Mary+Paul+-+Final+Project

__**Childhood ADHD: A Comparison of the Controversial Treatment Options**__
Attention Deficit Hyperactive Disorder (ADHD) is the most prevalent behavioral disorder among US children today. [17,22] While many skeptics have long doubted the actuality of the disorder, claiming that it is ultimately just an excuse for bad behavior, over 30 years of research have proven otherwise. [17,21] ADHD is, in fact, a true disorder affecting approximately 3-7% of US school children. [11] These children are plagued with overwhelming difficulties in their school and social lives. The name says it all: ADHD is marked by excessive inattentiveness, hyperactivity, and recklessness that are beyond the individual’s control. [19] Symptoms of ADHD, more often than not, persist throughout adolescence and adulthood. [11] This brings about the risk for additional problems concerning socializing, academics, family life, drug abuse, low self-esteem and, later, workplace problems. [11] The focus of our attention continues to remain on the children however, since it is those young, tender ages when ADHD is first recognized and symptoms are 40% more prevalent. [26]  Wherever there are children involved, there is likely to be controversy involved. A prime example is seen when confronting the treatment of childhood ADHD. Studies have proven only three treatment options to be successful: medication, behavioral therapy, or some combination of the two. [4] Stimulant drugs have long been the most successful and widely used method. [1] However, there is always a great deal of controversy regarding the safety of giving stimulant drugs to children. [6] The risk of addiction and abuse associated with these drugs has incited decades of research to find alternative treatment options. Common areas of research include nutrition, environmental factors, social factors, and brain injuries. [1] Among these, the idea that nutritional intervention can reduce hyperactive behavior in children has gained the most popularity in the past 40 years. [11] Extensive research has revealed a direct relationship between nutrition and hyperactivity; however, inconsistent results and inadequate study parameters have resulted in much disagreement and continuing skepticism. [3]
 * Introduction **

As of 2003, an approximated 4.5 million children in the US were diagnosed with ADHD. [20] It affects considerably more boys than girls, with boys typically exhibiting more hyperactivity and girls exhibiting more inattentiveness. [4,21] Still fairly misunderstood today, it is the most commonly studied psychiatric disorder among children. [1] Scientists have not clearly determined a cause, a cure, or even a definitive diagnostic test. [1,21] Attentiveness cannot be quantified, but it can be inferred as the mind’s ability to process information about its environment. [14] The ability to concentrate is essential to learning or remembering an environmental stimulus or event. [14] Impairment of this ability is what defines ADHD as a neurobehavioral learning disorder.
 * ADHD – An Overview **

Diagnosing ADHD is purely subjective and is based predominantly on the characteristics of inattentiveness and hyperactivity. Common symptoms include: fidgetiness, compulsive aggression, excitability – impulsiveness, low tolerance for failure and frustration, short attention span, exceptional clumsiness, poor sleep habits, cognitive disturbances, and perceptive disturbances. [9] The disorder develops gradually in early childhood and can usually be detected by the age of 7. [21] Although it remains indefinite what causes ADHD, research suggests that it is primarily a genetic disorder. This idea is strongly supported by studies that compared occurrences in adopted children’s assumed and biological relatives, as well as studies showing that the concordance rate is significantly higher in identical twins than fraternal twins. [11] Possibilities such as prenatal complications, toxin exposure, and environmental factors are among other popular arguments. [11] Although environmental factors are indeed capable of exacerbating the symptoms, they do not actually cause ADHD. [21] It is believably a multifaceted disorder, and every case is unique. [11]

Recent scientific advances have given rise to a better understanding of the neurological disparity of an ADHD patient. The primary area of the brain responsible for the symptoms of ADHD is the prefrontal cortex (PFC). The PFC is an area located in the front of the brain that is associated with attention, self-control, decision-making, and personality. [4] Dopamine levels in the extracellular synapses of the PFC, where neurotransmitters do their job, are significantly lower than those of other patients. [27] Dopamine is a neurotransmitter that has been linked with movement, attention, learning, memory, and the brain’s pleasure-and-reward system. [10] Increased dopamine transporters in ADHD patients suggest that the dopamine deficiencies are likely caused by excess transporters reabsorbing the neurotransmitter into nerve cells, decreasing the concentration in the synapses. [24,27] The interference of the pleasure-and-reward system that results from the decreased dopamine levels is a probable starting point of ADHD, disrupting feelings of reward and, therefore, motivation. [10] Without reward, a child will lack interest; and without interest, a child will lack the ability to pay attention. Studies show that a normal child’s dopamine responses is able to send cues predicting positive reinforcement when behavioral reinforcement is delayed, whereas a child with ADHD lacks the ability to predict positive reinforcement in the absence of behavioral reinforcement. [23] Stephen Hinshaw, chair of the department of psychology at the University of California, Berkeley, told TechNewsWorld “We know that many ADHD patients do well when there’s an immediate reward, as in a video game. But maybe if there’s a deficiency in the chemicals flowing through the brain, they have trouble visualizing that there will be a reward after a long task such as working on a project for a month at work.” [10]

Medication therapy has consistently been the most commonly used approach for treating childhood ADHD. With the exception of one non-stimulant drug, Strattera, all drugs approved for the treatment of ADHD are stimulants. [5] They are primarily available in two forms: methylphenidate-based stimulants and amphetamine-based stimulants. [5] Methylphenidate is more universally prescribed, the available brands being Concerta, Metadate, Methylin, and Ritalin. [5] Over 200 studies have proven methylphenidate’s effectiveness in treating ADHD. [5] For those children who don’t respond well to methylphenidate, amphetamine is available as Adderall, Desoxyn, Dexedrine, Dextrostat, and Vyvanse. [1] Both stimulant options are available in long-acting or short-acting forms. [1]. The non-stimulant drug Strattera, which is atomoxetine based, is prescribed to children who either do not respond to stimulants or who have troubles with the side effects associated with them. [5] A list of the approved drugs available today for the treatment of ADHD can be seen in Figure 1.
 * A Stimulating Approach **

Figure 1 [1]

The number of children on medication for ADHD has increased substantially in recent years. Among the stimulants available, Ritalin is the most commonly taken, and its use has increased 700% in the past 10 years. [4] As of 2003, an approximated 2.2 million children in the US were taking a stimulant medication for ADHD. [20] Another estimate approximated that 2-3 children in every classroom are prescribed. [27] The numbers might appear extreme when thinking of children; however in actuality they understate the true number of children suffering from ADHD today. This is due to the fact that around 25% of parents refuse to give drugs to their children. [4] Common belief is that stimulant drugs work for ADHD patients by producing an “opposite effect” and calming them down. Although these children appear calmer as their hyperactivity is being managed, there is much more to it than that. Drugs like Ritalin work by obstructing the dopamine receptors in the PFC, thereby preventing binding of the neurotransmitter and resulting in a significant increase of dopamine in the extracellular synapses. [24] Positron Emission Tomography (PET) studies have shown that dopamine levels increase roughly one hour after the consumption of medication. [18] Increasing dopamine activates these pleasure-and-reward circuits, stimulating motivation and interest in children and therefore promoting attentiveness. [18] Furthermore, dopamine decreases background firing of unrelated neurons that can divert a child’s attention. [18] While medication therapy is an efficient temporary relief, it is not a long-term solution; the drugs enter the body quickly, and leave the body quickly. [4]

In the face of overwhelming controversy, an increasing amount of research suggests that medication therapy isn’t as dangerous as it is perceived. It has successfully benefited children of all ages in the treatment of ADHD. [21] One study revealed that in 82-85% of children treated with medication, enough symptoms were eliminated to nullify the diagnosis. [4] Even the widespread concern that stimulant drugs promote addiction is progressively being challenged by scientific investigation. Logically, stimulant drugs face concern due to the fact that all addiction drugs commonly increase levels of dopamine in the brain. [18] However, for a drug to successfully trigger addiction it must increase dopamine levels very quickly, creating a feeling of euphoria, and orally consumed stimulant drugs take approximately one hour to have an effect. [18] Additionally, targeting primarily the PFC, it has been shown that the drugs have no effect on the areas of the brain associated with over-arousal and addiction. [6]

Of course, the underlying drawbacks cannot be avoided. As with any drug, potential side-effects can be problematic for some, especially children. Common side effects of these stimulant drugs can include: decreased appetite, weight loss, decreased growth rates, sleep problems, anxiety, irritability, stomachaches, headaches, mild blood pressure increases, and the potential for abuse. [1,11] Additional, more severe risks are capable of arising from outside factors such as timing and certain drug combinations. It has been proposed that introducing children to these stimulants during adolescence, the age at which the forebrain dopamine systems undergo significant remodeling, may hold severe neurobehavioral consequences. [16] Some of these consequences include: long-term modulation of self-control abilities, decreased sensitivity to natural and drug reward, enhanced stress-induced emotionality, and enhanced cortical control over sub-cortical dopamine systems. [16] Similarly, combining stimulants like Ritalin with Prozac, a drug used for the treatment of the commonly co-existing Major Depressive Disorder, could have grave consequences. [26] The mixture of the drugs is said to enhance vulnerability to stressful situations and provoke long-term disruptions in extracellular signal-regulated kinase (ERK) signaling within the ventral tagmental area (VTA). [26] These disruptions in ERK signaling are potential risk factors for cancer development. [15] In the midst of the potential risks associated with these stimulant drugs, an uncertainty concerning their long-term effects still lingers. There have yet been no long-term studies done to eliminate any threat of medication therapy over extended periods of time. [9] The considerable public anxiety that has arisen concerning this treatment approach just isn’t enough to make a change. Doctors continue to follow this approach simply because it works better than anything else.

Nutritional manipulation is undoubtedly the most popular and controversial alternative treatment method for childhood ADHD. It has gained its popularity since Benjamin Feingold published a study in 1973 on the effect of certain foods and food additives on the behavior of children, claiming that 50% of children in his study showed improved behavior after diet manipulation. [20] A California allergist, Feingold first made his discovery when he noticed behavioral changes in his patients who were being treated for food allergies. [11] With a desperate need for alternative options, parents took a keen interest in Feingold’s ideas. The Feingold diet ultimately strives to remove phenols from a child’s diet. [8] It targets artificial colorings, flavorings, and preservatives, all of which are strong phenols made from petroleum base, as well as salicylates, which are naturally occurring phenols in plants. [8] Some foods containing natural salicylates are listed in Figure 2.
 * A Nutritional Approach **

Figure 2 [9]

It has been shown that many children with ADHD have trouble processing phenols and salicylates. [8] A build-up of these chemicals can negatively affect the brain, resulting in behavioral and physical alterations. [8] Some common indications of phenol sensitivity in children include: dark eye circles, red cheeks/ears, ear infections, asthma, diarrhea, hyperactivity, impulsivity, aggression, headache, head-banging/self-injury, impatience, short attention span, difficulty falling asleep, night-walking for hours, inappropriate laughter, hives, stomach aches, bed wetting and day wetting, dyslexia, sensitivity to noise/touch/lights, speech difficulties, tics, and some forms of seizures. [8]

In today’s food industry, artificial colorings and flavorings make up around 80% of the chemicals used in food processing (See Figure 3).

Figure 3 [9]

It comes as no wonder that nutritional manipulation has gained such eminent controversy in recent years. These chemicals that make up such a large fraction of our food supply commonly trigger adverse reactions in most bodily systems and they have no nutritional value whatsoever. [9] Today, the amount of food dye per capita has risen to five times that of the 1950’s, with azo dyes making up the majority of artificial colorings. [3,25] A table of permissible artificial colorings can be seen in Figure 4.

Figure 4 [22]

Tartrazine, better known as Yellow #5, is the most commonly considered food dye in research regarding behavior and hyperactivity, along with Erythrosin B, or Red #3, which has been proposed to induce hyperkinesis in vulnerable children. [12,25] Following artificial colorings and flavorings being identified as potential risk factors, artificial preservatives were also considered in the Feingold Diet. He eliminated preservatives such as butylated hydroxytoluene (BHT), butylated hydroxyanisole (BHA), and tert-butylhydroquinone (TBHQ), claiming that they also triggered hyperactivity. [22] A major drawback of the Feingold Diet is that it isn’t easily adhered to. Strict and consistent supervision of a child’s diet is needed in order for the diet to have significance. The diet can be followed in two stages: first, elimination of specific food additives and salicylates, and second, identifying tolerance to various salicylates. [7] Guidelines that must be followed to achieve successful treatment include adherence to the diet, complete family participation, and permanent avoidance of non-tolerated food additives. [11]

<span style="font-family: 'Verdana','sans-serif'; font-size: 13.3333px;">Since Feingold’s groundbreaking elimination idea, over 30 years of research has confirmed a relationship between artificial food colorings and hyperactive behavior. [3] Additionally, studies in the 1990’s demonstrated that diets eliminating artificial additives improve behavior in 75% of children. [7] Results from a sample study in Figure 5 show hyperactivity levels between a control group and a diet group over a 13-week period.

Figure 5 [19]

These findings applied to all children, however; they were not specific to only those children suffering from ADHD. Further studies have agreed that behavioral changes resulting from artificial food additives occur independently of pre-existing hyperactivity. [2] Despite hopeful results, disagreement still prevails. Inadequate experimental parameters exacerbate the fact that behavior can be difficult to measure, offering no conclusion as to how many or which children are affected by diet manipulation. If dyes are in fact harmful, it is possible that they only affect particular children with some hidden genetic sensitivity. [3] Various studies show, however, that age is a key factor in the degree and speed of response, with younger children being the most responsive. [9] Among a wide variety of studies and outcomes, it is universally agreed that while nutritional can aid in benefited children suffering from ADHD, it does not cause the disorder itself. [11]

<span style="font-family: 'Verdana','sans-serif'; font-size: 13.3333px;">
 * <span style="font-family: 'Verdana','sans-serif';">Conclusion **

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