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Attention Deficit Hyperactivity Disorder



Attention Deficit Hyperactivity Disorder (ADHD) is defined by the Center for Disease
Control (CDC) as being “a neurobehavioral disorder characterized by pervasive inattention and/or
hyperactivity
-
impulsivity and r
esulting in significant functional impairment” (CDC, 2005). It has
been estimated by the CDC that there may be as many as 4.4 million children between the ages
of four and seventeen with ADHD, making it one of the most common neurobehavioral disorders
of c
hildhood. Of those children that have been diagnosed with ADHD and roughly 2.5 million of
them

are receiving medication
s

for the disorder (CDC, 2005). A person with ADHD will have a
chronic level of inattention, impulsive hyperactivity, or both of those wh
ich will affect their overall
daily functioning (CDC, 2005). The levels at which they have inattention and/or impulsive
hyperactivity are usually expressed as being much higher than those levels found to be normal at
different developmental stages thereby
making that person’s ability to function at home, school,
or other places very difficult (CDC, 2005).


There are several different types of ADHD categorized several different ways. The
Diagnostic Statistical Manual for Mental Disorders (DSM
-
IV) has three
categories of ADHD which
are as follows:



Predominantly inattentive type: the person has inattention but no hyperactivity



Predominantly hyperactive


impulsive type: the person has hyperactivity
-

impulsivity but
no inattention



Combined type: the person ha
s both inattention and hyperactivity with impulsion
(WebMD, 2008).

The DSM
-
IV’s way of categorizing ADHD is used predominantly by pediatricians, psychiatrists
and psychologists based on a series of inattention and hyperactivity symptoms that the child or
adult displays for six months or more (WebMD, 2008). The other method of categorizing ADHD is
the Amen’s types, in which ADHD is categorized based on a combination of brain scans and
symptoms giving rise to the following six types of ADHD and the best way
to treat the different
types:



Type I
-

classic ADHD: the person displays hyperactivity and impulsivity and they will
respond to stimulant medications



Type 2
-

inattentive ADHD: the person shows the classic signs of ADHD but instead of
having hyperactivity th
ey have very low energy but also will respond to stimulant
medications



Type 3
-

over focused ADHD: the person shows classic signs of ADHD but also have
negative thoughts and behaviors like arguing and they respond better to antidepressants
combined with sti
mulants



Type 4
-

temporal lobe ADHD: the person shows classic signs of ADHD but they are
irritable, aggressive and have memory and learning problems and may respond better to
anti
-
seizure medications than to stimulants



Type 5
-

limbic ADHD: the person shows
classic signs of ADHD and depression and
shows signs of low energy and decreased motivation and they will respond better to
stimulating antidepressants than to plain old stimulants



Type 6
-

the ring of fire: is a cross between ADHD and bipolar disorder and
they will
respond to anticonvulsants and newer antipsychotic medications than just stimulants
alone. (WebMD, 2008)

It should be noted that the DSM
-
IV’s categorizing of ADHD is more widely accepted over Amen’s.
While Amen’s is a little more scientific than
DSM
-
IV’s, its methods behind its categorization have
been criticized by the American Psychological Association (APA) Council of Children,
Adolescents, and Their Families saying that the cost of the single photon emission computed
tomography (SPECT) brain s
cans cost too much and expose children to too much radiation
(WebMD, 2008).


ADHD can be very difficult to diagnosis and should only be done by a medical doctor,
psychiatrist, and/ or psychologist who will take into account the person’s symptoms since more

often than not it is a multilayer disorder.
When a child or adult is diagnosed with ADHD the first
step is to designate what type of ADHD the child has using either of the two types of

2

categorizations for ADHD (American Academy of Pediatrics, 2000). Once
the type of ADHD is
determined then the physician may evaluate the patient further to determine whether or not there
are any associated/co
-
existing conditions, like learning/ language disorders, oppositional defiant
disorder, conduct disorder, anxiety, dep
ression, or other conditions present also (American
Academy of Pediatrics, 2000). If there are associated conditions present, then they must be
evaluated also and confirmed that they do indeed exist and then once those are confirmed then
the patient may be

educated along with a parent if it is so warranted and the patient will be
treated (American Academy of Pediatrics, 2000).


ADHD like many other illnesses and disorders has a number of different treatments
available like Concerta and Ritalin. Concerta (m
ethylphenidate HCl) extended
-
release tablets are
classified as a schedule II controlled substance by federal regulation (RxList, 2008). It is used in
the treatment of ADHD in children as young as six years old on up to adults as old as sixty
-
five
years ol
d. Concerta (methylphenidate HCl) is a central nervous system (CNS) stimulant (RxList,
2008). It is a once daily tablet. The dosage of the medication is based on the age of the patient,
the weight of the patient, as well as to what degree they suffer from
ADHD, as well as many other
considerations. Its therapeutic action when it comes to treating ADHD is not known at this time
(RxList, 2008). However, it is thought that the methylphenidate may block the reuptake of
dopamine and norepinephrine into the presy
naptic neuron thereby increasing the release of
nor
e
pinephrine and dopamine into the extra neuronal space (RxList, 2008). Concerta is promptly
absorbed by the body following an oral dose of the medication and the plasma concentrations of
the medication wil
l increase rapidly to reach an initial maximum within about an hour. That
concentration will go on to gradually increase over a five to nine hour time period after which is
followed by a gradual decrease in the plasma concentration. Concerta’s peak plasma
concentration should occur within the sixth to tenth hour following the oral administration (RxList,
2008). Concerta is primarily metabolized via de
-
etherification to phenyl
-
piperidine acetic acid
(PPAA) which shows no signs of pharmacological activity (Rx
List, 2008). “After oral dosing of
radiolabel methylphenidate in humans, about 90% of the radioactivity was recovered in urine. The
main urinary metabolite was PPAA, accounting for approximately 80% of the dose” (RxList,
2008). It has also been thought to
undergo hepatic metabolism predominantly by hydrolysis and
then excreted as ritalinic acid and the rest could be oxidized by a hepatic mixed
-
function oxidase
(Kolar, 2008). Some of the various side effects of using Concerta include: decreased appetite,
hea
dache, dry mouth, nausea, insomnia, anxiety, decrease in weight, drug dependence,
agitation, glaucoma, hypersensitivity to methylphenidate, tics, serious cardiovascular events,
psychiatric adverse events, long
-
term growth suppression, seizures, visual dist
urbances, and the
possibility for gastrointestinal obstruction, all of which are some of the more common side effects
(RxList, 2008). Some of Concerta’s toxic effects include chest pain, jaundauce, and abnormal
liver function just to name a few (RxList, 20
08).


Adderall is another medication used to treat people with ADHD. Adderall is a single entity
amphetamine product that combines neutral sulfate salts of dextroamphetamine and
amphetamine, with the dextro isomer of amphetamine saccharate and d, l
-

amphet
amine
aspartate monohydrate (PDR, 2001). The mode of action for Adderall is not fully understood but
is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and
increase the release of those monoamines into the extra neu
ronal space just like Concerta does
(PDR, 2001). The body clearance mechanisms behind Adderall is thought to be done through a
series of oxidations and deaminations until benzoic acid and its glucuronide the glycine conjugate
hippuric acid are formed and t
hen those are excreted in the urine (RxList, 2008). Of course the
pH of the urine should be watched very carefully as any alteration in the pH of the urine may
dictate how much amphetamine and the other items it breaks down into are excreted into the
urine

(RxList, 2008). Adderall’s toxic effects may include irregular heart beat, high blood pressure,
and insomnia just to name a few (RxList, 2008).


Ritalin is another ADHD medication that is widely used. Ritalin is a mild central nervous
system stimulant (Rx
List, 2008). Unlike Concerta, Ritalin is taken several times a day primarily
before a meal. Its mode of action is not completely understood but is thought to activate the brain
stems arousal system and the cortex in order to have its stimulant effect on a
person (RxList,
2008). Ritalin, once in the body, is absorbed to a slower extent with its peak being about 1.9
-

4.7
hours post administration. Just like Concerta, it is excreted in the urine as PPAA (RxList, 2008).

3

Some of the common side effects of Ritali
n are as follows: headache, stomach pain, nausea,
irritability, loss of appetite, trouble sleeping, uncontrolled movements, weight loss, verbal tics,
mood swings, ect. (RxList, 2008).


Like with most other things, there are some natural ways of treating A
DHD although they
are not widely used. One natural way would be focusing on the patient’s diet. The ADHD diet
focuses on eliminating things such as sugar or other stimulants, which most ADHD patients are
highly sensitive to and trying to go as organic as p
ossible, and thus is considered to be a so
-
called “back to basics” sort of diet (Cowan, oneaddplace.com). To start the diet, for two weeks
the patient must not have dairy products (especially not cow’s milk), no yellow foods, no junk
foods, no fruit juice
s, no Nutrasweet, no processed meats, no MSG, the intake of sugar,
chocolate and fried foods must be cut by ninety percent, and the patient should also try to avoid
food coloring whenever possible (Cowan, oneaddplace.com). After two weeks then the patient
should try reintroducing the items that were avoided in the previous two weeks. Every other day a
new food should be reintroduced and should be readily consumed the day it is introduced. If there
happens to be a reaction to the food that was introduced the
n that would be the food to eliminate
from the diet (Cowan, oneaddplace.com). Dr. Cowan who reported on the ADHD diet on the
oneaddplace.com web site gives the following suggestions for “feeding the ADHD brain”:
Breakfast should consist of low carb high p
rotein meals (cereals should be avoided), lots of
protein supplements throughout the day, mineral supplements, ATTEND, EXTRESS, or
MEMORIN from VAXA, flax seed and primrose oil, and of course you should always eat lots of
fruits and vegetables and avoid al
uminum as much as possible (Cowan, oneaddplace.com).


Another important aspect of care is suggested by Canadian Attention Deficit Hyperactivity
Disorder Resource Alliance (CADDRA). CADDRA provides letters for elementary, junior high and
high school student
s suggesting some accommodations for the students as they go through
school to help them reach their fullest potential (CADDRA, 2008).The letters are available on the
CADDRA website; some of CADDRA’s suggestions for students with ADHD include: additional
t
ime for assignments, class work, tests/exams, flexibility with due dates, and that note copying
from the blackboard or white board be kept to an absolute minimum. (Rayner G., 2008).


There have, of course, been many studies done on ADHD some of which are d
escribed
below. In 2008 there was a study published in
Neurotoxicology

by a Dr. Ha and his associates on
the possibility of a link existing between low blood levels of lead and mercury and ADHD. Dr. Ha’s
study included roughly eighteen hundred children in
ten schools in Korea and he found that there
was a link between low blood levels of lead and an increase in ADHD symptoms but not between
low blood mercury levels and ADHD.


Another very interesting study that was done with regard to ADHD looked at the
pos
sibility of there being several gene polymorphisms that may in fact be responsible for the
expression ADHD in a person. The study looked at not only ADHD but also DAT1 40bp VNTR,
DRD4 7+, and DBH TaqI A2 alleles all of which are considered to be dopamine r
eceptor genes,
dopamine transporter genes, or dopamine beta hydroxylase genes (Barkley RA, Smith KM,
Fischer M, and Navia B; 2006). The study began by studying children and then later studying
them as adolescents and then on into adulthood; and at each of
those stages the test subjects
were rigorously tested. Children were tested using the following tests: Genetic testing, Conner’s
parent rating scale, 10 item hyperactivity index, Werry
-
Weiss
-
Peters activity rating scale, home
situations questionnaire, and
child behavior checklist. As adolescents they were evaluated using
the following exams: home situations questionnaire, youth self report form, teacher report form,
conflict behavior questionnaire, Gordon diagnostic system, matching familiar figures test
-
20
, and
the Wisconsin card sort task. Finally as adults they were evaluated using the following exams:
young adult behavior checklist, young adult self report form, high school performances
-

mainly
high school transcripts, job performance
-

14 DSM

III
-

R,
a 5 point Likert scale, Gordon
diagnostic system, cancellation task, and Card playing task (Barkley RA, Smith KM, Fischer M,
and Navia B; 2006). The study found that when the DBH TaqI A2 allele was homozygous, it was
associated with childhood hyperactivity

as well as some other symptoms of ADHD; it also found
that DAT1 40bp VNTR 9/10 polymorphism pairing with a heterozygous 9/10 are more likely to
have hyperactivity with ADHD than those whom may be 10/10 homozygous polymorphism
(Barkley RA, Smith KM, Fische
r M, and Navia B; 2006). The study also found that in children that
had been diagnosed with ADHD, roughly thirty
-
five to eighty percent of them had their symptoms

4

persist on into adolescence and eventually into adulthood (Barkley RA, Smith KM, Fischer M,
and
Navia B; 2006).


In today’s world it has been stated by many that ADHD is often over diagnosed
(Panksepp, 2007). As a Dr. Panksepp said when he looked at a correlation between ADHD and
play “despite years of psychiatric research, most of what gets diag
nosed as ADHD may be little
more than natural variability of brain maturation that results partly from genetic factors and partly
from the social environments we have created.” This is so evident when a person goes to any
given grade school, it can at time
s be hard to find a child who has not been diagnosed with
ADHD. It could be thought of as a catch
-
all for any child that may have a short attention span
and/or who may just have a lot of energy. Also in today’s world or at least in the United States it is
very common to have you children in all sorts of other activities when they are not in school,
which does not leave much time for the children to play. And as Dr. Panksepp suggested in a
paper he wrote on ADHD and play, that play may actually be the key to

ADHD and that play
somehow affects the development of the mind. He said that children with ADHD played less and
then became less social as time went on as compared to a so
-
called “typical” child, but when
children with ADHD were allowed to play, their sym
ptoms of ADHD diminished and they were
less likely to have the ADHD continue on into adulthood (Panksepp, 2007).


In summary, this paper leaves more questions than it answers. There is some agreement
on what ADHD is and what to do for it there is a lot of

room for variation. There is very little
information on how the medications really work. One nagging question is: why do the databases
that normally carry lots of toxicology information on everything say the ADHD meds are all
perfectly safe? There are w
arnings about not taking them when pregnant or taking them with a
very long list of other drugs or even with vitamin C. As all of the drugs are CNS stimulants all
chiropractic patients on these drugs should be monitored for changes caused by the nervous
s
ystem corrections.



References


1.

CDC. “Attention
-

Deficit/ Hyperactivity Disorder (ADHD)”,
http://www.cdc.gov/ncbddd/ADHD/
. accessed 12/13/08

2.

CDC. “What is Attention
-

Deficit/Hyperactivity Disorder (ADHD)?”
http://www.cdc.gov/ncbddd/ADHD/what.htm
. accessed 12/13/08

3.

WebMD. “Types of ADHD”.
http://www.webmd.com/add
-
adhd/guide/types
-
of
-
adh
d
.
accessed 12/13/08

4.

RxList. “Concerta”
http://www.rxlist.com/concerta
-
drug.htm .

accessed 12/13/2008

5.

Kolar, D.;Keller, A; Golfinopoulos, M; Cumyn, L; Syer, C; and Hechtman, L.

“Treatment of
adults with attention
-
deficit/hyperactivity disorder”.
Neuropsychiatric Disease and
Treatment
. 2008. February; 4(1): 107
-
121.
http://www.pubmedc
entral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2515906
.
accessed 121/13/08

6.

Sonuga
-
Barkee, EJS; Swanson, JM; Coghhill, D; DeCory, HH; Hatch, SJ. “Efficancy of
two once
-
daily methylphenidate formulations compared across dose levels at different
time
s of the day: Preliminary indications from a secondary analysis of the COMACS
study data”
BMC Psychiatry
. 2004. 4:28 <

http://www.pubmedcentral.nih.gov/articler
ender.fcgi?tool=pmcentrez&artid=524494
>
accessed 12/13/08

7.

RxList. “Ritalin”
http://www.rxlist.com/ritalin
-
drug.htm
. accessed 12/13/08

8.

Physicians Desk Reference “Adderall”. ©200
1, Medical Economics company, Inc. page
3034
-
3035.

9.

RxList. “Adderall”
http://www.rxlist.com/adderall
-
drug.htm

accessed 12/13/08

10.

American Academy of Pediatrics. Pediatrics. “
Clinical Practice Guidelin
e: diagnosis and
evaluation of the child with attention deficit/hyperactivity disorder”. Vol. 105 (5). May
2000.
http://aappolicy.aapublication.org/cgi/reprint/pediatr
ics;105/5/1158.pdf

accessed 12/29/08


5

11.

Cowan D., ADHD Diet.
http://www.oneaddplace.com/adhd
-
diet.php

accessed
12/29/08

12.

Ha M, Kwon HJ, Lim MH, Jee YK, Hong YC, Leem JH, Sakong J, Bae JM, Hong SJ, Roh

YM, Jo SJ.
Neurotoxicology

“Low blood levels of lead and mercury and symptoms of
attention deficit hyperactivity in children: A report of the children’s health and environment
research (CHEER)”. 2008. November 30. <
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&
TermToSearch=19100765&log$=activity
> accessed 12/29/08

13.

Barkley RA, Smith KM, Fischer M, and Navia B. “
An Examination of Behavioraland
Neuropsychological Correlates of Three ADHD Candidate Gene Polymorphisms (DRD4
7+, DBH Taql A2, and DAT1 40bpVNTR) in Hyperactive and NormalChildren Followed to
Adulthood”
American Journal Med. Genet B Neuropsychiatr. Genet.

2006 July 5;
141B(5): 487
-
498.<

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2562041&tool=pmcentrez
>
accessed 12/30/08

14.

Panksepp J. “Can play dim
inish ADHD and facilitate the construction of the social brain”.

Journal of the Canadian Academy of Child and Adolescent Psychiatry
. 2007 May; 16(2):
57
-
66. <
h
ttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2242642&tool=pmce
ntrez
> . accessed 1/1/09

15.

CADDRA. “Elementary School Accommodations Letter and Secondary and Post
-
Secondary School Accommodations Letter”.
http://www.caddra.ca/joomla/index.php?option=com_content&task=view&id=90&Itemid=1
35

. accessed 1/5/09


Rayner G. “Classroom Accommodations for Specific Behavior”. 2008.

<
http://www.caddac.ca/cms/page.php?66