Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is characterized by persistent inattentiveness, impulsivity, and/or hyperactivity that interfere with functioning and are present in two or more settings.[1] The disorder affects an estimated 11% of US children aged 4-17, with increased prevalence in teen years,[2] and more than 4% of American adults.[3] It can affect cognitive, academic, behavioral, emotional, and social functioning and may be associated with comorbid psychiatric conditions, such as oppositional-defiant and conduct disorders, learning disabilities, anxiety, depression, and, later in life, substance-use disorders.

This neurobehavioral disorder is probably caused by a combination of genetic and environmental factors. Neurotransmitter abnormalities have been postulated, focusing on catecholamine metabolism in the cerebral cortex and basal ganglia. An imbalance between norepinephrine and dopamine in the prefrontal cortex is suspected. Methylphenidate, a stimulant that is effective in treating ADHD symptoms, is known to increase synaptic dopamine concentrations.

Inattention may present as disorganization, forgetfulness, frequent misplacing of things, inability to follow instructions, academic underachievement, distractibility, inability to finish tasks, poor concentration, careless mistakes, or poor attention to detail. Hyperactivity is identified by fidgeting, restlessness, difficulty remaining seated, and talking excessively or inability to remain quiet when appropriate.

Impulsivity is noted by difficulty waiting turns, disruptive classroom behavior, interrupting others, peer rejection, and attempting risky activities without considering consequences. Affected adults may show inattention and impulsivity, rather than hyperactivity, and may have difficulty keeping a schedule, managing money, maintaining steady employment, or maintaining a relationship.

Risk Factors

Male gender. ADHD is identified 2-3 times more frequently in boys than in girls.

Age. The average age of diagnosis is 7 years.[2] Although some cases remit by adolescence, others persist into adulthood. ADHD has historically been considered a disorder that develops in childhood; however, new evidence is beginning to suggest that some cases may be late-onset or adult-onset.[4]

Genetics. Siblings of an individual with ADHD are at increased risk of the disorder,[5] and there is a 90% concordance in monozygotic twins. Several genes have been identified as possible candidates, notably dopamine receptor and transporter genes.

Environmental factors. Early lead exposure or head injury may increase risk.

Diagnosis

For a diagnosis of ADHD, the American Psychiatric Association requires at least 6 symptoms of inattention or at least 6 symptoms of hyperactivity and impulsivity, as outlined in the DSM-5. Symptoms must have lasted for at least 6 months, must have begun prior to age 12, and must be present in at least 2 settings (e.g., school and home). Also, there must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. Symptoms must be considered excessive for the developmental level of the child and other possible causative mental disorders must be ruled out.[1]

A medical, neurologic, psychological, and cognitive evaluation should be performed to rule out underlying medical contributors, cognitive deficiencies, and mimicking disorders. Diagnosis of adult ADHD is similar to that in children but may be complicated by a more subtle presentation, usually lacking the hyperactivity component. Girls with ADHD are also less likely to be hyperactive, making it less likely that the illness will be recognized and treated.

Treatment

A thorough history and physical exam, focusing particularly on cardiovascular stability as well as potential for substance abuse, should be performed prior to initiation of pharmacologic therapy for ADHD.[6]

Pharmacologic Treatments

Stimulants

Methylphenidate and dextroamphetamine are effective in 60%-70% of children with ADHD. They increase catecholamine release from presynaptic neurons. Sustained-release preparations and longer-acting medications, such as lisdexamfetamine, minimize rebound symptoms and irritability, as well as minimize disruptions in the school day caused by twice-daily or three-times-daily dosing schedules. Side effects may include decreased appetite, insomnia, anxiety, irritability, or headache. Moreover, sympathomimetic agents raise blood pressure and heart rate, potentially contributing to risk of sudden cardiac death.[7]

Nonstimulants. Several classes of nonstimulant medications may be effective, although controlled studies are limited.

Atomoxetine is a selective norepinephrine reuptake. It may be most appropriate for patients with a history of medication abuse or family members who may abuse medication.[8] The FDA has warned that this medication may cause hepatotoxicity, suicidal thinking, and serotonin syndrome (when used along with fluoxetine). It should be discontinued in patients who develop jaundice or laboratory evidence of hepatotoxicity.

Among antidepressant medications, tricyclic antidepressants (e.g., imipramine, nortriptyline) and dopamine reuptake inhibitors (e.g., bupropion) have both been shown to be modestly effective for treatment of adult ADHD.

Clonidine and guanfacine are alpha-2 adrenergic agonists that may be useful in children but have not been well studied in adults. Side effects may include hypotension, sedation, fatigue, headache, and urinary changes. In addition, several drugs may interact with clonidine, including alcohol, barbiturates, beta-blockers, digoxin, and cold medicines. Combined use with methylphenidate requires monitoring of blood pressure and pulse.

Allergic rhinitis treatments. ADHD prevalence may be higher in children with allergic rhinitis.[9] One study found a decrease in ADHD scores solely with treatment of allergic rhinitis.[8]

Nonpharmacologic Treatments

Behavioral interventions are recommended as initial treatment for preschool-aged children with ADHD, and may help to augment pharmacotherapy for school-aged children.[10] Behavioral interventions include parent-child therapy as well as school-based interventions, such as seating near the teacher, daily report card with home reinforcement, and extended time to complete tasks.

Physical activity in children plays a critical role in their growth and development.[11] Research suggests physical activity may help to reduce the symptoms of ADHD in children.[12] Also, sports and other social activities help children learn appropriate social skills.

Biofeedback. Electroencephalographic (EEG) biofeedback training may be a promising investigational treatment. Research studies have demonstrated that some individuals who have ADHD have excess slow-wave activity and reduced fast-wave activity compared with matched peers. Using video and auditory feedback, individuals can learn to reduce their slow-wave activity and/or increase their fast-wave activity.[13] Case series report that approximately 75% of patients have a positive clinical response.[14]

Nutritional Considerations

The role of diet in ADHD has been controversial ever since it was first proposed in the book Why Your Child Is Hyperactive by pediatrician Ben Feingold, MD.[15] Dr. Feingold demonstrated that the removal of synthetic colorings, flavorings, and preservatives from the diet led to a marked improvement in many children. (Feingold suspected a much wider array of dietary sensitivities, but those 3 were the easiest to study.) Later research suggested that these sensitivities were relevant in only rare ADHD cases. However, subsequent studies have reasserted the role of diet, suggesting that unhealthy, ‘Western’ dietary patterns, characterized by high intakes of sugar, salt, fat and minimal consumption of whole grains, fruits, vegetables and fish, are associated with risk of ADHD.[16] ,[17] This association may be stronger in boys than girls.[18]

The following nutritional factors are under study for their effect on ADHD:

Diets free of artificial food colorings and common allergens.

Artificial food colorings do not appear to cause ADHD, but may exacerbate symptoms in some ADHD patients.[19] An elimination diet is a valuable tool to identify problematic foods.[20] At least 8 controlled studies have demonstrated either significant behavioral improvement on oligoantigenic (elimination) diets compared with regular diets or behavioral deterioration on a placebo-controlled challenge with foods suspected of aggravating symptoms. In one of these studies, parental reports indicated that more than half the subjects exhibited a reliable improvement in behavior on an oliogoantigenic diet.[21] A study looking at 35 years of elimination diets found that > 70% of children responded positively.[22]

Some children with ADHD may also be sensitive to foods other than artificial colorings, such as milk, chocolate, soy, eggs, wheat, corn, and legumes, as well as salicylate-containing foods (e.g., grapes, tomatoes, and oranges).[22]

Aspartame or sucrose restriction. Controlled trials of sugar-restricted diets found no effect on behavioral s ymptoms in ADHD, even in children thought to be sugar-sensitive.[23] Similarly, studies have not supported a causal role for aspartame in ADHD.[24]

Adequate vitamin and mineral intake or supplementation. Deficiency of several minerals (iron, copper, zinc, magnesium, calcium) is common in ADHD patients[25] and theoretically may influence neurotransmission in the central nervous system.[26] Some studies have suggested a contributory role of nutrient-poor meals and snacks.[25] Controlled studies have not established a clear benefit of supplementation[27] ,[28] though research on multi-nutrient supplementation looks promising.[29] ,[30]

Zinc. As a cofactor for neurotransmitters, zinc influences regulation of γ-aminobutyric acid (GABA), serotonin, and dopamine, all of which may play roles in ADHD. Poor zinc status is common and can delay cognitive development; it has been found with greater frequency in hyperactive children compared with controls.[31] A small study in Canada found ADHD children were 8 times more likely to have zinc deficiency compared with age-matched population data.[32]

Zinc status has been reported in a small sample to correlate with response to amphetamine treatment,[31] and controlled clinical trials in the Middle East, an area of zinc deficiency, support the possibility that supplemental zinc (55-150 mg ZnSO4/day) may improve response to methylphenidate[33] or improve symptoms of hyperactivity and impulsiveness when used as monotherapy.[34] However, these reports leave questions about sample retention and data analysis, and further controlled clinical trials are required.[35]

Iron. A recent meta-analysis found low serum ferritin levels to be more prevalent in patients with ADHD than in healthy controls. Iron deficiency is associated with decreased dopamine transporter density and activity, causing increased extracellular dopamine. Deficiency may also result in dysfunction in the basal ganglia.[36] Supplementation may improve symptoms in ADHD patients with low serum ferritin.[37] ,[38]

Polyunsaturated fatty acids. ADHD patients may have lower levels of omega-3 fatty acids,[39] higher levels of omega-6 and a higher n6:n3 ratio.[31] A recent meta-analysis supports these findings and suggests this leads to an overproduction of pro-inflammatory cytokines that alters neurotransmitter systems.[40] The efficacy of supplementation continues to be evaluated.[41] ,[42]

Oxidative stress. Markers of inflammation may be higher in ADHD patients[43] suggesting insufficient responses to oxidative stress.[44] This could be exacerbated by nutrient-poor diets. Some have hypothesized that antioxidant-rich plant compounds such as Ginkgo biloba, Ginseng, and Pycnogenol (Pine Bark Extract) may help reduce oxidative stress.[45]

A diet based on whole grains, beans, fruits and vegetables could supply these nutrients as well as antioxidants to reduce inflammation, although the direct benefit of this on ADHD symptoms has not been evaluated through clinical trials.

Orders

See Basic Diet Orders Chapter

What to Tell the Family

ADHD can impair learning, work performance, and social relationships. However, several effective treatments are available. Although many parents have understandable concerns about drug therapy, medications are highly effective and generally provide rapid and dramatic relief. Other options—behavioral treatment, special educational programming, and, for a subset, oligoantigenic diet—may be tried separately or in combination with medication.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). 5 th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  2. Visser SN et al: Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry 53:34, 2014  [PMID:24342384]
  3. Kessler RC et al: The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 163:716, 2006  [PMID:16585449]
  4. Moffitt TE et al: Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study. Am J Psychiatry 172:967, 2015  [PMID:25998281]
  5. Franke B et al: The genetics of attention deficit/hyperactivity disorder in adults, a review. Mol Psychiatry 17:960, 2012  [PMID:22105624]
  6. American Academy of Child and Adolescent Psychiatry: Practice parameter on the use of psychotropic medication in children and adolescents. J Am Acad Child Adolesc Psychiatry 48:961, 2009  [PMID:19692857]
  7. Nissen SE: ADHD drugs and cardiovascular risk. N Engl J Med 354:1445, 2006  [PMID:16549404]
  8. Yang MT et al: Attention-deficit/hyperactivity disorder-related symptoms improved with allergic rhinitis treatment in children. Am J Rhinol Allergy 30:209, 2016  [PMID:27216352]
  9. Yang MT et al: Hyperactivity and impulsivity in children with untreated allergic rhinitis: corroborated by rating scale and continuous performance test. Pediatr Neonatol 55:168, 2014  [PMID:24211085]
  10. Subcommittee on Attention-Deficit/Hyperactivity Disorder et al: ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 128:1007, 2011  [PMID:22003063]
  11. Cooper DM, Nemet D, Galassetti P: Exercise, stress, and inflammation in the growing child: from the bench to the playground. Curr Opin Pediatr 16:286, 2004  [PMID:15167015]
  12. Gapin JI, Labban JD, Etnier JL: The effects of physical activity on attention deficit hyperactivity disorder symptoms: the evidence. Prev Med 52 Suppl 1:S70, 2011  [PMID:21281664]
  13. Butnik SM: Neurofeedback in adolescents and adults with attention deficit hyperactivity disorder. J Clin Psychol 61:621, 2005  [PMID:15723361]
  14. Monastra VJ: Electroencephalographic biofeedback (neurotherapy) as a treatment for attention deficit hyperactivity disorder: rationale and empirical foundation. Child Adolesc Psychiatr Clin N Am 14:55, 2005  [PMID:15564052]
  15. Feingold BF. Why Your Child Is Hyperactive: The Bestselling Book on How ADHD is caused by Artificial Food Flavors and Colors . New York, NY: Random House; 1985.
  16. Howard AL et al: ADHD is associated with a "Western" dietary pattern in adolescents. J Atten Disord 15:403, 2011  [PMID:20631199]
  17. Woo HD et al: Dietary patterns in children with attention deficit/hyperactivity disorder (ADHD). Nutrients 6:1539, 2014  [PMID:24736898]
  18. Wu X, Ohinmaa A, Veugelers PJ: The Influence of Health Behaviours in Childhood on Attention Deficit and Hyperactivity Disorder in Adolescence. Nutrients Dec 02  [PMID:27918425]
  19. Arnold LE, Lofthouse N, Hurt E: Artificial food colors and attention-deficit/hyperactivity symptoms: conclusions to dye for. Neurotherapeutics 9:599, 2012  [PMID:22864801]
  20. Pelsser LM et al: Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Lancet 377:494, 2011  [PMID:21296237]
  21. Kaplan BJ et al: Overall nutrient intake of preschool hyperactive and normal boys. J Abnorm Child Psychol 17:127, 1989  [PMID:2745894]
  22. Stevens LJ et al: Dietary sensitivities and ADHD symptoms: thirty-five years of research. Clin Pediatr (Phila) 50:279, 2011  [PMID:21127082]
  23. Wolraich ML et al: Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children. N Engl J Med 330:301, 1994  [PMID:8277950]
  24. Fitch C, Keim KS, Academy of Nutrition and Dietetics: Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J Acad Nutr Diet 112:739, 2012  [PMID:22709780]
  25. Villagomez A, Ramtekkar U: Iron, Magnesium, Vitamin D, and Zinc Deficiencies in Children Presenting with Symptoms of Attention-Deficit/Hyperactivity Disorder. Children (Basel) 1:261, 2014  [PMID:27417479]
  26. Daley KC: Update on attention-deficit/hyperactivity disorder. Curr Opin Pediatr 16:217, 2004  [PMID:15021207]
  27. Rucklidge JJ, Johnstone J, Kaplan BJ: Nutrient supplementation approaches in the treatment of ADHD. Expert Rev Neurother 9:461, 2009  [PMID:19344299]
  28. Hariri M, Azadbakht L: Magnesium, Iron, and Zinc Supplementation for the Treatment of Attention Deficit Hyperactivity Disorder: A Systematic Review on the Recent Literature. Int J Prev Med 6:, 2015  [PMID:26445630]
  29. Rucklidge JJ, Kaplan BJ: Broad-spectrum micronutrient treatment for attention-deficit/hyperactivity disorder: rationale and evidence to date. CNS Drugs 28:775, 2014  [PMID:25056569]
  30. Gordon HA et al: Clinically Significant Symptom Reduction in Children with Attention-Deficit/Hyperactivity Disorder Treated with Micronutrients: An Open-Label Reversal Design Study. J Child Adolesc Psychopharmacol 25:783, 2015  [PMID:26682999]
  31. Colter AL, Cutler C, Meckling KA: Fatty acid status and behavioural symptoms of attention deficit hyperactivity disorder in adolescents: a case-control study. Nutr J 7:, 2008  [PMID:18275609]
  32. Kiddie JY et al: Nutritional status of children with attention deficit hyperactivity disorder: a pilot study. Int J Pediatr 2010:, 2010  [PMID:20652039]
  33. Akhondzadeh S, Mohammadi MR, Khademi M: Zinc sulfate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: a double blind and randomized trial [ISRCTN64132371]. BMC Psychiatry 4:, 2004  [PMID:15070418]
  34. Bilici M et al: Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry 28:181, 2004  [PMID:14687872]
  35. Arnold LE et al: Zinc for attention-deficit/hyperactivity disorder: placebo-controlled double-blind pilot trial alone and combined with amphetamine. J Child Adolesc Psychopharmacol 21:1, 2011  [PMID:21309695]
  36. Wang Y et al: Iron Status in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. PLoS ONE 12:, 2017  [PMID:28046016]
  37. Konofal E et al: Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol 38:20, 2008  [PMID:18054688]
  38. Cortese S et al: Iron and attention deficit/hyperactivity disorder: What is the empirical evidence so far? A systematic review of the literature. Expert Rev Neurother 12:1227, 2012  [PMID:23082739]
  39. Hawkey E, Nigg JT: Omega-3 fatty acid and ADHD: blood level analysis and meta-analytic extension of supplementation trials. Clin Psychol Rev 34:496, 2014  [PMID:25181335]
  40. LaChance L et al: Omega-6 to Omega-3 Fatty Acid Ratio in Patients with ADHD: A Meta-Analysis. J Can Acad Child Adolesc Psychiatry 25:87, 2016  [PMID:27274744]
  41. Gillies D et al: Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev Jul 11  [PMID:22786509]
  42. Königs A, Kiliaan AJ: Critical appraisal of omega-3 fatty acids in attention-deficit/hyperactivity disorder treatment. Neuropsychiatr Dis Treat 12:1869, 2016  [PMID:27555775]
  43. Mitchell RH, Goldstein BI: Inflammation in children and adolescents with neuropsychiatric disorders: a systematic review. J Am Acad Child Adolesc Psychiatry 53:274, 2014  [PMID:24565356]
  44. Joseph N et al: Oxidative Stress and ADHD: A Meta-Analysis. J Atten Disord 19:915, 2015  [PMID:24232168]
  45. Ahn J et al: Natural Product-Derived Treatments for Attention-Deficit/Hyperactivity Disorder: Safety, Efficacy, and Therapeutic Potential of Combination Therapy. Neural Plast 2016:, 2016  [PMID:26966583]
  46. Pliszka S, AACAP Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 46:894, 2007  [PMID:17581453]

Last updated: November 14, 2017

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TY - ELEC T1 - Attention Deficit Hyperactivity Disorder ID - 1342020 Y1 - 2017/11/14/ PB - Nutrition Guide for Clinicians UR - https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342020/all/Attention_Deficit_Hyperactivity_Disorder ER -