Attention Deficit Hyperactivity Disorder in Adults and Children
Attention deficit hyperactivity disorder is a highly publicized childhood disorder that affects approximately 3 percent to 5 percent of all children. What is much less well known is the probability that, of children who have ADHD, many will still have it as adults. Several studies done in recent years estimate that between 30 percent and 70 percent of children with ADHD continue to exhibit symptoms in the adult years.

Due to its high frequency and its broad range of effects, there is a significant health and economic impact of ADHD. While the symptoms of distractibility, impulsivity, and hyperactivity can interfere with daily activities at work, school, or home, they may also contribute to the increased incidence of accidents (e.g. automobile collisions, poisoning, and fractures) occurring in patients with ADHD. Persons with ADHD are also more likely to exhibit additional mental health conditions such as learning disorders (25%), a conduct disorder (15%), anxiety disorder (20%), and/or depression (30%). The social and economic impact of ADHD reaches beyond the greater than average share of healthcare, mental health, social, and special education services extended to the patients directly, to include the health and work outcomes of caregivers. Family members are faced with both the additional challenge of living with or caring for a person who has ADHD, as well as the fact that at least some of them may also have psychological disorders since ADHD is a marker of genetic risk for mood disorder among family members.

Typically, adults with ADHD are unaware that they have this disorder—they often just feel that it's impossible to get organized, to stick to a job, to keep an appointment. The everyday tasks of getting up, getting dressed and ready for the day's work, getting to work on time, and being productive on the job can be major challenges for the ADHD adult.

Diagnosing AD/HD
Diagnosing an adult with ADHD is not easy. Many times, when a child is diagnosed with the disorder, a parent will recognize that he or she has many of the same symptoms the child has and, for the first time, will begin to understand some of the traits that have given him or her trouble for years—distractibility, impulsivity, restlessness. Other adults will seek professional help for depression or anxiety and will find out that the root cause of some of their emotional problems is ADHD. They may have a history of school failures or problems at work. Often they have been involved in frequent automobile accidents.

To be diagnosed with ADHD, an adult must have childhood-onset, persistent, and current symptoms.18 The accuracy of the diagnosis of adult ADHD is of utmost importance and should be made by a clinician with expertise in the area of attention dysfunction. For an accurate diagnosis, a history of the patient's childhood behavior, together with an interview with his life partner, a parent, close friend, or other close associate, will be needed. A physical examination and psychological tests should also be given. Comorbidity with other conditions may exist such as specific learning disabilities, anxiety, or affective disorders.

A correct diagnosis of ADHD can bring a sense of relief. The individual has brought into adulthood many negative perceptions of himself that may have led to low esteem. Now he can begin to understand why he has some of his problems and can begin to face them. This may mean, not only treatment for ADHD but also psychotherapy that can help him cope with the anger he feels about the failure to diagnose the disorder when he was younger.

What Causes Attention Deficit Disorder/ADHD?
Although the exact causes of ADHD are unknown, it is most likely caused by an interaction of genetic, environmental, and nutritional factors, with a strong focus on the interaction of multiple genes (genetic loading) that together cause ADHD.

The Role of Neurotransmitters in Attention Deficit Disorder
There is some evidence that people with ADHD do not produce adequate quantities of certain neurotransmitters, among them dopamine, norepinephrine, and serotonin. Some experts theorize that such deficiencies lead to self-stimulatory behaviors that can increase brain levels of these chemicals (Comings DE et al 2000; Mitsis EM et al 2000; Sunohara GA et al 2000).

 Find out more about the Neurotransmitter tests for Attention Deficit Disorder that are available!

Epinephrine
Epinephrine activation of receptors on the cranial vagus nerve increases the release of central norepinephrine and has been shown to enhance memory formation. Patients with ADHD have been shown to have a reduced urinary epinephrine level. Contrary findings are seen in patients with anxiety or PTSD. Given the high incidence of anxiety within ADHD patients as well as the increased risk of accident and injury, testing of epinephrine in ADHD patients should consider these other factors in order to have a better understanding of the role of epinephrine in ADHD.

Dopamine
ADHD is believed to be in part the result of a reduced or hypodopaminergic state. In conjunction with this assumption are the needs for stronger and less delayed behavioral reinforcement. Dopamine is involved in the reward cascade and the increased reinforcement threshold may be a manifestation of the hypodopaminergic state. Children with ADHD have displayed normal task performance under conditions of high incentive, but deficient performance under conditions of low incentive.  Methylphenidate is believed to be beneficial in ADHD in part due to its ability to enhance dopamine signaling and therefore may enhance a deficient reward system in ADHD patients. Like many parameters that affect cognitive performance, dopamine levels also display an inverted U-shaped curve when plotted against factors like impulsivity.

The development of the dopamine system prior to and during early adolescence is quite rapid, while the development of the serotonin system during this same time remains steady. A relative deficit in dopamine maturity would be concordant with an increased impulsivity and increased reward threshold seen in ADHD.

A delayed rate of brain development in ADHD is also supported by studies that find patients have increased level of delta and theta brain wave activity compared to controls. Delta and theta brain wave activity normally decreases until adulthood. As such, increased delta and theta wave brain activity can be an indicator of slowed brain maturity. Differences in the rate of serotonin and dopamine system development also may explain why significant numbers of children outgrow their ADHD symptoms.

Norepinephrine 
Norepinephrine is an excitatory neurotransmitter that is important for attention and focus. Norepinephrine is synthesized from dopamine by means of the enzyme dopamine beta-hydroxylase, with oxygen, copper, and vitamin C as co-factors. Dopamine is synthesized in the cytoplasm, but norepinephrine is synthesized in the neurotransmitter storage vesicles.; Cells that use norepinephrine for formation of epinephrine use SAMe as a methyl group donor. Levels of epinephrine in the CNS are only about 10% of the levels of norepinephrine.

The noradrenergic system is most active when an individual is awake, which is important for focused attention. Elevated norepinephrine activity seems to be a contributor to anxiousness. Also, brain norepinephrine turnover is increased in conditions of stress. Interestingly, benzodiazepines, the primary anxiolytic drugs, decrease firing of norepinephrine neurons.

PEA
PEA (phenylethylamine) is an excitatory neurotransmitter that tends to be lower in patients with ADHD. Studies that tested urine levels of PEA in subjects with ADHD during treatment with stimulants (methylphenidate or dextroamphetamine), found that the levels of PEA were increased. Additionally, studies report that the efficacy of the treatment correlated positively with the degree to which urinary PEA increased.

Serotonin
Many of the effects of serotonin occur due to its ability to modify the actions of other neurotransmitters. Specifically, serotonin regulates dopamine release. This is evident in the observation that antagonists of either the 5-HT2a or the 5-HT2c serotonin receptor will stimulate dopamine outflow while agonists inhibit dopamine outflow. Similarly, dopamine has a regulatory effect on serotonin and neonatal damage to the dopamine system has been shown to cause large increases in serotonin.

Aspects of the interaction between serotonin and dopamine are believed to affect attention. Evidence of this interaction is present in the observation that reduced serotonin synthesis impairs the positive effects of methylphenidate on learning. Meaning some aspects of methylphenidate's therapeutic effects require serotonin. Serotonin levels are significantly affected by stress and coping abilities combined with other environmental factors and the person's genetic make-up to determine serotonin activity. 

Brain Structural Differences in Attention Deficit Hyperactivity Disorder

There may also be some structural and functional abnormalities in the brain itself in children who have ADHD (Pliszka SR 2002; Mercugliano M 1999). Evidence suggests that there may be fewer connections between nerve cells. This would further impair neural communication already impeded by decreased neurotransmitter levels (Barkley R 1997). Evidence from functional studies in patients with ADHD demonstrates decreased blood flow to those areas of the brain in which "executive function," including impulse control, is based (Paule MG et al 2000). There may also be a deficit in the amount of myelin (insulating material) produced by brain cells in children with ADHD (Overmeyer S et al 2001).

Some prenatal factors that increase the risk of developing ADHD have been identified. These include complications during pregnancy that limit oxygen supply to the brain such as toxemia and eclampsia. Other factors during pregnancy that have an impact on normal prenatal development and increase the risk of a child developing ADHD include smoking and fetal alcohol syndrome.

Other factors, such as stress, significantly affect the way the brain functions. If the temperament of the individual under stress allows them to cope in a positive manner, stress can actually increase performance and health. If however, the temperament of the individual under stress is such that the individual does not cope with the stress, the adaptive changes that allow the body to enhance its performance and stress may fail to function. This may lead to either an inability of the body to compensate or the inactivation of some neurological systems. Alternatively, neurological systems may become chronically elevated. In either case, the altered functions of these regions may underlie clinical symptoms.

Genetics.
Attention disorders often run in families, so there are likely to be genetic influences. Studies indicate that 25 percent of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5 percent in the general population.6 Many studies of twins now show that a strong genetic influence exists in the disorder.7

Researchers continue to study the genetic contribution to ADHD and to identify the genes that cause a person to be susceptible to ADHD. Since its inception in 1999, the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network has served as a way for researchers to share findings regarding possible genetic influences on ADHD.8

Environmental Agents.

Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD in the offspring of that pregnancy. As a precaution, it is best during pregnancy to refrain from both cigarette and alcohol use.

Another environmental agent that may be associated with a higher risk of ADHD is high levels of lead in the bodies of young preschool children. Since lead is no longer allowed in paint and is usually found only in older buildings, exposure to toxic levels is not as prevalent as it once was. Children who live in old buildings in which lead still exists in the plumbing or in lead paint that has been painted over may be at risk.

Brain Injury.
One early theory was that attention disorders were caused by brain injury. Some children who have suffered accidents leading to brain injury may show some signs of behavior similar to that of ADHD, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

Food Additives and Sugar.
It has been suggested that attention disorders are caused by refined sugar or food additives, or that symptoms of ADHD are exacerbated by sugar or food additives. In 1982, the National Institutes of Health held a scientific consensus conference to discuss this issue. It was found that diet restrictions helped about 5 percent of children with ADHD, mostly young children who had food allergies.3 A more recent study on the effect of sugar on children, using sugar one day and a sugar substitute on alternate days, without parents, staff, or children knowing which substance was being used, showed no significant effects of the sugar on behavior or learning.4

In another study, children whose mothers felt they were sugar-sensitive were given aspartame as a substitute for sugar. Half the mothers were told their children were given sugar, half that their children were given aspartame. The mothers who thought their children had received sugar rated them as more hyperactive than the other children and were more critical of their behavior.5

Diagnosing ADHD
Accurate diagnosis of ADHD in adults is challenging and requires attention to early development and symptoms of inattention, distractibility, impulsivity and emotional lability. Diagnosis is further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions such as depression and substance abuse.

Diagnosis of Attention Deficit Hyperactivity Disorder is made using symptom checklist, rating scales, and mental status testing using the diagnosis criteria listed in the DSM-IV-TR.

Medical conditions that may mimic adult ADHD include hyperthyroidism, petit mal and partial complex seizures, hearing deficits, hepatic disease and lead toxicity

Sleep apnea and drug interactions should be considered as possible causes of inattention and hyperactivity. Patients with a history of head injury may also have problems with attention, concentration and memory.

Essential fatty acids. A growing body of scientific literature is helping parents and doctors better understand the link between fatty acids and behavioral disorders such as ADHD. The ratio between omega-3 and omega-6 fatty acids (such as arachidonic acid) seems especially important. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are omega-3 fatty acids found in flaxseed oil and cold water fish. In the typical Western diet, we tend to consume more omega-6 fatty acids relative to omega-3 fatty acids. The ratio of omega-3 to omega-6 fatty acids has been shown to influence the development of neurotransmitters and other chemicals that are essential for normal brain function. Increased intake of omega-3 fatty acids has been shown to reduce the tendency toward hyperactivity among children with ADHD (Haag M 2003).

Hypoglycemia is characterized by low blood sugar concentrations. Hypoglycemia can reduce the glucose supply to brain, contributing to difficulty in concentrating, irritability, mood swings and fatigue. In a subgroup of people with ADD/ADHD, hypoglycemia may be a major contributing factor.

Heavy Metals and AD/HD
An accumulation of heavy metals in the body can contribute to behavioral disorders. Hair mineral analysis is a valuable resource used for testing for toxic mineral accumulation.

Attention Deficit Disorder Testing

• Neurotransmitter Testing
• Glucose Tolerance Test
• Food Sensitivities or Food Allergies
• Hair Mineral Analysis
• Thyroid Panel
• Serum Lead
• Fatty Acid Analysis

ADD Nutritional Supplements

As previously mentioned, AD/HD is most likely caused by multiple factors, including nutritional issues. Children and adults with ADHD may have specific nutrient deficiencies that aggravate their condition.

Omega-3 fatty acids are essential components of brain cell membranes, including those of neurotransmitter receptors. Omega-3 fatty acids also alter signal transduction and electrical activity in brain cells and control the synthesis of chemicals such as eicosanoids and cytokines, which may have a direct effect on mood and behavior. Evidence supporting the role of fatty acid imbalances in the pathology of ADD/ADHD:

Research consistently finds people with ADD/ADHD have lower levels of essential fatty acids than controls. A large proportion of people with ADD/ADHD display essential fatty acid deficiency symptoms (e.g. excessive thirst, frequent urination, vision impairment, dry skin and hair, learning difficulties.)
There is evidence of an abnormality in essential fatty acid metabolism in a significant proportion of people with ADD/ADHD. Research suggests that people with lower levels of essential fatty acids have higher levels of behavior, learning and health problems. Several studies have examined the role of essential fatty acids in ADHD, with very encouraging results:

In one pilot study, children with ADHD were given flaxseed oil, which is rich in alpha-linolenic acid. In the body, alpha-linolenic acid is metabolized into EPA and DHA. At the end of the study, researchers found that the symptoms of children with ADHD who were given the flaxseed oil improved on all measures (Joshi K et al 2006).
Another study examined the effects of flaxseed oil and fish oil, which provide varying degrees of omega-3 fatty acids, on adults with ADHD. The patients were given supplements for 12 weeks. Their blood levels of omega-3 fatty acids were tracked throughout the 12 weeks. Researchers found that high-dose fish oil increased omega-3 acids in the blood relative to omega-6 acids. An imbalance between arachidonic acid and omega-3 fatty acids is considered a risk factor for ADHD (Young GS et al 2005).
Finally, one study compared 20 children with ADHD who were given a dietary supplement (that included omega-3 fatty acids) to children with ADHD who were given methylphenidate. The dietary supplement was a mix of vitamins, minerals, essential fatty acids, probiotics, amino acids, and phytonutrients. Amazingly, the groups showed almost identical improvement on commonly accepted measures of ADHD (Harding KL et al 2003).
One study has also indicated that children with ADHD benefit from intake of a combination of essential fatty acids and vitamin E (Stevens L et al 2003).

Magnesium and vitamin B6. Combining magnesium and vitamin B6 has shown promise for reducing symptoms of ADHD. Vitamin B6 has many functions in the body, including assisting in the synthesis of neurotransmitters and forming myelin, which protect nerves. Magnesium is also very important; it is involved in more than 300 metabolic reactions. At least three studies have demonstrated that the combination of magnesium and vitamin B6 improved behavior, decreased anxiety and aggression, and improved mobility among children with ADHD (Nogovitsina OR et al 2006a,b; Nogovitsina OR et al 2005; Mousain-Bosc M et al 2004).

Iron. Iron deficiency may be implicated in ADHD (Konofal E et al 2004), although supplementation studies have shown minimal or no effects (Millichap JG et al 2006). Because of the potential toxicity of iron supplements, parents should consult their children's pediatrician before beginning supplementation.

Zinc. Zinc is a cofactor for production of neurotransmitters, fatty acids, prostaglandins, and melatonin, and it indirectly affects metabolism of dopamine and fatty acids. However, the role of zinc in ADHD is still emerging. Numerous studies have shown that children with ADHD are often deficient in zinc. However, researchers have not determined that a zinc deficiency causes ADHD or that treatment with zinc can improve symptoms of ADHD (Arnold LE et al 2005a,b).

Acetyl-L-carnitine. This superior form of L-carnitine, which is responsible for transporting fatty acids into the mitochondria, has been associated with a host of positive health benefits, including reducing impulsivity. In an animal model of ADHD, acetyl-L-carnitine was shown to reduce the impulsivity index (Adriani W et al 2004).

Additional Nutrients and Hormones
 Melatonin. Melatonin is a hormone secreted at night by the pineal gland. It participates in multiple body processes, including regulation of the sleep/wake cycle. Because many children and adults who have ADHD also have sleep problems, melatonin can be an important part of an integrative therapy. By some estimates, up to 25 percent of children with ADHD also have sleep disorders. Unfortunately, however, conventional therapy treats the hyperactivity portion of the disease but neglects the sleep disorder (Betancourt-Fursow de Jimenez YM et al 2006). In one study of 27 children with ADHD and insomnia, 5 milligrams (mg) of melatonin, combined with sleep therapy, helped reduce insomnia (Weiss MD et al 2006).

Dehydroepiandrosterone (DHEA). DHEA is an important neuroactive steroid hormone that may be involved in ADHD, although researchers are still trying to understand the relationship. ADHD is associated with low blood levels of DHEA, its principal precursor pregnenolone, and its principal metabolite dehydroepiandrosterone-sulfate (DHEA-S). Higher blood levels of these neurosteroids are associated with fewer symptoms (Strous RD et al 2001). Furthermore, a study of adolescent boys with ADHD showed that DHEA levels rise after a 3-month course of methylphenidate treatment, which implies that DHEA somehow plays a role in the drug's effectiveness (Maayan R et al 2003).

Ginkgo biloba and ginseng. A combination of these two herbs has been studied for its ability to improve symptoms among patients with ADHD. In a study of 36 children ranging in age from 3 to 17 years old, a combination of Ginkgo biloba and American ginseng was administered twice a day on an empty stomach for 4 weeks. At the end of the study, more than 70 percent of patients had experienced improvement on a widely used measure of ADHD symptoms (Lyon MR et al 2001).

Attention Deficit Diet

Dietary interventions (as contrasted with dietary supplements) are based on the concept of elimination, that one or more foods are eliminated from one's diet.

The Feingold Program eliminates these additives:

Artificial (synthetic) coloring
Artificial (synthetic) flavoring
Aspartame (Nutrasweet, an artificial sweetener)
Artificial (synthetic) preservatives BHA, BHT, TBHQ
Many ADD/ADHD sufferers have found improvement in their symptoms by removing these from their diets.  For more information www.feingold.org

Foods to Avoid:

• Dairy products Artificial Sweetners (Especially Nutrasweet)
• Eliminate simple sugars (such as cakes, candy, ice cream, pastries) and simple carbohydrates that are readily broken down to sugar (such as bread, pasta, rice, potatoes). Refined carbohydrates have a negative impact on dopamine levels in the brain.
• Fruit Juice, Soda, Kool Aid
• Processed Meats
• Food Additives, Preservatives, Artificial Coloring

ADD/ADHD Food Suggestions:

lean meats, eggs, low fat cheeses, nuts and  beans, fresh vegatables (organic if possible) Complex carbohydrates (brown rice)

Treatment of ADHD in an Adult.

Medications. As with children, if adults take a medication for ADHD, they often start with a stimulant medication. The stimulant medications affect the regulation of two neurotransmitters, norepinephrine and dopamine. The newest medication approved for ADHD by the FDA, atomoxetine (Strattera®), has been tested in controlled studies in both children and adults and has been found to be effective.19

Antidepressants are considered a second choice for treatment of adults with ADHD. The older antidepressants, the tricyclics, are sometimes used because they, like the stimulants, affect norepinephrine and dopamine. Venlafaxine (Effexor®), a newer antidepressant, is also used for its effect on norepinephrine. Bupropion (Wellbutrin®), an antidepressant with an indirect effect on the neurotransmitter dopamine, has been useful in clinical trials on the treatment of ADHD in both children and adults. It has the added attraction of being useful in reducing cigarette smoking.

In prescribing for an adult, special considerations are made. The adult may need less of the medication for his weight. A medication may have a longer "half-life" in an adult. The adult may take other medications for physical problems such as diabetes or high blood pressure. Often the adult is also taking a medication for anxiety or depression. All of these variables must be taken into account before a medication is prescribed.

Education and psychotherapy. Although medication gives needed support, the individual must succeed on his own. To help in this struggle, both "psychoeducation" and individual psychotherapy can be helpful. A professional coach can help the ADHD adult learn how to organize his life by using "props"—a large calendar posted where it will be seen in the morning, date books, lists, reminder notes, and have a special place for keys, bills, and the paperwork of everyday life. Tasks can be organized into sections, so that completion of each part can give a sense of accomplishment. Above all, ADHD adults should learn as much as they can about their disorder.

Psychotherapy can be a useful adjunct to medication and education. First, just remembering to keep an appointment with the therapist is a step toward keeping to a routine. Therapy can help change a long-standing poor self-image by examining the experiences that produced it. The therapist can encourage the ADHD patient to adjust to changes brought into his life by treatment—the perceived loss of impulsivity and love of risk-taking, the new sensation of thinking before acting. As the patient begins to have small successes in his new ability to bring organization out of the complexities of his or her life, he or she can begin to appreciate the characteristics of ADHD that are positive—boundless energy, warmth, and enthusiasm.

Excerpts from NIMH and Neuroscience Inc.

Last Modified 3/22/08