ADHD is a chronic disorder that starts in childhood and impacts multiple aspects of a person’s well-being. It is characterized by inattention (difficulty focusing on one thing), hyperactivity (inappropriate excess movement), and impulsivity (jumping to action without proper thought) that interferes with development and functioning.
ADHD is one of the most common mental health issues affecting 5–8% of children, and 2.5% of adults. It mostly affects men.
Symptoms and Diagnosis
ADHD is often first identified in school-aged children as it leads to difficulties with schoolwork or disturbance in the class.
Based on the presentation ADHD can be categorized into three:
Predominantly inattentive – difficulty focusing, wandering off task, being disorganized, not being able to follow instructions.
Predominantly hyperactive/impulsive – fidgeting, talkativeness, not being able to sit still, doing things without considering the effect, and the like.
Combined presentation – when criteria for both the above presentations are met.
For diagnosis symptoms must start before age 12, persist for a minimum of 6 months, and be present in more than one setting.
Figure 1. Diagnostic criteria for ADHD [1]
Pathogenesis
pathogenesis of ADHD is not definitively known but there are factors that appear to play a role.
Genetic – Although there is no single gene for ADHD a genetic imbalance of catecholamine metabolism in the cerebral cortex seems to play a significant role. Moreover, an increased risk of ADHD is seen in first-degree relatives and the heritability of ADHD is found to be approximately 74 - 75%.
Prenatal exposure - to tobacco smoke, Neurotoxin (e.g., lead), infections (e.g., encephalitis), and alcohol.
Prematurity and low birth weight - the more extreme the low weight, the greater the risk.
Structural and functional differences –Differences are particularly noted in the anterior brain areas of ADHD patients compared to those who don’t have ADHD.
Additionally, factors such as Visual and hearing impairments, metabolic abnormalities, and nutritional deficiencies which may not have a direct link to causing ADHD are considered as possible influences on the symptoms.
Comorbidity
Although ADHD is more common in males, females with ADHD have higher rates of a number of comorbid disorders. Some of the disorder cooccurring with ADHD includes:
Oppositional defiant disorder - in 50% of children with combined presentation and in 25% with predominantly inattentive presentation.
Conduct disorder- in about 25% of children or adolescents with combined presentation.
Autism spectrum disorder
Substance use disorders.
Delays in language, motor, or social development.
Depression,
Anxiety disorder
Learning disorders
Personality disorders
Functional Impacts
ADHD is associated with multiple detrimental outcomes in a person’s life. Children with ADHD tend to have poorer academic performance, self–esteem and social function. Additionally, young adults and adults will have less job stability, poor work performance or attainment, and a higher probability of unemployment. People with ADHD are also more likely to get into interpersonal conflicts and develop behavioral and personality disorders.
Research has shown that untreated ADHD can lead to long-term outcomes of antisocial behavior, addictive behavior, decreased self-esteem, and social function. They also suffer from difficulties in service use, driving, and other functions.
Treatment
There is no cure for ADHD as of now but there are treatments for alleviating the symptoms of ADHD, although not to normal levels. Management can be either medical or psychosocial. stimulants are more effective than psychosocial therapies in treating these symptoms.
Medications -
psychostimulants - first-line medications for management of ADHD symptoms and consist of formulations of methylphenidate and amphetamine. There is about 70% response rate.
Non-stimulants – atomoxetine which is an SNRI can be used to treat patients with inattention; however, its effect on hyperactivity and impulsivity is less pronounced than that of stimulants. The selective α-2 adrenergic agonists guanfacine and clonidine are also effective in alleviating core symptoms in school-aged children and adolescents. Bupropion is also another option for treating inattention.
Psychosocial treatments – it is shown that behavioral therapy and training interventions can be effective treatments.
Cognitive behavioral therapy is one method that can be used.
In-school neurofeedback training - shown to be better than cognitive training in improving inattention and hyperactivity/impulsivity in some research.
Parental Training and Behavior Management (PTBM) has the most evidence to support its use in children with ADHD, especially in preschool children (ages 4-6 years).
Behavioral classroom interventions are also another method that should be implemented.
So, the management of ADHD should include medications along with PTBM and/or behavioral classroom intervention taking age into consideration as well.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022.
2. AUSTERMAN, J. “ADHD and Behavioral Disorders: Assessment, Management, and an Update from DSM-5.” Cleveland Clinic Journal of Medicine, vol. 82, no. suppl 1, 1 Nov. 2015, pp. S2–S7, mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/issues/articles/Austerman_ADHD.pdf, https://doi.org/10.3949/ccjm.82.s1.01. Accessed 24 Nov. 2023.
3. Kevin R, Krull, PHD, and Eugenia Chan, MD, MPH. “UpToDate.” Www.uptodate.com, Mar. 2023, www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-epidemiology-and-pathogenesis?topicRef=623&source=see_link#H11. Accessed 24 Nov. 2023.
4. Posner, Jonathan, et al. “Attention-Deficit Hyperactivity Disorder.” The Lancet, vol. 395, no. 10222, Feb. 2020, pp. 450–462, https://doi.org/10.1016/s0140-6736(19)33004-1.
5. “Psychiatry.org - What Is ADHD?” Psychiatry.org, June 2022, www.psychiatry.org/patients-families/adhd/what-is-adhd#section_6. Accessed 22 Nov. 2023.
6. Shaw, Monica, et al. “A Systematic Review and Analysis of Long-Term Outcomes in Attention Deficit Hyperactivity Disorder: Effects of Treatment and Non-Treatment.” BMC Medicine, vol. 10, no. 1, 4 Sept. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3520745/, https://doi.org/10.1186/1741-7015-10-99. Accessed 24 Nov. 2023.
7. Wolraich, Mark L., et al. “Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.” Pediatrics, vol. 144, no. 4, 2019, p. Article e20192528, pediatrics.aappublications.org/content/early/2019/09/26/peds.2019-2528, https://doi.org/10.1542/peds.2019-2528.
8. World Health Organization. ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD). 2019.
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