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Search ClinicalTrials.gov for other NIH studies on Attention Deficit Hyperactivity Disorder
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Related Information
Learn more about Attention Deficit Hyperactivity Disorder (ADHD, ADD)
Attention Deficit Hyperactivity Disorder, ADHD, is one of the most common
mental disorders that develop in children. Children with ADHD have impaired
functioning in multiple settings, including home, school, and in relationships
with peers. If untreated, the disorder can have long-term adverse effects into
adolescence and adulthood.
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This page last reviewed: February 26, 2009
http://www.nimh.nih.gov/health/trials/attention-deficit-hyperactivity-disorder-adhd-add.shtml
Comparing the Effectiveness of New Versus Older Treatments for Attention Deficit
Hyperactivity Disorder (NOTA)
This study is currently recruiting participants.
Verified by National Institute of Mental Health (NIMH), May 2009
First Received: April 27, 2009 Last Updated: May 11, 2009 History of Changes
Sponsored by:
National Institute of
Mental Health (NIMH)
ClinicalTrials.g
NCT00889915
ov Identifier:
Purpose
This study will determine whether two new psychostimulant medications are more effective,
tolerable, and acceptable than two older medications for treating attention deficit hyperactivity
disorder.
Condition
Attention Deficit Disorder
With Hyperactivity
Intervention
Drug: Methylphenidate transdermal
system
Drug: Lisdexamfetamine dimesylate
Drug: Osmotic-release oral system
methylphenidate (OROS MPH)
Drug: Mixed amphetamine salts
extended release
Pha
se
Phas
e IV
Study Type:
Interventional
Study
Design:
Official Title:
Estimated Enrollment:
480
April 2009
September 2009
Arms
Assigned Interventions
1: Active Comparator
Participants will receive methylphenidate
transdermal system.
2: Active Comparator
Participants will receive lisdexamfetamine
dimesylate.
3: Active Comparator
Participants will receive osmotic-release oral
system methylphenidate (OROS MPH).
4: Active Comparator
Participants will receive mixed amphetamine salts
extended release.
Detailed Description:
Attention deficit hyperactivity disorder (ADHD) is characterized by impulsiveness,
hyperactivity, and inattention. It is seen primarily in children and adolescents and is often treated
with psychostimulant medications. Osmotic-release oral system (OROS) methylphenidate, brand
name Concerta, and mixed amphetamine salts extended release, brand name Adderall XR, are
psychostimulant medications that have shown both efficacy (that they can have therapeutic
benefits) and effectiveness (that they typically have therapeutic benefits in practice). Two newer
psychostimulant medicationslisdexamfetamine dimesylate, brand name Vyvanse, and
methylphenidate transdermal system, brand name Daytranahave shown efficacy but have not
been tested for effectiveness, nor have they been tested head-to-head against the older
psychostimulants. This study will test the effectiveness, tolerability (lack of side effects), and
acceptability (ease of use for patients) of the two newer psychostimulant medications and
compare them to each other and to the two older psychostimulants.
Participation in this study will last 6 weeks, although some treatments may continue past the end
of the study. At enrollment, participants will undergo a series of baseline evaluations. These will
include interviews and assessments of ADHD symptoms, concurrent psychiatric disorders,
medical and psychiatric history, family history of mental illness, risk and protective factors, other
treatments, treatment expectancy of both the youth and parent, and vital signs. In consultation
with their doctors, participants will be allowed to exclude zero, one, or two of the study
medications; if they choose to exclude both of the new ADHD medications, they will not able to
participate in the study. Participants will then be randomly assigned to one of the treatments they
choose to include. They will receive a prescription for the medication and instructions for how to
use it from their doctors; the study protocol does not specify a particular treatment regimen.
Participants will undergo a second set of evaluations after 6 weeks of treatment or before, if the
treatment ends earlier. This will include interviews and assessments similar to those administered
at baseline as well as evaluation of any medication side effects.
Eligibility
Ages Eligible for Study:
Genders Eligible for Study:
Accepts Healthy Volunteers:
Criteria
6 Years to 17 Years
Both
No
Inclusion Criteria:
Speaks English
Willing to be randomly assigned to one of the study treatment options as outlined in the
protocol
Willing to initiate study medication for ADHD within 7 days of the study baseline visit
May be receiving stable treatment with other drug for a comorbid disorder, defined as no
changes in dose or form of drug treatment for at least 2 weeks prior to the study
enrollment visit
Exclusion Criteria:
Received treatment with a monoamine oxidase inhibitor (MAOI) within the past 30 days
Presence of psychosis
jerry.kirchner@duke.e
du
alice.petersen@duke.e
du
919-668-8091
Locations
United States, North Carolina
Child and Adolescent Psychiatry Trials Network (CAPTN)
Durham, North Carolina, United States, 27710
Contact: Jerry Kirchner, BS CCRP
919-668-7818
jerry.kirchner@duke.edu
Recruiting
alice.petersen@duke.edu
Additional Information:
Click here for the Child and Adolescent Psychiatry Trials Network (CAPTN) Web site
Click here for the Duke Clinical Research Institute Web site
Click here for the American Academy of Child and Adolescent Psychiatry Web site
No publications provided
Responsible Party:
Study ID Numbers:
Last Updated:
ClinicalTrials.gov Identifier:
NCT00889915
Health Authority:
History of Changes
Dopamine
Attention Deficit Disorder with Hyperactivity
Mental Disorders
Dextroamphetamine
Mental Disorders Diagnosed in Childhood
Hyperkinesis
Neurologic Manifestations
Dopamine Agents
Amphetamine
Peripheral Nervous System Agents
Disease
Sympathomimetics
Nervous System Diseases
Attention Deficit and Disruptive Behavior
Disorders
Central Nervous System Stimulants
Dyskinesias
Pharmacologic Actions
Methamphetamine
Autonomic Agents
Dextroamphetamine
Neurologic Manifestations
Amphetamine
Dopamine Agents
Peripheral Nervous System Agents
Central Nervous System Agents
reduced and not significant. CONCLUSIONS: Interventions that target attention problems at
school entry should be tested as a potential avenue for improving educational achievement.
http://www.ncbi.nlm.nih.gov/sites/entrez?
cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=19482756&tool=Medline
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A patient
information handout
on attention-deficit/
hyperactivity disorder
in adults, written by
the authors of this
article, is provided on
page 2091.
See editorial
on page 1983.
cognitive-behavioral symptoms that may affect adults more than children. Third, the most
effective treatment is long-term use of a schedule II drug with potential for abuse.3
The family physician's role as diagnostician is further complicated by the high rates of selfdiagnosis of ADHD in adults. Many of these persons are influenced by the popular press. Studies
of self-referral suggest that only one third to one half of adults who believe they have ADHD
actually meet formal diagnostic criteria.4 While family physicians are knowledgeable about
childhood ADHD, there is a noticeable absence of guidelines for primary care evaluation and
treatment of adults with symptoms of the disorder.
TABLE 1
DSM-IV Diagnostic Criteria for ADHD
g. Often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books or tools)
2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for
at least six months to a degree that is maladaptive and inconsistent with
developmental level:
Hyperactivity
Impulsivity
C Some impairment from the symptoms is present in two or more settings (e.g., at school [or
work] and at home).
Adults who have retained some, but not all, of the symptoms of childhood ADHD may be best
diagnosed as having ADHD in partial remission.5,6 While the DSM-IV criteria for ADHD may be
applied to adults, these dimensions tend to reflect presentations in children. The subtlety of
ADHD symptoms among adults has led to several modifications of existing criteria. Rather than
requiring six DSM-IV symptoms of inattention or hyperactivity, some investigators propose
requiring only five such behaviors for older patients.7 In addition, the symptoms take different
forms in adults.
There is growing consensus that the central feature of ADHD is disinhibition.8 Patients are
unable to stop themselves from immediately responding, and they have deficits in their capacity
for monitoring their own behavior. Hyperactivity, while a common feature among children, is
likely to be less overt in adults. The "on the go" drivenness seen in many ADHD children is
replaced in adults with restlessness, difficulty relaxing and a feeling of being chronically "on
edge."1
Deficits in sustained attention and concentration are likely
to remain and may become more apparent in late
Evaluating ADHD requires the
adolescence and early adulthood as responsibilities
physician to weigh and integrate a
increase. Appointments, social commitments and
range of data, including the patient's
deadlines are frequently forgotten. Impulsivity often takes
history, self-reported symptoms and
the form of socially inappropriate behavior, such as
mental status testing.
blurting out thoughts that are rude or insulting. While
many of the symptoms are reported by others in the
patient's life, the problem often expressed by adults with
ADHD is frustration over the inability to be organized.1 Prioritizing is another common source of
frustration. Important tasks are not completed while trivial distractions receive inordinate time
and attention.
TABLE 2
Utah Criteria for ADHD in Adults
Wender developed a set of ADHD criteria, referred
to as the Utah criteria, that reflect the distinct
features of the disorder in adults (Table 2).2(pp122-43)
The diagnosis of ADHD in an adult requires a
longstanding history of ADHD symptoms, dating
back to at least age seven. In the absence of
treatment, such symptoms should have been
consistently present without remission. In addition,
hyperactivity and poor concentration should be
present in adulthood, along with two of five
additional symptoms: affective lability; hot temper;
inability to complete tasks and disorganization;
stress intolerance; and impulsivity.
The Utah criteria include the emotional aspects of
the syndrome. The episodes of hot temper, typified
by frequent angry eruptions out of proportion to the
precipitants, often "blow over" more quickly for the
patient than for coworkers and family members.
Affective lability is characterized by brief, intense
affective outbursts ranging from euphoria to despair
to anger, and is experienced by the ADHD adult as
being out of control. Under conditions of increased
emotional arousal from external demands, the
patient becomes more disorganized and
distractible.2(pp122-43)
ADHD = attention-deficit/hyperactivity
disorder.
Adapted from Wender PH. Attention-deficit
hyperactivity disorder in adults. New York:
Oxford University Press, 1995:122-43.
Another model of adult ADHD diverges from DSM-IV but overlaps with Wender's criteria and
includes five areas.9 In this model, the five core ADHD dimensions include the following:
activation and organization; sustained attention; sustained energy and effort; managing affective
interference; and working memory and accessing recall. Activation refers to difficulties initiating
and organizing daily tasks. Sustained attention includes such aspects as distractibility,
daydreaming and having to reread material to understand it. Sustained energy and effort refers to
drowsiness, inconsistent performance and poor task completion. Managing affective interference
includes difficulty managing criticism as well as being easily frustrated, irritable and poorly
motivated. Memory difficulties encompass recent and remote memory for daily activities and
task-related materials.9
Another model, which serves as the basis for the Copeland symptom checklist for ADHD in
adults, includes eight dimensions: inattention and distractibility; impulsivity; activity level
Evaluation
The subtlety and subjectivity of ADHD symptoms
in adults, together with the absence of a single "gold
standard" for confirming the diagnosis, make
assessment particularly challenging. Evaluation of
adults with symptoms of ADHD requires weighing
and integrating a range of data, including the
patient's history, the patient's self-report of
symptoms and mental status testing (Table 3). A
thorough history should include an emphasis on past
school performance and conduct, previous and
current psychiatric therapies, and reports of specific
symptoms of inattention, distractibility and
disorganization. ADHD is currently understood as a
neurobehavioral condition that is typically apparent
in preschool years and becomes more pronounced in
the early elementary grades.
An extended, consistent pattern of ADHD
symptoms, dating back to early childhood, should
be uncovered during history taking. Patients with
ADHD may have difficulty accurately recalling
relevant history.11Adult patients should be asked to
provide any available school records and gather
information from parents and other adults who
knew them as children. Because adults with ADHD
may not appreciate their symptoms, the patient's
spouse or another significant person in the patient's
life should ideally be included in the interview. The
recent onset of symptoms or sporadic episodes of
symptoms should raise concern about the
appropriateness of the diagnosis of ADHD.
TABLE 3
Process of Assessment for
ADHD in Adults
ADHD = attention-deficit/hyperactivity
disorder.
The three most commonly used self-report measures for ADHD are the Wender rating scale,12 the
Copeland symptom checklist and the Brown scale (Table 4). While self-report instruments may
be useful for initial screening, they should not be used alone to diagnose adult ADHD. High
scores are likely in a variety of psychiatric conditions. Problems with attention, concentration,
affective lability, impulsivity and task completion are nonspecific and can be associated with
many forms of psychopathology.
Mental status testing is often useful when evaluating the patient's cognitive functioning in the
office, but impaired performance on mental status testing may result from numerous psychiatric
and medical conditions. Cognitive tasks include recitation of serial 7s for assessment of
concentration, digit span forward and backward for assessment of attention, and immediate recall
for assessment of short-term memory. Short-term memory can be evaluated by asking patients to
verbally recall a short paragraph that was read to them. The patient's ability to attend to relevant
stimuli while ignoring distractions can be assessed through vigilance tasks in which the patient is
read a string of letters and told to tap a finger when a target letter is spoken. Verbally
administered mathematic problems are more demanding tasks that require concentration and
problem solving.
The medical evaluation should include a neurologic examination. There are suggestions that
patients with ADHD exhibit a greater incidence of "soft neurologic signs," including problems
with right-left discrimination, motor overflow movements and sequencing difficulties.13
Laboratory tests may include a serum lead level and thyroid function tests.13,14
TABLE 4
Features of Self-Report Scales for Adults with ADHD
Scale
Number of
items
Format
Content
Copeland Symptom
Checklist for Adult
ADHD
63
3-point severity
rating scale
61
5-point severity
rating scale
40
Differential Diagnosis
Patients with a range of psychiatric conditions may emphasize difficulty with concentration,
attention or short-term memory when they describe their problems to the physician.14 It is
important to exclude other psychiatric conditions, most of which are actually more prevalent than
ADHD among adults (Table 5). Major depression and substance abuse, in particular, commonly
accompany adult ADHD.
TABLE 5
Psychiatric Disorders to Consider in the Differential Diagnosis of ADHD in
Adults
Psychiatric disorder
Major depression
Bipolar disorder
Generalized anxiety
Fidgetiness; difficulty
concentrating
Substance abuse or
dependence
Personality disorders,
particularly borderline
and antisocial
personality
Importantly, most adults with ADHD do not have a "pure" form of the disorder. Comorbidity is
more likely to be the rule than the exception. It is not clear whether these comorbid psychiatric
conditions are a psychologic effect of preexisting ADHD or are simply associated with ADHD.2
For example, substance abuse may have developed as a way to reduce the frustration arising
from distractibility, inattention and impulsivity. If a comorbid psychiatric disorder exists in a
patient with ADHD, the patient should be educated about the ADHD symptoms that will resolve
with stimulant therapy and the symptoms of the other psychiatric condition that may warrant
additional treatment.
In addition to the physical examination and laboratory findings, a thorough history is valuable in
the differential diagnosis. Medical conditions that may mimic adult ADHD include
hyperthyroidism, petit mal and partial complex seizures, hearing deficits, hepatic disease and
lead toxicity.13 In addition, sleep apnea and drug interactions should be considered as possible
causes of inattention and hyperactivity.13,15 Patients with a history of head injury may also have
problems with attention, concentration and memory.16
Pharmacotherapy
Stimulants
The pathophysiologic basis of ADHD centers on an imbalance in catecholamine metabolism in
the cerebral cortex, and the agents used to treat this disorder in adults, as in children, enhance the
availability of dopamine and norepinephrine.17,18 Pharmacotherapy options are summarized in
Table 6. As with children, stimulants are the most commonly used category of medications in
adults with ADHD.
TABLE 6
Pharmacotherapy of ADHD in Adults
Drug
Formulations
Starting
daily
dosage
$ 50 to 76 (43
to 67)
5 to 10 mg
40 to 90 mg
18 mg
36 to 54 mg **
37.5 mg
75 mg
5 to 10 mg
20 to 45 mg 46 (27)
5 to 10 mg
20 to 45 mg 92
20 to 45 mg 37
20-mg (slow-release)
tablets
18-, 36-mg controlledrelease tablets
(Concerta)
Pemoline (Cylert)
95 to 103 (79
to 82)
5-mg tablets
5-, 10-, 15-mg longacting tablets
5 to 10 mg
Desipramine (Norpramin)
10 to 25 mg 100 to 150
mg
81 (32 to 38)
Imipramine (Tofranil)
10 to 25 mg 100 to 150
mg
58 (41 to 44)
Nortriptyline (Pamelor)
10 to 25 mg 100 to 150
mg
Bupropion (Wellbutrin)
37.5 mg
95
300 to 450
mg
Economics Data, 2000. Cost to the patient will be higher, depending on prescription filling fee.
**--Cost figures not available at press time.
Because of the risk of hepatitis with pemoline, the use of this agent is recommended only in
patients who have failed to respond to other stimulants.18 A baseline serum alanine
aminotransferase (ALT) determination should be obtained before initiating therapy with
pemoline and every two weeks during therapy. According to the manufacturer, pemoline therapy
should be discontinued if the ALT level exceeds two times the upper limits of normal or if
symptoms of liver disease develop. The manufacturer of pemoline has developed a consent form
that describes the risks associated with this drug and recommends that patients sign the form
before initiation of therapy.
Some prescribing issues surround the use of controlled substances such as stimulants. Caution
should be exercised not only in making the diagnosis of ADHD but also in avoiding the use of
stimulants in patients with a history of substance abuse. On the other hand, adult patients may
require larger dosages than those usually prescribed to children. Therefore, it is important to
document the patient's symptoms and the patient's response to each dosage as the amount is
titrated upward. Because methylphenidate and dextroamphetamine are C-II controlled
substances, most states limit prescriptions to a 30-day supply and do not authorize refills. In
addition, written copies of the prescription are usually required. Such requirements necessitate
frequent contact between the patient and physician for reevaluation and prescription renewal.
Pemoline is classified as a C-IV controlled substance, which can usually be refilled up to five
times over the six months following the initial prescription.
Antidepressants
As a means of increasing the concentration of catecholamines in the central nervous system,
antidepressants that inhibit reuptake of norepinephrine have been evaluated for the treatment of
ADHD.17 Tricyclic antidepressants (TCAs), which inhibit the uptake of norepinephrine and
serotonin, may be effective, while the response to selective serotonin reuptake inhibitors (SSRIs)
has been less promising in adults with ADHD.18,21 The secondary amine TCAs, such as
desipramine (Norpramin) and nortriptyline (Pamelor), may be preferred because of greater
effects on norepinephrine than on serotonin and a better side effect profile.17 Bupropion
(Wellbutrin), an atypical antidepressant with more stimulant properties than the TCAs, may be
effective as well.17 Therapy with monoamine oxidase (MAO) inhibitors has produced variable
responses in patients with ADHD, but may be tried in patients who have responded poorly to
other therapies.
Antidepressant therapy in adults with ADHD may be
particularly helpful in reducing affective instability and
Because the effects of stimulants on controlling a coexistent mood disturbance. Because of the
blood pressure may be variable,
different effects of stimulants and antidepressants, some
hypertension should be controlled
patients may benefit from the combination of a stimulant
and closely monitored when
and an antidepressant.
beginning therapy with stimulants for
adult ADHD.
electrocardiogram should be obtained before initiating TCA therapy and after the dosage is
stabilized. Drowsiness is common but may be minimized by taking the antidepressant at bedtime
and slowly titrating to the target dosage. Anticholinergic effects such as dry mouth, constipation
and urinary retention may also be troublesome. Weight gain and postural hypotension may be
problematic. Sexual dysfunction is more common with the agents that affect serotonin reuptake,
so it may be less common with secondary amine TCAs. If sedation is problematic, bupropion
may be an alternative agent. However, the use of bupropion is contraindicated in patients with a
history of seizures. If an antidepressant is tolerated at an effective dosage, it may be a reasonable
alternative in patients with coexisting depression or an alternative to a controlled substance.
Other Medications
Sympatholytics have also been used in the management of ADHD. Clonidine (Catapres) is a
centrally acting alpha2 agonist that decreases sympathetic outflow from the central nervous
system. While this agent may be beneficial in children and adolescents, particularly those with
significant hyperactivity and aggressive behavior, the benefits in adults are less clear. Sedation is
the most common adverse effect of clonidine. The antihypertensive effects of clonidine may be
beneficial in a patient with hypertension but may limit its usefulness in other patients.
Self-Management Strategies
Adults with ADHD benefit considerably from direct education about the disorder. They can use
information about their deficits to develop compensatory strategies. Planning and organization
can be improved by encouraging patients to make lists and use computerized schedules. Placing
a large calendar with important dates and deadlines in a central location in the home or
workplace is a valuable memory aid.20 Ways to reduce distractions may include having a clutterfree desk, a carrel-style desk or a windowless office. ADHD adults may benefit from going to
work early to accomplish tasks before coworkers arrive and phones begin ringing. Most adults
are aware of their "personal clock" and know their prime times for completing intellectually
demanding tasks. Task completion can be improved by systematically breaking down large
projects into manageable "chunks," each with its own deadline.20
Adults with ADHD should be educated about their elevated risk for drug and alcohol dependence
and should be encouraged to drink in moderation or practice abstinence.
Psychotherapy
Marital and individual counseling and self-help groups are often valuable adjuncts to
pharmacotherapy and skill training. Among newly diagnosed adults in particular there may be an
extended psychologic history of low self-esteem, failure, frequent job changes and relationship
problems. Individual psychotherapy that focuses on core issues of self-worth along with ways to
improve the patient's ability to monitor work and social skills can be invaluable.
Married patients often have significant relationship conflicts stemming from forgotten
commitments, impulsive decisions and emotional outbursts. Working with the couple to enhance
communication skills, conflict resolution and problem solving, and educating the patient's spouse
about ADHD can dramatically improve the relationship.20 Finally, self-help organizations such as
Children and Adults with Attention Deficit Disorder (CHADD;
800-233-4050
The Authors
H. RUSSELL SEARIGHT, PH.D.,
is director of behavioral medicine at the Family Medicine of St. Louis Residency Program. Dr.
Searight is also adjunct associate professor of community and family medicine at Saint Louis
University School of Medicine and adjunct professor of psychology at Saint Louis University.
He received a doctorate in clinical psychology from Saint Louis University.
JOHN M. BURKE, PHARM.D.,
is a clinical pharmacist on the faculty with the Family Medicine of St. Louis Residency Program
and associate professor of pharmacy practice at the Saint Louis College of Pharmacy. Dr. Burke
received a doctorate in pharmacology from the University of Texas and completed a clinical
pharmacy residency at Truman Medical Center, Kansas City, Mo. He is board certified as a
pharmaceutical care specialist.
FRED ROTTNEK, M.D.,
is currently director of community services at the Institute for Research and Education in Family
Medicine, St. Louis. He formerly was medical director and community medicine coordinator at
the Family Medicine of St. Louis Residency Program. A graduate of Saint Louis University
School of Medicine, he completed a residency at Family Medicine of St. Louis. He also
completed a fellowship in faculty development at the University of North Carolina, Chapel Hill.
Address correspondence to H. Russell Searight, Ph.D., Family Medicine of St. Louis Residency Program,
6125 Clayton Ave., St. Louis, MO 63139. Reprints are not available from the authors.
REFERENCES
1. Vollmer S. AD/HD: it's not just in children. Family Pract Recertif 1998;20:45-6.
2. Wender PH. Attention-deficit hyperactivity disorder in adults. New York: Oxford
University Press, 1995.
3. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attentiondeficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs,
American Medical Association. JAMA 1998;279:1100-7.
4. Roy-Byrne P, Scheele L, Brinkley J, Ward N, Wiatrak C, Russo J, et al. Adult attentiondeficit hyperactivity disorder: assessment guidelines based on clinical presentation to
a specialty clinic. Compr Psychiatry 1997;38:133-40.
8. Barkley RA. ADHD and the nature of self-control. New York: Guilford, 1997:10-1.
9. Brown TE. Brown ADD scales. San Antonio, Tex.: Psychological Corp., 1996:5-6.
10. Copeland ED. Medications for attention disorders (ADHD/ADD) and related medical
problems. (Tourette's syndrome, sleep apnea, seizure disorders). Atlanta: SPI Press,
1991.
12. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the
retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J
Psychiatry 1993;150:885-90 [Published erratum appears in Am J Psychiatry 1993;
150:1280].
13. Fargason RE, Ford CV. Attention deficit hyperactivity disorder in adults: diagnosis,
treatment, and prognosis. South Med J 1994;87:302-9.
14. Nahlik JE, Searight HR. Diagnosis and treatment of attention deficit hyperactivity
disorder. Prim Care Rep 1996;2:65-74.
15. Ball JD, Wooten V, Crowell TA. Adult ADHD and/or sleep apnea? Differential diagnostic
considerations with six case studies. J Clin Psychol Med Settings 1999;6(3):259-71.
17. Wilens TE, Biederman J, Prince J, Spencer TJ, Faraone SV, Warburton R, et al. Sixweek, double-blind, placebo-controlled study of desipramine for adult attention deficit
hyperactivity disorder. Am J Psychiatry 1996;153:1147-53.
18. Wilen TE, Spencer TJ, Biederman J. Pharmacotherapy of adult ADHD: In: Barkley RA,
ed. Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment.
2d ed. New York: Guilford, 1998:592-606.
21. Spencer TJ, Biederman J, Wilen T. Pharmacotherapy of ADHD with antidepressants. In:
Barkley RS, ed. Attention deficit hyperactivity disorder: a handbook for diagnosis and
treatment. 2d ed. New York: Guilford, 1998:552-63.
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Copyright 2000 by the American Academy of Family Physicians.
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Drug Approval
In 2007, the Food and Drug Administration (FDA) approved lisdexamfetamine (Vysvanse), a
new stimulant drug for the treatment of attention-deficit/hyperactivity disorder (ADHD). The
active ingredient in lisdexamfetamine is similar to dextroamphetamine, the drug used in
Dexedrine and Adderall.
Drug Warning
In 2007, the FDA instructed the manufacturers of all ADHD drugs to include drug warning labels
describing the risks for heart and psychiatric side effects. Doctors should carefully evaluate
patients for any risk factors. Reports have linked ADHD drugs to sudden death in patients with
serious heart problems. There is also a slightly increased risk for auditory hallucinations,
paranoia, and manic behavior even in patients with no history of psychiatric problems. The FDA
warning applies to all stimulant ADHD drugs and to the non-stimulant drug atomoxetine
(Strattera).
Ritalin Can Stunt Growth
After 3 years of methylphenidate (Ritalin) treatment, children are about an inch shorter and 6
pounds lighter than their peers who do not take this drug, according to a 2007 study in the
Journal of the American Academy of Child and Adolescent Psychiatry.
ADHD Improves Over Time
ADHD symptoms may improve over time regardless of the treatment approach, indicates a 2007
study in the Journal of the American Academy of Child and Adolescent Psychiatry. Researchers
found that medication, behavioral therapy, or a combination of the two all helped produce
improvement after 3 years. There appeared to be no significant difference between children who
took medication and those who did not.
Neurofeedback May Help ADHD
Neurofeedback (also known as biofeedback) is a non-drug treatment that may help improve
attention and behavior problems associated with ADHD. This treatment approach involves
teaching children to control their brain wave activity.
Introduction
According to the U.S. National Institute of Mental Health, attention deficit hyperactivity disorder
(ADHD) is a legitimate psychologic condition.
ADHD is a syndrome generally characterized by the following symptoms:
Distractibility
Inattention
Impulsivity
Hyperactivity
There is some debate over these criteria. Some argue the condition is over-diagnosed. Others say
it's underdiagnosed. (See Difficulties in Identifying Children with ADHD later in this article.)
One-third of cases are accompanied by learning disabilities and other neurologic or emotional
problems, making an ADHD diagnosis particularly difficult. It is likely that the term attentiondeficit hyperactivity disorder will eventually give way to subgroups of problems that include
some of these general symptoms.
General Description of a Child with ADHD
In the United States, about 4.7 million children ages 3 - 17 have been diagnosed at some point
with ADHD. This accounts for 7.4% of all American children in this age range.
ADHD is a genuine disorder, but it is telling that the U.S. accounts for 90% of worldwide
prescriptions for stimulants for ADHD. It is not known whether this reflects a real increase in
ADHD, or a better ability to recognize it. Some say it may be an indication of a culture that
places excessive value on normalcy and academic achievement at the expense of more frequent
diagnoses.
Symptoms of ADHD usually occur before the age of 7. Studies indicate that ADHD symptoms in
preschool children with ADHD do not differ significantly from older children.
The classic ADHD symptoms do not always adequately describe the child's behavior, nor do they
describe what is actually happening in the child's mind. Some experts are focusing on deficits in
"executive functions" of the brain to understand and describe all ADHD behaviors. Such
impaired executive functions in ADHD children can cause the following problems:
Hyperactivity. The term hyperactive is often confusing since, for some, it suggests a child racing
around non-stop. A boy with ADHD playing a game, for instance, may have the same level of
activity as another child without the syndrome. But when a high demand is placed on the ADHD
child's attention, his brain motor activity intensifies beyond the levels of the other children. In a
busy environment, such as a classroom or a crowded store, ADHD children often become
distracted and react by pulling items off the shelves, hitting people, or spinning out of control
into erratic, silly, or strange behavior.
Impulsivity and Temper Explosions. Even before the "terrible twos," impulsive behavior is often
apparent. The toddler may gleefully make erratic and aggressive gestures, such as hair pulling,
pinching, and hitting. Temper tantrums, normal in children after age 2, are usually exaggerated
and not necessarily linked to a specific negative event in the life of an ADHD child. One of the
most painful events a parent may experience is an abrupt and aggressive attack that may occur
after cuddling a young ADHD child. Often this reaction seems to be caused not by anger, but by
the child's apparent inability to endure overstimulation or displays of physical affection.
Attention and Concentration. ADHD children are usually distracted and made inattentive by an
overstimulating environment (such as a large classroom). They are also inattentive when a
situation is low-key or dull. Some experts believe that certain parts of the brain in ADHD
children may be underactive, so the children fail to be aroused by nonstimulating activities. In
contrast, they may exhibit a kind of "super concentration" to a highly stimulating activity (such
as a video game or a highly specific interest). Such children may even become over-attentive -so absorbed in a project that they cannot modify or change the direction of their attention.
Impaired Short-Term Memory. Many experts now believe that an essential feature in ADHD, as
well as in learning disabilities, is an impaired working (also called short-term) memory. People
with ADHD can't hold groups of sentences and images in their mind long enough to extract
organized thoughts. They are not necessarily inattentive. Instead, a patient with ADHD may be
unable to remember a full explanation (such as a homework assignment), or unable to complete
processes that require remembering sequences, such as model building. In general, children with
ADHD are often attracted to activities (television, computer games, or active individual sports)
that do not tax the working memory, or produce distractions. Children with ADHD have no
differences in long-term memory compared with other children.
Inability to Manage Time. Studies suggest that children with ADHD have difficulties being on
time and planning the correct amount of time to complete tasks. (This may coincide with shortterm memory problems.) In one study, although children with probable ADHD were able to selfreport many ADHD symptoms, they tended to believe they used their time wisely, in contrast to
reports by their teacher.
Lack of Adaptability. ADHD children have a very difficult time adapting to even minor changes
in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to
bed. Any shift in a situation can precipitate a strong and noisy negative response. Even when
they are in a good mood, they may suddenly shift into a tantrum if met with an unexpected
change or frustration. In one experiment, ADHD children could closely focus their attention
when directly cued to a specific location, but they had difficulty shifting their attention to an
alternative location.
Hypersensitivity and Sleep Problems. ADHD children are often hypersensitive to sights, sounds,
and touch. They usually complain excessively about stimuli that seem low key or bland to others.
Sleeping problems usually occur well after the point when most small children sleep through the
night. In one study, 63% of children with ADHD had trouble sleeping.
Diagnostic Criteria for ADHD in Children
2. Should have 6 or more of the following symptoms of hyperactivity-impulsivity that lasts for at
least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Often blurts out answers to questions before they have been completed
Note: Patients with A1 symptoms are diagnosed with ADHD, predominantly inattentive type.
Those with A2 are diagnosed with ADHD, predominantly hyperactive-impulsive type. Those
with both A1 and A2 are diagnosed as ADHD, combined-type.
B. Onset of some symptoms before the age of 7. However, children with the inattentive subtype
are not often diagnosed until they are above 7 years of age.
C. Symptoms occur in two or more settings. For example, at home and at school.
D. Clear evidence of significant impairment in social or academic functioning.
E. Not caused by a pervasive developmental disorder, schizophrenia, or any other psychotic
disorder, and is not better accounted for by another mental disorder, including anxiety or
depression.
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th Ed. (Text Revision). Washington, DC: 2000.
Risk Factors
Gender and ADHD
ADHD is most often diagnosed in boys. However, there is some evidence that it is
underdiagnosed in girls. Until recently, all major studies were conducted using boys as subjects.
Important studies on girls with ADHD are now underway. A major study reported that girls with
the condition experience the same multiple impairments as boys do.
Adults with ADHD
Research suggests that ADHD affects 2 - 6% of the adult population, assuming that one- to twothirds of cases persist into adulthood. ADHD in adults always occurs as a continuum of the
childhood condition. Adult-onset symptoms are likely due to other factors. Diagnosing adult
ADHD can be a difficult problem since hyperactivity typically wanes as children get older, while
attention and organizational problems may develop in older people. Some experts believe, then,
that the number of adults with ADHD is underestimated.
A rating scale using four factors may be useful in identifying adults with ADHD:
Doctors use adult reports of their childhood behaviors and experiences when searching for clues
for a diagnosis. Interestingly, the disorder seems to be distributed equally between adult women
and men.
How Serious Is Attention Deficit Disorder in Adults?
Accompanying Emotional, Personality, and Learning Disorders. Between 19 - 37% of adults
with ADHD have depression or bipolar disorder. Between 25 - 50% have an anxiety disorder.
Bipolar disorder plus ADHD, in fact, may be very difficult to differentiate from ADHD alone in
adults.
Accompanying Learning Disorders. About 20% of adults with ADHD have learning disorders,
usually dyslexia and auditory processing problems. These problems should be considered in any
treatment plan.
Effect on Work. Compared to adults without ADHD, those with the condition tend to reach lower
educational levels, earn less money, and be fired more often. In fact, one article reported that by
the time they are in their 30s, about 35% of ADHD adults are self-employed.
Substance Abuse. About 1 in 5 adults with ADHD also contend with substance abuse. Studies
indicate that adolescents with ADHD are twice as likely to smoke cigarettes as their peers who
do not have ADHD. Cigarette smoking during adolescence is a risk factor for the development of
substance abuse in adulthood.
Sleep Disorders. Sleep disorders, especially restless legs syndrome and sleep apnea, are common
in adults and children with ADHD. Sleep apnea is a disorder in which a person temporarily stops
breathing during sleep, perhaps hundreds of times. In most cases the person is unaware of it,
although sometimes they awaken and gasp for breath. It is usually accompanied by snoring. One
report suggested that treating sleep apnea in adults with both conditions may help reduce ADHD
symptoms. [For more information, see In-Depth Report #65: Sleep apnea.]
Causes
Brain Structures. Research using advanced imaging techniques shows there is a difference in the
size of certain parts of the brain in children with ADHD compared to children who do not have
ADHD. The areas showing change include the prefrontal cortex, the caudate nucleus and globus
pallidus, and the cerebellum:
The prefrontal cortex is located in the front of the brain. It is thought to be the
brain's command center. It regulates the brains ability to block certain
responses. Numerous imaging studies have indicated that the prefrontal
cortex of the brain in people with ADHD may be less active than in those
without the disorder.
The caudate nucleus and globus pallidus, located near the center of the
brain, speed up or stop orders coming from the prefrontal cortex. In some
reports, these areas have been smaller than average in young children with
ADHD, but tended to become normal as the children got older. Abnormalities
in these areas may impair a person's ability to stop certain actions, resulting
in the impulsivity typical of people with ADHD.
The cerebellum is the area above the brain stem. This area helps control
muscle tone and balance, and synchronizes muscle activity. This has been
found to be smaller in children with ADHD compared to those without the
condition.
Brain Chemicals. Abnormal activity of certain brain chemicals in the prefrontal cortex may
contribute to ADHD. The chemicals dopamine and norepinephrine are of special interest.
Dopamine and norepinephrine are neurotransmitters, or chemical messengers, that affect both
mental and emotional functioning. They also play a role in the "reward response." This response
occurs when a person experiences pleasure in response to certain stimuli (such as food or love).
Studies suggest that increased levels of the brain chemicals glutamate, glutamine, and GABA -collectively called Glx -- interact with the pathways that transport dopamine and norepinephrine.
Nerve Pathways. Another area of interest is a network of nerves called the basal-ganglia
thalamocortical pathways. Abnormalities along this neural route have been associated with
ADHD, Tourette syndrome, and obsessive-compulsive disorders, all of which share certain
symptoms.
Genetic Factors
Genetic factors may play the most important role in ADHD. The relatives of ADHD children
(both boys and girls) have much higher rates of ADHD, antisocial, mood, anxiety, and substance
abuse disorders than the families of non-ADHD children. A study reported that 90% of children
with a diagnosis of ADHD shared it with their twin.
Genetic Factors Regulating Dopamine and Advantages in Early Man. Most of the research on
the underlying genetic mechanisms targets the neurotransmitter dopamine. Variations in genes
that regulate specific dopamine receptors have been identified in a high proportion of people
with addictions and ADHD. Such genes have been associated with novelty seeking and
extroversion. Some experts theorize that the genetic variants may have first appeared thousands
of years ago, and affect as many as half of ADHD children. Furthermore, the genetic variations
may have offered some benefits to their early carriers. In such people, a genetic predilection for
novelty-seeking and risk-taking may have supplied an advantage in reproduction, mating,
hunting, and achieving dominance.
Genetic Resistance to Thyroid Hormone. About 50% of adults and 70% of children with a
genetic resistance to thyroid hormone, essential for normal brain development, have ADHD.
People who have this condition appear to have a more severe form of ADHD. The thyroid
disorder is not a common cause of ADHD. Only those with a family history of thyroid disease
are at risk.
Dietary Factors
Infant malnutrition is a strong risk indicator of ADHD. Even if children receive enough food
later on, infants who suffer from malnutrition may develop behavior problems, the most
prevalent being attention-deficit disorder.
Deficiencies in Zinc and Essential Fatty Acids. Several dietary factors have been researched in
association with ADHD, including sensitivities to certain food chemicals, deficiencies in fatty
acids (compounds that make up fats and oils) and zinc, and sensitivity to sugar.
Some studies have found an association between deficiencies in certain fatty acids and ADHD.
Other research reports an association between zinc deficiencies and ADHD. Zinc aids in the
breakdown of fatty acids, which affects dopamine, the neurotransmitter likely to be involved
with ADHD.
No clear evidence has emerged, however, that implicates any of these nutritional factors in
ADHD.
Environmental Factors
Research suggests that prenatal exposure to tobacco, alcohol, environmental lead, and other
toxins may increase the risk for ADHD and conduct disorders.
Diagnosis
No laboratory or imaging tests exist to reliably diagnose ADHD. A diagnosis relies only on
behavioral symptoms and ruling out other disorders. Many experts believe that the disorder is
both over- and underdiagnosed. Diagnosis of attention-deficit hyperactivity disorder is difficult
for some of the following reasons:
Factors Leading to the Over-Diagnosis of ADHD:
Other factors that may contribute to misdiagnosis include children who are
young for their grade and therefore socially and intellectually immature, and
social and economic problems such as single parent households.
Some evidence suggests that many girls with ADHD may go underdiagnosed.
Research indicates that girls with ADHD are often inattentive but not
hyperactive or impulsive. In fact, older girls with ADHD tend to have social
problems due to withdrawal and internalized emotions, showing symptoms of
anxiety and depression. The inattentive subtype, in any case, may first show
up in older children and adolescents.
Doctors may fail to diagnose children with ADHD because they often behave
normally in the quiet doctor's office where there are no distractions to trigger
symptoms. In addition, doctors may be unfamiliar with how to diagnose the
condition.
In spite of the fact that there seems to be no differences in response to
treatment among population groups, African-American, Hispanic, and Asian
children with ADHD are half as likely to be diagnosed and treated as
Caucasian children. By high school, the racial disparity increases to the level
that the medication rate for blacks is one-fifth of that for whites.
History of Behavior
The doctor will first require a detailed history of the child's behavior. Doctors will match this
against a standardized checklist to define the disorder.
The parents should describe the following:
Sibling relationships
Eating habits
Sleep patterns
The health professional will want to know how the parents handle different situations, and may
want to observe them interacting with the child.
Physical Examination
The child should also be given a general physical examination to determine if any medical
conditions are present. The child should be given a hearing test to rule out hearing abnormalities
as a source of behavioral problems.
Screening Tests
Various tests are available to test neurologic, intellectual, and emotional development problems.
Most involve learning and problem solving tasks that help define the particular areas that are
most disabling. Blood or other laboratory tests are currently recommended only if the doctor
suspects lead toxicity or other medical problems.
Drug Trial
Although some doctors use a trial of a psychostimulant (usually Ritalin) to facilitate diagnosis,
most experts strongly recommend against this method of diagnosis, because it is not always
accurate. An improvement in symptoms is considered suggestive of ADHD, while in non-ADHD
children the stimulant often increases agitation and hyperactivity. Many children and adults
without the disorder have a similar response, and such a diagnostic trial may lead to unnecessary
prescriptions of this drug.
Other Disorders Associated with ADHD
Several disorders may mimic or accompany attention-deficit disorder. ADHD exists alone in
only about one-third of children. Many professionals object to the use of the single term
"attention-deficit hyperactivity disorder" to encompass such a wide spectrum of behaviors, which
they believe should be categorized into subgroups. Many of these problems require other modes
of treatment and should be diagnosed separately, even if they accompany ADHD.
Attention-Deficit Disorder without Hyperactivity
Attention-deficit disorder can appear without hyperactivity, in which case the child's primary
symptoms are distractibility and an inability to persist in tasks.
Oppositional-Defiant Disorder
About 14% of children diagnosed with ADHD also have oppositional-defiant disorder (ODD).
The most common symptom for this disorder is a pattern of negative, defiant, and hostile
behavior toward authority figures that lasts more than 6 months. In addition to displaying
inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper
tantrums, and display antisocial behavior. A significant number of children with ODD also have
anxiety disorders and depression, which should be treated separately. Many children who
develop ODD at an early age go on to develop conduct disorder.
Conduct Disorder
Some children with ADHD also have conduct disorder, which describes a complex group of
behavioral and emotional disturbances seen in children. It includes aggression towards people
and animals, destruction of property, deceitfulness, lying, or stealing, and general violation of
rules.
Pervasive Developmental Disorder
Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behavior,
hand-flapping, repetitive statements, slow social development, and speech and motor problems.
If a child who has been diagnosed with ADHD does not respond to treatment, the parents might
inquire about PDD, which often responds to antidepressants. Some children with PDD may also
benefit from stimulants.
Central Auditory Processing Disorder and Hearing Problems
Children with ADHD often have difficulties with tasks that involve listening or hearing.
Research is indicating that symptoms of the two disorders often overlap but may actually be two
distinct disorders. Hearing problems themselves may cause ADHD symptoms.
Bipolar Disorder (Manic Depression)
Children diagnosed with attention-deficit disorder may also have bipolar disorder, commonly
called manic depression. Indications of this problem include episodes of depression and mania
(with symptoms of irritability, rapid speech, and disconnected thoughts), sometimes occurring at
the same time. [For more information, see In-Depth Report #66: Bipolar disorder.] Both
disorders often cause inattention and distractibility and may be difficult to distinguish,
particularly in children. Children with mania and ADHD may have more aggression, behavioral
problems, and emotional disorders than those with ADHD alone. In some cases, ADHD in
children or adolescents can even be a marker for an emerging bipolar disorder. The primary way
to differentiate bipolar disorder from ADHD is by the presence of a manic or hypomanic episode,
which occurs in patients with bipolar disorder but not with ADHD. Most children with bipolar
will also respond to the drug valproate, which does not typically work for ADHD in children.
Anxiety Disorders
Sleep disorders or disturbances are very common with ADHD patients. Insomnia is common. In
addition, specific sleep disorders -- restless legs syndrome and sleep-disordered breathing -- have
been identified with hyperactivity and conduct disorder.
Restless Legs Syndrome (RLS). Some experts believe RLS and periodic limb movement disorder
are strongly associated with ADHD in some children. One theory is that the two are linked by a
common mechanism. The disorders have much in common, including poor sleep habits,
twitching, and the need to get up suddenly and walk about frequently. They may even be
genetically linked. For example, both have been associated with lower levels of dopamine in the
brain, which is associated with faulty motor control, a common problem in both disorders.
Sleep-Disorder Breathing and Sleep Apnea. Some research has shown an association between
mild symptoms of ADHD and sleep-disordered breathing, including snoring and obstructive
sleep apnea in children and adults. Treating the sleep-related breathing disorders may improve
the attention disorder in some children. (One study indicated that such problems are unlikely to
be associated with children with moderate to severe ADHD.) [For more information, see InDepth Report #65: Sleep apnea.]
Other Diagnoses
Tourette Syndrome and Other Genetic Disorders. Several genetic disorders cause symptoms
resembling ADHD, including fragile X and Tourette syndrome. About 50% of those with
Tourette syndrome also have ADHD, and some of the treatments are similar.
Other Medical Conditions. A number of medical conditions, including hyperthyroidism and
vision problems, can produce ADHD-like symptoms.
Lead. Children who ingest even low amounts of lead may manifest symptoms similar to those of
ADHD. A child may be easily distractible, disorganized, and have trouble thinking logically. The
major cause of lead toxicity is exposure to leaded paint, particularly in homes that are old and in
poor repair.
Complications
Emotional Disorders
More than half of children with attention-deficit disorder have accompanying disorders,
including anxiety, depression, and conduct disorders. Children with ADHD who experience
anxiety or depression are also more likely to suffer from low self-esteem.
Social Problems
Anti-Social Behavior. Even if these emotional disorders are absent in childhood, the ADHD
child's relationship with others is volatile, and they are often unhappy from a very young age.
Research indicates that any boy or girl with ADHD, particularly an aggressive child, has trouble
getting along with others, and is less liked by his or her peers.
Children with the inattentive subtype of ADHD are more likely to be picked on
and to spend time alone.
Children with the combined subtypes tend to have different problems. Boys
with ADHD are less likely than others to empathize with people in difficult
circumstances. A best friend can turn into an enemy overnight when, for
example, a boy with ADHD does not perceive his friend's fearful response to
over-aggressive roughhousing and fails to let up. The next day the child with
ADHD has forgotten the event; the ex-friend hasn't. When a child with ADHD
hurts someone, the child either may go into a state of denial or blame himself
excessively. As ostracism, fear, and ridicule from peers persist from year to
year, the unstable behavior, originally neurologic, becomes emotionally
based. Unless this cycle is broken, serious adult problems can evolve.
Substance Abuse in Young People. Studies consistently report that young people with ADHD -in particular those with conduct or mood disorders -- have a higher than average risk for
substance abuse and that it starts in younger ages. In one study, for example, by age 11 nearly
20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. Biologic
factors associated with ADHD may make these individuals susceptible to substance abuse. Many
of these young people are self-medicating their condition. In fact, according to a major analysis,
Ritalin or other stimulants used to treat ADHD may help protect such patients against substance
abuse. (Boys with ADHD and conduct disorder, however, still face a high risk for substance
abuse. Girls with ADHD and emotional disorders may also still have a higher risk.)
High-Risk Behavior. Impulsivity in young people with ADHD can certainly cause them to take
chances before thinking them through, putting them in situations where the consequences
become clear only after the action has been taken. Children with ADHD and high levels of
aggression are at higher risk for delinquent behavior in adolescents and criminal activity in
adulthood. However, children with ADHD who are not aggressive have a lower and even normal
risk for dangerous activities. Even in aggressive children with ADHD, close parental attention
and early treatment can limit the risk considerably.
Learning Problems
Although speech and learning disorders are common in children with ADHD, the disorder does
not affect intelligence. People with ADHD span the same IQ range as the general population.
Many children with ADHD are underachievers, and half are held back in school at least once.
Some evidence suggests that inattention may be a major factor in low academic performance in
these children. About 20% also have reading difficulties, and 60% have serious handwriting
problems. Adults with ADHD are also at very high risk for these conditions.
Persistence of ADHD into Adulthood
Some research suggests that ADHD persists in one- to two-thirds of those diagnosed with the
condition in childhood. Many researchers describe the pattern of ADHD as they would a chronic
illness, with remission and periods of worsening.
Effect on Family
The time and attention needed to deal with a child with ADHD can change internal family
relationships and have devastating effects on parents and siblings.
Effect on Parents. Studies indicate that any intervention for the child must include the parents.
Parents who are responsive to their child in a positive way can help reduce the chances for
oppositional behaviors. But it can be very difficult. A child with ADHD is wonderful one day and
terrible the next, for no apparent reason. The parent can feel betrayed and hurt, and believe they
have no control over their child. Parents must protect themselves and their child by establishing
tough but kind rules about where their space ends and the child's begins. The are many effects on
parents:
Mothers generally get the brunt of the emotional and physical abuse that a
child with ADHD can produce.
Parents may have to give up on the idea of an immaculate house and a hot
meal every night. Parents must learn that striving for perfection is among the
most counterproductive goals to pursue in raising a child with ADHD, or any
child.
Parents must face the hostility and anger of other parents and see their own
child rejected. It is very easy to fall into an emotional black hole, and feel
alone, inadequate, and helpless.
Marriages are often stressed to the breaking point because of exhaustion and
disagreements between the husband and wife on how to respond to the child.
Effect on Siblings. Siblings of children with ADHD have particular difficulties, and are also at
risk for psychologic impairment, depression, drug abuse, and language disorders. The nonADHD sibling does not have the control a parent does in the management of the ADHD child's
behavior and is very likely to feel alienated and alone. Children without ADHD are often
victimized by siblings with ADHD who may be demanding or bullying.
A sibling who does not receive attention in their own right may begin to imitate undesirable
behaviors or to act out negatively in other ways. It is very important to make the brothers and
sisters equally vital to the family's functioning. However, they should never be made to feel that
their value in the family is as caregivers of the ADHD sibling.
Treatment
A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitivebehavioral therapy is proving to be the best option for treatment of children with ADHD.
Although medication can be helpful during the initial years of treatment, some research indicates
that the benefits of medication eventually wear off. It appears that for ADHD symptoms may
improve naturally over time, regardless of the treatment approach.
Signs that ADHD may be easing include not having to adjust medication dosages during growth
spurts, no deterioration when a drug dose is missed, or new abilities to concentrate during drug
holidays. (School vacation times are a good period to test the effectiveness of temporarily
stopping medication.) The American Academy of Child and Adolescent Psychiatry suggests that
parents evaluate whether medication can safely be withdrawn when children with ADHD have
been free of symptoms for at least 1 year. If a childs condition worsens after medication
withdrawal, the drug should be resumed.
Developing a Treatment Approach. The following guidelines may be useful in determining a
treatment approach for children with ADHD:
Behavioral techniques, possibly including dietary changes, should be tried
first, if possible.
Cognitive behavioral therapy (CBT) is often administered by mental health providers, with both
primary care physicians and psychiatrists prescribing medications. Unfortunately, many children
do not have access to behavioral therapies, either because of lack of time or available resources.
Specific Patient Populations. Unfortunately, such guidelines do not address the following
specific patient groups:
There are no definite guidelines for treating preschool children with severe
ADHD. Some parents have reported very good long-term results with
behavioral interventions at this age.
There are no defined treatments for children with ADHD and accompanying
emotional problems, such as bipolar or anxiety disorders. (There is some
evidence, for example, that children with ADHD plus anxiety disorders do
worse on psychostimulants.)
Determining a Medication Regimen. Doctors still have a difficult time predicting which
medications will produce beneficial results, so treatment is individualized and performed on a
trial and error basis, which requires close observation and cooperation between all participants.
In developing an effective medication plan, the following steps may be helpful:
Both the doctor and the parents should be very clear about the specific
behaviors they hope the medication will target.
The goal is to use the lowest possible dosage that produces improved
behavior.
If an initial regimen doesn't work, changing the dosage, or changing to a
different medication often brings improvement.
Arguments For and Against Psychostimulants. Many parents are very disturbed by the idea of
putting their children on intensive stimulant drug regimens, possibly for years, particularly given
the uncertainties in diagnosis and the negative publicity surrounding the use of these drugs.
Although the decision to use these drugs should not be made lightly, the negative social and
emotional effects of the disorder itself for many children with ADHD are far more severe and
long-lasting than the use of these drugs. For some parents and children, medication seems like a
miracle and can provide desperate families with a quality of life for which they had almost given
up hope. Whether or not psychostimulants are used, children and families should understand that
ongoing efforts around behavior control will be necessary.
Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool
children. Although low doses of methylphenidate (Ritalin) may help preschoolers (ages 3 - 5
years) with ADHD, the drug can cause considerable side effects in many children. These side
effects include insomnia, nervousness, anxiety, loss of appetite and weight, and slowed growth.
Children in one large study grew about an inch less and weighed about 6 pounds less than normal
after 3 years of methylphenidate treatment. Doctors must carefully consider the risks versus
benefits when prescribing ADHD drugs to preschoolers. Children who do receive these drugs
need to be carefully monitored by their doctors.
Treatment for Adult ADHD. As with children, adults with ADHD are treated with a combination
of medication and psychotherapy. For medication, stimulant drugs or the non-stimulant drug
atomoxetine (Strattera) are usually first-line treatments, with antidepressants a secondary option.
Atomoxetine is approved specifically for adults with ADHD. Adults who have heart problems or
heart condition risk factors should be aware of the cardiovascular risks associated with ADHD
medication. There have been ADHD medication-associated incidents of sudden death in patients
with underlying serious heart problems, and reports of stroke and heart attack in adults with
cardiac risk factors.
Help for Families and Teachers
Research increasingly supports the view that interventions for the ADHD child must also include
the parents if they are to be successful. Teachers and school officials should also be educated and
involved in the process.
Parents who feel they have the most control over their child's situation experience the least
psychological stress and depression. Parents who are responsive in a positive way also help
reduce the chances for their child developing oppositional behaviors. But it can be very difficult,
particularly for parents who have ADHD themselves. In fact, parents who have severe ADHD
symptoms are less likely to respond to parent training programs unless they get help for
themselves.
In addition to behavioral therapy for the child, family therapy may help ADHD children and their
parents and siblings cope with the emotional conflicts that nearly always arise in the lifelong
process of managing the condition. Separate psychological therapies for specific family members
might be needed, particularly in light of the high incidence of psychiatric and other emotional
problems in families with ADHD children.
Medications
Psychostimulants are the primary drugs used to treat ADHD. Although these drugs stimulate the
central nervous system, they have a calming effect on people with ADHD.
These drugs include:
Dexmethylphenidate (Focalin)
Amphetamine-Dextroamphetamine (Adderall)
Lisdexamfetamine (Vyvanse)
Pemoline (Cylert), another stimulant drug, was withdrawn from the U.S. market in 2005 after
several reports of liver failure.
Methylphenidate and Dexmethylphenidate. Methylphenidate drugs (Ritalin, Metadate, Concerta,
Daytrana) are the most commonly used psychostimulants for treating ADHD in both children
and adults. Dexmethylphenidate (Focalin) is a similar drug. These drugs increase dopamine, a
neurotransmitter important for cognitive functions such as attention and focus.
With the exception of Daytrana, all of these drugs are pills taken by mouth. Daytrana, approved
in 2006, is the first skin patch drug for ADHD. A patch is applied to the hip each day and delivers
a 9-hour dose of methylphenidate.
These drugs are available in short-acting and long-acting dosage forms. The short-acting forms
need to be taken several times a day, including during school hours. As the drug wears off, a
rebound effect can occur, and ADHD symptoms can intensify. For this reason, the long-acting
dosage forms have become popular.
Amphetamine, Dextroamphetamine, and Lisdexamfetamine. Amphetamine-dextroamphetamine
(Adderall), dextroamphetamine (Dexedrine, Dextrostat), and lisdexamfetamine (Vyvanse) work
by blocking the reabsorption of the brain chemicals dopamine and norepinephrine. Side effects
can include stomach problems and mood changes, including sadness, anxiety, and irritability.
Risks of Stimulants
Psychostimulant medications are associated with some significant risks. All ADHD stimulant
drugs carry warnings that they should not be used by patients with structural heart problems or
pre-existing heart conditions (high blood pressure, heart failure, or heart rhythm disturbances).
These drugs have been associated with sudden death in children with heart problems. They have
also been associated with sudden death, stroke, and heart attack in adults with a history of heart
disease. In addition, these drugs may slightly increase the risk for auditory hallucinations,
paranoia, and manic behavior even in patients who do not have a history of psychiatric problems.
The FDA has directed manufacturers of ADHD medications to warn all patients taking these
medicines of their potential cardiovascular and psychiatric risks.
Stimulant drugs may also:
Cause a mixed or manic episode in patients who have both ADHD and bipolar
disorder.
Slow growth and weight gain in children. Children who take stimulant drugs
should have their growth monitored. If they do not gain height or weight at a
normal rate, they may need to stop taking the drug.
Symptoms of Overdose. Symptoms of overdose include changes in heart rhythm and rate,
hypertension, confusion, breathing difficulties, sweating, vomiting, and muscle twitches. If they
occur, parents should call the doctor immediately. Even among young people who abuse Ritalin,
however, less than 1% experience severe side effects (rapid heart rate, hypertension), and
outcomes are generally good. Side effects may be very severe, however, if Ritalin is overused
and taken with other drugs. A 2006 study reported that over 3,000 people are treated in hospital
emergency rooms due to side effects from ADHD drugs. Sixty-one percent of these visits
involved accidental ingestion or overdose.
Concerns for Abuse. Studies on both animals and humans suggest that Ritalin lacks the
properties that create addiction, particularly in doses used for treating ADHD. Although
methylphenidates have properties similar to amphetamines, their drug levels rise very slowly in
the brain at the oral doses given for ADHD. This slow rise prevents a so-called "high" and
subsequent addiction to the drug. Some stimulant drugs, such as lisdexamfetamine, may pose a
lower risk for abuse than others.
The primary danger for drug abuse from stimulants appears to occur in non-ADHD young people
who purchase these drugs illegally. In one study, for instance, 16% of children with ADHD
reported pressure from their fellow students to sell or give them their medication. While people
ages 18 - 25 are more likely to use ADHD drugs for non-medical uses, children ages 12 - 17 are
more likely to suffer adverse effects from medication misuse and to require treatment at an
emergency room. If a child abuses another drug (alcohol, prescription medication) along with the
ADHD medication, the chance for serious side effects is even greater.
Non-Stimulant: Atomoxetine
Atomoxetine (Strattera) was the first non-stimulant approved for ADHD in children and the first
treatment approved for adult ADHD. The drug works by increasing levels of both norepinephrine
and dopamine, which are generally lower than normal in ADHD. The most common side effect is
decreased appetite. A few cases of atomoxetine-associated liver injury have been reported, and
the FDA has warned doctors that the drug should be discontinued at the first signs of jaundice or
liver problems. Long-term effects, such as any impact on growth, are still unknown. Atomoxetine
may cause suicidal thinking in children and adolescents, especially during the first few months of
treatment. Parents should monitor children taking atomoxetine for any changes in mood or
behavior, and immediately contact their doctor if changes occur.
Antidepressants
Antidepressants are not FDA-approved for ADHD treatment, but may be helpful in certain
circumstances. Because antidepressants appear to work about as well as behavioral therapy,
doctors recommend that patients first try psychotherapy before using antidepressants.
Bupropion (Wellbutrin) and tricyclics are the types of antidepressants used for ADHD.
Bupropion affects the reuptake of the serotonin, norepinephrine, and dopamine
neurotransmitters. Side effects include restlessness, agitation, sleeplessness, headache, and
stomach problems. Bupropion should not be used by patients who have a seizure disorder.
Tricyclics are an older type of antidepressant that are effective but have many side effects.
Imipramine (Tofranil) and nortriptyline (Pamelor, Aventil) are the tricyclics most commonly
prescribed for ADHD. A third tricyclic, desipramine (Norpramin) should only be used if patients
are not helped by other tricyclics. (Desipramine has caused sudden death in some children and
adolescents.)
Tricyclic antidepressants can cause disturbances in heart rhythm. Children should have an
electrocardiogram when they first begin to take this drug, and after any dose increase.
[For more information, see In-Depth Report #8: Depression ].
Alpha-2 Agonists (Clonidine)
These drugs have a number of side effects. Sedation is the most common. A clonidine skin patch,
which gradually releases the medication, helps reduce the sedative effect. Because clonidine
slows the heart down, it can have adverse effects in some children. Going off too quickly or
missing doses can cause rapid heartbeats and other symptoms that may lead to severe problems.
Doctors strongly recommend that no child be given this medication without a preliminary
examination for heart problems, and no child with existing heart, kidney, or circulatory problems
should take it.
Behavioral Management
Behavioral techniques for managing the child with ADHD are not intuitive for most parents and
teachers. To learn them, caregivers may need help from qualified health care professionals or
from ADHD support groups. At first, the idea of changing the behavior of a highly energetic,
obstinate child is daunting. It is futile and damaging to try to force a child with ADHD to be like
most children. It is possible, however, to limit destructive behavior and to instill a sense of selfworth that will help overcome negativity toward life, which is one of the great dangers of the
disorder.
Behavioral Techniques at Home
Bringing up a child with ADHD, like bringing up any child, is a process. No single point is ever
reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to
do anything more." The child's self worth will evolve with an increasing ability to step back and
consider the consequences of an action and then to control that action before taking it. But this
does not happen overnight. A growing child with ADHD is different from other children in very
specific ways, presenting challenges at every age.
Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some
parents are easygoing and can accept a wide range of behaviors, while others cannot. To help a
child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some
tips to help the parents include:
Parents should prepare a list giving priority to those behaviors they think are
the most negative, such as fighting with other children or refusing to get up
in the morning. The least negative behaviors on the bottom of the list should
be ignored temporarily or even permanently (refusing to wear anything but
red T-shirts).
Certain odd behaviors that are not hurtful to the child or to others may be an
indication of creative or humorous attempts to adapt (making up silly songs
or drawing violent pictures). These should be accepted as part of the child's
unique and positive development, even if they seem peculiar to the parent.
Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their
approach to the child, which should reward good behavior and discourage destructive behavior.
Rules should be well-defined but flexible enough to incorporate harmless idiosyncrasies. It is
very important to understand that children with ADHD have much more difficulty adapting to
change than do children without the condition. (For example, the child should do homework
every day but might choose to start it after a TV show or computer game.)
Managing Aggression. Some useful tips for managing aggression include:
Parents should try to give little attention to mildly disruptive behaviors that
allow this energetic child to let off some harmless steam. The parent will also
be wasting energy that will be needed when the negative behavior becomes
destructive, abusive, or intentional.
The use of "time-out," isolating the child immediately for a short period of
time, is an effective measure for allowing both the caregiver and the child to
cool down. The child should immediately (and without emotion) be removed
from a situation in which they are endangered or endangering others. The
child should view time out as a way of cooling off and getting a distance on
their behavior, not as isolation from others.
Establishing a Reward System. Children with ADHD respond particularly well to reward
systems. One study reported that they performed equally well when encouraged either by a direct
reward for a correct response or with the use of a system called response-cost. With this system,
the child is given the reward first and allowed to keep it if their behavior remains appropriate.
Some suggested tips for rewarding the ADHD child are:
Create charts with points or stars for good behavior or for completed tasks. It
is important to give points for even simple positive behaviors, which may be
taken for granted in other children (responding happily to a change in plans,
changing an obscenity to a more acceptable expletive).
Rewards for any child can include playing a favorite game with the child,
extending bedtime by an hour, or allowing an extra half-hour of TV.
Rewards of food or gifts should be used infrequently, if at all. They can create
other problems, such as being overweight, having a bad diet, or making
continuous demands for objects.
Children with ADHD respond better with small rewards promised in the shortterm than large rewards offered in the future. One approach that employs
both short- and long-term rewards uses a system that gives the child points
for specific positive behaviors. As the children accumulate points, they can
use them for larger tangible rewards, such as a favorite video game or CD.
Rewards should be promised only when caregivers are fairly certain they can
follow through. ADHD children respond with much greater frustration than
non-ADHD children to disappointment, and are likely to have a strong (and
noisy) negative reaction. A parent must remember that this response is part
of the ADHD child's make-up and not necessarily in their control.
Improving Concentration and Attention. Research indicates that ADHD children perform
significantly better when their interest is engaged. Parents should be on the lookout for activities
that hold the child's concentration. Some options that may help an ADHD child to focus include:
Many ADHD children are particularly lured by the computer, which is a very
promising tool. A number of non-violent computer games are available that
offer problem-solving techniques using characters, narrative, and humor.
Swimming, tennis, and other sports that focus attention and limit peripheral
stimuli are often appealing. ADHD children often do not do well with team
sports, although they are interested. Children with ADHD are less likely to
become distracted in sports that require constant alertness, such as football
or basketball. In baseball, positions such as pitching or catching are
preferable to the outfield, where attention easily wanders. Finding a coach
that understands the childs difficulties is very helpful.
Some experts are enthusiastic about martial arts, such as Tae Kwon Do,
which can offer an appropriate and controlled emotional outlet, help to focus
attention, and teach self-restraint, self-discipline, and tolerance. Care should
be taken to select an instructor who makes such goals a priority.
Learning an instrument may be one of the best ways for an ADHD child to
develop a more rhythmic and balanced sense of self. Music, even simply
listening to it, is often very important for these children. (Parents may have to
tolerate music that does not please them.)
Management at School
Even if a parent is successful in managing the child at home, difficulties often arise at school.
The ultimate goal for any educational process should be the happy and healthy social integration
of the ADHD child with their peers.
Preparing the Teacher. Although teachers can expect at least one student in every classroom to
have ADHD, there is currently little training that prepares them for managing these children. The
teacher should be prepared for the certain behaviors in the child with ADHD:
Students with ADHD are often demanding, talkative, and highly visible.
Lack of fine motor control makes taking notes very difficult, and handwriting
is often poor. Using a typewriter or computer can compensate for this. One
useful skill that has helped some children is learning to type at an early age,
around the third or fourth grade.
Rote memorization and math computation, which require following a set of
ordered steps, are often difficult. (Children with ADHD may do better with
math concepts.)
Many children with ADHD respond well to school tasks that are rapid, intense,
novel, or of short duration (such as spelling bees or competitive educational
games), but they almost always have problems with long-term projects where
there is no direct supervision.
The Role of the Parent in the School Setting. The parent can help the child by talking to the
teacher before the school year starts about their child's situation:
The first priority for the parent is to develop a positive, not adversarial,
relationship with the child's teacher.
The parent must acknowledge the teacher's situation, for the teacher must
deal not only with the ADHD child's behavior but also with the needs of all the
other children.
Frequent brief and sympathetic conversations with the teacher can be helpful
and can lead to coordination of efforts, particularly if they provide reciprocal
information about progress or setbacks.
Finding a tutor to help after school may be helpful. It is not clear, however, if
tutoring offers significant benefits for children whose academic problems
stem from inattention unless it is structured specifically to address this
problem.
Special Education Programs. The Individuals with Disabilities Education Act (IDEA) requires
the school to identify and evaluate children who may need help and to provide special services.
However, parents sometimes report pressure by the school to put their children on medication or
force them into special classrooms without clear educational justification. The schools, in these
cases, may be acting illegally.
High-quality special education can be extremely helpful in improving learning and developing a
child's sense of self worth. Many families, however, may not have appropriate programs
available for them. Programs vary widely in their ability to provide quality education. Parents
must be aware of certain limitations and problems with special education:
Special education programs within the normal school setting often increase
the child's feelings of social alienation.
If, in fact, ADHD is as common as studies are indicating, the best approach may be to treat the
syndrome as a variant of the norm and train teachers to manage these children within the context
of a normal classroom.
Special programs are also required under the Rehabilitation Act and by the Americans with
Disabilities Act (ADA) for students at institutions of higher learning. It is the student's
responsibility, however, to inform the administration at their college or university that they need
such services. Unfortunately, many college students are reluctant to do this, although such
programs can provide important and beneficial assistance in improving their academic
performance.
Other Treatments
Dietary Approaches
A number of diets have been suggested for people with ADHD. Several well-conducted studies
have failed to support dietary effects of sugar and food additives on behavior, except possibly in
a very small percentage of children. Still various studies have reported behavioral improvement
with diets that restrict possible allergens in the diet. Parents may want to discuss with their doctor
implementing an elimination diet of certain foods that would not be harmful and that might help.
Food Allergies. Evidence suggests that children with behavioral difficulties may be sensitive to
certain chemicals in foods. Studies vary widely, however, on how many cases of ADHD may be
associated with sensitivities or allergies to food chemicals or additives, with results ranging
widely from 5 - 62%. Among the suspected additives and foods that parents and studies report as
inciting behavioral changes are the following:
Any artificial colorings (particularly yellow, red, or green)
Chocolate
Milk
Eggs
Wheat
Foods containing salicylates, including all berries, chili powder, apples and
cider, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes,
tomatoes
In one small study, 62% of children who were given only rice, turkey, pears, and lettuce to eat for
2 weeks experienced at least a 50% improvement in symptoms. Nevertheless, about a quarter of
the children pulled out because they could not stick with the diet or they became ill.
Feingold Diet. The most well-known diet for ADHD is the Feingold diet, a salicylate- and
additive-free diet, which requires rigorous vigilance over a child's eating habits. This diet also
prohibits aspirin, which contains salicylates. Some parents report great success with this diet,
although it may be difficult to impose. One study that reported the diets efficacy suggested that it
might not provide enough nutritive value, although the diet provides a wide range of healthy
foods to select from. It is certainly wise, in any case, to avoid food with artificial colors and
flavors and to provide a healthy balance of fresh, natural foods.
Essential Fatty Acids. Omega-3 fatty acids, found in fatty fish and certain vegetable oils, are
important for normal brain function and may have some benefits for people with ADHD. It is not
clear if supplements of fatty acid compounds, such as docosahexaenoic acid (DHA) and
eicosapentaneoic acid (EPA), provide any advantages.
Zinc. Zinc is important for the metabolism of certain neurotransmitters that play a role in ADHD,
and deficiencies have been associated with some cases of ADHD. Long-term use of zinc,
however, can cause anemia and other side effects in people without deficiencies and it has no
effect on ADHD in these patients. In any case, testing for trace minerals, such as zinc, is not
standard procedure when evaluating children suspected to have ADHD.
Sugar. Although parents often blame sugar for causing children to become impulsive or
hyperactive, a number of studies strongly indicate that sugar plays no role in hyperactivity. One
study reported, in fact, that ADHD children had fewer problems after a high-carbohydrate
breakfast than after a high-protein one. Another reported that children actually moved more
slowly after a high-sugar meal, suggesting the carbohydrates may have a sedative effect. (Still,
it's probably always wise for any child to cut down on sugar.)
Feedback Approaches
Techniques that use biologic or auditory feedback are proving to be effective tools for increasing
children's attention -- a primary factor in low academic performance.
Neurofeedback. Neurofeedback is an approach that uses electronic devices to help the child
control their own brain wave activity. Electrodes are pasted to the child's head and pick up
signals from the brain. The child watches images, such as moving graphs, on a computer monitor
that reflect the child's brain wave activity. Children are then taught certain high-level mental
activities at the point when feedback information on the screen indicates that they are fully
concentrating. Children usually attend forty 50-minute sessions, usually twice a week. Small
studies have reported significant improvement in inattention, impulsivity, and response time.
Interactive Metronome and Musical Therapy. Interactive metronome uses feedback from sound
to improve attention, motor control, and certain academic skills. In this technique study, children
wear headphones and sensors on their hands and feet. They perform a number of exercises to a
rhythmic computer-beat. Training sessions are completed in 3 - 5 weeks. Some small studies
have reported improvement in attention, motor control, language processing, and behavior. (In
support of this, some parents report that learning a musical instrument helped their children
significantly.)
Other Alternative Remedies
Procedures and Non-Drug Therapies. A number of alternative approaches are used for children
and adults with mild ADHD symptoms. For example, daily massage therapy may help people
with ADHD feel happier, fidget less, be less hyperactive, and focus on tasks. Other alternative
approaches that may be helpful include relaxation training, meditation, and music therapy. Based
on existing evidence, these treatments may be helpful for symptom management but are not
proven to benefit the underlying disorder.
Natural Remedies. A number of parents resort to alternative remedies as an alternative to
psychostimulants and other drugs. Small trials have found some herbs and supplements -- such
as oral flower essence, ginkgo biloba, panax ginseng, melatonin, and pine bark extract
(Pycnogenol) --may possibly have benefits for ADHD. Based on existing evidence, however,
none can be recommended, particularly for children.
Herbs and Supplements
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval
to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and
therefore have the potential to produce side effects that may be harmful. There have been a
number of reported cases of serious and even lethal side effects from herbal products. Always
check with your doctor before using any herbal remedies or dietary supplements.
The following are special concerns for people taking natural remedies for attention-deficit
disorders:
Gingko. The risk for side effects from gingko appear to be low, but there is an
increased risk for bleeding and interaction with anti-clotting medications at
high doses.
Braun JM, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to environmental toxicants
and attention deficit hyperactivity disorder in U.S. children. Environ Health Perspect. 2006
Dec;114(12):1904-9.
Heinrich H, Gevensleben H, Strehl U. Annotation: neurofeedback - train your brain to train
behaviour. J Child Psychol Psychiatry. 2007 Jan;48(1):3-16.
Jensen PS, Arnold LE, Swanson JM, et al. 3-year follow-up of the NIMH MTA study. J Am Acad
Child Adolesc Psychiatry. 2007 Aug;46(8):989-1002.
Nigg JT, Breslau N. Prenatal smoking exposure, low birth weight, and disruptive behavior
disorders. J Am Acad Child Adolesc Psychiatry. 2007 Mar;46(3):362-9.
Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and
treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad
Child Adolesc Psychiatry. 2007 Jul;46(7):894-921.
Steiner H, Remsing L; Work Group on Quality Issues. Practice parameter for the assessment and
treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child
Adolesc Psychiatry. 2007 Jan;46(1):126-41.
Swanson JM, Elliott GR, Greenhill LL, et al. Effects of stimulant medication on growth rates
across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 2007
Aug;46(8):1015-27.
Valera EM, Faraone SV, Murray KE, Seidman LJ. Meta-analysis of structural imaging findings
in attention-deficit/hyperactivity disorder. Psychiatry. 2007 Jun 15;61(12):1361-9. Epub 2006
Sep 1.
Wilens TE, Upadhyaya HP. Impact of substance use disorder on ADHD and its treatment. J Clin
Psychiatry. 2007 Aug;68(8):e20.
Williams JH, Ross L. Consequences of prenatal toxin exposure for mental health in children and
adolescents: a systematic review. Eur Child Adolesc Psychiatry. 2007 Jun;16(4):243-53. Epub
2007 Jan 2.
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Click to enlarge
Attention-Deficit/Hyperactivity
Disorder
instructions and
fails to finish
schoolwork, chores,
or duties in the
workplace (not due
to oppositional
behavior or failure
to understand
instructions)
6. often avoids,
dislikes, or is
reluctant to engage
in tasks that require
sustained mental
effort (such as
schoolwork or
homework)
8. is often easily
distracted by
extraneous stimuli
9. is often forgetful in
daily activities
1.
seat
5. is often on the go
or often acts as if
driven by a motor
6. often talks
excessively
Impulsivity
9. often interrupts or
intrudes on others
(e.g., butts into
conversations or
games)
B. Some hyperactiveimpulsive or
inattentive
symptoms that
cause impairment
were present before
age 7 years.
Prevalence
ADHD, which is the most commonly diagnosed
behavioral disorder of childhood, occurs in 3 to 5
percent of school-age children in a 6-month
period (Anderson et al., 1987; Bird et al., 1988;
Esser et al., 1990; Pelham et al., 1992; Shaffer et
al., 1996c; Wolraich et al., 1996). Pediatricians
report that approximately 4 percent of their
patients have ADHD (Wolraich et al., 1990), but
in practice the diagnosis is often made in children
who meet some, but not all, of the criteria
recommended in DSM-IV (Wolraich et al., 1990)
(see also Treatment later in this section). Boys are
four times more likely to have the illness than
girls are (Ross & Ross, 1982). The disorder is
found in all cultures, although prevalences differ;
differences are thought to stem more from
differences in diagnostic criteria than from
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Related Links
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
A non-profit organization serving individuals with AD/HD through advocacy, research,
education, and support.
Clinicaltrials.gov
AD/HD research studies identified through the U.S. National Library of Medicine's link to
federally and privately funded studies worldwide.
A person is considered to have ADHD if they have at least 6 symptoms from the following
categories, lasting for at least 2 months. In diagnosing children, the symptoms must appear
before age 7 and pose a significant challenge to everyday functioning in at least two areas of life
(usually home and school). Most children do not show all the symptoms, and they may be
different in boys and girls (boys may be more hyperactive and girls more inattentive).
Inattention
Is easily distracted
Talks excessively
No one is sure what causes ADHD. Although environment may play a role, researchers are now
looking to find answers in the structure of the brain.
Altered brain function -- Brain scans have shown 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 part of the brain thought to be the command center. This may affect
their ability to control impulsive and hyperactive behaviors. Researchers also
believe hyperactive behavior in children can be caused by too much slowwave (or theta) activity in certain regions of the brain.
Risk Factors:
Heredity -- children with ADHD usually have at least one first-degree relative
who also has the disorder.
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 or infant to toxins, including lead and PCBs;
nutritional deficiencies and imbalances.
Other behavioral disorders, especially those that involve too much aggression
(such as oppositional defiant or conduct disorder).
Because there is no objective test for ADHD, making a diagnosis can be hard. A number of tests
and observations may be used. For this reason, it is crucial to make sure the doctor who evaluates
you or your child has training in diagnosing ADHD.
To evaluate a child, the doctor will take a complete medical history and do a thorough exam to
check for conditions that may mimic ADHD, such as hyperthyroidism or problems with vision,
hearing, and sleeping. Because many symptoms show up at home or school rather than the
doctor's office, you may be asked to fill out questionnaires. Your child's teacher may be
interviewed. Your doctor will try to determine not only how the child behaves but also where the
behavior occurs and how long it lasts. Children with ADHD have long-lasting symptoms that
usually show up during stressful situations or situations that require sustained attention (such as
schoolwork).
Diagnosing an adult with ADHD can be even more challenging. Because your symptoms would
have appeared when you were young, your doctor may try to find out as much as possible about
you when you were a child by getting information from your parents or former teachers. (If your
symptoms are recent, you are not considered to have adult ADHD.) In addition to ruling out the
other conditions mentioned above, your doctor may also check for depression and bipolar
disorder, which can mimic ADHD.
Preventive Care:
Because the cause or causes of ADHD are not known, there is no way to prevent the condition. It
can be managed with medication, behavioral therapy, and lifestyle changes.
Treatment Options:
Parent skills training offered by skilled clinicians provides parents with tools and techniques for
managing their child's behavior. Behavior therapy rewards appropriate behavior and discourages
destructive behavior. It can be performed by parents and teachers working together with
therapists and doctors. For example, older children with ADHD may be rewarded with points or
tokens, or even written behavioral contracts with their parents. Creating charts with stars for
good behavior may work for younger children. On the other hand, timeouts may discourage
undesirable behavior. Other techniques include:
Avoiding repeated commands once the child has been reminded of the
consequences
Following discipline with praise when the child follows the rules and behaves
appropriately
In addition to behavioral intervention at home, changes in the classroom environment (or work,
in the case of adolescents or adults) are significant parts of the treatment plan. Hyperactive
children do best in highly structured circumstances with a teacher experienced in handling their
disruptive behavior and capable of adapting to their distinctive cognitive style. Interactions with
groups are often very challenging for a child with ADHD. Social skills training, appropriate
classroom placement, and clear rules of engagement with peers are essential.
Adults with ADHD may benefit from behavioral therapies, including cognitive remediation,
couple therapy, and family therapy.
Drug Therapies
Stimulant medications are the most widely researched and commonly prescribed treatments for
ADHD. Although researchers do not fully understand how these drugs improve ADHD
symptoms, studies indicate they boost the amount of dopamine and serotonin in the brain.
Dopamine is a chemical that is associated with activity; and serotonin is a chemical associated
with mood and well-being. Medications prescribed for ADHD include:
Dextroamphetamine (Dexadrine) -- a stimulant that is effective in 70 75% of people with ADHD; not recommended for children under 3
years of age
Amphetamine/Dextroamphetamine (Adderall)
The most common side effects from these medications are trouble sleeping, decrease in appetite,
and nervousness.
Complementary and Alternative Therapies
According to a recent survey, many parents use complementary and alternative treatments for
their children with ADHD, with nutritional therapies being the most common. Although studies
show conflicting results, if your child appears sensitive to certain foods, talk to your doctor about
eliminating them for a brief period to see if his symptoms improve. Putting a child on any diet
should be done only under the supervision of your doctor.
Diets
The Feingold diet was developed in the 1970s by Benjamin Feingold. He believed that artificial
colors, flavors, and preservatives, as well as naturally occurring salicylates (chemicals similar to
aspirin that are found in many fruits and vegetables), were a major cause of hyperactive behavior
and learning disabilities in children. Studies examining the diet's effect have been mixed. Most
show no benefit, although there is some evidence that salicylates may play a role in hyperactivity
in a small number of children. Because the Feingold diet is difficult to follow and also involves
changes in family lifestyle (children are encouraged to participate in creating meals, for
example), you should talk with your doctor before trying it.
Other dietary therapies may concentrate on eating foods that are high in protein and complex
carbohydrates, and eliminating sugar and artificial sweeteners from the diet. However, studies
show no relation between sugar and ADHD. In one study, children whose diets were high in
sugar or artificial sweeteners behaved no differently than children whose diets were free of these
substances. This was true even among children whose parents described them as having a
sensitivity to sugar.
Some doctors who focus on nutrition say they see positive results when testing for food allergies
and using an elimination diet. If you think your child might benefit from food allergy testing or
an elimination diet, talk to a doctor who has experience in nutrition for children with ADHD.
Vitamins and Minerals
Vitamin B6 -- Adequate levels of vitamin B6 are needed for the body to make
and use brain chemicals, including serotonin, dopamine, and norepinephrine,
the chemicals affected in children with ADHD. One preliminary study found
that B6 pyridoxine was slightly more effective than Ritalin in improving
behavior among hyperactive children. However, the study used a high dose
of B6, which could cause nerve damage (although none occurred in the
study). Other studies have shown that B6 has no effect on behavior. Because
high doses can be dangerous, do not give your child B6 without your doctor's
supervision.
Zinc (35 mg per day) -- Zinc regulates the activity of brain chemicals, fatty
acids, and melatonin, all of which are related behavior. Several studies have
found that zinc may help improve behavior, but only slightly. Higher doses of
zinc can be dangerous, so talk to your doctor before giving zinc to a child or
taking it yourself.
Essential fatty acids -- Fatty acids, such as those found in fish and fish oil
(omega-3 fatty acids) and evening primrose oil (omega-6 fatty acids), are
"good fats" that play a key role in normal brain function. Experts have
suggested them as a treatment for ADHD. The results of studies are mixed,
but research continues. Omega-3 fatty acids are also good for heart health in
adults, but high doses may increase the risk of bleeding. If you want to try
fish oil to see if it reduces ADHD symptoms in you or your child, talk to your
doctor about the best dose.
L-carnitine -- L-carnitine is formed from an amino acid and helps cells in the
body produce energy. One study found that 54% of a group of boys with
ADHD showed improvement in behavior when taking L-carnitine, but more
research is needed to confirm any benefit. Because L-carnitine has not been
studied for safety in children, talk to your doctor before giving a child Lcarnitine.
Herbs
Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy,
you should work with your health care provider to get your problem diagnosed before starting
any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites
(glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make
teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and
10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in
combination as noted.
Several herbal remedies for ADHD are sold in the United States and Europe. But few scientific
studies have been done to see whether these herbs improve symptoms of ADHD. One or more of
the following calming herbs may be recommended for people with ADHD:
Massage
Relaxation techniques and massage can reduce anxiety and activity levels in children and teens.
In one study, teenage boys with ADHD who received 15 minutes of massage for 10 consecutive
school days showed significant improvement in behavior and concentration compared to those
who were guided in progressive muscle relaxation for the same duration of time.
Homeopathy
Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your
physical, emotional, and psychological makeup. An experienced homeopath assesses all of these
factors when determining the most appropriate treatment for each individual.
In a study of 43 children with ADHD, those who received an individualized homeopathic remedy
showed a significant improvement in behavior compared to children who received placebo. The
homeopathic remedies found to be most effective included:
Cina -- for children who are irritable and dislike being touched; whose
behavior is physical and aggressive
Hyoscyamus niger -- for children who have poor impulse control, talk
excessively or act overly exuberant
Biofeedback
Mind-body techniques such as hypnotherapy, progressive relaxation, and biofeedback may be
useful in treating children and teens. Through these techniques, children are often able to learn
coping skills they can use for the rest of their lives. These treatments allow children to gain a
sense of control and mastery, increase self-esteem, and decrease stress.
Biofeedback operates on the principle that children can be trained to modify brain activity
associated with ADHD and increase brain activity associated with attention. Several studies have
shown positive results.
Other Considerations:
Prognosis and Complications
As many as half of all children with ADHD who receive appropriate treatment learn to control
symptoms and function well as adults. Research suggests that children who receive treatment
that combines therapies such as medication, behavioral therapy, and biofeedback are less likely
to have behavioral problems as they grow up. In most cases, ADHD can be effectively managed
throughout life.
Alternative Names:
ADHD
Supporting Research
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