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Attention-Deficit
/ Hyperactivity Disorder |
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Overview |
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Attention-deficit-hyperactivity disorder (ADHD) is a complex, controversial,
neurobehavioral disorder. Characterized by excessive, long-term, and pervasive
behavior appearing before the age of 7 years, the disorder presents as
distractibility, impulsivity, and hyperactivity. The condition may present
without the hyperactivity component. Often misdiagnosed because symptoms overlap
with other physical or psychological illnesses, it is the most prevalent
behavioral disorder in the juvenile population, affecting 3% to 5% of
children—90% of whom are boys. Fully 60% experience
significant symptoms throughout their lifetime, causing extreme difficulties
across educational, vocational, home, and social settings. Accurate diagnosis is
essential and challenging; early intervention is key. |
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Definition |
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Diagnostic criteria is fully defined in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV), although many primary health
providers do not rely on rigid diagnostic criteria.
Either A1 or A2:
A1. Six (or more) symptoms of inattention (see Signs and Symptoms)
persistent for at least six months to a maladaptive degree inconsistent with
developmental level
A2. Six (or more) symptoms of hyperactivity-impulsivity (see Signs and
Symptoms) persistent for at least six months to a maladaptive degree
inconsistent with developmental level
- Some symptoms of A1 or A2 present before the age of 7
years
- Some impairment from symptoms present in two or more settings (e.g.,
school/work, and home)
- Clear evidence of clinically significant impairment in
functioning
- Symptoms not exclusively present during other mental
disorders
Specific types are:
- Combined: if both A1 and A2 are met
- Predominantly inattentive: if A1 is met but A2 is not
- Predominantly hyperactive-impulsive: if A2 is met but A1 is
not
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Etiology |
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There are several factors known or suspected to have a role in the
development of ADHD.
- Biological influences on neurotransmitter activity
- Environmental factors (associative), poor prenatal health, low birth
weight, hypoxia at birth, in vivo exposure to toxins, including lead, mercury,
alcohol, cocaine, nicotine
- Genetic predisposition (possibly as high as 80%); one-third of
fathers with childhood ADHD may bear ADHD children; concordance rate in
monozygotic twins vs. dizygotic twins up to 60%
- Nutritional (controversial): allergies to food/food
coloring/additives, heavy metal intoxification, nutrient
deficiencies
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Risk Factors |
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- Presence in a family member
- Maternal drug, cigarette, and alcohol use
- Poor prenatal nutrition
- Communication/learning disabilities
- Conduct disorder/oppositional defiant disorder (present in 40% of
ADHD children)
- Tourette's syndrome (half of Tourette's patients have
ADHD)
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Signs and Symptoms |
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Criteria A1—Inattention:
- Fails to give close attention to details or makes careless
mistakes
- 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
- 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
- Easily distracted by extraneous stimuli
- Forgetful in daily activities
Criteria
A2—Hyperactivity-Impulsivity:
- Fidgets with hands or feet or squirms in seat
- Leaves seat in situations where remaining seated is
expected
- Runs or climbs excessively in appropriate situations (in adolescents
or adults, may be limited to subjective feelings of restlessness)
- Difficulty playing or engaging in leisure activities
quietly
- Acts as if "driven by a motor"
- Talks excessively
Impulsivity:
- Blurts out answers before questions are completed
- Difficulty awaiting turn
- Interrupts or intrudes on
others
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Differential
Diagnosis |
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- Age-appropriate behavior in active children
- Mental retardation/learning, hearing, vision disorder
- Pervasive developmental disorder
- Psychotic disorder
- Understimulating environments
- Oppositional behavior
- Lead poisoning/mercury toxicity
- Substance-related disorder not otherwise specified
- Dysfunctional family
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Diagnosis |
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Physical Examination |
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- Restlessness: difficulty paying attention, easily
distracted
- Motor tics in some cases
- Assessment for ADHD criteria
- Nutritional history—caffeine stimulants,
sugar, preservatives
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Laboratory Tests |
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- Hair analysis to eliminate heavy metal toxicity
- Five-hour fasting glucose tolerance
tests—abnormal curves in 74% of people with ADHD
indicates connection to poor carbohydrate metabolism
- Thyroid function studies to rule out hyperthyroidism
- Test for food allergies, wheat gluten sensitivity, lactose
intolerance, red dye sensitivity
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Pathology/Pathophysiology |
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- Low levels of dopamine
- Low levels of MHPG (breaks down norepinephrine)
- Differences in brain
structure
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Imaging |
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Not required for diagnosis.
- PET scans to determine brain metabolism/activity
- MRI to view brain structure
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Other Diagnostic
Procedures |
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- Extensive, detailed history from parent, teachers, baby-sitters,
grandparents; synthesize information
- Observe behavior in environment comfortable to the child, e.g., in
playroom
- Review report cards for comments pertaining to inattention,
hyperactivity, disruptive behavior
In adults:
- Wechsler Intelligence Test to measure IQ
- Conners' Continuous Performance Test and Rey-Osterrieth Complex
Figure Test to measure neuropsychological functioning
In children:
- Conners' Parent and Teacher Rating Scales
- McLean Test to measure both attention and body
movement
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Treatment Options |
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Treatment Strategy |
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Multimodal treatment most effective with some allowance and adaptability to
the special needs of the patient required. Treatments include:
Pharmacological, to reduce inattention, hyperactivity, impulsivity
Behavioral modification/cognitive/psychodynamic therapies, to aid
social/vocational skills; for example:
- Positive stimuli to change undesirable behavior
- Specific, positive incentives/rewards (eliminate negative/physical
punishment)
- Exercises and activities to improve cognitive deficits
- Parent/teacher cooperation to design individualized education
program
- Esteem-raising activities such as sports or other special
interests
- Elimination/challenge diet, or food allergy testing, to detect
possible allergic underpinnings
- Regimented work and play
schedules
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Drug Therapies |
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- Methylphenidate (Ritalin): 70% to 80% positive impact on
hyperactivity, 0.3 to 0.7 mg/kg/day up to 60 mg/day; sustained release form
available
- Pemoline (Cylert): 18.75 to 112.5 mg/day
- Dextroamphetamine (Dexedrine): 0.1 to 0.5
mg/kg/day
In more severe cases:
- Beta-blockers (propranolol/nadolol) to reduce jitters
- Antidepressants (imipramine/bupropion) when severe symptoms coupled
with low self-esteem
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Complementary and Alternative
Therapies |
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Many parents seek alternative treatment for ADHD, because of concerns with
side effects from pharmacotherapy, and initiating chronic drug therapy in young
children. Some, but not all, children respond dramatically to dietary
manipulation. Herbal treatment can be very effective, as can homeopathic
treatment. Behavioral optometry has been found to be quite helpful in certain
cases. The doses listed are for children. For adults, increase the dose by 1½ to
2 times. |
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Nutrition |
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- Essential fatty acids help regulate inflammation and nervous
irritability. Dietary manipulation includes reducing animal fats and increasing
fish and vegetable oil intake, especially olive and grape seed oils. A mix of
omega-6 (evening primrose) and omega-3 (flaxseed) may be most optimum (2 tbsp.
oil/day or 1,000 to 1,500 mg bid). For pre-pubescent children under 10, cod
liver oil may be the most effective (1 tsp./day).
- Diet: Some children respond dramatically to food additives,
artificial colorings, and flavorings. Avoid processed foods. Decrease soda and
red meat intake. Foods containing salicylates (almonds, apples, berries,
tomatoes, oranges) may be another dietary factor. A possible mechanism is
related to prostaglandin metabolism. The most common food sensitivities are
dairy, corn, wheat, soy, and eggs. An elimination/challenge diet will help
identify offending foods.
- Vitamins: C (1,000 mg bid), E (400 IU/day), B-complex (50 to 100
mg/day)
- Minerals: Calcium/magnesium (250/500 mg/day) especially before
bed
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted. The focus for herbal treatment is calming the nervous and digestive
systems.
- Lemon balm (Melissa officinalis): mild sedative, carminative,
spasmolytic, especially with insomnia
- Lavender (Lavandula angustifolia): mild sedative, cholagogue,
especially with restlessness
- Chamomile (Matricaria recutita): anti-inflammatory,
antispasmodic
- Passionflower (Passiflora incarnata): nervous gastrointestinal
complaints
- Linden (Tilia cordata): mild sedative,
antispasmodic
- Catnip (Nepeta cataria): sedative, spasmolytic
- Kava Kava (Piper methysticum):
anti-anxiety
A combination of four to six of the above herbs (1 cup tea bid to tid, or 30
to 60 drops tincture) can be helpful. A cup of tea before homework or bed often
provides a nice structure. |
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Homeopathy |
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Homeopathic remedies may be very helpful for ADHD. An experienced homeopath
should assess individual constitutional types and severity of disease to select
the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a
12X to 30C remedy every one to four hours until acute symptoms
resolve.
- Chamomilla for irritability with great sensitivity to any
stimuli, especially if one cheek is red and the other is pale
- Arsenicum album for anxiety, especially with stomach pains and
insomnia or restless sleep
- Argentum nitricum for anxious children that may be very
cheerful, but do not control their
impulses
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Acupuncture |
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Adults, and some children, respond well to acupuncture. |
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Massage |
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May be quite helpful. Parents can be taught massage techniques to use on
their children. |
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Patient Monitoring |
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- Ensure stimulants are effective; if not, diagnosis may be
inaccurate.
- Monitor cardiovascular side effects: increased blood pressure,
tachycardia.
- Monitor for headache, abdominal pain, insomnia, poor eating habits,
and poor growth.
- Behavior/cognitive therapies are usually only effective while
ongoing.
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Other
Considerations |
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Complications/Sequelae |
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Antisocial behavior, poor self-esteem, and poor school/work performance if
left untreated. |
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Prognosis |
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- Long-term condition that may become more manageable with increasing
age.
- May be effectively controlled.
- Adolescents and adults may develop adaptive measures to aid daily
functioning.
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Pregnancy |
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Good prenatal care and avoidance of toxins may have a positive impact. Avoid
sugar excesses, particularly to avoid fluctuating blood sugar levels related to
glucose intolerance. |
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References |
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American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association;
1994.
Balch JF, Balch PA. Prescription for Nutritional Healing. Garden City
Park, NY: Avery Publishing Group; 1997.
Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:270, 238.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:160, 107.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:929, 961-963, 967-968,
991-992, 1015-1016.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:33-36, 39-44, 115-117.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998:372-377.
Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing; 1988:221-226. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |