Attention Deficit-Hyperactivity Disorder

Attention deficit-hyperactivity disorder (ADHD) is a common group of behavioral disorders that may affect children and adults. ADHD is usually diagnosed in childhood. This condition is characterized by difficulty listening to instructions; inability to organize oneself and school work; fidgeting with hands and feet; talking too much; leaving projects, chores, and homework unfinished; and having trouble paying attention to and responding to details. There are several types of ADHD.

Other Names

 * Attention Deficit Disorder (ADD)

Types
There are three types of ADHD described in the Diagnostic and Statistical Manual of Mental Disorders, a book published by the American Psychiatric Association containing classification information for mental disorders.

ADHD, predominantly inattentive type
This type of ADHD, previously known only as Attention Deficit Disorder (ADD), is characterized by difficulty paying attention and staying on task. Children with this type of ADHD are usually not impulsive or hyperactive. They are often not recognized as easily since they don't have the same behavioral issues as children with hyperactivity or impulsivity. Homework is often difficult for these children, as is paying attention in class and following directions.

ADHD, predominantly hyperactive-impulsive type
Children with the hyperactivity component of ADHD are constantly in motion. They have difficulty sitting still. They often talk, fidget, tap, or touch incessantly, and may report constant feelings of restlessness.

Impulsiveness is characterized by difficulty controlling one's thoughts or actions. These children will often do or say things without thinking them through. This impulsivity can cause significant problems in the teenage or adult years when work, driving, and more adult relationships become important.

ADHD, combined type
This type of ADHD is characterized by features of both inattention and hyperactive-impulsive types.

Signs and Symptoms
Signs and symptoms of inattention may include:


 * Failing to pay attention to details or making careless mistakes in schoolwork or other activities.
 * Difficulty maintaining attention during tasks or play.
 * Seeming not to listen even when spoken to directly.
 * Difficulty with following through on instructions and often failing to finish schoolwork, chores, or other tasks in a timely manner.
 * Difficulty with organization of tasks or activities.
 * Avoiding or disliking tasks that require sustained mental effort, such as schoolwork or homework.
 * Frequently losing needed items, such as books, pencils, toys, or tools.
 * Becoming easily distracted.
 * Being forgetful often.

Signs and symptoms of hyperactivity or impulsive behavior may include:


 * Frequent fidgeting or squirming.
 * Not remaining seated when expected.
 * Running or climbing when not appropriate or in an excessive manner.
 * Difficulty playing quietly.
 * Constantly being in motion.
 * Talking excessively.
 * Frequently blurting out the answers before questions have been completely asked.
 * Difficulty waiting for a turn.
 * Interrupting or intruding on others' conversations or games.
 * Frequently feeling restless (especially in adolescence).

Causes
No definitive external cause of ADHD has been identified, and no single cause applies to everyone with ADHD. Clearly genetic heritability ranges from 75%(non-twin) - 91%(twin) - meaning if one twin has ADHD the possibility of another twin having the condition can range up to 91%. Family genetics are significantly contributory. Viruses, harmful chemicals in the environment, problems during pregnancy or delivery, food additives, and anything that impairs brain development have all been brought up as possible role players in causing attention problems in ADHD.

Dietary deficiencies are known to cause behavioral problems, and can exacerbate ADHD. In addition, some studies indicate that poor nutrition may be a risk factor for ADHD. Food additives, food allergies, infant malnutrition, insufficient omega-3 fatty acids, or other dietary problems may contribute to or possibly cause ADHD or ADD. "Picky eaters" are some of the most difficult to treat with ADHD for this reason.

Studies increasingly support the importance a protein breakfast to provide the amino acid neurotransmitter precursors so that sufficient neurotransmitters are available for modulation with stimulant medications.

Diagnosis
ADHD is generally diagnosed and can be treated with medication and behavioral therapy by either child psychiatrists or psychologists, developmental/behavioral pediatricians, or behavioral neurologists. Diagnosis and medical treatment can also be done by a pediatrician or family physician.

According to the DSM-IV, either A or B must be present to diagnose ADHD:

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

Inattention:
 * Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
 * Often has trouble focusing attention on tasks or play activities.
 * Often does not seem to listen when spoken to directly.
 * 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).
 * Often has trouble organizing activities.
 * 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).
 * Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools).
 * Is often easily distracted.
 * Is often forgetful in daily activities.

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

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

Impulsivity
 * Often blurts out answers before questions have been finished.
 * Often has trouble waiting one's turn.
 * Often interrupts or intrudes on others (for example, butts into conversations or games).
 * Some symptoms that cause impairment were present before age 7 years.
 * Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
 * There must be clear evidence of significant impairment in social, school, or work functioning.
 * The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (for example, mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Based on these criteria, three types of ADHD are identified:


 * ADHD, Combined Type: if both criteria A and B are met for the past six months


 * ADHD, Predominantly Inattentive Type: if criterion A is met but criterion B is not met for the past six months


 * ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion B is met but Criterion A is not met for the past six months.

Treatment
Most experts agree that treatment for ADHD should address multiple aspects of the individual's functioning and should not be limited to the use of medications alone.

Medications
The classic class of medication used for treatment of ADHD is the stimulants. These medicines were prescribed as early as the 1930s. It was initially thought that the stimulant medicines worked by having a paradoxical (opposite) calming effect on the hyperactivity of ADHD.

It is now known that the stimulant medicines work by increasing neurotransmitters like dopamine (high levels reduce hyperactivity) and norepinephrine, which improves attention.

The long-term effects of ADHD medication (primarily stimulants) was studied by the Mayo clinic on a group of individuals studied since thier births in 1976 to 1982. The study showed that the medicines were generally effective and safe for long-term use.

Stimulants
The common stimulant medicines used for treatment of ADHD are:
 * Dextroamphetamine and levoamphetamine (Adderall) and (Adderall XR) are intermediate and extended release amphetamines. The short-acting version is dextroamphetamine sulfate (Dexedrine, Dextrostat), which was introduced in the 1950s.
 * Lisdexamfetamine (Vyvanse) is a new extended release, prodrug formulation of dextroamphetamine, with a significantly increased duration of effectiveness, and improved safety profile.
 * Dextromethylphenidate hydrocholoride (Focalin XR) which is more potent than levomethylphenidate and twice as potent as methylphenidate. It was approved in 2005.
 * Methylphenidate (Ritalin). Ritalin SR is the intermediate-acting version.  Ritalin was introduced in the 1950s, and its duration is four hours.  Concerta (or Ritalin LA), introduced in 2000, is the long-acting version of this drug.

The stimulant class of medicines have some bothersome side effects, especially if dosages are not carefully monitored. These include the following:
 * Loss of appetite, which can often lead to weight loss, especially if not given with a protein breakfast
 * Headache
 * Stomachache
 * Insomnia
 * Rapid heart beat (palpitations)
 * Irritability
 * Anger
 * Depression

Monitor and adjust dosages for side effects. It is not recommended to skip weekends and holidays, and research shows much better outcomes with regular compliance.

One of the most frequent challenges with stabilizing stimulant medications is the importance of recognizing the significant differences in metabolism with each individual. Parameters such as weight and age are not significantly predictable of outcomes.

Selective serotonin reuptake inhibitors (SSRIs)
The SSRIs, medicines like sertraline and paroxetine, have not been approved for the treatment of ADHD. These are most commonly used to treat depression and some forms of anxiety. A frequently observed clinical finding, corroborated by SPECT imaging with decreased function of the prefrontal cortex, is the secondary aggravation of ADHD by SSRIs, with an increase in impulsivity, loss of attention, and cognitive dulling. Not commonly appreciated is the fact that some SSRIs Prozac - fluoxetine, and Paxil - paroxetine often significantly alter stimulant medication metabolism, blocking CYP450-2D6, the metabolic path for amphetamines such as Adderall and Vyvanse. This relative blockage may, over time, create a toxic reaction to an amphetamine stimulant secondary to the accumulation of that stimulant.

Tricyclic antidepressants (TCAs)
This class of medication, which includes imipramine, desipramine, amitryptiline, nortriptyline, and clomipramine, was used to treat ADHD before the advent of the SSRIs.

TCAs increase the levels of neurotransmitters but also have some significant side effects, such as irregular heart beat, low blood pressure, fatigue, nausea, dizziness, sleep difficulty, and, rarely, confusion and seizures. These medicines have been used in children with tics, difficulty tolerating stimulant medicines, or other coexistent medical problems (like depression, anxiety, insomnia, or bedwetting).

Other medicines
Bupropion (Wellbutrin) is another antidepressant that acts by increasing dopamine. While not as helpful with symptoms of inattention as the stimulant medicines, bupropion has been used for adult and adolescent ADHD since it is not a controlled substance and tends to help with mood problems (such as depression).

Clonidine, used to treat low blood pressure, blocks norephinephrine receptors. It has been used to treat hyperactive, impulsive, and explosive behavior. Because of the potential for adverse interactions with methylphenidate, clonidine is not used as much any more.

Newer medicines

 * Modafinil, a drug used to treat narcolepsy and the fatigue associated with sleep apnea, improved ADHD symptoms in clinical trials and was expected to become an alternative medication. FDA approval was not received for this indication, however, due to unexpected side effects (rash).


 * Nuvigil (made of one of the isomers of modafinil) is longer-acting than modafinil and does not appear to have the side effects. It has received FDA approval for obstructive sleep apnea, narcolepsy, and shift work sleep disorder but is not yet approved for use in children or for ADHD.


 * Atomoxetine (Strattera), was FDA-approved in 2002. It inhibits reuptake of norepinepherine. It is FDA approved for ages six and above. While some studies show it is as effective as and tolerated as well as the stimulants, there are some greater cautions. Atomoxetine should not be taken with MAO inhibitors, and there are some cautions regarding individuals with either high or low blood pressure and for those with kidney or liver difficulties. There are some reports that it may also improve mood or mood swings, particularly with higher doses. Though response is immediately seen with stimulants, full effects with Strattera may not be seen for three to four weeks. Its long-lasting and around-the-clock response can be achieved with one or two doses a day. Atomoxetine side effects are not unlike other stimulants or some of the antidepressants and consist of some reports of headache and sometimes dizziness, gastrointestinal complaints such as stomachaches, nausea or vomiting, decreased appetite, and dry mouth. While improvement in mood is usually seen, some individuals reported mood swings or fatigue and some reported nervousness or sleep difficulties. Some adults experience difficulty with urination, erectile difficulties, prostate difficulties, menstrual irregularities, or insomnia.

The FDA has asked drug manufacturers to develop patient medication guides for all medicines used to treat ADHD. The guides are meant to warn patients and their families of the cardiovascular and psychiatric risks of the medication.

Therapies
Treatment should include structured classroom management, parent education (to address discipline and limit-setting), and tutoring and behavioral therapy for the child.

Some other modalities that may help with the management of ADHD include the following:
 * Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. A therapist may be able to help someone with ADHD understand how they can change or better cope with their disorder.
 * Behavioral therapy helps people develop more effective ways to work on changing thinking and coping in order to change behavior.
 * Social skills training can also help children learn new behaviors by developing new ways to play and work with others.
 * Support groups help parents connect with other people who have similar problems and concerns with their children with ADHD.
 * Parenting skills training gives parents tools and techniques for managing their child’s behavior.

Holistic and alternative treatments
Alternative treatments are often sought by families with ADHD.

A recent randomized, double-blinded, placebo-controlled crossover study confirmed that certain food additives (artificial colors and sodium benzoate preservatives) cause symptoms of hyperactivity in three-year-old and eight- to nine-year-old children. Avoiding these additives may reduce the symptoms of ADHD.

Cures
There is no "cure" for ADHD. Children with the disorder seldom outgrow it. However, some may find adaptive ways to accommodate the ADHD as they mature.

Lifestyle changes
Children with ADHD often function better with rules and order.

Examples are:
 * Having a set schedule for most activities. The schedule should be posted in plain view and any changes should be made as far in advance as possible.
 * Organizing everyday items, such as creating a specific space where backpacks, jackets, boots, and other personal items can be put away
 * Using binders and other school supplies to organize homework
 * Setting and reinforcing a set of rules

Chances of Developing
According to the Centers for Disease Control and Prevention, between January 2003 and July 2004, approximately 7.8% of children in the United States between the ages of 4 and 17 had been diagnosed with ADHD. The incidence increased with age, from a low of 6% in boys aged 4 to 8 to a high of 13% in boys aged 13 to 17. ADHD was diagnosed two and one half times more often in boys than in girls. The incidence was also higher in non-Hispanic, primarily English-speaking children with health insurance. Other factors included family education level (high school graduate or below had a higher incidence than those with a higher education level) and family income (ADHD was more prevalent in families with an income below the poverty level). Incidence of ADHD also varied by state, from a low of 5% in Colorado to a high of 11.1% in Alabama.

Over half (56.3%) of children with an ADHD diagnosis were taking medication at the time of the survey. This corresponds to 4.3% of the general population.

Risk factors
Some tantalizing studies hint at other risk factors for ADHD. Minimizing or eliminating these risks may possibly decrease the risk of ADHD.

Research shows that a mother's use of cigarettes, alcohol, or other drugs during pregnancy may have damaging effects on the unborn child. These substances may be dangerous to the fetus' developing brain. It appears that alcohol and the nicotine in cigarettes may distort developing nerve cells. For example, heavy alcohol use during pregnancy has been linked to fetal alcohol syndrome (FAS), a condition that can lead to low birth weight, intellectual impairment, and characteristic physical defects. Many children born with FAS show much of the same type of hyperactivity, inattention, and impulsivity as children with ADHD.

Complications
Stimulant medicines, while effective in treating ADHD, carry the potential for abuse. A 2006 press release from the Substance Abuse and Mental Health Services Administration (SAMHSA) reports almost 8,000 visits to the emergency room in 2004 for ADHD stimulant-related complaints. Polydrug use (one or more drugs being used in addition to ADHD medication) was common among those visiting the emergency department for problems involving the misuse of ADHD medication. Polydrug use may also increase possible health risks. For all age groups reporting nonmedical use of ADHD medications, 32% of patients had ingested the ADHD medication alone. For the 68% using one or more drugs in addition to the ADHD medication, 20% reported using alcohol, 26% used an illicit drug, and 57% used another pharmaceutical.

Comorbidity
These following disorders are sometimes also associated with ADHD.

Learning disabilities
Many children with ADHD have a co-existing learning disability. These may include difficulty understanding specific words or sounds or difficulty in expressing oneself in words. Reading or spelling disabilities, writing disorders, and arithmetic disorders may also appear during grade school years. Dyslexia is quite common in conjunction with ADHD.

Tourette syndrome
A very small proportion of people with ADHD have a neurological disorder called Tourette syndrome. People with Tourette syndrome have various nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others may clear their throats frequently, snort, sniff, or bark out words. These behaviors can be controlled with medication. While very few children have this syndrome, many of the cases of Tourette syndrome have associated ADHD. In such cases, both disorders often require treatment.

Oppositional defiant disorder
As many as one-third to one-half of all children with ADHD have another condition, known as oppositional defiant disorder (ODD). These children are often defiant, stubborn, non-compliant, have outbursts of temper, or become belligerent. They argue with adults and refuse to obey.

Conduct disorder
About 20%–40% of children with ADHD may eventually develop conduct disorder, a more serious pattern of antisocial behavior. These children frequently lie or steal, fight with or bully others, and are at a real risk of getting into trouble at school or with the police. They violate the basic rights of other people, are aggressive toward people or animals, destroy property, break into people’s homes, commit thefts, carry or use weapons, or engage in vandalism. These children or teens are at greater risk for substance use, experimentation, and later dependence and abuse.

Anxiety and depression
Anxiety or depression may also coexist with ADHD. If the anxiety or depression is recognized and treated, the child will be better able to handle the problems that accompany ADHD. Conversely, effective treatment of ADHD can have a positive impact on anxiety as the child is better able to master academic tasks.

Bipolar disorder
There are no accurate statistics on how many children with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar disorder in childhood can be difficult. Bipolar disorder is characterized by cycling moods between periods of intense highs and lows. But in children, bipolar disorder is often seen as frequent mood fluctuation between elation, depression, and irritability. There are also some symptoms that can be present both in ADHD and bipolar disorder, such as a high level of energy and a reduced need for sleep. Bipolar disorder usually is associated with more grandiose thoughts and elevated mood than ADHD, providing a way to differentiate between the two conditions.

Clinical Trials
The National Institues of Mental Health (NIMH) has a list of current clinical trials, listed by date and location, available at Attention Deficit Hyperactivity Disorder (ADHD, ADD).

There are also many ongoing clinical trials listed at ADHD ClinicalTrials.gov.

Recent discoveries

 * Brain structures and activity as a cause of ADHD: High Resolution MRI of children with ADHD showed significant differences in blood flow and size to specific areas of the brain thought to control attention and impulse control.


 * Research shows that ADHD tends to run in families, so a genetic component for ADHD is likely. Children who have ADHD usually have at least one close relative who also has ADHD. At least one-third of all fathers who had ADHD in their youth bear children who have ADHD. The majority of identical twins share the ADHD trait. More research is needed to determine the genes responsible for ADHD and to evaluate the relationship between genetic and environmental causes of ADHD.


 * Maternal stress in pregnancy also seems to affect the severity of ADHD and response to treatment in children.


 * Drugs such as cocaine—including the smokable form known as crack—seem to affect the normal development of brain receptors. Receptors are part of brain cells and help to transmit incoming signals from our skin, eyes, and ears, which in turns helps control our responses to the environment. Current research suggests that drug abuse may harm these receptors. Some scientists believe that such damage may lead to ADHD.


 * Toxins in the environment may also disrupt brain development or brain processes, which may lead to ADHD. Lead is one such possible toxin. Lead is found in dust, soil, and flaking paint in areas where leaded gasoline and paint were once used. Lead is also present in some water pipes. Some animal studies suggest that children exposed to lead may develop symptoms associated with ADHD, but only a few human cases have actually been found.


 * On September 10, 2007, the Food Standards Agency (United Kingdom) advised parents of children showing signs of hyperactivity that cutting certain artificial colors from their diets might have some beneficial effects. The colors&mdash;Sunset yellow (E110), Quinoline yellow (E104), Carmoisine (E122), Allura red (E129), Tartrazine (E102) Ponceau 4R (E124), and Sodium benzonate (E211)&mdashlwere studied as part of new FSA-commissioned research. The agency also stated “However, we need to remember that there are many factors associated with hyperactive behaviour in children. These are thought to include genetic factors, being born prematurely, or environment and upbringing.”


 * Imaging of the brains of adolescent boys with ADHD has identified abnormalities in the function of dopamine, which may account for some of the symptoms of ADHD.

Current research
The National Institute of Mental Health will be conducting the following research:
 * The use of neurofeedback or EEG feedback as an alternative treatment for ADHD.
 * Using a new combination of traditional ADHD behavioral therapy and the cognitive-behavoral and psychoeductional therapy used in children with mood disorders (such as bipolar disorder). Children with ADHD and mood disorder features often have difficulty with the traditional stimulant medicines used to treat ADHD because the stimulants can induce a manic episode. The hope is that the combined behavioral therapy will be effective in children with a dual diagnosis.

Recent news
The University of California at Berkeley published a press release early in 2007 reporting that the use of medications for ADHD has tripled since 1993 and that although the United States leads in diagnosed cases, there are many other countries worldwide where ADHD is quite prevalent.

Debate
A recent research study looked at the connection between the amount of television that very young children watched and attention problems years later when those children were in school. The researchers found that early television exposure (ages one to three) was associated with attentional problems at age seven. Another recent study disputes these findings.

There is significant concern in the psychiatric community about whether the use of stimulant medicines to treat ADHD increases the risk of substance abuse later in life. The stimulants used to treat ADHD increase the amount of dopamine in the brain, as do many drugs of abuse. One thought is that use (and abuse) of stimulants in childhood may create dependence and therefore lead to drug-seeking behavior in adolescence and childhood. Another school of thought proposes that treatment of ADHD with stimulant medicines may reduce a later risk of substance abuse. The editorial mentions that studies recently done have relatively small sample sizes, and the children in the studies had a relatively short exposure to stimulant medicines. A larger study, the Multimodal Treatment Study of ADHD, is ongoing.

In the News
PBS's Frontline ran a show about lawsuits related to ADHD in the early 1980s and 1990s. They also produced a series of shows about ADHD, available for viewing at Medicating Kids.

FoxNews.com ran an article in 2007 about a Mayo Clinic study showing improved academic performance in children with ADHD who use stimulant medication.

Expected Outcome
Children with ADHD are at increased risk of substance abuse, depression, and personality disorder in adolescence, according to one study from 2002.

History
ADHD was first described by Dr. Heinrich Hoffman in 1845. A physician who wrote books on medicine and psychiatry, Dr. Hoffman was also a poet who became interested in writing for children when he couldn't find suitable materials to read to his 3-year-old son. The result was a book of poems, complete with illustrations, about children and their characteristics. "The Story of Fidgety Philip" was an accurate description of a little boy who had attention deficit hyperactivity disorder. Yet it was not until 1902 that Sir George F. Still published a series of lectures to the Royal College of Physicians in England in which he described a group of impulsive children with significant behavioral problems. He hypothesized that this behavior was caused by a genetic dysfunction and not by poor child rearing.