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ADD/ADHD

ADD (attention deficit disorder) and ADHD (attention deficit/hyperactivity disorder) are conditions that typically begin in childhood and continue into adulthood.

There are three subtypes that fall in the category of ADHD

  1. Predominantly inattentive (ADD)
  2. Predominantly hyperactive or impulsive
  3. Combined

ADHD - Predominantly Inattentive Presentation

  • Fails to give close attention to details or makes careless mistakes.
  • Has difficulty sustaining attention.
  • Does not appear to listen.
  • Struggles to follow through on instructions.
  • Has difficulty with organization.
  • Avoids or dislikes tasks requiring sustained mental effort.
  • Loses things.
  • Is easily distracted.
  • Is forgetful in daily activities.

ADHD - Predominantly Hyperactive/Impulsive Presentation

  • Fidgets with hands or feet or squirms in chair.
  • Has difficulty remaining seated.
  • Runs about or climbs excessively in children; extreme restlessness in adults. Difficulty engaging in activities quietly.
  • Acts as if driven by a motor; adults will often feel internally as if they were driven by a motor.
  • Talks excessively.
  • Blurts out answers before questions have been completed.
  • Difficulty waiting or taking turns.
  • Interrupts or intrudes upon others.

ADHD - Combined Presentation

  • Individual meets both sets of inattention and hyperactive/impulsive criteria.

As ADHD symptoms affect each person to varying degrees, the DSM-5 requires professionals who diagnose the condition to specify the severity of the disorder in the affected individual, Clinicians can designate the severity of ADHD presentation as "mild," "moderate" or "severe" under the criteria in the DSM-5:

  • Mild: Few symptoms beyond the required number for diagnosis are present and symptoms result in minor impairment at home, school, work and/or in social settings.
  • Moderate: Symptoms or impairment between "mild" and "severe" are present.
  • Severe: Many symptoms are present beyond the number needed to make a diagnosis, or multiple symptoms are particularly severe, or symptoms extremely impair an individual at home, school, work and/or in social settings.

It is also important to note that the severity level and presentation of ADHD can change during a person's lifetime. This includes the possibility that ADHD can go in to partial remission. For this to happen, an individual who previously met all the criteria for a diagnosis would need to experience less than the original number of symptoms found to be present when they were first diagnosed, during the previous six month period.  (From CHADD, see www.help4adhd.org)

From ADDitudemag.org:

Who can diagnose ADD/ADHD? 

The Psychiatrist

A psychiatrist, an M.D. who treats the brain, may prescribe medication or other treatment.

Advantages:

  • Trained in diagnosis
  • Able to diagnose, prescribe medication and treat.

Disadvantages

  • Cost - fees usually start about $200 an hour (at least!) and go up from there.
  • While psychiatrists can diagnose and treat, they may not be trained in counseling, especially in the areas of day to day life skills which may be needed by the person who has ADD/ADHD.

The Psychologist

A psychologist understands how the mind works, but is not a physician and cannot prescribe medications. If the psychologist feels that medications are called for, he or she will have to refer the patient to either a medical doctor or a psychiatrist.

Advantages:

  • trained in diagnosis
  • trained in counseling
  • cost less than a psychiatrist (though some testing can be expensive)

Disadvantages

  • Cannot prescribe medications
  • Need to refer for MRI or any other testing, which could assist in diagnosis.

Your Family Doctor

Most family doctors know of ADD/ADHD but may lack the extensive knowledge of more specialized professionals.

Advantages:

  • Is already familiar with you and your medical history
  • Is usually easier to see for an appointment
  • Can prescribe medications if needed
  • Less expensive

Disadvantages

  • May have limited experience with ADD/ADHD, especially in adults
  • Cannot offer counseling (but can refer)
  • Brief office visits often mean a hurried diagnosis (depending on the practitioner)

Causes of ADHD

Scientists are studying cause(s) and risk factors in an effort to find better ways to manage and reduce the chances of a person having ADHD.  The cause(s) and risk factors for ADHD are unknown, but current research shows that genetics plays an important role.

ADHD is very likely caused by biological factors which influence neurotransmitter activity in certain parts of the brain, and which have a strong genetic basis. Studies at NIMH using a PET (positron emission tomography) scanner to observe the brain at work have shown a link between a person's ability to pay continued attention and the level of activity in the brain.

Specifically researchers measured the level of glucose used by the areas of the brain that inhibit impulses and control attention. In people with ADHD, the brain areas that control attention used less glucose, indicating that they were less active. It appears from this research that a lower level of activity in some parts of the brain may cause inattention and other ADHD symptoms.

There is a great deal of evidence that ADHD runs in families, which is suggestive of genetic factors. If one person in a family is diagnosed with AD/HD, there is a 25% to 35% probability that any other family member also has ADHD, compared to a 4% to 6% probability for someone in the general population.

According to the National Institutes of Mental Health, the following are possible causes of ADHD:

  • Genes
  • Brain injury, though only a small percentage of patients have had a traumatic brain injury
  • Environmental exposures (e.g., lead)
  • Alcohol and tobacco use during pregnancy
  • Premature delivery
  • Low birth weight

Treatment for ADHD

In most cases, ADHD is best treated with a combination of medication and behavior therapy.

Medication is often used to help normalize brain activity, as prescribed by a physician. Stimulant medications are commonly used because they have been shown to be most effective for most people with ADHD. However, many other medications may also be used at the discretion of the physician.

Behavior therapy and cognitive therapy are often helpful to modify certain behaviors and to deal with the emotional effects of ADHD. Many adults also benefit from working with an ADHD coach to help manage problem behaviors and develop coping skills, such as improving organizational skills and improving productivity.

No single treatment is the answer for every person and good treatment plans will include close monitoring, follow-ups and any changes needed along the way.

Medical treatment generally involves the use of stimulant medications. These medications have the counterintuitive effect (in an already hyperactive mind) to be very calming and allow for focus. It is thought that this effect is due to the effect these medication have in the frontal lobe of the brain. In ADD/ADHD, the frontal lobe is deficient in the neurotransmitter dopamine. Dopamine works as an excitatory neurotransmitter. In the frontal lobe exist the areas of focus, impulse control, and judgment. In ADD/ADHD, these areas are affected by diminished dopamine. Stimulant medications work by blocking the reuptake of dopamine and having a direct excitatory effect on the neural synapse. This allows for the improved firing of this area of the brain with the result being improved focus and improved impulse control. These medications work very well but caution must be taken due to potential adverse effects.

From NIMH (National Institute of Mental Health)

What causes ADHD?

Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.

  1. Inherited from our parents, genes are the "blueprints" for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder.4,5 Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments.

A study of children with ADHD found that those who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.6

Researchers are also studying genetic variations that may or may not be inherited, such as duplications or deletions of a segment of DNA. These "copy number variations" (CNVs) can include many genes. Some CNVs occur more frequently among people with ADHD than in unaffected people, suggesting a possible role in the development of the disorder.7,8

Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children.9,10 In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, have a higher risk of developing ADHD.11

Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury.

  1. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it.12 In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities than those who received the sugar substitute.13Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results.14

In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical of their behavior, compared to mothers who thought their children received aspartame.15

Food additives. There is currently no research showing that artificial food coloring causes ADHD. However, a small number of children with ADHD may be sensitive to food dyes, artificial flavors, preservatives, or other food additives. They may experience fewer ADHD symptoms on a diet without additives, but such diets are often difficult to maintain.12,16

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References

4. Faraone SV, Mick E. Molecular genetics of attention deficit hyperactivity disorder. PsychiatrClin North Am. 2010 Mar;33(1):159–80. Review. PubMed PMID: 20159345; PubMed Central PMCID: PMC2847260.

5. Gizer IR, Ficks C, Waldman ID. Candidate gene studies of ADHD: a meta-analytic review. Hum Genet. 2009 Jul;126(1):51–90. Epub 2009 Jun 9. Review. PubMed PMID: 19506906.

6. Shaw P, Gornick M, Lerch J, Addington A, Seal J, et al. Polymorphisms of the dopamine D4 receptor, clinical outcome, and cortical structure in attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2007 Aug;64(8):921–31. PMID: 17679637.

7. Elia J, Glessner JT, Wang K, Takahashi N, Shtir CJ, et al. Genome-wide copy number variation study associates metabotropic glutamate receptor gene networks with attention deficit hyperactivity disorder. Nat Genet. 2011 Dec 4;44(1):78–84. doi: 10.1038/ng.1013. PMID: 22138692.

8. Williams NM, Franke B, Mick E, Anney RJ, Freitag CM, et al. Genome-wide analysis of copy number variants in attention deficit hyperactivity disorder: the role of rare variants and duplications at 15q13.3. Am J Psychiatry. 2012 Feb;169(2):195–204. PMID: 22420048.

9. Nomura Y, Marks DJ, Halperin JM. Prenatal exposure to maternal and paternal smoking on attention deficit hyperactivity disorders symptoms and diagnosis in offspring. J NervMent Dis. 2010 Sep;198(9):672–8. PubMed PMID: 20823730; PubMed Central PMCID: PMC3124822.

10. Millichap JG. Etiologic classification of attention-deficit/hyperactivity disorder.Pediatrics. 2008 Feb;121(2):e358–65. Review. PubMed PMID: 18245408.

11. Froehlich TE, Lanphear BP, Auinger P, Hornung R, Epstein JN, Braun J, Kahn RS. Association of tobacco and lead exposures with attention-deficit/hyperactivity disorder.Pediatrics. 2009 Dec;124(6):e1054–63. Epub 2009 Nov 23. PubMed PMID: 19933729; PubMed Central PMCID: PMC2853804.

12. Millichap JG, Yee MM. The diet factor in attention-deficit/hyperactivity disorder. Pediatrics. 2012 Feb;129(2):330–7. Epub 2012 Jan 9. Review. PubMed PMID: 22232312.

13. Wolraich M, Milich R, Stumbo P, Schultz F. Effects of sucrose ingestion on the behavior of hyperactive boys. J Pediatr. 1985 Apr;106(4):675–82. PMID: 3981325.

14. Wolraich ML, Lindgren SD, Stumbo PJ, Stegink LD, Appelbaum MI, Kiritsy MC. Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children. N Engl J Med. 1994 Feb 3;330(5):301–7. PMID: 8277950.

15. Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interactions. J Abnorm Child Psychol. 1994 Aug;22(4):501–15. PMID: 7963081.

16. Nigg JT, Lewis K, Edinger T, Falk M. Meta-analysis of attention-deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. J Am Acad Child Adolesc Psychiatry. 2012 Jan;51(1):86–97.e8. PMID: 22176942.

See http://www.help4adhd.org/en/about/wwk on the CHAAD site for much more comprehensive information.

Side Effects to ADD/ADHD medications

The side effects to stimulant medications are common. These effects include dry mouth, loss of appetite, weight loss, sleep issues, and mood swings. Many of these effects are dose related. In the longer-acting medications, these effects are reduced, though not eliminated. There are also fears about long term effects on the brain and the cardiovascular system but to date, the long-term studies have been inconclusive or flawed. We wait for further information. Generally, with proper usage, these medications are considered safe and effective. Nevertheless, caution must be taken in the use of these medications.