ATTENTION DEFICIT DISORDERS

There are two types of attention processes in the brain: those driven by unconscious processes (bottom-up) and those driven by conscious processes (top-down). Attention problems can be caused by any number of factors that disrupt either type of attention. The 7 most common causes of attention problems include:

allergies and metabolic disorders

hypovigilance

sleep disorders

boredom intolerance

learning disabilities

sensory processing disorders

sleep disturbances

depression and other psychiatric conditions

Attention deficit is a diagnosis based on subjective measures such as parent or teacher reports. Some clinical tests exist, primarily concerning a child's ability to remain still for extended periods or their ability to tolerate a boring task such as waiting several minutes for a sound or target movement on a computer screen; Children who qualify on one measure as attention deficit often do not qualify on others. Other complications in the diagnosis are due to the fact that children who have difficulty paying attention in school often do not have difficulty paying attention to a fun or preferred activity.

 

Many metabolic, nutritional, psychological, cognitive, and sensory processing disorders can mimic attention deficit. Therefore the concdition of attention deficit is difficult to diagnose. A solid understanding of typical development, sensory processing disorders, and metabolic and immune dysfunction is necessary in order to avoid misdiagnosing ADD. Laboratory tests are available to rule out other disorders.

Before a diagnosis of ADD is given, a complete laboratory and sensory processing work-up should be performed in order to rule out any of these underlying factors.

TESTS FOR SENSORY PROCESSING DISORDERS include the SCAN-C or SCAN-A tests of auditory processing, VESTIBLAR TESTS including rotational chair, balance, and VOR, and VISUAL processing tests such as the VPT.

TESTS FOR ALLERGIES

ALLERGIES AND METABOLIC DISORDERS

Encounters with allergens stimulate the release of serotonin and histamine from mast cells in the body. This increase affect chemokines which in turn alter arousal, attention, activity and vigilance. A highly allergic child can be either quite lethargic or hyperactive as a result, depending upon the individual mechanisms of the allergic reaction. Frequently eliminating all allergens from the diet will eliminate hyperactivity or lethargy and inattention.

Appl Psychophysiol Biofeedback. 2003 Mar;28(1):63-75.

Nutrition in the treatment of attention-deficit hyperactivity disorder: a neglected but important aspect.

Schnoll R, Burshteyn D, Cea-Aravena J.Department of Health and Nutrition Sciences, Brooklyn College, City University of New York, 2900 Bedford Avenue, Brooklyn, New York 11210-2889, USA. rschnoll@brooklyn.cuny.edu

Attention-deficit hyperactivity disorder (ADHD) is multidetermined and complex, requiring a multifaceted treatment approach. Nutritional management is one aspect that has been relatively neglected to date. Nutritional factors such as food additives, refined sugars, food sensitivities/allergies, and fatty acid deficiencies have all been linked to ADHD. There is increasing evidence that many children with behavioral problems are sensitive to one or more food components that can negatively impact their behavior. Individual response is an important factor for determining the proper approach in treating children with ADHD. In general, diet modification plays a major role in the management of ADHD and should be considered as part of the treatment protocol.

Ann Allergy. 1994 May;72(5):462-8.

Foods and additives are common causes of the attention deficit hyperactive disorder in children.

Boris M, Mandel FS.

North Shore Hospital-Cornell Medical Center, Manhasset, New York.

 

The attention deficit hyperactive disorder (ADHD) is a neurophysiologic problem that is detrimental to children and their parents. Despite previous studies on the role of foods, preservatives and artificial colorings in ADHD this issue remains controversial. This investigation evaluated 26 children who meet the criteria for ADHD. Treatment with a multiple item elimination diet showed 19 children (73%) responded favorably, P < .001. On open challenge, all 19 children reacted to many foods, dyes, and/or preservatives. A double-blind placebo controlled food challenge (DBPCFC) was completed in 16 children. There was a significant improvement on placebo days compared with challenge days (P = .003). Atopic children with ADHD had a significantly higher response rate than the nonatopic group. This study demonstrates a beneficial effect of eliminating reactive foods and artificial colors in children with ADHD. Dietary factors may play a significant role in the etiology of the majority of children with ADHD

Altern Med Rev. 2000 Oct;5(5):402-28.

Comment in: Altern Med Rev. 2000 Oct;5(5):401.

 Attention deficit/hyperactivity disorder (ADHD) in children: rationale for its integrative management.

Kidd PM.

Attention Deficit/Hyperactivity Disorder (ADHD) is the most common behavioral disorder in children. ADHD is characterized by attention deficit, impulsivity, and sometimes overactivity ("hyperactivity"). The diagnosis is empirical, with no objective confirmation available to date from laboratory measures. ADHD begins in childhood and often persists into adulthood. The exact etiology is unknown; genetics plays a role, but major etiologic contributors also include adverse responses to food additives, intolerances to foods, sensitivities to environmental chemicals, molds, and fungi, and exposures to neurodevelopmental toxins such as heavy metals and organohalide pollutants. Thyroid hypofunction may be a common denominator linking toxic insults with ADHD symptomatologies. Abnormalities in the frontostriatal brain circuitry and possible hypofunctioning of dopaminergic pathways are apparent in ADHD, and are consistent with the benefits obtained in some instances by the use of methylphenidate (Ritalin) and other potent psychostimulants. Mounting controversy over the widespread use of methylphenidate and possible life-threatening effects from its long-term use make it imperative that alternative modalities be implemented for ADHD management. Nutrient deficiencies are common in ADHD; supplementation with minerals, the B vitamins (added in singly), omega-3 and omega-6 essential fatty acids, flavonoids, and the essential phospholipid phosphatidylserine (PS) can ameliorate ADHD symptoms. When individually managed with supplementation, dietary modification, detoxification, correction of intestinal dysbiosis, and other features of a wholistic/integrative program of management, the ADHD subject can lead a normal and productive life.

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HYPOVIGILANCE AND SLEEP DISTURBANCES

Hypovigilance is a naturally occurring state in which some individuals need more sensory stimulation to stay awake. If there is insufficient stimulation in the environment the child will be driven to provide it for themselves. A simple technique for determining if hypovigilance is present is to ask the child to remain absolutely still for three minutes. Children with hypovigilance will either fall asleep or become drowsy during this test. Some children will tell you that they do not want to comply because they are afraid that they will fall asleep if they stop moving. Researchers have found that adding small amounts of stimulation will eliminate hyperactivity and improve attention in these children.  Some idease include allowing a child to listen to music (their own preferred variety) or to have some type of handwork (e.g. needlework, knitting, manipulating clay, drawing, etc.) to do during periods when a child must stay still. Researchers have found that even simple sensory stimulation such as adding color to workbooks or providing books of photographs for the child to flip through will normalize attention.

Semin Pediatr Neurol. 1996 Mar;3(1):44-50.

The impact of inadequate sleep on children's daytime cognitive function.

Dahl RE.

University of Pittsburgh, School of Medicine, Department of Psychiatry, PA, USA.

This report describes the relationship between sleep and cognitive function in children. As reviewed, the empiric data to directly address the effects of sleep loss or disruption on children's cognitive function are quite sparse. However, a wide range of clinical and observational data support a general picture that inadequate sleep results in tiredness, difficulties with focussed attention, low threshold to express negative affect (irritability and easy frustration), and difficulty modulating impulses and emotions. In some cases these symptoms may resemble attention deficit hyperactivity disorder. These findings are discussed in relation to a model of sleep loss influencing prefrontal cortex including executive functions involved in the control of attention and emotions.

J Child Psychol Psychiatry. 2000 Sep;41(6):803-12.

Sleep and alertness in children with ADHD.

Lecendreux M, Konofal E, Bouvard M, Falissard B, Mouren-Simeoni MC.

Service de Psychopathologie de I'Enfant et de I'Adolescent, Hopital Robert Debre, Paris, France. Marie-Christine.Mouren-Simeoni@rdb.ap-hp-Paris.fr

 

OBJECTIVE: To evaluate sleep and alertness and to investigate the presence of possible underlying sleep/wake disorders in children with attention-deficit/hyperactivity disorder (ADHD). METHOD: After 3 nights of adaptation in a room reserved for sleep studies in the department of child psychiatry, children underwent polysomnography (PSG) followed by the Multiple Sleep Latency Test (MSLT) and reaction time tests (RT) during the daytime. Thirty boys diagnosed as having ADHD (DSM-IV), aged between 5 and 10 years, and 22 age- and sex-matched controls participated in the study. All children were medication-free and showed no clinical signs of sleep and alertness problems. RESULTS: No significant differences in sleep variables were found between boys with ADHD and controls. The mean latency period was shorter in children with ADHD. Significant differences were found for MSLT 1, 2 and 3 (p < .05). Mean reaction time was longer in children with ADHD, with significant differences in all tests (p < .05). Number and duration of sleep onsets measured by the MSLT correlated significantly with the hyperactivity-impulsivity and inattentive-passivity indices of the CTRS and CPRS. CONCLUSION: Children with ADHD were more sleepy during the day, as shown by the MSLT, and they had longer reaction times. These differences are not due to alteration in the quality of nocturnal sleep. The number of daytime sleep onsets and the rapidity of sleep-onsets measured as MSLT were found to be pertinent physiological indices to discriminate between ADHD subtypes. These results suggest that children with ADHD have a deficit in alertness. Whether this deficit is primary or not requires further studies.

 

Neurol Clin. 1993 Feb;11(1):59-78.

Vigilance and its disorders.

Weinberg WA, Harper CR.

Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas.

 

Vigilance has been defined as steady-state alertness-wakefulness. The right cerebral hemisphere, predominantly the right inferior parietal lobule and posterior parietal cortices, seems specialized for vigilance. Studies of the primary disorder of vigilance, a genetically determined condition, should provide a better understanding of the neurobiology of vigilance. Common causes of secondary hypovigilance (depression, learning disability, narcolepsy, and acquired focal right cerebral hemisphere brain lesions) explain the symptom complex of ADHD. If these specific entities producing hypovigilance are correctly identified, treatment is successful and with favorable outcome. The neuroanatomic substrate of lowered vigilance seems to be loss of modulating influence of the right cerebral hemisphere on the diencephalon and select brain stem nuclei. We propose that the right (more than the left) cerebral hemisphere is responsible for alertness and wakefulness (vigilance) with the reticular formation being accountable for sleep.

BOREDOM INTOLERANCE

Some children, particularly those who are bright or highly creative, can not tolerate boredom.  These children often "get" information the first time it is presented and process information quite rapidly.  When they must wait to hear it presented repetitively for other members of the class they become bored.   Many children who are highly intelligent need a great deal of stimulation and will provide such stimulation for themselves if the environment does not do so.  These children may become class clowns or trouble makers to entertain themselves.  They may also need to wander, do other work, or have higher level challenges while others are learning the material.  It is critical to address these very real cognitive needs through increased self-directed learning and more freedom.

J Abnorm Child Psychol. 1985 Dec;13(4):501-11

Effects of color stimulation and information on the copying performance of attention-problem adolescents.

Zentall SS, Falkenberg SD, Smith LB.

 

The optimal stimulation theory proposes that hyperactive children are less tolerant of lower levels of arousal than nonhyperactive children and should thus derive greater gains from stimulation added to repetitive copying tasks than do comparisons. To test this hypothesis, 16 adolescents, rating high on attention and behavior problems, were matched on the basis of age and poor handwriting performance to 16 controls. Matched pairs were randomly assigned to treatment order (high-stimulation colored letters followed in 2 weeks by low-stimulation black letters or the reverse order) and to level of information (color added to difficult letter parts or added to randomly selected letters), counterbalanced for treatment order and level of information within each order. Errors and activity were subjected to a mixed-design analysis of covariance, with IQ the covariate. The major findings indicated that attention-problem adolescents performed better with high-stimulation task stimuli than with low, relative to the opposite performance pattern of controls. Different responding was significant for experimental but not for control children.

LEARNING DISABILITIES

Dev Neuropsychol. 2002;22(2):501-31.

Neuropsychological evaluation of deficits in executive functioning for ADHD children with or without learning disabilities.

Wu KK, Anderson V, Castiello U.

Department of Clinical Psychology, Caritas Medical Centre, Shamshuipo, Kowloon, Hong Kong. wukyk@ha.org.hk

This study investigates multiple aspects of executive functioning in children with attention deficit/hyperactivity disorder (ADHD). These areas include attentional components, impulsiveness, planning, and problem solving. The rationale of the study is based on neurophysiological studies that suggest frontal lobe dysfunction in ADHD. As frontal lobe functioning is related to abilities in executive control, ADHD is hypothesised to be associated with deficits in various areas of executive functioning. The specific effect of comorbidity of learning disability (LD) was also investigated. Eighty-three children with ADHD and 29 age-matched controls (age 7-13) participated in the study. A battery of neuropsychological tests was utilized to evaluate specific deficits in speed of processing, selective attention, switching attention, sustained attention, attentional capacity, impulsiveness, planning and problem solving. Findings indicated that children with ADHD have slower verbal responses and sustained attention deficit. Deficits in selective attention and attentional capacity observed were largely related to the presence of LD. No specific deficit associated with ADHD or the comorbidity of LD was identified in switching attention, impulsiveness, planning, and problem solving. These results revealed that ADHD is not associated with a general deficit in executive functioning. Instead, ADHD is related to a specific deficit in regulation for attentional resources. The importance of isolating the deficit related to LDs for examining the specific deficit associated with ADHD is highlighted. Results also emphasized the importance of isolating the effect of lower level of abilities (e.g., speed of processing) and the utilization of specific definition for the examination of executive functions.

MEDICATIONS

J Clin Psychiatry. 2002;63 Suppl 12:16-22.

Novel treatments for attention-deficit/hyperactivity disorder in children.

Spencer TJ, Biederman J, Wilens TE, Faraone SV.

Pediatric Psychopharmacology Unit, Psychiatry Service, Massachusetts General Hospital, Boston, USA.

 

Optimal medications for children with attention-deficit/hyperactivity disorder (ADHD) would be effective, well tolerated, and long acting and not cause mood swings or worsen comorbid conditions. Current medications work on brain dopamine and/or norepinephrine systems, which are thought to be involved in ADHD. The medication class with the most evidence of efficacy in ADHD is stimulants, but they may be abused, are effective for only 4 to 12 hours, and may cause mood swings or increase tic severity. In recent years, alternative treatments have been explored. Tricyclic antidepressants have efficacy comparable to that of stimulants but may cause constipation, dry mouth, tremors, blood pressure changes, and potentially serious side effects including cardiac conduction and repolarization delays. Monoamine oxidase inhibitors may improve ADHD symptoms but are associated with severe dietary restrictions. Serotonin reuptake inhibitors have little or no effect in ADHD but may improve comorbid depression. Bupropion, although less effective than stimulants, may improve both ADHD symptoms and comorbid depression. Antihypertensive agents may improve impulsivity, hyperactivity, and comorbid tics but cause sedation or rebound hypertension. Atomoxetine, which is being developed for ADHD, reduces symptoms of ADHD without exacerbating comorbid conditions and is associated with only minor side effects, including subtle changes in blood pressure and heart rate. Before prescribing a treatment, physicians should consider the appropriateness and effectiveness of any medication for children with ADHD, who may be less tolerant of side effects and less able to monitor and express concerns about their well-being than adults.

 

Arch Gen Psychiatry. 1995 Jun;52(6):456-63.

Is methylphenidate like cocaine? Studies on their pharmacokinetics and distribution in the human brain.

Volkow ND, Ding YS, Fowler JS, Wang GJ, Logan J, Gatley JS, Dewey S, Ashby C, Liebermann J, Hitzemann R, et al.

Medical Department, State University of New York, Stony Brook, USA.

BACKGROUND: The purposes of this study were to investigate the pharmacokinetics of methylphenidate hydrochloride (Ritalin) in the human brain, to compare them with those of cocaine, and to evaluate whether cocaine and methylphenidate compete for the same binding sites. METHODS: We used positron emission tomography to measure the temporal and spatial distribution of carbon 11 (11C)-labeled methylphenidate. These results were compared with those obtained previously for [11C]cocaine. Eight healthy male subjects, 20 to 51 years of age, were scanned with [11C]methylphenidate. Three were tested twice to assess test-retest variability, four were tested at baseline and after administration of methylphenidate, and one was tested with [11C]methylphenidate and [11C]cocaine. Two baboons were scanned to evaluate whether there was competition between cocaine and methylphenidate for the same binding sites in the brain. RESULTS: The uptake of [11C]methylphenidate in the brain was high (mean +/- SD, 7.5% +/- 1.5%), and the maximal concentration occurred in striatum. Pretreatment with methylphenidate decreased binding only in striatum (40%). Although the regional distribution of [11C]methylphenidate, was identical to that of [11C]cocaine and they competed with each other for the same binding sites, these two drugs differed markedly in their pharmacokinetics. Clearance of [11C]methylphenidate from striatum (90 minutes) was significantly slower than that of [11C]cocaine (20 minutes). For both drugs, their fast uptake in striatum paralleled the experience of the "high." For methylphenidate, the high decreased very rapidly despite significant binding of the drug in the brain. In contrast, for cocaine, the decline in the high paralleled its fast rate of clearance from the brain. CONCLUSION: We speculate that because the experience of the high is associated with the fast uptake of cocaine and methylphenidate in the brain, the slow clearance of methylphenidate from the brain may serve as a limiting factor in promoting its frequent self-administration.

Synapse. 1999 Jan;31(1):59-66.

Comparable changes in synaptic dopamine induced by methylphenidate and by cocaine in the baboon brain.

Volkow ND, Fowler JS, Gatley SJ, Dewey SL, Wang GJ, Logan J, Ding YS, Franceschi D, Gifford A, Morgan A, Pappas N, King P.

Medical Department, Brookhaven National Laboratory, Upton, New York 11973, USA. volkow@bnl.gov

Though the blockade of dopamine transporters (DAT) is associated with cocaine's and methylphenidate's reinforcing effects, it is the stimulation of dopamine (DA) receptors, achieved by increases in synaptic DA, that enables these effects to occur. Positron emission tomography (PET) and [11C]raclopride were used to assess the levels of occupancy of DA D2 receptors by dopamine achieved by doses of cocaine or methylphenidate previously documented to block over 70% of DAT. Studies were performed in five baboons using a paired scan protocol designed to measure DA D2 receptor availability (Bmax/Kd) at baseline conditions and after intravenous administration of either cocaine or methylphenidate. Cocaine (1-2 mg/kg) or methylphenidate (0.5 mg/kg) administered 5 min prior to [11C]raclopride decreased Bmax/Kd by 29+/-3% and 32 + 4%, respectively. Smaller reductions in Bmax/Kd (13% for cocaine given 30 min before [11C]raclopride and 25+/-10% for methylphenidate given 40 min before [11C]raclopride) were seen with longer periods between drug and radioligand. These observations are consistent with the slower striatal clearance kinetics of [11C]methylphenidate than [1C]cocaine observed in previous PET experiments and with the approximately twofold higher potency of methylphenidate than cocaine in in vitro experiments. Though the elevation of synaptic DA induced by >70% occupancy of DAT by these drugs lead to a modest increase in occupancy of D2 receptors (25-30%), further studies are required to assess if this is an underestimation because of differences in D2 receptor binding kinetics between raclopride and DA.

Altern Med Rev. 2003 Aug;8(3):319-30.

Outcome-based comparison of Ritalin versus food-supplement treated children with AD/HD.

Harding KL, Judah RD, Gant C.

McLean Hospital, Belmont, Massachusetts, USA.

 

Twenty children with attention deficit/hyperactivity disorder (AD/HD) were treated with either Ritalin (10 children) or dietary supplements (10 children), and outcomes were compared using the Intermediate Visual and Auditory/Continuous Performance Test (IVA/CPT) and the WINKS two-way analysis of variance with repeated measures and with Tukey multiple comparisons. Subjects in both groups showed significant gains (p less than 0.01) on the IVA/CPT's Full Scale Response Control Quotient and Full Scale Attention Control Quotient (p less than 0.001). Improvements in the four sub-quotients of the IVA/CPT were also found to be significant and essentially identical in both groups: Auditory Response Control Quotient (p less than 0.001), Visual Response Control Quotient (p less than 0.05), Auditory Attention Quotient (p less than 0.001), and Visual Attention Quotient (p less than 0.001). Numerous studies suggest that biochemical heterogeneous etiologies for AD/HD cluster around at least eight risk factors: food and additive allergies, heavy metal toxicity and other environmental toxins, low-protein/high-carbohydrate diets, mineral imbalances, essential fatty acid and phospholipid deficiencies, amino acid deficiencies, thyroid disorders, and B-vitamin deficiencies. The dietary supplements used were a mix of vitamins, minerals, phytonutrients, amino acids, essential fatty acids, phospholipids, and probiotics that attempted to address the AD/HD biochemical risk factors. These findings support the effectiveness of food supplement treatment in improving attention and self-control in children with AD/HD and suggest food supplement treatment of AD/HD may be of equal efficacy to Ritalin treatment.

 

THEORIES AND DIAGNOSIS

Acta Paediatr. 2003 Jul;92(7):776-84.

"Maturational lag" hypothesis of attention deficit hyperactivity disorder: an update.

El-Sayed E, Larsson JO, Persson HE, Santosh PJ, Rydelius PA.

Department of Woman and Child Health, Child and Adolescent Psychiatric Unit, Karolinska Institutet, Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden. Eman.El-Sayed@kbh.ki.se

This article discusses the relationship of maturation to ADHD and hyperkinetic disorder (HKD), with an emphasis on current research in ADHD and HKD, persistence and remission of ADHD symptoms over time and brain maturational trajectories. CONCLUSION: ADHD is a broad, heterogeneous syndrome and only a subgroup of subjects has a diagnosis of HKD, which is a subset of individuals with severe ADHD combined subtype. Children showing symptoms above the threshold for a diagnosis of ADHD are at risk of developing comorbid conditions and increasing stress in both parents and teachers. In some subjects, ADHD symptoms can improve over time during maturation and development. These children with a diagnosis of ADHD could be viewed as showing variants of normal childhood behaviour with maturational trajectories that are lagging behind but will catch up. ADHD could therefore represent a continuum from normality at one extreme to a severe disorder, HKD according to ICD-10, at the other extreme.

 

J Abnorm Child Psychol. 2000 Oct;28(5):415-24

Does the Conners' Continuous Performance Test aid in ADHD diagnosis?

McGee RA, Clark SE, Symons DK.

Child and Adolescent Mental Health Services, Valley Regional Hospital, Kentville, Nova Scotia, Canada. robin.mcgee@ns.sympatico.ca

The performance of clinic-referred children aged 6-11 (N = 100) was examined using the Conners' Continuous Performance Test (CPT) and measures of auditory attention (Auditory Continuous Performance Test; ACPT), phonological awareness, visual processing speed, and visual-motor competence. The Conners' CPT overall index was unrelated to measures of visual processing speed or visual-motor competence. Although the Conners' CPT converged with the ACPT, the latter demonstrated age and order effects. Significant variance in Conners' CPT parameters was predicted by phonological awareness measures, suggesting that Reading Disordered (RD) children could be "false positives" on the Conners' CPT. The Conners' CPT overall index, phonological awareness, and visual-motor measures were submitted to a 2 x 2 MANCOVA (ADHD vs. RD, covarying for age and socioeconomic status): a main effect for RD status was found. Children with ADHD did not have higher Conners' CPT scores than did clinical controls; however, children with Reading Disorders did. Phonological measures distinguished RD children from ADHD children and other clinical controls. ADHD children who failed the Conners' CPT were rated by teachers as more hyperactive. Despite the strengths of the Conners' CPT, its utility for differential diagnosis of ADHD is questioned.