attention deficit hyperactivity disorder

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More about Attention-Deficit/Hyperactivity Disorder (ADHD): Causes and symptoms Diagnosis Treatment Alternative treatment Prognosis Resources

Definition

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities.

Description

ADHD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3-9% of children, and afflicts boys more often than girls. Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age two or three, but the symptom picture changes as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood, but impulsivity and inattention problems remain with up to 50% of ADHD individuals throughout their adult life.

Children with ADHD have short attention spans, becoming easily bored and/or frustrated with tasks. Although they may be quite intelligent, their lack of focus frequently results in poor grades and difficulties in school. ADHD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting, but often have trouble with gross and fine motor skills and, as a result, may be physically clumsy and awkward. Their clumsiness may extend to the social arena, where they are sometimes shunned due to their impulsive and intrusive behavior.

— Paula Anne Ford-Martin

For more information on attention deficit (hyperactivity) disorder (ADD or ADHD), visit Britannica.com.

Definition

Attention deficit hyperactivity disorder (ADHD) is not a clinically definable illness or disease. Rather, as of December 2003, ADHD is a diagnosis that is made for children and adults who display certain behaviors over an extended period of time. The most common of these behavioral criteria are inattention, hyperactivity, and marked impulsiveness.

In the American description, there are three types of ADHD, depending on which diagnostic criteria have been met. These are: ADHD that is characterized by inattention, ADHD characterized by impulsive behavior, and ADHD that has both behaviors.

The European description of ADHD places the disorder in a subgroup of what are termed hyperkinetic disorders (hallmarks are inattention and over-activity).

Description

ADHD is also known as attention deficit disorder (ADD), attention deficit disorder with and without hyperactivity, hyperkinesis, hyperkinetic impulse disorder, hyperactive syndrome, hyperkinetic reaction of childhood, minimal brain damage, minimal brain dysfunction, and undifferentiated deficit disorder.

The term attention deficit is inexact, as the disorder is not thought to involve a lack of attention. Rather, there appears to be difficulty in regulating attention, so that attention is simultaneously given to many stimuli. The result is an unfocused reaction to the world. As well, people with ADHD can have difficulty in disregarding stimuli that are not relevant to the present task. They can also pay so much attention to one stimulus that they cannot absorb another stimulus that is more relevant at that particular time.

For many people with ADHD, life is a never-ending shift from one activity to another. Focus cannot be kept on any one topic long enough for a detailed assessment. The constant processing of information can also be distracting, making it difficult for an ADHD individual to direct his or her attention to someone who is talking to him or her. Personally, this struggle for focus can cause great chaos that can be disruptive and diminish self-esteem.

The neurological manifestations of ADHD are disturbances of what are known as executive functions. Specifically, the six executive functions that are affected include:

• the ability to organize thinking
• the ability to shift thought patterns
• short-term memory
• the ability to distinguish between emotional and logical responses
• the ability to make a reasoned decision
• the ability to set a goal and plan how to approach that goal

About half or more of those people with ADHD meet criteria set out by the American Psychiatric Association (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) for at least one of the following other illnesses:

• learning disorder
• restless leg syndrome
• depression
• anxiety disorder
• antisocial behavior
• substance abuse
• obsessive-compulsive behavior

Demographics

ADHD is a common childhood disorder. It is estimated to affect 3–7% of all children in the United States, representing up to two million children. The percentage may in fact be even higher, with up to 15% of boys in grades one through five being afflicted. On average, at least one child in each public and private classroom in the United States has ADHD. In countries such as Canada, New Zealand, and Germany, the prevalence rates are estimated to be 5–10% of the population.

The traditional view of ADHD is that boys are affected more often than girls. Community-based samples have found an incidence rate in boys that is double that of girls. In fact, statistics gathered from patient populations have reported male-to-female ratios of up to 4:1. However, as the understanding of ADHD has grown since the early 1990s and as the symptoms have been better recognized, the actual number of females who are affected by ADHD may be more similar to males than previously thought.

Causes and symptoms

The cause of ADHD is unknown. However, evidence is consistent with a biological cause rather than an environmental cause (e.g., home life). Not all children from dysfunctional homes or families have ADHD.

For many years, it was thought that ADHD developed following a physical blow to the head, or from an early childhood infection, leading to the terms "minimum brain damage" and "minimum brain dysfunction." However, these definitions apply to only a very small number of people diagnosed with ADHD, and so have been rejected as the main cause.

Another once-favored theory was that eating refined sugar or chemical additives in food produced hyperactivity and inattention. While sugar can produce changes in behavior, evidence does not support this proposed association. Indeed, in 1982, the results presented at a conference sponsored by the U.S. National Institutes of Health conclusively demonstrated that a sugar- and additive-restricted diet only benefits about 5% of children with ADHD, mostly young children and those with food allergies.

The biological roots of ADHD may involve certain areas of the brain, specifically the frontal cortex and nearby regions. One explanation is that the executive functions are controlled by the frontal lobes of the brain. Magnetic resonance imaging (MRI) examination of subjects who are exposed to a sensory cue has identified decreased activity of regions of the brain that are involved in tasks that require attention. Another MRI-based study published in November 2003 also implicates a region of the brain that controls impulsive behavior. Finally, a study conducted by the U.S. National Institute of Mental Health (NIMH) documented that the brains of children and adolescents with ADHD are 3–4% smaller than those of their ADHD-free counterparts. Additionally, the decreased brain size is not due to the use of drugs in ADHD treatment, the researchers concluded in a paper published in October 2002.

ADHD symptoms can sometimes be relieved by the use of stimulants that increase a chemical called dopamine. This chemical functions in the transmission of impulses from one neuron to another. Too little dopamine can produce decreased motivation and alertness. These observations led to the popular "dopamine hypothesis" for ADHD, which proposed that ADHD results from the inadequate supply of dopamine in the central nervous system.

The observations that ADHD runs in families (10–35% of children with ADHD have a direct relative with the disorder) point to an underlying genetic origin. Studies with twins have shown that the occurrence of ADHD in one twin is more likely to be mirrored in an identical twin (who has the same genetic make-up) than in a fraternal twin (whose genetic make-up is similar but not identical).

The genetic studies have implicated the binding, transport, and enzymatic conversion of dopamine. Two genes in particular have been implicated: a dopamine receptor (DRD) gene on chromosome 11 and the dopamine transporter gene (DAT1) on chromosome 5.

There may be environmental factors that influence the development of ADHD. Complications during pregnancy and birth, excessive use of marijuana, cocaine, and/or alcohol (especially by pregnant women), ingestion of lead-based paint, family or marital tension, and poverty have been associated with ADHD in some people. However, many other ADHD sufferers do not display any of these associations.

Heavy use of alcohol by a pregnant woman can lead to malformation of developing nerve cells in the fetus, which can result in a baby of lower than normal birth weight with impaired intelligence. This condition, called fetal alcohol syndrome, can also be evident as ADHD-like hyperactivity, inattention, and impulsive behavior.

Diagnosis

ADHD is sometimes difficult to diagnose. Unlike the flu or a limb fracture, ADHD lacks symptoms that can be detected in a physical examination or via a chemical test. Rather, the diagnosis of ADHD relies on the presence of a number of characteristic behaviors over an extended period of time. Often the specialist will observe the child during high-stimuli periods such as a birthday party and during quieter periods of focused concentration. Diagnosis uses the DSM-IV criteria, originally published in 1994, in combination with an interview and assessment of daily activity by a qualified clinician. (As of December 2003, revised DSM criteria are pending. These revisions will reflect the increased awareness of the greater-than-perceived prevalence of ADHD in girls and women.)

The benchmarks for either inattention or for hyperactivity/impulsive behavior must be met. These benchmarks typically occur by the age of seven and are not exclusive to one particular social setting such as school. These benchmarks must have been present for an extended period of time, at least six months or more. There are nine separate criteria for each category. For diagnosis, six of the nine criteria must be met. Examples of diagnostic signs of inattention include difficulty in maintaining concentration on a task, failure to follow instructions, difficulty in organizing approaches to tasks, repeated misplacement of tools necessary for tasks, and tendency to become easily distracted. Examples of hyperactivity or impulsive behavior include fidgeting with hands or feet, restlessness, difficulty in being able to play quietly, excessive talk, and tendency to verbally or physically interrupt.

Because ADHD can be associated with the use of certain medications or supplements, diagnosis involves screening for the past or present use of medications such as anticonvulsant or antihypertensive agents, and caffeinecontaining drugs.

Diagnosis of ADHD can also be complicated by the simultaneous presence of another illness. Diagnosis involves screening for bipolar disorder, depression, eating disorder, learning disability, panic disorder (including agoraphobia), sleep disorder, substance abuse, or Tourette's syndrome. Almost half of all children (mostly boys) with ADHD display what has been termed "oppositional defiant behavior." These children tend to be stubborn, temperamental, belligerent, and can lash out at others over a minor provocation. Without intervention, such children could progress to more serious difficulties such as destruction of property, theft, arson, and unsafe driving.

Other, nonclinical information such as legal infractions (arrests, tickets, vehicle accidents), school reports, and interviews with family members can be valuable, as ADHD can be perceived as antisocial, erratic, or uncommon behavior.

A complete physical examination is recommended as part of the diagnosis. The examination offers the clinician an opportunity to observe the behavior of the person. More specific tests can also be performed. Children can be assessed using the Conner's Parent and Teacher Rating Scale. Adolescent and adult assessment can utilize the Brown Attention Deficit Disorder Scale. Impulsive and inattentive behavior can be assessed using the Conner's Continuous Performance Test (CPT) or the Integrated Visual and Auditory CPT. Girls can be specifically assessed using the Nadeau/Quinn/Littman ADHD Self-Rating Scale.

Treatment team

The treatment team involves behavioral and medical specialists. Concerning behavior, teachers play a very important role. Their daily observation of the child and the use of standard evaluation tests can help in the diagnosis and treatment of ADHD. More specialized consultants within the school system, such as psychometrists, may also be available. Outside of the school setting, psychologists, social workers, and family therapists can also be involved in treatment.

The use of medications involves physicians, nurses, and pharmacists.

Treatment

Behavior treatment can consist of the monitoring of school performance and the use of standard evaluation tests. For older children, adolescents, and adults, support groups can be valuable. As well, ADHD patients can learn behavioral techniques that are useful in self-monitoring their behavior and making the appropriate modifications (such as a time out). Behavior treatment is useful in combination with drug therapy or as a stand-alone treatment in those cases in which the use of medication is not tolerated or is not preferred.

Medical treatment can consist of the use of drugs such as Ritalin that are intended to modify over-exuberant behavior, or other drugs that have differing targets of activity. Psychostimulant medications like Ritalin, Cylert, and Dexedrine increase brain activity by increasing the brain concentration of chemicals such as dopamine, which are involved in the transmission of impulses or by stimulating the receptors to which the chemicals bind. Psychostimulant medications can sometimes disrupt sleep, depress appetite, cause stomachaches and headaches, and trigger feelings of anger and anxiousness, particularly in people afflicted with psychiatric illnesses such as bipolar disorder or depression. For many people, the side effects are mild and can become even milder with long-term use of the drugs.

Antidepressant medications such as imipramine act by slowing down the absorption of chemicals that function in the transmission of impulses. Central alpha agonists are particularly used in the treatment of hyperactivity. By restricting the presence of neurotransmitter chemicals in the gap between neurons, drugs such as clonidine and guanfacine restrict the flow of information from one neuron to the next. There have been four reported cases of sudden death in people taking clonidine in combination with the drug methylphenidate (Ritalin), and reports of nonfatal heart disturbances in people taking clonidine alone.

Finally, medications known as selective norepinephrine reuptake inhibitors restrict the production of norepinephrine between neurons, which inhibits the sudden and often hyperactive "fight or flight" response.

Recovery and rehabilitation

After a patient has been stabilized, typically using medication, follow-up visits to the physician are recommended every few months for the first year. Then, follow-ups every three or four months may be sufficient. The use of medications may continue for months or years.

Recovery and rehabilitation are not terms that apply to ADHD. Rather, a child with ADHD can be assisted to an optimum functionality. Assistance can take the form of special education in the case of those who prove too hyperactive to function in a normal classroom; the child may be seated in a quieter area of the class; or by using a system of rules and rewards for appropriate behavior. Children and adults can also learn strategies to maximize concentration (such as list making) and strategies to monitor and control their behavior.

Clinical trials

Beginning in 1996, the U.S. National Institute of Mental Health (NIMH) and the Department of Education began a clinical trial that included nearly 600 elementary school children ages seven to nine. The study, which compared the effects of medication alone, behavior management alone, or a combination of the two, found the combination to produce the most marked improvement in concentration and attention. Additionally, the involvement of teachers and other school personnel was more beneficial than if the child was examined only a few times a year by their family physician.

As of January 2004, a number of clinical studies were recruiting patients, including:

• Behavioral and functional neuroimaging study of inhibitory motor control. The basis of the inability to control behavior in ADHD was assessed using behavioral tests and the technique of magnetic resonance imaging (MRI).
• Brain imaging in children with ADHD. MRI was used to compare the connections between brain regions in children with and without ADHD.
• Brain imaging of childhood onset psychiatric disorders, endocrine disorders, and healthy children. MRI was used to investigate the structure and activity in the brains of healthy people and those with childhood onset psychiatric disorders, including ADHD.
• Genetic analysis of ADHD. Blood samples from a child with ADHD and his or her immediate family members were collected and analyzed to determine the genetic differences between ADHD and non-ADHD family members.
• Biological markers in ADHD. People with ADHD, their family members, and a control group of healthy people who had previously undergone magnetic resonance examination were assessed using psychiatric interviews, neuropsychological tests, and genetic analysis.
• Study of ADHD using transcranial magnetic stimulation. The technique, in which a magnetic signal is used to stimulate a region of the brain that controls several muscles, was used to investigate whether ADHD patients have a delayed maturation of areas of their nervous system responsible for such activity. Detectable differences could be useful in diagnosing ADHD.
• Clonidine in ADHD Children. The trial evaluated the benefits and side effects of two drugs (clonidine and methylphenidate) used individually or together to treat childhood ADHD.
• Nutrient intake in children with ADHD. The study determined if children with ADHD have a different eating pattern, such as intake of less food or a craving for carbohydrates, than children without ADHD. The information from the study would be used in probing the origins of ADHD and in devising treatment strategies.
• Preventing behavior problems in children with ADHD. The study was designed to gauge the effectiveness of a number of treatment combinations in preventing behavior that is characteristic of ADHD in children.
• Psychosocial treatment for ADHD Type I. The study focused on ADHD that is characterized by inattention. The aim of the study was to develop effective treatment strategies for Type I ADHD.
• Treatment of adolescents with comorbid alcohol use and ADHD. The effectiveness of a drug (bupropion) that is designed to be released at a constant rate over time was evaluated in the treatment of ADHD adolescents (14–18 years) who are also alcohol abusers.
• Behavioral treatment, drug treatment, and combined treatment for ADHD. The effectiveness of the three treatment approaches was compared, and the interactions between different levels of the behavioral and drug treatments were examined.
• Attention deficit disorder and exposure to lead. The effect of past exposure to lead was studied in children with ADHD.

Prognosis

The outlook for a patient with ADHD can be excellent, if the treatment regimen is followed and other existing conditions and disabilities have been identified and are treated. Methylphenidate, the major psychostimulant used in the treatment of ADHD, has been prescribed since the 1960s. The experience gained over this time has established the drug as being one of the safest pharmaceuticals for children. Indeed, intervention can be beneficial. Researchers from the Massachusetts General Hospital reported in 1999 that drug treatment of children diagnosed with ADHD could dramatically reduce the future risk of substance abuse.

Special concerns

The diagnosis of ADHD continues to be controversial. While some children do benefit from the use of medicines, other children who behave differently than is the norm may be needlessly medicated. The inattention, hyperactivity, and impulsive behavior that are the hallmarks of ADHD can be produced by many other conditions. The death of a parent, the discomfort of a chronic ear infection, and living in a dysfunctional household are all situations that can cause a child to become hyperactive, uncooperative, and distracted.

Evidence since the 1960s has led to the consensus that the medications used to treat ADHD, particularly methylphenidate (Ritalin), pose no long-term hazards. However, research published in December 2003 documented that rats exposed to the drug tended to avoid rewarding stimuli and instead became more anxious. More research on the effects of long-term drug treatment in ADHD is scheduled.

Resources

BOOKS

National Institutes of Health. Attention Deficit Hyperactivity Disorder. NIH Publication No. 96–3572, 1996.

PERIODICALS

Bolaños, Carlos A., Michel Barrot, Oliver Berton, Deanna Wallace-Black, and Eric J. Nestler. "Methylphenidate Treatment During Pre- and Periadolescence Alters Behavioral Responses to Emotional Stimuli at Adulthood." Biological Psychiatry (December 2003).

Castellanos, F. Xavier, Patti P. Lee, Wendy Sharp, et al. "Developmental Trajectories of Brain Volume Abnormalities in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder." Journal of the American Medical Association (October 9, 2002) 288: 1740–1748.

Rowland, Andrew S., David M. Umbach, Lil Stallone, A. Jack Naftel, E. Michael Bohlig, and Dale P. Sandler. "Prevalence of Medication Treatment for Attention Deficit-Hyperactivity Disorder among Elementary School Children in Johnston County, North Carolina." American Journal of Public Health (February 2002) 92: 231–234.

Sowell, Elizabeth R., Paul M. Thompson, Suzanne E. Welcome, Amy L. Henkenius, Arthur W. Toga, and Bradley S. Peterson. "Cortical Abnormalities in Children and Adolescents with Attention-Deficit Hyperactivity Disorder." Lancet (November 2003) 362: 1699–1702.

OTHER

National Institute of Neurological Disorders and Stroke. NINDS Attention Deficit-Hyperactivity Disorder Information Page. December 9, 2003 (February 18, 2004). http://www.ninds.nih.gov/health_and_medical/disorders/adhd.htm.

ORGANIZATIONS

Attention Deficit Disorder Association (ADDA). PO Box 543, Pottstown, PA 19464. (484) 945-2101; Fax: (610) 970-7520. mail@add.org. http://www.add.org.

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). 8181 Professional Place, Suite 150, Bethesda, MD 20785. (301) 306-7070 or (800) 233-4050; Fax: (301) 306-7090. http://www.chadd.org.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Bethesda, MD 20892-9663. (301) 443-4513 or (866) 615-6464; Fax: (301) 443-4279. nimhinfor@nih.gov. http://www.nimh.nih.gov.

National Institute of Neurological Disorders and Stroke. 6001 Executive Boulevard, Bethesda, MD 20892-9663. (301) 446-5751 or (800) 352-9424. http://www.ninds.nih.gov.

Brian Douglas Hoyle

A common psychiatric disorder of childhood characterized by attentional difficulties, impulsivity, and hyperactivity; known earlier as attention deficit disorder. Other older names for this disorder include minimal brain dysfunction, minimal brain damage, hyperactivity, hyperkinesis, and hyperactive child syndrome. Over time, these names were modified due to their implications about etiology and core symptoms: minimal brain dysfunction seemed to imply that children with this disorder were brain-damaged, while hyperactivity and its synonyms named a feature seen in many but not all of these children.

The three defining symptoms of attention deficit disorder are as follows:

(1) Attentional deficits. The child is described as having a short attention span. The child often fails to finish things he or she starts, does not seem to listen, and is easily distracted or disorganized. In more severe instances the child is unable to focus attention on anything, while in less severe cases attention can be focused on things of interest to the child.

(2) Impulsivity. The child is often described as acting before thinking, shifting excessively and rapidly from one activity to another, or having difficulty waiting for a turn in games or group activities.

(3) Hyperactivity. Many children with this disorder are hyperactive—and indeed, may have been noted to be so prior to birth. They may fidget, wiggle, move excessively, and have difficulty keeping still. This excessive activity is not noticeable when the children are playing; however, in the classroom or other quiet settings, the child cannot decrease his or her activity appropriately. Some affected children are active at a normal level or even sluggish. On the basis of the predominating symptoms, children with attention deficit hyperactivity disorder are subcategorized as having hyperactive symptoms (hyperactive type), lacking hyperactivity (inattentive type), and having both inattention and hyperactivity or impulsivity (combined type).

Many children with attention deficit hyperactivity disorder frequently show an altered response to socialization. They are often described by their parents as obstinate, impervious, stubborn, or negativistic. With peers, many affected children are domineering or bullying, and thus may prefer to play with younger children. Another characteristic often seen in children with the disorder is emotional lability. Their moods change frequently and easily, sometimes spontaneously, and sometimes reactively. Because of their behavioral difficulties, children with the disorder often have conflicts with parents, teachers, and peers. Commonly, difficulties in discipline and inadequacies in schoolwork lead to reproof and criticism. As a consequence, children with the disorder usually also have low self-esteem. Attention deficit hyperactivity disorder is frequently associated with other disorders, including disruptive behavior disorders, internalizing (mood and anxiety) disorders, and developmental disorders. See also Affective disorders.

Formerly believed to be largely caused by brain damage, and more recently believed by some to be caused by food allergy, attention deficit hyperactivity disorder is now considered to be mainly hereditary. It is estimated that 3–10% of children of elementary school age (roughly 6–19 years) manifest significant symptoms of attention deficit hyperactivity disorder. About twice as many boys as girls are affected with the disorder. The girls are much less likely than the boys to be aggressive and have serious behavioral difficulties, making the girls vulnerable to underidentification and undertreatment. It was formerly believed that attention deficit hyperactivity disorder was out-grown during adolescence. Although some signs of the disorder such as excessive activity may diminish or disappear in some affected children, other signs such as attentional difficulties, impulsivity, and interpersonal problems may persist. Despite the fact that this disorder is not uncommon in adults, the lower rates of hyperactivity in adults may result in the condition being frequently overlooked.

The treatment of the child or adult with this disorder involves three steps: evaluation, explanation of the problem to parents and child, and therapeutic intervention. Evaluation requires a detailed history of the child's psychological development and current functioning. Next, because the disorder is frequently associated with learning problems in school, it is desirable to obtain an individual intelligence test as well as a test of academic achievement. Since attention deficit hyperactivity disorder is often associated with other psychiatric disorders, it is important to carefully evaluate the presence of these other conditions. If a diagnosis of attention deficit hyperactivity disorder is confirmed, the parents or family should be educated regarding the nature of the condition and other associated conditions. Medication and guidance are the mainstays of the treatment. Approximately 70–80% of the children manifest a therapeutic response to one of the major stimulant drugs, such as amphetamines and methylphenidate. When effective, these medications increase attention, decrease impulsivity, and usually make the child more receptive to parental and educational requests and demands. Hyperactivity, when present, is usually diminished as well. Although usually less effective, other medications can be helpful to individuals who cannot tolerate or do not respond to stimulants. The common mechanism of action for such medications is their impact upon the neurotransmitters dopamine and norepinephrine.

A childhood neurologic disorder that manifests itself as excessive movement, irritability, immaturity, and an inability to concentrate or control impulses. It affects learning and skill acquisition.

Definition

Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities.

Description

ADHD, also known as hyperkinetic disorder (HKD) outside the United States, is estimated to affect 7% of children ages six to 11, or about 1.6 million children in the United States. It also affects about 4% of adults. The disorder affects boys more often than girls. Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age two or three, but the symptom picture changes as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood. However, impulsivity and inattention problems remain with up to 50% of ADHD individuals throughout their adult life.

Children with ADHD have short attention spans and are easily bored and/or frustrated with tasks. Although they may be quite intelligent, their lack of focus frequently results in poor grades and difficulties in school. ADHD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting, but often have trouble with gross and fine motor skills. As a result, they may be physically clumsy and awkward. Their clumsiness may extend to the social arena, where they are sometimes shunned due to their impulsive and intrusive behavior. Some critics argue that ADHD is a condition created and diagnosed in the Western world, particular to the environment of highly developed countries, since it is not diagnosed in other cultures. These critics of the ADHD diagnosis feel that medicating a child does not address the true underlying problem. They also note that there may not be a problem at all because children are naturally active and impulsive.

Causes & Symptoms

The causes of ADHD are not known. However, it appears that heredity plays a major role in the development of ADHD. Children with an ADHD parent or sibling are more likely to develop the disorder. Before birth, ADHD children may have been exposed to poor maternal nutrition, viral infections, or maternal substance abuse. In early childhood, exposure to lead or other toxins can cause ADHD-like symptoms. Traumatic brain injury or neurological disorders also may trigger ADHD symptoms. Although the exact cause of ADHD is not known, an imbalance of certain neurotransmitters (the chemicals in the brain that send messages between nerve cells) is believed to be the mechanism behind ADHD symptoms.

A widely publicized study conducted by Ben Fein-gold in the early 1970s suggested that allergies to certain foods and food additives caused the characteristic hyperactivity of ADHD children. Although some children may have adverse reactions to certain foods that can affect their behavior (for example, a rash might temporarily cause a child to be distracted from other tasks), carefully controlled follow-up studies have uncovered no link between food allergies and ADHD. Another popularly held misconception about food and ADHD is that eating sugar causes hyperactive behavior. Again, studies have shown no link between sugar intake and ADHD. It is important to note, however, that a nutritionally balanced diet is important for normal development in all children.

People with ADHD suffer from a variety of symptoms. These symptoms include such things as distraction, not paying attention, inconsistency, forgetfulness of even simple tasks, fidgeting, verbal impulsivity, and so on. It is interesting to note that everyone suffers from these symptoms at times, but an individual with ADHD will have more of these symptoms more of the time.

Some doctors indicated immature symmetric tonic neck reflex (STNR) as a possible cause of certain symptoms. Other studies in 1993 and 1994 showed a link between the disorder and diet, dyes, and preservatives. In another study in 1996, ADHD was linked to maternal smoking during pregnancy.

Psychologists and other mental health professionals typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for determining the presence of ADHD. For a diagnosis of ADHD, DSM-IV requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined.

Inattention

• fails to pay close attention to detail or makes careless mistakes in schoolwork or other activities
• has difficulty sustaining attention in tasks or activities
• does not appear to listen when spoken to
• does not follow through on instructions and does not finish tasks
• has difficulty organizing tasks and activities
• avoids or dislikes tasks that require sustained mental effort (like homework)
• is easily distracted
• is forgetful in daily activities

Hyperactivity

• fidgets with hands or feet or squirms in seat
• does not remain seated when expected to
• runs or climbs excessively when inappropriate (in adolescents and adults, feelings of restlessness)
• has difficulty playing quietly
• is constantly on the move
• talks excessively

Impulsivity

• blurts out answers before the question has been completed
• has difficulty waiting for his or her turn
• interrupts and/or intrudes on others

DSM-IV also requires that some symptoms develop before age seven, and that they significantly impair functioning in two or more settings (e.g., home and school) for at least six months. Children who meet the symptom criteria for inattention, but not for hyperactivity/impulsivity are diagnosed with Attention-deficit/hyperactivity disorder, predominantly inattentive type, commonly called ADD. (Young girls with ADHD may not be diagnosed because they have mainly this subtype of the disorder.)

Diagnosis

The first step in determining if a child has ADHD is to consult with a pediatrician, a doctor who treats children. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The doctor also should perform a comprehensive physical examination to rule out any organic causes of ADHD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist, psychiatrist, neurologist, neuropsychologist, or learning specialist typically is consulted to perform a comprehensive ADHD assessment. A complete medical, family, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews also may be conducted with the child, depending on his or her age. Along with these interviews, several clinical inventories also may be used, such as the Conners Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations. In addition, the Wender Utah Rating Scale has been adapted for use in diagnosing ADHD in adults.

It is important to note that mental disorders such as depression and anxiety disorder can cause symptoms similar to ADHD. A complete and comprehensive psychiatric assessment is critical to differentiate ADHD from other possible mood and behavioral disorders. Bipolar disorder, for example, may be misdiagnosed as ADHD.

Public schools are required by federal law to offer free ADHD testing upon request. A pediatrician also can provide a referral to a psychologist or pediatric specialist for ADHD assessment. Parents should check with their insurance plans to see if these services are covered.

Treatment

A 2003 survey showed that approximately 54% of parents reported using complementary or alternative medicine treatments for their children in the previous year. Some parents reported turning to these therapies because doctors don't always agree on the ADHD diagnosis and cannot adequately explain how allopathic drug treatments calm people and improve mental focus. Behavior modification therapy uses a reward system to reinforce good behavior as well as task completion and can be used both in the classroom and at home. A tangible reward such as a sticker may be given to the child every time he completes a task or behaves in an acceptable manner. A chart system may be used to display the stickers and visually illustrate the child's progress. When a certain number of stickers are collected, the child may trade them in for a bigger reward such as a trip to the zoo or a day at the beach. The reward system stays in place until the good behavior becomes ingrained.

A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help ADHD children build self-esteem, give them a place to discuss their worries and anxieties, and help them gain insight into their behavior and feelings. Family therapy also may be beneficial in helping family members develop coping skills and work through feelings of guilt or anger they may be experiencing.

ADHD children perform better within a familiar, consistent, and structured routine with positive reinforcements for good behavior and real consequences for bad. Family, friends, and caretakers should be educated on the special needs and behaviors of the ADHD child. Communication between parents and teachers is especially critical to ensuring an ADHD child has an appropriate learning environment.

A number of alternative treatments exist for ADHD. Although there is a lack of controlled studies to prove their efficacy, proponents report that they are successful in controlling symptoms in some ADHD patients. Some of the more popular alternative treatments are listed.

• Electroencephalograph (EEG) biofeedback. By measuring brain wave activity and teaching the ADHD patient which type of brain wave is associated with attention, EEG biofeedback attempts to train patients to generate the desired brain wave activity.
• Dietary therapy. Based in part on the Feingold food allergy diet, dietary therapy focuses on a nutritional plan that is high in protein and complex carbohydrates and free of white sugar and salicylate-containing foods such as strawberries, tomatoes, and grapes.
• Herbal therapy. Herbal therapy uses a variety of natural remedies to address the symptoms of ADHD. Ginkgo (Gingko biloba) is used for memory and mental sharpness and chamomile (Matricaria recutita) extract is used for calming. The safety of herbal remedies has not been demonstrated in controlled studies. For example, it is known that gingko may affect blood coagulation, but controlled studies have not yet evaluated the risk of the effect.
• Vitamin and mineral supplements. Some vitamin and mineral supplements that are thought to be effective by some alternative practitioners include calcium, zinc, magnesium, iron, inositol, trace minerals, blue-green algae. Also recommended are the combined amino acids GABA, glycine, taurine, L-glutamine, L-phenylalanine, and L-tyrosine. In 2003, a study reported that a combination of omega-3 and omega-6 fatty acids supplements may help with cognitive and behavioral symptoms of ADHD.
• Homeopathic medicine. This is probably the most effective alternative therapy for ADD and ADHD because it treats the whole person at a core level. Constitutional homeopathic care is most appropriate and requires consulting with a well-trained homeopath who has experience working with ADD and ADHD individuals.
• Auricular acupuncture. A small study in 1997 indicated that this type of acupuncture therapy might be effective in some children.

Allopathic Treatment

Psychosocial therapy, usually combined with medications, is the treatment approach of choice to alleviate ADHD symptoms. Psychostimulants, such as dextroamphetamine (Dexedrine), pemoline (Cylert), and methylphenidate (Ritalin) commonly are prescribed to control hyperactive and impulsive behavior and increase attention span. They work by stimulating the production of certain neurotransmitters in the brain. Possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia. However, the medications usually are well-tolerated and safe in most cases. But according to Carolyn Chambers Clark, R.N., Ed.D., 25% of the children with ADHD do not respond to stimulant drugs.

In children who don't respond well to stimulant therapy, tricyclic antidepressants such as desipramine (Norpramin, Pertofane) and amitriptyline (Elavil) are frequently recommended. Reported side effects of these drugs include persistent dry mouth, sedation, disorientation, and irregular heartbeat (particularly with desipramine). Other medications prescribed for ADHD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an antidepressant; and carbamazepine (Tegretol, Atretol), an anticonvulsant drug. Clonidine (Catapres), a medication for high blood pressure, also has been used to control aggression and hyperactivity in some ADHD children, although it should not be used with Ritalin. A child's response to medication will change with age and maturation, so ADHD symptoms should be monitored closely and prescriptions adjusted accordingly.

In mid-2003, the first new drug for treating ADHD was about to become available. Called atomoxetine (Strattera), it was planned to offer several advantages over standard stimulants. First, atomoxetine is not a controlled substance, so physicians can write prescriptions for a larger number of pills and refills. Further, it doesn't have the potential for abuse that the stimulant drugs pose.

Expected Results

Untreated, ADHD negatively affects a child's social and educational performance and can seriously damage his or her sense of self-esteem. ADHD children have impaired relationships with their peers and may be looked upon as social outcasts. They may be seen as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings toward the ADHD child.

Some ADHD children also develop a conduct disorder problem. For those adolescents who have both ADHD and a conduct disorder, up to 25% go on to develop anti-social personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that are symptomatic of it. Children diagnosed with ADHD also are more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 70-80% of ADHD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. Approximately half of ADHD children seem to "outgrow" the disorder in adolescence or early adulthood. The other half will retain some or all symptoms of ADHD as adults. With early identification and intervention, careful compliance with a treatment program, and a supportive and nurturing home and school environment, ADHD children can flourish socially and academically.

Resources

Books

Alexander-Roberts, Colleen. The ADHD Parenting Handbook: Practical Advice for Parents from Parents. Dallas: Taylor Publishing Co., 1994.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press Inc., 1994.

Diller, Laurence H. Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill. New York: Bantam Books, 1998.

Hallowell, Edward M., and John J. Ratey. Driven to Distraction. New York: Pantheon Books, 1994.

Kennedy, Patricia, Leif Terdal, and Lydia Fusetti. The Hyperactive Child Book. New York: St. Martin's Press, 1993.

Maxmen, Jerrold S., and Nicholas G. Ward. "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence." In Essential Psychopathology and Its Treatment, 2nd ed. New York: W.W. Norton, 1995, 419-457.

Osman, Betty B. Learning Disabilities and ADHD: A Family Guide to Living and Learning Together. New York: John Wiley & Sons, 1997.

Periodical

"Complementary, Alternative Medicine Being Used by Parents for ADHD." The Brown University Child and Adolescent Psychopharmacology Update (August 2003):1-3.

Gaby, Alan R. "Essential Fatty Acids for ADHD." Townsend Letter for Doctors and Patients (April 2003):43.

Glicken, Anita D. "Attention Deficit Disorder and the Pediatric Patient: A Review." Physician Assistant 21, no. 4 (April 1997): 101-111.

Hallowell, Edward M. "What I've Learned from A.D.D." Psychology Today 30, no. 3 (May-June 1997): 40-46.

Monaco, John E. "New Drug for ADHD." Pediatrics for Parents (June 2003):7-11.

"New National ADHD Resource Center Opens in Maryland." Special Education Report (June 2003):12.

"Parents Increasingly Seek Alternative ADHD Treatments." Mental Health Weekly (September 22, 2003):7.

Swanson, J.M., et al. "Attention-deficit Hyperactivity Disorder and Hyperkinetic Disorder." The Lancet 351 (February 7, 1997): 429-433.

Organization

Children and Adults with Attention Deficit Disorder. (CH.A.D.D.). 499 Northwest 70th Ave., Suite 101, Plantation, FL 33317. (800) 233-4050.

The National Attention Deficit Disorder Association. (ADDA). 9930 Johnnycake Ridge Rd., Suite 3E, Mentor, OH 44060. (800) 487-2282.

The National Resource Center of ADHD. (800) 233-4050.

[Article by: Kim Sharp; Teresa G. Odle]

Definition

Attention-deficit/hyperactivity disorder (AD/HD) is a neurobiological disorder characterized by hyperactivity, impulsive behavior, and the inability to remain focused on tasks or activities.

Description

AD/HD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3–7 percent of school-aged children, and seems to afflict boys more often than girls. However, the prevalence in boys may be cited because often girls are not diagnosed until later in age. Although difficult to assess in infancy and toddlerhood, signs of AD/HD may begin to appear as early as age two or three, but visible symptoms change as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood, while impulsivity and inattention problems often continue.

First documented in 1902, AD/HD has been called minimal brain dysfunction, hyperkinetic reaction, and attention-deficit disorder (ADD). The name AD/HD reflects the various behaviors of inattention, hyperactivity, and impulsiveness that characterize the disorder. Its more precise classification is a result of the Diagnostic and Statistical Manual, fourth edition (DSM-IV) system for characterizing and diagnosing mental and behavioral disorders.

Children with AD/HD have difficulties with inattention that can be manifest as a lack of concentration, an easily distracted focus, and an inability to know when and how long to focus. The characteristics of inattention vary with each AD/HD child; however, all most often translate into poor grades and difficulties in school and other social arenas. AD/HD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting. Yet, they often have trouble with gross and fine motor skills and, as a result, they may be physically clumsy and awkward. Their clumsiness may also extend to their social skills. They are sometimes shunned by peers due to their impulsive and intrusive behavior.

Demographics

Of the 3–7 percent of school-aged children with AD/HD, some will have a reduction of symptoms as they reach adulthood. However, 65 percent of AD/HD children will continue to display characteristics of AD/HD through adulthood. Until recently, it was believed that boys were three times more likely to have AD/HD; however, that gap has been narrowed. It is more likely that the presence of AD/HD is distributed equally between boys and girls. The reason for the discrepancy was, in part, because young boys tend to more readily and overtly manifest the characteristics of AD/HD, making diagnosis easier. In addition, the inattentive form affects girls more than the hyperactive form; as a result, girls may be less likely to be diagnosed.

Causes and Symptoms

The causes of AD/HD are not specifically known. However, it is a neurologically based disease that may be genetic. Children with an AD/HD parent or sibling are more likely to develop the disorder themselves. Although the exact cause of AD/HD is not known, an imbalance or deficiency of certain neurotransmitters—the chemicals in the brain that transmit messages between nerve cells—is believed to be the mechanism behind AD/HD symptoms.

A widely publicized study conducted by Dr. Ben Feingold in the early 1970s suggested that allergies to certain foods and food additives caused the characteristic hyperactivity of AD/HD children. By eliminating the food allergen, the premise was that AD/HD characteristics would disappear. Although some children may have adverse reactions to certain foods and food additives that can affect their behavior, carefully controlled follow-up studies have uncovered no link between food allergies and AD/HD. Another popularly held misconception about food and AD/HD is that the consumption of sugar causes the hyperactive behavior in an AD/HD child. Again, studies have shown no link between sugar intake and AD/HD. (In a recent study conducted by the National Institute of Mental Health, the level of glucose use in the brain was actually lower in individuals with AD/HD. Since glucose is the main source of fuel for the brain, this is a significant finding.) Finally, parenting style is not a cause for AD/HD. While certain parenting skills and/or deficiencies can affect the environment of an AD/HD child and, as a result, exasperate or help manage the characteristics of AD/HD, it appears that neurological issues are the primary causal agents at play.

In order to diagnose AD/HD, psychologists and other mental health professionals typically use the criteria listed in the DSM-IV. DSM-IV requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined.

Inattention:

• fails to pay close attention to detail or makes careless mistakes in schoolwork or other activities
• has difficulty sustaining attention in tasks or activities
• does not appear to listen when spoken to
• does not follow through on instructions and does not finish tasks
• has difficulty organizing tasks and activities
• avoids or dislikes tasks that require sustained mental effort (e.g., homework)
• is easily distracted
• is forgetful in daily activities

Hyperactivity:

• fidgets with hands or feet or squirms in seat
• does not remain seated when expected to
• runs or climbs excessively when inappropriate (in adolescence and adults, feelings of restlessness)
• has difficulty playing quietly
• is constantly on the move
• talks excessively

Impulsivity:

• blurts out answers before the question has been completed
• has difficulty waiting for his or her turn
• interrupts and/or intrudes on others

Of those symptoms, AD/HD can be categorized further by three subtypes. Each subtype exhibits particular behaviors that make up the general symptoms of a child with AD/HD. They are:

AD/HD predominantly inattentive type (AD/HD-I)

• is disorganized
• is easily distracted
• is forgetful
• has unsustained attention
• has difficulty following instructions
• appears to have poor listening skills
• makes careless mistakes

AD/HD predominantly hyperactive-impulsive type (AD/HD-HI)

• fidgets
• is unable to engage in quiet activity
• is interruptive or intrusive
• cannot remain seated
• speaks out of turn
• climbs or runs about inappropriately
• talks excessively

AD/HD combined type (AD/HD-C) is a combination of the symptoms exhibited by the other two subtypes (inattentive type and hyperactive-impulsive type). Also, for a complete diagnosis, DSM-IV requires that some symptoms develop before age seven, and that they significantly impair functioning in two or more settings (e.g., home and school) for a period of at least six months.

Diagnosis

AD/HD cannot be diagnosed with a laboratory test. Diagnosis is difficult and it takes into consideration many aspects of the child's behavior. Often the child's teacher is the one to bring the first signs to the attention of the parents. However, the first step in determining if a child has AD/HD is to consult with a pediatrician. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The physician should also perform a comprehensive physical examination to rule out any organic causes of AD/HD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist, psychiatrist, neurologist, neuropsychologist, or learning specialist is typically consulted to perform a comprehensive AD/HD assessment. A complete medical, family, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews may also be conducted with the child, depending on his or her age. Along with these interviews, several clinical inventories may also be used, such as the Conners' Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations.

Other disorders such as depression, anxiety disorder, and learning disorders can cause symptoms similar to AD/HD. A complete and comprehensive psychiatric assessment is critical to differentiate AD/HD from other possible mood and behavioral disorders. Bipolar disorder, for example, may be misdiagnosed as AD/HD.

Public schools are required by federal law to offer free AD/HD testing upon request. A pediatrician can also provide a referral to a psychologist or pediatric specialist for AD/HD assessment. Parents should check with their insurance plans to see if these services are covered.

Treatment

Despite similar behavioral characteristics, AD/HD must be treated individually by developing an approach combining various types of treatment. The use of medication in combination with behavioral interventions, classroom accommodations, and proactive parents provide the best treatment option.

Psychostimulants and their effects have been studied in approximately 6,000 children and the positive results of their use have been documented. Such psychostimulants as dextroamphetamine (Dexedrine, Dextrostat), pemoline (Cylert), methylphenidate (Ritalin, Concerta, Metadate, Focalin), and mixed salts of a single-entity amphetamine product (Adderall, Adderall XR) are commonly prescribed to control hyperactive and impulsive behavior as well as to increase attention. They work by stimulating the production of certain neurotransmitters in the brain. Generally, short-acting medication lasts for four hours, while long-lasting preparations will last for six to eight hours. Some medication is effective for 10–12 hours. Specific dosages depend upon the patient and that is determined by trial and error in conjunction with close monitoring by a physician in order to find the most beneficial strength. Possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia. However, the medications are usually tolerated and safe in most cases. In fact, 70–80 percent of AD/HD children respond well to psychostimulants.

In children who do not respond well to stimulant therapy, nonstimulant medications are prescribed. In 2002, the Food and Drug Administration (FDA)approved atomoxetine (Strattera) for the treatment of AD/HD. Unlike the stimulant medications, atomoxetine is not a controlled substance and can be prescribed with refills. (With the use of stimulant medication, the physician must write prescriptions each month of treatment.) Atomoxetine usually takes three to four weeks of use until its effect is evident. In January 2005 the FDA warned that evidence of atleast two cases of liver problems in an adult and teenage patient taking atomoxetine were reported. In both cases, the individuals fully recovered. The manufacturer of atomoxetine (Strattera) planned to notify users of the new FDA warning; however, the company, Eli Lilly & Co., believed that the risk-benefit analysis during trials of the drug was still positive. Such tricyclic antidepressants as desipramine (Norpramin, Pertofane) and amitriptyline (Elavil) are frequently recommended as well. Reported side effects of these drugs include persistent dry mouth, sedation, disorientation, and cardiac arrhythmia (particularly with desipramine).

Other medications prescribed for AD/HD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an SSRI antidepressant; and carbamazepine (Tegretol, Atretol), an anticonvulsant drug. Clonidine (Catapres), an antihypertensive medication, has also been used to control aggression and hyperactivity in some AD/HD children, although it should not be used in combination with Ritalin.

A child's response to medication will change with age and maturation, so AD/HD symptoms should be monitored closely and prescriptions adjusted accordingly.

Behavior interventions are also crucial to AD/HD treatment. In a Nation Institute of Mental Health (NIMH) study conducted on 579 children over the course of 14 months it was observed that the children receiving AD/HD medication or both medication and behavioral interventions were more likely to see the most relief from their symptoms than those children that only received community aid. The use of a reward system to reinforce good behavior and task completion can be implemented both in the classroom and at home. A chart system may be used to visually illustrate the child's progress and encourage continued success with the use of larger rewards after a certain number of daily rewards are achieved. The reward system stays in place until the appropriate behavior becomes second nature to the child.

A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help an AD/HD child build self-esteem, give them a place to discuss their worries and anxieties, and help them gain insight into their behavior and feelings. Family therapy may also be beneficial in helping family members develop coping skills and in working through feelings of guilt or anger parents may be experiencing.

AD/HD children perform better within a familiar, consistent, and structured routine with an emphasis on positive reinforcements for good behavior and minimal use of punishments. When a negative behavior must be acknowledged and corrected, "time outs" give the child with AD/HD an opportunity to regroup without negative reinforcement. Family, friends, and caretakers should all be educated on the special needs and behaviors of the AD/HD child.

Alternative Treatment

A number of alternative treatments exist for AD/HD; however, there are very few studies to prove their efficacy. When choosing a treatment option, it is important to investigate authoritative sources that provide a basis through documented studies for the validity of the treatment. AD/HD is not a disorder that can be cured but rather it is one that is managed by a variety of treatment options. Some of the more popular alternative treatments include:

• EEG (electroencephalograph) biofeedback. By measuring brainwave activity and teaching the AD/HD patient which type of brainwave is associated with attention, EEG biofeedback attempts to train patients to generate the desired brainwave activity. This treatment has been in use for over 25 years and it has had positive response from parents. However, no consistent medical studies are available.
• Chelation therapy focuses on removing excess lead within the body. This treatment is based on the idea that excessive lead in animals causes hyperactivity; yet, not enough medical studies have been done. A physician should be consulted when this approach is considered.
• Intractive metronome training uses a similar instrument as the metronome used by musicians to keep time in order to train individuals to develop their motor and timing skills through repetitively tapping the beat.
• Nutritional supplements claiming to be a cure for AD/HD are not regulated by the Food and Drug Administration (FDA) and should not be considered a treatment option without consultation with a medical doctor.

There are many advertised alternative and complementary treatment options for AD/HD. Only a few are listed here; however, it is always necessary to consult a physician to develop a fine-tuned treatment plan specific to each child's needs.

Nutritional Concerns

As mentioned, links between nutrition and AD/HD have not been confirmed through medical studies. However, it is important to note that a nutritionally balanced diet is important for normal development in all children.

Prognosis

Untreated, AD/HD negatively affects a child's social and educational performance and can seriously damage his or her self-esteem. Children with AD/HD have impaired relationships with their peers, and may be looked upon as social outcasts. They may be perceived as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings towards the AD/HD child.

Some AD/HD children also develop a conduct disorder. For those adolescents who have both AD/HD and a conduct disorder, up to 25 percent go on to develop antisocial personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that are symptomatic of it. Children diagnosed with AD/HD are also more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 70–80 percent of AD/HD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. Approximately half of AD/HD children seem to "outgrow" the disorder in adolescence or early adulthood; the other half will retain some or all symptoms of AD/HD as adults. With early identification and intervention, careful compliance with a treatment program, and a supportive and nurturing home and school environment, children with AD/HD can flourish socially and academically.

Parental Concerns

Because AD/HD is often indicated when the AD/HD child is in school, parents are extremely concerned about their child's academic progress. Communication between parents and teachers is especially critical to ensure an AD/HD child has an appropriate learning environment. Educational interventions under Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 mandate that AD/HD children will be served within the public school system. This means that upon request the public school is required to test the child for AD/HD as well as other learning disabilities if they are suspected. In addition, special education services are mandated for those children with AD/HD that need extra help and accommodation. It is important that parents assume a positive relationship with their child's educator and school in order to develop the best possible teaching strategies and learning environment for their AD/HD child.

Development of self-esteem is another particular concern for parents of AD/HD children. Because they often have difficulty in school and in social relationships, low self-esteem can be a factor that leads the school aged children toward dangerous or destructive behaviors as they reach adolescence. Finding one activity that the child excels at is essential in fostering a positive self-image. Often parents look to sports as an appropriate outlet. Individual sports such as karate, swimming, tennis, etc. are less socially demanding than team sports; yet they provide an opportunity for the child to thrive in a competitive activity.

AD/HD is a chronic condition. Parents can feel overwhelmed when they have to deal with AD/HD characteristics on a daily basis. Parent should face the issues honestly and directly while fostering a positive relationship with their AD/HD child. The best advocate the AD/HD child has is a parent so it is important that parents be proactive and keep up to date on the latest research. Learning about AD/HD and the various treatment options helps parents cope with their own concerns at the same time they are helping their child.

Resources

Books

Alexander-Roberts, Colleen. The ADHD Parenting Handbook: Practical Advice for Parents from Parents. Dallas: Taylor Publishing Co., 1994.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Barkley, Russell A. Taking Charge of ADHD. Revised Edition. New York: Guilford Press, 2000.

Hallowell, Edward M., and John J. Ratey. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood. New York: Touchstone, 1995.

Osman, Betty B. Learning Disabilities and ADHD: A Family Guide to Living and Learning Together. New York: John Wiley & Sons, 1997.

Periodicals

Foley, Kevin. "Experiencing Nature May Quell ADHD in Kids." Pediatric News 38 (Nov. 2004).

Franklin, Deeanna. "FDA Issues Warning for ADHD Drug." Pediatric News 39 (Jan. 2005):42.

Glicken, Anita D. "Attention Deficit Disorder and the Pediatric Patient: A Review." Physician Assistant 21, no. 4 (Apr. 1997):101-11.

Hallowell, Edward M. "What I've Learned from A.D.D." Psychology Today 30, no. 3 (May/June 1997): 40-6.

Swanson, J. M., et al. "Attention-deficit Hyperactivity Disorder and Hyperkinetic Disorder." The Lancet 351 (7 Feb. 1997): 429-33.

Organizations

American Academy of Child and Adolescent Psychiatry. (AACAP). 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. Web site:

Children and Adults with Attention Deficit Disorder (CH.A.D.D.). 8181 Professional Place, Ste. 150, Landover, MD 20785. (800) 233-4050. (305) 306-7070.

National Attention Deficit Disorder Association. (ADDA). 9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH 44060. (800) 487-2282. Web site:

Web Sites

Schwablearning.org: A Parent's Guide to Helping Kids with Learning Difficulties. (cited March 8, 2005). Available online at: www.schwablearning.org.

[Article by: Jacqueline L. Longe Paula A. Ford-Martin]

Attention deficit/hyperactivity disorder (ADHD) is a condition characterized by inattention and/or impulsivity and hyperactivity that begins in children prior to the age of seven. Their inattention leads to daydreaming, distractibility, and difficulties sustaining effort on a single task for a prolonged period of time. Their impulsivity disrupts classrooms and creates problems with peers, as they blurt out answers, interrupt others, or shift from schoolwork to inappropriate activities. Their hyperactivity is frustrating to those around them and poorly tolerated at school. Children with ADHD show academic underachievement and conduct problems. As they grow older, they are at risk for low self-esteem, poor peer relationships, conflict with parents, delinquency, smoking, and substance abuse.

Course, Prevalence, and Treatment

Although the longitudinal course of this condition and its prevalence in adulthood have been sources of controversy, a growing literature has documented the persistence of ADHD into adulthood, with about two-thirds of ADHD children continuing to experience impairing symptoms of the disorder though adulthood. Over time, symptoms of hyperactivity and impulsivity are more likely to diminish compared with symptoms of inattention.

Prevalence studies from North America, Europe, and Asia show that ADHD affects about 5 percent of the population. The impact of the disorder on society, in terms of financial cost, stress to families, and disruption in schools and workplaces, is enormous. Although current treatments for the disorder are not 100 percent effective, clinical trials have shown that stimulant medications, such as methylphenidate and amphetamine, relieve symptoms and lessen adverse outcomes, while showing few adverse side effects. Because these medicines increase the availability of the neurotransmitter dopamine in the brain, dysregulation of dopamine systems has been a primary candidate for the pathophysiology of ADHD. But drugs like desipramine and alomoxeline, which have their effects on other brain systems, also exert strong anti-ADHD effects. This suggests that dysregulation of dopamine systems cannot completely explain the pathophysiology of ADHD.

Neuropsychological and neuroimaging studies provide converging evidence for the hypothesis that brain dysfunction causes the symptoms of ADHD. Neuropsychological tests show many ADHD patients to have deficits in the executive functions needed for organizing, planning, sequencing, and inhibiting behaviors. These performance deficits are similar to, albeit milder than, the deficits seen among patients with frontal lobe disorders. Several structural and functional neuroimaging studies implicate networks of regions throughout the brain, not just in the frontal lobes.

The Genetic Epidemiology of Adhd

Family, twin, and adoption studies provide strong support for the idea that genes influence the etiology of ADHD. Family studies find the parents and siblings of ADHD children to have a five-fold increase in the risk for ADHD. Children of ADHD adults have a ten-fold increase in risk, which has led to the idea that persistent cases of ADHD may have a stronger genetic component. Consistent with a genetic theory of ADHD, second-degree relatives (such as cousins) are at increased risk for the disorder but their risk is lower than that seen in first-degree relatives.

Family studies have provided evidence for the genetic heterogeneity of ADHD. Studies that systematically assess other psychiatric disorders suggest that ADHD and major depression often occur together in families; that ADHD children with conduct and/or bipolar disorders might be a distinct familial subtype of ADHD; and that ADHD is familially independent from anxiety disorders and learning disabilities. It may therefore be appropriate to divide ADH children into those with and those without conduct and bipolar disorders, thus forming more familially homogeneous subgroups. In contrast, major depression may be a nonspecific manifestation of different ADHD subforms.

Several twin studies have provided evidence of genetic influence on hyperactive and inattentive symptoms. An early study found the heritability of hyperactivity to be 64 percent. A study of ADHD in twins who also had reading disabilities reported the heritability of attention-related behaviors to be 98 percent. All twin studies considered together suggest that the heritability of ADHD is about 70 percent, which makes it one of the most heritable of psychiatric disorders.

Adoption studies also implicate genes in the etiology of ADHD. Two early studies found that the adoptive relatives of hyperactive children were less likely to be hyperactive or have associated conditions than the biological relatives. Biological relatives of hyperactive children also performed more poorly on standardized measures of attention than did adoptive relatives. A study using the contemporary definition of ADHD found that biological, not adoptive, relationships account for the transmission of ADHD.

The Molecular Genetics of Adhd

Molecular genetic studies have already implicated several genes as mediating the susceptibility to ADHD. Researchers have examined candidate genes in dopamine pathways because animal models, theoretical considerations, and the effectiveness of stimulant treatment implicate dopaminergic dysfunction in the pathophysiology of this disorder. Dopamine is a neural trans-Dopamine mitter in the brain used in both movement control and pleasure/reward systems. In its simplest form, the dopamine hypothesis holds that excess clearance of dopamine between neurons may contribute to ADHD.

Many studies have focused on the D4 dopamine receptor gene (DRD4) which encodes a protein receptor that mediates the post-synaptic action of dopamine. A meta-analysis of these studies showed a small but statistically significant association, which could not be accounted for by any single study or by publication biases. Although the nature of the mutations in DRD4 have not been conclusively described, a version of the gene known as the 7repeat allele has generated much interest because this allele causes a blunted response to dopamine and has been implicated in novelty seeking, a personality trait of many ADHD patients.

Several authors have reported an association between ADHD and a particular allele of the dopamine transporter (DAT) gene. This finding has been replicated by some, but not all studies. The link between the DAT gene and ADHD is further supported by a study that relates this gene to poor methylphenidate response in humans, a "knockout" mouse study showing that its elimination leads to hyperactivity in mice, and two molecular neuroimaging studies that found elevated DAT density in the striatum of ADHD adults.

Molecular genetics studies of ADHD have also targeted other genes that are related to the dopamine system. Four studies have examined the Catechol-O-Methyltransferase (COMT) gene, whose protein product breaks down dopamine and norepinephrine. Although one study found ADHD was associated with the high-activity form of COMT, three others could not replicate the finding. Other candidate genes that show promising results for ADHD are the D5 dopamine receptor gene and the serotonin 1B receptor. This latter finding is intriguing because, although serotonergic medicines do not help ADHD symptoms, these systems have been implicated in animal models of the disorder.

Bibliography

Faraone, S. V., D. Tsuang, and M. T. Tsuang. Genetics of Mental Disorders: A Guide for Students, Clinicians, and Researchers. New York: Guilford, 1999.

Faraone, S. V., and A. Doyle. "The Nature and Heritability of Attention Deficit Hyperactivity Disorder." Child and Adolescent Psychiatric Clinics of North America 10 (2001): 299-316.

Faraone, S. V., and J. Biederman. "Neurobiology of Attention Deficit Hyperactivity Disorder." Biological Psychiatry 44 (1998): 951-958.

—Stephen V. Faraone

The most common reason that children are referred to child-guidance clinics is for attention deficit hyperactivity disorder (ADHD). ADHD is a behavioral disorder with a strong hereditary component, which likely results from neurological dysfunction. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there are three diagnostic categories of ADHD: (1) ADHD, Predominantly Inattentive Type; (2) ADHD, Predominantly Hyperactive-Impulsive Type; and (3) ADHD, Combined Type. ADHD often occurs simultaneously with other behavioral and learning problems, such as learning disabilities, emotional or behavioral disabilities, or Tourette's syndrome.

A 1998 study by Russell A. Barkley stated that ADHD is a deficit in behavior inhibition, which sets the stage for problems in regulating behavior. Students with ADHD may experience problems in working memory (remembering things while performing other cognitive operations), delayed inner speech (self-talk that allows people to solve problems), problems controlling emotions and arousal, and difficulty analyzing problems and communicating solutions to others. Hence, students with ADHD may find it difficult to stay focused on tasks such as schoolwork - tasks that require sustained attention and concentration, yet are not intrinsically interesting. In addition, the majority of individuals with ADHD experience significant problems in peer relations and demonstrate a higher incidence of substance abuse than that of the general population.

Although professionals did not recognize ADHD as a diagnostic category until the 1980s, evidence of the disorder dates from the beginning of the twentieth century. The physician George F. Still is credited with being one of the first authors to bring those with "defective moral control" to the attention of the medical profession in 1902. In the 1930s and 1940s Heinz Werner and Alfred Strauss were able to identify children who were hyperactive and distractible - children who exhibited the Strauss syndrome. Later, in the middle of the twentieth century, the term minimal brain injury was used to refer to children of normal intelligence who were inattentive, impulsive, and/or hyperactive. This term fell out of favor and was replaced by hyperactive child syndrome. Professionals eventually rejected this term, as inattention, not hyperactivity, was recognized as the major behavior problem associated with the disorder.

Students with ADHD are eligible for special education services under the category "other health impaired (OHI)." This category has dramatically increased in size; however, the number of students served in this category remains well below the estimated prevalence rate of 3 to 5 percent of the school-age population. From discrepancies such as this, researchers have estimated that fewer than half of all students with ADHD are receiving special education services.

As Barkley noted in his 1998 study, the effective diagnosis of ADHD requires a medical exam, a clinical interview, and teacher and parent rating scales. During the medical exam the physician must rule out other possible causes of the behavior problem, and through the clinical interview, the clinician obtains information from both parents and child about the child's physical and psychological characteristics. Finally, parents, teachers, and in some cases children themselves, complete behavioral rating scales, such as the Connors scales and the ADHD Rating Scale - IV in order to quantify observed behavior patterns.

Frequently students with ADHD are treated with psychostimulants, such as methylphenidate (Ritalin), which stimulate areas of the brain responsible for inhibition. Despite some negative publicity in the media, most authorities in the area of ADHD are in favor of Ritalin's use. In addition to medication, students with ADHD also benefit from carefully designed educational programming. In the early 1960s William Cruickshank was one of the first to establish an educational program for students who would meet what has become the criteria for ADHD. This program, proposing a degree of classroom structure rarely seen in the early twenty-first century, advocated: (1) a reduction of stimuli irrelevant to learning and enhancement of material important for learning and (2) a structured program with a strong emphasis on teacher direction. In addition to educational programs that emphasize and provide structure, a 1997 study by Robert H. Horner and Edward G. Carr indicated that students with ADHD benefited from instructional approaches examining the consequences, antecedents, and setting events that maintain inappropriate behaviors. Other researchers' findings indicated that they also profited from behavior management systems in which the student with ADHD learns to monitor his or her own behavior. These strategies, although effective, are not generally powerful enough to completely remedy the symptoms of children with ADHD. The majority of children diagnosed with ADHD continue to demonstrate symptoms in adulthood.

Bibliography

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, Text Revision, 4th edition. Washington, DC: American Psychiatric Association.

Barkley, Russell. A. 1998. Attention-Deficit Hyperactive Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press.

Connors, C. Keith. 1989. Connors Teacher Rating Scale-28. Tonawanda, NY: Multi-Health Systems.

Dupaul, George J.; Power, Thomas J.; Anastopolous, Arthur D.; and Reid, Robert. 1998. ADHD Rating Scale - IV: Checklists, Norms, and Clinical Interpretations. New York: Guilford Press.

Hallahan, Daniel P., and Cottone, E. A. 1997. "Attention Deficit Hyperactivity Disorder." In Advances in Learning and Behavioral Disabilities, Vol. 11, ed. Thomas E. Scruggs and Margo A. Mastropieri. Greenwich, CT: JAI Press.

Horner, Robert H., and Carr, Edward G. 1997. "Behavioral Support for Students with Severe Disabilities: Functional Assessment and Comprehensive Intervention." Journal of Special Education 31:1 - 11.

Shapiro, Edward S.; Dupaul, George J.; and Bradley-Klug, Kathy L. 1998. "Self-Management as a Strategy to Improve the Classroom Behavior of Adolescents with ADHD." Journal of Learning Disabilities 31:545 - 555.

— DEVERY R. MOCK, DANIEL P. HALLAHAN

Attention-deficit hyperactivity disorder
Classification and external resources
ICD-10	Ff90.htm+ f90 90 .
ICD-9	314.00, 314.01
OMIM	143465
DiseasesDB	6158
MedlinePlus	001551
eMedicine	med/3103 ped/177
MeSH	D001289

Attention-deficit hyperactivity disorder (ADHD or AD/HD) is a neurobehavioral^[1] developmental disorder.^[2] ADHD is primarily characterized by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone."^[3] While symptoms may appear to be innocent and merely annoying nuisances to observers, "if left untreated, the persistent and pervasive effects of ADHD symptoms can insidiously and severely interfere with one's ability to get the most out of education, fulfill one's potential in the workplace, establish and maintain interpersonal relationships, and maintain a generally positive sense of self."^[4]:p.2

ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5% of children globally with symptoms starting before seven years of age.^[5][6] ADHD is a common chronic disorder in children^[7] with 30 to 50% of those individuals diagnosed in childhood continuing to have symptoms into adulthood.^[8][9] Adolescents and adults with ADHD tend to develop coping mechanisms to compensate for some or all of their impairments.^[10] However, many aspects of daily life that most people take for granted are rendered more difficult by the symptoms of ADHD.^{[4][clarification needed]}

Though previously regarded as a childhood diagnosis, ADHD can continue throughout adulthood.^[11] 4.7 percent of American adults are estimated to live with ADHD.^[12] ADHD is diagnosed two to four times as frequently in boys as in girls,^[13][14] though studies suggest this discrepancy may be due to subjective bias of referring teachers.^[15] ADHD management usually involves some combination of medications, behavior modifications, lifestyle changes, and counseling. Its symptoms can be difficult to differentiate from other disorders, increasing the likelihood that the diagnosis of ADHD will be missed^[4] or vice versa. Additionally, most clinicians have not received formal training in the assessment and treatment of ADHD, particularly in adult patients.^[4]

ADHD and its diagnosis and treatment have been considered controversial since the 1970s.^[16] The controversies have involved clinicians, teachers, policymakers, parents and the media. Opinions regarding ADHD range from not believing it exists at all to believing there are genetic and physiological bases for the condition as well as disagreement about the use of stimulant medications in treatment.^[17][18][19] Most healthcare providers accept that ADHD is a genuine disorder with debate in the scientific community centering mainly around how it is diagnosed and treated.^[20][21][22] The AMA Council on Scientific Affairs concluded in 1998 that "(d)iagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness."^[23]

Contents 1 Classification 1.1 Subtypes 1.2 Childhood ADHD 1.3 Adult ADHD 2 Symptoms 2.1 ADHD and other medical conditions 3 Causes 3.1 Genetic factors 3.1.1 Evolutionary theories 3.2 Environmental factors 3.2.1 Diet 3.3 Social factors 3.3.1 Neurodiversity 3.3.2 Social construct theory of ADHD 3.3.3 Low arousal theory 4 Pathophysiology 5 Diagnosis 5.1 DSM-IV criteria 5.2 ICD-10 5.3 Other diagnostic guidelines 5.4 Comorbid conditions 5.5 Differential diagnoses 6 Management 6.1 Behavioral interventions 6.2 Pharmacological treatment 6.2.1 Stimulant medication 6.2.2 Antipsychotic medication 6.2.3 Other non-stimulant medications 6.3 Experimental/ Alternative treatments 7 Prognosis 8 Epidemiology 9 History 10 Society and culture 11 Controversies 12 References 12.1 Bibliography 13 Further reading 14 External links

Classification

ADHD may be seen as one or more continuous traits found normally throughout the general population.^[24] ADHD is a developmental disorder in which certain traits such as impulse control lag in development.^[25] Using magnetic resonance imaging of the prefrontal cortex, this developmental lag has been estimated to range from 3 to 5 years.^[26] These delays are considered to cause impairment. ADHD has also been classified as a behavior disorder.^[27] A diagnosis of ADHD does not, however, imply a neurological disease.^{[24][clarification needed]}

ADHD is classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder and antisocial disorder.^[28]

Subtypes

ADHD has three subtypes:^[29]

• Predominantly hyperactive-impulsive
  • Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
  • Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
• Predominantly inattentive
  • The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
  • Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.
• Combined hyperactive-impulsive and inattentive
  • Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
  • Most children with ADHD have the combined type.

Childhood ADHD

Attention-deficit hyperactivity disorder or ADHD is a common childhood illness that can be treated. It is a health condition involving biologically active substances in the brain. ADHD may affect certain areas of the brain that allow problem solving, planning ahead, understanding others’ actions, and impulse control.^[30]

The American Academy of Child Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child:

• The behaviors must appear before age 7.
• They must continue for at least six months.
• The symptoms must also create a real handicap in at least two of the following areas of the child’s life:
  • in the classroom,
  • on the playground,
  • at home,
  • in the community, or
  • in social settings.^[30]

If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.^[30]

Even if a child’s behavior seems like ADHD, it might not actually be ADHD; careful attention to the process of differential diagnosis is mandatory. Many other conditions and situations can trigger behavior that resembles ADHD. For example, a child might show ADHD symptoms when experiencing:

• A death or divorce in the family, a parent’s job loss, or other sudden change
• Undetected seizures
• An ear infection that causes temporary hearing problems
• Problems with schoolwork caused by a learning disability
• Anxiety or depression^[30]
• Insufficient or poor quality sleep
• Child abuse

Adult ADHD

Main article: Adult attention-deficit disorder

It has been estimated that about eight million adults have ADHD in the United States.^[31] Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized and may rely on non-prescribed drugs and alcohol to get by.^[32] They often have such associated psychiatric comorbidities as depression, anxiety disorder, bipolar disorder, substance abuse, or a learning disability.^[32] A diagnosis of ADHD may offer adults insight into their behaviors and allow patients to become more aware and seek help with coping and treatment strategies.^[31] There is controversy amongst some experts on whether ADHD persists into adulthood. Recognized as occurring in adults in 1978, it is currently not addressed separately from ADHD in childhood. Obstacles that clinicians face when assessing adults who may have ADHD include developmentally inappropriate diagnostic criteria, age-related changes, comorbidities and the possibility that high intelligence or situational factors can mask ADHD.^[33]

Symptoms

Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. The symptoms of ADHD are especially difficult to define because it is hard to draw the line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin.^[4] To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.

The symptom categories of ADHD in children yield three potential classifications of ADHD—predominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met:^[4]:p.4

Predominantly inattentive type symptoms may include:^[34]

• Be easily distracted, miss details, forget things, and frequently switch from one activity to another
• Have difficulty focusing on one thing
• Become bored with a task after only a few minutes, unless they are doing something enjoyable
• Have difficulty focusing attention on organizing and completing a task or learning something new
• Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
• Not seem to listen when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions.

Predominantly hyperactive-impulsive type symptoms may include:^[34]

• Fidget and squirm in their seats
• Talk nonstop
• Dash around, touching or playing with anything and everything in sight
• Have trouble sitting still during dinner, school, and story time
• Be constantly in motion
• Have difficulty doing quiet tasks or activities.

and also these manifestations primarily of impulsivity:^[34]

• Be very impatient
• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
• Have difficulty waiting for things they want or waiting their turns in games

Most people exhibit some of these behaviors, but not to the degree where such behaviors significantly interfere with a person's work, relationships, or studies. The core impairments are consistent even in different cultural contexts.^[35]

Symptoms may persist into adulthood for up to half of children diagnosed with ADHD. Estimating this is difficult as there are no official diagnostic criteria for ADHD in adults.^[4]

A 2009 study found that children with ADHD move around a lot because it helps them stay alert enough to complete challenging tasks.^[36]

ADHD and other medical conditions

ADHD may accompany other disorders such as anxiety or depression. Such combinations can greatly complicate diagnosis and treatment. Academic studies and research in private practice suggest that depression in ADHD appears to be increasingly prevalent in children as they get older, with a higher rate of increase in girls than in boys, and to vary in prevalence with the subtype of ADHD. Where a mood disorder complicates ADHD it would be prudent to treat the mood disorder first, but parents of children who have ADHD often wish to have the ADHD treated first, because the response to treatment is quicker.^[37]

Inattention and "hyperactive" behavior are not the only problems in children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it. Many co-existing conditions require other courses of treatment and should be diagnosed separately instead of being grouped in the ADHD diagnosis. Some of the associated conditions are:

• Oppositional defiant disorder (35%) and conduct disorder (26%) which both are characterized by anti-social behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, or stealing.^[38]
• Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.^[38]
• Mood disorders. Boys diagnosed with the combined subtype have been shown likely to suffer from a mood disorder.^[39]
• Bipolar disorder. As many as 25% of children with ADHD have bipolar disorder. Children with this combination may demonstrate more aggression and behavioral problems than those with ADHD alone.^[38]
• Anxiety disorder, which has been found to be common in girls diagnosed with the inattentive subtype of ADHD.^[40]
• Obsessive-compulsive disorder. OCD is believed to share a genetic component with ADHD and shares many of its characteristics.^[38]

Causes

A specific cause of ADHD is not known.^[41] There are, however, a number of factors that may contribute to ADHD. They include genetics, diet and social and physical environments.

Genetic factors

Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75% of ADHD cases.^[24] Hyperactivity also seems to be primarily a genetic condition; however, other causes do have an effect.^[42]

Researchers believe that a large majority of ADHD cases arise from a combination of various genes, many of which affect dopamine transporters. Candidate genes include dopamine transporter, dopamine receptors D₂/D₃,^[43] dopamine beta-hydroxylase monoamine oxidase A, catecholamine-methyl transferase, serotonin transporter promoter (SLC6A4), 5-hydroxytryptamine 2A receptor (5-HT2A), 5-hydroxytryptamine 1B receptor (5-HT1B),^[44] the 10-repeat allele of the DAT1 gene,^[45] the 7-repeat allele of the DRD4 gene,^[45] and the dopamine beta hydroxylase gene (DBH TaqI).^[46]

The broad selection of targets indicates that ADHD does not follow the traditional model of "a genetic disease" and should therefore be viewed as a complex interaction among genetic and environmental factors. Even though all these genes might play a role, to date no single gene has been shown to make a major contribution to ADHD.^[47]

Evolutionary theories

See also: Hunter vs. farmer theory

The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of ADHD. The theory proposes that hyperactivity may be an adaptive behavior in pre modern humans^[48] and that those with ADHD retain some of the older "hunter" characteristics associated with early pre-agricultural human society. According to this theory, individuals with ADHD may be more adept at searching and seeking and less adept at staying put and managing complex tasks over time.^[49] Further evidence showing hyperactivity may be evolutionarily beneficial was put forth in 2006 in a study which found it may carry specific benefits^{[clarification needed]} for a society.^[50]

Environmental factors

Twin studies to date have also suggested that approximately 9% to 20% of the variance in hyperactive-impulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared environmental (nongenetic) factors.^{[51][52][53][54]}

Environmental factors implicated include alcohol and tobacco smoke exposure during pregnancy and environmental exposure to lead in very early life.^[55] The relation of smoking to ADHD could be due to nicotine causing hypoxia (lack of oxygen) to the fetus in utero.^[56] It could also be that women with ADHD are more likely to smoke^[57] and therefore, due to the strong genetic component of ADHD, are more likely to have children with ADHD.^[58] Complications during pregnancy and birth—including premature birth—might also play a role.^[59] ADHD patients have been observed to have higher than average rates of head injuries;^[60] however, current evidence does not indicate that head injuries are the cause of ADHD in the patients observed.^[61]

Diet

Main article: Diet and attention deficit hyperactivity disorder

A study^[62] conducted by researchers at Southampton University in the United Kingdom and published in The Lancet on November 3, 2007 found a definitive link between children’s ingestion of many commonly used artificial food colors, the preservative sodium benzoate and hyperactivity. In response to these findings, the British government took prompt action. According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers are being encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009. Following the FSA’s actions, the European Commission ruled that any food products containing the “Southampton Six” (The contentious colourings are: sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124)) must display warning labels on their packaging by 2010. In the US, little has been done to curb food manufacturer’s use of artificial food colors, despite the new evidence presented by the Southampton study. However, the existing US Food Drug and Cosmetic Act^[63] had already required that artificial food colors be approved for use, that they must be given FD&C numbers by the FDA, and the use of these colors must be indicated on the package.^[64] This is why food packaging in the USA may state something like: "Contains FD&C Red #40."

Social factors

There is no compelling evidence that social factors alone can cause ADHD.^[25] However, many researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD.^[65] Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse.^[24][66] Furthermore, Complex Post Traumatic Stress Disorder can result in attention problems that can look like ADHD.^[67] ADHD is also considered to be related to sensory integration dysfunction.^[68]

Neurodiversity

Main article: Neurodiversity

Proponents of the neurodiversity theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected just like any other human difference. Social critics argue that while biological factors may play a large role in difficulties with sitting still in class and/or concentrating on schoolwork in some children, these children could have failed to integrate others' social expectations of their behavior for a variety of other reasons.^[69] It has been said that ADHD has a link with creativity.^[70] As genetic research into ADHD proceeds, it may become possible to integrate this information with the neurobiology in order to distinguish disability from varieties of normal or even exceptional functioning in people along the same spectrum of attention differences.^[71]

Social construct theory of ADHD

Main article: Social construct theory of ADHD

Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Thus society members including physicians, parents, teachers, and others are the ones who determine which diagnostic criteria are applied and thus determine the number of people affected.^[72] This is exemplified in the fact that the DSM IV arrives at levels of ADHD three to four times higher than those obtained with use of the ICD 10.^[14] Thomas Szasz, an extreme proponent of this theory, has gone so far as to state that ADHD was "invented and not discovered."^[73][74]

Low arousal theory

Main article: Low arousal theory

According to the low arousal theory, people with ADHD need excessive activity as self-stimulation because of their state of abnormally low arousal.^[75][76] The theory states that those with ADHD cannot self-moderate, and their attention can only be gained by means of environmental stimuli,^[75] which in turn results in disruption of attentional capacity and an increase in hyperactive behaviour.^[77]

Without enough stimulation coming from the environment, an ADHD child will create it him or herself by walking around, fidgeting, talking, etc. This theory also explains why stimulant medications have high success rates and can induce a calming effect at therapeutic dosages among children with ADHD. It establishes a strong link with scientific data that ADHD is connected to abnormalities with the neurochemical dopamine and a powerful link with low-stimulation PET scan results in ADHD subjects.^[75]

Pathophysiology

Diagram of a human brain.

The pathophysiology of ADHD is unclear and there are a number of competing theories.^[78] Research on children with ADHD has shown a general reduction of brain volume, but with a proportionally greater reduction in the volume of the left-sided prefrontal cortex. These findings suggest that the core ADHD features of inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction, but other brain regions particularly the cerebellum have also been implicated.^[79] Neuroimaging studies in ADHD have not always given consistent results and as of 2008 are only used for research not diagnostic purposes.^[80] A 2005 review of published studies involving neuroimaging, neuropsychological genetics, and neurochemistry found converging lines of evidence to suggest that four connected frontostriatal regions play a role in the pathophysiology of ADHD: The lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, and putamen.^[81]

In one study a delay in development of certain brain structures by an average of three years occurred in ADHD elementary school aged patients. The delay was most prominent in the frontal cortex and temporal lobe, which are believed to be responsible for the ability to control and focus thinking. In contrast, the motor cortex in the ADHD patients was seen to mature faster than normal, suggesting that both slower development of behavioral control and advanced motor development might be required for the fidgetiness that characterizes ADHD.^[82] It should be noted that stimulant medication itself may affect growth factors of the central nervous system.^[83]

The same laboratory had previously found involvement of the "7-repeat" variant of the dopamine D4 receptor gene, which accounts for about 30 percent of the genetic risk for ADHD, in unusual thinness of the cortex of the right side of the brain; however, in contrast to other variants of the gene found in ADHD patients, the region normalized in thickness during the teen years in these children, coinciding with clinical improvement.^[84]

Additionally, SPECT scans found people with ADHD to have reduced blood circulation (indicating low neural activity),^[85] and a significantly higher concentration of dopamine transporters in the striatum which is in charge of planning ahead.^[86][87] A study by the U.S. Department of Energy’s Brookhaven National Laboratory in collaboration with Mount Sinai School of Medicine in New York suggest that it is not the dopamine transporter levels that indicate ADHD, but the brain's ability to produce dopamine itself. The study was done by injecting 20 ADHD subjects and 25 control subjects with a radiotracer that attaches itself to dopamine transporters. The study found that it was not the transporter levels that indicated ADHD, but the dopamine itself. ADHD subjects showed lower levels of dopamine across the board. They speculated that since ADHD subjects had lower levels of dopamine to begin with, the number of transporters in the brain was not the telling factor. In support of this notion, plasma homovanillic acid, an index of dopamine levels, was found to be inversely related not only to childhood ADHD symptoms in adult psychiatric patients, but to "childhood learning problems" in healthy subjects as well.^[88]

A 1990 PET scan study by Alan J. Zametkin et al. found that global cerebral glucose metabolism was 8% lower in medication-naive adults who had been hyperactive since childhood.^[89] Further studies found that chronic stimulant treatment had little effect on global glucose metabolism,^[90] a 1993 study in girls failed to find a decreased global glucose metabolism, but found significant differences in glucose metabolism in 6 specific regions of the brains of ADHD girls as compared to control subjects. The study also found that differences in one specific region of the frontal lobe were statistically correlated with symptom severity.^[91] A further study in 1997 also failed to find global differences in glucose metabolism, but similarly found differences in glucose normalization in specific regions of the brain. The 1997 study also noted that their findings were somewhat different than those in the 1993 study, and concluded that sexual maturation may have played a role in this discrepancy.^[92] The significance of the research by Zametkin has not been determined and neither his group nor any other has been able to replicate the 1990 results.^[93][94][95]

Critics, such as Jonathan Leo and David Cohen, who reject the characterization of ADHD as a disorder,^{[citation needed]} contend that the controls for stimulant medication usage were inadequate in some lobar volumetric studies which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for the decreased thickness observed^[96] in certain brain regions. While the main study in question used age-matched controls, it did not provide information on height and weight of the subjects. These variables it has been argued could account for the regional brain size differences rather than ADHD itself.^[97][98] They believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.^[97]

Diagnosis

ADHD is diagnosed via a psychiatric assessment; to rule out other potential causes or comorbidities, physical examination, radiological imaging, and laboratory tests may be used.^[99]

In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD-10.^[100] If the DSM-IV criteria is used rather than the ICD-10 a diagnosis ADHD is 3–4 times more likely.^[14] Factors other than those within the DSM or ICD however have been found to effect the diagnosis in clinical practice. A child's social and school environment as well as academic pressures at school are likely to be of influence.^[101]

Many of the symptoms of ADHD occur from time to time in everyone; in patients with ADHD, the frequency of these symptoms is greater and patients' lives are significantly impaired. Impairment must occur in multiple settings to be classified as ADHD. As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified:

1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
2. ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
3. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but criterion 1A is not met for the past six months.

The previously used term ADD expired with the most recent revision of the DSM. Consequently, ADHD is the current nomenclature used to describe the disorder as one distinct disorder which can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD, predominately hyperactive-impulsive type) or inattention (ADHD predominately inattentive type) or both (ADHD combined type).

DSM-IV criteria

I. Either A or B:^[102]

EITHER

(A.) Six or more of the following signs of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

• Inattentive:

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.
6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Often forgetful in daily activities.

OR

(B.) Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

• Hyperactivity:

1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.

• Impulsiveness:

1. Often blurts out answers before questions have been finished.
2. Often has trouble waiting one's turn.
3. Often interrupts or intrudes on others (example: butts into conversations or games).

II. Some signs that cause impairment were present before age 7 years.

III. Some impairment from the signs is present in two or more settings (such as at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a Personality Disorder).

ICD-10

In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name "Hyperkinetic disorders". When a conduct disorder (as defined by ICD-10^[103]) is present, the condition is referred to as "Hyperkinetic conduct disorder". Otherwise the disorder is classified as "Disturbance of Activity and Attention", "Other Hyperkinetic Disorders" or "Hyperkinetic Disorders, Unspecified". The latter is sometimes referred to as, "Hyperkinetic Syndrome".^[103]

Other diagnostic guidelines

The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria:^[104]

• The use of explicit criteria for the diagnosis using the DSM-IV-TR.
• The importance of obtaining information about the child’s signs in more than one setting.
• The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

All three criteria are determined using the patient's history given by the parents, teachers and/or the patient.

Adults often continue to be impaired by ADHD. Adults with ADHD are diagnosed under the same criteria, including the stipulation that their signs must have been present prior to the age of seven.^[102] Adults face some of their greatest challenges in the areas of self-control and self-motivation, as well as executive functioning, usually having more signs of inattention and fewer of hyperactivity or impulsiveness than children do.^[105]

Comorbid conditions

Common comorbid conditions include oppositional defiant disorder (ODD). About 20% to 25% of children with ODD meet criteria for a learning disorder.^[106] Learning disorders are more common when there are inattention signs.^[107]

Comorbid disorders or substance abuse can make the diagnosis and treatment of ADHD more difficult. Psychosocial therapy is useful in treating some comorbid conditions.^[108] ADHD is not, in boys, associated with increased substance misuse unless there is comorbid conduct disorder; but "research needs to examine the extent to which ADHD in adulthood increases the risk of substance use disorders."^[109]

Depression may also coincide with ADHD, increasingly prevalent among girls and older children.^[37]

Epilepsy is a commonly found comorbid disorder in ADHD diagnosed individuals. Some forms of epilepsy can also cause ADHD like behaviour which can be misdiagnosed as ADHD.^[110][111]

Differential diagnoses

To make the diagnosis of ADHD, a number of other possible medical and psychological conditions must be excluded.

Medical conditions

Medical conditions that must be excluded include: hypothyroidism, anemia, lead poisoning, chronic illness, hearing or vision impairment, substance abuse, medication side effects, sleep impairment and child abuse, among others.^[112]

Sleep conditions

As with other psychological and neurological issues, the relationship between ADHD and sleep is complex. In addition to clinical observations, there is substantial empirical evidence from a neuroanatomic standpoint to suggest that there is considerable overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal.^[113] Primary sleep disorders play a role in the clinical presentation of symptoms of inattention and behavioral dysregulation. There are multilevel and bidirectional relationships among sleep, neurobehavioral functioning and the clinical syndrome of ADHD.^[114]

Behavioral manifestations of sleepiness in children range from the classic ones (yawning, rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to mood lability and inattentiveness.^[113][115] Many sleep disorders are important causes of symptoms which may overlap with the cardinal symptoms of ADHD; children with ADHD should be regularly and systematically assessed for sleep problems.^[113][116]

From a clinical standpoint, mechanisms that account for the phenomenon of excessive daytime sleepiness include:

• Chronic sleep deprivation, that is insufficient sleep for physiologic sleep needs,
• Fragmented or disrupted sleep, caused by, for example, obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD),
• Primary clinical disorders of excessive daytime sleepiness, such as narcolepsy and
• Circadian rhythm disorders, such as delayed sleep phase syndrome (DSPS). A study in the Netherlands compared two groups of unmedicated 6-12-year-olds, all of them with "rigorously diagnosed ADHD". 87 of them had problems getting to sleep, 33 had no sleep problems. The larger group had a significantly later dim light melatonin onset (DLMO) than did the children with no sleep problems.^[117]

Management

Main article: Attention-deficit hyperactivity disorder management

Methods of treatment often involve some combination of behavior modification, life-style changes, counseling, and medication. A 2005 study found that medical management and behavioral treatment is the most effective ADHD management strategy, followed by medication alone, and then behavioral treatment.^[118] While medication has been shown to improve behavior when taken over the short term, they have not been shown to alter long term outcomes.^[119]

Behavioral interventions

A 2009 review concluded that the evidence is strong for the effectiveness of behavioral treatments in ADHD.^[120]

Psychological therapies used to treat ADHD include psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training and parent management training.^[24]

Parent training and education have been found to have short term benefits.^[121] Family therapy has shown to be of little use in the treatment of ADHD,^[122] though it may be worth noting that parents of children with ADHD are more likely to divorce than parents of children without ADHD, particularly when their children are younger than eight years old.^[123]

Several ADHD specific support groups exist as informational sources and to help families cope with challenges associated with dealing with ADHD.

A 2009 study found that children with ADHD move around a lot because it helps them stay alert enough to complete challenging tasks. The researcher advises that when they are doing homework, one should let them fidget, stand or chew gum since it may help them cope. Unless their behavior is destructive, severely limiting their activity could be counterproductive.^[36]

Pharmacological treatment

Management with medication has been shown to be the most cost-effective, followed by behavioral treatment and combined treatment in a 14 month follow-up study.^[118] However, a longer follow-up study of 3 years found that stimulant medication offered no benefits over behavioural therapy.^[124] Stimulant medication or non-stimulant medication may be prescribed. A 2007 drug class review found that there are no good studies of comparative effectiveness between various drugs for ADHD and that there is a lack of quality evidence on their effects on overall academic performance and social behaviors.^[125] The long term effects of ADHD medications in preschool children are unknown and are not recommended for pre-school children.^[24][126] There is very little data on the long-term adverse effects or benefits of stimulants for ADHD.^[127]

Stimulant medication

Stimulants are the most commonly prescribed medications for ADHD. The most common stimulant medications are the chain subsitituted amphetamine methylphenidate (Ritalin, Metadate, Concerta), dextroamphetamine (Dexedrine), mixed amphetamine salts (Adderall),^[128][129] dextromethamphetamine (Desoxyn)^[130] and lisdexamfetamine (Vyvanse).^[131]

A meta analysis of clinical trials found that about 70% of children improve after being treated with stimulants in the short term but found that this conclusion may be biased due to the high number of low quality clinical trials in the literature. There have been no randomized placebo controlled clinical trials investigating the long term effectiveness of methylphenidate (Ritalin) beyond 4 weeks. Thus the long term effectiveness of methylphenidate has not been scientifically demonstrated. Serious concerns of publication bias regarding the use of methylphenidate for ADHD has also been noted.^[132]

Higher rates of schizophrenia and bipolar disorder as well as increased severity of these disorders occur in individuals with a past history of stimulant use for ADHD in childhood.^[133]

Both children with and without ADHD abuse stimulants, with ADHD individuals being at the highest risk of abusing or diverting their stimulant prescriptions. Between 16 and 29 percent of students who are prescribed stimulants report diverting their prescriptions. Between 5 and 9 percent of grade/primary and high school children and between 5 and 35 percent of college students have used nonprescribed stimulants. Most often their motivation is to concentrate, improve alertness, "get high," or to experiment.^[134]

Stimulants used to treat ADHD raise the extracellular concentrations of the neurotransmitters dopamine and norepinephrine which causes an increase in neurotransmission. The therapeutic benefits are due to noradrenergic effects at the locus coeruleus and the prefrontal cortex and dopaminergic effects at the nucleus accumbens.^[135]

One study found that children with ADHD actually need to move more to maintain the required level of alertness while performing tasks that challenge their working memory. Performing math problems mentally and remembering multi-step directions are examples of tasks that require working memory, which involves remembering and manipulating information for a short time. These findings may also explain why stimulant medications improve the behavior of most children with ADHD. Those medications improve the physiological arousal of children with ADHD, increasing their alertness.^[36] Previous studies have shown that stimulant medications temporarily improve working memory abilities.

Although "under medical supervision, stimulant medications are considered safe",^[104][136] the use of stimulant medications for the treatment of ADHD has generated controversy because of undesirable side effects, uncertain long term effects^{[11][127][137][138][139]} and social and ethical issues regarding their use and dispensation. The FDA has added black-box warnings to some ADHD medications,^[140][141] while the American Heart Association and the American Academy of Pediatrics feel that it is prudent to carefully assess children for heart conditions before treating them with stimulant medications.^[142]

Antipsychotic medication

On the contrary to stimulant medication, atypical antipsychotic drug use is rising among ADHD children. Antipsychotics work by blocking dopamine whereas stimulants trigger its release, putting further stigma on the pharmacological treatment of ADHD. As a second-line approach to treatment in children who do not respond to stimulant medications, this class of drugs has not been well-studied or proven to work safely in children with the disorder. Weight gain, heart rhythm problems, diabetes and the possibility of irreversible movement disorders (tardive dyskinesia) are among the short and long-term adverse events associated with antipsychotic drugs.^[143][144]

Other non-stimulant medications

Atomoxetine (Strattera) is currently the only non-stimulant drug approved for the treatment of ADHD. Other medications which may be prescribed off-label include alpha-2A adrenergic receptor blockers such as guanfacine and clonidine, certain antidepressants such as tricyclic antidepressants, SNRIs or MAOIs.^{[145][146][147][148]}

Another non-stimulant drug that has been used to treat ADHD is the analeptic drug modafinil. There have been double-blind randomised controlled trials that have demonstrated the efficacy and tolerability of modafinil,^[149][150] however there are risks of serious side effects such as skin reactions and modafinil is not recommended for use in children.^[151]

Experimental/ Alternative treatments

Dietary supplements and specialized diets are sometimes used by people with ADHD with the intent to mitigate some or all of the symptoms. For example, Omega-3 supplementation (seal, fish or krill oil) may reduce ADHD symptoms for a subgroup of children and adolescents with ADHD "characterized by inattention and associated neurodevelopmental disorders."^[152] Although vitamin or mineral supplements (micronutrients) may help children diagnosed with particular deficiencies, there is no evidence that they are helpful for all children with ADHD. Furthermore, megadoses of vitamins, which can be toxic, must be avoided.^[153] In the United States, no dietary supplement has been approved for the treatment for ADHD by the FDA.^[154] There is however a pilot study done which shows that phosphatidyl serine (PS) can help against ADHD.^[155][156]

EEG biofeedback is a treatment strategy used for children, adolescents and adults with ADHD.^[157] The human brain emits electrical energy which is measured with electrodes on the brain. Biofeedback alerts the patient when beta waves are present. This theory believes that those with ADHD can train themselves to decrease ADHD symptoms. There is a distinct split in the scientific community about the effectiveness of the treatment. A number of studies indicate the scientific evidence has been increasing in recent years for the effectiveness of EEG biofeedback for the treatment of ADHD. According to a 2007 review, with effectiveness of the treatment was demonstrated to be equivalent to that of stimulant medication. The review noted, improvements are seen at the behavioral and neuropsychological level with the symptoms of inattention, hyperactivity and impulsivity showing significant decreases after treatment. There are no known side effects from EEG biofeedback therapy. There are methodological limitations and weaknesses in study designs however. In a 2005 review, Loo and Barkley stated that problems including lack of blinding such as placebo control and randomisation are significant limitations to the studies into EEG biofeedback and make definitive conclusions impossible to make.^[158] As a result more robust clinical studies have been strongly recommended.^[159] A German review in 2004 found that EEG biofeedback, also sometimes referred to as neurofeedback, is more effective than previously thought in treating attention deficiency, impulsivity and hyperactivity; short-term effects match those of stimulant treatment and a persistent normalization of EEG parameters is found which is not found after treatment with stimulants.^[160] There are no known side effects from biofeedback therapy although research into biofeedback has been limited and further research has been recommended.^[160] An American review the following year also emphasized the benefits of this method.^[161] Similar findings were reported in a study by another German team in 2004.^[162]

Aerobic fitness may improve cognitive functioning and neural organization related to executive control during pre-adolescent development, though more studies are needed in this area.^[163] One study suggests that athletic performance in boys with ADHD may increase peer acceptance when accompanied by fewer negative behaviors.^[164]

Art is thought by some to be an effective therapy for some of the symptoms of ADHD. Other sources, including some psychologists who have written on the subject, feel that cutting down on time spent on television, video games, or violent media can help some children. One study indicated a correlation between excessive TV time as a child with higher rates of ADHD symptoms.^[165] Other therapies that have been effective for some have been ADHD coaching, positive changes in diet, such as low sugar, low additives, and no caffeine. Children who spend time outdoors in natural settings, such as parks, seem to display fewer symptoms of ADHD, which has been dubbed "Green Therapy".^[166]

Prognosis

Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment.^[167] In the United States, 37% of those with ADHD do not get a high school diploma even though many of them will receive special education services.^[25] A 1995 briefing citing a 1994 book review says the combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish high school.^[168] Also in the US, less than 5% of individuals with ADHD get a college degree^[169] compared to 28% of the general population.^[170] Those with ADHD as children are at increased risk of a number of adverse life outcomes once they become teenagers. These include a greater risk of auto crashes, injury and higher medical expenses, earlier sexual activity, and teen pregnancy.^[171] Russell Barkley states that adult ADHD impairments affect "education, occupation, social relationships, sexual activities, dating and marriage, parenting and offspring psychological morbidity, crime and drug abuse, health and related lifestyles, financial management, or driving. ADHD can be found to produce diverse and serious impairments".^[172] The proportion of children meeting the diagnostic criteria for ADHD drops by about 50% over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD.^{[112][124][138]} ADHD persists into adulthood in about 30-50% of cases.^[8] Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.^[10]

Epidemiology

ADHD's global prevalence is estimated at 3-5% in people under the age of 19. There is, however, both geographical and local variability among studies. Geographically, children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East,^[173] well published studies have found rates of ADHD as low as 2% and as high as 14% among school aged children.^[27] The rates of diagnosis and treatment of ADHD are also much higher on the East Coast of the USA than on the West Coast.^[174] The frequency of the diagnosis differs between male children (10%) and female children (4%) in the United States.^[175] This difference between genders may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.^[176]

Rates of ADHD diagnosis and treatment have increased in both the UK and the USA since the 1970s. In the UK an estimated 0.5 per 1,000 children had ADHD in the 1970s, while 3 per 1,000 received ADHD medications in the late 1990s. In the USA in the 1970s 12 per 1,000 children had the diagnosis, while in the late 1990s 34 per 1,000 had the diagnosis and the numbers continue to increase.^[24]

In the UK in 2003 a prevalence of 3.6% is reported in male children and less than 1% is reported in female children.^[177]

As of 2009^[update], eight percent of all Major League Baseball players have been diagnosed with ADHD, making the disease epidemic among this population. The increase coincided with the League's 2006 ban on stimulants (q.v. Major League Baseball drug policy).^[178]

History

Main article: History of attention-deficit hyperactivity disorder

Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his 1798 book.^[179][180] The terminology used to describe the symptoms of ADHD has gone through many changes over history including: "minimal brain damage", "minimal brain dysfunction", "learning/behavioral disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood". In the DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced. In 1987 this was changed to ADHD in the DSM-III-R and subsequent editions.^[181] The use of stimulants to treat ADHD was first described in 1937.^[182]

Society and culture

The media have reported on many issues related to ADHD. In 2001 PBS's Frontline aired a one-hour program about the effects of the diagnosis and treatment of ADHD in minors, entitled "Medicating Kids."^[183] The program included a selection of interviews with representatives of various points of view. In one segment, entitled Backlash, retired neurologist Fred Baughman and Peter Breggin whom PBS described as "outspoken critics who insist [ADHD is] a fraud perpetrated by the psychiatric and pharmaceutical industries on families anxious to understand their children's behavior"^[184] were interviewed on the legitimacy of the disorder. Russell Barkley and Xavier Castellanos, then head of ADHD research at the National Institute of Mental Health (NIMH), defended the viability of the disorder. In the interview with Castellanos, he stated that little is scientifically understood.^[185] Lawrence Diller was interviewed on the business of ADHD along with a representative from Shire Plc.^{[citation needed]}

A number of notable individuals have given controversial opinions on ADHD. Scientologist Tom Cruise's interview with Matt Lauer was widely watched by the public. In this interview he spoke about postpartum depression and also referred to Ritalin and Adderall as being "street drugs" rather than as ADHD medication.^[186] In England Baroness Susan Greenfield, a leading neuroscientist, spoke out publicly about the need for a wide-ranging inquiry in the House of Lords into the dramatic increase in the diagnosis of ADHD in the UK and possible causes^[187] following a 2007 BBC Panorama programme which highlighted US research (The Multimodal Treatment Study of Children with ADHD by the University of Buffalo showing treatment results of 600) suggesting drugs are no better than other forms of therapy for ADHD in the long term.^[188]

Controversies

This article's Criticism or Controversy section(s) may mean the article does not present a neutral point of view of the subject. It may be better to integrate the material in those sections into the article as a whole. (September 2009)

Main article: Attention-deficit hyperactivity disorder controversies

ADHD and its diagnosis and treatment have been considered controversial since the 1970s.^{[16][18][189]} The controversies have involved clinicians, teachers, policymakers, parents and the media. Opinions regarding ADHD range from not believing it exists at all to believing there are genetic and physiological bases for the condition as well as disagreement about the use of stimulant medications in treatment.^[17][18][19] Most healthcare providers accept that ADHD is a genuine disorder with debate in the scientific community centering mainly around how it is diagnosed and treated.^[20][21][22]

Others have included that it may stem from a misunderstanding of the diagnostic criteria and how they are utilized by clinicians,^[4]:p.3 teachers, policymakers, parents and the media.^[17] Debates center around: whether ADHD is a disability or whether it is merely a neurological description, the cause of the disorder, the changing of the diagnostic criteria, and the rapid increase in diagnosis of ADHD and the use of stimulants to treat the disorder.^[190] Some do not believe it exists at all.^[17] Long term possible side effects of stimulants and their usefulness are largely unknown because of a lack of long term studies.^[191] Some research raises questions about the long term effectiveness and side effects of medications used to treat ADHD.^[192]

In 1998, the US National Institutes of Health (NIH) released a consensus statement on the diagnosis and treatment of ADHD. The statement, while recognizing that stimulant treatment is controversial, supports the validity of the ADHD diagnosis and the efficacy of stimulant treatment. It found controversy only in the lack of sufficient data on long-term use of medications, and in the need for more research in many areas.^[193]

The British Psychological Society said in a 1997 report that physicians and psychiatrists should not follow the American example of applying medical labels to such a wide variety of attention-related disorders: "The idea that children who don’t attend or who don’t sit still in school have a mental disorder is not entertained by most British clinicians."^[194][195]

However, several years later, in 2009, the British Psychological Society, in collaboration with the Royal College of Psychiatrists, released a set of guidelines for the diagnosis and treatment of ADHD.^[196]

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Bibliography

• Dr Jennifer Erkulwater; Dr Rick Mayes; Dr Catherine Bagwell (2009). Medicating Children: ADHD and Pediatric Mental Health. Cambridge: Harvard University Press. pp. 5. ISBN 0-674-03163-6. 

Further reading

Look up ADHD, ADHD-PI, ADHD-C, or ADHD-PH/I in Wiktionary, the free dictionary.

• Barkley, Russell A. Take Charge of ADHD: The Complete Authoritative Guide for Parents (2005) New York: Guilford Publications.
• Conrad, Peter Identifying Hyperactive Children (Ashgate, 2006).
• Crawford, Teresa I'm Not Stupid! I'm ADHD!
• Faraone, Stephen V. (2005). The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Eur Child Adolesc Psychiatry 14, 1-10.
• Faraone, Stephen, V.Straight Talk about Your Child's Mental Health: What to Do When Something Seems Wrong (2003) New York:Guilford Press
• Green, Christopher, Kit Chee, Understanding ADD; Doubleday 1994; ISBN 0-86824-587-9
• Hanna, Mohab. (2006) Making the Connection: A Parent's Guide to Medication in ADHD, Washington D.C.: Ladner-Drysdale.
• Hartmann, Thom (2003). The Edison gene: ADHD and the gift of the hunter child. Rochester, Vt: Park Street Press. ISBN 0-89281-128-5. 
• Matlen, Terry. (2005) "Survival Tips for Women with AD/HD". ISBN 1-886941-59-9
• Ninivaggi, F.J. "Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: Rethinking Diagnosis and Treatment Implications for Complicated Cases", Connecticut Medicine. September 1999; Vol. 63, No. 9, 515-521. PMID 10531701
• Southall, Angela (2007). The Other Side of ADHD:Attention Deficit Hyperactivity Disorder Exposed and Explained. Radcliffe Publishing Ltd. ISBN 1846190681. http://books.google.ca/books?id=AKXhThWgvyYC&pg=PA41&lpg=PA41&dq=barkley+drug+company+funding&source=bl&ots=X-Twuf7Jvx&sig=FE3J6Ov1puhnrxC3c-464VbbVaE&hl=en&sa=X&oi=book_result&resnum=1&ct=result#PPP1,M1. Retrieved 2009-05-02. 

Adult ADHD

• Kelly, Kate, Peggy Ramundo. (1993) You Mean I'm Not Lazy, Stupid or Crazy?! A Self-Help Book for Adults with Attention deficit Disorder. ISBN 0-684-81531-1
• Ratey, Nancy. (2008) The Disorganized Mind: Coaching Your ADHD Brain to Take Control of Your Time, Tasks, and Talents. ISBN 0312355335
• Weiss, Lynn. (2005) Attention Deficit Disorder in Adults, 4th Edition: A Different Way of Thinking ISBN 1589792378

External links

• National Institute of Mental Health on ADHD
• "CG72 Attention deficit hyperactivity disorder (ADHD): full guideline" (PDF). NHS. 09 March 2009. http://www.nice.org.uk/nicemedia/pdf/ADHDFullGuideline.pdf. Retrieved 2009-01-08. 
• New Zealand MOH Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder

v • d • e Attention-deficit hyperactivity disorder Main articles History of ADHD · ADHD in adults · ADHD controversies · ADHD management · List of ADHD organizations · Social construct theory of ADHD · ADHD coaching Major characteristics: Attention · Hyperactivity · Impulsivity Sub-types ADHD predominantly inattentive (ADHD-I, formerly ADD) · ADHD predominantly hyperactive (ADHD-H, formerly ADHD) · ADHD combined type (ADHD-C) Notable Publications Driven to Distraction (1994) · Delivered from Distraction (2005) Notable Experts Russell Barkley · Stephen Faraone · Edward Hallowell · John Ratey · Joseph Biederman · 19th Century: Alexander Crichton Relevant Drugs methylphenidate (Ritalin) · dextroamphetamine (Dexedrine) · mixed amphetamine salts (Adderall) · Non-stimulant: Atomoxetine (Strattera) · More... See also: Low arousal theory · Sluggish cognitive tempo · Sensory integration dysfunction · Hypokalemic sensory overstimulation · Deficits in Attention, Motor control and Perception

v • d • e Mental and behavioral disorders (F · 290–319) Neurological/symptomatic Dementia (Alzheimer's disease, multi-infarct dementia, Pick's disease, Creutzfeldt–Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex, Frontotemporal dementia, Sundowning, Wandering) · Delirium · Post-concussion syndrome · Organic brain syndrome Psychoactive substance/ substance abuse/ drug abuse/ substance-related disorder alcohol (acute alcohol intoxication, drunkenness, alcohol dependence, alcoholic hallucinosis, Alcohol withdrawal, delirium tremens, Korsakoff's syndrome, alcohol abuse) · opioids (opioid overdose, opioid dependency) · sedative/hypnotic (benzodiazepine overdose, benzodiazepine dependence, benzodiazepine withdrawal) · cocaine (cocaine dependence) · general (Intoxication/Drug overdose, Physical dependence, Rebound effect, Withdrawal) Schizophrenia, schizotypal and delusional Psychosis (Schizoaffective disorder, Schizophreniform disorder, Brief reactive psychosis) · Schizophrenia (Disorganized schizophrenia, Delusional disorder, Folie à deux) · Personality disorder (Schizotypal personality disorder) Mood (affective) Mania · Bipolar disorder (Bipolar I, Bipolar II, Cyclothymia) · Depression (Major depressive disorder, Dysthymia, Seasonal affective disorder, Atypical) Neurotic, stress-related and somatoform Anxiety disorder Phobia Agoraphobia · Social anxiety/Social phobia (Anthropophobia) · Specific phobia (Claustrophobia) Other Panic disorder/Panic attack · Generalized anxiety disorder · OCD · stress (Acute stress reaction, PTSD) Adjustment disorder Adjustment disorder with depressed mood Somatoform disorder Somatization disorder · Body dysmorphic disorder · Hypochondriasis · Nosophobia · Da Costa's syndrome · Psychalgia · Conversion disorder (Ganser syndrome, Globus pharyngis) · Neurasthenia Dissociative disorder Dissociative identity disorder · Psychogenic amnesia · Fugue state · Depersonalization disorder Physiological/physical behavioral Eating disorder Anorexia nervosa · Bulimia nervosa · Rumination syndrome · NOS Nonorganic sleep disorders Dyssomnia (Nonorganic hypersomnia, Nonorganic insomnia) · Parasomnia (REM behavior disorder, Night terror, Nightmare) Sexual dysfunction Erectile dysfunction · Premature ejaculation · Vaginismus · Dyspareunia · Hypersexuality · Female sexual arousal disorder Postnatal Postpartum depression · Postnatal psychosis Adult personality and behavior Personality disorder · Impulse control disorder (Kleptomania, Trichotillomania, Pyromania) · Factitious disorder (Munchausen syndrome) · Sexual maturation disorder · Ego-dystonic sexual orientation · Sexual relationship disorder · Paraphilia (Voyeurism, Fetishism) Mental disorders diagnosed in childhood Mental retardation X-Linked mental retardation (Lujan-Fryns syndrome) Psychological development (developmental disorder) Specific speech and language (expressive language disorder, aphasia, expressive aphasia, receptive aphasia, Landau–Kleffner syndrome, lisp) · Scholastic skills (dyslexia, dysgraphia, Gerstmann syndrome) · Motor function (developmental dyspraxia) Pervasive Autism · Rett syndrome · Asperger syndrome Behavioral and emotional ADHD · Conduct disorder (ODD) · emotional disorder (Separation anxiety disorder) · social functioning (Selective mutism, RAD, DAD) · Tic disorder (Tourette syndrome) · Speech (Stuttering, Cluttering) · Movement disorder (Stereotypic) psychology navs: mental processes, disorders, symptoms/signs, speech/voice, psychotherapy

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