Understanding and Treating Attention Deficit Hyperactivity Disorder (ADHD)
"I was trying to daydream but my mind kept wandering."-Steven Wright
Attention Deficit/Hyperactivity Disorder, or ADHD, is one of the most commonly diagnosed disorders in children today. Indeed, researchers and clinicians believe that 2-5% of all children suffer from ADHD, a significant number to say the least. (Gluck) Characterized by an individual’s inability to focus and sustain attention, as well as a cumbersome level of hyperactivity and impulsivity, this disorder creates seemingly insurmountable hurtles for school-age children. Not only children suffer from ADHD, however – the condition is chronic, meaning that it persists throughout the lifetime. (asha.org) Fortunately there is hope; we live in an exciting time for ADHD research, constantly uncovering new information regarding the source of the disorder and options for treatment.
Unfortunately, misinformation regarding ADHD is widespread among the general public. Many believe that it isn’t a disorder at all, and that the symptoms are simply part of the natural range of behavior during childhood. Others insist it’s a personality defect; poor behavior due to a lousy disposition or a faulty upbringing. But the fact is that there is empirical evidence demonstrating the physical differences in people who suffer from this disorder, indicating that it is biological in nature.
Neurotransmitters carry information from one neuron to the next, transmitting messages throughout the entire body. This is how your brain gives and receives data and instructions.
Dopamine Levels Explain Behavior
ADHD is understood to be characterized by low levels of dopamine in the brain. Dopamine is a type of neurotransmitter, which are molecules that carry messages between neurons in your body. Dopamine in particular is associated with pleasure and reward, playing a vital role in the influence of behavior and motivation. Thus, reduced levels of the neurotransmitter provide an explanation for difficulties producing motivation in ADHD children. Indeed, clinical trials in which rats are given dopamine-blocking drugs result in incredibly lazy behavior. Although the rats will eat their food if placed in front of them, they cannot be motivated to work for it as rats with healthy dopamine levels will (by pressing a lever, for example). Similarly, when given a choice between eating mediocre food without effort or eating a preferred treat that requires some work, the dopamine-deficient rats will settle for the easy, less delicious snack. (Gluck) This behavior is consistent with the ADHD symptom of “delay discounting”, which refers to “a preference for smaller, immediate rewards over larger, delayed rewards”. (Shiels, p. 291)
Low dopamine also sheds light on the elevated levels of drug abuse and obesity in individuals with ADHD. They may be unconsciously attempting to boost their dopamine levels through these typically physiologically rewarding behaviors. (bnl.gov)
Physical Clues in the Brain
In addition to physiological clues, there are physical differences in the brains of attention-deficit individuals. Neuroimaging of children’s brains with ADHD reveal smaller right prefrontal-cortex regions, an area of the brain associated with spatial attention and working memory. Working memory refers to the manipulation of our short-term memories. If you are mentally calculating the price of a sale item, repeating a phone number as you reach for the phone, or mapping out your day’s schedule, you are using your working memory. These deficits in ADHD patients have been demonstrated in studies involving mental calculations that require the use of this mental tool. (Gluck)
Higher Doses Affect Performance Differently
In the working memory task described, It’s worth noting that reaction time actually decreased at the highest levels of task difficulty and Ritalin dose. On the other hand, accuracy continued to increase. This may indicate that higher levels of the stimulant reduced impulsivity and allowed the participants to take more care with the perceived difficulty of the task. (Berman)
The Medical Method
There are several different approaches to the treatment of ADHD, with perhaps the most common being psychopharmacological – the use of medicine to influence behavior. Common treatments employ drugs that increase dopamine levels in the brain, either by increasing the release or blocking the reuptake of dopamine. You’ve likely heard of Ritalin, the common name for the psychoactive drug methylphenidate.This stimulant blocks the reuptake of dopamine, leaving a higher extracellular concentration available to be used for neurotransmission. (Sheils)
Clinical trials studying the effects of Ritalin have established its effectiveness in relieving various ADHD symptoms. One study explored the effects on working memory in children between the ages of 7 and 13. Healthy participants showed appropriate improvement of accuracy and reaction time as age increased. All ages of ADHD participants, on the other hand, displayed accuracy and reaction times comparable to the youngest non-ADHD children. The application of varying levels of Ritalin showed significant improvements in the performance of ADHD participants, with a positive correlation between dose and performance. (Berman)
Another study tested ADHD children between the ages of 9 and 12 for delay discounting, using a point currency system that offered choices between small immediate rewards and larger, delayed rewards. The double-blind experiment randomly assigned Ritalin or placebo pills to each participant before completing the task. Results demonstrated a significant reduction in the preference for the smaller, immediate rewards in the medicated children, while demonstrating no change from the placebo. (Sheils)
Behavioral Therapy and Bimodal Approaches
Another popular and less intrusive approach to the treatment of ADHD symptoms in children is behavioral therapy. This method typically uses a point system to reinforce desired behavior and punish negative behavior in various settings, such as the classroom or at home. While behavioral therapy has demonstrated some success in these treatments, research has repeatedly indicated that a combination of both psychoactive medication and behavioral therapy produces the most significant changes in clinical trials. (Conway)
One example studied 27 ADHD-diagnosed children between the ages of 6 and 12 during a summer treatment program. The children were randomly assigned varying combinations of behavioral therapy, Ritalin, and placebo pills and observed in a classroom setting over several weeks. Their behavior was assessed by evaluators blind to their treatment and evaluated based on academic productivity, compliance to rules, and interactions with peers and adults. Results found that non-medicated children were almost 19 times more likely to reach their daily point “goals” on the days when behavioral therapy was employed. Even more impressively, these children were 4-13 times even more likely to reach their daily goals if receiving both medication and behavioral therapy.
It’s important to note that these results are only produced with low doses of stimulants, however – as dosage increases, the benefits of the behavioral therapy disappear. This particular experiment found 5 – 10 mg of Ritalin most effective. (Pelham) This is good news for parents who aren’t comfortable heavily medicating their child!
A Dietary Fix?
In addition to behavioral and pharmacological therapies, there is some evidence that ADHD symptoms can be influenced by lifestyle changes, particularly diet. Dr. Benjamin Feingold claimed in 1973 that many of the symptoms of ADHD were the result of sensitivity to salicylates (substances found in some fruits and vegetables as well as artificial coloring and flavors) and that removing them from the diet reduced symptoms in 30% – 50% of his patients. Unfortunately, the research methods used to test the “Kaiser-Permanente (KP) diet” were questionable.
The work has inspired numerous comparable studies over the past years, however, and there is evidence that Feingold was on the right track. A meta-analysis was conducted of several studies that applied an “oligoantigenic” diet, which is an incredibly simple diet including only a few foods, none of which commonly trigger allergies. After un-medicated children with ADHD followed the strict diet for 3 to 4 weeks, positive responses were seen in 71% - 82% of them. Various foods were then slowly incorporated back in to the diets in order to identify the “problem foods”. Artificial colors and flavors were the most common issues by far, but the vast majority of participants had a reaction to more than one item. Other common culprits included soy, milk, chocolate, eggs, wheat, corn, and legumes. (Stevens)
Another study tested the red blood cells of 75 children with ADHD for unsaturated fatty acid levels. A significant positive correlation was found between levels of omega-6 polyunsaturated fatty acids and key ADHD symptoms, including inattention and deficits in reading, vocabulary, and spelling abilities. These fatty acids are obtained through diet, particularly in four major types of oil (palm, rapeseed, soybean, and sunflower). This study suggests that it’s no coincidence that the American diet contains unusually high levels of these oils, and that the American population contains unusually high levels of ADHD-diagnosed children. (Milte)
The implications of this research are quite exciting – that perhaps some parents can choose to treat their children without the questionable side-effects of medication and inconveniences of ongoing behavioral therapy.
Attention Deficit Hyperactivity Disorder is a very real problem that affects many families. It’s vital that parents of ADHD children understand their treatment options in order to find the best solution for their child. Some may find that a simple dietary change works miracles, or that a few behavioral modification techniques can alleviate conflict in the home and in the classroom. Others may discover that medication breaks down the barrier between their child and education. And all of us should keep an eye out for new and exciting research happening every day, as health professionals work towards the best solution for our children.
More Tools for Parents
Berman, T., Douglas, V. I., & Barr, R. G. (1999). Effects of methylphenidate on complex cognitive processing in attention-deficit hyperactivity disorder. Journal Of Abnormal Psychology, 108(1), 90-105. doi:10.1037/0021-843X.108.1.90
Conway, F. (2012). Psychodynamic Psychotherapy of ADHD: A Review of the Literature. Psychotherapy, doi:10.1037/a0027344:
Gluck, Mark A. Learning and Memory: From Brain to Behavior. New York: Worth Publishers, 2008.
Milte, M., Catherine, Sinn, Natalie, Buckley, D., Jonathan, Coates, M., Alison, Young, M., Ross, & Howe, R.C., Peter. (2011). Polyunsaturated fatty acids, cognition and literacy in children with ADHD with and without learning difficulties. Child Health Care. 15: 299. doi: 10.1177/1367493511403953
Pelham, W. E., Burrows-MacLean, L., Gnagy, E. M., Fabiano, G. A., Coles, E. K., Tresco, K. E., & ... Hoffman, M. T. (2005). Transdermal Methylphenidate, Behavioral, and Combined Treatment for Children With ADHD. Experimental And Clinical Psychopharmacology, 13(2), 111-126. doi:10.1037/1064-1218.104.22.168
Shiels, K., Hawk, L. r., Reynolds, B., Mazzullo, R. J., Rhodes, J. D., Pelham, W. r., & ... Gangloff, B. P. (2009). Effects of methylphenidate on discounting of delayed rewards in attention deficit/hyperactivity disorder. Experimental And Clinical Psychopharmacology, 17(5), 291-301. doi:10.1037/a0017259
Stevens, J., Laura, Kuczek, Thomas, John, R., Burgess, Hurt, Elizabeth, & Arnold, Eugene, L. (2010). Dietary Sensitivities and ADHD Symptoms: Thirty-five Years of Research. Clinical Pediatrics. 50:279. doi: 10.1177/0009922810384728
Attention Deficit / Hyperactivity Disorder (ADHD). American Speech-Language-Hearing Association, 2012. Web. 8 May 2012. http://www.asha.org
Deficits in Brain’s Reward System Observed in ADHD Patients. Brookhaven National Laboratory News, 8 September, 2009. Web. 8 May 2012. http://www.bnl.gov
© By: Allison A. Green, All Rights Reserved