What is ADHD?

Most people are fairly familiar with ADHD, or Attention Deficit Hyperactivity Disorder, as a childhood disorder, but recent research indicates that children with ADHD grow up to become teenagers and adults with ADHD. And while core symptoms of the disorder do not change, the ways in which those symptoms manifest in adulthood can take on distinctly different characteristics.

ADHD is a mental disorder that affects four to six percent of the U.S. population. Although the exact nature and severity of symptoms vary from person to person, it is generally accepted that people with ADHD lack ability to focus attention, inhibit impulsiveness and, in some cases, control motor functioning. Only about two-thirds of people with the disorder have the overactive behavior component. This is why the generic term, ADD, is commonly used to refer to all types of ADHD, even among professionals.

ADHD is recognized as a disability under under federal legislation. (the Rehabilitation Act of 1973; the Americans with Disabilities Act; and the Individuals with Disabilities Education Act). Appropriate accommodations are made at school for children with ADHD and at work for adults with the disorder to help them become more efficient and productive.

Who's at Risk?

It was once thought that ADHD was primarily a childhood disorder. However, recent data now suggest that nearly 70 percent of children diagnosed with ADHD retain symptoms into adulthood . These symptoms often have a significant impact on family, work and personal relationships.

Research indicates that ADHD occurs in approximately three to five percent of school-age children and approximately two to four percent of adults. ADHD is more common among males. Three out of four children diagnosed are boys and two of every three adults are men. ADHD is found to exist in every country in which it has been studied. That list includes North America, South America, Great Britain, Scandinavia, Europe, Japan, China, Turkey, and the Middle East.

What Causes ADHD?

Although no single cause for ADHD has been established, current research indicates that ADHD does not stem from adversity at home or school, but from biological causes.

ADHD has been a popular and controversial subject in the media. Unfortunately, what sells news doesn't always turn out to be fact. The following have all been reported in the media as causes of ADHD. However, the research tells us that ADHD is probably not caused by any of these factors.

• Bad parenting
• Poor home life
• Poor schools
• Early psychological trauma
• Minor head injuries
• Excessive television viewing
• Poverty

In recent years, as new technologies for studying the brain have been developed, scientists have been able to test new theories and have concluded the following.

• Attention problems may be seen as dopamine deficiencies within the brain.
• ADHD is likely caused by biological factors which influence the brain's neurotransmitter activity and which have a strong genetic basis.
• Positron Emission Tomography (PET) scans of the brain in people with ADHD show low levels of glucose in areas that control attention and impulse inhibition, indicating less activity.
• ADHD tends to run in families, which is highly indicative of genetic factors. Family members of people with ADHD have a 25 to 35 percent chance of having the disorder as well, compared to a four to six percent chance for someone in the general population. Children who have ADHD usually have at least one close relative who also has it. And at least one-third of all fathers who had ADHD in their youth bear children who have ADHD. Even more convincing: the majority of identical twins share the trait.

What Role does Diet Play in the Causes and Symptoms of ADHD?

When looking for underlying causes of this mental disorder, it seems only natural to suspect diet and nutrition as a culprit. The importance of eating healthy has been well established as crucial in achieving and maintaining optimal mental functioning. However, research shows diet and nutrition to be one of the lesser contributing factors.

One theory was that refined sugar and food additives make children hyperactive and inattentive. Parents were encouraged to stop serving children foods containing artificial flavorings, preservatives, and sugars. However, in 1982, the National Institutes of Health (NIH), the Federal agency responsible for biomedical research, held a conference to discuss the issue. After studying the data, scientists concluded the following.

• Restricted diet only seemed to help about five percent of children with ADHD, mostly either young children or children with food allergies.
• There is very little evidence to support claims that food allergies and sensitivities significantly contribute to causes and symptoms of ADHD.
• Sugar, chocolate, colors, additives, flavors, eggs, milk, wheat and corn can produce symptoms that mimic those of ADHD but do not contribute to the cause of it.
• There has been some evidence that children with ADHD lack amino acids and zinc needed for proper brain functioning, but little has been studied about this.

A new study also shows a definite correlation between high manganese, an ingredient in soy-based formula for infants, and lower dopamine levels. This may indicate that elevated exposure to manganese during early development increases children's risk for hyperactivity or other behavior problems. Millions of infants drink soy-based formula, which can contain as much as 80 times the amount of manganese as breast milk. More research is still needed to determine whether high manganese doses result in permanent behavioral problems, including ADHD.

What's on the Research Horizon?

Ongoing research will continue to try to unravel the remaining mysteries surrounding ADHD and its causes. Scientists hope to improve treatment methods and someday even find a cure for the disorder. The following are some specific goals of future research.

• At the National Institute of Mental Health (NIMH), researchers hope to identify a gene that may be involved in transmitting ADHD in a small number of families with a genetic thyroid disorder.

• Scientists hope to discover why there is less activity in some areas of the brain by comparing glucose usage and activity levels in mild and severe cases of ADHD.

• Researchers hope to answer questions as to why some medications used to treat ADHD work better than others, and if the more effective medications increase activity in certain parts of the brain.

• Research on how the brain normally develops in the fetus offers some clues about what may disrupt the process. By studying brain development in animals and humans, scientists are gaining a better understanding of how the brain works when the nerve cells are connected correctly and incorrectly. Scientists at NIMH and other research institutions will continue to track clues to determine what might prevent nerve cells from forming the proper connections.

• Researchers will continue to investigate a suspected link between ADHD and a mother's use of cigarettes, alcohol, or other drugs during pregnancy. The use of these substances may be dangerous to the fetus's developing brain. It appears that alcohol and the nicotine in cigarettes may distort developing nerve cells. For example, heavy alcohol use during pregnancy has been linked to fetal alcohol syndrome (FAS), a condition that can lead to low birth weight, intellectual impairment, and certain physical defects. Many children born with FAS show much the same hyperactivity, inattention, and impulsivity as children with ADHD.

• Drugs such as cocaine, including the smokable form known as crack, seem to affect the normal development of brain receptors. These brain cell parts help to transmit incoming signals from our skin, eyes and ears, and help control our responses to the environment.Current research suggests that drug abuse may harm these receptors and some scientists believe that such damage may lead to ADHD.

• Scientists will continue to explore a possible link between ADHD and toxins in the environment that are thought to disrupt brain development or brain processes. Lead is one such possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline and paint were once used. It is also present in some water pipes. Some animal studies suggest that children exposed to lead may develop symptoms associated with ADHD, but only a few cases have actually been found.

Symptoms and Diagnosis of ADHD

There is no formal test for the diagnosis of Attention Deficit Hyperactivity disorder. It cannot be identified by a lab test or seen on an x-ray. ADHD can only be diagnosed by looking for certain characteristic behaviors or symptoms that are usually apparent before the age of seven. These symptoms come in many forms, differ from person to person and tend to morph as a person passes from one stage of life to the next. ADHD in adults is sometimes referred to as the "hidden disorder" because the symptoms typically appear in the form of problems with relationships, organization, mood disorders, substance abuse, employment or other psychological difficulties

Doctors make a distinction between symptoms by classifying ADHD diagnosis into three subtypes: inattention, hyperactivity, and impulsivity.While most people with ADHD experience a combination of all three subtypes, there is usually one symptom pattern that stands out.

1. Inattention: People with ADHD who are inattentive display difficulty keeping their mind on any one thing. They may get bored easily with a task and bounce from one task to another. Organizing and completing a task proves troublesome, though they may give undivided and effortless attention to activities and topics they enjoy. People with ADHD often find that focusing deliberate, conscious attention to learning something new is extremely difficult.

2. Hyperactivity: People who display the symptoms of hyperactivity always seem to be in motion. Sitting still may be difficult. They may dash around, squirm in their seats, roam around the room or talk incessantly. They often do repetitive motions like wiggling their feet or tapping their pencil to bring them back to focus and burn off excessive energy. Many people who display the symptoms of Attention Deficit Disorder with hyperactivity feel intensely restless, fidget and may try to do several things at once, alternating from one activity to the next.

3. Impulsivity: People with ADHD who are overly impulsive seem unable to curb their immediate reactions or think before they act. As a result, they may blurt out inappropriate comments, display their emotions without restraint or act without regard for the consequences of their conduct. They may find it difficult to restrain from interrupting others and waiting for anything can be tortuous. Their impulsivity may make it hard for them to accomplish tasks in which gratification is delayed.

Diagnostic Criteria for ADHD

Diagnosis is usually made by a specialist, such as a psychiatrist, psychologist, developmental pediatrician, or neurologist, and is based in large part on a history obtained from the patient, parent, family members, and/or teachers.

Below are the current diagnostic criteria for ADHD, taken from the text-revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which was published in the summer of 2000.

(A) Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level; Inattention:

• often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• often has difficulty sustaining attention in tasks or play activities
• often does not seem to listen when spoken to directly
• often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• often has difficulty organizing tasks and activities
• often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• is often easily distracted by extraneous stimuli
• is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity:

• often fidgets with hands or feet or squirms in seat
• often leaves seat in classroom or in other situations in which remaining seated is expected
• often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• often has difficulty playing or engaging in leisure activities quietly
• is often "on the go" or often acts as if "driven by a motor"
• often talks excessively

Impulsivity

• often blurts out answers before questions have been completed
• often has difficulty awaiting turn
• often interrupts or intrudes on others (e.g., butts into conversations or games)

(B) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

(C) Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

(D) There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

(E) The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).

Adult Diagnosis

Diagnosis of adults can be particularly difficult. Many adults grew up at a time when very little was known about ADHD. Diagnosis requires evidence of a history of pervasive problems since before the age of seven. This can be a problem since the parents, teachers and caregivers of adults seeking diagnosis may be deceased, difficult to locate, or unable to remember circumstances many years in the past.

The relatively recent acceptance of adult ADHD means that many adults remain undiagnosed and are unaware that their behaviors are part of an identifiable condition. Adults who have learned they have the disorder often say that before they were diagnosed, they had come to the conclusion that they were incapable, unintelligent, and sometimes even crazy. They are likely to have frequently changed jobs, experienced difficulties with relationships, partners, and marriage, and often have a history of alcohol or substance abuse.

The current criteria for diagnosing ADHD in adults are the same as the DSM-IV criteria used to diagnose children. Although other symptom checklists are sometimes used in assessing adults for ADHD, the DSM-IV criteria are currently considered the most empirically valid.Clinicians must look for the symptoms as they would appear in the life of an adult. These core symptoms of ADHD are often disguised as other mental, social and psychological problems. Here are the criteria, according to the DSM-IV, reworded to reflect symptoms as they would appear in an adult.

• Often fails to give close attention to details or make careless mistakes at work
• Often fidgets with hands or feet or squirm in seat
• Often has difficulty sustaining attention in tasks or fun activities
• Often leaves seat in situations where seating is expected
• Often doesn't listen when spoken to directly
• Often feels restless
• Often doesn't follow through on instructions and fail to finish work
• Often has difficulty engaging in leisure activities quietly
• Often has difficulty organizing tasks and activities
• Often feels "on the go" or "driven by a motor"
• Often avoids, dislikes, or is reluctant to engage in work that requires sustained mental effort
• Often talks excessively
• Often loses things necessary for tasks and activities
• Often blurts out answers before questions have been completed
• Often easily distracted
• Often has difficulty awaiting turn (impatient)
• Often forgetful in daily duties
• Often interrupts or intrudes on others

The above symptoms often lead to associated problems and consequences that often co-exist with adult ADHD. The following is a list of some of those problems.

• Problems with self-control and regulating behavior
• Poor working memory
• Poor persistence of efforts toward tasks
• Difficulties with regulation of emotions, motivation and arousal
• Greater than normal variability in task or work performance
• Chronic lateness and poor time perception
• Easily bored
• Low self-esteem
• Anxiety
• Depression
• Mood swings
• Employment difficulties
• Relationship problems
• Substance abuse
• Risk-taking behaviors
• Poor time management

The impairment from both the core symptoms and associated features of ADHD can range from mild to severe in its impact on academic, social and occupational domains. Symptoms of ADHD are common to many other psychiatric and medical conditions, so adults should seek a comprehensive evaluation from a qualified professional. The first step in getting help for ADHD is making a correct diagnosis.

Treatment of ADHD

After the diagnosis is made, a number of different treatments can offer help for people who have ADHD. Studies show that the most effective treatment plan for controlling the core symptoms of ADHD, improving performance at work or school and helping with social problems, is a combination of both pharmacological and non-pharmacological treatments.

Pharmacological Treatment

Despite years of scientific research, advances in understanding how these medications work, and significant improvements in the quality of life for millions of people around the world, there are still those who question, doubt and attack the role that medication provides in the treatment of ADHD.

Even more controversial is treating recovering alcoholics and addicts with stimulant medication. However, research indicates that ADHD patients treated with stimulants are, in fact, less likely to use substances problematically than patients who are not treated with these drugs, and there is little evidence that prescription stimulant use under a medical program administered by a doctor leads to problematic use.

Stimulant Medications

Stimulants are usually the first choice of medications in both children and adults due to their high rate of effectiveness in all but a few cases and because they are so well tolerated in most people. There have been many studies showing the effectiveness of stimulants in the treatment of ADHD in children, adolescents and adults. In fact, stimulants effectively decrease inattention, distractibility and impulsivity in over 70 percent of individuals with ADHD. Stimulant medications increase the release, or block the reabsorption of dopamine and norepinephrine, two brain neurotransmitters. This increases the transmission between certain neurons. Since each stimulant achieves this slightly differently, a medication that is effective for one individual with ADHD may not be as effective for another. The first two are, by far, the most commonly prescribed.

• Methylphenidate (Ritalin, Concerta, Metadate, Riphenidate, Methylin) is the most commonly prescribed stimulant and is approved for patients as young as six years old. Research on mice suggests that methylphenidate elevates levels of serotonin, and that this may account for some of its calming effects. It usually starts to work about 15 to 30 minutes after it is taken. It peaks an average of 90-120 minutes after it is taken. This can vary from person to person. The effect of dose can be from 2.5 to 4 hours.

• Amphetamine (Dexedrine, Adderall) is one of the standard treatments of ADHD and is available as a once daily preparation. It is approved for ages three and older. It is also short acting but usually lasts an hour or so longer than methylphenidate. DeAmphetamine and dextroamphetamine are used in combination to treat ADHD.

• Pemoline (Cylert) is given once a day. It is not a first-line drug because it carries a risk for liver failure. There have been 15 deaths due to liver failure associated with pemoline. It is used rarely, perhaps if other drugs fail to produce results, and liver function levels must be monitored every 2 weeks during treatment. It is approved for ages 6 and older. It takes about one or two hours to take effect and lasts up to eight hours. Pemoline may take days to build up enough to have an effect. It should be given seven days a week.

• Methamphetamine (Desoxyn) is the medication most effective at enhancing concentration and decreasing distractibility, with the least occurrence of side effects. However, since it has a higher potential for abuse than the other stimulants, Desoxyn is often used as a second-line medication when the first-line medications have been found deficient. The greater primary effectiveness of Desoxyn is believed to be caused by the extra methyl group of methamphetamine, which basic amphetamine does not have. This may increase the solubility of methamphetamine and therefore be more thoroughly and deeply absorbed into the brain. Generally, the recommended uses of Desoxyn are similar to the other amphetamine-class stimulants. Used carefully in selected patients, it can be an effective treatment for ADHD.

Stimulant Side Effects

Many individuals take stimulants with few side effects. Others experience mild problems, and a small percentage are unable to tolerate stimulants. Most side effects are mild and tend to diminish after a few weeks. Often, annoying side effects can be treated so the individual can continue to take the stimulant. The following is a list potential side effects.

• Reduced appetite
• Rebound
• Headache
• Jittery feeling
• Gastrointestinal upset
• Sleep difficulty
• Irritability
• Depression
• Anxiety
• Blood glucose changes
• Increased blood pressure
• Psychosis or paranoia
• Tics and stereotyped movements

Non-stimulant medication

Doctors may prescribe this non-stimulant for certain individuals who, for whatever reason, are better suited for non-stimulant therapy. It is unrelated to the other two types of medications availble for treatment of ADHD.

Atomoxetine HCl (Strattera) may be used to treat ADHD in adults and children over six year old.. Strattera is a non-stimulant that increases levels of the neurotransmitter norepinephrine. It is available in oral capsule form in several dosage strengths. Strattera  is usually taken once or twice a day, with or without food.*You should stop taking Strattera and call your health care provider immediately if you get swelling or hives. The most common side effects of Strattera are:

• Upset stomach
• Decreased appetite
• Nausea or vomiting
• Dizziness
• Fatigue
• Mood swings
• Constipation
• Dry mouth
• Nausea
• Decreased appetite
• Dizziness
• Problems sleeping
• Sexual side effects
• Problems urinating
• Menstrual cramps
• *Note -- Strattera can cause a serious allergic reaction in rare cases

Tricyclic Antidepressant Medication

Tricyclic antidepressant medications are a second-line therapy used in treating ADHD when stimulants cannot be used. They are typically prescribed when patients have a co-existing mood disorder, substance abuse problem, or when patients cannot tolerate or show no signs of improvement on stimulants. The effectiveness and safety of these compounds has also been studied extensively. The research has found that antidepressants are generally less effective in treating the core symptoms of ADHD and have a higher rate of side effects. Most Tricyclic antidepressants work by inhibiting the re-uptake of the neurotransmitters norepinephrine and serotonin by nerve cells. Medications in this class of compounds include the following:

• Amitriptyline (Elavil, Tryptanol, Endep)
• Amoxapine (Asendin)
• Clomipramine (Anafranil)
• Dothiepin hydrochloride(Prothiaden, Thaden)
• Doxepin (Adapin, Sinequan)
• Imipramine (Tofranil)
• Lofepramine (Gamanil, Lomont)
• Nortriptyline(Pamelor Aventyl
• Protriptyline(Vivactil)
• trimipramine (Surmontil)
• Desipramine (Norpramin Pertofrane)-- less prescribed due to some unexplained sudden deaths which appeared to be related to heart conduction patterns.

Side Effects of Tricyclic Antidepressants

• Drowsiness
• Anxiety
• Restlessness,
• Dry mouth
• Constipation
• Urinary retention or difficulty with urination
• Cognitive and memory difficulties,
• Weight gain
• Sweating
• Dizziness
• Hypotension
• Akathsia
• Mecrease in sexual ability and desire
• Muscle twitches
• Weakness
• Nausea
• Increased heart rate and irregular heart rhythms (rare)

In some cases, physicians may also prescribe other anti-depressants to treat ADHD. Although there is some research evidence that these medications can be helpful in treating ADHD, relatively few controlled studies of their effectiveness exist. These medications include

• Fluoxetine (Prozac, Fontex, Seromex, Seronil, Sarafem, Symbyax, Fluctin, Prodep, Fludac)
• Bupropion (Wellbutrin)

Non-pharmacological Treatment of ADHD

Psychotherapy

During psychotherapy, a licensed and trained mental health care professional helps people with ADHD to like and accept themselves, despite their disorder. It does not address the symptoms or underlying causes of the disorder. Patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can improve or better cope with their disorder. The following explains some of the most common types of psychotherapy used in the treatment of ADHD.

• Behavioral Therapy: This approach helps to weaken the connections between troublesome situations and the habitual reactions to them. It teaches that reactions common to ADHD such as fear, anxiety, depression, anger, and self-damaging behavior can be controlled. The support might be practical assistance, like help in organizing tasks or dealing with emotionally charged events. Or the support might be in self-monitoring one's own behavior and giving self-praise or rewards for acting in a desired way, such as controlling anger or thinking before acting. Scheduling, organizing items needed everyday, and using a notebook or organizer are examples of some simple behavioral interventions.

• Cognitive Therapy: Working in conjunction with behavior therapy, this approach helps patients identify how certain thinking patterns may trigger symptoms by giving a distorted picture of reality. False negative perceptions can lead to anxiety, depression or anger, thus provoking him or her into negative action. Resolving the cognitive aspect of ADHD can mean improved interaction with others and a more positive outlook on life.

• Social Skills Training: In social skills training, the therapist discusses and models appropriate behaviors important in developing and maintaining social relationships. Such skills include learning to sit still and concentrate for longer periods. They learn communication skills such as listening and self-editing,. They practice controlling impulses to interrupt others or speak rapidly and excessively.  Social skills training helps individuals to develop better listening skills, as a lack of attention may be interpreted by others as a lack of care or concern.

• Support Groups: Members of support groups meet on a regular basis to hear lectures from experts on ADHD, share frustrations and successes, and obtain referrals to qualified specialists and information about what works. Connecting with other people who have similar problems and concerns helps people know that they aren't alone

Controversy surrounding ADHD will likely continue, but knowing the facts is crucial in developing one's own opinions in the debate. Armed with information, you will be better able to discuss symptoms and treatment options with your doctor, should you suspect ADHD in yourself or someone in your family.