ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

WHAT IS ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)?

Attention deficit hyperactivity disorder (ADHD) is a brain disorder that is most commonly marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity which interferes with the person’s functioning or development (1).  ADHD is often noticed in school-aged children when they have concentration problems, trouble with homework, or disrupt class.  According to the American Psychiatric Association, ADHD is one of the most common mental disorders that affects children, with about 5 percent of children being diagnosed with it (2).

Literally, thousands of studies have been conducted on attention deficit hyperactivity disorder (ADHD).  Despite this long research history, ADHD is not necessarily well understood among the lay public, given the many controversies and public misconceptions concerning the disorder (3,4).  Some longitudinal evidence suggests that childhood ADHD persists into young adulthood in 60-70% of the cases when defined relative to same-age peers and in 58% of the cases when DSM-V criteria and parental reports are used (5,6,7). Because of its prevalence and many misconceptions, the scientific status of ADHD is one of the most controversial issues in child health.

RISK FACTORS FOR ADHD

While the cause of ADHD is unknown, there are certain risk factors that could contribute to ADHD including:

• Genes
• Cigarette smoking, alcohol use, or drug use during pregnancy
• Exposure to environmental toxins during pregnancy
• Exposure to environmental toxins, such as high levels of lead, at a young age
• Low birth weight
• Brain injuries (1)

SYMPTOMS OF ADHD

To be diagnosed with ADHD, a person must exhibit at least 6 symptoms if under 17 years old or at least 5 symptoms if 17 years old or older from the following categories and last for a minimum of 6 months.  The symptoms, however, must be inappropriate for the person’s developmental level (8).

Inattention: Failure to pay attention to details, makes careless mistakes; difficulty sustaining attention in task or play; does not seem to listen when spoken to directly; does not follow through on instructions  or does not complete tasks; has difficulty organizing tasks and activities; avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort; loses things needed for tasks or activities; is easily distracted; is forgetful in daily activities (8).

Hyperactivity/Impulsivity: Fidgets with hands or feet or squirms when seated; does not remain seated when expected to; runs or climbs excessively in inappropriate situations; difficult playing or engaging in leisure activities quietly; acts as if driven by a motor; talks excessively; blurts out answers before questions are completed; has difficulty waiting his or her turn; interrupts or intrudes on others (8).

Some of the symptoms listed must be present before the age of 12 or be present in multiple settings (8).

For more information on ADHD and diagnosis:  1. Talk to your doctor  2. Visit the National Institute of Mental Health website 3. Visit the Attention Deficit Disorder Association website  4. Visit the Centers for Disease Control and Prevention website

ADHD FACTS AND STATISTICS

ADHD is one of the most common psychiatric conditions in children (2).  Based on the Health Resources and Services Administration’s National Survey of Children’s Health, the percentage of children aged 4–17 years diagnosed with ADHD increased from 7.8% in 2003 to 9.5% in 2007, representing a 21.8% increase in just 4 years (9).  ADHD is diagnosed in boys at a rate of two to four times that of girls, although this observation may be the result of referral patterns from teachers (10,11).

Although ADHD was once regarded as a disorder of childhood and adolescence, an estimated 50% of patients diagnosed with ADHD under the age of 18 years continue to have symptoms as an adult (12).  Overall, the prevalence of ADHD in adults ranges from 3.5% to 4.5% (13).  ADHD is found in all countries surveyed with rates similar to, if not higher than, those found in North America (14,15).

Production of the medications used to treat attention deficit hyperactivity disorder ADHD has skyrocketed in recent decades.  The Centers for Disease Control and Prevention (CDC) say that ADHD diagnoses in children increased by 41% between 2003 and 2011.  It was estimated that 11% of children between the ages of 4 and 17 years old had been diagnosed with ADHD, as of 2011.  That is 6.4 million children in total (16).

MEDICAL TREATMENT OF ADHD

There is no cure for ADHD and treatment for ADHD remains controversial.  A long-term study concluded that medication by itself without some kind of therapy may not be successful in long-term outcomes (17). Doctors commonly prescribe two types of medications for ADHD, namely stimulants and non-stimulants (1).

Stimulants are the most commonly prescribed medications for ADHD and are often the first course of drugs used for ADHD treatment.  They work by increasing the amounts of the hormones called dopamine and norepinephrine in the brain.  This effect usually improves concentration and decreases the fatigue (1).  Some stimulant medications include:

• Amphetamines: amphetamine, dextroamphetamine or lisdexamfetamine.  Marketed as Adderall XR: Dexedrine, Dyanavel, XREvekeo, ProCentra, and Vyvanse.
• Methylphenidate: works by helping the reuptake of norepinephrine and dopamine in the brain and is also a mild stimulant.  Brand names include: Aptensio XR; Metadate ER; Concerta; Daytrana; Ritalin; Ritalin LA; Methylin; QuilliChew; Quillivant; Focalin (18).

Non-stimulants affect the brain differently than stimulants do.  These drugs also affect neurotransmitters, but they don’t increase dopamine levels.  In general, it takes longer to see results from these drugs than from stimulants.  A doctor might prescribe non-stimulants when stimulants aren’t safe or are ineffective for the patient.  They may also prescribe them if a person wants to avoid the side effects of stimulants (1).

• Atomoxetine (Strattera) lets norepinephrine work longer in the brain.  The drug is long-acting (18).
• Clonidine (Kapvay) is used to reduce hyperactivity, impulsiveness, and distractibility in people with ADHD.  This drug is also used to treat high blood pressure.  Because it also lowers blood pressure, people taking it for ADHD may feel lightheaded (18).
• Guanfacine (Intuniv) is normally prescribed for high blood pressure in adults.  This drug is available as a generic, but only the time release version and its generics are approved for use in children with ADHD.  This drug may help with memory and behavioral problems.  It may also help improve aggression and hyperactivity (18).

Potential side-effects of stimulant and non-stimulant drugs include:

• Sleep problems
• Mood swings
• Loss of appetite
• Heart problems
• Suicidal thoughts or actions (1)

NATURAL WAYS TO SUPPORT MENTAL FOCUS

Practices to Support Mental Focus:

• Diet: Avoid some artificial colorings and additives, eat omega-3 rich foods, and eat a balanced diet of minerals and vitamins (19).

• Electroencephalographic (EEG) biofeedback: EEG is a type of neurotherapy that measures brain waves.  A 2011 study suggested that EEG training was a promising treatment for ADHD.  A child may play a special video game during a typical session.  They’ll be given a task to concentrate on, such as “keep the plane flying.”  The plane will start to dive, or the screen will go dark if they’re distracted.  The game teaches the child new focusing techniques over time.  Eventually, the child will begin to identify and correct their symptoms  (20).
• Yoga (21)
• Behavioral Therapy (22)

Natural Supplements to Support Mental Focus:

• Magnesium (23,24)
• Vitamin B6 (24)
• Zinc (23)
• Essential fatty acids (23)
• Valerian (Valerian officinalis) (25,26)
• Lemon balm (Melissa officinalis) (26)
• Passionflower (Passiflora incarnata) (25)
• Gingko (Gingko biloba) (25)
• American ginseng (Panax quinquefolium) (25)

REFERENCES

1. Attention Deficit Hyperactivity Disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml. Accessed July 9, 2018.
2. What is ADHD? American Psychiatric Association. https://www.psychiatry.org/patients-families/adhd/what-is-adhd. Accessed July 9, 2018.
3. Ghanizadeh A. Psychometric analysis of the new ADHD DSM-V derived symptoms. BMC Psychiatry 2012;12:21.
4. Jenson P. Current concept and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder. Curr Psychiatry Rep 2000;2:102-9
5. Burke JD, Rowe R, Boylan K. Functional outcomes of child and adolescent oppositional defiant disorder symptoms in young adult men. J Child Psychol Psychiatry 2014;55:264-72. doi:10.1111/jcpp.12150
6. Barkley RA, Fisher M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of the disorder. J Abnorm Psychol 2002;111:279-89.
7. Keenan K, Shaw DS, Walsh B. DSM-III-R disorders in preschool children from low-income families. J Am Acad Child Adolesc Psychiatry 1997;36:620-7. DOI: 10.1097/00004583-199705000-00012.
8. Attention-Deficit / Hyperactivity Disorder (ADHD). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed July 9, 2018.
9. Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children — the United States, 2003 and 2007. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2010 Nov; 59(44):1439-43.
10. Sciutto MJ, Nolfi CJ, Bluhm C. Effects of child gender and symptom type on referrals for ADHD by elementary school teachers. J. Emotion Behav. Disord. 2004;12:247–253
11. Kutcher JS. Treatment of attention-deficit hyperactivity disorder in athletes. Curr Sports Med Rep. 2011;Jan-Feb; 10(1):32-6. DOI: 10.1249/JSR.0b013e3182091d79
12. Wilens TE, et al. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008 Jan; 47(1):21-31. DOI: 10.1097/chi.0b013e31815a56f1
13. Kutcher JS. Treatment of attention-deficit hyperactivity disorder in athletes. Curr. Sports Med. Rep. 2011;10:32–36. DOI: 10.1249/JSR.0b013e3182091d79
14. Faraone SV, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry. 2003;2:104–113
15. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and meta-regression analysis. Am. J. Psychiatry. 2007;164:942–948. DOI: 10.1176/ajp.2007.164.6.942
16. Barnett J E H. HELPING STUDENTS WITH ADHD IN THE AGE OF DIGITAL DISTRACTION. Physical Disabilities: Education and Related Services, 2017, 36(2), 1-7. doi: 10.14434/pders.v36i2.23913.
17. Raine ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf. Accessed July 9, 2018.
18. Drug Treatments for ADHD. WebMD.  https://www.webmd.com/add-adhd/adhd-medical-treatment#1-2. Accessed July 9, 2018.
19. Diet and attention deficit hyperactivity disorder. Harvard Health Publishing Harvard Medical School. https://www.health.harvard.edu/newsletter_article/Diet-and-attention-deficit-hyperactivity-disorder Accessed July 9, 2018.
20. Lansbergen M M, Dongen-Boomsma M V, Buitelaar J K, Slaats-Willemse D. ADHD and EEG-neurofeedback: a double-blind randomized placebo-controlled feasibility study. J Neural Transm. 2011 Feb; 118(2): 275–284. doi:10.1007/s00702-010-0524-2
21. Hariprasad VR, Arasappa R, Varambally S, Srinath S, Gangadhar BN. Feasibility and efficacy of yoga as an add-on intervention in attention deficit-hyperactivity disorder: An exploratory study. Indian J Psychiatry 2013;55, Suppl S3:379-84.
22. Behavior therapy for young children with ADHD. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html.
23. Huss M, Völp A, Stauss-Grabo M. Supplementation of polyunsaturated fatty acids, magnesium and zinc in children seeking medical advice for attention-deficit/hyperactivity problems – an observational cohort study. Lipids Health Dis. 2010 Sep 24;9:105. doi: 10.1186/1476-511X-9-105.
24. Mousain-Bosc M, Roche M, Polge A, Pradal-Prat D, Rapin J, Bali JP. Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6. I. Attention deficit hyperactivity disorders. Magnes Res. 2006 Mar;19(1):46-52.
25. Ahn J, Ahn H S, Cheong J H, Peña I. Natural Product-Derived Treatments for Attention-Deficit/Hyperactivity Disorder: Safety, Efficacy, and Therapeutic Potential of Combination Therapy. Neural Plast. 2016; 2016: 1320423. doi:10.1155/2016/1320423
26. Gromball J, Beschorner F, Wantzen C, Paulsen U, Burkart M. Hyperactivity, concentration difficulties and impulsiveness improve during seven weeks’ treatment with valerian root and lemon balm extracts in primary school children. Elsevier. 2014 Jul;21(8-9):1098-1103.