Attention deficit/hyperactivity disorder (ADHD) is the most commonly
diagnosed behavioral disorder of childhood, estimated to affect between 3% and
5% of school-aged children. The core symptoms of ADHD include inattention,
hyperactivity, and impulsivity. Although many people occasionally have
difficulty sitting still, paying attention, or controlling impulsive behavior,
these behaviors are so persistent in people with ADHD that they interfere with
daily life. Generally, these symptoms appear before the age of 7 years and cause
significant functional problems at home, in school, and in various social
settings. One- to two-thirds of all children with ADHD (somewhere between 1% and
6% of the general population) continue to exhibit ADHD symptoms into adult life.
Diagnosis is difficult (usually requiring more than one visit) but essential, as
early treatment can substantially alter the course of a child's educational and
Signs and Symptoms
A person is considered to have ADHD if he or she demonstrates symptoms of
inattention, hyperactivity, and impulsivity for at least 6 months in at least
two settings (such as at home and in school). The signs and symptoms listed
below are typically seen in children with ADHD and usually appear before age
seven. (In order to diagnose ADHD in adults, psychiatrists must determine how
the adult patient behaved as a child.)
Symptoms of Inattention
Fails to pay close attention to details or makes careless
Has difficulty sustaining attention in tasks or play
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace
Has difficulty organizing tasks and activities
Avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort
Loses things necessary for tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Symptoms of Hyperactivity and Impulsivity
Fidgets with hands or feet or squirms in seat
Leaves seat in situations where remaining seated is
Runs or climbs excessively in inappropriate situations (in adolescents
or adults, may be limited to subjective feelings of restlessness)
Has difficulty playing or engaging in leisure activities
Acts as if "driven by a motor"
Blurts out answers before questions are completed
Has difficulty awaiting turn
Interrupts or intrudes on
Like most complex neurobehavioral disorders, the cause of ADHD is unknown.
Genetic factors as well as those affecting brain development during prenatal and
postnatal life are likely involved. Brain scans have revealed a number of
differences in the brains of ADHD children compared to those of non-ADHD
children. For example, many children with ADHD tend to have altered brain
activity in the prefrontal cortex, a region thought to be the brain's command
center. Irregularities in this area may impair an individual's ability to
control impulsive and hyperactive behaviors. Researchers also believe that
hyperactive behavior in children results from excessive slow-wave (or theta)
activity in certain regions of the brain. Other studies indicate that ADHD may
be caused by abnormally low levels of dopamine, a neurotransmitter involved with
mental and emotional functioning.
Heredity: children with ADHD usually have at least one first-degree
relative who also has ADHD and one-third of all fathers who had ADHD in their
youth have children with ADHD
Gender: ADHD is four to nine times more common in boys than in girls
(some experts believe that the disorder is underdiagnosed in girls,
Prenatal and early postnatal health: maternal drug, alcohol, and
cigarette use; exposure of the fetus to toxins, including lead and
polychlorinated biphenyls (PCBs); nutritional deficiencies and imbalances
Learning disabilities, communication disorders, and tic disorders such
as Tourette's sydrome
Other behavioral disorders, particularly those that involve excessive
aggression (such as oppositional defiant or conduct disorder)
Nutritional factors (controversial): allergies or intolerances to
food, food coloring, or additives (see
Nutrition and Dietary
The names and symptoms for ADHD have changed frequently since the turn of the
century. What is now referred to as ADHD has been described in the past as
Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, and Attention
Deficit Disorder (ADD) With or Without Hyperactivity. The name ADHD was adopted
in 1987 by the third revision of the Diagnostic and Statistical Manual of Mental
Diagnosis is largely dependent on specific observed behaviors. The first step
in establishing the diagnosis of ADHD is to determine whether the individual
meets the diagnostic criteria as defined in the DSM-IV. The DSM-IV's symptomatic
criteria were developed for children; there are no specific criteria for ADHD in
adults. In these cases, physicians will often determine the psychiatric status
of the adult patient as a child and make a retroactive diagnosis of childhood
ADHD. Since most of the characteristic behaviors of childhood ADHD occur at home
and in the school setting, parents and teachers play an important role in
providing information to establish the diagnosis.
DSM-IV Diagnostic Criteria:
Either (1) or (2) 1.Six (or more) symptoms of
inattention that persist for at least 6 months to a maladaptive degree
inconsistent with the child's developmental level 2.Six (or more)
symptoms of hyperactivity-impulsivity that persist for at least 6 months to a
maladaptive degree inconsistent with the child's developmental level
Some inattentive or hyperactive-impulsive symptoms that caused
impairment were present before the age of 7 years
Some impairment from symptoms present in two or more settings (such as
at school/work and home)
Clear evidence of significant impairment in functioning
Symptoms not secondary to another pyschological disorder (such as mood
disorder, anxiety disorder)
Although most children with ADHD have symptoms of both inattention and
hyperactivity-impulsivity, some tend to demonstrate symptoms from one cluster or
the other. These specific subtypes of ADHD are based on the predominant symptom
pattern exhibited for the past 6 months:
ADHD, Combined Type: if both A1 and A2 criteria are met
ADHD, Predominantly Inattentive Type: if A1 is met but A2 is
ADHD, Predominantly Hyperactive-Impulsive Type: if A2 is met but A1 is
There are no targeted prevention programs for ADHD. Nevertheless, the
following steps may be taken to help reduce the risk of neurobehavioral
disorders including ADHD:
Minimizing exposures to potential neurotoxins (such as lead, heavy
metals, pesticides, herbicides) in the environment
Screening children for high levels of lead in the blood and treating
Obtaining comprehensive healthcare during and immediately following
Addressing psychosocial stressors in the lives of all children
Despite the effectiveness of stimulant
medications, multiple strategies are
required to effectively manage ADHD over the long-term. A combination of
prescription drugs and
lifestyle changes, including behavioral
therapies, is proving to be the best option for many children. Currently, the
most accepted treatments include individual and family education, behavioral
therapy, school remediation, and social skills training. Although
nutritional management (such as
elimination diets and high-dose vitamin supplementation) is among the most
frequently explored alternative therapy among parents, relatively few studies
support its effectiveness for ADHD. A growing number of studies suggest an
association between essential fatty acid (EFA) deficiencies and hyperactivity in
children, yet intervention studies using EFAs to treat behavioral problems have
reported varying results. Preliminary evidence also indicates that
mind/body techniques, particularly
biofeedback, may significantly improve behavior among children with
There are two basic ways to manage hyperactive children: change the child's
environment or change the child. The former can be accomplished by actively
modifying a child's social and family interactions, a process that usually
begins with parental training. The latter involves stimulant medication and
other interventions discussed in the sections that follow. Notably, a recent
study sponsored by the National Institute of Mental Health (NIMH) indicated that
a comprehensive treatment regimen that combines medication with intensive
behavioral interventions (such as parental training) is among the most effective
treatments for elementary school children with ADHD.
Parental training offered by skilled clinicians provides parents with tools
and techniques for managing their child's behavior. Behavior modification is
accomplished by rewarding appropriate behavior and discouraging destructive
behavior. Parents are taught to be as consistent as possible in their discipline
and to deliver praise and punishment that is appropriate to their child's
developmental level. For example, older children with ADHD may be rewarded with
points or tokens, or even written behavioral contracts with their parents.
Creating charts with stars for good behavior may be more effective for younger
children. Positive reinforcement must also be counterbalanced by swift and
consistent consequences for undesirable behavior. The following disciplinary
strategies have been shown to effectively distinguish undesirable behavior:
Establish rules that are easily understood, developmentally
appropriate, and not unduly harsh
Avoid repeated commands once the child has been reminded of the
Discipline the child before becoming too angry and
Follow disciplinary actions with praise when the child adheres to the
rules and behaves appropriately
In addition to behavioral intervention at home, modifications in the
classroom environment (and/or work, in the case of adolescents or adults) are
significant aspects of the treatment plan. Hyperactive children do best in
highly structured circumstances under the direction of a teacher experienced in
handling their disruptive behavior and capable of adapting to their distinctive
cognitive style. Since group interactions are often particularly challenging,
social skills training, appropriate classroom placement, and explicit rules of
engagement with peers are essential.
Adults with ADHD may benefit from a variety of behavioral interventions
including cognitive remediation, couple therapy, and family
According to the NIMH, stimulant medications are the most widely researched
and commonly prescribed treatments for ADHD. Although researchers do not fully
understand how these medications improve ADHD symptoms, studies indicate that
methylphenidate (the most commonly prescribed stimulant) significantly increases
dopamine levels in the brain. People with ADHD are believed to have abnormally
low levels of dopamine in the brain. Approximately 70% of people with ADHD
benefit from the first stimulant prescribed (usually methylphenidate), and an
additional 20% may respond to one of the other two drugs in this class if the
first did not work. The NIMH reports that the two most effective treatments for
children with ADHD are a closely monitored medication treatment and a treatment
that combines medication with intensive behavioral interventions.
Stimulant medications prescribed for ADHD include:
Methylphenidate: most commonly used medication for ADHD; effective in
75% to 80% of patients; not recommended for children under 6 years of
Dextroamphetamine: effective in 70% to 75% of patients; not
recommended for children under 3 years of age
Pemoline: effective in 65% to 70% of children; not recommended for
children under 6 years of age; should not be considered the first-choice
medication for ADHD because its use has been associated with liver failure
The following medications are recommended for those who do not improve from
Alpha2-agonists (such as clonidine, guanfacine): helpful in
individuals who are particularly aggressive or oppositional; may cause low blood
pressure in some individuals
Antidepressants: bupropion for children who also have mood disorders
such as depression; tricyclics (such as imipramine) for individuals who also
have tic disorders or significant symptoms of anxiety and
Nutrition and Dietary Supplements
According to a recent survey, nutritional therapies are the most commonly
used alternative treatment among American children with ADHD. Dietary management
of ADHD takes two basic forms: restriction and supplementation.
Additives and allergies
In 1975, Benjamin Feingold, a practicing allergist, proposed that artificial
colors, flavors, and preservatives, as well as naturally occurring salicylates
(found in many fruits and vegetables), were a major cause of hyperactive
behavior and learning disabilities in children. According to his observations,
eliminating all of these substances dramatically improved ADHD symptoms in 50%
of children, and reintroducing them one at a time caused the symptoms to recur.
Feingold's hypothesis, however, was based solely on experience and speculation
rather than scientific validation. A 1986 review of studies assessing the
Feingold diet determined that only 1% of children consistently improved on the
elimination diet and only 10% developed symptoms when challenged with artificial
Although the original Feingold diet has shown no consistent benefit for ADHD
children, a number of well-designed studies have found an association between
certain dietary constituents and poor behavior in children.
One such study assessed the effects of food coloring on behavior in 34
hyperactive children and 20 children with no behavioral problems. All children
were maintained on a color-free diet and were randomly given one colorless
capsule containing either lactose (placebo) or tartrazine (yellow food coloring)
at varying doses each morning for 21 days. Twenty-four of the 54 children became
more irritable and restless after taking tartrazine, whereas all of the children
behaved normally when given placebo. In a similar study of 26 children with
ADHD, behavior improved on days when certain foods (corn, wheat, milk, soy,
oranges, and food coloring) were eliminated from the diet. Behavior worsened on
days when these same foods were re-introduced to the diet. Notably, most of the
children who demonstrated an improvement in behavior with these restrictive
diets in both of the studies described also had a history of allergies (such as
asthma and allergic rhinitis). Eggs, peanuts, and fish are foods believed to
carry a high risk of causing an allergic reaction. Some researchers speculate
that eliminating these foods from the diet may improve symptoms of ADHD in
certain children. Elimination diets, however, should only be used under the
guidance and direction of a registered dietician because of the potential risk
Sugar and Artificial Sweeteners
There are virtually no scientific studies supporting the widespread belief
that sugar consumption causes or worsens ADHD behavior. In one study, children
who consumed diets high in sugar or high in artificial sweeteners behaved no
differently than children who consumed diets free of these substances. This was
true even among children whose parents described them as having a sensitivity to
sugar. A review of 12 studies also failed to find any evidence that ingestion of
sugar (including candy and chocolate) worsens behavior among children with ADHD.
A well-balanced diet rich in micronutrients is essential for normal brain
development, particular in young children. In fact, many children with nutrient
deficiencies have significant cognitive and behavioral problems. These
conditions, however, are extremely rare in children living in industrialized
countries like the United States. Nevertheless, children with ADHD tend to have
irregular eating habits and are therefore at slightly increased risk for
becoming mildly deficient in certain nutrients.
Using high-dose vitamin treatment (up to 10 times the recommended daily
allowance) has been advocated as a treatment for many chronic conditions,
including ADHD. However, there is no consistent evidence that megavitamin
therapy is of benefit in hyperactive children, and, in some cases such therapy
may actually have toxic effects.
Symptoms of magnesium deficiency include irritability, decreased attention
span, and mental confusion. Mild magnesium deficiency is not uncommon in
normally nourished children, and some experts believe that children with ADHD
may be exhibiting the effects of mild magnesium deficiency. In one study of 116
children with ADHD, 95% were magnesium deficient. In a separate study, 75
magnesium-deficient children with ADHD were randomly assigned to receive
magnesium supplements in addition to standard treatment or standard treatment
alone for 6 months. Those who received magnesium demonstrated a significant
improvement in behavior, whereas the control group exhibited worsening behavior.
Adequate levels of vitamin B6 (pyridoxine) are required for normal brain
development and are essential for the synthesis of essential brain chemicals
including serotonin, dopamine and norepinephrine. A preliminary study found that
pyridoxine was slightly more effective than methylphenidate (the most commonly
used stimulant) in improving behavior among hyperactive children. The results,
however, were not significant and no other studies have been able to confirm
these findings. Therefore, supplementation with vitamin B6 is not considered a
standard treatment for ADHD.
Iron deficiency is common among children and adolescents, particularly in
lower socioeconomic groups where it affects half of all infants. Normal levels
of iron in the blood are necessary for optimal brain function. Symptoms of iron
deficiency include decreased attention, arousal, and social responsiveness.
There is little scientific evidence, however, that iron supplementation in those
who are deficient improves behavior in children with ADHD. Since iron can be
toxic in children who are not deficient, there is little justification for its
supplementation as treatment for ADHD in those with normal levels of this
mineral. If iron levels are low, a healthcare provider can determine whether
replacement is needed.
Zinc regulates the activity of neurotransmitters, fatty acids, and melatonin,
all of which are related to the biology of behavior. Two separate studies found
that children with ADHD have significantly lower blood zinc levels than children
without ADHD. Another study indicated that ADHD children with mild zinc
deficiency may be less likely to improve from a commonly prescribed stimulant
than children with adequate zinc levels. To date, however, no studies have been
conducted to evaluate whether zinc supplementation improves behavior in children
with ADHD who are deficient in this mineral.
Although melatonin supplementation probably has no direct effect on the
primary symptoms of ADHD, it may be effective in managing sleep cycle
disturbances in children with a variety of developmental disorders, including
Essential Fatty Acids
Fatty acids play a key role in normal brain function. Since the body cannot
synthesize essential fatty acids (EFA), they must be provided in the diet. There
are two major types of EFAs: omega-3 fatty acids (found in cold-water fish such
as salmon, mackerel, halibut, and herring) and omega-6 fatty acids (found in
commonly used cooking oils, such as sunflower oil, safflower oil, corn oil, and
soybean oil). Omega-3 fatty acids are highly concentrated in the brain and
appear to play a particularly important role in cognitive and behavioral
function. Specific enzymes convert EFAs (such as alpha linolenic acid [ALA])
into other substances known as long-chain polyunsaturated fatty acids (PUFAs).
PUFAs, including eicosapentaenoic acid (EPA) and docosahexanoic (DHA), are also
essential for normal brain function. Some researchers believe that individuals
with ADHD may have difficulty converting EFAs to PUFAs and may be deficient in
both of these substances. In a recent study, researchers reported the following
findings in hyperactive boys compared to boys of the same age who were not
Lower blood levels of PUFAs and omega-3 fatty acids
More allergies and other health problems associated with EFA
Less likelihood of having been breastfed (breast milk contains
Another study found that boys with lower levels of omega-3 fatty acids had
more learning and behavioral problems (such as temper tantrums and sleep
disturbances) than boys with normal omega-3 fatty acid levels. Despite the
accumulation of evidence suggesting a link between PUFA deficiency and ADHD,
however, further studies are necessary before EFA supplementation can be
recommended for children with ADHD.
Several herbal remedies for ADHD are sold in the United States and Europe but
few scientific studies have investigated whether these herbs improve symptoms of
ADHD. Herbs, like other medications, may have side effects or interact with
other medications. They should therefore be used with caution and under the
guidance of a professionally trained and qualified herbalist. One or more of the
following calming herbs may be recommended for people with ADHD:
Roman chamomile(Chamaemelum nobile)
Kava kava (Piper methysticum)
Valerian (Valerian officinalis)
Lemon balm (Melissa officinalis)
Passionflower (Passiflora incarnata)
Other herbs commonly contained in botanical remedies for ADHD
Pycnogenol: a bioflavonoid antioxidant extracted from pine bark
Gingko (Gingko biloba): this herb has been used clinically in
Europe for circulatory and memory disorders.
American ginseng (Panax quinquefolium) and gingko: One recent
study suggests that gingko in combination with ginsengmay improve
symptoms of ADHD.
Massage and Physical Therapy
Relaxation and massage techniques have been shown to reduce anxiety and
activity levels in children and adolescents with a variety of psychiatric
illnesses. In one study of 28 teenage boys with ADHD, those who received 15
minutes of massage for 10 consecutive school days demonstrated significant
improvement in measures of behavior and concentration compared to those who were
guided in progressive muscle relaxation for the same duration of time.
In a study of 43 children with ADHD, those who received an individualized
homeopathic remedy demonstrated a significant improvement in behavior compared
to children who received placebo. The homeopathic remedies found to be most
Mind/body techniques such as hypnotherapy, progressive relaxation, and
biofeedback are particularly well suited to children and adolescents. Children
tend to readily accept hypnotic suggestion and the visual process of biofeedback
works well for children of this generation because many are accustomed to
computerized graphics. Through these techniques, children are often able to
learn coping skills that will stay with them for the rest of their lives. These
treatments allow children to gain a sense of control and mastery, increase
self-esteem, and decrease stress.
Many researchers believe that hyperactive behavior in children results from
excessive slow-wave (or theta) activity in certain regions of the brain. In EEG
biofeedback, or neurofeedback, an individual is provided with information
regarding his or her brain activity. The subject is then trained to suppress
slow wave activities while enhancing faster brain waves, over a period of
usually 40 or more sessions. The belief is that these children can be trained to
consciously modify and permanently change this underlying abnormal electrical
brain activity associated with ADHD.
In one study of 23 hyperactive children and teenagers, those who successfully
decreased their theta activity after 2 to 3 months of intensive neurofeedback
training showed significant improvements in behavior and attention. In a similar
study of 18 children and adolescents with ADHD, those who attended 40
neurofeedback sessions over a 6-month period demonstrated a significant
improvement in IQ scores and a substantial reduction in inattentive behavior
compared to those who did not attend the neurofeedback sessions.
A larger, more recent study found that a combination of 40 behavioral
treatments (neurofeedback and metacognitive strategies, a technique designed to
help individuals consciously monitor how they learn and remember things),
significantly improved ADHD symptoms, academic performance, and IQ scores among
children and adults with ADHD. The combined treatment also dramatically reduced
the need for medications; 30% of the participants were taking stimulant
medication at the beginning of the study compared to only 6% at the end of the
study. To be most effective for ADHD, however, these mind/body techniques should
be incorporated into an overall comprehensive treatment plan that is tailored to
the particular individual.
Traditional Chinese Medicine
Although no published studies have evaluated qi gong as a treatment for ADHD,
preliminary evidence from unpublished research suggests that weekly qi gong
breathing techniques may improve attention and reduce disruptive behaviors in
To prevent ADHD in their unborn children, pregnant women should obtain high
quality prenatal medical care, abstain from cigarette, alcohol, and drug use,
and should avoid exposure to toxic substances, including
Prognosis and Complications
As many as half of all children with ADHD who receive appropriate treatment
learn to control symptoms and function well in adulthood, while the remaining
continue to exhibit symptoms of inattention and impulsivity throughout life. As
many as 50% to 80% of those who do not seek treatment for ADHD may demonstrate
delinquent and antisocial behavior into adulthood. Research suggests that
children who receive sustained comprehensive treatment (such as medication,
behavioral therapy, and biofeedback) are less likely to have behavioral problems
in adolescence. In most cases, ADHD can be effectively managed throughout life,
particularly when multiple treatment strategies are combined.
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Review Date: December 2001
Reviewed By: Participants in the review process include: Richard Glickman-Simon, MD,
Department of Family Medicine, New England Medical Center, Tufts University,
Boston, MA; Jacqueline A. Hart, MD, Department of Internal Medicine,
Newton-Wellesley Hospital, Harvard University and Senior Medical Editor
Integrative Medicine, Boston, MA; James Lake, MD, Psychiatry, Community Hospital
of the Monterey Peninsula, Pacific Grove,
The publisher does not accept any responsibility for the accuracy of
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