WHAT CAUSES ATTENTION-DEFICIT HYPERACTIVITY DISORDER?

Physical Factors

Advanced imaging techniques have detected differences in the brains
of ADHD children compared to those of non-ADHD children.

Brain Structures. Increasingly, research is suggested that ADHD is a
disorder of the right side of the brain. Specific areas on the right
side may be important in understanding ADHD:

The prefrontal cortex. The prefrontal cortex, which is located in
the front of the brain, is thought to be the brain’s command center;
it regulates the brain’s ability to inhibit responses. A number of
imaging studies has indicated that the prefrontal cortex of the
brain in ADHD may be underactive in comparison with those without
ADHD.

The caudate nucleus and the globus pallidus. The caudate nucleus and
globus pallidus, located near the center of the brain, speed up or
stop orders coming from the prefrontal cortex. Abnormalities in
these areas may impair a person’s ability to brake actions,
resulting in the impulsivity typical of people with ADHD.
Dopamine and Other Brain Chemicals. Important neurotransmitters
(chemical messages in the brain) affect mental and emotional
functioning. Dopamine is under particular scrutiny. Studies have
suggested that dopamine levels are abnormal in the brains of those
with ADHD, with its effects being inhibited in the prefrontal lobes
of the brain, which helps regulate concentration, attention, and
inhibition. Deficiencies in norepinephrine, another brain chemical
that is involved in the fight or flight response, may also be
critical in ADHD. Both of these neurotransmitters are also important
in the “reward” response, in which a person experiences pleasure in
response to certain stimuli (such as food or love). Deficiencies in
these neurotransmitters create an intense need that causes
individuals to seek chemicals, such as nicotine or certain drugs,
that actually attach to receptors for dopamine and that help reduce
these needs.

Nerve Pathways. Another area of interest is a network of nerves
called the basal-ganglia thalamocortical pathways. Abnormalities
along this neural route have been associated with ADHD, Tourettes
syndrome, and obsessive-compulsive disorders, which all share
certain symptoms.

Problems Surrounding Pregnancy. ADHD is often associated with
problem pregnancies and with difficult deliveries. Maternal smoking
during pregnancy is also associated with a higher risk for ADHD. One
study indicated that an increased risk also existed in children of
women who were exposed during pregnancy to environmental toxins,
including dioxins and polychlorinated biphenyls (PCBs).

Genetic Factors

Evidence is increasing that genetic factors play the most important
role in ADHD. The relatives of ADHD children (both boys and girls)
have much higher rates of ADHD, antisocial, mood, anxiety, and
substance abuse disorders than the families of non-ADHD children. In
a twin study, 90% of children with a full diagnosis of ADHD shared
it with their twin. Most likely more than one gene is responsible
for inherited cases. This is not surprising, since there is no
consensus that ADHD is even a single disorder.

Genetic Factors Regulating Dopamine. Researchers are reporting
underlying genetic mechanisms that regulate hyperactivity,
particularly those that affect the neurotransmitter dopamine.
Studies are finding that a variation of a dopamine D4 receptor gene
is common in a high proportion of people with addictions and ADHD,
and it appears to be associated with novelty seeking and
extroversion. Other genes under investigation are those that
regulate dopamine; one is called the dopamine D2 receptor gene. Not
all studies, however, have confirmed the role of dopamine in ADHD.

Genetic Resistance to Thyroid Hormone. About 50% of adults and 70%
of children with a genetic resistance to thyroid hormone, essential
for normal brain development, have ADHD. People who have this
condition appear to have a more severe form of ADHD. The thyroid
disorder is not a common cause of ADHD, however, and only those with
a family history of thyroid disease are at risk.

Dietary Factors

Food and Allergies. Studies on the effect of food and food-additive
allergies are controversial. For example, one reported that 62% of
ADHD children had symptoms provoked by various foods and additives.
Another study indicated, however, that less than 5% of children with
ADHD are affected by food additives and even then, the effect is
very slight. Evidence does suggest, however, that certain children
with behavioral difficulties may be sensitive to certain chemicals
in foods. It should be noted that allergies themselves have recently
been associated with a higher risk for behavioral problems. Children
who respond to allergen-restrictive diets, then, may not have had
true ADHD in the first place. Among the additives and foods that
parents and studies report as culprits in inciting behavioral
changes are the following:

Any artificial colorings (particularly yellow, red, or green).

Other additives.

Milk.

Chocolate.

Eggs.

Wheat.

Aspirin and foods containing salicylates (the compound in aspirin).
They include berries (all), chili powder, apples and cider, cloves,
grapes, oranges, peaches, peppers (bell & chili), plums, prunes, and
tomatoes.
Deficiencies in Zinc and Essential Fatty Acids. Some studies have
found an association between deficiencies in certain fatty acids
(compounds that make up fats and oils) and ADHD. Related to these
findings are studies reporting an association between zinc
deficiencies and ADHD. (Zinc is important in the metabolism of fatty
acids, which in turn affects dopamine, the neurotransmitter likely
to be involved with ADHD.)

Sugar. Although parents often blame sugar for causing children to
become impulsive or hyperactive, a number of studies now strongly
suggest that sugar plays no role in hyperactivity. One study
reported, in fact, that ADHD children had fewer problems after a
high-carbohydrate breakfast than after a high-protein one. Another
reported that children actually moved more slowly after a high-sugar
meal, suggesting the carbohydrates may have a sedative effect.

Infant Malnutrition. Even if they receive enough food later on,
children who suffer from malnutrition as infants may develop
behavior problems, the most prevalent being attention-deficit
disorder.

Treatment

Psychostimulant drugs combined with counseling best control
symptoms. Used alone, psychostimulants have been effective
predominantly with less impulsive ADD children and with children
with primary inattention who have stable home environments. ADD
children with poor impulse control often are less helped by
treatment than are children with primary inattention.

Elimination diets, megavitamin treatments, use of antioxidants or
other compounds, and nutritional and biochemical interventions (eg,
the administration of neurochemicals) have had the least effect. The
value of biofeedback is unsubstantiated. Most studies have found
minimal change in behavior and no sustained benefit.

Introduction

Oppositional defiant disorder (ODD) is a psychiatric behavior disorder that is characterized by aggressiveness and a tendency to purposefully bother and irritate others.  These behaviors cause significant difficulties with family and friends and at school or work.

Oppositional defiant disorder is sometimes a precursor of conduct disorder. 

Much of the literature tends to lump these two conditions together.   However, they seem to be distinct entities and, although conduct disorder does have a genetic component, ODD does not.

Description

Oppositional defiant children show a consistent pattern of refusing to follow commands or requests by adults.   These children repeatedly lose their temper, argue with adults, and refuse to comply with rules and directions.  They are easily annoyed and blame others for their mistakes.  Children with ODD show a pattern of stubbornness and frequently test limits, even in early childhood.

These children can be manipulative and often induce discord in those around them.  Commonly they can incite parents and other family members to fight with one and other rather than focus on the child, who is the source of the problem.

Behavioral Symptoms

Common behaviors seen in oppositional defiant disorder include:

1. Losing one’s temper
2. Arguing with adults
3. Actively defying requests
4. Refusing to follow rules
5. Deliberately annoying other people
6. Blaming others for one’s own mistakes or misbehavior
7. Being touchy, easily annoyed
8. Being easily angered, resentful, spiteful, or vindictive.
9. Speaking harshly, or unkind when upset
10. Seeking revenge
11. Having frequent temper tantrums

Many parents report that their ODD children were rigid and demanding from an early age.

Normal children, especially around the ages or 2 or 3 or during the teenage years, display most of these behaviors from time to time.  When children are tired, hungry, or upset, they may be defiant.  However, children with oppositional defiant disorder display these behaviors more frequently and to the extent that they and interfere with learning, school adjustment, and, sometimes, with the child’s social relationships. 

Diagnosis

The diagnosis of ODD is not always straight forward and needs to be made by a psychiatrist or some other qualified mental health professional after a comprehensive evaluation.  The child must be evaluated for other disorders as well since ODD usually does not come alone.  If the child has ADHD, mood disorders, or anxiety disorders, these other problems must be addressed before you can begin to work with the ODD.

If you feel your child may have ODD, there is a quick screening test.  Go to:   http://addadhdadvances.com/ODDtest.html

Causes

What is the cause of ODD?  The real answer is that nobody knows.  However, since as scientist we hate to admit this, we have two current theories.

The developmental theory proposes that ODD is really a result of incomplete child development.  For some reason, these children never complete the developmental tasks that normal children learn to master during the toddler years.

The learning theory suggests that ODD comes as a response to negative
interactions.  The techniques used by parents and authority figures on these children bring about the oppositional defiant behavior.

ODD is the most common psychiatric diagnosis in children and it usually
persists into adulthood. One would think a lot of research would be done on this condition. That is not the case.  While there are hundreds of research studies on ADHD and childhood mood disorders, there is very little research on ODD.

Co-morbidity

ODD is frequently goes along with other disorders.  50-65% of ODD children also have ADHD.  35% of these children develop some form of affective disorder.  20% have some form of mood disorder, such as depression or anxiety.  15% develop some form of personality disorder.  These children frequently have learning disorders and academic difficulties. 

If your child has ODD it is important to know there are other co-existing problems.  These other problems usually must be addressed before you can begin to help your child with ODD. 

Prognosis

So what happens to these children?  There are four possible paths.

1. Some will grow out of it.  Half of the preschoolers that are labeled ODD are normal by the age of 8.  However, in older ODD children, 75% will still fulfill the diagnostic criteria later in life.
2. The ODD may turn into something else.  5-10 % of preschoolers with ODD have their diagnosis changed from ODD to ADHD.  In some children, the defiant behavior gets worse and these children eventually are diagnosed with Conduct Disorder.  This progression usually happens fairly early.  If a child has ODD for 3-4 years and he hasn’t developed Conduct Disorder, then he won’t ever develop it.
3. The child may continue to have ODD without any thing else.  This is unusual.  By the time preschoolers with ODD are 8 years old, only 5% have ODD and nothing else.
4. The child develops other disorders in addition to ODD.  This is very common.

Treatment

Most of these children have some other disorder along with their ODD.  Treating this other disorder is the key to proper ODD management.  This frequently means giving medication.  Although this type of medical intervention does not make the children “normal”, it can make a big difference.  It often allows other non-medical interventions to work much better.

For example, if a child has both ODD and ADHD, then giving the child Ritalin may have a significant effect on his ODD, also.  This positive effect does not seem to be related to the severity of the ADHD.  That means even if the child has mild ADHD and could do without Ritalin, if he is treated medically, you might see an improvement in his ODD. 

Once the other problems are under control, the best treatment for ODD is parent training.  In a study published in 1998, eighty-two research studies were evaluated were examined for efficacy.  Approaches focusing on parent training were the most affective techniques.

The main point is that some parent-training program is essential in addressing ODD.  This is not going to work for everyone, but it is the best treatment that we have available for ODD.

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