1 Definition and History of ADHD................... 1 Brain Damage Syndromes........................ 1 Alternative Terms for ADHD...................... 2 Evolution of Present Concept of ADHD................ 2 Diagnostic Criteria for ADHD Subtypes................ 3 Further Diagnostic Criteria....................... 3 ADHD, a Continuum or Medical Syndrome.............. 4 ADHD, a Medical Deficit or Social Deviance.............. 4 Prevalence of ADHD and Gender Factor................ 5 Age of Onset of ADHD......................... 5 Summary................................. 6 References................................ 6 2 Causative Factors............................ 9 Etiological Classification........................ 9 Evidence for a Neurological Basis for ADHD............. 10 Role of Genetic Factors in Etiology of ADHD............. 12 Chromosomal Anomalies Associated with ADHD........... 14 Molecular Genetic Studies........................ 14 Environmental Factors in Etiology................... 14 Role of Adverse Home and School Environments........... 15 ADHD in Adopted Children....................... 15 Biochemical Basis for ADHD...................... 16 Infectious Causes of ADHD....................... 16 Perinatal and Early-Life Risk Factors.................. 16 Postnatal Risk Factors.......................... 17 Head Injury as a Cause of ADHD and Learning Disorders....... 17 Hypoglycemia and ADHD........................ 18 Role of Sugar and Other Dietary Factors in ADHD........... 18 Feingold Theory of Food Additives as a Cause of ADHD....... 19 Role of Food Allergy in ADHD..................... 20 Iron Deficiency and ADHD....................... 20 Role of Zinc in ADHD.......................... 21 xi
xii Iodine Deficiency, Thyroid Function and ADHD............ 21 Lead Exposure as a Cause of ADHD.................. 22 Cocaine-Exposed Infants at Risk of ADHD............... 23 Fetal Exposure to Alcohol, Marijuana, or Cigarettes and Increased Risk of ADHD...................... 24 PCBs and Other Environmental Toxins as Potential Causes of ADHD. 24 Role of Diet During Infancy in the Cause of ADHD.......... 26 Summary................................. 26 References................................ 26 3 Symptoms and Signs of ADHD.................... 31 Occasional Inattentiveness or an Attention Deficit Disorder?................................ 31 Measurement of Attention........................ 32 When Is Hyperactivity Abnormal?................... 33 Devices Used to Measure Motor Activity................ 33 Subtle or Soft Neurological Signs................. 34 Developmental Coordination Disorder Diagnostic Criteria....... 36 Relation Between Motor Performance and ADHD........... 37 Summary................................. 37 References................................ 38 4 Diagnosis and Laboratory Tests.................... 39 Significance of History and Examination................ 39 Questions Asked of Parent in Making ADHD Diagnosis........ 40 Physical and Neurological Examinations................ 40 Indications for an EEG in Children with ADHD............ 41 Indications for an MRI or CT Scan in a Child with ADHD....... 41 Blood Tests Sometimes Indicated in ADHD.............. 41 Indications for Electrocardiogram and/or Cardiac Consult....... 42 Tests of Research Interest Only..................... 43 Early Risk Factors for a Diagnosis of ADHD in Childhood...... 43 Summary................................. 44 References................................ 44 5 Oppositional, Conduct, and Other ADHD Comorbid Disorders.. 47 Oppositional Defiant Disorder...................... 47 Conduct Disorder............................ 47 Mood Disorders............................. 48 Anxiety Disorders............................ 49 Prevalence of Psychiatric Disorders Among Children with ADHD............................... 49 Relation Between Oppositional Defiant and Conduct Disorders and ADHD.......................... 50 Factors That Predispose to Conduct Disorders in Children with ADHD............................... 50
xiii Influence of an Adverse Family Environment on ADHD and Comorbid Disorders......................... 51 Childhood Conduct Disorder and Adult Criminality.......... 51 Relation of Mood and Anxiety Disorders to ADHD.......... 51 ADHD and Drug Abuse Disorders in Adolescents........... 53 Effect of Stimulant Treatment on Risk of Drug Abuse......... 53 ADHD and Drug Abuse in Adults Compared to Adolescents...... 53 Risk of ADHD Persistence into Adolescence.............. 54 ADHD and Risk of Early Cigarette Smoking.............. 54 Neurological Basis for Obsessive Compulsive Disorder........ 54 Other Comorbid Disorders Associated with ADHD.......... 55 Asperger s Disorder (299.80) and ADHD................ 55 Sleep Disorders and ADHD....................... 56 Summary................................. 56 References................................ 57 6 Learning and Language Disorders.................. 59 Definitions of Dyslexia......................... 60 Early Signs of Dyslexia......................... 61 The Genetic Factor in Reading Disability................ 61 Evidence for a Neuroanatomical Basis for Dyslexia.......... 62 Brain Imaging Scanners Used in Dyslexia Research.......... 62 Brain Activation During Reading.................... 63 Evidence for a Visual Pathway Disorder in Dyslexics......... 64 Articulatory Feedback and Disconnection Theories of Dyslexia.... 64 Selection of Reading Remediation Methods for Dyslexics....... 65 Alternative Methods of Reading Remediation.............. 65 Computer-Based Language Exercises.................. 66 Dietary and Pharmacological Therapies................. 67 Prognosis of Developmental Dyslexia.................. 67 Writing and Arithmetic Learning Disorders............... 67 Influence of Gender on Attention and Learning Ability......... 70 Speech and Language Disorders..................... 70 Normal Development of Speech and Language........... 70 Signs of Language Delay....................... 70 Types of Aphasia and Their Treatment................. 71 Methods of Treatment of Aphasia.................... 72 Summary................................. 72 References................................ 73 7 Tics, Tourette Syndrome, Seizures, and Headaches......... 77 Tics and Tourette Syndome....................... 77 Prevalence of Tourette Syndrome................... 78 Causes of Tics and Tourette Syndrome................ 78 Genetics of Tourette Syndrome and Tic Disorders.......... 79 Structural Brain Abnormalities and Tourette Syndrome....... 79
xiv Relation of Streptococcal Infection to Tics and OCD........ 80 Evidence for Encephalitis as a Cause of Tourette Syndrome..... 80 Tourette Syndrome and Risk of Learning Disabilities........ 81 Bipolar Disorder and Tourette Syndrome............... 81 Treatment of Tourette Syndrome Complicating ADHD....... 82 Seizures and ADHD........................... 84 Epilepsies Comorbid with ADHD in Children............ 84 Prevalence and Significance of EEG Abnormalities with ADHD.. 85 Stimulant Therapy in Comorbid Epilepsy/ADHD.......... 87 Epileptiform EEG and Transient Cognitive Deficit.......... 87 Cognitive Effects of Antiepileptic Drugs............... 88 EEG Localization, Epilepsy, and Learning Disability........ 88 Prevalence of ADHD in Children with Epilepsy........... 88 Behavior Disorders as a Form of Epilepsy.............. 89 Headache Disorders and ADHD..................... 89 Classification of Headaches...................... 89 Prevalence of Headache in Children................. 90 Classifications of Headache Diagnoses Compared.......... 91 Diagnostic Modifications for Pediatric Migraine........... 91 Indications for MRI or CT in Children with Headaches....... 93 Treatment of Headaches with ADHD................. 93 Psychological Interventions in Management of Headaches..... 93 Summary................................. 94 References................................ 94 8 Methods of Management of ADHD.................. 97 American Academy of Pediatrics Clinical Practice Guidelines..... 97 Principal Forms of Therapy of ADHD................. 99 Roles of the Psychologist and Psychiatrist in the Management of the Child with ADHD.............. 99 Physician s Role in Helping the Parents to Understand and Deal with the Problem of ADHD.................. 100 Useful Advice for Parents in Management of ADHD.......... 100 Motivational Techniques Emphasized in Parent Counseling and Training Sessions.......................... 101 The Child s Involvement in Management of ADHD.......... 102 Behavior Modification Therapy: Methods and Results......... 102 The Role of the Teacher and School System in the Management of ADHD...................... 103 Federal Laws Relating to Educational Rights of Children with ADHD............................... 104 Classroom Accommodations for Children with ADHD and Learning Disorders......................... 104 Public School Special Education Placements for Children with ADHD............................... 104
xv Professional Support Services in Public Schools............ 105 Indications for a Private or Therapeutic School Education for Children with ADHD........................ 106 Role of the Tutor in the Education of the Child with ADHD...... 106 Resource Groups and Associations Available to Parents for Information on ADHD and Learning Disabilities.......... 106 Summary................................. 108 References................................ 108 9 Medications for ADHD......................... 111 Stimulant Medications Recommended for Treatment of ADHD.... 111 Paradoxical Calming Effect of Stimulant Medications......... 112 Specific Benefits of Stimulant Medication in ADHD.......... 113 ADHD Patients Most Likely to Respond to Stimulant Medication................................ 114 Creativity and Flexibility of Thinking During Treatment with Methylphenidate.......................... 114 Relation of the Dose of Methylphenidate to the Response of ADHD Symptoms........................... 114 Twice Daily Versus Three Times Daily MPH Dose Schedule.... 116 Safety and Effectiveness of Methylphenidate in Preschool Children with ADHD.......................... 116 MPH Effectiveness in ADHD Adolescents............... 117 Child s Perspective of Stimulant Medication and Its Effect on Peer Relations............................ 117 Duration of Action of Immediate-Release and Extended-Release Formulations of Stimulant Medications for ADHD........... 118 Immediate-Release MPH Formulations................ 118 Intermediate-Release MPH Formulations............... 119 Extended-Release MPH Formulations................ 119 Amphetamine and Other Stimulants................. 121 Duration of Treatment with Stimulant Medication........... 122 Long-Term Usage of Stimulants and Outcome of ADHD........ 122 Continuity of Therapy with Immediate-Release cf Extended-Release Methylphenidate................... 123 Multimodal Treatment Study of ADHD (MTA)............. 123 Prolonged Usage of MPH Through Adolescence and Young Adulthood and Risks of Motor Vehicle Accidents Related to ADHD.. 124 Side Effects of Stimulant Medications................. 124 Side Effects of Methylphenidate and Their Prevalence........ 124 Effect of Medication on Growth of Children with ADHD...... 125 Obesity in Children Untreated for ADHD................ 127 Mood Changes Sometimes Associated with MPH and Their Avoidance......................... 127
xvi Management of Tics Developing During Stimulant Therapy for ADHD.......................... 127 Behavioral Rebound Associated with MPH Treatment for ADHD.. 128 Methylphenidate and Exacerbation of Seizures............. 128 Unusual Side Effects of Methylphenidate and Other Stimulants.... 130 Alternative Medications to Stimulants.................. 131 Indications for the Nonstimulant, Atomoxetine (Strattera R ), Usage, and Side Effects......................... 132 Long-Term Effects of Strattera R on Growth and Blood Pressure in Children with ADHD......................... 132 Dopamine Transporter DAT1 Genotype and Response to Atomoxetine cf Methylphenidate................... 133 Indications for Clonidine or Guanfacine in ADHD........... 133 Adverse Effects of Clonidine...................... 134 Guidelines for Use of Clonidine in Treating ADHD.......... 134 Well-Tried Stimulant Medications Versus Novel Less-Established Remedies for ADHD................. 136 Summary................................. 137 References................................ 137 10 Dietary and Alternative Therapies.................. 143 Reasons Why Parents May Be Convinced of Benefits from Scientifically Unproven Treatments................ 143 Diets and Diet Supplements Advocated in the Treatment and Prevention of ADHD and Learning Disorders........... 144 Evidence for and Against a Sugar-Restricted Diet for ADHD..... 144 Effects of Aspartame and Diet Sodas in ADHD Children........ 147 Current Medical Opinion of the Additive and Salicylate-Free Diet in ADHD.............................. 147 Foods Omitted and Foods Permitted in the Feingold, Additive-Free Diet for ADHD...................... 149 Oligoantigenic Diet for ADHD..................... 149 Food Antigen Desensitization...................... 150 Calming Effect of the Ketogenic Diet in Children with ADHD and Epilepsy............................... 150 Omega-3 Fatty Acids in ADHD and Dyslexia.............. 150 Orthomolecular and Megavitamin Therapy for ADHD and Learning Disorders......................... 151 Mineral and Trace Element Treatment of ADHD............ 151 Zinc Deficiency and ADHD....................... 152 Iron Deficiency and ADHD....................... 152 Electroencephalographic Biofeedback (Neurotherapy) in the Treatment of ADHD....................... 153 Vestibular and Sensory Integrative Therapy for ADHD......... 154 Central Auditory Evaluation and Training in ADHD.......... 154
xvii Scientific Basis for Music in Facilitating Learning and Attention............................... 155 Effect of Green Play Settings in Children with ADD.......... 156 Summary................................. 156 References................................ 157 11 Prognosis and Prevention....................... 161 Do Children Outgrow Symptoms of ADHD?.............. 161 Symptoms Associated with ADHD in Adults.............. 162 Does Stimulant Usage in Childhood Lead to an Increased Risk of Substance or Drug Abuse Among Adolescents and Adults with ADHD?......................... 163 Indications of a Good Prognosis in Childhood ADHD......... 163 Indications of a Guarded or Poor Prognosis............... 164 Reasons Why It Is Difficult to Predict the Outcome of ADHD..... 164 Preventive Measures Based on Known Potential Causes of ADHD............................ 164 Summary................................. 165 References................................ 165 12 Management Roles and Research Goals............... 167 Parent s Role in the Management of the Child with ADHD...... 167 Teacher and Remedial Teacher Roles.................. 167 Role of the Psychologist......................... 168 Role of Nurse Practitioner and Other Healthcare Providers....... 169 Occupational, Speech, and Social Worker Services........... 169 Physician s Role in Research and Improved Management of the Child with ADHD......................... 169 Summary................................. 170 References................................ 170 Index..................................... 171