ADHD

Overview: ADHD

• In the 1930s, hyperactivity, impulsivity, learning disability, and distractibility in childhood were described as “minimal brain damage” or “minimal brain dysfunction.”

• This label was modified in the 1950s to “hyperactive child syndrome” and in 1968 to “hyperkinetic reaction of childhood.”

• More recently, investigators have recognized that for nearly 66% of patients, the core symptoms of impulsivity and distractibility characteristic of attention deficit hyperactivity disorder (ADHD) persist into adulthood.

• One of the most commonly diagnosed and costly mental health problems in the United States, ADHD is diagnosed in 3% to 10% (depending on age and gender) of school-age children.

• It is diagnosed more commonly in boys than girls (3:1 ratio); the peak age of diagnosis is between 8 and 10 years old.

• The drugs used to treat ADHD, such as methylphenidate (Concerta), atomoxetine (Strattera), and a combination of amphetamine and dextroamphetamine (Adderall), are three of the top five (ranked by spending) for children younger than 18 years in the United States.

• The prevalence of ADHD in adults is estimated at 2.5%. Unlike an acute bacterial infection, ADHD is a chronic condition requiring ongoing management.

• The classic image is that of an energetic boy who talks a lot, interrupts others, acts as if driven by a motor, fidgets and squirms, has a messy room, acts impulsively, has trouble following rules, and often breaks or loses things; he is often admonished to sit still, pay attention, and clean up his room.

• The quiet girl who daydreams and is inattentive in class has a second classic type of ADHD (ADHD without hyperactivity).

Dietary Essentials for Optimal Attention

Stress Management Strategies

Herbs as Additional Therapy

Important Points to Consider

• The National Institute of Clinical Excellence (NICE) recommends stimulant medications only for children with severe symptoms, not for children with mild to moderate ADHD

Prevention Prescription

• Advise pregnant women to stop smoking and avoid drinking alcohol.

• Advise parents not to smoke around their children and to limit exposure to television and pesticides.

• Encourage families to live a healthy lifestyle focusing on the following: a whole foods dietthat limits intake of artificial colors, flavors, sweeteners, and preservatives and foods that cause sensitivity reactions and that avoids deficiencies of essential omega-3 fatty acids, amino acids, vitamins and minerals; daily physical activity, preferably outdoors in natural surroundings; adequate sleep; effective stress and emotional self-management; strength-based communication skills and participation in supportive community networks; and a safe, structured, well-organized environment.

Therapeutic Review for ADHD

Accurate Diagnosis

• Use standard rating scales such as the Vanderbilt Parent and Teacher Rating Scales to assess ADHD symptoms and response to interventions.Rule out medical and neuropsychological conditions that impair attention and self-discipline such as hypothyroidism, vision, hearing, and specific learning deficits. Consider requesting a neuropsychological examination to assess IQ and learning difficulties.

Encouraging Healthy Habits in a Healthy Habitat

Dietary:

• Assess diet and correct nutritional deficiencies with a better diet or dietary supplements.

• Encourage patients to maintain a steady blood glucose level by eating regular meals with foods having a low glycemic index.

• Foods containing artificial colors, sweeteners, flavors, and preservatives should be avoided, as should foods with a heavy burden of pesticides.

• Instruct patients to avoid dehydration.

• Consider recommending coffee or tea as mild dietary stimulants and monitoring for insomnia and other common side effects.

Sleep and activity

• Promote adequate sleep with sleep hygiene.Consider melatonin (0.3 to 3 mg an hour before bed) or sedative herbal remedies (a cup of chamomile tea or lavender aromatherapy) as a first-line approach to improving sleep.

• Encourage vigorous daily activity, at least 30 minutes daily of activity vigorous enough to break a sweat or make it difficult to talk and move at the same time.

• Stress management and emotional self-management skills

• Assess stress management and emotional self-management skills.

• Counsel families about stress management.Consider referral for meditation training, including moving meditation practices such as yoga and tai chi.

• Consider referral for effective counseling and cognitive-behavioral therapy.

Social support

• Refer families to support networks of other families such as Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD).

• Encourage positive family communication, focusing on goals rather than problems. Help families view overall long-term goals in terms of short-term achievable objectives.

• Help families learn to make specific, measurable, achievable, relevant, time-specific (SMART) plans, including ways to celebrate success.

• Consider referring families for additional support for parenting and discipline skills a skill development.

Healthy environment

• Advocate for appropriate testing and learning accommodations at school.

• Referral for additional professional assistance.

• Consider referral to a psychologist for neurofeedback.

• Consider a referral for massage therapy.

Pharmaceutical management

• Remember that 65% of people do respond to stimulant medication, at least initially.

• Consider recommending an N-of-1 trial of a stimulant medication, comparing a low dose (e.g., 5 mg methylphenidate twice daily) with a middle dose (10 mg twice daily) with placebo for 1 week each.

• If patient notes improvement, consider switching to a longer-acting medication to reduce the number of pills or doses required dally.

• Monitor and support families with regular follow-up every 3 to 4 months.

Key Web Sources

• Rating Scales Vanderbilt Teacher Rating Scale. http://www.brightfutures.org/ mentalhealth/pdf/professionals/bridges/adhd.pdf.

• Vanderbilt Parent Rating Scale. http://www.vanderbiltchildrens. org/uploads/documents/DIAGNOSTIC_PARENT_RATING_ SCALE(1).pdf.

• Activity U.S. Centers for Disease Control and Prevention. http://www.cdc. gov/healthyyouth/physicalactivity/.

• ABC for Fitness.

• Activity bursts in the classroom. http://www. davidkatzmd.com/abcforfitness.aspx.

• Diet Feingold diet. www.feingold.org.

• Nutrition information from the Center for Science in the Public Interest. http://www.cspinet.org/.

• Food pesticide levels from Environmental Working Group. http://www.foodnews.org/.

• Support Groups All Kinds of Minds (AKOM). www.allkindsofminds.org.

• Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD). www.chadd.org.