Attention Deficit Hyperactivity Disorder

Sign/Symptoms
Drugs
Treatments
Attributes
Commonality = 8
Further Tests
Our Records are Incomplete for Further Tests

Efficacy of Alternative and Other Treatments According to GRADE* Ranking:

St John's Wort (Goatweed, tipton weed, Hypericum Perforatum) [1, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17]:

Please note, this management does NOT treat the condition itself. It may mildly help with some of the symptoms, and even then has insufficient evidence to back up this claim at present.

Recommendation: No recommendation (Available evidence does not support claims that St Johns Wort can help to treat ADHD)

Grade of Evidence: low quality of evidence

* www.gradeworkinggroup.org

Flower Remedies [1, 5, 6]:

Please note, this management does NOT treat the condition itself. It may mildly help with some of the symptoms, and even then has insufficient evidence to back up this claim at present.

Recommendation: no recommendation  (There is insufficient evidence to support claims that flower remedies help to treat ADHD)

Grade of Evidence: very low quality of evidence

Evening Primrose Oil  [1, 2, 3, 4]:

Please note, this management does NOT treat the condition itself. It may mildly help with some of the symptoms, and even then has insufficient evidence to back up this claim at present.

Recommendation: no recommendation  (There is insufficient evidence to support claims that Primrose Oil helps to treat ADHD in any way.)

Grade of Evidence: very low quality of evidence

Craniosacral Therapy

Recommendation: weak (available evidence does not support claims that Craniosacral therapy helps treat ADHD)

Grade of Evidence: low quality of evidence

Hypnosis:

Recommendation: weak (There is insufficient evidence to show that hypnosis helps to treat ADHD)

Grade of Evidence: very low quality of evidence


* www.gradeworkinggroup.org

Attention Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is a neurobehavioral developmental disorder[http://www.loni.ucla.edu/Research/Projects/ADHD.shtml#CurrentResearch LONI: Laboratory of Neuro Imaging][http://www.ninds.nih.gov/disorders/adhd/adhd.htm NINDS Attention Deficit-Hyperactivity Disorder Information Page.] National Institute of Neurological Disorders and Stroke (NINDS/NIH) February 9, 2007. Retrieved on 2007-08-13.[http://www.russellbarkley.org/adhd-facts.htm Dr. Russell A. Barkley Official Site, Authority ADHD, Attention Deficit Hyperactivity Disorder] affecting about 3-5% of the world's population under the age of 19. It typically presents itself during childhood, and is characterized by a persistent pattern of inattention and/or hyperactivity, as well as forgetfulness, poor impulse control or impulsivity, and distractibility.Diagnostic and Statistical Manual of [American Psychiatric Association, 2000.[http://www.behavenet.com/capsules/disorders/adhd.htm Psychiatric Association|the American Psychiatric Association], Fourth Edition, htm Attention-Deficit/Hyperactivity Disorder (ADHD).] Behavenet.com. Retrieved on December 11, 2006. ADHD is currently considered to be a persistent and chronic condition for which no medical cure is available, although medication can be prescribed. ADHD is most commonly diagnosed in children and, over the past decade, has been increasingly diagnosed in adults. About 60% of children diagnosed with ADHD retain the condition as adults.[http://www.webmd.com/content/article/89/100385.htm Attention-Deficit / Hyperactivity Disorder: ADHD in Adults.] WebMd.com. Retrieved on December 11, 2006. It appears to be highly heritable, although one-fifth of all cases are estimated to be caused from trauma or toxic exposure. Methods of treatment usually involve some combination of medications, behavior modifications, life style changes, and counseling. The scientific consensus in the field, and the consensus of the national health institutes of the world, is that ADHD is a disorder which impairs functioning, and that many adverse life outcomes are associated with ADHD.

 

Classification

ADHD is a developmental disorder, in that, in the diagnosed population, certain traits such as impulse control significantly lag in development when compared to the general population. Using magnetic resonance imaging, this developmental lag has been estimated to range between 3 years, to 5 years in the prefrontal cortex of those with ADHD patients in comparison to their peers[http://www.sciencedaily.com/releases/2007/11/071112172200.htm Brain Matures A Few Years Late In ADHD, But Follows Normal Pattern]; consequently these delayed attributes are considered an impairment. ADHD has also been classified as a behavior disorder and a neurological disorder [http://www.loni.ucla.edu/Research/Projects/ADHD.shtml#CurrentResearch LONI: Laboratory of Neuro Imaging] or combinations of these classifications such as neurobehavioral or neurodevelopmental disorders.
Three forms of ADHD exist, ADHD-PI or ADHD Primarily Inattentive (previously known as ADD or Attention Deficit Disorder), ADHD-PH/I or ADHD Primarily Hyperactive/Impulsive, and ADHD-C or combined type. The majority of studies have looked at ADHD-C, with much less work done on ADHD-PI.

 

Symptoms

The most common symptoms of ADHD are distractibility, difficulty with concentration and focus, short term memory loss, procrastination, problems organizing ideas and belongings, tardiness, impulsivity, and weak planning and execution. Not all people with ADHD exhibit all symptoms. The Diagnostic and Statistical Manual of Mental Disorders categorises the symptoms of ADHD into two clusters: Inattention symptoms and Hyperactivity/Impulsivity symptoms. Most ordinary people exhibit some of these behaviors but not to the point where they seriously interfere with the person's work, relationships, or studies or cause anxiety or depression. Children do not often have to deal with deadlines, organization issues, and long term planning so these types of symptoms often become evident only during adolescence or adulthood when life demands become greater. According to an advanced high-precision imaging study by researchers at the United States National Institutes of Health's National Institute of Mental Health, a delay in physical development in some brain structures, with a median value of three years, was observed in the brains of 223 ADHD patients beginning in elementary school, during the period when cortical thickening during childhood begins to change to thinning following puberty. The delay was most prominent in the frontal cortex and temporal lobe, which are believed responsible for the ability to control and focus thinking, attention and planning, suppress inappropriate actions and thoughts, remember things from moment to moment, and work for reward, all functions whose disturbance is associated with a diagnosis of ADHD; the region with the greatest average delay, the middle of the prefrontal cortex, lagged a full five years in development in the ADHD patients. In contrast, the motor cortex in the ADHD patients was seen to mature faster than normal, suggesting that both slower development of behavioral control and advanced motor development might both be required for the restlessness and fidgetiness that characterize an ADHD diagnosis. Aside from the delay, both groups showed a similar back-to-front development of brain maturation with different areas peaking in thickness at different times. This contrasts with the pattern of development seen in other disorders such as autism, where the peak of cortical thickening occurs much earlier than normal.[http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-in-adhd-but-follows-normal-pattern.shtml Brain Matures a Few Years Late in ADHD, But Follows Normal Pattern] NIMH Press Release, November 12, 2007 The same laboratory had previously found involvement of the "7-repeat" variant of the dopamine D4 receptor gene, which accounts for about 30 percent of the genetic risk for ADHD, in unusual thinness of the cortex of the right side of the brain; however, in contrast to other variants of the gene found in ADHD patients, the region normalized in thickness during the teen years in these children, coinciding with clinical improvement.[http://www.nimh.nih.gov/science-news/2007/gene-predicts-better-outcome-as-cortex-normalizes-in-teens-with-adhd.shtml Gene Predicts Better Outcome as Cortex Normalizes in Teens with ADHD] NIMH Press Release, August 6, 2007 Hyperactivity is common among children with ADHD but tends to disappear during adulthood. However, over half of children with ADHD continue to have symptoms of inattention throughout their lives. Inattention and "hyperactive" behavior are not the only problems with children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it. Many of these co-existing conditions require other courses of treatment and should be diagnosed separately instead of being grouped in the ADHD diagnosis. Some of the associated conditions are: a. Oppositional Defiant Disorder (35%) and Conduct Disorder (26%). These are both characterized by extreme anti-social behaviors. These disorders are frequently characterized by aggression, frequent temper tantrums, deceitfulness, lying, or stealing. b. Primary Disorder of Vigilance. Characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch, and appear to be hyperactive in order to remain alert and active. c. Bipolar disorder. As many as 25% of children with ADHD may have bipolar disorder. Children with this combination may demonstrate more aggression and behavioral problems than those with ADHD alone. d. Anxiety Disorders. Commonly accompany ADHD, particularly Obsessive-Compulsive Disorder. OCD is believed to share a genetic component with ADHD, and shares many of its characteristics. Although children with ADHD have an inability to maintain attention, conversely, they may also fixate.[http://www.nimh.nih.gov/healthinformation/adhdmenu.cfm] There is evidence of hypothalamic-pituitary-adrenal axis (HPA axis) abnormalities in ADHD patients due to stress.Hong,Shin,Lee,Oh,Noh, Yonsei University College of Medicine, Seoul, Korea, [http://www.eymj.org/abstracts/viewArticle.asp?year=2003&page=608 HPA Axis Activity in ADHD], 2003.

 

Causes

 

=Genetic Factors=

According to a majority of medical research in the United States, as well as other countries, ADHD is today generally regarded as a chronic disorder for which there are some effective treatments, but no true cure.[http://www.ninds.nih.gov/disorders/adhd/adhd.htm NINDS Attention Deficit-Hyperactivity Disorder Information Page.] National Institute of Neurological Disorders and Stroke (NINDS/NIH) February 9, 2007. Retrieved on 2007-08-13. Evidence suggests that hyperactivity has a strong heritable component, and in all probability ADHD is a heterogeneous disorder, meaning that several causes could create very similar symptomology. Candidate genes include dopamine transporter (DAT), dopamine receptor D4 (DRD4), dopamine beta-hydroxylase (DBH), monoamine oxidase A (MAOA), catecholamine-methyl transferase (COMT), serotonin transporter promoter (SLC6A4), 5-hydroxytryptamine 2A receptor (5-HT2A), and 5-hydroxytryptamine 1B receptor (5-HT1B). Researchers believe that a large majority of ADHD arises from a combination of various genes, many of which affect dopamine transporters.Roman T, Rohde LA, Hutz MH. (2004). "Polymorphisms of the dopamine transporter gene: influence on response to methylphenidate in attention deficit-hyperactivity disorder." American Journal of Pharmacogenomics 4(2):83–92 PMID 15059031 Suspect genes include the 10-repeat allele of the DAT1 gene,Swanson JM, Flodman P, Kennedy J, et al. "Dopamine Genes and ADHD." Neurosci Biobehav Rev. 2000 Jan;24(1):21–5. PMID 10654656 the 7-repeat allele of the DRD4 gene, and the dopamine beta hydroxylase gene (DBH TaqI).Smith KM, Daly M, Fischer M, et al. "Association of the dopamine beta hydroxylase gene with attention deficit hyperactivity disorder: genetic analysis of the Milwaukee longitudinal study." Am J Med Genet B Neuropsychiatr Genet. 2003 May 15;119(1):77–85. PMID 12707943 Genome wide surveys have shown linkage between ADHD and loci on chromosomes 7, 11, 12, 15, 16, and 17. If anything, the broad selection of targets indicates the likelihood that ADHD does not follow the traditional model of a "genetic disease" and is better viewed as a complex interaction among genetic and environmental factors. As the authors of a review of the question have noted, "Although several genome-wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ADHD susceptibility, to date no single gene with a major contribution to ADHD has been identified." Studies show that there is a familial transmission of the disorder which does not occur through adoptive relationships.Barkley, Russell A. [http://www.continuingedcourses.net/active/courses/course003.php Attention-Deficit/Hyperactivity Disorder: Nature, Course, Outcomes, and Comorbidity.] ContinuinedEdCourse.Net. Retrieved on 2007-08-12. Twin studies indicate that the disorder is highly heritable and that genetics contribute about three quarters of the total ADHD population. While the majority of ADHD is believed to be genetic in nature, roughly one-fifth of all ADHD cases are thought to be acquired after conception due to brain injury caused by either toxins or physical trauma prenatally or postnatally.

 

=Common Symptoms=

Additionally, SPECT scans found people with ADHD to have reduced blood circulation,Lou HC, Andresen J, Steinberg B, McLaughlin T, Friberg L. "The striatum in a putative cerebral network activated by verbal awareness in normals and in ADHD children." Eur J Neurol. 1998 Jan;5(1):67–74. PMID 10210814 and a significantly higher concentration of dopamine transporters in the striatum which is in charge of planning ahead. Medications focused on treating A.D.H.D.(such as methylphenidate) work because they force blood to flow in certain areas of the brain, such as those that control and regulate concentration, which usually don't receive a normal or sufficient amount of blood flow or circulation in the brains of individuals with A.D.H.D. A study by the U.S. Department of Energy’s Brookhaven National Laboratory in collaboration with Mount Sinai School of Medicine in New York suggest that it is not the dopamine transporter levels that indicate ADHD, but the brain's ability to produce dopamine itself. The study was done by injecting 20 ADHD subjects and 25 control subjects with a radiotracer that attaches itself to dopamine transporters. The study found that it was not the transporter levels that indicated ADHD, but the dopamine itself. ADHD subjects showed lower levels of dopamine across the board. They speculated that since ADHD subjects had lower levels of dopamine to begin with, the number of transporters in the brain was not the telling factor. In support of this notion, plasma homovanillic acid, an index of dopamine levels, was found to be inversely related not only to childhood ADHD symptoms in adult psychiatric patients, but to "childhood learning problems" in healthy subjects as well. Although there is evidence for dopamine abnormalities in ADHD, it is not clear whether abnormalities of the dopamine system are the molecular abnormality of ADHD or a secondary consequence of a problem elsewhere. Researchers have described a form of ADHD in which the abnormality appears to be sensory overstimulation resulting from a disorder of ion channels in the peripheral nervous system. N Engl J Med. 1990 November 15;323(20):1361–6. PMID 2233902 "This PET scan was taken from Zametkin's landmark 1990 study, which found lower glucose metabolism, in the brains of patients with ADHD who had never taken medication. Scans were taken while patients were engaging in tasks requiring focused attention. The greatest deficits were found in the premotor cortex and superior prefrontal cortex."]] An early PET scan study found that global cerebral glucose metabolism was 8.1% lower in medication-naive adults who had been diagnosed as ADHD while children. The image on the left illustrates glucose metabolism in the brain of a 'normal' adult while doing an assigned auditory attention task; the image on the right illustrates the areas of activity in the brain of an adult who had been diagnosed with ADHD as a child when given that same task; these are not pictures of individual brains, which would contain substantial overlap, these are images constructed to illustrate group-level differences. Additionally, the regions with the greatest deficit of activity in the ADHD patients (relative to the controls) included the premotor cortex and the superior prefrontal cortex. A second study in adolescents failed to find statistically significant differences in global glucose metabolism between ADHD patients and controls, but did find statistically significant deficits in 6 specific regions of the brains of the ADHD patients (relative to the controls). Most notably, lower metabolic activity in one specific region of the left anterior frontal lobe was significantly inversely correlated with symptom severity.Zametkin AJ, Liebenauer LL, Fitzgerald GA,, et al. "Brain metabolism in teenagers with attention-deficit hyperactivity disorder." Arch Gen Psychiatry.. 1993 May 50;333(5). PMID 2233902 These findings strongly imply that lowered activity in specific regions of the brain, rather than a broad global deficit, is involved in ADHD symptoms. However, these readings are of subjects doing an assigned task. They could be found in ADHD diagnosed patients because they simply were not attending to the task. Hence the parts of the brain used by others doing the task would not show equal activity in the ADHD patients.

 

=Environmental Factors=

The estimated contribution of non genetic factors to the contribution of all cases of ADHD is 20 percent. SchwabLearning.org.

 

==Pre-Natal

 

The environmental factors implicated are common exposures and include alcohol, ''in utero tobacco smoke and lead exposure, believed to stress babies prenatally. Lead concentration below the [[Center for Disease Control]]'s action level account for slightly more cases of ADHD than tobacco smoke (290 000 versus 270 000, in the USA, ages 4 to 15).: "Compared with the lowest quintile of blood lead levels, children with blood lead levels > 2.0 µg/dL were at a '4.1-fold increased risk of ADHD. When we limited the analysis to children with blood lead levels ≤ 5 µg/dL, the association between increased blood lead levels and ADHD remained. These results are consistent with previous reports that have found significant associations between blood or dentin lead levels and behavior problems .... Our results further indicate that blood lead levels below the CDC action level of 10 µg/dL are associated with an increased risk for ADHD in children. This result is consistent with previous studies that have found cognitive deficits in children with blood lead levels < 10 µg/dL.''" Complications during pregnancy and birth—including premature birth—might also play a role. It has been observed that women who smoke while pregnant are more likely to have children with ADHD.Kotimaa AJ, Moilanen I, Taanila A, et al. ,"Maternal smoking and hyperactivity in 8-year-old children". 2003, J Am Acad Child Adol Psychiatry Jul;42(7):826–33. PMID 12819442 This could be related to the fact that nicotine is known to cause hypoxia (lack of oxygen) in utero, but it could also be that ADHD women have more probabilities to smoke both in general and during pregnancy, being more likely to have children with ADHD due to genetic factors. Another factor that may be correlated with ADHD is mobile phone usage. A study surveying over 13,000 children found use of mobile phone handsets by pregnant mothers raised the risk of hyperactivity, emotional problems, and conduct problems, much to the researchers' surprise.

 

==Diet

 

Studies have found that malnutrition is also correlated with attention deficits. Diet seems to cause ADHD symptoms or make them worse. Many studies point to synthetic preservatives and artificial coloring agents aggravating ADD & ADHD symptoms in those affected.Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomized, double-blinded, placebo-controlled trialâ€Â, Lancet, Sept 20071997 Graduate Student Research Project conducted at the University of South Florida. Author- Richard W. Pressinger M.Ed. Older studies were inconclusive quite possibly due to inadequate clinical methods of measuring offending behavior. Parental reports were more accurate indicators of the presence of additives than clinical tests."Food Additives May Affect Kids' Hyperactivity", WebMD Medical News, May 24, 2004 Several major studies show academic performance increased and disciplinary problems decreased in large non-ADD student populations when artificial ingredients, including artificial colors were eliminated from school food programs.A different kind of school lunch", PURE FACTS October 2002The Impact of a Low Food Additive and Sucrose Diet on Academic Performance in 803 New York City Public Schools, Schoenthaler SJ, Doraz WE, Wakefield JA, Int J Biosocial Res., 1986, 8(2); 185-195. Professor John Warner stated, “significant changes in children’s hyperactive behaviour could be produced by the removal of artificial colourings and [[sodium benzoate]] from their diet.â€Â and “you could halve the number of kids suffering the worst behavioural problems by cutting out additivesâ€Â. In 1982, the NIH had determined, based on research available at that time, that roughly 5% of children with ADHD could be helped significantly by removing additives from their diet. The vast majority of these children were believed to have food allergies. http://www.nimh.nih.gov/health/publications/adhd/complete-publication.shtml#pub4 More recent studies have shown that approximately 60-70% of children with and without allergies improve when additives are removed from their diet, that up to almost 90% of them react when an appropriate amount of additive is used as a challenge in double blind tests, and that food additives may elicit hyperactive behavior and/or irritability in normal children as well. ==

 

Head Injuries

 

Head injuries can cause a person to present ADHD-like symptoms,McAvinue L, O'Keeffe F, McMackin D, Robertson IH, et al. "Impaired sustained attention and error awareness in traumatic brain injury: implications for insight" ''Neuropsychological Rehabilitation. 2005 Dec;15(5):569–87. PMID 16381141 possibly because of damage done to the patient's frontal lobes. Because these types of symptoms can be attributable to brain damage, one earlier designation for ADHD was "Minimal Brain Damage".[http://www.add.org/articles/causeadd.html What Causes ADD.] Attention Deficit Disorder Association. Retrieved on 2007-08-13. ===Social Factors

 

 

Diagnosis

Many of the symptoms of ADHD occur from time to time in everyone. In those with ADHD the frequency of these symptoms occurs frequently and impairs regular life functioning typically at school or at work. Not only will they perform poorly in task oriented settings but they will also have difficulty with social functioning with their peers. No objective physical test exists to diagnose ADHD in a patient. As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these critera are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified: # ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months # ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months # ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months. The terminology of ADD expired with the revision of the most current version of the DSM. Consequently, ADHD is the current nomenclature used to describe the disorder as one distinct disorder which can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD, predominately hyperactive-impulsive type) or inattention (ADHD predominately inattentive type) or both (ADHD combined type).

 

=DSM-IV criteria for ADHD= I. Either A or B: :A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: :# Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. :# Often has trouble keeping attention on tasks or play activities. :# Often does not seem to listen when spoken to directly. :# Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). :# Often has trouble organizing activities. :# Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). :# Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). :# Is often easily distracted. :# Often forgetful in daily activities. :B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: Hyperactivity: :# Often fidgets with hands or feet or squirms in seat. :# Often gets up from seat when remaining in seat is expected. :# Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). :# Often has trouble playing or enjoying leisure activities quietly. :# Is often "on the go" or often acts as if "driven by a motor". :# Often talks excessively. Impulsiveness: :# Often blurts out answers before questions have been finished. :# Often has trouble waiting one's turn. :# Often interrupts or intrudes on others (e.g., butts into conversations or games). II. Some symptoms that cause impairment were present before age 7 years. III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). IV. There must be clear evidence of significant impairment in social, school, or work functioning. V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). In the tenth edition of the [[International Statistical Classification of Diseases and Related Health Problems]] (ICD-10) the symptoms of ADD are given the name "Hyperkinetic disorders". When a [[conduct disorder]] (as defined by ICD-10 [http://www.who.int/classifications/apps/icd/icd10online/ ICD Version 2006: F91.] World Health Organization. Retrieved on December 11, 2006.) is present, the condition is referred to as "Hyperkinetic conduct disorder". Otherwise the disorder is classified as "Disturbance of Activity and Attention", "Other Hyperkinetic Disorders" or "Hyperkinetic Disorders, Unspecified". The latter is sometimes referred to as, "Hyperkinetic Syndrome". The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria:Perrin JM, Stein MT, Amler RW, Blondius TA. 2001. "Clinical practice guideline: treatment of school-aged children with Attention Deficit/Hyperactivity Disorder". Pediatrics 108 (4):1033-1044. PMID 11581465 * The use of explicit criteria for the diagnosis using the DSM-IV-TR. * The importance of obtaining information about the child’s symptoms in more than one setting. * The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning. The first criterion can be satisfied by using an ADHD-specific instrument such as the Conners' Rating Scale. The second criterion is best fulfilled by examining the individual's history. This history can be obtained from parents and teachers, or a patient's memory.Ratey, John; Hallowell, Edward. Driven to Distraction first edition, p. 42 The requirement that symptoms be present in more than one setting is very important because the problem may not be with the child, but instead with teachers or parents who are too demanding. The use of intelligence testing, psychological testing, and neuropsychological testing (to satisfy the third criterion) is essential in order to find or rule out other factors that might be causing or complicating the problems experienced by the patient.Ninivaggi, F. J. "Borderline intellectual functioning and academic problem." In: Sadock B.J. Sadock, V.A., eds. Kaplan & Sadock's Comprehensive Textbook of psychiatry. 8th ed. Vol. II. Baltimore: Lippincott William and Wilkins; 2005: 2272–76. Neuropsychological tests such as T.O.V.A. objectively measure attention. The Centers for Disease Control and Prevention (CDC) state that a diagnosis of ADD should only be made by trained health care providers, as many of the symptoms may also be part of other conditions, such as bodily illness or other physiological disorders, such as hypothyroidism. It is not uncommon that physically and mentally nonpathological individuals exhibit at least some of the symptoms from time to time. Severity and pervasiveness of the symptoms leading to prominent functional impairment across different settings (school, work, social relationships) are major factors in a positive diagnosis. Adults often continue to be impaired by ADD. Adults with ADD are diagnosed under the same criteria, including the stipulation that their symptoms must have been present prior to the age of seven.[http://www.psychiatryonline.com/content.aspx?aID=7721 Attention-Deficit/Hyperactivity Disorder.] Psychiatry Online. Retrieved on 2007-08-13. Adults face some of their greatest challenges in the areas of self-control and self-motivation, as well as executive functioning, usually having more symptoms of inattention and fewer of hyperactivity or impulsiveness than children do.Jensen, PS. [http://medoffice.medscape.com/viewarticle/530193_2 Exploring the Neurocircuitry of the Brain and Its Impact on Treatment Selections in ADD.] Medscape. Retrieved on 2007-08-13. Common comorbid conditions are Oppositional Defiance Disorder (ODD). About 20% to 25% of children with ADD meet criteria for a learning disorder. Learning disorders are more common when there are inattention symptoms.

 

=Concerns about the impact of labeling= Parents are generally concerned that telling children they have a brain disorder and could possibly harm their self-esteem. Dr. Russell Barkley believes labeling is a double-edged sword; there are many pitfalls to labeling but that by using a precise label, services can be accessed. He also believes that labeling can help the individual understand and make an informed decision how best to deal with the disorder using evidence based knowledge.[http://www.pbs.org/wgbh/pages/frontline/shows/medicating/interviews/barkley.html PBS - frontline: medicating kids: interviews: russell barkley] Furthermore studies also show that the education of the siblings and parents has at least a short term impact on the outcome of treatment. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf Dr. Russell Barkley states this about ADHD rights: "..because of various legislation that has been passed to protect them. There are special education laws with the Americans with Disabilities Act, for example, mentioning ADHD as an eligible condition. If you change the label, and again refer to it as just some variation in normal temperament, these people will lose access to these services, and will lose these hard-won protections that keep them from being discriminated against. . . ."[http://www.pbs.org/wgbh/pages/frontline/shows/medicating/interviews/barkley.html PBS - frontline: medicating kids: interviews: russell barkley] Psychiatrist Harvey Parker, who founded CHAAD, states, "we should be celebrating the fact that school districts across the country are beginning to understand and recognize kids with ADHD, and are finding ways of treating them. We should celebrate the fact that the general public doesn't look at ADHD kids as "b-a-d" kids, as brats, but as kids who have a problem that they can overcome".http://www.pbs.org/wgbh/pages/frontline/shows/medicating/interviews/parker.html Social critics believe that this knowledge can effectively become a self-fulfilling prophecy mainly through self-doubt. Dr. Thomas Armstrong states that the ADHD label is a "tragic decoy" which severely erodes the potential to see the best in a child http://www.thomasarmstrong.com/myth_add_adhd.htm. Armstrong is a proponent of the idea that there are many types of "smarts" and has adopted the term [[neurodiversity]] (first used by [[autistic rights]] activists) as an alternative, less damaging, label [http://www.newhorizons.org/spneeds/inclusion/information/armstrong.htm Special Education and the Concept of Neurodiversity]. Thom Hartmann has said that the brain disorder label is "a pretty wretched label for any child to have to bear."[http://www.brightword.com/thom-hartmann.html Hartmann Interview]

 

Treatment

Singularly, stimulant medication is the most efficient and cost effective method of treating ADHD. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf [http://ajp.psychiatryonline.org/cgi/content/full/162/9/1628 Free full text] Over 200 controlled studies have shown that stimulant medication is an effective way to treat ADHD.Barkley, Russell A. [http://www.continuingedcourses.net/active/courses/course006.php?PHPSESSID=169b92182fe1584725 Treating Children and Adolescents with ADHD: An Overview of Empirically Based Treatments.] ContinuingEdCourses.Net. Retrieved on 2007-08-13. Methods of treatment usually involve some combination of medications, behaviour modifications, life style changes, and counseling. Behavioral Parent Training, behavior therapy aimed at parents to help them understand ADHD, has also shown short term benefits.Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf Omega-3 fatty acids, phosphatidylserine, zinc and magnesium may have benefits with regard to ADHD symptoms. Comorbid disorders or substance abuse can make finding the proper diagnosis and the right overall treatment more costly and time-consuming. Psychosocial therapy is useful in treating some comorbid conditions.

 

Prognosis

The diagnosis of ADHD implies an impairment in life functioning. Many adverse life outcomes are associated with ADHD. During the elementary years, an ADHD student will have more difficulties with work completion, productivity, planning, remembering things needed for school, and meeting deadlines. Oppositional and socially aggressive behavior is seen in 40-70% of children at this age. Even ADHD kids with average to above average intelligence show "chronic and severe under achievement". Fully 46% of those with ADHD have been suspended and 11% expelled.U.S. Department of Education [http://www.ed.gov/rschstat/research/pubs/adhd/adhd-identifying_pg4.html "How Does ADHD Affect School Performance?"], 2007 37% of those with ADHD do not get a high school diploma even though many of them will receive special education services. The combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish high school. Only 5% of those with ADHD will get a college degree compared to 27% of the general population. (US Census, 2003)

 

Epidemiology

A review of 102 studies estimated ADHD's worldwide prevalence in people under the age of 19 to be 5.29%. There was wide variability in prevalence estimates, mostly due to the methodological characteristics of studies (for example, diagnostic criteria used) and, to a lesser extent, geographic location (North America having a significantly higher rate of ADHD than Africa and the Middle East). 10% of males, and (only) 4% of females have been diagnosed in the U.S. . Centers for Disease Control (March, 2004). Retrieved on December 11, 2006. This apparent sex difference may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.Staller J, Faraone SV. (2006) "Attention-deficit hyperactivity disorder in girls: epidemiology and management." CNS Drugs. 2006;20(2):107–23. PMID 16478287Biederman J, Faraone SV. (2004) "The Massachusetts General Hospital studies of gender influences on attention-deficit/hyperactivity disorder in youth and relatives." Psychiatr Clin North Am. Jun;27(2):225–32. PMID 15063995

 

 Summary References

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3. http://nccam.nih.gov/health/eveningprimrose/

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6. http://www.ncbi.nlm.nih.gov/pubmed/12635462

7. http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm

8. http://www.nimh.nih.gov/health/publications/depression/how-is-depression-detected-and-treated.shtml

9. http://www.ncbi.nlm.nih.gov/pubmed/11939872

10. http://www.ncbi.nlm.nih.gov/pubmed/12132963

11. http://www.ncbi.nlm.nih.gov/pubmed/16423519

12. http://jama.ama-assn.org/cgi/content/full/299/22/2633

13. http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/st-johns-wort

14. http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-stjohnswort.html

15. http://www.ncbi.nlm.nih.gov/pubmed/18843608

16. http://www.ncbi.nlm.nih.gov/pubmed/11939866

17. http://nccam.nih.gov/health/stjohnswort/ataglance.htm





 

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