ADD / ADHD

Attention deficit/hyperactivity disorder

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

Signs and Symptoms

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

Symptoms of Inattention
Fails to pay close attention to details or makes careless mistakes Has difficulty sustaining attention in tasks or play activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities

Symptoms of Hyperactivity and Impulsivity

Fidgets with hands or feet or squirms in seat Leaves seat in situations where remaining seated is expected Runs or climbs excessively in inappropriate situations (in adolescents or adults, may be limited to subjective feelings of restlessness) Has difficulty playing or engaging in leisure activities quietly Acts as if "driven by a motor" Talks excessively Blurts out answers before questions are completed Has difficulty awaiting turn Interrupts or intrudes on others

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

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

Diagnosis
The names and symptoms for ADHD have changed frequently since the turn of the century. What is now referred to as ADHD has been described in the past as Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, and Attention Deficit Disorder (ADD) With or Without Hyperactivity. The name ADHD was adopted in 1987 by the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR). Diagnosis is largely dependent on specific observed behaviors. The first step in establishing the diagnosis of ADHD is to determine whether the individual meets the diagnostic criteria as defined in the DSM-IV. The DSM-IVs symptomatic criteria were developed for children; there are no specific criteria for ADHD in adults. In these cases, physicians will often determine the psychiatric status of the adult patient as a child and make a retroactive diagnosis of childhood ADHD. Since most of the characteristic behaviors of childhood ADHD occur at home and in the school setting, parents and teachers play an important role in providing information to establish the diagnosis.

DSM-IV Diagnostic Criteria:

Either (1) or (2) Six (or more) symptoms of inattention that persist for at least 6 months to a maladaptive degree inconsistent with the child's developmental level Six (or more) symptoms of hyperactivity-impulsivity that persist for at least 6 months to a maladaptive degree inconsistent with the child's developmental level Some inattentive or hyperactive-impulsive symptoms that caused impairment were present before the age of 7 years Some impairment from symptoms present in two or more settings (such as at school/work and home) Clear evidence of significant impairment in functioning Symptoms not secondary to another psychological disorder (such as mood disorder, anxiety disorder) Although most children with ADHD have symptoms of both inattention and hyperactivity-impulsivity, some tend to demonstrate symptoms from one cluster or the other. These specific subtypes of ADHD are based on the predominant symptom pattern exhibited for the past 6 months: ADHD, Combined Type: if both A1 and A2 criteria are met ADHD, Predominantly Inattentive Type: if A1 is met but A2 is not ADHD, Predominantly Hyperactive-Impulsive Type: if A2 is met but A1 is not

Preventive Care
There are no targeted prevention programs for ADHD. Nevertheless, the following steps may be taken to help reduce the risk of neurobehavioral disorders including ADHD: Minimizing exposures to potential neurotoxins (such as lead, heavy metals, pesticides, herbicides) in the environment Screening children for high levels of lead in the blood and treating this immediately

Obtaining comprehensive healthcare before, during and immediately following pregnancy (optimal vitamin, mineral, and essential fatty acid status) Addressing psychosocial stressors in the lives of all children

Nutrition and Dietary Supplements

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

Dietary Restrictions
Additives and allergies In 1975, Benjamin Feingold, a practicing allergist, proposed that artificial colors, flavors, and preservatives, as well as naturally occurring salicylates (found in many fruits and vegetables), were a major cause of hyperactive behavior and learning disabilities in children. According to his observations, eliminating all of these substances dramatically improved ADHD symptoms in 50% of children, and reintroducing them one at a time caused the symptoms to recur. Although the original Feingold diet was based on his clinical experience, a number of well-designed studies have found an association between certain dietary constituents and poor behavior in children. One such study assessed the effects of food coloring on behavior in 34 hyperactive children and 20 children with no behavioral problems. All children were maintained on a color-free diet and were randomly given one colorless capsule containing either lactose (placebo) or tartrazine (yellow food coloring) at varying doses each morning for 21 days. Twenty-four of the 54 children became more irritable and restless after taking tartrazine, whereas all of the children behaved normally when given placebo. In a similar study of 26 children with ADHD, behavior improved on days when certain foods (corn, wheat, milk, soy, oranges, and food coloring) were eliminated from the diet. Behavior worsened on days when these same foods were reintroduced to the diet. Notably, most of the children who demonstrated an improvement in behavior with these restrictive diets in both of the studies described also had a history of allergies (such as asthma and allergic rhinitis). Eggs, peanuts, and fish are foods believed to carry a high risk of causing an allergic reaction. Some researchers speculate that eliminating these foods from the diet may improve symptoms of ADHD in certain children.

Dietary supplements
A well-balanced diet rich in micronutrients is essential for normal brain development, particular in young children. In fact, many children with nutrient deficiencies have significant cognitive and behavioral problems.

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

Vitamin B6
Adequate levels of vitamin B6 (pyridoxine) are required for normal brain development and are essential for the synthesis of essential brain chemicals including serotonin, dopamine and norepinephrine. A preliminary study found that pyridoxine was slightly more effective than methylphenidate (the most commonly used stimulant) in improving behavior among hyperactive children.

Iron

Iron deficiency is common among children and adolescents, particularly in lower socioeconomic groups where it affects half of all infants. Normal levels of iron in the blood are necessary for optimal brain function. Symptoms of iron deficiency include decreased attention, arousal, and social responsiveness.

Zinc
Zinc regulates the activity of neurotransmitters, fatty acids, and melatonin, all of which are related to the biology of behavior. Two separate studies found that children with ADHD have significantly lower blood zinc levels than children without ADHD. Another study indicated that ADHD children with mild zinc deficiency may be less likely to improve from a commonly prescribed stimulant than children with adequate zinc levels.

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

Essential Fatty Acids

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

Massage and Physical Therapy

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

Mind/Body Medicine
Mind/body techniques such as hypnotherapy, progressive relaxation, and biofeedback are particularly well suited to children and adolescents. Children tend to readily accept hypnotic suggestion and the visual process of biofeedback works well for children of this generation because many are accustomed to computerized graphics. Through these techniques, children are often able to learn coping skills that will stay with them for the rest of their lives. These treatments allow children to gain a sense of control and mastery, increase self-esteem, and decrease stress. Many researchers believe that hyperactive behavior in children results from excessive slow-wave (or theta) activity in certain regions of the brain. In EEG biofeedback, or neurofeedback, an individual is provided with

information regarding his or her brain activity. The subject is then trained to suppress slow wave activities while enhancing faster brain waves, over a period of usually 40 or more sessions. The belief is that these children can be trained to consciously modify and permanently change this underlying abnormal electrical brain activity associated with ADHD. In one study of 23 hyperactive children and teenagers, those who successfully decreased their theta activity after 2 to 3 months of intensive neurofeedback training showed significant improvements in behavior and attention. In a similar study of 18 children and adolescents with ADHD, those who attended 40 neurofeedback sessions over a 6-month period demonstrated a significant improvement in IQ scores and a substantial reduction in inattentive behavior compared to those who did not attend the neurofeedback sessions. A larger, more recent study found that a combination of 40 behavioral treatments (neurofeedback and metacognitive strategies, a technique designed to help individuals consciously monitor how they learn and remember things), significantly improved ADHD symptoms, academic performance, and IQ scores among children and adults with ADHD. The combined treatment also dramatically reduced the need for medications; 30% of the participants were taking stimulant medication at the beginning of the study compared to only 6% at the end of the study. To be most effective for ADHD, however, these mind/body techniques should be incorporated into an overall comprehensive treatment plan that is tailored to the particular individual.

Traditional Chinese Medicine

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