Ph.D. R. Ptacek*, candidate of psychological sciences O. Kolyukh**, senior teacher A. Zhunusova**

* Department of Psychiatry, 1st Faculty of Medicine, Charles University, Prague, Czech Republic

** department of Psychology and Pedagogics, PSU named after . S.Toraigyrov, Pavlodar

Attention deficit hyperactivity disorder, growth and obesity

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed childhood psychiatric disorders (Culpepper, Mattingly, 2008; Setoodeh, Teleffson, 2007) and constitute a group of developmental disorders (Schubiner, Katragadda, 2008; Spencer, 2008), which are characterized by inadequate level of attention, excessive activity and impulsivity (Cormier, 2008; Stephen, Kevin, 2008). It is also a developmental disorder with a probable strong genetical binding (Lasky-Su et al., 2008; Kopeckova et al., 2008).

ADHD is manifested in every part of children´s behavior (Cormier, 2008). Biochemical (Bulut et al., 2007; Paclt et al., 2005), endocrinological (Shim et al., 2008; Cormier, 2008), neurological (Cormier, 2008; Spencer, 2008) and even neuroanatomical (Garrett et al., 2008; Uhlikova et al., 2007) changes appear in children with ADHD often. In this connection and according to current studies children with ADHD show a probable changes in growth and development (i.e.: Lam, Yang, 2007; Zachor et al., 2006; Drappatz et al., 2006; Hubel et al., 2006). ADHD is claimed to be disorder with multiple symptomatology and heterogenous ethiology (Cormier, 2008) as some other developmental disorders i.e. autism (Kelemenova, Ostatnikova, 2008; Mutter et al., 2008). Specific changes in brain developement of ADHD childrem may be caused by disorder itself (Spencer, 2008) or it can be caused by other non-related factors (i.e. Dorener et al., 2007).

Changes in growth and development in non-medicated children with ADHD are the aim of this paper. There are very few studies on this topic. The results of these studies are very different and methodics is usually heterogenous and insufficient. Some of the studies describe changes in growth and habitus, other studies contradict that. Many studies are done on changes in growth only associated with medical treatment of children ADHD (i.e: Poulton, Nanan, 2008; Faraone, Giefer, 2007; Drappatz et al. 2006; ). However changes in development and growth can be a manifestation of the disorder itself (Setoodeh, Teleffson, 2007; Spencer, Biederman, Wilens, 1998).

The aim of this backroud research was to compare studies worked on the theme growth and development in children with ADHD, without consequance to the medication. The aim was to compare the results of these studies, point to potential insufficiency in methodics and according to these findings suggest a recomended progress in following studies and also in clinical practise.

Most of the studies examine possible differencies in BMI between children with ADHD and children without ADHD. As the prevalence of childhood obesity increases, identifying groups of children who are at increased risk of overweight is important. Therefore some studies estimated the prevalence of overweight in children and adolescents in relation to attention-deficit/hyperactivity disorder (Waring et al., 2008). According to other studies obesity and ADHD demonstrate significant comorbidity (Bazar et al., 2006).

Some research has been conducted to examine the prevalence of obesity in children with developmental disabilities, particularly in individuals with Down syndrome and Prader-Willi syndrome who are reported to have a higher prevalence of overweight than in the general population (Bell, Bhate, 1992; Holm et al., 1993). However, a few studies have been undertaken to assess the prevalence of overweight in children with other developmental disorders, such as attention deficit hyperactivity disorder (Curtin, Bandini et al., 2005). It is considered that many symptoms of ADHD can be manifestated by children with other mental or somatic disorders (Spencer, 2008) or in some cases the symptoms or the disorder itself can be reaction to traumatic events (Wozniak et al., 1999) and show similarity with other traumatic phenomenons i.e. dissociation (Bob, 2008; Bob et el., 2005).

The literature on obesity in children with ADHD is sparse. Historically, inquiries into weight status of children with ADHD have focused on the potential for growth suppression associated with the use of stimulant medication. (Curtin, Bandini et al., 2005).

One of the first researches of its kind was specialized on growth in children with ADHD. It was done by McGee et al. (McGee et al., 1985). This study included groups of seven-year-old boys (identified as hyperactive-only, aggressive-hyperactive, aggressive-only and non-aggressive/non-hyperactive). Anthropometric data were collected on these groups. Measures included: stature, weight, skeletal maturity, mid-upper arm circumference, triceps and subscapular fatfolds and body-mass index. The hypothesis that hyperactive-only boys would show delayed maturation, as indicated by lower bone-age, was not confirmed. However, these boys had significantly smaller mid-upper arm circumference, triceps fatfold and body-mass index than the other groups. The results suggest that body leanness may discriminate 'pure' hyperactive boys from aggressive-hyperactive boys.

Other studies were mainly specialized on only obesity in ADHD children. The study by Holtkamp et al. (2004) evaluated a sample of 97 boys with ADHD in Germany. Holtkamp et al. tested the hypothesis that hyperactive boys would have a lower prevalence of obesity than an age-matched healthy male reference population in connection to their increased activity. This study was done during 1999 - 2001 and included 97 boys with ADHD (according to the DSM-IV) in age 5,5 to 14,5. 56 boys had other behavior dissorders. BMI was compared. Contrary to expectations, they found that a significant number of subjects with ADHD had a BMI ≥ 90^th percentile (19.6%) and 7.2% had a BMI ≥ 97^th percentile. BMI was significantly higher than age-adapted reference values of the German population.

In 2002 Altafas (2002) realized study on decreasing obesity among ADHD adults. Altafas (2002) conducted a chart review of 215 adults seen in a weight control clinic (1 year). A sample of 215 patients (90% of whom were female) was divided in two groups: ADHD (27.4%), symptoms of ADHD but did not meet formal diagnostic criteria (33.5%), without ADHD (39.1%). All of the patients with ADHD were classified as having the inattentive type of the disorder An average descrease in ADHD group was 2,6 BMI (kg/m2), in group without ADHD was 4 BMI (kg/m2). Among men whose BMI was more than 40 the diference was more significant. Of those patients with a BMI ≥ 40, 42.6% had ADHD. Loss in group of men with ADHD was 2,9 BMI (kg/m2), without ADHD 7 BMI (kg/m2). The authors noted that patients with ADHD were less successful at losing weight than those without ADHD.

Most studies of childhood obesity and psychopathology are cross-sectional or retrospective (Curtin, Bandini et al., 2005; Waring et al., 2008; Hubel et al., 2006; Altafas, 2002). The following study was different.

The relations between obesity and psychopatology were monitored by study of Mustillo et al. (2003). This study is one of the very few longitudinal studies. Measures of height and weight were taken annually over 8 years in 9-16 years old children, together with annual information about family characteristics and mental health. The children were dividend according to psychiatric diagnoses into 7 groups: conduct disorder, oppositional defiant disorder, depressive disorders (including major depression, dysthymia, and depression not otherwise specified), anxiety disorders (including separation anxiety, generalized anxiety disorder, simple phobia, social phobia, agoraphobia, and panic), bulimia, substance abuse, and attention-deficit/hyperactivity disorder (ADHD). Chronic obesity was more common in children from poor and less-educated families, and it had implications for mental health. Psychopathology was most common in the chronically obese group. However there were no significant associations between obesity trajectory membership and bulimia, ADHD, substance use, conduct disorder, or anxiety, controlling for comorbid psychiatric disorders.

Similar reasearch was done by Curtin et al. (2005). This retrospective study found and compared predispositions to obesity in group of children with ADHD (98) and in group of children with autism (42). Retrospective chart review of 140 charts of children ages 3–18 years seen between 1992 and 2003 at a tertiary care clinic that specializes in the evaluation and treatment of children with developmental, behavioral, and cognitive disorders. Diagnostic, medical, and demographic information was extracted from the charts: primary diagnoses of ADHD (according to DSM-IV; DSM, 1994), race/ethnicity, age, gender, height, and weight. Information was also collected on medications. Body mass index (BMI) was calculated from measures of height and weight recorded in the child's chart. BMI above 85th percentil was supposed to be the prevalence of at-risk-for-overweigh. BMI value above 95th percentil was supposed to be obesity. The prevalence appeared highest in the 2–5 year old group, but differences among age groups were not statistically significant. The data of this study suggest that the problem of overweight in children with ADHD. However the prevalence of overweight that is similar to children in the general population.

Swanson et al. (1998) analyzed data from over 4400 subjects from 18 studies, Subjects were 6-17 years old and their weight and height were included in the analyses. Average height was on 51st percentile, weight on 61st percentile. Growth patterns for children with ADHD were considerably different from current norms. According to these results children are taller and larger than expected at an early age. Age-matched stimulant users are both shorter and lighter than their untreated counterparts, suggesting some stimulant-related growth suppression.

Study by Waring et al. (Waring et al., 2008) was a cross-sectional analysis of 62 887 children and adolescents aged 5 to 17 years from the 2003–2004 National Survey of Children's Health, a nationally representative sample of children and adolescents in the United States. Attention-deficit disorder/attention-deficit/hyperactivity disorder was determined by response to the question "Has a doctor or health professional ever told you that your child has attention-deficit disorder or attention-deficit/hyperactive disorder, that is, ADD or ADHD?" Children and adolescents were classified as underweight, normal weight, at risk of overweight, or overweight according to BMI for age and gender. After adjustment for age, gender, race/ethnicity, socioeconomic status, and depression/anxiety, children and adolescents with attention-deficit disorder/attention-deficit/hyperactivity disorder not currently using medication had 1.5 times the odds of being overweight.

Hubel et al. (2006) investigated a possible association between attention-deficit/hyperactivity disorder (ADHD) and overweight by measuring weight status and energy expenditure (basal metabolic rate, BMR) in 39 8-14 years ADHD-boys with hyperactivity. Weight and height were measured and BMI values were calculated. BMR was determined by indirect calorimetry. Significant differences were obtained between the ADHD- and the control-group. Both BMI and BMR were higher in the group of ADHD-boys. The authors supposed that impulsive behavior in ADHD-boys with hyperactivity may lead to an increased food intake.

According to the resume of presented studies it is unclear whether children with ADHD show differencies in anthropometrics characteristics or in growth generally. The main diference against normal population is usually being founded in BMI factor. Most of the studies which have been done on this topics have mostly methodological insufficiencies. There are even usually not mentioned important factors which can play an important role in changes in development (i.e. complex antrhopometrics measurement, craniometry, socio-conomical factor, feeding). These findings lead to conclusion that further research reflecting complexity of the problem should be done.

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