADHD. Although researchers do not fully understand how these drugs improve ADHD symptoms, 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 chemical associated with mood and well being. Medications prescribed for ADHD include:
- Methylphenidate (Ritalin, Concerta). A stimulant and most commonly used medication for ADHD; effective in 75 to 80% of people with the condition; not recommended for children under 6 years of age
- Dextroamphetamine (Dexadrine). A stimulant that is effective in 70 to 75% of people 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 suicidal thoughts in young children and teenagers.
Antihypertensives (clonidine, guanfacone): These medications are not approved by the Food and Drug Administration (FDA) for the treatment of ADHD, however, they have been used off label for years. Antihypertensives are not as effective as stimulants, however, they are commonly used with stimulants to treat stimulant-induced tics and insomnia.
The most common side effects from these medications are trouble sleeping, decrease in appetite, and nervousness.
Complementary and Alternative Therapies
According to a recent survey, many parents use complementary and alternative treatments (CAM) for their children with ADHD. Nutritional therapies are the most common strategy. Studies show conflicting results, however, if your child appears sensitive to certain foods, talk to your doctor about eliminating them for a brief period to see if symptoms improve. DO NOT put a child on any supplement or CAM diet without the supervision of your doctor.
Developed in the 1970's by Benjamin Feingold, the Feingold diet is based on the idea that artificial colors, flavors, and preservatives, as well as naturally-occurring salicylates (chemicals similar to aspirin that are found in many fruits and vegetables), are a major cause of hyperactive behavior and learning disabilities in children. Studies examining the diet's effects have been mixed. Most show no benefit, although there is some evidence that salicylates may play a role in hyperactivity in a small number of children. Because the Feingold diet is difficult to follow, and also involves changes in family lifestyle (children are encouraged to participate in creating meals, for example), you should talk with your doctor before trying it.
Other dietary therapies may concentrate on eating foods that are high in protein and complex carbohydrates, and eliminating sugar and artificial sweeteners. One study found increased hyperactivity among children after eating foods with artificial food coloring and additives. However, studies show no relation between sugar and ADHD. In one study, children whose diets were high in sugar or artificial sweeteners behaved no differently than children whose diets were free of these substances. This was true even among children whose parents described them as being "sugar sensitive". However, some researchers believe that chronic excessive sugar intake leads to alterations in brain signaling, which would contribute to the symptoms associated with ADHD.
Some doctors who focus on nutrition say they see positive results when testing for food allergies and using an elimination diet. If you think your child might benefit from food allergy testing or an elimination diet, talk to a doctor who has experience in nutrition for children with ADHD.
Vitamins and Minerals
- Magnesium. Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion. Some experts believe that children with ADHD may have a mild magnesium deficiency. In one preliminary study of 75 magnesium-deficient children with ADHD, those who received magnesium supplements showed an improvement in behavior compared to those who did not receive the supplements. Too much magnesium can be dangerous and magnesium can interfere with certain medications, including antibiotics and blood pressure medications. Talk to your doctor.
- Vitamin B6. The body needs sufficient vitamin B6 to make the brain chemicals affected in children with ADHD, including serotonin, dopamine, and norepinephrine. One preliminary study found that B6 pyridoxine was slightly 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 show that B6 has no effect on behavior. Because high doses can be dangerous, do not give your child B6, or take high doses yourself, without your doctor's supervision.
- Zinc. Zinc regulates the activity of brain chemicals, fatty acids, and melatonin, all of which are related to behavior. Several studies show that zinc may help improve behavior. Higher doses of zinc can be dangerous, so talk to your doctor 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-3 fatty acids) and evening primrose oil (omega-6 fatty acids), are "good fats" that play a key role in normal brain function. Study results are mixed. Omega-3 fatty acids are also good for heart health in adults, but high doses may increase the risk of bleeding. Talk to your doctor about the best dose.
- L-carnitine. L-carnitine is formed from an amino acid and helps cells in the body produce energy. One study found that 54% of a group of boys with ADHD showed improvement in behavior when taking L-carnitine. More research is needed. 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 of hypothyroid worse, and may increase the risk of seizures in people who have had seizures before. It can also interact with some medications. Talk to your doctor.
Herbs may help strengthen and tone the body's systems. As with any therapy, you should work with your health care provider before starting treatment. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups 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 few scientific studies have investigated whether these herbs improve symptoms of ADHD. One or more of the following calming herbs may be recommended for people with ADHD:
- Roman chamomile (Chamaemelum nobile). Chamomile may cause an allergic reaction in people sensitive to Ragweed. Chamomile may have estrogen-like effects in the body and therefore should be used with caution in people with hormone-related conditions, such as breast, uterine, or ovarian cancers, or endometriosis. Chamomile can 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 sedative medications.
Other herbs commonly contained in botanical remedies for ADHD include:
- Gingko (Gingko biloba). Used to improve memory and mental sharpness. Use gingko with caution if you have 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 that gingko in combination with ginseng may improve symptoms of ADHD. Use American ginseng with caution if you have a history of diabetes, hormone-sensitive conditions, insomnia, or schizophrenia. It can interact with several medications, including but not limited to, blood-thinning medications.
Relaxation techniques and massage can reduce anxiety and activity levels in children and teens. In one study, teenage boys with ADHD who received a 15-minute massage for 10 consecutive school days showed significant improvement in behavior and concentration compared to those who were guided in progressive muscle relaxation for the same duration of time.
Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all 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 homeopathic remedy showed significant improvement in behavior compared to children who received placebo. The homeopathic remedies found to be most effective included:
- Stramonium. For children who are fearful, especially at night.
- Cina. For children who are irritable and dislike being touched; whose behavior is physical and aggressive.
- Hyoscyamus niger. For children who have poor impulse control, talk excessively, or act overly exuberant.
Mind/body techniques such as hypnotherapy, progressive relaxation, and biofeedback may be useful in treating children and teens. Through these techniques, children are often able to learn coping skills they can use for the rest of their lives. These treatments allow children to gain a sense of control and mastery, increase self esteem, and reduce stress.
Biofeedback operates on the principle that children can be trained to modify brain activity associated with ADHD and increase brain activity associated with attention. Several studies have shown positive results.
Preliminary studies suggest participating in yoga may help reduce symptoms of ADHD.
Prognosis and Complications
As many as half of all children with ADHD who receive appropriate treatment learn to control symptoms and function well as adults. Research suggests that children who receive treatment that combines therapies such as medication, behavioral therapy, and biofeedback are less likely to have behavioral problems as they grow up. Nevertheless, studies show that ADHD persists into adulthood in 60 to 70% of people diagnosed with ADHD in childhood. In most cases, ADHD can be effectively managed throughout life.
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