Understanding AD/HD

Attention-Deficit/Hyperactivity Disorder (AD/HD) is a chronic disorder that plagues both children and at least 4 percent of adults.

It can have devastating effects on the lives of its victims and their families. Left untreated, it will, at the very least, prevent its victims from ever realizing their full potential.

AD/HD is a hot topic of conversation these days. Mainstream Media reports often suggest that the rate of diagnosis is increasing at an alarming rate, and more and more concerned parents of children diagnosed with AD/HD are seeking alternatives to pharmaceuticals. A decade ago, it was generally believed that 3 to 7 percent of American children between the ages of 3 – 17 suffered from AD/HD (DSM-IV-TR, 2000). By 2010, the Center for Disease Contro, Vital & Health Statistics (CDC) was reporting that 8.4 percent of American children have AD/HD. While misdiagnosis, as well as underdiagnosis in the past, might help partially explain the increase in AD/HD diagnoses over the past decade, AD/HD is, in fact, is the most commonly diagnosed behavioral disorder in children.

The primary characteristics of AD/HD are:

• Inattention
• Hyperactivity
• Impulsivity

Most people with AD/HD have symptoms of all three of these subtypes, but some only have symptoms of inattentiveness, with no hyperactivity-impulsivity symptoms.

While it is normal for children to sometimes be hyperactive or inattentive, when these behaviors are severe and impair the child’s life, it may be time to seek help.

Children mature and develop at different rates and have different personalities, temperaments, and energy levels. It’s normal for all kids to be inattentive, hyperactive, or impulsive sometimes, but for those with AD/HD, these behaviors are more severe, more frequent, and tend to significantly impair the child’s life.

People struggling with uncontrolled AD/HD can be restless, careless, and avoidant.

People who have AD/HD — especially children — are often described as “never walking, only running.” They may seem “motor-driven,” restless, have trouble sitting quietly. They may attempt to do several things at once, most of them unsuccessfully. They have trouble completing tasks and tend to bounce from one uncompleted project to another. Their work is often messy, careless, and performed without thought or focus. They tend to avoid tasks that require sustained mental effort (e.g., complex organization or close concentration) because they experience these tasks as unpleasant and wish to avoid the feeling of failing. They tend to prefer quick fixes, rather than working to achieve greater long-term rewards.

AD/HD is experienced differently by males and females, as well as people of different ages.

Toddlers, Preschoolers, and School Age Children

Toddlers and preschoolers with AD/HD may constantly dart back and forth, run through the house, climb on furniture, always seem to be “into everything.” They have trouble sitting still in preschool for “quiet” tasks (e.g., listening to a story). School-age children display similar behaviors, but with less intensity and frequency. They might fidget with objects, tap their hands, shake their feet or legs excessively. They talk excessively, make excessive noise during quiet activities and tend to jump up from the table during meals while watching television, or while doing homework.

Adolescents and Adults

Hyperactive adolescents and adults tend to feel restless and jittery and have difficulty engaging in quiet, sedentary activities. Teens often try to do too many things at once. They tend to look for quick payoffs and engage in risky, impulsive behaviors; for example, teens with AD/HD get three times as many speeding tickets as their peers and are involved in nearly four times as many auto accidents.

Symptoms of AD/HD generally emerge before age 7, but typically aren’t diagnosed until ages 8 – 10. Developmental milestones, however, may be revealed much earlier than that; for example, mothers sometimes report that their AD/HD child cried more than other babies, slept less, or was colicky or irritable. Some even swear that the child kicked more in the womb.

Inattention, impulsivity and hyperactivity can all manifest in academic, occupational or social settings.

AD/HD symptoms usually appear between the ages of 3 and 6, but because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other children, or seems constantly “out of control.” Often, teachers notice the symptoms first; for example, a child may have trouble following rules in class.

At least 4 percent of adults are living with AD/HD, many of whom don’t realize they suffer from the disorder. For some, a diagnosis of AD/HD might actually bring a sense of relief because they may have had a long history of academic failure, problems at work, and troubled relationships, but never understand the root cause of their problems. They may have struggled their whole lives with the simplest daily tasks — getting to work on time, organizing a schedule, sticking to a job, remembering appointments.

More than 70 percent of hyperactive children continue to meet the criteria for AD/HD as adolescents, and up to 65 percent of AD/HD children continue to experience symptoms as adults.

Hyperactivity often diminishes with age and is more frequent among those who are culturally deprived or disadvantaged.

AD/HD is diagnosed 2 to 3 times more frequently in males than in females; when the hyperactivity component is present, the rate of occurrence in males is even higher.

In 2010, the CDC reported that of children age 3 – 17, 11.2 percent of boys were diagnosed with AD/HD; 5.5 percent of girls.

While diagnosed less frequently, girls can struggle with the impact of AD/HD.

AD/HD is often experienced differently by boys and girls, and girls can be more difficult to diagnose early, since they tend to be less aggressive and boisterous than boys, in general. But girls may develop a broader range of problems in adolescence than boys. Older girls with AD/HD are more likely than younger girls to also suffer from depression and anxiety. Adolescent girls with AD/HD also stand a substantially greater risk of developing eating disorders. They frequently develop body-image dissatisfaction, and may engage in the repetitive cycles of binge eating and purging behaviors common to bulimia nervosa.

Girls suffering with AD/HD have difficulty coping with stress and are highly sensitive to criticism, thus they tend to withdraw — struggling quietly, masking their symptoms.

They lack the vigor and energy to develop the personality and skillsets that their peers have. In some cases, parents may have unintentionally made the situation worse by hurling criticisms like “Stop acting so silly!” or “Why can’t you be as smart as your brother?” Continuous criticism breeds low self-esteem and feelings of worthlessness. They may grow even more impulsive, disorganized, and distracted.

Boys suffering with AD/HD tend to be more impulsive, more hyperactive and are more likely to engage in reward-seeking behavior.

One study co-funded by the National Institute of Mental Health and the UW’s Royalty Research Fund, suggests that they may actually have trouble flipping the “OFF” switch on fun.

The study showed that, when rewarded, boys with AD/HD exhibit different brain activity patterns from normally developing boys. The research focused on two brain areas: the striatum, which is a network of structures in the midbrain that motivates us to engage in pleasurable or rewarding behavior, and the anterior cingulate cortex, an area higher in the brain that normally activates when an expected reward stops.

In the normal brain, when the reward stops, behavior stops — a process known as extinction. But when the reward was stopped for boys with AD/HD, fMRI brain scans showed that they continued to focus on the reward long afterward. The striatum did not turn off, and the anterior cingulate did not turn on. In other words, there was no extinction, and that may be the mechanism that often gets them into trouble.

People with any of the following are at higher risk for AD/HD:

• Genetic dopamine deficiency
• Traumatic brain injury
• Tourette’s Syndrome
• A parent with AD/HD
• A parent with Antisocial Personality Disorder
• A depressed parent
• A parent with a substance-related disorder (e.g., alcoholism)
• Unpredictable home environments; (e.g., divorce, marital turmoil or conflicting disciplinary approaches
• Learning disabilities, especially problems with reading
• Children whose mothers experienced abnormal pregnancies; e.g., premature birth and low birth weight
• Exposure while in utero to toxic environmental factors such as lead poisoning or tobacco smoke

There is no single cause of Attention-Deficit/Hyperactivity Disorder, but contributory factors may include: genetics, diet, and social and physical environments. AD/HD is both a neurobehavioral and a developmental disorder.

Genetic links to AD/HD and neurobiological mechanisms.

We know that AD/HD is highly heritable; in fact, genes have been found to play a role in about 75 percent of AD/HD cases. Hyperactivity appears to be primarily a genetic condition, though it can be caused by a variety of other factors.

So far, no single gene has been identified as the primary culprit behind AD/HD.

Many researchers believe that most occurrences of AD/HD involve multiple genes, some of which may affect dopamine transporters. For example, the “7-repeat” variant of the dopamine D4 receptor gene is believed to account for about 30 percent of the genetic risk for AD/HD (Shaw, Gornick, et al, 2007).

While there is clear evidence that people who suffer from AD/HD have dopamine abnormalities, there are competing theories about causation.

For example, a study conducted by the U.S. Department of Energy’s Brookhaven National Laboratory and the  New York Mount Sinai School of Medicine suggests that it is not the dopamine transporter levels that indicate ADHD, but the brain’s ability to produce dopamine. Several other studies have confirmed a dopamine production deficiency in the brains of adults with AD/HD, including an older 1998 study at the National Institute of Health. PET scans suggested that an abnormality in dopamine production occurs in only one of the dopamine-rich brain regions — the anterior frontal cortex, which is involved in motor activity and cognitive processes such as attention.

Many researchers believe that a malfunction with the neurotransmitter dopamine in people with AD/HD causes an abnormally low arousal state, which provokes them to seek constant environmental stimulation and activity.

People may be attempting to create their own excitement and stimulation, and they have trouble self-moderating.

SPECT scans have revealed that people with AD/HD have reduced blood circulation (which indicates low neural activity), and a significantly higher concentration of dopamine transporters in the striatum — an area of the brain that’s in charge of planning ahead. (Shaw, Gornick, et al, 2007).

Developmental Delays.

Some MRI studies of elementary school kids with AD/HD suggest that developmental traits such as impulse control lag behind on the normal developmental curve, typically by as much as 3 to 5 years.  This developmental delay seems to be most prominent in the frontal cortex and temporal lobe, which are responsible for controlling and focusing thinking. In contrast, the motor cortex in children with AD/HD appears to mature faster than normal, suggesting that both slower development of behavioral control and faster motor development may contribute to the fidgetiness that characterizes AD/HD.

Environmental factors.

There’s some evidence to suggest that AD/HD may be caused by exposure to high levels of lead early in life, as well as alcohol, nicotine, and tobacco smoke during pregnancy. Nicotine may cause hypoxia (lack of oxygen) to a fetus in utero, which could contribute to AD/HD. And unfortunately mothers who have AD/HD themselves may be more likely to smoke, which is a genetic-environmental cocktail.

Nutritional Deficiencies.

The widely-debated theory that sugar causes AD/HD or makes symptoms worse is still controversial. Sugar doesn’t seem to impact some AD/HD children, while in others, sugar seems to increase both inattentiveness and hyperactivity. Dietary sugar and starch do raise insulin levels which, in turn, disrupt brain chemistry by interfering with essential fatty acid metabolism.

People with AD/HD should be aware of their consumption of sugar, processed foods, and modern vegetable oils that lack EPA and DHA.

Several studies have found that brain volume, in all regions, is 3 to 4 percent smaller in children with AD/HD. Some researchers believe that modern vegetable oils may be unbalancing our essential fatty acid intake. Today’s fats and oils are largely devoid of lipids from the omega-3 essential fatty acid family, including essentials like EPA (eicosapentaenoic acid), and DHA (docosahexaenic acid). As a result, mothers are often deficient in DHA during pregnancy and while nursing, and DHA and AA (arachidonic acid) are virtually absent from infant formula. DHA and AA are required building blocks for proper development of a baby’s brain and eyes.

These high levels of omega-6 fatty acids, coupled with deficiencies of both EPA and DHA and/or high and unstable insulin levels, can also lead to higher cortisol levels and lower serotonin and dopamine levels in the brain. Low levels of both serotonin and dopamine are common in AD/HD patients. Low serotonin is associated with depression, impulsive behavior and violence.  Low dopamine has been associated with violent behaviors and an inability to concentrate or focus on a task. Excessive cortisol causes impaired short-term memory and feelings of stress.

While the mechanisms that cause AD/HD have not been fully determined, AD/HD appears to be a complex interaction between genetic and environmental factors, and treating it safely may require a creative combination of strategies.