Diseases

No one knows for sure whether the prevalence of ADHD (total number of patients) has risen, but it is very clear that the number of children newly identified annually (incidence) with the disorder and who obtain treatment has risen over the past decade. Some of this increased identification and increased treatment seeking is due in part to greater media interest, heightened consumer awareness, and the availability of effective treatments. Teachers are better trained to recognize the condition and suggest that the family seek help, especially in the more mild to moderate cases. The established DSM-IV ADHD criteria are concise and more exact than those diagnostic tools used previously. This may allow establishment of the diagnosis in children with more subtle or milder expression of the symptoms. The diagnosis of ADHD is also less of a social stigma than in the past. This more enlightened perspective reflects the understanding that ADHD is a biochemical disorder and not merely an "out of control child." As such, more parents are receptive to medical therapy for the condition rather than resorting to less effective home/school discipline techniques. Interestingly, the increase in prevalence of ADHD is not solely an American phenomenon but has been noted also in other countries. Whether the number of patients with ADHD has truly increased or rather our better recognition and acceptance of ADHD as a diagnosis has "increased," the number of patients remains to be further defined.

DietNo specific food or diet has been clearly shown to have a significant positive or negative effect on the symptoms or course of ADHD. People with ADHD should eat a healthy diet and probably avoid caffeine, a stimulant. That having been said, some parents note that a dietary change (such as decreased refined sugar intake) is beneficial. If an individual is not deprived of necessary nutrients, there is certainly no harm in trying to follow such a dietary adjustment. A good rule of thumb is to discuss the proposed plan with the child's pediatrician.ExerciseRegular physical activity has been shown to play an important role in some of the common related conditions (for example, depression, anxiety) and to improve concentration. Regular exercise may be beneficial in people with ADHD. Several studies on children with ADHD not taking medication have shown an improvement in concentration and reduction in inattentive and hyperactive behaviors if one hour of vigorous after-school play occurs before starting homework.Alternative therapiesCAM (complementary and alternative medicine) therapies are considered and/or tried in over half of patients with ADHD. Many times these modalities are used covertly, and it is important for the treating physician to inquire about CAM to encourage open communication and review the risks versus benefits of such an approach. CAM treatment modalities incorporating vision training, special diets and megavitamin therapy, herbal and mineral supplements, EEG biofeedback, and applied kinesiology have all been advocated. The benefits of these approaches, however, have not been confirmed in double-blinded controlled studies. Families should be aware that such programs might require a long-term financial commitment that may not have insurance reimbursement as an option.

The cause of ADHD has not been defined. One theory springs from observations regarding variations in functional brain-imaging studies of those with and without symptoms. However, these variations have been shown in studies of the structure of the brain of ADHD affected and unaffected individuals. Animal studies have demonstrated differences in the chemistry of brain transmitters involved with judgment, impulse control, alertness, planning, and mental flexibility. A genetic predisposition has been demonstrated in (identical) twin and sibling studies. If one identical twin is diagnosed with ADHD, there is a 92% probability of the same diagnosis in the twin sibling. When comparing nonidentical twin sibling subjects, the probability falls to 33%. The overall population incidence is 3%-10%.Genes that control the relative levels of chemicals in the brain called neurotransmitters seem to be different in ADHD, and levels of these neurotransmitters are out of normal balance.

• MRI and other imaging studies suggest that these imbalances occur in parts of the brain that control certain types of movement and executive function (see below).
• These areas of the brain may be smaller and/or less active in people with ADHD.

While most teens and adults with ADHD are no longer hyperactive in behavior, they commonly have a suboptimal executive function skill set. The six major tasks of executive function that are most commonly distorted with ADHD are the following:

• Shifting from one mindset or strategy to another (that is, flexibility)
• Organization (for example, anticipating both needs and problems)
• Planning (for example, goal setting)
• Working memory (that is, receiving, storing, then retrieving information within short-term memory)
• Separating emotions from reason
• Regulating speech and movements appropriately

Stimulant medications have been successfully used to treat patients with ADHD for more than 50 years. This class of medication, when used under proper medical supervision, has an excellent safety record in patients with ADHD. In general, the side effects of the stimulant class of medications are mild, often transient over time, and reversible with adjustment in dosage amount or interval of administration. The incidence of side effects is highest when administered to preschool-aged children. Common side effects include appetite suppression, sleep disturbances, and weight loss. Less common side effects include an increase in heart rate/blood pressure, headache, and emotional changes (social withdrawal, nervousness, and moodiness). Patients treated with the methylphenidate patch (Daytrana) may develop a skin sensitization at the site of application. Approximately 15%-30% of children treated with stimulant medications develop minor motor tics (involuntary rapid twitching of facial and/or neck and shoulder muscles). These are almost always short lived and resolve without stopping the use of medication.A recent investigation studied the possibility of stimulant medication used to treat ADHD and cardiovascular side effects. Concern focused on a possible association with heart attack, heart rate and rhythm disturbances, and stroke. At this time, there is no certainty in a proposed relationship to these events (including sudden death) when medication is used in a pediatric population screened for prior cardiovascular symptoms or structural pathology of the heart. A positive family history for certain conditions (for example, unusual heart rhythm patterns) may be considered a risk factor. The current position of the American Academy of Pediatrics is that a screening EKG is not indicated before the initiation of stimulant medication in a patient without risk factors."Diversion" is the transfer of medication from the patient for whom it was prescribed to another individual. Several large studies have indicated that 5%-9% of grade- and high-school students and 5%-35% of college-aged individuals reported use of nonprescribed stimulant medication, and 16%-29% of students for whom stimulant medications were prescribed reported being approached to give, trade, or sell their medication. Misuse was more frequently seen in whites, members of fraternities and sororities, and students with a lower GPA. Diversion was more likely with the short-acting preparations. The most common reasons cited for use of non-prescribed stimulants were "helped with studying," improved alertness, drug experimentation, and "getting high."ADHD is a controversial diagnosis for several reasons. Many well-meaning individuals have spoken out against making children behave according to a norm or taking medications for the sake of improving grades. These individuals have expressed concern about addiction or drugging children. This kind of concern is valid. However, the following must also be considered:

• The negative consequences of not using medication for children with ADHD have to be weighed against the known risks. Long-term outcome studies have now been conducted with large numbers of adults diagnosed with ADHD as children, and one clear finding is that those who received medication for their disorder in childhood are more functional and have a better quality of life as adults than those who had the symptoms of the disease but did not receive medicine.
• Stimulants used for ADHD do not cause addiction. Although tolerance usually develops for the stimulant-associated effects of anorexia, insomnia, or mild euphoria, tolerance does not develop to the increased levels of neurotransmitters.
• These medications should not be used just to improve grades or quiet down classrooms. School performance should be looked at as a sign of how well the child is doing, just like other areas of health. These medications often improve school performance dramatically, which is linked to better social skills and heightened self-esteem.
• Studies that have examined whether taking a psychostimulant for ADHD in childhood contributes to future substance abuse have shown this to not be the case. In one very large study, in fact, children who received stimulant medication for ADHD had half the risk of future substance abuse of similar children with ADHD who did not receive medication.

The use of psychostimulants in children should be scrutinized carefully. Fortunately, methylphenidate (Ritalin [and its long-lasting formulation, Concerta]) has been available since 1955. This long period of clinical experience has shown that this is one of the safest medications used in children.

The medical community recognizes three basic expressions of the disorder:

• Primarily inattentive: The child exhibits recurrent inattentiveness and an inability to maintain focus on tasks or activities. In the classroom, this may be the child who is "spacing out" and "can't stay on track."
• Primarily hyperactive-impulsive: Impulsive behaviors and inappropriate movement (fidgeting, inability to keep still) or restlessness are the primary problems. Unlike the inattentive ADHD-type child, this individual is more often the "class clown" or "class devil" -- either manifestation leads to recurrent disruptive problems.
• Combined: This is a combination of the inattentive and hyperactive-impulsive forms.

The combined type of ADHD is the most common. The predominantly inattentive type is being recognized more and more, especially in girls and in adults. The predominantly hyperactive-impulsive type, without significant attention problems, is rare and is commonly seen in boys during early grammar school.In the United States, ADHD affects about 3%-10% of children. Similar rates have been reported in other developed countries such as Germany, New Zealand, and Canada.

• Usually, the abnormal behaviors are established by the time the child is about 7 years old. ADHD is rarely newly diagnosed in teenagers or young adults. Children with ADHD are often noted to be emotionally delayed, with some individuals having a delay in maturity of up to 30% when compared with their peers. Thus a 10-year-old student may behave like a 7-year-old, whereas a 20-year-old young adult may respond more like a 14-year-old teenager.
• Boys are more likely than girls to be diagnosed with ADHD. At one time, the ratio of boys to girls with ADHD was thought to be as high as 4:1 or 3:1. This ratio has been decreasing, however, as more is known about ADHD. Greater recognition of the inattentive form of ADHD has increased the number of girls diagnosed with the disorder.
• Hyperactive symptoms may decrease with age, usually diminishing at puberty, perhaps due to gaining greater self-control as they mature.
• Inattention symptoms are less likely to fade with maturity and tend to remain constant into adulthood.
• People with ADHD are also more likely than the general population to have a family member with ADHD.

Since 1994, the establishment of the diagnosis of childhood ADHD has relied upon specific criteria outlined in the DSM-IV. The newly published DSM-V has reaffirmed criteria for establishing a diagnosis of ADHD. The guidelines emphasize that symptoms must be present for at least six months and generally were noted to be causing disruption of age-appropriate activity before 7 years of age. According to the criteria, such disruption should occur in at least two settings (such as home and school). In addition, these symptoms must not be better explained by another mental disorder (such as anxiety disorder).

Attention deficit hyperactivity disorder (ADHD), whether it affects an adult or a child brings many challenges. People with ADHD can learn, achieve, succeed, and create a happy life for themselves with effort. But making changes is not always easy. Sometimes it helps to have someone to talk to.This is the purpose of support groups. Support groups consist of people in the same situation. They come together to help each other and to help themselves. Support groups provide reassurance, motivation, and inspiration. They help individuals see that their situation is not unique and not hopeless, and that gives them power. They also provide practical tips on coping with ADHD and navigating the medical, educational, and social systems that people will rely on for help for themselves or their child. Being in an ADHD support group is strongly recommended by most mental-health professionals.Support groups meet in person, on the telephone, or on the Internet. To find a support group, contact the following organizations. They also serve as an excellent source of accurate information about ADHD. Ask a health-care professional, behavioral therapist, education specialist, or look on the Internet.Attention Deficit Disorder Associationhttp://www.add.orgChildren and Adults With Attention-Deficit/Hyperactivity Disorderhttp://www.chadd.orgLearning Disabilities Association of Americahttp://www.ldanatl.org

Literature supports the clinical observation that as many as 50% of children with ADHD will have symptoms persist into adulthood. One caveat needs to be mentioned -- many studies previously conducted focused on a patient population of males who were evaluated or treated by psychiatrists/psychologists or in clinics specially developed for such a patient population. The value of generalizing these results to the entire patient population with ADHD should be done with caution. Fortunately, new studies are being conducted to address this issue.The following are current areas of concern:

1. Education: Follow-up studies of children with ADHD growing into adolescence showed impairment of academic success. A few studies into adulthood have demonstrated persistence of these findings. Completion of expected schooling, lower achievement scores, and failure of courses are areas of concern.
2. Employment: The rate of adult employment of those with and without a diagnosis of ADHD did not vary; however, those with ADHD did have occupations with a lower "job status."
3. Socialization issues: A significant subset of children with ADHD has accompanying disruptive behavior disorders (oppositional defiant disorder or conduct disorder). In studies that followed children with ADHD into adulthood, between 12%-23% have socialization problems, versus 2%-3% of the general population.
4. Substance abuse: Studies examining whether those with ADHD have a higher likelihood for such high-risk behaviors are controversial. The largest study to date supports other smaller studies that indicate ADHD patients who consistently take their medication have twice the likelihood of not using illicit drugs or excessive alcohol.
5. Driving: A teen with ADHD is two to four times more likely to have a motor-vehicle accident or have his/her license suspended than a peer without such a diagnosis. Impulsivity and inattention again seem to be limited when at-risk teens consistently take their recommended medication.

A school-age child may need evaluation for ADHD if he or she exhibits any of the following behaviors:

• Has a shorter attention span than peers and needs frequent teacher intervention to keep on task (Parents will often report the need for constant surveillance during homework.)
• Avoids work that requires sustained attention
• Daydreams excessively, derailing the completion of tasks
• Is hyperactive or fidgety
• Disrupts classroom by leaving seat, moving around room, talking inappropriately, and/or engaging others in play
• Provokes daily arguments at home about completing homework and chores

The evaluation of a child suspected of having ADHD involves many disciplines, including comprehensive medical, developmental, educational, and psychosocial evaluations. Interviewing parents and the patient and contacting the patient's teacher(s) is crucial. Investigation regarding the family history for behavioral and/or social problems is helpful. While direct person-to-person contact is considered vital at the outset of an investigation, follow-up studies may be guided by comparing standardized questionnaires (from parents and teachers) completed prior to intervention and subsequent to medication, behavioral therapy, or other treatment approaches. While there is no unique finding on the physical exam in patients with ADHD, unusual physical features should prompt consideration of consultation with a geneticist due to the high association with ADHD behavioral patterns and certain well-recognized genetic syndromes (for example, fetal alcohol syndrome).At this time, no lab test, X-ray, imaging study, or procedure is known to suggest or confirm the diagnosis of ADHD. Specific tests may be ordered if indicated by specific symptoms.Physicians and parents should be aware that schools are federally mandated to perform an appropriate evaluation if a child is suspected of having a disability that impairs academic functioning. This policy was recently strengthened by regulations implementing the 1997 reauthorization of the Individuals With Disabilities Act (IDEA), which guarantees appropriate services and a public education to children with disabilities from ages 3 to 21. If the assessment performed by the school is inadequate or inappropriate, parents may request that an independent evaluation be conducted at the school's expense. Furthermore, some children with ADHD qualify for special-education services within the public schools under the category of "Other Health Impaired." In these cases, the special-education teacher, school psychologist, school administrators, classroom teachers, along with parents, assess the child's strengths and weaknesses and design an Individualized Education Program (IEP). These special-education services for children with ADHD are available though IDEA.Despite this "federal mandate," the reality is that many school districts, because of underfunding or understaffing, are unable to perform "an appropriate evaluation" for all children suspected of having ADHD. School districts have the latitude to define the degree of "impairment of academic functioning" necessary to approve "appropriate evaluation." This usually means the children who are failing or near-failing in their academic performance. A very large segment of the ADHD-affected children will be "getting by" (not failing) academically (at least in their early years of school), but they are usually achieving well below their potential and getting more and more behind each year on the academic prerequisite skills necessary for later school success. Unfortunately, some families will have to assume the financial burden of an independent educational evaluation. These evaluations are commonly done by an educational psychologist and may involve approximately eight to 10 hours of testing and observation spread out over several sessions. A primary goal of an educational evaluation is to exclude/include the possibility of learning disorders (including dyslexia, language disorders, etc.).

Children experiencing ADHD should be held to the same expectations as their peers of the same emotional developmental level. Assuming the child has no learning disturbance, children with ADHD will have both academic strengths and weaknesses like all non-ADHD classmates. Athletic ability will vary in a similar manner as will social interaction; some children with ADHD are very outgoing while others are more reserved. Children with ADHD are often noted to be emotionally delayed, with some individuals having a delay in maturity of up to 30% when compared with their peers. Thus, a 10-year-old student may behave like a 7-year-old; a 20-year-old young adult may respond more like a 14-year-old teenager.

Medical treatmentThe two major components of treatment for children with attention deficit hyperactivity disorder (ADHD) are behavioral therapy and medication.

• Home and school interventions: Parents can help their child's behavior with specific goals such as (1) maintaining a daily schedule, (2) keeping distractions to a minimum, (3) setting reasonable goals, (4) rewarding positive behavior, (5) using charts and checklists to keep a child "on task," and (6) finding activities in which the child will succeed (sports, hobbies). Children with ADHD may require adjustments in the structure of their educational experience, including tutorial assistance and the use of a resource room. Many children function well throughout the entire school day with their peers. However, some patients with ADHD will benefit from a "pull-out session" to complete tasks, review specific homework assignments, and develop "management" skills necessary for higher education. Extended time for class work/tests may be necessary as well as assignments written on the board and preferential seating near the teacher. An IEP (Individualized Educational Program) should be developed and reviewed periodically with the parents. ADHD is considered a disability falling under U.S. Public Law 101-476 (Individuals With Disabilities Education Act or IDEA). As such, individuals with ADHD may qualify for "appropriate accommodations within the regular classroom" within the public-school system. In addition, the Americans With Disabilities Act (ADA) indicates that secular private schools may be required to provide similar "appropriate accommodations" in their institutions.
• Psychotherapy: ADHD coaching, a support group, or both can help teens feel more normal and provide well-focused peer feedback and coping skills. Counselors such as psychologists, child and adolescent psychiatrists, behavioral/developmental pediatricians, clinical social workers, and advanced practice nurses can be invaluable to both the children and families. Behavior modification and family therapy are usually necessary for the best possible outcome.

MedicationsThe medications used to treat ADHD are psychoactive. This means they affect the chemistry and the function of the brain.Psychostimulants are by far the most widely used medications in treating ADHD. When used appropriately, approximately 80% of individuals with ADHD have a very good to excellent response in reduction of symptoms. These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.

• The most common adverse effects are short term. They include reduction of appetite, sleep disturbances, rebound (for example, agitation, anger, lethargy as the last dose starts to wear off), and mild anxiety. Most individuals who take psychostimulants for ADHD build up tolerance to adverse effects within a few weeks.
• Individuals with certain coexistent psychiatric disorders (for example, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to adverse effects if they do not receive appropriate concurrent treatment for the coexistent condition.

The psychostimulants most often used in ADHD include the following:

• Methylphenidate (Ritalin, Concerta, Daytrana patch, Quillivant XR)
• Dexmethylphenidate (Focalin, Focalin XR)
• Dextroamphetamine and amphetamine mixture (Adderall, Adderall XR, Vyvanse)

Atomoxetine (Strattera) is a newer nonstimulant used to treat ADHD. Less is known about its long-term side effects. This drug has several benefits over stimulants, but its use may also carry several negative aspects.

• It is not a controlled substance and is not considered a drug of potential abuse by the U.S. Food and Drug Administration (FDA). Since it is not a controlled substance, pharmacies may accept phone-requested medical refills.
• It is usually taken only once a day for full 24-hour effectiveness.
• It is much less likely than stimulants to disrupt eating or sleeping.
• For some children, atomoxetine is not enough to control their ADHD symptoms. Many other children do very well on this medicine alone.
• Specialists treating individuals with ADHD have found Strattera seems to best help improve the problems associated with a disruption in executive function skills. Inattention and hyperactivity symptoms are less responsive.
• When starting atomoxetine therapy, a gradually increasing dosage schedule is recommended. It may take up to three weeks before full therapeutic benefit is achieved. For this reason, patients may need to remain on previously prescribed stimulant medication during the "build up" phase. In addition, atomoxetine must be taken daily; short-term "medication holidays" (for example, school vacations and weekends) will limit its efficacy.
• Studies have indicated a higher than expected incidence of suicide ideation during early treatment. This occurred in patients with pure ADHD as well as in those patients with ADHD accompanied by other emotional disorders (for example, depression, anxiety, bipolar disorder).

Some medications originally developed to treat depression (antidepressants) also have important roles in treating some individuals with ADHD. Since these medicines have been used for many years to treat other mental-health conditions, their adverse effects are well understood.

• Imipramine (Tofranil): an antidepressant that increases levels of neurotransmitters norepinephrine and/or serotonin in the brain
• Bupropion (Wellbutrin): an antidepressant that increases levels of neurotransmitters in the brain, especially dopamine
• Desipramine (Norpramin): an antidepressant that increases levels of the neurotransmitter norepinephrine in the brain

Other medicines that were originally developed to treat high blood pressure (alpha agonists) may also be useful in the treatment of those having ADHD. Again, due to widespread and long-term use, their side effects are well known to doctors.

• Clonidine (Catapres): an alpha agonist that stimulates certain receptors in the brain stem. The overall effect is to "turn down the volume" of hyperactive movement and speech.
• Guanfacine (Tenex, Intuniv): another alpha agonist with an effect similar to that of clonidine. These medications are designed to be used in combination with other medications listed above. They are not effective when taken as a single and only medication.

The initial evaluation of a child whose behavioral issues may be indicative of ADHD can generally by managed by the pediatrician. A current physical examination is indicated to rule out potential medical issues that may either reinforce a potential ADHD diagnosis or rule out the condition. Further history regarding the various behavioral and academic strengths and weaknesses of the child are elicited and it is imperative to gather feedback from both the parents and teacher. If any concerns are developed regarding potential learning disorders (for examples, dyslexia, auditory processing disorders, etc.), specialized testing should be obtained. This evaluation may be secured either through the child's school district or private agencies. Standardized questionnaires (such as Connors Rating Scales) are often used to provide objective evaluations in both the home and school settings. In addition, these scales commonly have sections to evaluate for other mental-health issues (including depression, anxiety, etc.) that may also be present in a child with ADHD. Once a diagnosis is established, a pediatrician can discuss with the patient and the parents the various treatment options. Children whose physical or mental-health history is more complicated may warrant an evaluation by either a pediatrician with specialty training in developmental disorders, a pediatric neurologist, a psychologist, or a psychiatrist. Should a patient have a poor response or excessive side effects to commonly used medications, a pediatric neurologist or psychiatrist consultation may be especially helpful.