According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, a diagnosis of ADHD is based on having at least
Six of nine symptoms of inattention:
2. Reduced attention
3. Poor listening skills
4. Poor completion of tasks or instructions
5. Difficulty organizing
6. Avoids or dislikes chores/homework
7. Loses things needed for activities
8. Easily distracted by extraneous stimuli
9. Forgetful in daily activities
Or having at least six of nine symptoms of hyperactivity/impulsivity:
1. Fidgets with hands/feet
2. Cannot remain seated in class
3. Uncontrollable restlessness
4. Difficulty engaging in play or leisure activities
5. Often on the go
6. Excessive talking
7. Blurts out answers prior to completion of question
8. Difficulty waiting turn
9. Interrupts or intrudes on others
The symptoms must have occurred for six or more months. The symptoms must have appeared before the age of 7 years, with impairment seen in two or more different settings (e.g., at school and at home). Also, the symptoms cannot be due to another psychiatric disorder. The symptoms also must lead to impairment in social, academic occupational functioning. Depending on which category the patient’s symptoms fall
Is it Hereditary?
The etiology of ADHD is multifaceted, and multiple factors tend to be involved with the development of the disorder. ADHD is a heritable disorder, although no single gene has been identified as the root cause for developing the disorder. Children who have a first degree relative with the diagnosis have up to an eightfold increased chance of developing the disorder compared with the general population.
Risk factors for developing ADHD include
A family history, perinatal stress, low birth weight, severe traumatic brain injury, exposure to lead, maternal smoking during pregnancy and early social deprivation. The neurobiology and pathophysiology of ADHD also is complex in nature and is not completely understood. In general, ADHD is viewed as a disorder where norepinephrine and dopamine signals in the cerebral cortex are weak, thus leading to inefficient processing of information.
Non pharmacologic strategies
Exercising is one of the easiest and most effective ways to reduce the symptoms of ADHD/ADD. Physical activity immediately boosts the brain’s dopamine, norepinephrine, and serotonin levels—all of which affect focus and attention. In this way, exercise and medications for ADHD/ADD such as Ritalin and Adderall work similarly. But unlike ADHD/ADD medication, exercise doesn’t require a prescription and it’s side effect free.
Activities that require close attention to body movements, such as dance, gymnastics, martial arts, and skateboarding, are particularly good for kids with ADHD/ADD. Team sports are also a good choice. The social element keeps them interesting.
The importance of sleep in ADHD / ADD treatment
Regular quality sleep can lead to vast improvement in the symptoms of ADHD/ADD. However, many kids with ADHD/ADD have problems getting to sleep at night. Sometimes, these sleep difficulties are due to stimulant medications, and decreasing the dose or stopping the medication entirely will solve the problem.
However, a large percentage of children with ADHD/ADD who are not taking stimulants also have sleep difficulties. If your child is one of them, the following tips can help.
- Set a regular bedtime (and enforce it).
- If background noise keeps your child up, try a sound machine or a fan.
- Turn off all electronics (TV, computer, video games, iPhone) at least an hour before bed.
- Limit physical activity in the evening.
- Good nutrition can help reduce ADHD / ADD symptoms
Studies show that what, and when, you eat makes a difference when it comes to managing ADHD/ADD.
- Schedule regular meals or snacks no more than three hours apart. This will help keep your child’s blood sugar level, minimizing irritability and supporting concentration and focus.
- Try to include a little protein and complex carbohydrates at each meal or snack. These foods will help your child feel more alert while decreasing hyperactivity.
- Check your child’s zinc, iron, and magnesium levels. Many children with ADHD/ADD are low in these important minerals. Boosting their levels may help control ADHD/ADD symptoms. Increasing iron may be particularly helpful. One study found that an iron supplement improved symptoms almost as much as taking stimulant medication.
- Add more omega-3 fatty acids to your child’s diet. Studies show that omega-3s improve hyperactivity, impulsivity, and concentration in kids (and adults) with ADHD/ADD. Omega-3s are found in salmon, tuna, sardines, and some fortified eggs and milk products. However, the easiest way to boost your child’s intake is through fish oil supplements.
Although there are many ways you can help a child with ADHD/ADD at home, you may want to seek professional help along the way. ADHD/ADD specialists can help you develop an effective treatment plan for your child. Since ADHD/ADD responds best to a combination of treatments and strategies, consulting several specialists is advisable.
Medications: Sometimes non medication treatments need to be used in conjunction with medication for success
-Psychostimulants are considered a first-line intervention for ADHD, unless there are co-morbid conditions or safety issues that preclude their use. The psychostimulants used in the treatment of ADHD are methylphenidate and amphetamines. Both methylphenidate and amphetamines are equally effective for ADHD, with efficacy rates ranging from 70% to 90%.19 If a patient fails a product from one of the major classes, the next appropriate treatment would be a stimulant from a different class. An example of this would be if a patient failed a methylphenidate product, the next appropriate medication option would be an amphetamine product, and vice versa.
The stimulants are the one medication class used in ADHD that does not have delayed onset of action. All of the other medications utilized for ADHD have a delay of two to four weeks in onset of action information regarding the individual stimulant products. Patients may benefit from starting treatment with long-acting preparations due to their ease of once-daily administration and improvement in compliance rates. Long-acting stimulants also prevent children in school from having to receive mid-day doses of immediate-release stimulants, which decreases stigma of the disorder in this population.
The disadvantage of using long-term stimulants is that use may worsen nighttime insomnia due to the longer duration of action. The main adverse effects include insomnia, appetite suppression, weight loss, headache, stomach upset and small increases in blood pressure and pulse. Tolerance to these adverse effects will develop with time. To reduce gastrointestinal upset, the medication should be administered with a meal, although this may delay the time to effect. Insomnia tends to be more troublesome with long-acting preparations, especially longer acting amphetamine products. There are non-pharmacological strategies for patients complaining of insomnia. Strategies for alleviating insomnia include moving the dose to an earlier time in the day or reducing the total daily dose of the stimulant. Immediate-release stimulants may be substituted for long-acting stimulants if insomnia persists. If nonpharmacological treatment strategies fail, the addition of low-dose melatonin
(3 mg) may be used adjunctively and has been shown to help alleviate insomnia in children treated with ADHD. Other agents occasionally used to combat stimulant-induced insomnia are the antihistamines diphenhydramine and cyproheptadine, as well as the alpha2 agonists clonidine and guanfacine.
Appetite suppression is an adverse effect that can be challenging for caregivers and patients alike. Patients should consume their highest caloric meal of the day at breakfast, prior to taking the stimulant. Use of high-calorie drinks or snacks also may be used at times of the day when the stimulant has worn off. If weight loss is prominent and is impacting growth, a switch to another stimulant or nonstimulant medication is indicated. Height and weight should be monitored frequently for children and adolescents during treatment. Those that are not gaining adequate weight or growth may require changes to their medication or even interruption of therapy.
Anxiety potentially can be exacerbated by stimulants, and patients with concurrent anxiety should be monitored for worsening of their anxiety symptoms. Stimulants should not be used in patients with seizure disorders or psychotic disorders, since stimulants may exacerbate these conditions as well.
-Atomoxetine is a selective norepinephrine reuptake inhibitor that is FDA approved for the treatment of ADHD in children, adolescents and adults. This drug is less effective than the first line treatment stimulants, such as long-acting methylphenidate and mixed-amphetamine salts.
Atomoxetine may be used as a first- or second line treatment option for both children and adults. The principle advantage of using atomoxetine is that it is not a controlled substance and it can be used safely in patients with an active substance abuse problem. -Atomoxetine may also be preferable in patients with other co morbidities, including patients with concurrent tic disorders that may be exacerbated by stimulants. Other advantages of atomoxetine compared with the stimulants include less insomnia and growth effects.
One disadvantage compared with stimulants is that atomoxetine has a delayed onset of action (three to four weeks Patients and caregivers should be counseled that atomoxetine’s onset is delayed, and the maximum efficacy may not be seen until after four weeks.
Adverse events associated with atomoxetine include nausea, vomiting and asthenia. stimulants. Sexual side effects may occur in adult patients, including decreased libido and erectile dysfunction. Serious adverse effects associated with atomoxetine include potential hepatotoxicity, as well as a black-box warning for increased risk of suicidal thinking and behavior in children and adolescents.
Clonidine (Kapvay) and guanfacine (Intuniv). These are nonstimulant medicines approved to treat aggression and impulsivity not controlled by other ADHD medicines.
Certain antidepressants are sometimes also recommended.
The diagnosis and treatment of ADHD are very complex and controversial. Although there is consensus that this disorder exists, professionals continue to struggle to make an accurate diagnosis and prescribe treatments with established long-term efficacy. Thoughtful, comprehensive care, both diagnostically and therapeutically, needs to be provided for patients who present with ADHD symptoms. A thorough reassessment should be done when a patient previously diagnosed with ADHD transitions from pediatric to adult primary care. Physicians must vigilantly monitor the evolving research related to this complex disorder to ensure that they continue to provide the quality of care that children and adults with ADHD symptoms need.