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Attention deficit hyperactivity disorder

Highlights

Drug Approval

In 2006, Daytrana was approved as the first skin patch medication for treatment of attention deficit hyperactivity disorder (ADHD). Daytrana contains methylphenidate, the same drug used in Ritalin pills.

Drug Warning

• All ADHD stimulant medications now carry warnings that patients with a history of structural heart problems, high blood pressure, or disturbances in heart rhythm (arrhythmia) should not use these drugs. These warnings appear on the prescribing labels of methylphenidate (Ritalin, Concerta) and amphetamine drugs (Adderall, Dexedrine).
• In 2006, the manufacturer of Dexedrine added additional warning information to its drug label. In addition to heart warnings, the label advises that this drug can worsen behavioral and psychiatric problems in patients with ADHD and accompanying psychotic or bipolar disorders. The drug may also slow growth.
• The Food and Drug Administration is now requiring makers of ADHD medications to warn patients of potential heart and psychiatric risks.

ADHD Drugs and Emergency Room Visits

According to researchers from the U.S. Centers for Disease Control, more than 3,000 patients visited an emergency room in 2004 for treatment of side effects associated with ADHD medication. The researchers reported that these adverse events were due to:

• Unintentional ingestion or overdose (61%)
• Side effects including heart symptoms such as chest pain, high blood pressure, irregular heart beat (33%)
• Allergic reactions (6%)

Most of these incidents occurred in male patients younger than 18 years old. Another 2006 study indicated that non-medical misuse of ADHD medication may account for a large percentage of these emergency room visits.

ADHD Drugs for Preschoolers?

The first long-term study to evaluate the safety and effectiveness of ADHD drugs for preschoolers indicated that these drugs may benefit some children. However, the Preschool ADHD Treatment Study (PATS) also suggested that these drugs carry serious risks, especially for slowing growth and reducing weight gain. The researchers recommend that doctors seriously consider the risks versus benefits before prescribing ADHD medication to children ages 3 – 5 years. Children who do receive medication should be carefully monitored.

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:

• Inattention
• Distractibility
• Impulsivity
• Hyperactivity

Some experts categorize ADHD into three subtypes:

• Behavior marked by hyperactivity and impulsivity, but not inattentiveness
• Behavior marked by inattentiveness, but not hyperactivity and impulsivity
• A combination of the above two

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 attention-deficit hyperactivity disorder will eventually give way to subgroups of problems that include some of these general symptoms.

General Description of a Child with ADHD

Symptoms of ADHD usually occur before the age of seven. 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:

• Inability to hold information in short-term memory
• Impaired organization and planning skills
• Difficulty in establishing and using goals to guide behavior, such as selecting strategies and monitoring tasks
• Inability to keep emotions from becoming overpowering
• Inability to shift efficiently from one mental activity to another

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 two's," 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 short-term memory problems.) In one study, although children with probable ADHD were able to self-report 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.

Risk Factors

In the U.S., the number of diagnosed cases of ADHD in children increased from 1990 to 1996, from nearly 950,000 to over 2.4 million. As of 2004, about 4.5 million children between the ages of 3 - 17 had been diagnosed at some point with ADHD. This accounts for 7.4% of all 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.

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

Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit disorder in adults are on the rise. Methylphenidate (Ritalin) was prescribed for nearly 800,000 adults in the U.S. in 1997, nearly three times the number in 1992. As of 2005, experts estimated that ADHD affects about 4.1% of adults ages 18 - 44 years in a given year.

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 prefrontal cortex is located in the front of the brain. It is thought to be the brain's command center. It regulates the brain’s 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 the globus pallidus. The caudate nucleus and globus pallidus, located near the center of the brain, speed up or stop orders coming from the prefrontal cortex. A major 2002 study reported that it was smaller than average in young children with ADHD, but tended to normalize as 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. The cerebellum is the area above the brain stem. This area helps control muscle tone and balance, and synchronizes muscle activity. An important 2002 study reported that this area tends 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.

Pregnancy and ADHD

ADHD is often associated with problem pregnancies and difficult deliveries. If a women smokes during pregnancy, a genetically susceptible child is at higher risk for ADHD. Some studies also suggest that an increased risk also exists in children of women who were exposed during pregnancy to environmental toxins, including dioxins and polychlorinated biphenyls (PCBs).

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.

Diagnosis

The American Academy of Pediatrics issued its first guidelines for diagnosing attention-deficit hyperactivity disorder (ADHD) in children in 2002. They include:

• Children between ages 6 - 12 should first be evaluated for ADHD if they show symptoms of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems in at least two settings. Such behaviors should have been harmful for the child academically or socially for at least 6 months.
• The child should meet the official symptom guidelines.
• A diagnosis requires detailed reports by parents or caregivers. It should be noted that a mother's description of her child's behavior is a very accurate and reliable guide for diagnosing ADHD. Parents should not be shy about insisting on further evaluation if their experience does not match a doctor's single observation of their child.
• Guidelines for primary care doctors emphasize the importance of obtaining direct evidence from the classroom teacher or other school-based professionals about the child's symptoms and their duration, and evidence of functional impairment in the school setting.
• The child should be assessed for accompanying conditions (such as learning difficulties).

Difficulties in Identifying Children with ADHD

There are currently no laboratory or imaging tests 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:

Arguments that ADHD is Overdiagnosed in Some Children.

• The popularity methylphenidate (Ritalin) has encouraged some parents and teachers to pressure doctors into prescribing this standard ADHD drug for children who are aggressive or who have poor grades. In one study of fifth graders in two different cities, 18% and 20% of Caucasian boys were being treated with medications. In one center, after careful testing, ADHD was the actual diagnosis in only 11% of children referred for ADHD, and 18% had no disability. Others were simply poorer learners or had no problems at all.
• In one study, children more likely to receive medication were young for their grade, indicating they may have been socially and intellectually immature, rather than behaviorally impaired.
• Being poor and growing up in a single parent household contribute to emotional and behavioral problems. The significant increase in these problems has also paralleled an increase in the diagnosis of ADHD children, who may simply be responding to social and economic problems.

Arguments that ADHD is Underdiagnosed in Some Children.

• 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 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.
• ADHD may also be underdiagnosed in adults. Some experts, in fact, believe that ADHD may be the most common chronic undiagnosed psychiatric disorder in adults.

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:

• Specific problems beginning as early as possible they have encountered during the child's development -- school reports are very helpful.
• Sibling relationships
• Recent life changes
• A family history of ADHD
• Eating habits
• Sleep patterns
• Speech and language development
• Any problems during the mother's pregnancy or during delivery
• Any history of medical or physical problems, particularly allergies, chronic ear infections, and hearing difficulties

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

Continuous Performance Test. A test called the Continuous Performance Test is sometimes helpful in evaluating sustained attention and impulsivity. The child sits in front of a computer screen and is asked to press or not press certain keys in response to images on the screen.

Other Screening Tests. Other 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.

Investigative Objective Tests

Optical Tracking and Attention Test. OPTax (optical tracking and attention test) uses two approaches:

• A test that measures the child's ability to be on task. According to a small study, untreated children with ADHD score 41.6% on average, and children without ADHD score 82.4%. (Children who had been treated raised their scores to 75.4%.)
• A videotape that shows the child's head movements. Children with ADHD typically have movement characteristics that differ from children without ADHD.

Such a test offers a possible simple and objective way to determine a diagnosis.

QEEG Test. The quantitative electroencephalographic procedure (QEEG) assesses the electrical activity in a part of the brain called the prefrontal cortex. Evidence suggests that ADHD is associated with low activity in this region. Studies are reporting that it may be highly accurate in both diagnosing and ruling out ADHD in patients.

Imaging Techniques. Brain scans using imaging techniques, including magnetic resonance imaging (MRI) or single photon emission computed tomography (SPECT) may eventually help confirm a diagnosis. At this time, however, they are used only for research.

Drug Trials

Although it is fairly common to use a trial of a psychostimulant (usually Ritalin) to facilitate diagnosis, 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 35% 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. Up to 25% of children with ODD have phobias and other anxiety disorders, which should be treated separately.

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. Preliminary research also suggests that children with PDD may benefit from stimulants such as methylphenidate (Ritalin, Concerta). A 2005 study reported that methylphenidate worked better than placebo in treating hyperactivity in children with PDD. However, these children did not respond as well to methylphenidate as children with ADHD. The drug also caused side effects in many of the children with PDD.

Primary Disorder of Vigilance

Primary disorder of vigilance is a term for a syndrome that includes poor attention and concentration as well as difficulties staying awake. The term is not recognized as an official diagnosis by the American Psychiatric Association, but some experts believe it represents a fairly well defined set of behaviors. People with vigilance disorder tend to fidget, yawn and stretch, and appear to be hyperactive in order to remain alert. They typically have kind and affectionate temperaments. The condition appears to be inherited and gets worse with age. It is treatable with 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)

One study found that as many as 25% of 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. [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

Anxiety disorders commonly accompany ADHD. Obsessive-compulsive disorder is a specific anxiety disorder that shares many characteristics with ADHD and may share a genetic component. Young children who have experienced traumatic events, including sexual or physical abuse or neglect, exhibit characteristics of ADHD, including impulsivity, emotional outbursts, and oppositional behavior.

Sleep 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.) [See In-Depth 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 he or she is 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. 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. This is a classic situation repeated time and again. 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.
• A 2000 study found that boys with ADHD are less likely than others to empathize with people in difficult circumstances. One speculative explanation is that this is a self-protective reaction to prevent negative feelings, which children with ADHD are highly prone to all the time.

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.

One study suggested, however, that 90% of children with ADHD were underachievers, and that half were held back 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 experts, in fact, describe the pattern of ADHD as they would a chronic illness, in terms of whether it goes into remission or not. They define this remission in three categories of severity:

• Syndromatic Remission. Person does not have all the symptoms of full-fledged ADHD, but significant functional impairment in social or occupational activities is present.
• Symptomatic Remission. Person has few symptoms and some functional impairment.
• Functional Remission (Full Recovery). Few symptoms and no functional impairment.

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, which is sadly ironic because the child tends to love the mother intensely and feel safe with her.
• Parents may have to give up on the idea of an immaculate house and a hot meal every night. (One advantage of a child with ADHD in the family is that the parents learn that they are not perfect, nor do they have to be. In fact, 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 raise 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 non-ADHD 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 is not given attention in his or her 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 cognitive-behavioral therapy is proving to be the best option for treatment of children with ADHD.

In 1999, a large study compared medication, behavior therapy, a combination of both, and standard community care. While all four groups improved, medication -- when carefully monitored -- was more effective than behavior therapy alone, and its effects were similar to combination therapy. The combined approach, however, allowed lower doses of medication and also improved academic performance and family relations. In addition, it was more helpful for children who also had mood disorders (such as depression or anxiety) or oppositional-defiant disorder.

A 2001 study further suggested that 80% of adolescents with ADHD who were treated with a combined approach showed an improvement in academic performance.

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.
• If the symptoms are severe or do not respond, then a trial using medication (usually psychostimulants), in conjunction with behavior modification therapy, is advisable.

Unfortunately, most children do not have access to behavioral therapies, either because of lack of time or available resources. A 2000 study reported that fewer than half of all doctor's visits involving a psychostimulant prescription included psychologic intervention. In addition, there was no follow-up at all after 21% of these visits. One study suggested that a simple 8-week program conducted in the primary care doctor's office may be of some help. Children in the study received either a combination of drugs with the program or drugs alone. They had no complicating problems, such as anxiety or conduct disorder. Children who received the combination approach showed improved functioning at home that persisted for at least 6 months, although teachers observed no differences in two groups.

Specific Patient Populations. Unfortunately, such guidelines do not address the following specific patient groups:

• There are no authoritative treatment guidelines for treating adolescents and adults with ADHD. Increasingly, evidence suggests that psychostimulants are a reasonable choice for adults with a confirmed diagnosis of ADHD.
• 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 reliable guidelines on how to treat the inattentive subtype of ADHD, which might be more common in girls.
• There are no defined treatments for ADHD patients with accompanying conditions, including impaired working memory and deficits in language processing.
• 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.)

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.

Still, there are a number of questions, particularly for taking psychostimulants alone without additional behavioral therapy. There is evidence the drugs may be over-prescribed, and parents should discuss the question of medications very carefully with doctors. ADHD represents a growing market for pharmaceutical companies. Although psychostimulants and alternative drugs are proving to be helpful for many families, no one should underestimate the influence of the economic issues involved.

Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children. A major long-term 2006 study funded by the U.S. National Institute of Mental Health found that low doses of methylphenidate (Ritalin) may help preschoolers (ages 3 - 5 years) with ADHD. However, the Preschool ADHD Treatment Study (PATS) also reported that the drug caused considerable side effects in many of the children. These side effects included insomnia, nervousness, anxiety, loss of appetite and weight, and slowed growth. Children in the study grew about half an inch less and weighed about 3 pounds less than normal. The researchers recommended that doctors 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.

Another major study reported that children with ADHD will benefit to some degree from any treatment, whether behavioral therapies, medication, or simple mental health intervention. Combinations of behavioral therapy and medications appear to be best, however. Stimulants are not a cure-all, and children should not grow up believing that taking a pill will solve life's problems without their having to make self-efforts.

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

Several medications are available to treat ADHD.

Psychostimulants: Methylphenidate (Ritalin) and Similar Drugs

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:

• Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
• Dexmethylphenidate (Focalin)
• Amphetamine-Dextroamphetamine (Adderall)
• Dextroamphetamine (Dexedrine, Dextrostat)

Pemoline (Cylert), another stimulant drug, was withdrawn from the U.S. market in 2005 after several reports of liver failure.

As of 2006, all ADHD stimulant medications 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 February 2007, the Food and Drug Administration directed manufacturers of ADHD medications to warn all patients taking these medicines of potential cardiovascular and psychiatric risks.

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 and Dextroamphetamine. Amphetamine-dextroamphetamine (Adderall) and dextroamphetamine (Dexedrine, Dextrostat) 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.

In 2006, the manufacturer of Dexedrine updated its prescription label. In addition to strengthening the warning that Dexedrine may be fatal for children and adolescents with heart problems, the updated label also warns that stimulant drugs:

• May worsen behavior and thought disturbance in patients with a pre-existing psychotic disorder.
• May cause a mixed or manic episode in patients who have both ADHD and bipolar disorder.
• May be associated with increased aggressive behavior or hostility. Patients beginning stimulant drug treatment should be monitored for worsening of these behaviors.
• May cause slowing of growth 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.

Side Effects. All stimulants have a number of side effects:

• The most common side effects of any stimulant are nervousness and sleeplessness, although some parents have reported improved sleep patterns in their children after taking stimulants.
• These drugs may interfere with height and weight gain.
• Tics or jerky, disordered movements occur in about 9% of children.
• Other side effects include irritability, withdrawal, stomach pain, headache, depression, hallucinations, hair loss, and lack of spontaneity.

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.

A major analysis in 2003 indicated that methylphenidate treatment may protect young people with ADHD from abusing alcohol or other drugs. In such cases, methylphenidates may reduce the need to self-medicate ADHD symptoms using nicotine, alcohol, or illegal drugs. (Ritalin does not protect against substance abuse in young people with ADHD and conduct disorder, however.)

Dependence has not been reported in children who have taken this drug for long periods in appropriate dosages. It should be noted, however, that crushing the pills and inhaling them nasally can provide a euphoric state. 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. A 2006 study indicated that 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. In 2005, the FDA warned that 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

Specific antidepressants are proving to be helpful under certain conditions, and some may be reasonable alternatives to psychostimulants for some people with ADHD.

Designer Antidepressants. Bupropion (Wellbutrin), reboxetine (Edronax), and venlafaxine (Effexor) are sometimes referred to as designer antidepressants. They affect one or more neurotransmitters that are not targeted by older antidepressants. These drugs may be particularly helpful for treating patients with ADHD and accompanying disorders, including depression or conduct disorder. Most studies to date have focused on bupropion and have reported good results in both children and adults. Patients should be aware that venlafaxine carries a high risk of fatal overdose, particularly if it is taken in combination with alcohol or other drugs.

Tricyclics. Antidepressants known as tricyclics, which include desipramine (Norpramin, Pertofrane), or imipramine (Janimine, Tofranil), have been prescribed for children who do not respond to stimulants or who have accompanying problems, such as tics, anxiety, or depression. Desipramine appears to have the best results of the tricyclics and may even help control impulsivity. Tricyclics can have distressing side effects however, including dry mouth, sleepiness, and constipation. They have mild effects on blood pressure and heart rate, but such effects do not appear to be harmful in people without existing heart disease. Reports of sudden death of a few children taking tricyclics, however, have caused alarm, although these occurrences are extremely rare and the role tricyclics may have played is not clear. Reports of delirium and increased heart rate have occurred in adolescents who take tricyclics and smoke marijuana. Careful monitoring is important.

SSRIs. The antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs) -- which include fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), and paroxetine (Paxil) -- are sometimes recommended for treating depression in ADHD patients with both conditions. They have little effect on ADHD and may increase the risk for impulsive behavior. The effects of long-term use of SSRIs in young people are not clear. Some SSRIs, such as paroxetine (Paxil), have been linked to increased risk for suicidal thoughts and behavior in children and teenagers. Fluoxetine (Prozac) is currently the only SSRI approved for treating depression in children and adolescents. [For more information, see In-Depth Report #8: Depression].

Alpha-2 Agonists (Clonidine)

Alpha-2 agonists stimulate the neurotransmitter norepinephrine, which appears to be important for concentration. They include clonidine (Catapres) and guanfacine (Tenex). They are used for Tourette syndrome and may be beneficial when other drugs have failed for ADHD children with tics or those whose primary symptoms are severe impulsivity and aggression.

These drugs have a number of side effects. (Guanfacine may have fewer than clonidine.) 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.

Studies in general report that the drug is safe, including in combination with stimulants. Of concern, however, were reports of five deaths in children taking clonidine with other medications. Experts 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.

Other Medications Investigated for ADHD

Selegiline. Selegiline (Eldepryl, Movergan, Zelepar), also known as deprenyl, metabolizes into compounds found in methamphetamine and blocks monoamine oxidase B (MAO-B), an enzyme that degrades dopamine. A well-conducted study in 2003 suggested that it may be as effective as Ritalin with fewer size effects. Selegiline can cause hypertension if combined with drugs that increase serotonin levels -- such drugs include nearly every major antidepressant.

Modafinil. Modafinil (Provigil) promotes wakefulness and is used to treat patients with narcolepsy. It is being investigated for adults and children with ADHD, and is showing promising results.

Determining a Correct 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:

• Before any drug is administered, a child should be given a thorough examination for any medical problems to be sure there are no medical conditions that interfere with the medication.
• 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, adding another drug, or changing to a different medication often brings improvement. Some experts recommend trying a second psychostimulant if a first one fails. If the child still doesn't respond, antidepressants or other second-line drugs may be beneficial.
• Frequent follow-up visits should be scheduled to assess the response and to detect possible side effects.

Medications in Older Children. As children enter adolescence, the social stigma associated with ADHD often makes them reluctant to continue drug treatment. If the drug has proven to be effective, it is very important to keep the young person on the regimen during this critical period.

Medications for Adults. One report suggested that two-thirds of adults with ADHD may also be successfully treated with stimulants and psychotherapy. Certain antidepressants may also be effective treatments in adults.

Combination Therapy. A 2002 study reported that children with ADHD are increasingly being treated with a combinations of psychostimulants and certain antidepressants (such as tricyclic antidepressants and bupropion), and psychostimulants plus clonidine. Experts warn that there is little evidence that such combinations add any benefits, and their long-term safety is unknown. Nevertheless, combinations may be warranted in certain severe cases, such as in children who are also suffering from an accompanying psychiatric disorder, such as bipolar or anxiety disorder.

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 self-worth 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 and he or she presents 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.
• It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm.

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 he or she is endangered or is 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.
• To channel physical aggression and impulsivity in the ADHD toddler, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.)
• When the ADHD child becomes older and if the verbal responses become intentionally abusive and socially undesirable, then the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Competitive video games, such as sports games, may also be an option.
• Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible.

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.
• A reward system should rotate different types of rewards, because such children are easily bored.
• Children with ADHD respond better with small rewards promised in the short-term 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.
• A 2001 study reported that children with ADHD had better attention and functioning when they spent time in a natural setting.
• 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 child’s 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 his or her peers.

Preparing the Teacher. Although teachers can expect that at least one student in every classroom will 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.
• Inattention is a major factor in low academic performance. It causes them to frequently forget homework or miss assignments. Children with ADHD often require frequent reminders or visual cues (such as posters) for rules and regulations. Having the child sit in the front of the classroom may be helpful for both increasing attention and reducing noisy activity.
• 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 the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior.
• There is no federally funded special education category specifically targeted to ADHD.

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 or adding supplements 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)
• Other chemical additives -- for example, BHT or BHA
• Milk
• Chocolate
• 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 its 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.

Allergies themselves have been associated with a higher risk for behavioral problems. Children who respond to allergen-restrictive diets, then, may not have had true ADHD in the first place.

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. A 2001 study of DHA alone reported no reduction in ADHD symptoms.

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. In one study, IQs increased by an average of 12 points, and Ritalin use dropped significantly by the end of training period. To date, however, studies have been very limited, and the results could have been due to factors other than neurofeedback. This technique is also very expensive.

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 may benefit 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.

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.

Resources

• www.aap.org -- American Academy of Pediatrics
• www.nimh.nih.gov -- National Institute of Mental Health
• www.chadd.org -- Children and Adults with Attention-Deficit Disorder
• www.add.org -- Attention Deficit Disorder Association
• www.aabt.org -- Association for Behavioral and Cognitive Therapies
• www.psych.org -- American Psychiatric Association
• www.aacap.org -- American Academy of Child and Adolescent Psychiatry
• www.nichcy.org -- National Dissemination Center for Children with Disabilities
• www.ncld.org -- National Center for Learning Disabilities
• www.ldaamerica.org -- Learning Disabilities Association of America

References

Biederman J, Swanson JM, Wigal SB, Boellner SW, Earl CQ, Lopez FA, et al. A comparison of once-daily and divided doses of modafinil in children with attention-deficit/hyperactivity disorder: a randomized, double-blind, and placebo-controlled study. J Clin Psychiatry. 2006 May;67(5):727-35.

Biederman J, Swanson JM, Wigal SB, Kratochvil CJ, Boellner SW, Earl CQ, et al. Efficacy and safety of modafinil film-coated tablets in children and adolescents with attention-deficit/hyperactivity disorder: results of a randomized, double-blind, placebo-controlled, flexible-dose study. Pediatrics. 2005 Dec;116(6):e777-84.

Cohen AL, Jhung MA, Budnitz DS. Stimulant medications and attention deficit-hyperactivity disorder. N Engl J Med. 2006 May 25;354(21):2294-5.

Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006 Nov;45(11):1284-93.

Nissen SE. ADHD drugs and cardiovascular risk. N Engl J Med. 2006 Apr 6;354(14):1445-8.

Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, et al. Stimulant-related reductions of growth rates in the PATS. J Am Acad Child Adolesc Psychiatry. 2006 Nov;45(11):1304-13.

Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, et al. Safety and tolerability of methylphenidate in preschool children with ADHD. J Am Acad Child Adolesc Psychiatry. 2006 Nov;45(11):1294-303.

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