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.

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

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

• 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)

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

• 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

• Restlessness: difficulty paying attention, easily distracted
• Motor tics in some cases
• Assessment for ADHD criteria
• Nutritional history—caffeine stimulants, sugar, preservatives

• 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

• Low levels of dopamine
• Low levels of MHPG (breaks down norepinephrine)
• Differences in brain structure

Not required for diagnosis.

• PET scans to determine brain metabolism/activity
• MRI to view brain structure

• 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

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

• 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

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.

• 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

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.

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

Adults, and some children, respond well to acupuncture.

May be quite helpful. Parents can be taught massage techniques to use on their children.

• 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.

Antisocial behavior, poor self-esteem, and poor school/work performance if left untreated.

• 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.

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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