ADHD, or Attention Deficit Hyperactivity Disorder, used to be divided into two separate diagnoses, ADD and ADHD depending on whether a person exhibited inattention without hyperactivity, or exhibited inattention and hyperactivity. Currently, only the diagnosis of ADHD exists, with various subtypes.

All people are restless and inattentive occasionally. These qualities are more severe, persistent, and impairing in children with Attention-Deficit/Hyperactivity Disorder (ADHD).  A diagnosis of ADHD, requires that trouble with restlessness and inattention  must cause difficulty in multiple areas such as at home, in school, or with friends.

Children At Risk


  • 3-5 % of all children are affected by ADHD.
  • more than a million children in the U.S. have ADHD.
  • studies suggest that 10 million Adults are currently affected by ADHD, and only about 9% of them are treated


  • signs of ADHD may be apparent during the preschool years
  • most families seek help when the child is in elementary school and the child’s behavior interferes with adjustment and learning.
  • symptoms may worsen over time as the demands on the child increase.
  • Early and mid-adolescence are particularly difficult times for children with ADHD, as it affects academic and social situations
  • In some children the symptoms diminish or disappear during late adolescence.
  • About 1/3 of children with this disorder may outgrow the symptoms by early adulthood
  • In 2/3 of people, the disorder will be lifelong


  • ADHD is  4-9 times more prevalent in boys than girls
  • Symptoms of ADHD differ in boys and girls, and as we learn more, we may see the rate of ADHD in boys and girls become more equal

Family History

  • ADHD is not due to poor parenting, or laziness or bad behavior on the part of the child.
  • ADHD is genetic: it is 60% heritable
  • A sibling of a child with ADHD has a 3-fold increased risk for ADHD
  • If a child is diagnosed with ADHD, it is very likely that a parent has (diagnosed or undiagnosed) ADHD
  • If a parent has ADHD, the risk that a child will have ADHD increases 17-fold

Some environmental factors are thought to increase the risk of ADHD:

  • Exposure to alcohol and tobacco in utero
  • exposure to lead in very early life
  • complications during pregnancy and birth, including prematurity
  • infections during pregnancy, at birth and in early childhood (measles, varicella, rubella, enterovirus 71, and streptococcal bacterial infection)

Co-Occurring Disorders

Children with ADHD are at a high risk for other problems. They may have trouble with learning, such as reading and language processing that are not just because of inattention. They may have difficulty regulating their behavior and following rules, be obstinate, and resist limits and authority.  Children and adolescents with ADHD tend to seek excitement, feel bored more easily and spend little time planning things through, some gravitate toward thrill-seeking behaviors.

Anxiety and depression are more common in children with ADHD than in the general population. Some children may be so worried that they find it hard to stay focused on academic work. Similarly, sad children are also less likely to stay focused and to feel motivated to keep up with school demands. If they are irritable, they may resist direction or lash out.


Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD.

ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose.

Parents may first notice that their child loses interest in things sooner than other children, or seems constantly “out of control.” Often, teachers notice the symptoms first, when a child has trouble following rules, or frequently “spaces out” in the classroom or on the playground.

No single test can diagnose a child as having ADHD.

To diagnose ADHD, a health professional needs to gather information about the child, and his or herbehavior and environment.

Some pediatricians may assess a child themselves, but many will refer the family to a mental health specialist with experience in childhood mental disorders such as ADHD.

The first step is to consider whether there are other explanations for the symptoms. Certain situations, events, or health conditions may cause temporary behaviors in a child that seem like ADHD:

  • undetected seizures that could be associated with other medical conditions
  • middle ear infection that is causing hearing problems
  • undetected hearing or vision problems
  • medical problems that affect thinking and behavior
  • learning disabilities
  • anxiety or depression, or other psychiatric problems that might cause ADHD-like symptoms
  • significant and sudden environmental change, such as the death of a family member, a divorce, or parent’s job loss.

The second step is to check school and medical records for clues, to see if the child’s home or school settings appear unusually stressful or disrupted, and to gather information from the child’s parents and teachers, coaches, babysitters, and other adults who know the child well.

The third step is to consider whether the symptoms meet criteria in terms of severity, timing, and based on the child’s development.

  • Are the behaviors excessive and long-term, and do they affect all aspects of the child’s life?
  • Do they happen more often in this child compared with the child’s peers?
  • Are the behaviors a continuous problem or a response to a temporary situation?
  • Do the behaviors occur in several settings or only in one place, such as the playground, classroom, or home?

It is important to consider the  child’s behavior during different situations. Some situations are highly structured, some have less structure. Others would require the child to keep paying attention.

Most children with ADHD are better able to control their behaviors in situations where they are getting individual attention and when they are free to focus on enjoyable activities. These types of situations are less important in the assessment.

There are tests to help determine whether a child has ADHD.  But the tests can only provide guidance.

  • Some children have normal tests, but struggle in their environment with symptoms that clearly indicate a diagnosis of ADHD.
  • Some children may have abnormal tests, but their symptoms can be better explained by other factors, and they do not have ADHD.

A child  may sometimes be evaluated to see how he or she acts in social situations.

Finally, if after gathering all this information the child meets the criteria for ADHD, he or she will be diagnosed with the disorder.


ADHD symptoms fall into three main categories


  • difficulty sustaining attention,
  • trouble listening,
  • difficulty attending to detail
  • organization and study skills may be poor
  • distractibilility
  • forgetfulness


  • blurting out answers
  • often interrupting
  • difficulty waiting in school and in play situations
  • These characteristics frequently impede social relationships.


  • being in constant motion
  • fidgeting
  • squirming
  • often running or climbing
  • talking excessively
  • feeling restless inside

What Does it Feel Like to Have ADHD?

Imagine that it is tax time. Taxes are due on April 15 every year (unless you’re a farmer). On April 15 every year, we see a news reporter at out local post office, interviewing the line up of cars waiting to drop off their taxes at the last minute. Why are there so many people there?

Completion of taxes can be a complicated task, it requires the ability to collect multiple pieces of data, sort and organize them into a meaningful data set. We often don’t know where to start! We sometimes do not know how to break down the task into several smaller tasks that we can accomplish.We may sit down to work on our taxes and realize we are missing a receipt (we might lose some of the things we need between January and April). Then we have to go hunting for it in other piles, possibly in other rooms. Sometimes we get distracted and don’t go back to the taxes for several days (we procrastinate). We may feel that it is going to be impossible for us to sit down and sustain the mental effort necessary to work on our taxes for a sufficient amount of time. We may experience confusion, irritability, and annoyance, with the responsibility of taxes weighing us down. It isn’t that we are lazy, or that we don’t care about our finances; we just feel overwhelmed.

Now, imagine if you have ADHD, and most of your responsibilities feel this way.

Brain’s Executive Functions

The tasks of the brains’ executive function are behavioral control and inhibition. These are tasks that many people with ADHD show impairment in. Sometimes taking a look at how their behaviors can be understood in terms of impaired executive function can be helpful.

These are classes or types of executive function according to behavioral science:

Working Memory (nonverbal)

  • information in mind
  • Manipulate multiple thoughts at the same time
  • Imitate complex sequences of behavior
  • Have hindsight or value past behavior
  • Practice forethought—to anticipate the results of future behavior
  • Be self –aware
  • Organize behavioral sequences according to a “rule” or to achieve a  “goal”.

Internalization of speech/silent self-talk (verbal working memory)

  • Talk and think about the environment
  • Self-question/problem solve
  • Generate rules to guide behaviors
  • Instruct oneself to follow directions/rules
  • Comprehend what is read
  • Have moral reasoning

Self-control of emotions, motivation, arousal

  • Control one’s emotional sensitivity and reactions
  • Consider other points of view
  • Generate and control motivation
  • Generate and control the arousal needed to for goal-directed actions

Fluency-the smooth flow of behaviors

  • Organized, goal-directed and chained together seamlessly and carried out easily
  • Creative but organized or structured

Clinically, what we see can include:

Working Memory (nonverbal):

  • Poor short term memory
  • Poor concentration
  • Distractibility
  • Short attention span
  • Trouble learning from experience/repeating mistakes
  • Poor time management
  • Running late
  • Poorly organized work/projects
  • Daydreaming
  • Missing details
  • Not proof reading school work
  • Talkative
  • Blurts out inappropriately
  • Talks to self out loud
  • Noisy, disturbs others
  • Poor reading comprehension
  • Not liking to read
  • Acting without regard for rules, though the rules are known
  • Procrastination
  • Trial and error problem-solving

Internalization of speech/silent self-talk (verbal working memory)Talkative

  • Blurts out inappropriately
  • Talks to self out loud
  • Noisy, disturbs others
  • Poor reading comprehension
  • Not liking to read
  • Acting without regard for rules, though the rules are known
  • Procrastination
  • Trial and error problem-solving

Self-control of emotions, motivation, arousal

  • Moody
  • Oversensitive
  • Over-reacts
  • Hot/short-tempered
  • Low motivation
  • Trouble seeing other viewpoints
  • Stubborn, prefers self-selected tasks
  • Hyper or hypo active
  • Fidgety
  • Cannot turn thoughts off
  • Thinks too much/worries excessively
  • Cannot match activity to goals
  • Too loud
  • Impulsive
  • Poor verbal expression and oral reading
  • Poor movement control and fluency
  • Clumsy/awkward
  • Accident prone
  • Printing instead of cursive
  • Twitches/jerks

Fluency-the smooth flow of behaviors that are:

  • Impulsive
  • Poor verbal expression and oral reading
  • Poor movement control and fluency
  • Clumsy/awkward
  • Accident prone
  • Printing instead of cursive
  • Twitches/jerks

Adapted from Berkley, RA (1997) ADHD and the nature of self-control, NY, Guilford Press and Barkley RA (1998) Attention-Deficit Hyepractivity Disorder: A Handbook for Diagnosis and Treatment (2nd edition) NY Guilford Press and developed by EJ Cobb, PhD Adolescent Health cetner, Midlothian VA


Children with ADHD suffer from a brain-based biological disorder. They have lower levels of dopamine, a neurotransmitter. In addition, brain-imaging including MRIs and PET scans show that brain metabolism is lower in patients with ADHD than in normal controls, with significantly lower metabolic activity in regions of the brain that control attention, social judgment and movement.

Brain Imaging – Structural

The cerebral cortex is broken up into 4 lobes: frontal, occipital, parietal and temporal


Brain imaging studies suggest the frontal cortex is involved in ADHD

The frontal cortex is involved mainly with executive functions:

  • problem solving
  • attention
  • reasoning
  • planning

ADHD suffers usually have deficits in these functions.

  • these deficits become obvious in tests that are used during diagnosis, such as the Stroop test.

The brain has two hemispheres. The left is responsible for language and calculation, while the right is involved in attention.

  • some evidence suggests the right frontal lobe is smaller in children with ADHD than non-ADHD children
  • the right side of the brain is generally considered to be involved in attention processes
  • People with ADHD and people who have suffered frontal lobe damage or right hemisphere damage through illness or accident have similar symptoms

Brain Imaging – Functional

functional imaging techniques (SPECT & fMRI) allow us to view the brain while it works

Functional studies of ADHD demonstrate:

  • a decrease in the metabolic activity in the right frontal lobe
  • a decrease in the metabolic activity in the basal ganglia which is responsible for regulating movement and is connected with the frontal lobe region
  • 3 areas closely related to the basal ganglia are believed to be responsible for the symptoms of ADHD:

(Click on the name to see where in the brain each region is)

  1. the prefrontal cortex (part of the frontal lobe) ,thought to be the brain’s “command center”
  2. the caudate nucleus (part of the basal ganglia)
  3. the globus pallidus (part of the basal ganglia)

Some researchers believe that problems in the circuit between these three regions are the underlying mechanisms that cause ADHD symptoms.

Prefrontal Cortex


Marked areas:

A. Spatial working memory
B. Spatial working memory, performance of self-ordered tasks
C. Spatial, object and verbal working memory, self-ordered tasks, analytic reasoning
D. Object working memory, analytic reasoning

Image from Scientific American



Globus Pallidus


This image was produced by the Digital Anatomist Project

Alternative and Complimentary Treatments

Essential Fatty Acids

Essential fatty acids (EFAs), also known as omega-3 and omega-6 fatty acids, have been claimed to have beneficial effects as a treatment for attention-deficit-hyperactivity disorder (ADHD). Animal experiments have provided information about the role of EFA in the brain, and several mechanisms of EFA activity are well known. Clinical studies and review papers of EFA blood levels and EFA supplementation trials in children with ADHD support that  Children with ADHD present lower levels of blood EFAs, and open-label EFA supplementation trials in ADHD raise EFA blood levels and improve symptoms of ADHD. Randomized controlled trials, however, have generally been unsuccessful in demonstrating any behavioural treatment effects.

INTERPRETATION:  current findings do not support the use of EFA supplements as a primary or supplementary treatment for children with ADHD.  However, the risk-benefit ratio may be worthwhile.


Pycnogenol is an antioxidant plant extract from the bark of the French maritime pine tree, reduces ADHD in children, according to a 2006 study that was published in the journal of European Child & Adolescent Psychiatry.

The study sampled 57 outpatients with ADHD with an average age of 9 years, from the Department of Child Psychology at the Children University Hospital in Slovakia. Forty-one patients received Pycnogenol and 16 received placebo. Patients were not supplemented with any other drugs or with vitamins E or C during the study. Participants in the Pycnogenol group received 1 milligram of Pycnogenol or placebo for every kilogram of body weight, on a daily basis each morning, for one month.

Stress hormones were quantified from urine samples of the children taken before and after supplementation with either Pycnogenol or the placebo for a one-month period. After a one-month discontinuation of treatment, a third urine sample was taken that revealed that ADHD symptoms had recurred. The stress hormone levels had increased again during the period when children had stopped taking Pycnogenol, suggesting the effect of Pycnogenol on stress hormones accounts for the improvement of inattention and hyperactivity of the children.

The results reveal Pycnogenol lowers stress hormones by 26.2 percent in the case of adrenaline and decreases neurostimulant dopamine by 10.8 percent, which plays an important role in brain physiology involving learning, cognition, attention and behavior.

The studies findings support observations that children with ADHD have dramatically elevated levels of stress hormones and that these may increase heart rate and blood pressure to cause excitement, arousal and irritability, as compared to children without ADHD symptoms.

ADHD symptoms recurred after a one-month discontinuation of Pycnogenol treatment. Participants were given a basic psychiatric examination by teachers and parents one month after the study began and one month after the end of the study. After one month of treatment, there was a significant drop in hyperactivity and inattention compared to the start of the study and placebo. The researchers also found that, one month after termination of treatment, symptoms returned to their levels as measured before the study started in the Pycnogenol group, strongly suggesting the antioxidant’s effect on reducing ADHD symptoms.

INTERPRETATION: This report appears to support the use of pcynogenol in the treatment of ADHD. What is confusing for this psychiatrist, is that our understanding of ADHD is that it is related to lower levels of DA and NE in certain brain regions. I wonder what criteria were used to diagnose ADHD. I wonder whether Youth in Slovokia dont have fairly high levels of stress and anxiety that may mimic ADHD and result in higher stress hormones? At this time, the risk/benefit ratio suggests that a trial seems reasonable, with caution.

Visual therapy

Visual problems have been implicated in several developmental conditions, such as dyslexia. There is no scientific support for any theory claiming specific ocular exercises or coloured lens can alleviate ADHD (Lennerstrand & Ygge, 1992; Baumgaertel, 1999). There is also no evidence to support anecdotal reports of improvements in ADHD symptoms after introducing prismatic lenses (Baumgaertel, 1999). Any concerns about a child’s vision should be referred to an optometrist immediately.

INTERPRETATION: There are no scientific studies supporting the use of vision therapy to treat ADHD.


200 years ago, Fr Hahnemann developed a therapeutic system based on the concept that illness resulted from an imbalance of “vital energies”. This therapeutic system is now known as Homeopathy. Homeopathic treatments generally consist of highly individualised blends of plant, animal and/or mineral extracts. Homeopathic treatment regimes have become very popular throughout Europe and the United States. Linde et al (1994) conducted a careful review of homeopathic treatments and found them to be more effective than a placebo for various conditions.

Several homeopathic studies have also been conducted on ADHD children (Lamont, 1997) and statistically significant improvements have been shown. But these studies were not blinded (the investigators knew which children were getting which treatment and this may have influenced the outcome).

INTERPRETATION: The mechanisms at work in homeopathy are unknown and, therefore, further research is required before any definitive answer can be given on homeopathic treatments.

Auditory Stimulation

For a long time there has been a growing movement concerning the role of music in emotional and cognitive processes. However, there is only one study (that we know of) that has explored auditory stimulation as a possible treatment for ADHD. Abikoff et al. (1996)reported that the ability of ADHD boys to solve arithmetic problems improved when they were allowed to listen to their favourite music.
A French otalaryngologist, A. Tomatis has developed the Tomatis Metohd of Sound training. This system is based on the theory that auditory integration is critical to brain maturation and learning. It proposes that improvements to focus and attention can be achieved by combining auditory stimulation and listening training.

INTERPRETATION: There are no scientific investigations into this technique and the number of training sessions required (at least 75) is concerning.


Hypnosis is not a very effective means of controlling ADHD (Baumgaertel, 1999).

INTERPRETATION: Hypnosis has little to no effect on the core symptoms of ADHD. It is effective, though, in removing problems associated with the ADHD, such as sleep disturbances or tics (Sugarman, 1996)


The goal of biofeedback is the self regulation of physiological processes. This is achieved by monitoring a physiological process using a computerized feedback system. The threshold for a particular physiological activity is set and the patient’s task is to maintain or better the threshold. Generally biofeedback has been used (successfully) on people trying to lower their blood pressure. More recently, however, the technique has started to show positive results with children that have ADHD. Lubar (1997) and Mann et al. (1992) demonstrated that children with ADHD children with ADHD have increased theta (4-7.75 Hz) and decreased beta 1 (12.75-21 Hz) when compared with children without ADHD, with Lubar’s study showing improvements in 12/19 children.

Most of these treatment all state that they are most effective when part of a multi-modal treatment.