ADHD: Possible Causes and Treatments

As a teacher I can't help but notice what seems to be an increased number of children being prescribed medication to treat Attention Deficit Hyperactivity Disorder (ADHD). Often, I wonder whether or not the administration of medication to developing children will result in adverse long-term effects. I explored whether or not alternatives, such as caffeine, water and music provided positive results similar to effective stimulant medications, when given to children with ADHD. There were many articles available regarding specific prescription drugs used to treat children diagnosed with ADHD, but it was quite difficult locating any statistically significant research supporting alternative options. Maybe that has something to do with who funds research.

The DSM-IV lists specific criteria that a person must exhibit prior to being clinically diagnosed (Appendix A) with ADHD. However, the word 'often' is used throughout the DSM-IV guidelines; it's not specifically defined leaving a diagnosis to be subjective. Several authors cited throughout this paper referenced the DSM-IV when talking about the symptoms associated with ADHD (Ernst, et.al., 1999; Identifying and Treating ADHD: A Resource for School and Home, 2003; Lerner, 2003; Raby, 1995; Searight and Burke and Rottnek, 2000; Sylwester and Cho, 1993). Some of the hyperactivity characteristics listed are also similar to those described by Strauss (Lerner, 2003) characterizing the brain-injured child. Once a diagnosis is made, a treatment plan must be devised, but not all methods are equally effective for all children (Assessing complementary and/or controversial interventions, 2004). Some of the treatments suggested include medication, behavior management, or the multimodal approach (a combination of medication and behavior management therapy).

Opinions regarding treatment implementations vary. Stimulant medications, like Ritalin and Adderall, are considered to work well, consistently, and provide short-term quick results (Ballard et.al., 1997; Hall and Gushee, 2002; Identifying and Treating ADHD: A Resource for School and Home, 2003; Raby, 1995; Radcliff, 2000; Searight et.al., 2000; Sylwester and Cho, 1993). Multimodal treatment is a recommended choice also because it results in immediate positive changes and long-term behavior strategies (Assessing complementary and/or controversial interventions, 2004; Hall and Gushee, 2002; Identifying and Treating ADHD: A Resource for School and Home, 2003; Smith, 2004). Either way, the goal of treatment is to get the child to focus better. Those who select Ritalin or Adderall probably do so because each has proven to be effective in decreasing motor activity; however, Ritalin only lasts a few hours while Adderall can last up to eight hours (Hall and Gushee, 2002; Raby, 1995). Whichever method is selected, it is recommended that the choice be consistent (Identifying and Treating ADHD: A Resource for School and Home, 2003) and appropriate for the child.

Whether or not a particular treatment is appropriate sometimes raises controversy, especially when recommending stimulants like Ritalin and Adderall. Stimulant medications work by creating a neuro-chemical change in the brain; yet, the FDA only provides general guidelines and minimum ages for us (Hall and Gushee, 2002). Even though a lot of research has been done on Ritalin, I couldn't find any research stating that it is perfectly safe. Stimulant side effects include insomnia, loss of appetite (resulting in weight loss), increased heart rate, increased blood pressure, mood swings (causing depression), and tics (Ballard et.al., 1997; Hall and Gushee, 2002; Identifying and Treating ADHD: A Resource for School and Home, 2003; Lerner; Radcliff, 2000; Searight et.al., 2000). The main reason for the controversy does not surround all the above-mentioned side effects. Rather, it focuses upon the fact that stimulants like Ritalin and Adderall are classified as C-II, controlled substances (ADD/ADHD & behavioral problems: nutritional causes, prevention, and therapies, 2004). Controlled substances also include drugs like cocaine, morphine, and oxycontin (Searight et.al., 2000). It would be hard to dispute that those drugs are not addictive. So, is it safe to give an addictive stimulant to a child? When deciding whether or not to use a stimulant, individuals need to evaluate whether or not the positive side effects outweigh the negative side effects.

In order to evaluate the available options, one needs to understand how ADHD affects the brain. ADHD is a neurological condition involving inattention and hyperactivity and is the result of a developmental failure in the brain circuitry that monitors inhibition and self-control (Assessing complementary and/or controversial interventions, 2004; Ballard, et.al., 1997; Ernst et.al., 1999; Identifying and Treating ADHD: A Resources for School and Home, 2003; Neurobiology of ADHD, 2004; Sylwester and Cho, 1993). A study done by the National Institute for Mental Health (NIMH) indicated that children with ADHD had smaller prefrontal lobes and basal ganglia (Ballard et.al., 1997; Identifying and Treating ADHD: A Resources for School and Home, 2003; Radcliff, 2000). The smaller prefrontal lobes mean that ADHD children lack neurotransmitters, such as dopamine and norepinephrine necessary for cognition, emotions, moods, and behavior (Ballard et.al., 1997; Ernst et.al., 1998; Identifying and Treating ADHD: A Resources for School and Home, 2003; Lerner, 2003; Raby, 1995; Radcliff, 2000; Sylwester and Cho, 1993). The purpose of the basal ganglia is to modify movement and emotions (Neurobiology of ADHD, 2004). This may be why ADHD children have increased movement and tendencies to develop depression. Some people think that stimulants alter the brain in a way that brings about increased attention.

On the other hand, some people disagree with what came first, the brain 'shrinkage' or the ADHD. Dr. Baughman, a pediatric neurologist, pointed out that the NIMH study and PET scans of the brain have not been conclusively replicated, and interpretation of symptoms remains subjective. He also mentioned that studies conducted since 1998 mostly included stimulant treated ADHD patients indicating that the stimulant drug was the onset of brain atrophy; and until an objective way to diagnosis ADHD is devised, no one can know for sure if ADHD is a legitimate disease (Baughman, 2004). Dr. Baughman has been practicing neurology for the past forty years and as you can tell is against medicating children assumed to have ADHD.

Studies within the past decade have indicated that stimulants increase the levels of neurotransmitters in the brain; thereby, stimulating attention (Lerner, 2003; Neurobiology of ADHD, 2004) and giving children a better chance at focusing and completing academic tasks. Ritalin's successful effect on the brain may be why people are willing to take the risks of unknown long-term effects related specifically to the brain and dependency issues. Ritalin and other stimulants like Adderall activate the inhibited chemicals in the brain producing extra neurotransmitters; thereby, increasing the child's ability to pay attention, control impulses, and reduce hyperactivity (Hall and Gushee, 2002; Identifying and Treating ADHD: A Resources for School and Home, 2003; Searight et.al., 2000; Smith, 2004), but they do not necessarily increase academic performance (Smith, 2004). Those are all things people hope to accomplish when treating a child with ADHD, but no one can say for sure what the long-term effects are for children.

However, research indicated that amphetamines decrease growth hormones (decreasing height), and there were well documented studies done indicating an increase of drug abuse (Ballard et.al., 1997; Hall and Gushee, 2002). Being that stimulants are controlled substances, the drug abuse mentioned does not surprise me. Cocaine works in a similar fashion on the brain as does a drug like Ritalin. By blocking natural receptors and artificially increasing levels of dopamine and norephinephrine in the brain, cocaine leads to an addiction; the brain loses over time its ability to produce neurotransmitters on its own because the receptors become weak (How drugs affect neurotransmitters, 2004). Children with ADHD become addicted to Ritalin in order to function 'properly'. However, Diller (1998) pointed out in Running on Ritalin that Ritalin does not cause addictive behavior unless taken in large, abusive quantities. Children who take Ritalin in small doses do not experience any withdrawal symptoms if a dose is missed. Another study indicated that "short-term memory seems to be positively impacted by stimulants, although there is concern about recall when not on the medication" (Ballard et.al., 1997). Stimulants almost appear to be short-term solutions rather than life long solutions.

A life long solution may be adjusting one's diet. Raby (1995) believes that the brain dysfunction results in ADHD, but ADHD is not the cause of smaller brain regions. Pesticides and nutritional elements may have damaged the neurotransmitters in the brain's frontal lobes (Raby, 1995) resulting in an ADHD diagnosis. While food sensitivities and pesticide studies done by Feingold have not been conclusively proven (Assessing complementary and/or controversial interventions, 2004; Identifying and Treating ADHD: A Resources for School and Home, 2003), some people suspect that the 500% increase of pesticide use over the past 50 years is to blame for brain dysfunctions (Raby, 1995). The Environmental Protection Agency classified 70 pesticides commonly used on foods like fruit and vegetables as carcinogenic; these neurotoxic pesticides cause damage to neurotransmitters by inhibiting nerve synapses and transmissions (Raby, 1995). Plus, the United States has no control over fruits and vegetables grown outside the country and/or used in imported 'fruit' juices, even milk is allowed to have traces of herbicides. The symptoms resulted from over exposure to pesticides are then categorized as ADHD.

As for the nutritional variable, Feingold was mentioned regarding his 1975 diet theory (Lerner, 2003). Feingold's study did not show significant results, but did suggest that elimination of one or more foods, additives, caffeine, and/or sugar (Raby, 1995) could have positive results for children with ADHD (Assessing complementary and/or controversial interventions, 2004). One reason why it may be difficult to prove that diet has significant effects is because each child with ADHD displays symptoms in varying degrees (Raby, 1995); and therefore, he/she will respond differently to various treatments. Another reason why is may be difficult to prove diet changes successfulness is because people eat so many processed foods filled with preservatives and additives. It may be trying to differentiate amongst which foods are good for children. Although, if a change in diet cures a child completely, perhaps the child didn't even have ADHD.

Being that no one knows for sure what causes ADHD and no one has developed a known cure, I thought it would be interesting to explore ADHD associated with the brain's function. I took a look at how caffeine, music, and water affect the brain to see if there were any similarities between these alternative ideas and stimulant medications. If stimulant medications increase the release of neurotransmitters enabling the brain to inhibit unwanted restlessness (Ballard), could caffeine do the same? If low levels of dopamine decrease aggression, hostility, and violence, and low levels of norepinephrine require a person to need a high amount of stimulation to achieve a basic response (Radcliff, 2000), could music provide the appropriate stimulation? Being able to pay attention, focus, and sit still in class is necessary to learn. Those unable to do so are labeled hyperactive and many treated with Ritalin; however, the child's behavior may be explained by diet (Raby, 1995). Six classes of nutrients necessary to function properly are water, proteins, carbohydrates, fats, minerals, and vitamins (Raby, 1995). Perhaps, what is missing from the child's diet most is the vital nutrient, water, which is why I'll discuss that last.

Beginning with caffeine, it is a stimulant that many people like to have in the morning. Whether we like it for the jolt, smell, or taste, it does affect our bodies. While all individuals may feel caffeine's effects differently (O'Connor, 2001), one consensus is that it increases dopamine production by attaching to adenosine receptors responsible for sleepiness and increases neural activity (alertness) (How drugs affect neurotransmitters, 2004). Caffeine is considered an addictive substance, but some consider it a physical dependency rather than a brain dependency like cocaine (How drugs affect neurotransmitters, 2004). While caffeine works by attaching itself to adenosine receptors, cocaine works by inhibiting dopamine transporters naturally created in the brain. Maybe, caffeine's effect is temporary and cocaine's effect is permanent. If that's the case and Ritalin works in a similar way as cocaine, should children really be digesting such a medication?

However, caffeine has not been proven to be as effective as Ritalin. Children drink about 100 mg of caffeine via soda (Hughes & Hale, 1998) which is well above the recommended dose even for adults; thereby damaging a child's attention capacity (O'Connor, 2001). This makes it difficult to assess caffeine's effect in small doses because many children have already been exposed to too much caffeine. "This is important because high and low caffeine consuming children report different effects from caffeine" (Hughes & Hale, 1998). For children reported to consume low doses of caffeine, improved behavior was noticed in some cases, but doses varied (Hughes & Hale, 1998; O'Connor, 2001) making it difficult to generalize the findings. Also, "children who haphazardly consumed caffeine went through alternating cycles of withdrawal and agitated stimulation" (O'Connor, 2001). Over consumption and withdrawal symptoms are similar to the side effects of stimulants, so is caffeine any better? Maybe, caffeine is one of the causes of ADHD and not a solution after all.

Another suggestion to consider is music as a means of stimulation. Although, maybe the problem is that children are used to constant movement provided via computer games, video games, and television that they can't concentrate now, but I think most people would admit that music conjures up good feelings and memories. "Music stirs memories, banishes boredom, and creates a harmonious atmosphere in the classroom" (Jackson and Joyce, 2003). Music is indicated to decrease blood pressure and lower muscle tension (ADD/ADHD & behavioral problems: nutritional causes, prevention, and therapies, 2004) making it easier for children to concentrate. Some studies suggest that ADHD children work better with background music because it prevents boredom while doing a monotonous task (Abikoff and Courtney and Szeibel and Koplewicz, 1996). When music is played, both hemispheres of the brain are engaged, learning is enhanced, and stress alleviated. Children may be less likely to act out in frustration; thereby, curbing the need for discipline (Jackson and Joyce, 2003). There was study reported in the American Journal of Occupational Therapy indicating that IM (computerized interactive metronome) helped children with ADHD increase motor planning and timing skills by practicing matching the beat (Assessing complementary and/or controversial interventions, 2004). A tool like this may be especially useful for classroom teachers to consider.

Water, we know is an essential nutrient for survival which is why I thought it may play a role in how the brain functions. A lack of water can result in dehydration and even mild cases of dehydration can caused decreased concentration, decreased reaction rates, and decreased physical stamina (Should I worry about water?, 2004). Many children throughout a school day may only drink during lunch or after physical education. I know that my students rarely ask to go to the water fountain and they're with me from 8 A.M. until almost 4 P.M. They couldn't possibly be consuming enough water. Also, when they do drink during lunch, it tends to be a sugar filled liquid. Water is essential for the body to maintain its level of amino acids used by the brain to function optimally (Dehydration also causes neurological autoimmune disorders, 2004). When the body lacks amino acids, the body begins to overuse neurotransmitters (Dehydration also causes neurological autoimmune disorders, 2004). Maybe a constant state of dehydration is causing some children's brains to deplete the necessary dopamine and norepinephrine needed to control their attention and emotions.

While caffeine, music, and water are not well tested alternatives, it can't hurt to try them out appropriately, especially since there are about 2 million children (Identifying and Treating ADHD: A Resource for School and Home, 2003) currently diagnosed with ADHD. Addressing ADHD considering all possibilities ranging from brain dysfunctions at birth to brain dysfunctions from pesticides (Raby, 1995; Smith, 2004), will hopefully lead to further testing done on items other than stimulants. Many children are more sensitive to substances than an adult (Raby, 1995) so caution should be used when administering medications to a developing child. For a complete review of treatments, it's a good idea to look into diet, relaxation, behavior management, and drug therapy treatments (Raby, 1995). Possibly, a combination is best in the case of a specific child. As pointed out by the NIMH in 1999 after conducting a study on 579 children ranging from 7-10 years old nationwide and Canada, a multimodal program seems to be most effective. Those children in multimodal programs required a smaller dose of stimulants than those children just relying on the medication (Identifying and Treating ADHD: A Resource for School and Home, 2003).

It's important for ADHD treatments to be studied further and varied treatment options made available (Identifying and Treating ADHD: A Resource for School and Home, 2003) because it's becoming the fastest growing diagnosis for adults (Raby, 1995) indicating that children will not grow out of it. Another thing to remember is that the symptoms of ADHD are subjective. What may annoy one parent or teacher, may not affect another. Focusing and appealing to the child's positive attributes, such as creativity and spontaneity (Raby, 1995) may be useful in classroom instruction. I'm sure before ADHD was even a recognized disorder that teachers were trying to accommodate students who displayed ADHD-like characteristics. Not every child will fit the 'model' student profile of sitting still and paying attention all day.

Like any other learning disability, it's important for each child to be evaluated individually. Some students misbehave when frustrated due to a task being too hard leading to aggressive behavior (Jackson and Joyce, 2003). One problem that teachers may experience is teaching rote facts, such as multiplication. The process can be boring, and "effective teaching of skills can reduce students' active attention to the process" (Sylwester and Cho, 1993). This leaves teachers with the responsibility of coming up with creative ways to teach skills. Gaining the child's attention is important because "attention - the ability to focus the mind - is a prerequisite to learning and a basic element in classroom motivation and management (Sylwester and Cho, 1993). Teachers have the arduous task of balancing classroom management and good relationships with all their students. In, Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home (2003), some wonderful tips are suggested for parents and teachers (Appendix B). Similar tips are also listed in Learning Disabilities (233).

With IDEA and Section 504 of the Rehabilitation Act of 1973 in force, it's especially important for teachers to understand ADHD students' rights regarding FAPE, fair and appropriate public education, (Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home (2003). There has also been a rise in the category 'other health impaired' over the years because that is where classified ADHD children are placed (Lerner, Smith). In order for strategies to work with a child, it's helpful to have good communication between the parent(s) and teacher, and a commitment to cooperate by maintaining a routine, keeping consistent punishments/rewards for certain behaviors, and doing what is necessary to help an ADHD child focus enough to learn (Identifying and Treating ADHD: A Resource for School and Home (2003). This may be easier said than done when the parents do not recognize their child's behavior as problematic. Maybe when the parent hears it often enough that their child's distractibility is affecting his/her learning they'll be more wiling to cooperate.

Being a teacher, I know how disruptive it can be to have children in a class that can't sit still, call out without raising their hand, and move about in ways that may cause harm to themselves or other children. However, I struggle with the notion of medicating children in the prime of their development when research really can't prove the drugs safe from adverse long-term effects. I've seen many families struggle with medication dosages. Those struggles resulted in insomnia, weight loss, and depression. All those side effects seem like a great deal of stress to put on a child who is already struggling. My hope for children with ADHD is that they'll learn how to cope through behavior management therapy and grow up into professions that suit their personality. In the meantime, I'm interested in more studies being done to show whether or not alternative treatments are viable options to stimulant medications. I'm also interested in which came first ADHD or the smaller brain?

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