• Inattention.
• Distractibility.
• Impulsivity.
• Hyperactivity.

[For a refinement of these behaviors, which is used for a diagnosis, see Box Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder in Children below.] Some experts further categorize ADHD into three subtypes:

• Behavior marked by hyperactivity and impulsivity, but not inattentiveness.
• Behavior that is marked by inattentiveness, but not hyperactivity and impulsivity.
• A mixed type.

There are some issues with these criteria, and arguments exist for both an over- and underdiagnosis of this problem. Defining ADHD is made particularly difficult because one-third of the cases are accompanied by learning disabilities and other neurologic or emotional problems. It is likely that the term attention-deficit hyperactivity disorder will eventually give way to subgroups of problems that include some of these general symptoms. [For more details, see How is Attention-Deficit Hyperactivity Diagnosed? below.]

Studies now indicate that ADHD can be diagnosed in children by age four. Parents may notice symptoms even earlier. (One mother reported that three days after delivery, nurses were referring to her ADHD son as "Wild Willie.") The classic ADHD symptoms, inattention, distractibility, impulsivity, and hyperactivity often do not adequately describe the child's behavior, nor do they describe what is actually happening in the child's mind. Other behaviors also often coincide with the classic symptoms.

Some experts are focusing on deficits in so-called "executive functions" in the brain as the key to understanding all ADHD behaviors. Such impaired executive functions may include the following:

• Inability to hold information in short-term memory.
• Impaired organization and planning skills.
• Difficulty in establishing and using these goals to guide behavior, such as selecting strategies and monitoring tasks.
• Inability to keep emotions from becoming overpowering.
• Inability to shift efficiently from one mental activity to another.

Hyperactivity. The term hyperactive is often confusing for those who expect to observe a child racing unceasingly about. A boy with ADHD playing a game, for instance, may have the same level of activity as the other children without the syndrome. If a high demand is placed on the ADHD child's attention, however, then his motor activity intensifies beyond the levels of the other children. In a busy environment, such as a classroom or a crowded store, for example, ADHD children often become distracted and react by pulling items off the shelves, hitting people, or spinning out of control into erratic, silly, or strange behavior.

Impulsivity and Temper Explosions. Even before the "terrible two's," impulsive behavior is often apparent; the toddler may gleefully exhibit erratic and aggressive gestures, such as hair pulling, pinching, and hitting. Temper tantrums, normal in children after two, are usually exaggerated and not necessarily linked to a specific negative event in the life of an ADHD child. One of the most painful events a parent may experience is an abrupt and aggressive attack that may occur after cuddling a young ADHD child. Often this reaction seems to be caused not by anger, but by the child's apparent inability to endure overstimulation or displays of physical affection.

Attention and Concentration. ADHD children are usually distracted and made inattentive by an overstimulating environment (such as a large classroom). They are also inattentive when a situation is low-key or dull. Some experts believe that certain parts of the brain in ADHD children may be underactive so that they fail to be aroused by nonstimulating activities. In contrast, however, they may exhibit a kind of "super concentration" to a highly stimulating activity (such as a video game or a highly specific interest). Such children may even become over-attentive, so absorbed in a project that they cannot modify or change the direction of their attention.

Impaired Short-Term Memory. Many experts now believe that an essential feature in ADHD, as well as in learning disabilities, is impaired working, or short-term, memory. People with ADHD are unable to "hold" groups of sentences and images in their mind until they can extract organized thoughts from them. Such people then may not necessarily be inattentive so much as be unable to remember a full explanation (such as a homework assignment) or unable to complete processes that require remembering sequences, such as model building. In general, children with ADHD are often attracted to activities (e.g. television, computer games, or active individual sports) that do not tax this working memory or produce distractions. Children with ADHD have no differences in long-term memory compared with other children.

Inability to Manage Time. Studies suggest that children with ADHD have difficulties being on time and planning the correct amount of time to complete tasks. (This may coincide with short-term memory problems.) In one study, although children with probable ADHD were able to self-report many ADHD symptoms, they tended to believe they used their time wisely, in contrast to reports by their teacher.

Lack of Adaptability. ADHD children have a very difficult time adapting to even minor changes in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to bed. Any shift in a situation can precipitate a strong and noisy negative response. Even when they are in a good mood, they may suddenly shift into a tantrum if they meet with an unexpected change or frustration. In one experiment, ADHD children were able to closely anchor their attention when they were directly cued to a specific location, but they had difficulty shifting their attention to an alternative location.

Hypersensitivity and Sleep Problems. ADHD children are often hypersensitive to sights, sounds and touch, and complain excessively about stimuli that seem low key or bland to others. Sleeping problems usually occur well after the point at which most small children sleep through the night. In one study, 63% of children with ADHD had trouble sleeping.

• Children between ages six and 12 should first be evaluated for ADHD if they show symptoms of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems in at least two settings. Such behaviors should have been harmful for the child academically or socially for at least six months.
• The child should meet the official symptom guidelines. [See Table Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder in Children.]
• A diagnosis requires detailed reports by parents or caregivers. [See History of Behavior below.] It should be noted that a mother's description of her child's behavior is a very accurate and reliable guide for diagnosing ADHD. Parents should not be shy about insisting on further evaluation if their experience does not match a doctor's single observation of their child. This is particularly important now, because the cost of pursuing a diagnosis under managed care is not always covered.
• Guidelines for primary care physicians emphasize the importance of obtaining direct evidence from the classroom teacher or other school-based professionals about the child's symptoms and their duration, and evidence of functional impairment in the school setting.
• The child should be assessed for accompanying conditions (such as learning difficulties).

At this time no laboratory or imaging tests can indicate reliably whether a child does or does not have ADHD. A diagnosis relies only on behavioral symptoms and ruling out other disorders. Many experts believe that the disorder is both over- and underdiagnosed, depending on a variety of factors. Diagnosis of attention-deficit hyperactivity disorder is difficult for some of the following reasons:

Arguments that ADHD is Overdiagnosed in Some Children.

• Ritalin's popularity has encouraged some parents and teachers to pressure physicians into prescribing this standard ADHD drug for children, usually Caucasian boys, who are simply aggressive or who have poor grades. In one study of fifth graders in two different cities, 18% and 20% of Caucasian boys were being treated with medications. In one center, after careful testing, ADHD was the actual diagnosis in only 11% of children referred for ADHD and 18% had no disability. Others were simply poorer learners or had no problems at all.
• In one study, children more likely to receive medication were young for their grade, indicating they may have been socially and intellectually immature, rather than behaviorally impaired.
• Being poor and growing up in a single parent household contribute to emotional and behavioral problems. The significant increase in these problems has also paralleled an increase in the diagnosis of ADHD children, who may simply be responding to social and economic problems.

• Some evidence suggests that many girls with ADHD may go underdiagnosed. Research indicates that girls with ADHD are often inattentive but not hyperactive or impulsive. In fact, older girls with ADHD tend to have social problems due to withdrawal and internalized emotions, showing symptoms of anxiety and depression. The inattentive subtype, in any case, may first show up in older children and adolescents. However, according to the criteria, ADHD is not diagnosed in people whose symptoms appear after age seven.
• Physicians may fail to diagnose children with ADHD because they often behave normally in the quiet physician's office where there are no distractions to trigger symptoms.
• In spite of the fact that there seems to be no difference in the disorder among population groups, African-American, Hispanic, and Asian children with ADHD are half as likely to be diagnosed and treated as Caucasian children. By high school, the racial disparity increases to the level that the medication rate for blacks is one-fifth of that for whites.
• ADHD may also be underdiagnosed in adults. Some experts, in fact, believe that ADHD may be the most common chronic undiagnosed psychiatric disorder in adults. [ See Box ADHD in Adults.]

The physician will first require a detailed history of the child's behavior. Physicians will match this against a standardized checklist to define the disorder. [ See Diagnostic Criteria for Attention-Deficit Disorder, under What Is Attention-Deficit Hyperactivity Disorder?]

The parents should describe the following:

• Specific problems beginning as early as possible they have encountered during the child's development. (School reports are very helpful.)
• Sibling relationships.
• Recent life changes.
• A family history of ADHD.
• Eating habits.
• Sleep patterns.
• Speech and language development.
• Any problems during the mother's pregnancy or during delivery.
• Any history of medical or physical problems, particularly allergies, chronic ear infections, and hearing difficulties.

The health professional will want to know how the parents handle different situations and may want to observe them interacting with the child.

The child should also be given a general physical examination to determine if any medical causes are present. The child should be given a hearing test to rule out hearing abnormalities as a source of behavioral problems.

Continuous Performance Test. A test called the Continuous Performance Test is sometimes helpful in evaluating sustained attention and impulsivity. The child sits in front of a computer screen and is asked to press or not press certain keys in response to images on the screen.

Other Screening Tests. Other tests are available to test neurologic, intellectual, and emotional development problems. Most involve learning and problem solving tasks that help define the particular areas that are most disabling.

To date, there are no objective, physical tests for diagnosing ADHD. Blood or other laboratory tests are currently recommended only if the physician suspects lead toxicity or other medical problems. Some, however, are being investigated for diagnosing ADHD using recent knowledge of specific brain abnormalities.

QEEG Test. The quantitative electroencephalographic procedure (QEEG) assesses the electrical activity in a part of the brain called the prefrontal cortex. Evidence suggests that ADHD is associated with low activity in this region. Studies, including one in 2001, are reporting that it may be highly accurate in both diagnosing and ruling out ADHD in patients.

Imaging Techniques. Brain scans using imaging techniques, including magnetic resonance imaging (MRI) or single photon emission computed tomography (SPECT) may eventually help confirm a diagnosis. At this time, however, they are used only for research.

Blood Tests for Dopamine Deficiencies. People with ADHD appear to be deficient in the brain chemical dopamine. One promising investigative test, Altropane, detects a dopamine transporter, which, when elevated, suggests the presence of attention-deficit disorder.

Although it is fairly common to use a trial of a psychostimulant (usually Ritalin) to facilitate diagnosis, experts strongly recommend against this method of diagnosis, because it is not always accurate. An improvement in symptoms is considered suggestive of ADHD, while in non-ADHD children the stimulant often increases agitation and hyperactivity. Many children and adults without the disorder have a similar response, and such a diagnostic trial may lead to unnecessary prescriptions of this drug.
WHAT OTHER DISORDERS ARE ASSOCIATED WITH ATTENTION-DEFICIT HYPERACTIVITY DISORDER OR HAVE SIMILAR SYMPTOMS?

A number of disorders may mimic or accompany attention-deficit disorder. ADHD exists alone in only about one-third of children. Many professionals object to the use of the single term, attention-deficit disorder, to encompass such a wide spectrum of behaviors, which they believe should be categorized into subgroups. Many of these problems require other modes of treatment and should be diagnosed separately, even if they accompany ADHD.

Attention-deficit disorder can appear without hyperactivity, in which case the child's primary symptoms are distractibility and an inability to persist in tasks.

About 35% of children diagnosed with ADHD also have oppositional-defiant disorder (ODD). The most common symptom for this disorder is a pattern of negative, defiant, and hostile behavior toward authority figures that lasts more than six months. In addition to displaying inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper tantrums, and display antisocial behavior. Up to 25% of children with ODD have phobias and other anxiety disorders, which should be treated separately.

Conduct Disorder

As many as 26% of children with ADHD also have conduct disorder, which describes a complex group of behavioral and emotional disturbances seen in children. It includes aggression towards people and animals, destruction of property, deceitfulness, lying, or stealing, and general violation of rules.

Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behavior, hand-flapping, repetitive statements, slow social development, and speech and motor problems. If a child who has been diagnosed with ADHD does not respond to treatment, the parents might inquire about PDD, which often responds to antidepressants.

Primary disorder of vigilance is a term for a syndrome that includes poor attention and concentration as well as difficulties staying awake. The term is not recognized as an official diagnosis by the American Psychiatric Association, but some experts believe it represents a fairly well-defined set of behaviors. People with vigilance disorder tend to fidget, yawn and stretch, and appear to be hyperactive in order to remain alert; they typically have kind and affectionate temperaments. The condition appears to be inherited and gets worse with age; it is treatable with stimulants.

Children with ADHD often have difficulties with tasks that involve listening or hearing. Research is indicating that symptoms of the two disorders often overlap but may actually be two distinct disorders. Hearing problems themselves may cause ADHD symptoms.

One study found that as many as 25% of children diagnosed with attention-deficit disorder may also have bipolar disorder, commonly called manic depression. Indications of this problem include episodes of depression and mania (with symptoms of irritability, rapid speech, and disconnected thoughts), sometimes occurring at the same time. [ See Well-Connected Report #66, Bipolar Disorder. ] Children with mania and ADHD may have more aggression, behavioral problems, and emotional disorders than those with ADHD alone.

Anxiety disorders commonly accompany ADHD. Obsessive-compulsive disorder is a specific anxiety disorder that shares many characteristics with ADHD and may share a genetic component. Young children who have experienced traumatic events, including sexual or physical abuse or neglect, exhibit characteristics of ADHD, including impulsivity, emotional outbursts, and oppositional behavior.

Sleep disorders or disturbances are very common with ADHD patients. In addition to insomnia, specific sleep disorders have been associated with ADHD.

Restless Legs Syndrome (RLS). RLS and periodic limb movement disorder are thought by some experts to be strongly associated with ADHD in some children. A 2001 study found that adults with RLS had a higher incidence of ADHD than adults without the sleep disorder. One theory is that the two are linked by a common mechanism. The disorders have much in common, including poor sleep habits, twitching, and the need to get up suddenly and walk about frequently. For example, both have been associated with lower levels of dopamine in the brain, which is associated with faulty motor control, a common problem in both disorders.

Sleep Apnea. Some research has shown an association between obstructive sleep apnea and attention-deficit disorder. Sleep apnea is a disorder in which a person stops breathing during the night, perhaps hundreds of times. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath. It is usually accompanied by snoring. One report suggested that treating sleep apnea in adults with both conditions may help reduce ADHD symptoms.

Tourettes Syndrome and Other Genetic Disorders. A number of genetic disorders cause symptoms resembling ADHD, including fragile X and Tourettes syndrome. About 50% of those with Tourettes syndrome also have ADHD and some of the treatments are similar.

Other Medical Conditions. A number of medical problems, including hyperthyroidism and vision problems, can produce ADHD-like symptoms.

Lead. Children who ingest even low amounts of lead may manifest symptoms similar to those of ADHD; they are easily distractible, disorganized, and have trouble thinking logically. The major cause of lead toxicity is exposure to leaded paint, particularly in homes that are old and in poor repair.

In the US, the diagnosis of ADHD in children increased from 1.1% of office visits in 1990 to 3.6% in 1996, or from nearly 950,000 to over 2,400,000 children. Estimates of prevalence of the disorder range from 1.7% to 17.8% depending on where and how the studies were conducted. ADHD is a genuine disorder, but it should be strongly noted that the US accounts for 90% of worldwide prescriptions for stimulants for ADHD. It is not known whether this reflects a real increase in ADHD or a better ability to recognize it. Or it may be an indication of a culture that places excessive value on normalcy and academic achievement at the expense of more frequent diagnoses.

Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit disorder in adults are definitely on the rise. The disorder seems to be distributed equally between women and men in adulthood, although women have twice the reported incidence in young adulthood. It was estimated that Ritalin would be prescribed in nearly 800,000 adults in the US in 1997, nearly three times the number in 1992. [ See Box , ADHD in Adults.]

Even if these emotional disorders are absent in childhood, the ADHD child's relationship with others is volatile, and he or she is often unhappy from a very young age. Research indicates that any ADHD child, particularly an aggressive child, has trouble getting along with others and is less liked by his or her peers.

• ADHD children with the inattentive subtype only are more likely to be picked on and to spend time alone.
• Children with the combined subtypes have other problems. A best friend can turn into an enemy overnight when, for example, an ADHD boy does not perceive his friend's fearful response to over-aggressive roughhousing and fails to let up. The next day the ADHD child has forgotten the event; the ex-friend hasn't. This is a classic situation repeated time and again. The ADHD child hurts someone; he either may go into a state of denial because he can't accept his lack of self-control or he may blame himself excessively. As ostracism, fear, and ridicule from peers persists from year to year, the unstable behavior, originally neurologic, becomes emotionally based as well. Unless this cycle is broken, serious adult problems can evolve.

Although speech and learning disorders are common in children with ADHD, the disorder does not affect intelligence. People with the problem span the same IQ range as the general population. One study suggested, however, that 90% of ADHD children were underachievers and that half were held back at least once. About 20% have reading difficulties and 60% have serious handwriting problems. [ See also, What Other Disorders Have the Same Symptoms As Attention-Deficit Hyperactivity Disorder?, in this report .] Adults with ADHD are also at very high risk for these conditions.

The time and attention needed to deal with the ADHD child can change internal family relationships and have devastating effects on parents and siblings.

Effect on Parents. The ADHD child is wonderful one day and terrible the next and can hurt the parent's feelings as drastically as an adult can. Parents must protect themselves and their child by establishing tough but kind rules about where their space ends and the child's begins. The effects on parents are multiple:

• Mothers generally get the brunt of the emotional and physical abuse that an ADHD child can produce, which is sadly ironic because the child tends to love the mother intensely and feel safe with her.
• Parents may have to give up on the idea of an immaculate house and a hot meal every night. (One advantage of an ADHD child in the family is that the parents learn that they are not perfect, nor do they have to be. In fact, striving for perfection is among the most counterproductive goals to pursue in raising an ADHD, or any, child.)
• Parents must face the dislike and anger of other parents and see their own child rejected. It is very easy to fall into an emotional black hole, and feel alone, inadequate, and helpless.
• Marriages are often stressed to the breaking point because of exhaustion and disagreements between the husband and wife on how to raise the ADHD child.

Effect on Siblings. Siblings of ADHD children have particular difficulties, and are also at risk for psychologic impairment, depression, drug abuse, and language disorders. The non-ADHD sibling does not have the control a parent does in the management of the ADHD child's behavior and is very likely to feel alienated and alone. Non-ADHD children are often victimized by ADHD siblings who may be demanding or bullying.

A sibling who is not given attention in his or her own right may begin to imitate undesirable behaviors or to act out negatively in other ways. It is very important to make the brothers and sisters equally vital to the family's functioning. It should be strongly emphasized, however, that their value in the family should never be as fellow-caregivers of the ADHD sibling.

Little is known about the long-term effects of ADHD, although studies are now underway to determine them. Some research suggests that ADHD affects between 1% and 6% of the adult population and one- to two-thirds of those diagnosed with childhood ADHD continue to have some evidence of ADHD symptoms into adulthood. Many experts, in fact, describe the pattern of ADHD as they would a chronic illness, in terms of whether it goes into remission or not. They define this remission in three categories of severity:

• Syndromatic Remission. Person has fewer symptoms than fit the full definition of ADHD, but significant functional impairment in social or occupational activities is present.
• Symptomatic Remission . Person has few symptoms and some functional impairment.
• Functional Remission (Full Recovery). Few symptoms and no functional impairment.

In one study using these criteria, 60% of ADHD Caucasian boys were in syndromatic remission four years after the onset of the study and 10% were fully recovered (in functional remission). In other words, nearly all boys experienced fewer symptoms, although most still had significant social problems. Older individuals were more likely to retain symptoms of inattentiveness than those of impulsivity and hyperactivity. Because inattentiveness affects organizational skills, this could be a significant problem in adulthood. It should be noted, however, that the study lasted only four years and stopped between ages 18 and 20. (The study did not include girls or boys in other ethnic groups, so it is not known if these results are generally applicable.)

Substance Abuse. Studies suggested that up to half of individuals with persistent ADHD symptoms develop a substance abuse problem, including alcoholism, smoking, drug abuse, or combinations. In one study, for example, by age 11 nearly 20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. There is some evidence that neurologic factors associated with ADHD may make these individuals susceptible. Notably, deficiencies in the brain chemical dopamine may create a more intense need for "reward" seeking. Substance abuse, then, is a way of self-medicating. Nicotine, in particular, may act as a medication that improves ADHD symptoms.

High-Risk and Anti-Social Behaviors in Adulthood. ADHD has been associated with a higher risk for criminal activity in adulthood and risky and antisocial activities in ADHD children with severe symptoms, particularly aggressive behaviors. ADHD children without such behaviors have a low and even normal risk for dangerous activities. Even in aggressive ADHD children, close parental attention and early treatment can limit the risk considerably. Impulsivity in ADHD young people can certainly cause them to take chances before thinking them through, putting them in situations where the consequences become clear only after the action has been taken.

Accidents and Driving. Of concern is a significantly higher risk for injury-producing automobile accidents in older adolescents and young adult drivers. The major factors contributing to this higher risk were higher rates of drunken driving, street racing, and traffic violations. Those with more severe ADHD symptoms were more likely to be in danger. Whether ADHD traits, such as inattentiveness or hyperactivity, were involved with the risk is not known.

Financial Effects On Society

Studies in 2000 and 2001 reported that costs for medical care are higher for people with ADHD than for those without the condition. Such costs included those for medication, mental health treatment, and visits to the doctor.

Advanced imaging techniques have detected differences in the brains of ADHD children compared to those of non-ADHD children.

Brain Structures. Increasingly, research is suggested that ADHD is a disorder of the right side of the brain. Specific areas on the right side may be important in understanding ADHD:

• The prefrontal cortex. The prefrontal cortex, which is located in the front of the brain, is thought to be the brain's command center; it regulates the brain's ability to inhibit responses. A number of imaging studies has indicated that the prefrontal cortex of the brain in ADHD may be underactive in comparison with those without ADHD.
• The caudate nucleus and the globus pallidus. The caudate nucleus and globus pallidus, located near the center of the brain, speed up or stop orders coming from the prefrontal cortex. Abnormalities in these areas may impair a person's ability to brake actions, resulting in the impulsivity typical of people with ADHD.

Dopamine and Other Brain Chemicals. Important neurotransmitters (chemical messages in the brain) affect mental and emotional functioning. Dopamine is under particular scrutiny. Studies have suggested that dopamine levels are abnormal in the brains of those with ADHD, with its effects being inhibited in the prefrontal lobes of the brain, which helps regulate concentration, attention, and inhibition. Deficiencies in norepinephrine, another brain chemical that is involved in the fight or flight response, may also be critical in ADHD. Both of these neurotransmitters are also important in the "reward" response, in which a person experiences pleasure in response to certain stimuli (such as food or love). Deficiencies in these neurotransmitters create an intense need that causes individuals to seek chemicals, such as nicotine or certain drugs, that actually attach to receptors for dopamine and that help reduce these needs.

Nerve Pathways. Another area of interest is a network of nerves called the basal-ganglia thalamocortical pathways. Abnormalities along this neural route have been associated with ADHD, Tourettes syndrome, and obsessive-compulsive disorders, which all share certain symptoms.

Problems Surrounding Pregnancy. ADHD is often associated with problem pregnancies and with difficult deliveries. Maternal smoking during pregnancy is also associated with a higher risk for ADHD. One study indicated that an increased risk also existed in children of women who were exposed during pregnancy to environmental toxins, including dioxins and polychlorinated biphenyls (PCBs).

Evidence is increasing that genetic factors play the most important role in ADHD. The relatives of ADHD children (both boys and girls) have much higher rates of ADHD, antisocial, mood, anxiety, and substance abuse disorders than the families of non-ADHD children. In a twin study, 90% of children with a full diagnosis of ADHD shared it with their twin. Most likely more than one gene is responsible for inherited cases. This is not surprising, since there is no consensus that ADHD is even a single disorder.

Genetic Factors Regulating Dopamine. Researchers are reporting underlying genetic mechanisms that regulate hyperactivity, particularly those that affect the neurotransmitter dopamine. Studies are finding that a variation of a dopamine D4 receptor gene is common in a high proportion of people with addictions and ADHD, and it appears to be associated with novelty seeking and extroversion. Other genes under investigation are those that regulate dopamine; one is called the dopamine D2 receptor gene. Not all studies, however, have confirmed the role of dopamine in ADHD.

Genetic Resistance to Thyroid Hormone. About 50% of adults and 70% of children with a genetic resistance to thyroid hormone, essential for normal brain development, have ADHD. People who have this condition appear to have a more severe form of ADHD. The thyroid disorder is not a common cause of ADHD, however, and only those with a family history of thyroid disease are at risk.

Food and Allergies. Studies on the effect of food and food-additive allergies are controversial. For example, one reported that 62% of ADHD children had symptoms provoked by various foods and additives. Another study indicated, however, that less than 5% of children with ADHD are affected by food additives and even then, the effect is very slight. Evidence does suggest, however, that certain children with behavioral difficulties may be sensitive to certain chemicals in foods. It should be noted that allergies themselves have recently been associated with a higher risk for behavioral problems. Children who respond to allergen-restrictive diets, then, may not have had true ADHD in the first place. Among the additives and foods that parents and studies report as culprits in inciting behavioral changes are the following:

• Any artificial colorings (particularly yellow, red, or green).
• Other additives.
• Milk.
• Chocolate.
• Eggs.
• Wheat.
• Aspirin and foods containing salicylates (the compound in aspirin). They include berries (all), chili powder, apples and cider, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes, and tomatoes.

Deficiencies in Zinc and Essential Fatty Acids. Some studies have found an association between deficiencies in certain fatty acids (compounds that make up fats and oils) and ADHD. Related to these findings are studies reporting an association between zinc deficiencies and ADHD. (Zinc is important in the metabolism of fatty acids, which in turn affects dopamine, the neurotransmitter likely to be involved with ADHD.)

Sugar. Although parents often blame sugar for causing children to become impulsive or hyperactive, a number of studies now strongly suggest that sugar plays no role in hyperactivity. One study reported, in fact, that ADHD children had fewer problems after a high-carbohydrate breakfast than after a high-protein one. Another reported that children actually moved more slowly after a high-sugar meal, suggesting the carbohydrates may have a sedative effect.

Infant Malnutrition. Even if they receive enough food later on, children who suffer from malnutrition as infants may develop behavior problems, the most prevalent being attention-deficit disorder.

A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitive-behavioral therapy is proving to be the best option for treatment of children with ADHD. In 1999, a large study compared medication, behavior therapy, a combination of both, and standard community care. While all four groups improved, medication, when carefully monitored, was more effective than behavior therapy, and its effects were similar to combination therapy. The combined approach, however, allowed lower doses of medication and also improved academic performance and family relations. In addition, it was more helpful for children who also had mood disorders (such as depression or anxiety) or oppositional-defiant disorder. A 2001 study further suggested that 80% of adolescents with ADHD who were treated with a combined approach showed an improvement in academic performance.

General Guidelines. The following guidelines may be useful in determining a treatment approach for children with ADHD:

• Behavioral techniques, possibly including dietary changes, should be tried first, if possible.
• If the symptoms are severe or do not respond, then a trial using medication (usually psychostimulants), in conjunction with behavior modification therapy, is advisable.

Specific Patient Populations. Unfortunately, such guidelines do not address the following specific patient groups.

• There are no authoritative treatment guidelines for treating adolescents and adults with ADHD. Increasingly, evidence suggests that psychostimulants are a reasonable choice for adults with a confirmed diagnosis of ADHD.
• There are no definite guidelines for treating preschool children with severe ADHD. Some parents have reported very good long-term results with behavioral interventions at this age.
• There are no reliable guidelines on how to treat the inattentive subtype of ADHD, which might be more common in girls.
• Finally, there are no defined treatments for ADHD patients with accompanying conditions, including impaired working memory and deficits in language processing.

In addition to behavioral therapy for the child, family therapy may help ADHD children and their parents and siblings cope with the emotional conflicts that nearly always arise in the lifelong process of managing the condition. Separate psychological therapies for specific family members might be needed, particularly in light of the high incidence of psychiatric and other emotional problems in families with ADHD children. Teachers and school officials should be educated and involved in the process.

Psychostimulants are the primary drugs used to treat ADHD; they are effective for both children and adults with severe ADHD. Other drugs, including newer antidepressants, are proving to be effective in certain individuals. Children who also suffer from anxiety disorders, for example, have less success with stimulants and may need different treatments. A number of agents are also being investigated in clinical studies. While some of these agents may appeal to parents who are concerned about psychostimulants, all have side effects, and the psychostimulants have been intensively studied for decades with little evidence for any serious concern.

Many parents are very disturbed by the idea of putting their children on intensive stimulant drug regimens, possibly for years, particularly given the uncertainties in diagnosis and the negative publicity surrounding the use of these agents. Although the decision to use these drugs should not be made lightly, the negative social and emotional effects of the disorder itself for many children with ADHD are far more severe and long-lasting than the use of these agents. For some parents and children, medication seems like a miracle and can provide desperate families with a quality of life for which they had almost given up hope.

Still, there are a number of questions, particularly for taking psychostimulants alone without additional behavioral therapy. Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children, not only in the US but also in some European countries. There is much evidence the drugs are being over prescribed, and parents should discuss the question of medications very carefully with their physicians.

• Before any drug is administered, a child should be given a thorough examination for any medical problems to be sure there are no medical conditions that interfere with the medication.
• Both the physician and the parents should be very clear about the specific behaviors they hope the medication will target.
• The goal is to use the lowest possible dosage that produces improved behavior.
• If an initial regimen doesn't work, changing the dosage, adding another drug, or changing to a different medication often brings improvement. Some experts recommend trying a second psychostimulant if a first one fails. If the child still doesn't respond, antidepressants or other second-line drugs may be beneficial.
• Frequent follow-up visits should be scheduled to assess the response and to detect possible side effects.

Medications in Older Children. As children enter adolescence, the social stigma associated with ADHD often makes them reluctant to continue drug treatment. If the drug has proven to be effective, it is very important to keep the young person on the regimen during this critical period.

Medications for Adults. One report suggested that two-thirds of adults with ADHD may also be successfully treated with stimulants and psychotherapy. Certain antidepressants may also be effective treatments in adults.

Methylphenidate (Ritalin, Metadate, Concerta) is the most commonly used psychostimulant for ADHD. Its positive benefits for ADHD appear to be due to its actions in increasing dopamine, a neurotransmitter important for motor control. This agent is effective in both children and adults.

Regimen. To date, Ritalin has needed to be administered several times a day, making compliance difficult. A longer-acting form, Ritalin LA, has been approved. At this time, Ritalin has generally been recommended for hours spent at school and not during the evenings, weekends, and vacations. When taken in the morning, the medication usually wears off in the late afternoon. At this point, a rebound effect can occur and ADHD symptoms intensify. The family members, whose affection and on-going support is so important, become victims of the disruptions generated by rebound, and the quality of life can worsen for everyone. Some physicians, then, recommend a "homework" dose given after school to prevent rebound. The longer-acting form should help prevent these problems.

Metadate and Concerta are newer long-acting forms that only need to be taken once a day and may also eliminate the need for taking medication at school. A 2001 study showed that Concerta and a short-acting form of methylphenidate were equally effective, but parents tended to prefer Concerta. This study was conducted only over a three-week period, and longer studies are needed to confirm this finding. A patch form of methylphenidate is awaiting approval.

Side Effects. All stimulants have a number of side effects:

• The most common side effects of any stimulant are nervousness and sleeplessness, although some parents have reported improved sleep patterns in their children after taking stimulants.
• Tics or jerky, disordered movements occur in about 9% of children. Some studies indicate they are not caused by standard doses of Ritalin. In any case, low doses are often effective in controlling impulsivity without causing tics, even in some children who also have mild to moderate Tourettes syndrome.
• Other side effects include irritability, withdrawal, depression, hallucinations, and lack of spontaneity. (Children with developmental disabilities may be more susceptible to these side effects.)
• Symptoms of overdose include confusion, breathing difficulties, sweating, vomiting, and muscle twitches. If they occur, parents should call the doctor immediately.

Long-Term Complications. Few long-term complications have been reported, but the following warrant some caution:

• Children may lose weight and growth may be retarded during long-term treatment. Many people have taken Ritalin for years, however, without experiencing adverse effects or loss of effectiveness.
• A 2001 study on animals suggested that there may be some long-term effects from methylphenidate that may change brain cell structure or function. However, more research is needed to determine the kind of changes, if any, that occur.

Concerns for Abuse. Some people have become concerned about Ritalin abuse and the risk of addiction. Interestingly, a 2001 analysis of a number of studies reported that young people who took Ritalin for ADHD had a significantly lower risk for drug abuse than their peers. Experts suggested that this lower risk may have been due to benefits from methylphenidate that reduced their need to self-medicate using illegal agents. The primary danger for drug abuse appears to occur in peers. In one study, 16% of ADHD children reported pressure from their fellow students to sell or give them their medication.

There is also very little risk for addiction. Although Ritalin and other methylphenidates have properties similar to amphetamines, their drug levels rise very slowly in the brain at the oral doses given for ADHD. This slow rise prevents a so-called "high" and subsequent addiction to the drug. Dependence has not been reported in children who have taken this drug for long periods in appropriate dosages. (It should be noted that crushing the pills and inhaling them nasally can provide a euphoric state.)

Adderall combines four kinds of amphetamine salts. It is inexpensive and can be taken once or twice a day. (A new formulation, Adderall XR, which is specifically designed to be taken once a day, is waiting approval.) In two studies comparing standard Adderall given once daily with two daily doses of Ritalin, both drugs were beneficial and the effect on behavior was similar in children. Studies are indicating that Adderall may also be superior to methylphenidate in sustaining improvements. In one study, staff involved in monitoring the children taking these agents recommended Adderall over Ritalin by three to one. Adderall may also be effective for adults. Side effects include stomach problems and mood changes, including sadness, anxiety, and irritability. Studies are needed to determine long-term risks.

Pemoline. Pemoline (Cylert) is an effective stimulant in children who do not respond to other drugs. It has shown promise for adults with ADHD but has not been approved for this population. The agent takes longer (sometimes weeks) to produce improvement than the other drugs, but it allows once-daily administration. Of major concern is a risk of liver damage, particularly when taken in combination with other medications or alcohol. Although the risk is small, it can be life-threatening in rare cases. Physicians should monitor liver function every two weeks in children taking the agent. Parents or patients should watch for any symptoms of liver toxicity, including tenderness of the abdomen, yellow skin or eyes, vomiting, weight loss, or malaise. The drug was withdrawn in Canada in 1999.

Dextroamphetamine. Dextroamphetamine (Dexedrine) is similar to Ritalin. Although it is commonly believed that it is both less effective and less safe than Ritalin, there is no evidence of this, and one study reported a slightly better response with dextroamphetamine. Side effects are similar. The arguments against dextroamphetamine mainly rest on widespread abuse of this drug in earlier decades. Some experts believe it may be an useful alternative for people who do not respond to Ritalin.

Specific antidepressants are proving helpful and reasonable alternatives to psychostimulants for some people with ADHD. In fact, some experts recommend them as firstline treatments for adults with the disorder.

Designer Antidepressants. Bupropion (Wellbutrin), reboxetine (Edronax) and venlafaxine (Effexor) are unique antidepressants, sometimes referred to as designer antidepressants. Such agents affect one or more neurotransmitters that are not targeted by older antidepressants. These agents may also be particularly helpful for treating patients with ADHD and accompanying disorders, including depression or conduct disorder. Most studies to date have focused on bupropion and have reported good results in both children and adults. For example, a 2001 study also found it to be effective in improving ADHD symptoms in 76% of adults with ADHD.

SSRIs. The antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), sertraline (Zoloft), citalopron (Celexa) and paroxetine (Paxil), are effective and safe and often recommended for treating patients with both depression and ADHD. It should be noted, however, that SSRIs may increase the risk for impulsive behavior. Sertraline has also helped adults with pervasive development disorder, but its effect on children is unknown; other SSRIs have not been very helpful for childhood PDD.

Tricyclics. Antidepressants known as tricyclics, which include desipramine (Norpramin, Pertofrane), or imipramine (Janimine, Tofranil), have been prescribed for children who do not respond to stimulants or who have accompanying anxiety or depression. Desipramine appears to have the best results of the tricyclics. They are not thought to be helpful for adult ADHD without accompanying depression, although in one study of adults with the disorder, desipramine was as effective as Ritalin. Tricyclics have a mild effect on blood pressure and heart rate that does not appear to be harmful in people without existing heart disease. Reports of sudden death of a few children taking tricyclics, however, have caused alarm, although these occurrences are extremely rare and the role tricyclics may have played is not clear. Reports of delirium and increased heart rate have occurred in adolescents who take tricyclics and smoke marijuana. Careful monitoring is important.

Alpha-2 agonists stimulate the neurotransmitter norepinephrine, which appears to be important for concentration. Clonidine (Catapres) is the standard alpha-2 agonist. It is used for Tourettes syndrome and may be beneficial when other drugs have failed for ADHD children with tics or those whose primary symptoms are severe impulsivity and aggression. Few major studies have been conducted on its efficacy or safety in ADHD children, however. A similar drug, guanfacine (Tenex), also improves symptoms in ADHD children and may cause less drowsiness than clonidine.

Side Effects. Clonidine has a number of side effects. Sedation is the most common. A clonidine skin patch, which gradually releases the medication, helps reduce the sedative effect. Because clonidine slows the heart down, it can have adverse effects in some children. Going off too quickly or missing doses can cause rapid heartbeats and other symptoms that may lead to severe problems. Of concern are reports of adverse effects, including five deaths, in children taking the drug in combination with other medications. Experts strongly recommend that no child be given this medication without a preliminary examination for heart problems, and no child with existing heart, kidney, or circulatory problems should take it.

Atomoxetine. Atomoxetine is a unique drug being studied for ADHD that appears to block the transport system of the stress hormone norepinephrine. It is not a stimulant. Early trials have indicated that it may be effective and appears to be safe in children with ADHD. Side effects reported to date include increased appetite and sleepiness. It is in final trials, but has not yet been approved.

Modafinil. Modafinil promotes wakefulness and is used to treat patients with narcolepsy. Early studies suggest that it may be useful for adults and children with ADHD.

Anticholinesterases. Drugs known as central anticholinesterases, including tacrine (Cognex) and donepezil (Aricept), are used to treat symptoms of Alzheimer's disease. Currently, they are also being investigated for ADHD. Some early studies suggest that such an agent may be effective in the same way as psychostimulants and may also have additional benefits, including improving executive functions, such as organizational capacity. All these drugs have gastrointestinal side effects, including nausea. In high doses, they can also cause liver damage.

Nicotine Replacement. Nicotine improves ADHD symptoms. Although such findings should certainly not encourage anyone to smoke, some studies are focusing on benefits of nicotine therapy in adults with ADHD.

Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers. To learn them, caregivers may need help from qualified health care professionals or from ADHD support groups. At first, the idea of changing the behavior of a highly energetic, obstinate child is daunting. It is futile and damaging to try to force an ADHD child to be like most children. It is possible, however, to limit destructive behavior and to instill a sense of self-worth that will help overcome negativity toward life, which is one of the great dangers of the disorder.

Bringing up an ADHD child, like bringing up any child, is a process. No single point is ever reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to do anything more." Self-worth will evolve from the child's increasing ability to step back and consider the consequences of an action and then to control that action before taking it. But this does not happen over night. A growing ADHD child is different from other children in very specific ways and he or she presents challenges at every age.

Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some parents are easy going and can accept a wide range of behaviors, while others can't. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some tips to help the parent are as follows:

• Parents should prepare a list giving priority to those behaviors they think are the most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (e.g. refusing to wear anything but red T-shirts).
• Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (e.g. making up silly songs or drawing violent pictures). These should be accepted as part of the child's unique and positive development, even if they seem peculiar to the parent.
• It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm.

Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their approach to the child, which should reward good behavior and discourage destructive behavior. Rules should be well defined but flexible enough to incorporate harmless idiosyncrasies. It is very important to understand that ADHD children have much more difficulty adapting to change than do children without the condition. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.)

Managing Aggression. Some useful tips for managing aggression include the following:

• Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional.
• The use of "time-out," isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which he or she is endangered or is endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others.
• To channel physical aggression and impulsivity in the ADHD toddler, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.)
• When the ADHD child becomes older and if the verbal responses become intentionally abusive and socially undesirable, then the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Competitive video games, such sports games, may also be an option. (Some studies, including one in 2001, suggest that reducing watching of TV or playing video games will reduce aggressive behavior in all children. The 2001 study, however, did not explore the nature of the content and did not study ADHD children specifically. Patents should gauge for themselves what activities will reduce aggressive behavior.)
• Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible.

Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.

Some suggested tips for rewarding the ADHD child are as follows:

• Create charts with points or stars for good behavior or for completed tasks. It is important to give points for even simple positive behaviors, which may be taken for granted in other children (e.g. responding happily to a change in plans, changing an obscenity to a more acceptable expletive).
• Rewards for any child can include playing a favorite game with the child, extending bedtime by an hour, or allowing an extra half-hour of TV.
• Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects.
• A reward system should rotate different types of rewards, because such children are easily bored.
• ADHD children respond better with small rewards promised in the short-term than large rewards offered in the future. One approach that employs both short- and long-term rewards uses a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game or CD.
• Rewards should be promised only when caregivers are fairly certain they can follow through. ADHD children respond with much greater frustration than non-ADHD children to disappointment, and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the ADHD child's make-up and not necessarily in their control.

Improving Concentration and Attention. In one study, children were given training twice a week using visual and auditory tasks on two different levels of attention. Lower level attention included being able to focus and sustain attention over time, and higher attention involved the ability to allocate attention among tasks. At the end of the 18-week program, children with ADHD were able to perform as well as non-ADHD children. More research is needed to confirm these results.

Research indicates that ADHD children perform significantly better when their interest is engaged. Parents should be on the lookout for activities that hold the child's concentration. Some options that may help an ADHD child to focus are as follows:

• One very interesting experiment reported that when children with ADHD performed verbal word puzzles while watching themselves in the mirror, they did as well as non-ADHD children. The intent of the experiment was to focus attention back to the self and so avoid external stimuli.
• Many ADHD children are particularly lured by the computer, which is a very promising tool. A number of non-violent computer games are available that offer problem-solving techniques using characters, narrative, and humor.
• Swimming, tennis, and other sports that focus attention and limit peripheral stimuli are often appealing. ADHD children often do not do well with team sports, although they are interested. Children with ADHD are less likely to become distracted in sports that require constant alertness, such as football or basketball. In baseball, positions such as pitching or catching are preferable to the outfield, where attention easily wanders. Finding a coach that understands the child's difficulties is very helpful.
• Some experts are enthusiastic about martial arts, such as Tae Kwon Do, which can offer an appropriate and controlled emotional outlet, help to focus attention, and teach self-restraint, self-discipline, and tolerance. Care should be taken to select an instructor who makes such goals a priority.
• Learning an instrument may be one of the best ways for an ADHD child to develop a more rhythmic and balanced sense of self. Music, even simply listening to it, is often very important for these children. (Parents may have to tolerate music that does not please them.)

Even if a parent is successful in managing the child at home, difficulties often arise at school. The ultimate goal for any educational process should be the happy and healthy social integration of the ADHD child with his or her peers.

Preparing the Teacher. Although teachers can expect that at least one student in every classroom will have ADHD, there is currently little training that prepares them for managing these children. The teacher should be prepared for the following behaviors in the ADHD child:

• ADHD students are often demanding, talkative, and highly visible. Having the child sit in the front of the classroom may be helpful.
• Children with ADHD often require frequent reminders of or visual cues (such as posters) for rules and regulations.
• They frequently forget homework or miss assignments.
• Lack of fine motor control makes taking notes very difficult, and handwriting is often poor. Using a typewriter or computer can compensate for this. One useful skill that has helped some ADHD children is learning to type at an early age, around the third or fourth grade.
• Rote memorization and math computation, which require following a set of ordered steps, are often difficult. (ADHD children may do better with math concepts.)
• Many ADHD children respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision.

The Role of the Parent in the School Setting. The parent can help the child by talking to the teacher before the school year starts about their child's situation:

• The first priority for the parent is to develop a positive, not adversarial, relationship with the child's teacher.
• The parent must acknowledge the teacher's situation, for he or she must deal not only with the ADHD child's behavior but also with the needs of all the other children.
• Frequent brief and sympathetic conversations with the teacher can be helpful and can lead to coordination of efforts, particularly if they provide reciprocal information about progress or setbacks.
• Finding a tutor to help after school may be helpful.

Legal Issues. A number of legal issues have become both positively and negatively important in the management of ADHD in the classroom. In some districts teachers are not allowed to tell parents that they suspect their child has ADD or ADHD because of the risk of lawsuits, therefore preventing an unknowing parent from seeking help for their child. Parents sometimes report pressure by school administrators or teachers to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally.

Special Education Programs. High-quality special education can be extremely helpful in improving learning and developing a child's sense of self worth. Many families, however, may not have appropriate programs available for them. Programs vary widely in their ability to provide quality education. Parents must be aware of certain limitations and problems with special education:

• Special education programs within the normal school setting often increase the child's feelings of social alienation.
• If the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior.
• There is no federally funded special education category specifically targeted to ADHD.

If, in fact, ADHD is as common as studies are indicating, the best approach may be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom.

A number of diets have been suggested for people with ADHD. Several well-conducted studies have failed to support dietary effects of sugar and food additives on behavior, except possibly in a very small percentage of children. Various studies have reported behavioral improvement with diets that restrict possible allergens in the diet. They have been criticized for methodological weaknesses, and further study is needed in this area to confirm these findings.

Feingold Diet. The most well-known diet for ADHD is the Feingold diet, a salicylate- and additive-free diet, which requires rigorous vigilance over a child's eating habits. BHT or BHA and artificial food colors are specifically avoided. Salicylates are very common and are present in aspirin and many foods. They include apples and cider, berries (all), Chili powder, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes, and tomatoes. One study that reported its efficacy suggested that it might not provide enough nutritive value, although the diet provides a wide range of healthy foods to select from. Some parents report great success with this diet, although it may be difficult to impose, particularly on an ADHD child. It is certainly wise, in any case, to avoid food with artificial colors and flavors and to provide a healthy balance of fresh, natural foods.

Essential Fatty Acids. Essential fatty acids are found in fats and oils and some may have health benefits:

• Some researchers have investigated omega-3 fatty acids for treatment of ADHD. Omega-3 fatty acids are found in fatty fish and certain vegetable oils. Fish oils contain specific compounds called docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), which can also be obtained in supplements. A 2001 study found no benefits from DHA in treating symptoms of ADHD.
• One 2000 study compared groups of ADHD individuals who took primrose oil (an essential fatty acid), a psychostimulant, or placebo. In assessing the results, the authors suggested that primrose oil may benefit ADHD children who are moderately deficient in zinc. In fact, in those with borderline zinc levels, a combination of zinc and primrose oil was as effective as medications in reducing ADHD symptoms. (Neither zinc nor primrose oil had any effect on children who were not zinc deficient.) It is important to note that this study needs confirmation, and testing for trace minerals, such as zinc, is not standard procedure when evaluating children suspected to have ADHD.

Neurofeedback is an experimental approach that uses electronic devices to speed up or slow down brain wave activity. In one study, children given this treatment were taught certain high-level mental activities when feedback information indicated that they were fully concentrating. They attended four 50-minute sessions, usually twice a week. At the end of the study, Ritalin use had dropped from 30% to 6%. Significant improvement was reported in inattention, impulsivity, and response time, and IQs increased by an average of 12 points. A 1999 presentation at a professional meeting reported on a study suggesting that 85% of ADHD adults and children improved after 20 sessions. This study was not reviewed by other professionals, and critics have identified methodological problems with this and other studies on neurofeedback. For example, in the 1999 study, only 20% of the subjects had an actual diagnosis of ADHD. Nevertheless, the positive results from such studies warrant further research.

Massage

Daily massage therapy helps ADHD adolescents feel happier, fidget less, be less hyperactive, and focus on tasks, according to a study published in 1998.

Alternative Remedies

A number of parents resort to alternative remedies as an alternative to psychostimulants and other drugs. Small trials have found some agents, such as ginkgo biloba, panax ginseng, and melatonin may possibly have benefits for ADHD. None, however, can be recommended, particularly for children, where their safety and effectiveness are completely unproven. [See Warning Box.]

Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians, who have faculty positions at Harvard Medical School and Massachusetts General Hospital. Neither Harvard Medical School or Massachusetts General Hospital, as Institutions, review or endorse this content. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information, and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.

Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center

Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital

Edwin Huang, MD, Gynecology, Harvard Medical School, Physician, Massachusetts General Hospital

Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, MD, Psychiatry, Asscociate Professor of Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital