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Attention Deficit Hyperactivity Disorder During Childhood
Miriam Mulsow
Melinda Corwin
Adam Schwebach
Shu Yuan
Running Head: ADHD
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Introduction
There has been an explosion of research into various aspects of ADHD over the past
several years. Even with all of this interest, however, there is still no confirmed method of
preventing ADHD from occurring. There are some promising studies that suggest factors that
may contribute to ADHD or its severity. Much work has been done on dietary contributions,
exposure to natural environments, working memory training, mindfulness training, and rigorous
physical activity.
Multimodal treatment that includes both behavioral intervention and medication, as well
as neurofeedback, has been shown to help children with ADHD to function more like their peers
without ADHD, when these treatments are sustained. Thus, children with ADHD who are
treated with medication and behavioral interventions, with or without neurofeedback, are more
likely than children with untreated ADHD to avoid some of the secondary problems that arise
from living with ADHD. However, no treatment has been found, to date, that has effects that
continue over the long term after treatment is terminated. Thus, treatment needs to be sustained
for all but those children in whom ADHD symptoms subside on their own as children mature.
Definitions
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed
behavioral disorder of childhood. Core symptoms include developmentally inappropriate levels
of attention, hyperactivity, distractibility, and impulsivity (National Institutes of Health, 2013)
that appear before age 7 years, persist longer than 6 months, and create problems in multiple
settings (e.g., home, school, work, peer group). Not all symptoms need to be present for a
diagnosis. ADHD has also been called attention deficit disorder, hyperactive child syndrome,
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hyperkinesis, minimal brain dysfunction, hyperkinetic syndrome of childhood, and hyperkinetic
disorder.
Inattention symptoms include carelessness, difficulty sustaining concentration, reluctance
and difficulty organizing and completing work correctly, failure to follow through, tendency to
lose things, excessive forgetfulness, and high distractibility. Hyperactivity refers to excessive
movement, restlessness, fidgetiness, or excessive talking. Impulsivity, an inability to inhibit
behavior, makes it difficult to stop and think before behaving or to delay gratification.
Comorbidity means the existence of two different conditions in the same person. ADHD
is commonly comorbid with conduct disorder (CD) or oppositional defiant disorder (ODD).
These two terms are sometimes used interchangeably, although ODD may be more accurately
described as an earlier, less severe disorder similar to CD.
Scope
Prevalence estimates for ADHD range from 3 to10% of the child population and 1–5% of
the adult population (NIH, 2013). Dulcan, Dunne, Ayers, Arnold, Benson, and associates (1997)
report a prevalence of 10.1% of males and 3.3% of females aged 4–11 years in Ontario, Canada.
Children with ADHD are at risk to repeat a grade, be suspended from school, exhibit conduct
disorder and other behavioral problems, have delays in language development, have memory
deficits, make lower grades than they seem to be capable of making, and experience social
rejection, depression, anxiety, accidental injuries, risk-taking behavior, poor sense of time, and
sleep problems (Barkley, 1997, Rabiner, 2013). Family relationships are also impaired, with
families of ADHD children reporting more stress, frustration, disappointment, guilt, fatigue,
marital dysfunction, divorce, and psychological disorders including ADHD and depression in
parents and family therapy (Fisher, 1990). Individuals with ADHD consume numerous
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resources and attention from the health-care system, criminal justice system, schools, and other
social service agencies (NIH, 2013). “Additional national public school expenditures on behalf
of students with ADHD may have exceeded $3 billion in 1995. Moreover, ADHD, often in
conjunction with coexisting conduct disorders, contributes to societal problems such as violent
crime and illegal substance abuse (NIH, 2013).
Long-term problems are common among adults with a history of ADHD in childhood.
Some of these are more prevalent among adults who continue to have diagnosable levels of
ADHD symptoms, but some occur even in those who no longer meet diagnostic criteria
(Barkley, 1997, Rabiner, 2013). Among problems that have been reported at elevated levels in
adults who have ADHD or who have a history of ADHD in childhood are occupational
underachievement; substance abuse; depression; impulsivity; isolation; low educational
attainment; early, unintended pregnancy; marital disruption; inadequate financial and other
resources; poor coping skills; impulsive spending; arrests; gambling; accidents; impulsive
aggression/violence; delayed development; poverty; excessive driving violations; failed
marriages; and antisocial behavior. For example, among the children with ADHD followed
prospectively into adulthood in various studies, 28% experienced major depression, 75%
reported interpersonal problems, almost 10% attempted suicide, 20% committed acts of physical
aggression, 36–52% were arrested at least once, 30–32% never completed high school, only 5%
completed a university degree, 17% contracted a sexually transmitted disease, and 42% had their
licenses suspended or revoked (Barkley, 1998).
Theories
According to Barkley (1997), children with ADHD primarily lack self-control/self-
regulation, and problems with attention are secondary. During development, a child’s behavior
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gradually shifts from external to internal controls, rules, and standards, termed “self-control.”
Self-control requires the ability to delay response to stimuli long enough to consider those
internal rules and standards and possible consequences of violating those rules and standards.
Children with ADHD know the rules but lack ability to apply what they know before responding
to stimuli.
In true ADHD, this lack of self-control is due to nature (biological causes) rather than
nurture (parenting or other factors in the child’s current environment) (Barkley, 1997). These
same deficits interfere with the child’s working memory, self-talk/internalized speech, sense of
time, as well as ability to set and work toward goals. Lacking the ability to consider and respond
to internal cues, children with these deficits respond much more readily to external, immediate
consequences for their actions than to longer-term consequences. Thus, these children need a
system of external prompts, cues, and feedback (Rabiner, 2013).
Attention restoration theory suggests that children with ADHD respond to natural
environments because they provide an opportunity to “recharge” from situations that make high
demands on their ability to direct their attention. This theory suggests that attention is either
voluntary/directed or involuntary/natural. Voluntary attention requires conscious effort because
it involves things to which it is not inherently easy to attend, thus leading to fatigue. Exposure to
nature allows the child to use involuntary attention and rest from this fatigue (Rabiner, 2013).
Current Research
Primary prevention involves identifying methods to prevent ADHD from occurring in the
first place. ADHD has been strongly linked to genetic factors (Rabiner, 2013). A child with
ADHD has a 64% chance of having at least one parent with ADHD or a history of the disorder
(Evans, Vallano, & Pelham, 1994). If researchers can identify which genes are implicated in
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ADHD, they may eventually be able to prevent the disorder from occurring; however, further
research is needed. Secondary prevention involves identifying and treating ADHD (or risk
factors for ADHD) early in hopes of eliminating problems that could occur because of the
disorder. Tertiary prevention involves improving treatments for persons with ADHD so that they
can function as optimally and successfully as possible throughout their lifespan. Much of the
current ADHD research involves secondary and tertiary prevention, as described in the following
paragraphs.
Dietary factors may contribute to ADHD symptoms in some individuals. If this is the
case, then one possible way to prevent ADHD is to modify diet. Howard et al. (2011) found that
a Western-style diet (i.e., foods that are high in total fat, saturated fat, refined sugars, and
sodium) may be associated with ADHD. The researchers compared 1,799 adolescents regarding
whether they had a “Western” or “healthy” diet pattern and whether their scores were high or
low on their respective dietary type. Of those adolescents, 115 (approximately 6%) had been
diagnosed with ADHD. Findings revealed that a higher score for the Western-style dietary
pattern was associated with an adolescent diagnosis of ADHD. However, because the study was
cross-sectional in design, no causal conclusions could be made. One possible explanation could
be that individuals who already have ADHD tend to make poorer food choices (i.e., higher score
Western diets) rather than high score Western diets leading to ADHD. Additionally, this study
did not examine dietary changes and their effects on ADHD symptoms. Thus, one cannot
conclude that dietary changes will alter ADHD characteristics. One other interesting finding
from this study was that physical exercise at least twice per week was associated with
statistically decreased odds of having ADHD.
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Some studies have examined the benefits of physical activity for improving behavior and
cognitive abilities in individuals with ADHD. Verret, Guay, Berthiaume, Gardiner, and Beliveau
(2010) conducted an exploratory study with 21 children ages 7–12 years who had been
diagnosed with ADHD. Results revealed that the group of children who participated in a 10-
week fitness program involving moderate- to high-intensity physical activity demonstrated
improved muscular capacities, motor skills, behavior (as reported by parents and teachers), and
levels of information processing (sustained auditory attention). However, participants were not
randomly assigned to the experimental versus control group, and parents and teachers were
aware of the participants that received the fitness training; thus, overall conclusions are limited.
Additional studies are needed that involve larger samples, random assignment to groups, and
parent/teacher raters who are blind to treatment versus control group membership.
While there is no known method for preventing the onset of symptoms or diagnosis of
ADHD, some studies have investigated how to prevent ADHD symptoms from worsening and/or
negatively affecting the daily lives of individuals with ADHD in a detrimental way (i.e., tertiary
prevention). The Multimodal Treatment Study of Children with ADHD (MTA Cooperative
Group, 1999) involved 579 children from multiple sites who were carefully diagnosed with
ADHD. Participants were randomly assigned to one of four group conditions as follows: (1)
medication treatment only, (2) behavior treatment only, (3) combined medication and behavior
therapy, or (4) routine community care (control group). The group who received combined
medication and behavioral treatment showed greater benefits in terms of improved ADHD
symptoms as well as decreased anxiety symptoms and slightly increased parent-child relations
(as reported by parents), social skills (as report by teachers), and reading achievement. The
experimental period lasted for 14 months. However, results of a follow-up study conducted 22
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months later revealed no indication that the benefits continued beyond the treatment period.
Also, approximately half of the children in all four groups continued to meet the diagnostic
criteria for ADHD. Three classes of children were identified, without respect to which treatment
group they had been assigned, as follows: Class 1, who showed a gradual improvement over
time; Class 2, who showed an initially larger improvement that was maintained over time; and
Class 3, who initially showed a positive response but then returned to baseline symptom levels.
It should be noted that Class 2 children came from families with a higher socioeconomic status
(SES) and had higher scores on baseline measures compared to children in the other two classes.
Moline et al. and the MTA group (2009) completed a follow-up study 8 years after the
initial study which revealed no significant differences on any of the 20 outcome measures based
on the group to which individuals were initially assigned. Children from all four groups
demonstrated improvement relative to baseline measures, and there was a decline in use of
medication over time for all groups. Relative to the three different classes identified 8 years
earlier, the Class 2 participants continued to demonstrate better improvements over time
compared to Class 1 or Class 3 groups, indicating that initial response to treatment (regardless of
the type of treatment) was a better predictor of longer-term outcomes than type of treatment.
Despite overall improvement in functioning for the individuals with ADHD, these individuals
still had higher incidences of antisocial behavior, delinquency, and academic struggles compared
to same-age peers without any history of ADHD. Thus, additional information regarding tertiary
prevention of ADHD is needed.
Overview of Strategies
Primary prevention of ADHD is not yet possible; however, research in the area of
genetics may someday allow us to prevent the disorder before it occurs. To date, no successful
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intervention has been found that consistently prevents the dysfunction associated with ADHD
throughout the lifespan. Promising strategies related to secondary and tertiary prevention of
ADHD include diet modification, physical activity, and some combination of pharmaceutical and
behavioral treatment. Individuals whose socioeconomic status (SES) is adequate may fare better
compared to individuals with low SES. Additional research is warranted in these areas.
What Works
Multimodal treatment consisting of medication plus behavioral intervention (MTA
Cooperative Group, 1999) continues to be the most effective means of preventing long-term
problems among children with ADHD, as long as that treatment is continued. Effects are not
sustained when treatment is discontinued, for most children. There has been some concern about
the abuse of medications for ADHD. Despite media attention suggesting otherwise, nonmedical
use (abuse) of medications for ADHD among children decreased sharply from 2000 to 2011
(Johnston et al., 2012), although being asked for ADHD medications by friends and family was
still common. Furthermore, treatment with medication in childhood reduces the likelihood of
criminal behavior and other negative outcomes in adulthood among children with ADHD who
still have ADHD as adults (Lichtenstein et al., 2012).
While effect sizes are smaller than for multimodal treatment, a meta-analysis of studies of
neurofeedback shows that this treatment leads to improvement in ADHD symptoms in the short
term. Long-term efficacy has not been confirmed, but neither has it been confirmed for
medication or behavioral treatment (Lofthouse et al., 2012).
There are credible, easily understood resources available for learning about effective
treatments for ADHD, including websites for the National Institutes of Health’s The Multimodal
Treatment of Attention Deficit Hyperactivity Disorder Study (MTA): Questions and
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Answers(http://www.nimh.nih.gov/health/trials/practical/mta/the-multimodal-treatment-of-
attention-deficit-hyperactivity-disorder-study-mta-questions-and-answers.shtml); CHADD,
Children and Adults with Attention-Deficit/Hyperactivity Disorder
(http://www.chadd.org/Understanding-ADHD/Adults-with-ADHD/Evaluation-and-
Treatment.aspx); and Dr. David Rabiner’s Attention Research Update Archives
(http://www.helpforadd.com/archives.htm).
What Is Promising
Diet
Breastfeeding children for a minimum of six months has been found to be associated with
lower levels of ADHD, when breastfed children were compared to children whose mothers did
not breastfeed or breastfed for shorter periods of time (Kadziela-Olech & Piotrowska-
Jastrzebska, 2005; Mimouni-Bloch et al., 2013).
Higher levels of DHEA were associated with fewer symptoms of ADHD, and treatment
for ADHD increased levels of DHEA (Maayan et al., 2003; Strous et al,2001).
Among children with low zinc levels, zinc supplementation was shown to reduce
hyperactivity and impulsivity symptoms, but not inattention symptoms. Children with symptoms
of hyperactivity and impulsivity should be tested for low zinc levels, but zinc supplementation
by itself is not effective to treat or prevent ADHD.
Reduction in food additives for children who are sensitive to these additives has been
shown to be effective in reducing ADHD-like symptoms. Meta-analysis indicates that artificial
colors such as tartrazine significantly increase ADHD symptoms among some children
diagnosed with ADHD (McCann et al., 2007; Schab, & Trinh, 2004). Reduction of food
additives has not been found to work for all or even most children who exhibit ADHD
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symptoms. However, it is probably worth trying with all children suspected of having ADHD. It
is important to note that a child does not have to have ADHD to have a sensitivity to artificial
food colors that results in behavioral or attention problems when these additives are consumed.
Essential Fatty Acids (Omega-3): Increasing omega-3 fatty acids reduces hyperactivity,
and supplementation with EPA/DHA has been shown to improve inattention, hyperactivity,
oppositional/defiant behavior, and conduct disorder among children with ADHD (Rabiner, 2013,
Transler et al., 2010). These essential fatty acids can be found at high levels in fatty fish such as
salmon and tuna as well as in flax seed.
Exercise and Meditation
Mindfulness training has been shown to improve parent-child relationships in families of
children with ADHD when both parents and children participate. It also was linked to reduced
ADHD symptoms in parents’, but not teachers’ reports (van der Oord et al., 2012).
Rigorous physical activity that is done frequently and consistently is associated with
improvements in neuropsychological functioning, as reported by both teachers and parents.
However, this exercise alone is not enough to get children with ADHD into the range of children
without ADHD (Rabiner, 2013).
Working Memory Training
Children who participate in working memory training have fewer symptoms of ADHD as
reported by their parents. However, studies have not shown significant improvements in
academic performance as reported by teachers. A recent study by Green and associates (2012)
reports that children with ADHD who have five weeks of working memory training in their
homes score higher on a measure in the lab that predicts academic performance than controls.
While promising, this study will have to be replicated, and studies using teacher reports will be
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needed before working memory training can be confirmed as effective for improving academic
performance.
Environment
Children who spend more time in sunlight have fewer symptoms of ADHD. This may be
related to sleep disorders, which are common among children with ADHD. Places with higher
solar intensity have lower rates of diagnosis of childhood ADHD (Rabiner, 2013).
Several studies have suggested that time spent in nature reduces symptoms of ADHD.
Taylor and Kuo (2011) examined this by having children take a 20-minute walk in nature, then
testing them on a standardized measure of attention and concentration. Those children who
walked in nature exhibited higher levels of attention than those who walked in urban or suburban
settings (Taylor & Kuo, 2011).
Children who are young for their grade have higher rates of diagnosis of ADHD, as
reported by Evans et al. (2010) and Rabiner (2013). Thus, it is important to make sure that what
is being observed is actually ADHD and not simply immaturity caused by the child being
younger than average in his or her class. This is not a treatment or prevention strategy for
ADHD, but is an important factor when considering whether or not a child actually has ADHD.
In these cases, the child may need to wait a year before starting school to allow time to catch up
with the rest of the class (Evans et al., 2010).
What Does Not Work
Although there are many other reasons to restrict the amount of television a child
watches, and some of these reasons (e.g., lack of exposure to sunlight, lack of exercise) are
related to factors that may contribute to more severe symptoms of ADHD, eliminating television
has not been shown to prevent ADHD from occurring.
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Elimination of Sugar. The elimination of sugar from the diet has not resulted in significant
improvement in ADHD symptoms. There are promising results being found from more complex
dietary restrictions, but results to date suggest that most dietary restrictions may only be effective
for a small subgroup of children who have both ADHD symptoms and food allergies or
sensitivities (Dulcan et al., 1997).
Severe Discipline. Commonly, parents will initially deny the existence of a disorder in their
children with ADHD and will attempt to control their children’s behavior with increasingly strict
discipline. Although a highly structured environment has been shown to be effective in helping
children with ADHD to manage their disorder, severe discipline has not. In fact, studies indicate
that severe discipline contributes to a greater probability of negative outcomes among children
with ADHD (Hoza, Owens, Pelham, Swanson, Connors, et al., 2000).
Medication Without Any Other Intervention. Often, parents and teachers of children with
ADHD are so relieved at the improvements seen in children’s behavior after medication is
introduced that they overlook the problems that still exist despite the use of medication (NIH,
2013; MTA Cooperative Group, 1999). Findings are clear that medication alone will not prevent
long-term problems (Dulcan et al., 1997) among many children with ADHD.
Summary
In summary, there is no way to prevent ADHD currently available. Multimodal
treatment involving both medication and behavioral interventions, with medication continued
over the long term, has shown the highest level of improvements in long-term outcomes.
Neurofeedback has shown more modest levels of improvement and must also be continued in
order to remain effective. A healthy diet, beginning with breastfeeding early and fatty fish or
other sources of essential fatty acids and DHEA later, vigorous and frequent exercise, working
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memory training, mindfulness training, and spending time in nature and sunlight have all shown
promise and are probably worth trying for all children with ADHD, in combination with
multimodal treatment. Making sure a child actually has ADHD and not a deficiency in zinc,
immaturity due to being one of the youngest children in a grade level, or sensitivity to food
additives is also important. In some cases, a child who does have ADHD may need attention for
both ADHD and one or more of these issues.
See Also
http://www.helpforadd.com/archives.htm Dr. David Rabiner’s Help for ADHD e-newsletter is a
wonderful resource that summarizes research findings on ADHD for practitioners, educators, and
parents. This link is to an archive of all of his newsletters.
(http://www.nimh.nih.gov/health/trials/practical/mta/the-multimodal-treatment-of-attention-
deficit-hyperactivity-disorder-study-mta-questions-and-answers.shtml) National Institutes of
Health
(http://www.chadd.org/Understanding-ADHD/Adults-with-ADHD/Evaluation-and-
Treatment.aspx) CHADD: Children and Adults with Attention Deficit/Hyperactivity Disorder
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