ADD / ADHD Signs and Symptoms

A person is considered to have ADHD if he or she demonstrates symptoms of inattention, hyperactivity, and impulsivity for at least 6 months in at least two settings (such as at home and in school). The signs and symptoms listed below are typically seen in children with ADHD and usually appear before age seven. (In order to diagnose ADHD in adults, psychiatrists must determine how the adult patient behaved as a child.)

ADD / ADHD Symptoms of Inattention

• Fails to pay close attention to details or makes careless mistakes
• Has difficulty sustaining attention in tasks or play activities
• Does not seem to listen when spoken to directly
• Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
• Has difficulty organizing tasks and activities
• Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
• Loses things necessary for tasks or activities
• Is easily distracted by extraneous stimuli
• Is forgetful in daily activities

ADD / ADHD Symptoms of Hyperactivity and Impulsivity

• Fidgets with hands or feet or squirms in seat
• Leaves seat in situations where remaining seated is expected
• Runs or climbs excessively in inappropriate situations (in adolescents or adults, may be limited to subjective feelings of restlessness)
• Has difficulty 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 awaiting turn
• Interrupts or intrudes on others

ADD / ADHD Causes

Like most complex neurobehavioral disorders, the cause of ADHD is unknown. Genetic factors as well as those affecting brain development during prenatal and postnatal life are likely involved. Brain scans have revealed a number of differences in the brains of ADHD children compared to those of non-ADHD children. For example, many children with ADHD tend to have altered brain activity in the prefrontal cortex, a region thought to be the brain's command center. Irregularities in this area may impair an individual's ability to control impulsive and hyperactive behaviors. Researchers also believe that hyperactive behavior in children results from excessive slow-wave (or theta) activity in certain regions of the brain. Other studies indicate that ADHD may be caused by abnormally low levels of dopamine, a neurotransmitter involved with mental and emotional functioning.

ADD / ADHD Risk Factors

• Heredity: children with ADHD usually have at least one first-degree relative who also has ADHD and one- third of all fathers who had ADHD in their youth have children with ADHD
• Gender: ADHD is four to nine times more common in boys than in girls (some experts believe that the disorder is underdiagnosed in girls, however)
• Prenatal and early postnatal health: maternal drug, alcohol, and cigarette use; exposure of the fetus to toxins, including lead and polychlorinated biphenyls (PCBs); nutritional deficiencies and imbalances
• Learning disabilities, communication disorders, and tic disorders such as Tourette's syndrome
• Other behavioral disorders, particularly those that involve excessive aggression (such as oppositional defiant or conduct disorder)
• Nutritional factors: allergies or intolerances to food, food coloring, or additives

ADD / ADHD Diagnosis

The names and symptoms for ADHD have changed frequently since the turn of the century. What is now referred to as ADHD has been described in the past as Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, and Attention Deficit Disorder (ADD) With or Without Hyperactivity. The name ADHD was adopted in 1987 by the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).

Diagnosis is largely dependent on specific observed behaviors. The first step in establishing the diagnosis of ADHD is to determine whether the individual meets the diagnostic criteria as defined in the DSM-IV. The DSM- IV's symptomatic criteria were developed for children; there are no specific criteria for ADHD in adults. In these cases, physicians will often determine the psychiatric status of the adult patient as a child and make a retroactive diagnosis of childhood ADHD. Since most of the characteristic behaviors of childhood

ADHD occur at home and in the school setting, parents and teachers play an important role in providing information to establish the diagnosis.

ADD / ADHD Preventive Care

There are no targeted prevention programs for ADHD. Nevertheless, the following steps may be taken to help reduce the risk of neurobehavioral disorders including ADHD:

• Minimizing exposures to potential neurotoxins (such as lead, heavy metals, pesticides, herbicides) in the environment
• Screening children for high levels of lead in the blood and treating this immediately
• Obtaining comprehensive healthcare before, during and immediately following pregnancy  (optimal vitamin, mineral, and essential fatty acid status)
• Addressing psychosocial stressors in the lives of all children

ADD / ADHD Nutrition and Dietary Supplements

According to a recent survey, nutritional therapies are the most commonly used alternative treatment amongAmerican children with ADHD. Dietary management of ADHD takes two basic forms: restriction and supplementation.

ADD / ADHD Dietary Restrictions

• Additives and allergies

In 1975, Benjamin Feingold, a practicing allergist, proposed that artificial colors, flavors, and preservatives, as well as naturally occurring salicylates (found in many fruits and vegetables), were a major cause of hyperactive behavior and learning disabilities in children. According to his observations, eliminating all of these substances dramatically improved ADHD symptoms in 50% of children, and reintroducing them one at a time caused the symptoms to recur.

Although the original Feingold diet was based on his clinical experience, a number of well-designed studies have found an association between certain dietary constituents and poor behavior in children.

One such study assessed the effects of food coloring on behavior in 34 hyperactive children and 20 children with no behavioral problems. All children were maintained on a color-free diet and were randomly given one colorless capsule containing either lactose (placebo) or tartrazine (yellow food coloring) at varying doses each morning for 21 days. Twenty-four of the 54 children became more irritable and restless after taking tartrazine, whereas all of the children behaved normally when given placebo. In a similar study of 26 children with ADHD, behavior improved on days when certain foods (corn, wheat, milk, soy, oranges, and food coloring) were eliminated from the diet. Behavior worsened on days when these same foods were re-introduced to the diet. Notably, most of the children who demonstrated an improvement in behavior with these restrictive diets in both of the studies described also had a history of allergies (such as asthma and allergic rhinitis). Eggs, peanuts, and fish are foods believed to carry a high risk of causing an allergic reaction. Some researchers speculate that eliminating these foods from the diet may improve symptoms of ADHD in certain children.

ADD / ADHD Dietary supplements

A well-balanced diet rich in micronutrients is essential for normal brain development, particular in young children. In fact, many children with nutrient deficiencies have significant cognitive and behavioral problems.

Magnesium

Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion. Mild magnesium deficiency is not uncommon in normally nourished children, and some experts believe that children with ADHD may be exhibiting the effects of mild magnesium deficiency. In one study of 116 children with ADHD, 95% were magnesium deficient. In a separate study, 75 magnesium-deficient children with ADHD were randomly assigned to receive magnesium supplements in addition to standard treatment or standard treatment alone for 6 months. Those who received magnesium demonstrated a significant improvement in behavior, whereas the control group exhibited worsening behavior.

Vitamin B6

Adequate levels of vitamin B6 (pyridoxine) are required for normal brain development and are essential for the synthesis of essential brain chemicals including serotonin, dopamine and norepinephrine. A preliminary study found that pyridoxine was slightly more effective than methylphenidate (the most commonly used stimulant) in improving behavior among hyperactive children.

Iron

Iron deficiency is common among children and adolescents, particularly in lower socioeconomic groups where it affects half of all infants. Normal levels of iron in the blood are necessary for optimal brain function. Symptoms of iron deficiency include decreased attention, arousal, and social responsiveness.

Zinc

Zinc regulates the activity of neurotransmitters, fatty acids, and melatonin, all of which are related to the biology of behavior. Two separate studies found that children with ADHD have significantly lower blood zinc levels than children without ADHD. Another study indicated that ADHD children with mild zinc deficiency may be less likely to improve from a commonly prescribed stimulant than children with adequate zinc levels.

Melatonin

Although melatonin supplementation probably has no direct effect on the primary symptoms of ADHD, it may be effective in managing sleep cycle disturbances in children with a variety of developmental disorders, including ADHD.

Essential Fatty Acids

Fatty acids play a key role in normal brain function. Since the body cannot synthesize essential fatty acids (EFA), they must be provided in the diet. There are two major types of EFAs: omega-3 fatty acids (found in cold-water fish such as salmon, mackerel, halibut, and herring) and omega-6 fatty acids (found in commonly used cooking oils, such as sunflower oil, safflower oil, corn oil, and soybean oil). Omega-3 fatty acids are highly concentrated in the brain and appear to play a particularly important role in cognitive and behavioral function. Specific enzymes convert EFAs (such as alpha linolenic acid [ALA]) into other substances known as long-chain polyunsaturated fatty acids (PUFAs). PUFAs, including eicosapentaenoic acid (EPA) and docosahexanoic (DHA), are also essential for normal brain function. Some researchers believe that individuals with ADHD may have difficulty converting EFAs to PUFAs and may be deficient in both of these substances. In a recent study, researchers reported the following findings in hyperactive boys compared to boys of the same age who were not hyperactive:

• Lower blood levels of PUFAs and omega-3 fatty acids
• More allergies and other health problems associated with EFA deficiencies
• Less likelihood of having been breastfed (breast milk contains PUFAs)

Another study found that boys with lower levels of omega-3 fatty acids had more learning and behavioral problems (such as temper tantrums and sleep disturbances) than boys with normal omega-3 fatty acid levels.

ADD / ADHD Dietary Suggestion

• FirstLine Therapy® Diet

ADD / ADHD Massage and Physical Therapy

Relaxation and massage techniques have been shown to reduce anxiety and activity levels in children and adolescents with a variety of psychiatric illnesses. In one study of 28 teenage boys with ADHD, those who received 15 minutes of massage for 10 consecutive school days demonstrated significant improvement in measures of behavior and concentration compared to those who were guided in progressive muscle relaxation for the same duration of time.

ADD / ADHD Mind/Body Medicine

Mind/body  techniques  such  as  hypnotherapy,  progressive  relaxation,  and biofeedback are particularly well suited to children and adolescents. Children tend to readily accept hypnotic suggestion and the visual process of biofeedback works well for children of this generation because many are accustomed to computerized graphics. Through these techniques, children are often able to learn coping skills that will stay with them for the rest of their lives. These treatments allow children to gain a sense of control and mastery, increase self-esteem, and decrease stress.

Many researchers believe that hyperactive behavior in children results from excessive slow-wave (or theta) activity in certain regions of the brain. In EEG biofeedback, or neurofeedback, an individual is provided with information regarding his or her brain activity. The subject is then trained to suppress slow wave activities while enhancing faster brain waves, over a period of usually 40 or more sessions. The belief is that these children can be trained to consciously modify and permanently change this underlying abnormal electrical brain activity associated with ADHD.

In one study of 23 hyperactive children and teenagers, those who successfully decreased their theta activity after 2 to 3 months of intensive neurofeedback training showed significant improvements in behavior and attention. In a similar study of 18 children and adolescents with ADHD, those who attended 40 neurofeedback sessions over a 6-month period demonstrated a significant improvement in IQ scores and a substantial reduction in inattentive behavior compared to those who did not attend the neurofeedback sessions.

A larger, more recent study found that a combination of 40 behavioral treatments (neurofeedback and metacognitive strategies, a technique designed to help individuals consciously monitor how they learn and remember things), significantly improved ADHD symptoms, academic performance, and IQ scores among children and adults with ADHD. The combined treatment also dramatically reduced the need for medications; 30% of the participants were taking stimulant medication at the beginning of the study compared to only 6% at the end of the study. To be most effective for ADHD, however, these mind/body techniques should be incorporated into an overall comprehensive treatment plan that is tailored to the particular individual.

ADD / ADHD Traditional Chinese Medicine

Qi Gong

Although no published studies have evaluated qi gong as a treatment for ADHD, preliminary evidence from unpublished research suggests that weekly qi gong breathing techniques may improve attention and reduce disruptive behaviors in school-age children.

ADD / ADHD Supporting Research

1. American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158-1170.
2. American Psychiatric Association. Attention deficit/hyperactivity disorder. In:Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:78-85.
3. Arnold LE, Pinkham SM, Votolato N. Does zinc moderate essential fatty acid and amphetamine treatment of attention deficit/hyperactivity disorder? J Child Adolesc Psychopharmacol. 2000;10:111-117.
4. Arnold LE, Kleykamp D, Votolato N, Gibson RA, Horrocks L. Potential link between dietary intake of fatty acid and behavior: pilot exploration serum lipids in attention-deficit hyperactivity disorder. J Child Adolesc Psychopharmacol. 1994;4(3):171-182.
5. Baumgaertel A. Alternative and controversial treatments for attention-deficit/hyperactivity disorder. Pediatr Clin of North Am. 1999;46(5):977-
6. Bekaroglu M, Aslan Y, Gedik Y. Relationships between serum free fatty acids and zinc, and attention deficit hyperactivity disorder: a research note. J Child Psychol Psychiatry. 1996;37(2):225-227.
7. Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:160, 107.
8. Boris M, Mandel F. Foods and additives are common causes of the attention deficit hyperactive disorder in children. Ann Allergy. 1994;72:468.
9. Breakey J. The role of diet and behaviour in childhood. J Paediatr Child Health.1997; 33:190-194.
10. Burgess J, Stevens L, Zhang W, Peck L. Long-chain polyunsaturated fatty acids in children with attention-deficit hyperactivity disorder. Am Nutr. 2000; 71(suppl):327S-330S.
11. Carter CM, Urbanowicz M, Hemsley R, et al. Effects of a few food diet in attention deficit disorder. Arch Dis Child. 1993;69:564-568.
12. Daruna JH, Dalton R, Forman MA. Attention deficit hyperactivity disorder. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook Pediatrics. 16th ed. Philadelphia, Pa: W.B. Saunders Company; 2000:100-103.
13. Daviss WB, Bentivoglio P, Racusin R, et al. Bupropion sustained release in adolescents with comorbid attention-deficit/hyperactivity disorder depression. J Am Acad Child Adolesc Psychiatry. 2001;40(3):307-314.
14. Escher M, Desmeules J, Giastra E, Mentha G. Hepatitis associated with kava, a herbal remedy for anxiety. BMJ. 2001;322:139.
15. Field T, Quintino O, Hernandez-Reif M, Koslovsky G. Adolescents with attention deficit hyperactivity disorder benefit from massage therapy. Adolescence. 1998;33(129):103-108.
16. Food and Drug Administration. Medwatch: the FDA safety information and adverse event reporting program. Cylert (pemoline). Accessedhttp://www.fda.gov/medwatch/safety/1999/cylert19.htm on November 16, 2001.
17. Gutgesell H, Atkins D, Barst R, et al. Cardiovascular monitoring of children and adolescents receiving psychotropic drugs: a statement for healthcare professionals from the Committee on Congenital Cardiac Defects, Council on Cardiovascular Disease in the Young, American Association. Circulation. 1999; 99(7):979-82.
18. Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDRfor Herbal Medicines.Montvale, NJ: Medical Economics Co; 1998:929, 961-963, 967-991-992, 1015-1016.
19. Jan JE, Espezel H, Freeman RD, Fast DK. Melatonin treatment of chronic sleep disorders. J Child Neurol. 1998; 13(2):98.
20. Kanarek R. Does sucrose or aspartame cause hyperactivity in children? Nutr Rev.1994;52(5):173-175.
21. Kidd P. Attention deficit / hyperactivity disorder (ADHD) in children: rationale for its integrative management. Altern Med 2000;5(5):402-
22. Knochel JP. Disorders of magnesium metabolism. In: Fauci AS, Braunwald E, Isselbacher KJ, eds. Harrison‘s Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill Companies, Inc; 1998:2263.
23. Kozielec T, Starobrat-Hermelin B. Assessment of magnesium levels in children with attention deficit hyperactivity disorder. Magnes Res. 1997;10(2):143-148.
24. Krummel D, Seligson FH, Guthrie HA. Hyperactivity: is candy causal? Critical Reviews in Food Science and Nutrition. 1996;36(1 and 2):31-
25. Lamont J. Homoeopathic treatment of attention deficit hyperactivity disorder; a controlled study. Br Homoeopath J. 1997;86:196-200.
26. Lee S. Biofeedback as a treatment for childhood hyperactivity: a critical review of the literature. Psychol Rep. 1991;68:163-192.
27. Linden M, Habib T, Rodojevic V. A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback Self Regul. 1996;21(1):35-49.
28. Lubar J, Swartwood MO, Swartwood JN, O'Donnell PH. Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in TOVA scores, behavioral ratings and WISC-R performance. Biofeedback Self 1995;20(1):83-99.
29. Lyon MR, Cline JC, Totosy de Zepetnek J, et al. Effect of the herbal extract combination Panax quinquefolium and Ginkgo biloba on attention-deficit hyperactivity disorder: a pilot study. J Psychiatry Neurosci. 2001;26(3):221-228.
30. Mitchell EA, Aman MG, Turbott SH, Manku M. Clinical characteristics and serum essential fatty acid levels in hyperactive children. Clin Pediatr (Phila).1987;26:406-411.
31. Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:33-36, 39-44, 115-117.
32. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry.1999;56:1073-1086.
33. National Institute of Mental Health. Attention deficit hyperactivity disorder. Accessed at: www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml on November 9, 2001.
34. National Institutes of Health. Diagnosis and treatment of attention deficit hyperactivity disorder: National Institutes of Health Consensus Development Conference Statement. November 16-18, 1998. Accessed at:http://odp.od.nih.gov/consensus/cons/110/110_statement.htm on November 9, 2001.
35. Richardson AJ, Puri BK. The potential role of fatty acids in attention-deficit/hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2000;63(1/2):79-87.
36. Rowe KS, Rowe KJ. Synthetic food coloring and behavior: a dose response effect in a double-blind, placebo-controlled, repeated measures study. J Pediatr. 1994;125:691-698.
37. Sever Y, Ashkenazi A, Tyano S, Weizman A. Iron Treatment in children with attention deficit Hyperactivity disorder: a preliminary report.Neuropsychobiology. 1997; 35:178-180.
38. Starobrat-Hermelin B, Kozielec T. The effects of magnesium physiological supplementation on hyperactivity in children with attention deficit hyperactive disorder (ADHD): positive response to magnesium oral loading test. Magnesium Research. 1997; 10(2):149-156.
39. Stevens LJ, Zentall SS, Abate ML, Kuczek T, Burgess JR. Omega-3 fatty acids in boys with behavior, learning and health problems. Physiol Behav. 1996;59(4/5):915-920.
40. Stevens LJ, Zentall SS, Deck JL, et al. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. Am J Clin Nutr. 1995;62:761-768.
41. Stubberfield TG, Wray JA, Parry TS. Utilization of alternative therapies in attention-deficit hyperactivity disorder. J Paediatr Child Health. 1999;35:450-453.
42. Tan G, Schneider S. Attention-deficit hyperactivity disorder: pharmacotherapy and beyond. Postgrad Med. 1997;101(5):201-222.
43. Thompson L, Thompson M. Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD. Appl Psychophysiol Biofeedback. 1998;23(4):243-263.
44. Toren P, Eldar S, Sela BA, et al. Zinc deficiency in attention-deficit hyperactivity disorder. Biol Psychiatry. 1996; 40:1308-1310.
45. Volkow ND, Wang G, Fowler JS, et al. Therapeutic doses of oral methylphenidate significantly increase extracellular dopamine in the human brain. J Neurosci.2001;15;21(2):RC121.
46. Wender EH. The food additive-free diet in the treatment of behavior disorders: a review. J Dev Behav Pediatr. 1986;7(1):35-42.
47. Wender PH, Wolf LE, Wasserstein J. Adults with ADHD. An overview. Ann N Y Acad Sci. 2001;931:1-16.
48. Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing; 1988:221-226.
49. Wolraich M, Lindgren SD, Stumbo PJ, et al. Effects of diets in sucrose or aspartame on the behavior and cognitive performance of children. N Engl J Med.1994;330:301-307.
50. Wolraich M. Addressing behavior problems among school-aged children: traditional and controversial approaches. Pediatr Rev. 1997;18(8):266-270.
51. Wolraich M, Baumgaertel A. The practical aspects of diagnosing and managing children with attention deficit hyperactivity disorder. Clin Pediatr (Phila). 1997;36(9):497-504.