Attention-Deficit Hyperactivity Disorder (ADHD) in Children:

Introduction and General Information: What is ADHD?

Attention-Deficit/Hyperactivity Disorder - ADHD - is usually first diagnosed in children and adolescents. It is characterized by inappropriate degrees of inattention, impulsivity and/or hyperactivity. Children with ADHD - Attention-Deficit/Hyperactivity Disorder - are typically:

• impulsive
• forgetful
• restless to the point of disruption
• prone to fail
• unable to follow through on tasks
• unpredictable
• moody

These characteristics appear in early childhood, are relatively chronic in nature, and are not due to other physical, mental or emotional causes. From time to time, all children will be inattentive, impulsive and/or exhibit high activity levels. However, for children with ADHD, the persistence, pattern, and frequency of this behavior is much greater. These behaviors are the rule, not the exception. Performance variability is also common among children with ADHD. For instance, it is difficult for teachers to understand why a child can remember homework assignments on Monday and Tuesday but forget them on Wednesday.

When ADHD is left unidentified or untreated a child is at great risk for:

• impaired learning ability
• decreased self-esteem
• social problems
• family difficulties
• potential long-term effects

ADHD is not new, though our understanding of the disorder is still developing. Medical science first noticed children exhibiting inattentiveness, impulsivity, and hyperactivity in 1902. Since that time, the disorder has been given numerous names, including Minimal Brain Dysfunction, or Minimal Brain Damage, and Hyperkinesis, the Hyperkinetic Reaction of Childhood or Hyperactivity. In 1980, the diagnosis of Attention Deficit Disorder was formally recognized in the Diagnostic and Statistical Manual, 3^rd edition (DSM III), the official diagnostic manual of the American Psychiatric Association (APA).

It is estimated that ADHD affects 3-5% of the school-age population, which means as many as 3.5 million children.

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Diagnosis of ADHD

There is no concrete medical test to diagnose ADHD, which often makes the diagnosis of ADHD subjective. This is the reason why it is imperative that the diagnosis is done properly and by an appropriate and qualified person. The Diagnostic and Statistical Manual (1997), lists six essential steps in diagnosing ADHD.

• The first step is the parent interview. This should include presenting problems, developmental history, and family history.
• The next step is interviewing the child about home, school, and social functioning.
• Then behavior-rating scales describing home and school functioning are completed.
• The fourth step is to obtain data from school. The data should include grades, achievement test scores, current placement, and other pertinent information.
• Step five is the psychological testing for IQ and screening for a Learning Disability. This step may have been previously completed.
• The final step is physical and/or neurological exams.

These are only suggested steps and are not universally followed. Professionals who can diagnose include psychiatrists, psychologists, pediatricians or physicians, and neurologists. Parents, teachers, and professionals may provide important information to help in the diagnosis. The diagnosing professionals should always consider other possibilities and rule them out before diagnosis of ADHD (DSM-IV, 1997).

How is ADHD Diagnosed?

As above, the diagnosis must be based on a number of observations, since ADHD is not a defined biological entity, but a collection of symptoms and behaviors. Typically, to diagnose ADHD, parents and teachers complete questionnaires, children are observed at home and at school, psychological tests are administered, and a clinical interview of the child and the family is conducted.

One assessment tool is the use of behavioral rating scales in the identification of ADHD. The Conners' Teacher Rating Scale (CTRS), developed in 1969, has been used extensively since its publication (Grumpel, Wilson, & Shalev, 1998). This instrument (CTRS) is important because of its wide acceptance. The CTRS has been in use for about 25 years.

Although our understanding of ADHD has changed over the years, the preference for the scale has continued stable (Grumpel, et al., 1998). The Conners' Teacher Rating Scale uses a 4-point scale. It includes the following ratings: Not at all present, Just a little present, Pretty much present, and Very much present. There are 28 items in the scale with several questions that collect demographic information from the respondent (Grumpel, et al., 1998). Both the child's teacher and a parent complete the scale. A discrepancy score should be determined from the two completed questionnaires and a determination made as to whether the child is exhibiting symptoms proportionate with ADHD.

Another rating scale used widely is the Conners' Abbreviated Symptoms Questionnaire (ASQ). It is often referred to as the Hyperactivity Index. This 10-item scale is used for screening purposes to identify hyperactive children (Erford, Peyrot & Siska, 1998). The utility of the ASQ has chiefly been in diagnosing children as hyperactive and in assessing changes in hyperactive and conduct problems behaviors after interventions particularly stimulant drug therapy (Erford, et al., 1998). The results of the Analysis of Teacher Responses To The Conners Abbreviated Symptoms (Erford, et al., 1998) concluded that the ASQ over-identifies normal children and disproportionately identifies children who are hyperactive and aggressive, and under-identifies distractible children (Erford, et al., 1998). This rating scale is also known as the Conners' Abbreviated Parent-Teacher Questionnaire (APTQ).

Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type (formerly often called simply Attention Deficit Disorder or ADD) is particularly difficult to diagnose. Clinicians only correctly diagnose this subtype 50% of the time ⁶. Diagnostic tools include those of Barkley (1990) and BAADS (Boatwright-Bracken Adult Attention Deficit Disorder Scale) (1992). Brown (1993) uses the BAADS in combination with a careful clinical history of the individual and family, school reports, and an analysis of WISC/WAIS subtest scores using the Bannatyne method (since over 60% of ADHD adolescents show statistically significant differences between their verbal conceptualization and sequential scores on WISC/WAIS).

Clearly, an evaluation should integrate multiple informants and look at the child in a comprehensive manner since no single test can effectively diagnose the disorder.

ADD vs. ADHD: Diagnostic Subtypes

Originally, as in the DSM-III, the term Attention Deficit Disorder (ADD) was used and less attention was given to those with had this disorder without the hyperactivity that often, but not always accompanies it. The DSM-IV now uses only the term Attention Deficit / Hyperactivity Disorder (ADHD), but classifies it into three different subtypes, of which Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type is one.

Dr. Thomas Brown ¹ of Yale University has championed the recognition of children who have ADHD without hyperactivity. These children are underdiagnosed, since they rarely display the restless, intrusive, "driven by a motor," "Dennis the Menace" traits which most people, including many professionals, associate with ADHD. Brown notes that these children more closely resemble the stereotypes of "space cadet" or "couch potato" than the "whirling dervish" of ADHD. They are frequently overlooked by teachers, scapegoated by parents, and misdiagnosed by clinicians. Often they are seen as"just lazy" or "unmotivated" and are not given the support and treatment which could help them become markedly less frustrated and more productive. While ADHD is present in girls, it is more often the inattentive type without hyperactivity.

Brown tells us how even publications about ADHD offer little guidance about this disorder without hyperactivity. Most popular books and articles discuss just children who are chronically hyperactive, not those who are quiet or withdrawn. Some publications for professionals acknowledge that ADHD without hyperactivity is seen, but even in current journals for physicians, educators, and psychologists, there is rarely information about how to recognize and provide treatment for those whose ADHD do not include hyperactivity. Until recently, not much has been known about ADHD without hyperactivity.

Formal Diagnosis of ADHD (DSM-IV and International Classification of Diseases)

The formal diagnostic criteria for ADHD/ADD used in most North and South America is the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), 4^th Edition ⁵. Europe, Asia, and Africa use the International Classification of Diseases, 10^th edition (or the International Statistical Classification of Diseases and Health Related Problems (The) ICD-10, Second Edition). Each of these tools organizes the diagnosis slightly differently, but in both, the three major categories of symptoms are:

1. Hyperactivity
2. Problems with attention
3. Problems with conduct

The Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) from the DSM-IV are:

Criteria A - either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the child's developmental level:

1. often fails to give close attention to details or makes careless mistakes in
   1. school
   2. work
   3. other activities.
2. often has difficulty sustaining attention in tasks or play activities.
3. often does not seem to listen when spoken to directly.
4. often does not follow through on instructions and fails to
   1. finish schoolwork
   2. chores
   3. duties in the workplace (not due to oppositional behavior)
   4. failure to understand instructions
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
8. is often easily distracted by extraneous stimuli
9. is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity/impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the child's developmental level:

Hyperactivity

1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations in which remaining seated is expected
3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings or restlessness).
4. often has difficulty playing or engaging in leisure activities quietly
5. is often "on the go" or often acts as if "driven by a motor."
6. often talks excessively
7. Impulsivity
   1. often blurts out answers before questions have been completed
   2. often has difficulty awaiting turn
   3. often interrupts or intrudes on others (e.g., butts into conversations or games).

Criterion B: Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

Criterion C: Some impairment from the symptoms is present in at least two or more settings (e.g., at school [or work] and at home).

Criterion D: There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Criterion E: The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

The diagnosis is coded as:

314.01 ( Attention-Deficit/Hyperactivity Disorder, Combined Type) if both Criteria A1 and A2 are met for the past 6 months

314.00 (Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type): if Criterion A1 is met but not Criterion A2 is not met for during the past 6 months

314.01 ( Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type): if Criterion A2 is met but not Criterion A1 is not met for during the past 6 months

Additional Reflections on ADHD, Prominently Inattentive Type

Lahey & Carlson (1991) reviewed the research literature and concluded that was then called formerly called ADD (Attention-Deficit Disorder) was found in two independent dimensions:

1. one consisting of motor hyperactivity and impulsive behavior
2. the other consisting of inattention disorganization, and difficulty completing tasks

They concluded "it no longer seems doubtful that Attention-Deficit Disorder without Hyperactivity (ADD/WO) "exists," and that ADD without hyperactivity differs from ADD with hyperactivity (ADD/H) in clinically important ways."

Brown & Gammon (1992, 1993) at Yale suggest that more is involved in ADHD without hyperactivity than just inattention. Such is not just a mild case of ADHD, but can be a debilitating disorder in which even bright and talented people are unable to activate themselves and sustain their efforts for productive work. What is called apathy or lack of motivation is a chronic problem with activation, which may be central to understanding this type of ADHD.

Many of those with non-hyperactive ADHD report chronic problems with "getting cranked up" to do tasks, even tasks they recognize as urgent and important for their own welfare. Often this activation problem in ADHD extends to sustaining energy for tasks. Many patients report great difficulty keeping up their energy to read or write or do a task. They speak of feeling drowsy even after a good night's sleep. Some almost meet the diagnostic category for narcolepsy, reporting problems with dozing at long stoplights and difficulty fighting off drowsiness while studying, listening to lectures, or attending meetings. There appears to be chronic difficulty not only in activating to work, but in sustaining energy for tasks.

Chronic problems in activating and sustaining arousal make life difficult for high-IQ people, who are seen by themselves, parents, teachers, and employers as extremely bright, with great promise for successful achievement. The symptoms of chronic inattention, lethargy, failure to follow through, brings oscillating achievement, poor grades and frequent reminders that "you could do much better if only you'd be more consistent." The wide gap between their potential and actual achievement can make these patients vulnerable to demoralization and resignation to failure.

About 30% of children meet diagnostic criteria for both inattention and hyperactivity ². Depending upon the study, 30-70% of children with ADHD continue to exhibit symptoms of ADHD in adulthood. ADHD crosses all socioeconomic, cultural, and racial backgrounds.

Some current researchers believe that the inattention seen in children with ADHD, predominantly inattentive (PI) type - also known as ADD without hyperactivity or ADD/WO - may actually be a qualitatively different problem than the type of inattention seen in ADHD, HI or combined types: a problem with focused/selective attention versus one of poor goal-directed persistence and interference control or inhibiting distraction. (Barkley, in press; Barkley and colleagues; Goodyear and Hynd; Lahey and Carlson).

All of this leads to interesting implications for the nature of ADHD, chief among which is that we have possibly two separate and qualitatively distinct disorders on our hands. The PI type may be the true attention disorder while the other two types are simply different developmental stages of the same disorder, one that involves behavioral disinhibition that ultimately results in poor goal-directed persistence and defective resistance to distraction (Barkley, in press).

For additional information, please see:

• Attention Deficit Disorder Without Hyperactivity: ADHD, Predominantly Inattentive Type, by Jennifer Wheeler, M.A., and Caryn L. Carlson, Ph.D.
• Research Developments and Their Implications for Clinical Care of the ADHD Child, by Russell A. Barkley, Ph.D.

School-Based Assessments for ADHD Children

Often, concerns about a child's attention and activity levels are first noted in the context of school. This occurs because school places greater demands for attention and self-regulation on the child.

Recent recognition of ADHD as a disability to be served under existing education laws (IDEA, Other Health Impaired category, and Section 504 of the Rehabilitation Act of 1973, United States Department of Health & Human Services), has generated the need for assessment protocols for school-based evaluation teams. In keeping with these requirements, the school has a legal responsibility to provide assessment services for students who are suspected of having ADHD.

In the event that the assessment procedure indicates that ADHD exists, the school should determine if the ADHD is placing an adverse effect on educational performance. The process for these determinations generally involves the use of a school-based multidisciplinary team. At least one member of the team should be knowledgeable about the disability.

PGARD Two-Tiered Assessment Protocol

The Professional Group for ADD and Related Disorders (PGARD) suggests school-based personnel follow a two-tier approach to evaluate children suspected of having ADD. The guiding principle underlying both tiers of assessment is to use multiple sources of information. The assessment protocol recommended by PGARD is sufficient to determine the presence of ADHD behaviors and adverse affects on educational performance.

Tier I:

• Confirm the presence of the cardinal characteristics
• Confirm early onset and duration
• Rule out exclusionary criteria

Prior diagnosis by physician or psychologist can be used in lieu of Tier I

Tier II:

• Determine adverse impact on educational performance
• Determine impairment of academic performance

For further information:

• Professional Group for ADD and Related Disorders (PGARD)
  28 Fairview Road
  Scarsdale, NY 10583
  914-723-0118

What Other Behaviors Can Mimic ADHD?

A number of other conditions and disorders can mimic ADHD or have similar symptoms:

• Medical conditions
• Visual disturbances
• Thyroid disorders
• Some seizure disorders, [especially Temporal Lobe Epilepsy]
• Some genetic disorders
• Hearing loss
• Allergy and effects of allergy medication
• Chronic medical conditions
• Coordination or articulation problems
• Eencopresis
• Night terrors
• Eenuresis
• Sleep difficulties
• Schizophrenic and thought disorders
• Substance Use Disorders
• Autism and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)
• Tourette's Syndrome
• Conduct Disorder (CD)
• Oppositional Defiant Disorder (ODD)
• Anxiety Disorders
• Depressive Disorders

Please see our section on Related Mental Disorders and Comorbidity for more information on some of these factors.

Related Mental Disorders and Comorbidity

Over 50% of persons diagnosed with ADHD also have another psychiatric disorder, which may mask or complicate their diagnosis and treatment (Haleperin, Newcorn & Sharma, 1991). Depressive disorders, learning disorders, anxiety disorders, substance abuse, aggression and behavior disorders, and sleep disorders, have all been reported to occur in persons with ADD significantly more than in people without ADD (Biederman, 1991b; Wilens, 1994). Biederman and colleagues (1991a) demonstrated that close biological relatives of children with ADHD are far more likely to have ADHD, major depressive disorder, multiple anxiety disorders, conduct disorder, anti-social personality disorder, and/or substance abuse than are relatives of children without ADHD. All of these disorders tend to run in families and may be inherited in various combinations by some, though not all, family members.

Comorbidity may also be a reaction to living with ADHD. From their earliest years, many people with ADHD experience intense and sustained frustration in their efforts to learn, to work, and to get along with other people. Often, they suffer ongoing criticism from teachers, parents, siblings, and peers. Years of chronic, sustained frustration and criticism, especially if the ADHD has not been diagnosed and the individual feels, "It's all my fault," may produce dysthymia, a chronic, low-grade depression, comorbid to the ADHD. Other disorders may similarly develop reactively.

Jensen (1993) recently reported on a group of 47 school-aged children diagnosed as having Attention Deficit Hyperactivity Disorder (using DSM III-R) where 49% also received diagnoses of either depression alone (n=10), anxiety disorder alone (n=5), or both depression and anxiety (n=8).

People who are depressed often report difficulties with concentration and sustaining energy just over the course of their depression; those with ADHD generally report lifelong difficulties with symptoms of inattention and problems of activation, upon which depressive symptoms may be superimposed.

ADHD of the combined type is more often associated with oppositional defiant disorder (ODD), where a child is hostile and negativistic, chronically arguing and defying parents and other authorities. When a child with ADHD is severely oppositional, that child may meet ODD diagnostic criteria and need treatment for both ODD and ADHD.

About 35% of those with ODD also demonstrate the more severe behavior problems classified as conduct disorder (CD); these may include truancy, physical cruelty to animals or people, and criminal activities. Children whose ADHD is comorbid with just ODD are likely to get into trouble in school and community, but they do not carry the same high risk for poor long-term adult outcomes as do those with comorbid CD (Barkely, 1990).

Longitudinal studies indicate that among persons with ADHD who do not have conduct disorder (CD), the incidence of substance abuse is no higher than in the general population. However, for those with ADHD and comorbid CD, risk of substance abuse is greatly increased; among adults diagnosed as substance abusers, over 70% are estimated to have ADHD (Wilens, in press). This overlap raises the question as to whether persons who have ADHD and are recovering from addiction might increase their chances of abstinence if their ADHD is pharmacologically treated. There are certainly risks in treating recovering persons with medications for ADHD, but there are also risks in not treating ADHD in recovering persons.

Cantwell and Baker (1991) reported that in a sample of 600 children with impairments of speech and/or language, 30% had comorbid ADHD, while in a matched group who also had learning disorders, 63% had comorbid ADHD. Persons with ADHD who are impaired in their ability to communicate with others or whose ability to read, write, and/or do arithmetic is compromised are at significant risk for academic underachievement and for problems in social interaction and fragile self-esteem.

The Theories of the Causes of ADHD

The exact cause of ADHD remains undetermined, but the prevailing theories include genetic and hereditary factors, neurobiological conditions and pathologies, prenatal influences, nutritional factors and deficiencies and environmental/toxin influences. We have grouped these theories into three section below. As additional studies are made and as part of the development of this site, we will be elaborating on these theories and exploring them in greater depth.

A good resource for information on current and new research is:

• National Institutes of Health (NIH): National Institute of Mental Health (NIMH): ADHD
  Complete Publication: Attention Deficit Hyperactivity Disorder: What Causes ADHD?

Neurobiological Theories: Pathophysiological Views

While the exact cause of ADHD remains undetermined, frontal lobe lesions, anterior and medial to the pre-central motor cortex are considered the most likely neuroanatomic sources of ADHD. Cerebral blood flow studies have found central hypoperfusion in the frontal lobe and decreased blood flow to the caudate nucleus. (See Treatments: Methylphenidate [Ritalin])

Positron emission tomography scans of parents of ADHD children who also have symptoms of ADHD have shown decreased glucose metabolism in left frontal and parietal regions ⁸. These findings suggest the prefrontal cortex, which governs auditory attention, is less active among those with ADHD. Neurostimulants such as Ritalin are thought to increase the activity of these brain regions ⁹. Electroencephalographic studies of ADHD patients reveal abnormal reaction potentials in response to novel stimula after the subject has habituated to the test procedure ¹⁰.

Persons with ADHD have an unusually low rate of activity in brain areas responsible for motor control and attentiveness.

Please also see our new article, "Imaging Children with ADHD: MRI Technology Reveals Differences in Neuro-signaling". In this report, it was found that children with attention deficit-hyperactivity disorder (ADHD) may have significantly altered levels of important neurotransmitters in the frontal region of the brain, according to a study published in the December 2003 issue of the Journal of Neuropsychiatry and Clinical Neurosciences. "Our data show children with ADHD had a two-and-half-fold increased level of glutamate, an excitatory brain chemical that can be toxic to nerve cells," said lead author Helen Courvoisie, M.D., assistant professor, division of child and adolescent psychiatry, department of psychiatry and behavioral sciences at the Johns Hopkins Medical Institutions, Baltimore. "The data also suggest a decreased level of GABA, a neuro-inhibitor. This combination may explain the behavior of children with poor impulse control."

Genetic Theories of ADHD

Persons with ADHD have an unusually low rate of activity in parts of the brain areas responsible for motor control and attentiveness. However, the source of these neurological defects remain uncertain. Defects in the metabolism of dopamine, and, to a lesser degree, norepinephrine are postulated (Baren, 1995).

Molecular Studies have shown a link between ADHD and the Dopamine transporter gene and the Dopamine DR D4 receptor gene. The latter showed an increased frequency of the "7-repeat allele" in ADHD subjects.

Familial studies:

• The work of a Biederman group in Massachusetts have shown that 10-35% of the immediate family members of children with ADHD are likely to have the disorder.
• The risk to siblings is approximately 32%

Adoption studies:

• Morrison and Steward reported that there were higher rates of hyperactivity in the biological parents of hyperactive children that in adopted parents of such children.
• A study by Cadoret and Steward of 283 male adoptees found that if one of the biological parents had been a delinquent, the adopted away sons had a higher likelihood of ADHD.

Twin Studies:

• Greater concordance for hyperactivity in MZ (80-90%) twins than DZ (20-30%) twins

Additional Reading:

• Medscape Psychiatry & Mental Health: Expert Interview: Neurobiology and Genetics of ADHD: An Expert Interview With Stephen V. Faraone, Ph.D.

Environmental & Other Possible Factors as Causes for ADHD

Pregnancy and birth insults may affect the developing brain. Fetal exposure to alcohol has been linked to ADHD. Some argue that stress and poor nutrition during pregnancy can cause babies to have more allergic reactions that may cause developmental problems.

A variety of environmental factors, such as other pre- and perinatal abnormalities, central nervous system infections and reactions to sugar and food additives, are beginning to be evaluated with controlled studies.

• Smoking , High Sugar, High Carbohydrate Diet during Pregnancy Related to Behavior Problems:

  An Associated Press article published in April, 2000 indicated that smoking and eating a high carbohydrate, high sugar diet during pregnancy may be related to behavior problems in toddlers. Smoking lowers blood oxygen levels which is critical in fetal development, especially development of fetal brain cells. High carbohydrate, high sugar diets can also lower blood oxygen levels. Combined. these two factors may be related to ADHD behaviors in young children.

  It's important for pregnant mothers to eliminate smoking and high carbohydrate and sugar foods from their diets to help maintain high blood oxygen levels to promote healthy fetal development and prevent possible behavior disorders in their children.

Toxicity from lead and thyroid dysfunction should be considered is assessing ADHD as well.

Nutritional deficiencies (e.g., see: Purdue University Study: Deficiency in Omega-3 Fatty Acids Tied to ADHD in Boys) may also play a role.

Some of the most promising theories to date include exposure to various agents that can lead to brain injury (e.g., trauma, disease, fetal exposure to environmental toxins) and diminished brain activity.

ADD does occur in known biological syndromes, such as the fragile X and fetal alcohol syndrome. Psychosocial factors do not appear to play a primary etiologic role for the core symptoms, but certain types of parent/child interaction may be involved in the development of comorbid, oppositional and conduct disorder. Research also suggests that some predisposed children may become symptomatic after stressful or traumatic life events.

Environmental factors associated with ADHD include low birth weight, hypozia (too little oxygen) at birth, and exposure in utero to a number of toxins including alcohol, cocaine, and nicotine. Other studies have found correlations between certain toxic agents / nutrient deficiencies and learning disabilities. These include:

• Calcium deficiency
• High serum copper
• Iron deficiency can cause irritability and attention deficits
• Magnesium deficiency, which is characterized by fidgeting, anxiousness, restless, psycho- motor inability, and learning difficulties
• Malnutrition in general is related to learning disabilities; the child does not have to look malnourished, a fact forgotten in affluent countries
• Dyslexic children seem to have abnormal zinc and copper metabolism - low zinc and high copper
• Iodine deficiencies have been linked to learning difficulties

For additional reading see also:

• Can A Poisoned Environment Play A Major Role in a Child's Ability to Learn?
• Hyperactivity, Learning & Behavior

• Cocaine Use During Pregnancy Linked to ADHD:

A study done by researchers from Cornell University and the University of Kentucky suggests that cocaine use during pregnancy may be a cause of ADHD in children. The study is to be released in August, 2000.

Researchers from Yale University, Harvard and the Addiction Research Foundation have also observed a link between ADHD and addiction. In a Yale study of 298 cocaine addicts, 35 percent had a childhood history of ADHD and Harvard Medical School reports that adults with ADHD are three times more likely to abuse drugs and alcohol than those without the disorder.

An NIH conference scheduled for November is to examine possibilities that the drug Ritalin may mimic cocaine and may be the reason that those with ADHD are more likely to become addicted to cocaine.

Please see the following articles for more information:

• Cocaine Use During Pregnancy Connected to ADHD in Children
• Development and Neurobiology: Genetics of Childhood Disorders: ADHD: The Serotonin System
• Ritalin's "Cocaine Properties" May Lead to Later Drug Abuse

Creativity and ADHD

The "Theory of Disintegration", formulated by Dabrowski in 1960, asserts that persons born with 'overexcitabilities' have greater developmental potential than others. These individuals are hyperreactive to the environment in the following areas:

1. Psychomotor
2. Sensuality
3. Imagination
4. Intellectual behavior
5. Emotionality, including deep relationships, concern with death, feelings of compassion and responsibility, depression, the need for security, self-evaluation, shyness, and concern for others

These signs are common in creative people. People diagnosed with ADHD score higher on measures of creativity, and highly creative people are more active than the norm. Do the underlying neurological processes associated with ADHD also foster creativity? Supportive of this hypothesis is the fact that the brains of creative persons and ADHDers show similarities.

Studies have shown that the following personality traits associated with ADHD are also associated with highly creative people:

• inattention and daydreaming
• sensation seeking
• inability to finish projects
• hyperactivity
• enthusiasm and playfulness
• difficult temperament
• deficient social skills
• academic underachievement
• hypersensitivity to stimulation
• mood swings
• use of imagery in problem solving

For more information, please see the following:

• Intelligence and ADD
• ADHD or Intensities of Giftedness?
• The Social and Emotional Development of Gifted Children: What Do We Know?

Left-Brain/Right-Brain Theory of ADHD

Dr. Mary Ann Block, author of the book, No More Ritalin: Treating ADHD without Drugs, believes children with ADHD are usually right-brain dominant in their information processing and learning styles, as well as being more creative than those with left-brain dominant styles. They also show a tendency to be kinesthetic learners, which means that they learn best while using their hands. Most conventional schools accommodate left brain dominant information processors, who are typically logical thinkers and auditory and visual learners. The right brain dominant child is not as well accommodated.

The right brain dominant child may also be diagnosed as learning disabled even though often bright. These children are typically able to compensate in the early years of school, yet struggle when the classroom orientation shifts towards lecturing and writing assignments. Because these children are tactile learners they may spontaneously attempt to engage their sense of touch by picking up a pencil, touching the person in front of them, or by putting their hands in their pockets. Frequently these children are misinterpreted as being trouble makers, presumably because their style of learning has been frustrated.

Block suggests simple aids such as providing a squeezing ball for the child to use to engage the sense of touch while listening, reading, or writing. She asserts that doing so may enhance visual and auditory learning, as well as reduce unacceptable behavior in the classroom. She suggests that parents call their child's name first, prior to any directive statements.

ADHD children, being tactile learners, may not readily process auditory information or a parent's call. She suggests then that a parent should ground information by touching the child on the arm of shoulder once s/he has responded, and then giving verbal directions, in order to assist the child to process the information adequately.

More useful suggestions like this will be found under Educational and Behavioral Treatments for ADHD Children. You may also find this webpage interesting:

• Treating ADD/ADHD: An Interview with Dr. Mary Ann Block

Evolutionary Aspects of ADHD

Thom Hartman ³ says the traits of ADD/ADHD were actually beneficial to our hunter ancestors. These highly adaptive "hunters" were better suited to notice the subtle differences in their environment. Their more impulsive nature gave them bravery, their thirst for excitement sent them off better equipped for the hunt than their brother "farmers."

Today, we want our schools and offices full of farmers — patient, methodical, more passive. Though truth be told, our world is dependent on both hunters and farmers. Hartman's book, Beyond ADD : Hunting for Reasons in the Past & Present - which discusses brain chemistry and physiology and examines the pros and cons of the controversial drug Ritalin, is an excellent addition to the literature on this subject.

Some parents believe that their ADHD children would not be deemed deficient or disordered if they were allowed to follow their nature. They believe that the modern school classroom — over-crowded, based on boring busy work and visual learning, forces children to comply or fail. It forces children into a label that assumes their nature is a fault. Some parents believe that the "increase" in ADHD and some other learning disabilities is actually an increase in the labeling of children.

These parents believe that society wants these children labeled, boxed and compliant - even if it means drugging them. They say, "Whatever happened to kids being kids? Of course they don't want to sit in a classroom 8 hours a day! Of course they want to explore their world - to touch it, to taste it, to manipulate it, they want to run and play and fidget. Of course they are easily distracted, impatient, impulsive! Those are hallmarks of childhood. The problem comes when we expect our children to be compliant little robots who are willing to let others define their reality."

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Cerebral Palsy

What is Cerebral Palsy?

Cerebral palsy is an umbrella-like term used to describe a group of chronic disorders impairing control of movement that appear in the first few years of life and generally do not worsen over time. The term cerebral refers to the brain's two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement. Thus, these disorders are not caused by problems in the muscles or nerves. Instead, faulty development or damage to motor areas in the brain disrupts the brain's ability to adequately control movement and posture.

Symptoms of cerebral palsy lie along a spectrum of varying severity. An individual with cerebral palsy may have difficulty with fine motor tasks, such as writing or cutting with scissors; experience trouble with maintaining balance and walking; or be affected by involuntary movements, such as uncontrollable writhing motion of the hands or drooling. The symptoms differ from one person to the next, and may even change over time in the individual. Some people with cerebral palsy are also affected by other medical disorders, including seizures or mental impairment. Contrary to common belief, however, cerebral palsy does not always cause profound handicap. While a child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, a child with mild cerebral palsy might only be slightly awkward and require no special assistance.

How Many People Have This Disorder?

Infantile cerebral palsy (ICP) is one of the most common diseases of the nervous system in children. The incidence ranges from 2.5 to 5.9 cases per 1,000 newborns (L.O. Badalyan, 1984), but, taking into account the so-called perinatal and early postnatal encephalopathies, the number of affected children may be even higher.

The United Cerebral Palsy Associations estimate that more than 500,000 Americans have cerebral palsy. Despite advances in preventing and treating certain causes of cerebral palsy, the number of children and adults it affects has remained essentially unchanged or perhaps risen slightly over the past 30 years. This is partly because more critically premature and frail infants are surviving through improved intensive care. Unfortunately, many of these infants have developmental problems of the nervous system or suffer neurological damage. Research is under way to improve care for these infants, as in ongoing studies of technology to alleviate troubled breathing and trials of drugs to prevent bleeding in the brain before or soon after birth.

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What Are the Different Forms of Cerebral Palsy?

Cerebral palsy is classified into four broad categories -- spastic, athetoid, ataxic, and mixed forms -- in accordance with the type of movement disturbance.

Spastic cerebral palsy is the most common and affects 70 to 80 percent of patients. The muscles are stiffly and permanently contracted. The type of spastic cerebral palsy a patient has, is based on which limbs are affected. The names given to these types combine a Latin description of affected limbs with the term plegia or paresis, meaning paralyzed or weak.

When both legs are affected by spasticity, they may turn in and cross at the knees. As these individuals walk, their legs move awkwardly and stiffly and nearly touch at the knees. This causes a characteristic walking rhythm, known as the scissors gait.

Individuals with spastic hemiparesis may also experience hemiparetic tremors, in which uncontrollable shaking affects the limbs on one side of the body. If these tremors are severe, they can seriously impair movement.

Athetoid, or dyskinetic, cerebral palsy is characterized by uncontrolled, slow, writhing movements. These abnormal movements usually affect the hands, feet, arms, or legs and, in some cases, the muscles of the face and tongue, causing grimacing or drooling. The movements often increase during periods of emotional stress and disappear during sleep. Patients may also have problems coordinating the muscle movements needed for speech, a condition known as dysarthria. Athetoid cerebral palsy affects about 10 to 20 percent of patients.

Ataxic cerebral palsy is a rare form, affecting the sense of balance and depth perception. Affected persons often have poor coordination; walk unsteadily with a wide-based gait, placing their feet unusually far apart; and experience difficulty when attempting quick or precise movements, such as writing or buttoning a shirt. They may also have intention tremor. In this form of tremor, beginning a voluntary movement, such as reaching for a book, causes a trembling that affects the body part being used and that worsens as the individual gets nearer to the desired object. The ataxic form affects an estimated 5 to 10 percent of cerebral palsy patients.

Mixed forms: It is common for patients to have symptoms of more than one of the previous three forms. The most common mixed form includes spasticity and athetoid movements but other combinations are also possible.

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What Other Medical Disorders Are Associated With Cerebral Palsy?

Many individuals who have cerebral palsy have no associated medical disorders. However, disorders that involve the brain and impair its motor function can also cause seizures and impair an individual's intellectual development, attentiveness to the outside world, activity and behavior, and vision and hearing. Medical disorders associated with cerebral palsy include:

• Mental Impairment

About one-third of children who have cerebral palsy are mildly intellectually impaired, one-third are moderately or severely impaired, and the remaining third are intellectually normal. Mental impairment is even more common among children with spastic quadriplegia.

• Seizures or Epilepsy

As many as half of all children with cerebral palsy have seizures. In the person who has cerebral palsy and epilepsy, this disruption may be spread throughout the brain and cause varied symptoms all over the body -- as in tonic-clonic seizures -- or may be confined to just one part of the brain and cause more specific symptoms -- as in partial seizures.

Tonic-clonic seizures generally cause patients to cry out and are followed by loss of consciousness, twitching of both legs and arms, convulsive body movements, and loss of bladder control.

Partial seizures are classified as simple or complex. In simple partial seizures, the individual has localized symptoms, such as muscle twitches, chewing movements, and numbness or tingling. In complex partial seizures, the individual may hallucinate, stagger, perform automatic and purposeless movements, or experience impaired consciousness or confusion.

• Growth Problems

A syndrome called failure to thrive is common in children with moderate-to-severe cerebral palsy, especially those with spastic quadriparesis. Failure to thrive is a general term physicians use to describe children who seem to lag behind in growth and development despite having enough food. In babies, this lag usually takes the form of too little weight gain; in young children, it can appear as abnormal shortness; in teenagers, it may appear as a combination of shortness and lack of sexual development.

Failure to thrive probably has several causes, including, in particular, poor nutrition and damage to the brain centers controlling growth and development. In addition, the muscles and limbs affected by cerebral palsy tend to be smaller than normal. This is especially noticeable in some patients with spastic hemiplegia, because limbs on the affected side of the body may not grow as quickly or as large as those on the more normal side. This condition usually affects the hand and foot most severely. Since the involved foot in hemiplegia is often smaller than the unaffected foot even among patients who walk, this size difference is probably not due to lack of use. Scientists believe the problem is more likely to result from disruption of the complex process responsible for normal body growth.

• Impaired Vision or Hearing

A large number of children with cerebral palsy have strabismus, a condition in which the eyes are not aligned because of differences in the left and right eye muscles. In an adult, this condition causes double vision. In children, however, the brain often adapts to the condition by ignoring signals from one of the misaligned eyes. Untreated, this can lead to very poor vision in one eye and can interfere with certain visual skills, such as judging distance. In some cases, physicians may recommend surgery to correct strabismus.

Children with hemiparesis may have hemianopia, which is defective vision or blindness that impairs the normal field of vision of one eye. For example, when hemianopia affects the right eye, a child looking straight ahead might have perfect vision except on the far right. In homonymous hemianopia, the impairment affects the same part of the visual field of both eyes. Impaired hearing is also more frequent among those with cerebral palsy than in the general population.

• Abnormal Sensation and Perception

Some children with cerebral palsy have impaired ability to feel simple sensations like touch and pain. They may also have stereognosia, or difficulty perceiving and identifying objects using the sense of touch. A child with stereognosia, for example, would have trouble identifying a hard ball, sponge, or other object placed in his hand without looking at the object

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Does Birth Play a Role in Cerebral Palsy?

Most students of cerebral palsy agree that the causes are more often found in events during pregnancy than birth (see: British Medical Journal 1999;319:1054-9). Others dispute this hypothesis (see: BMJ 2000;320:1626 17 June), arguing that an important minority of neurodevelopmental problems in children are secondary to perinatal hypoxic-ischaemic damage (lack of oxygen during birth). The ongoing argument is to set the proportion related to pregnancy versus the proportion due to events during birth. Clearly an infant that is compromised during pregnancy is more vulnerable to the stress of birth, so the argument may be somewhat pointless.

Dr. Peter Dear, consultant and senior lecturer in neonatal medicine at St James's Hospital, Leeds, said of the British Medical Journal's consensus statement that most cerebral palsy is related to pregnancy events:

"It is based upon an inadequate and eclectic appraisal of the available literature. The notion of ... rigid statements about causation based upon outcome do not marry well with the duty of the clinician or medicolegal experts to form a balanced view based upon available evidence, without prejudice.

This consensus document attempts to define criteria in such a way as to disallow consideration of an intrapartum cause for damage in many cases. The arguments are not well founded and add little to the discussion in this controversial area."

Support for the consensus statement comes from Professor Alastair MacLennan, Associate Professor in Obstetrics and Gynecology, University of Adelaide, Australia, who calls for re-education of the public on the issue, emphasizing that no proof exists that any obstetric policies can be used to reduce cerebral palsy rates at term.

We would argue that against this statement, saying that the avoidance of analgesia, anesthesia, and other medications during labor and birth, would have some positive effect, though how much is unknown.

Dr. MacLennan argues that, "...[O]bstetricians and midwives should not be used as a de facto social welfare insurance scheme for children with cerebral palsy. Children with neurological disability would be better served with a limited speedy no-fault system run by the government. We need to re-educate the public and some paediatricians to the fact that the neuropathology of cerebral palsy is established in the large majority of cases antenatally."

Professor MacLennan also points out that magnetic resonance imaging is still not a good enough tool to judge adequately if a neuropathological event has occurred. Arnold Simanowitz, chief executive of the Action for Victims of Medical Accidents, said of the importance of this issue: "To know that it [a child's cerebral palsy] could have been avoided simply adds to the burden of parents."

The gist of this is that arguments exist about the degree to which birth events results in cerebral palsy. Our view is that both are correct.. Severe birth asphyxia (lack of oxygen) can damage children. But so can chronic events during pregnancy. We cannot dispute the many children who have normal, easy labors, but still have cerebral palsy. Nor can we dispute the children who have terribly traumatic labors, and are diagnosed with cerebral palsy.

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What Are the Risk Factors For Cerebral Palsy?

• Breech Presentation

Babies with cerebral palsy are more likely to present feet first, instead of head first, at the beginning of labor.

• Complicated Labor and Delivery

Vascular or respiratory problems of the baby during labor and delivery may sometimes be the first sign that a baby has suffered brain damage or that a baby's brain has not developed normally. Such complications can cause permanent brain damage.

• Low Apgar Score

The Apgar score (named for anesthesiologist Virginia Apgar) is a numbered rating that reflects a newborn's condition. To determine an Apgar score, doctors periodically check the baby's heart rate, breathing, muscle tone, reflexes, and skin color in the first minutes after birth. They then assign points; the higher the score, the more normal the baby's condition. A low score at 10-20 minutes after delivery is often considered an important sign of potential problems.

• Low Birthweight and Premature Birth.

The risk of cerebral palsy is higher among babies who weigh less than 2500 grams (5 lbs., 7 1/2 oz.) at birth and among babies who are born less than 37 weeks into pregnancy. This risk increases as birthweight falls.

• Multiple Births

Twins, triplets, and other multiple births are linked to an increased risk of cerebral palsy.

• Nervous System Malformations

Some babies born with cerebral palsy have visible signs of nervous system malformation, such as an abnormally small head (microcephaly). This suggests that problems occurred in the development of the nervous system while the baby was in the womb.

• Maternal Bleeding or Severe Proteinuria Late in Pregnancy

Vaginal bleeding during the sixth to ninth months of pregnancy and severe proteinuria (the presence of excess proteins in the urine) are linked to a higher risk of having a baby with cerebral palsy.

• Maternal Hyperthyroidism, Mental Retardation, or Seizures

Mothers with any of these conditions are slightly more likely to have a child with cerebral palsy.

• Seizures in the Newborn.

An infant who has seizures faces a higher risk of being diagnosed, later in childhood, with cerebral palsy.

Parents should not become too alarmed if their child has one or more of these factors. Most such children do not have and do not develop cerebral palsy.

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Can Cerebral Palsy Be Prevented?

Several of the causes of cerebral palsy that have been identified through research are preventable or treatable:

Head injury can be prevented by regular use of child safety seats when driving in a car, wearing helmets during bicycle rides, and by the elimination of child abuse. In addition, common sense measures around the household - like close supervision during bathing and keeping poisons out of reach - can reduce the risk of accidental injury.

Jaundice of newborn infants can be treated with phototherapy. In phototherapy, babies are exposed to special blue lights that break down bile pigments, preventing them from building up and threatening the brain. In the few cases in which this treatment is not enough, physicians can correct the condition with a special form of blood transfusion.

Rh incompatibility is easily identified by a simple blood test routinely performed on expectant mothers and, if indicated, expectant fathers. This incompatibility in blood types does not usually cause problems during a woman's first pregnancy, since the mother's body generally does not produce the unwanted antibodies until after delivery. In most cases, a special serum given after each childbirth can prevent the unwanted production of antibodies. In unusual cases, such as when a pregnant woman develops the antibodies during her first pregnancy or antibody production is not prevented, doctors can help minimize problems by closely watching the developing baby and, when needed, performing a transfusion to the baby while in the womb or an exchange transfusion (in which a large volume of the baby's blood is removed and replaced) after birth.

Rubella, or German measles, can be prevented if women are vaccinated against this disease before becoming pregnant. Be sure to see our comprehensive section on Vaccines.

In addition, it is always good to work toward a healthy pregnancy through regular prenatal care and good nutrition and by eliminating smoking, alcohol consumption, and drug abuse. Despite the best efforts of parents and physicians, however, children will still be born with cerebral palsy. Since in most cases the cause of cerebral palsy is unknown, only a small amount can currently be done to prevent it. As investigators learn more about the causes of cerebral palsy through basic and clinical research, doctors and parents will be better equipped to help prevent this disorder.

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What Are the Early Signs of Cerebral Palsy?

Early signs of cerebral palsy usually appear before 3 years of age, and parents are often the first to suspect that their infant is not developing motor skills normally. Infants with cerebral palsy are frequently slow to reach developmental milestones, such as learning to roll over, sit, crawl, smile, or walk. This is sometimes called developmental delay.

Some affected children have abnormal muscle tone. Decreased muscle tone is called hypotonia; the baby may seem flaccid and relaxed, even floppy. Increased muscle tone is called hypertonia, and the baby may seem stiff or rigid. In some cases, the baby has an early period of hypotonia that progresses to hypertonia after the first 2 to 3 months of life. Affected children may also have unusual posture or favor one side of their body.

Parents who are concerned about their baby's development for any reason should contact their physician, who can help distinguish normal variation in development from a developmental disorder.

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How is Cerebral Palsy Diagnosed?

Doctors diagnose cerebral palsy by testing an infant's motor skills and looking carefully at the infant's medical history. In addition to checking for those symptoms described above - slow development, abnormal muscle tone, and unusual posture - a physician also tests the infant's reflexes and looks for early development of hand preference.

Reflexes are movements that the body makes automatically in response to a specific cue. For example, if a newborn baby is held on its back and tilted so the legs are above its head, the baby will automatically extend its arms in a gesture, called the Moro reflex, that looks like an embrace. Babies normally lose this reflex after they reach 6 months, but those with cerebral palsy may retain it for abnormally long periods. This is just one of several reflexes that a physician can check.

Doctors can also look for hand preference - a tendency to use either the right or left hand more often. When the doctor holds an object in front and to the side of the infant, an infant with hand preference will use the favored hand to reach for the object, even when it is held closer to the opposite hand. During the first 12 months of life, babies do not usually show hand preference. But infants with spastic hemiplegia, in particular, may develop a preference much earlier, since the hand on the unaffected side of their body is stronger and more useful.

The next step in diagnosing cerebral palsy is to rule out other disorders that can cause movement problems. Most importantly, doctors must determine that the child's condition is not getting worse. Although its symptoms may change over time, cerebral palsy by definition is not progressive. If a child is continuously losing motor skills, the problem more likely springs from elsewhere - possibly including genetic diseases, muscle diseases, disorders of metabolism, or tumors in the nervous system. The child's medical history, special diagnostic tests, and, in some cases, repeated check-ups can help confirm that other disorders are not at fault.

The doctor may also order specialized tests to learn more about the possible cause of cerebral palsy. One such test is computed tomography, or CT, a sophisticated imaging technique that uses X-rays and a computer to create an anatomical picture of the brain's tissues and structures. A CT scan may reveal brain areas that are underdeveloped, abnormal cysts (sacs that are often filled with liquid) in the brain, or other physical problems. With the information from CT scans, doctors may be better equipped to judge the long-term outlook for an affected child.

Magnetic resonance imaging, or MRI, is a relatively new brain imaging technique that is rapidly gaining widespread use for identifying brain disorders. This technique uses a magnetic field and radio waves, rather than X-rays. MRI gives better pictures of structures or abnormal areas located near bone than CT scans.

A third test that can expose problems in brain tissues is ultrasonography. This technique bounces sound waves off the brain and uses the pattern of echoes to form a picture, or sonogram, of its structures. Ultrasonography can be used in infants before the bones of the skull harden and close. Although it is less precise than CT and MRI scanning, this technique can detect cysts and structures in the brain, is less expensive, and does not require long periods of immobility.

Finally, physicians may want to look for other conditions that are linked to cerebral palsy, including seizure disorders, mental impairment, and vision or hearing problems.

When the doctor suspects a seizure disorder, an electroencephalogram, or EEG, may be ordered. An EEG uses special patches called electrodes placed on the scalp to record the natural electrical currents inside the brain. This recording can help the doctor see telltale patterns in the brain's electrical activity that suggest a seizure disorder.

Intelligence tests are often used to determine if a child with cerebral palsy is mentally impaired. It is important to note, however, that sometimes a child's intelligence may be underestimated because problems with movement, sensation, or speech due to cerebral palsy make it difficult for him or her to perform well on these tests.

If problems with vision are suspected, the doctor may refer the patient to an ophthalmologist for examination; if hearing impairment seems likely, an otologist may be called in.

Identifying these accompanying conditions is important and is becoming more accurate as ongoing research yields advances that make diagnosis easier. Many of these conditions can then be addressed through specific treatments, improving the long-term outlook for those with cerebral palsy.

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How is Cerebral Palsy Conventionally Managed?

Conventional medical wisdom holds that cerebral palsy cannot be cured, with treatment aimed at improving the child's capabilities. There is no standard therapy that works for all patients.

Some approaches that can be included in this plan are drugs to control seizures and muscle spasms, special braces to compensate for muscle imbalance, surgery, mechanical aids to help overcome impairments, counseling for emotional and psychological needs, and physical, occupational, speech, and behavioral therapy. In general, the earlier treatment begins, the better chance a child has of overcoming developmental disabilities or learning new ways to accomplish difficult tasks.

A typical treatment team for a child with cerebral palsy might include:

• A physician, such as a family physician, pediatrician, pediatric neurologist, or pediatric physiatrist, trained to help developmentally disabled children. This physician, often the leader of the treatment team, works to synthesize the professional advice of all team members into a comprehensive treatment plan, implements treatments, and follows the patient's progress over a number of years.

• An orthopedist, a surgeon who specializes in treating the bones, muscles, tendons, and other parts of the body's skeletal system. An orthopedist might be called on to predict, diagnose, or treat muscle problems associated with cerebral palsy.

• A physical therapist, who designs and implements special exercise programs to improve movement and strength.

• An occupational therapist, who can help patients learn skills for day-to-day living, school, and work.

• A speech and language pathologist, who specializes in diagnosing and treating communication problems.

• A social worker, who can help patients and their families locate community assistance and education programs.

• A psychologist, who helps patients and their families cope with the special stresses and demands of cerebral palsy. In some cases, psychologists may also oversee therapy to modify unhelpful or destructive behaviors or habits.

• An educator, who may play an especially important role when mental impairment or learning disabilities present a challenge to education.

Individuals who have cerebral palsy and their family or caregivers should be intimately involved in all steps of planning, making decisions, and applying treatments. Studies have shown that family support and personal determination are two of the most important predictors of which individuals who have cerebral palsy will achieve long-term goals.

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What Other Major Problems Are Associated with Cerebral Palsy?

Poor control of the muscles of the throat, mouth and tongue sometimes leads to drooling. Drooling can cause severe skin irritation and, because it is socially unacceptable, can lead to further isolation of affected children from their peers. Although numerous treatments for drooling have been tested over the years, there is no one treatment that always helps. Drugs called anticholinergics can reduce the flow of saliva but may cause significant side effects, such as mouth dryness and poor digestion. Surgery, while sometimes effective, carries the risk of complications, including worsening of swallowing problems. Some patients benefit from a technique called biofeedback that can tell them when they are drooling or having difficulty controlling muscles that close the mouth. This kind of therapy is most likely to work if the patient has a mental age of more than 2 or 3 years, is motivated to control drooling, and understands that drooling is not socially acceptable.

Difficulty with eating and swallowing - also triggered by motor problems in the mouth - can cause poor nutrition. Poor nutrition, in turn, may make the individual more vulnerable to infections and cause or aggravate "failure to thrive" - a lag in growth and development that is common among those with cerebral palsy. To make swallowing easier, the caregiver may want to prepare semisolid food, such as strained vegetables and fruits. Proper position, such as sitting up while eating or drinking and extending the individual's neck away from the body to reduce the risk of choking, is also helpful. In severe cases of swallowing problems and malnutrition, physicians may recommend tube feeding, in which a tube delivers food and nutrients down the throat and into the stomach, or gastrostomy, in which a surgical opening allows a tube to be placed directly into the stomach.

A common complication is incontinence, caused by faulty control over the muscles that keep the bladder closed. Incontinence can take the form of bed-wetting (also known as enuresis), uncontrolled urination during physical activities (or stress incontinence), or slow leaking of urine from the bladder. Possible medical treatments for incontinence include special exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices to replace or aid muscles. Specially designed undergarments are also available.

Written and overseen by Lewis Mehl-Madrona, M.D., Ph.D.

Program Director, Continuum Center for Health and Healing,
Beth Israel Hospital / Albert Einstein School of Medicine

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