Attention Deficit Hyperactivity Disorder (ADHD)

Jai Ganesh · 2023-05-16 21:59:53

Attention Deficit Hyperactivity Disorder

Gist

ADHD is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.

Summary

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inappropriate.

ADHD symptoms arise from executive dysfunction, and emotional dysregulation is often considered a core symptom. In children, problems paying attention may result in poor school performance. ADHD is associated with other neurodevelopmental and mental disorders as well as some non-psychiatric disorders, which can cause additional impairment, especially in modern society. Although people with ADHD struggle to focus on tasks they are not particularly interested in completing, they are often able to maintain an unusually prolonged and intense level of attention for tasks they do find interesting or rewarding; this is known as hyperfocus.

The precise causes of ADHD are unknown in the majority of cases. Genetic factors play an important role; ADHD tends to run in families and has a heritability rate of 74%. Toxins and infections during pregnancy as well as brain damage may be environmental risks.

It affects about 5–7% of children when diagnosed via the DSM-IV criteria, and 1–2% when diagnosed via the ICD-10 criteria. Rates are similar between countries and differences in rates depend mostly on how it is diagnosed. ADHD is diagnosed approximately twice as often in boys than in girls, and 1.6 times more often in men than in women, although the disorder is overlooked in girls or diagnosed in later life because their symptoms sometimes differ from diagnostic criteria. About 30–50% of people diagnosed in childhood continue to have ADHD in adulthood, with 2.58% of adults estimated to have ADHD which began in childhood. In adults, hyperactivity is usually replaced by inner restlessness, and adults often develop coping skills to compensate for their impairments. The condition can be difficult to tell apart from other conditions, as well as from high levels of activity within the range of normal behaviour. ADHD has a negative impact on patient health-related quality of life that may be further exacerbated by, or may increase the risk of, other psychiatric conditions such as anxiety and depression.

ADHD management recommendations vary and usually involve some combination of medications, counseling, and lifestyle changes. The British guideline emphasises environmental modifications and education about ADHD for individuals and carers as the first response. If symptoms persist, parent-training, medication, or psychotherapy (especially cognitive behavioural therapy) can be recommended based on age. Canadian and American guidelines recommend medications and behavioural therapy together, except in preschool-aged children for whom the first-line treatment is behavioural therapy alone. Stimulant medications are the most effective pharmaceutical treatment, although there may be side effects and any improvements will be reverted if medication is ceased.

ADHD, its diagnosis, and its treatment have been considered controversial since the 1970s. These controversies have involved doctors, teachers, policymakers, parents, and the media. Topics have included causes of ADHD and the use of stimulant medications in its treatment. ADHD is now a well-validated clinical diagnosis in children and adults, and the debate in the scientific community mainly centers on how it is diagnosed and treated. ADHD was officially known as attention deficit disorder (ADD) from 1980 to 1987; prior to the 1980s, it was known as hyperkinetic reaction of childhood. Symptoms similar to those of ADHD have been described in medical literature dating back to the 18th century.

Signs and symptoms

Inattention, hyperactivity (restlessness in adults), disruptive behaviour, and impulsivity are common in ADHD. Academic difficulties are frequent as are problems with relationships. The symptoms can be difficult to define, as it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring interventions begin.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its text revision (DSM-5-TR), symptoms must be present for six months or more to a degree that is much greater than others of the same age. This requires at least six symptoms of either inattention or hyperactivity/impulsivity for those under 17 and at least five symptoms for those 17 years or older. The symptoms must be present in at least two settings (e.g., social, school, work, or home), and must directly interfere with or reduce quality of functioning. Additionally, several symptoms must have been present before age twelve.

Details

Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's behaviour. People with ADHD can seem restless, may have trouble concentrating and may act on impulse.

Symptoms of ADHD tend to be noticed at an early age and may become more noticeable when a child's circumstances change, such as when they start school.

Most cases are diagnosed when children are under 12 years old, but sometimes it's diagnosed later in childhood.

Sometimes ADHD was not recognised when someone was a child, and they are diagnosed later as an adult.

The symptoms of ADHD usually improve with age, but many adults who were diagnosed with the condition at a young age continue to experience problems.

People with ADHD may also have additional problems, such as sleep and anxiety disorders.

Getting help

Many children go through phases where they're restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD.

But you should discuss your concerns with your child's teacher, their school's special educational needs co-ordinator (SENCO) or a GP if you think their behaviour may be different from most children their age.

It's also a good idea to speak to a GP if you're an adult and think you may have ADHD, but were not diagnosed with the condition as a child.

What causes attention deficit hyperactivity disorder (ADHD)?

The exact cause of ADHD is unknown, but the condition has been shown to run in families.

Research has also identified a number of possible differences in the brains of people with ADHD when compared with those without the condition.

Other factors suggested as potentially having a role in ADHD include:

* being born prematurely (before the 37th week of pregnancy)
* having a low birthweight
* smoking or alcohol or drug abuse during pregnancy

ADHD can occur in people of any intellectual ability, although it's more common in people with learning difficulties.

How attention deficit hyperactivity disorder (ADHD) is treated

For children with ADHD, although there's no cure, it can be managed with appropriate educational support, advice and support for parents and affected children, alongside medicine, if necessary.

For adults with ADHD, medicine is often the first treatment offered, although psychological therapies such as cognitive behavioural therapy (CBT) may also help.

Living with attention deficit hyperactivity disorder (ADHD):

Parents of children with ADHD

Looking after a child with ADHD can be challenging, but it's important to remember that they cannot help their behaviour.

Some day-to-day activities might be more difficult for you and your child, including:

* getting your child to sleep at night
* getting ready for school on time
* listening to and carrying out instructions
* being organised
* social occasions
* shopping

Adults with ADHD

Adults with ADHD may find they have problems with:

* organisation and time management
* following instructions
* focusing and completing tasks
* coping with stress
* feeling restless or impatient
* impulsiveness and risk taking

Some adults may also have issues with relationships or social interaction.

Additional Information

Attention-deficit/hyperactivity disorder (ADHD) is a a behavioral syndrome characterized by inattention and distractibility, restlessness, inability to sit still, and difficulty concentrating on one thing for any period of time. Attention-deficit/hyperactivity disorder (ADHD) most commonly occurs in adolescents and children, though adults may also be diagnosed with the disorder. ADHD is three times more common in males than in females and occurs in approximately 5 to 7 percent of children worldwide. Although behaviours characteristic of the syndrome are evident in all cultures, they have garnered the most attention in the United States, where ADHD is among the most commonly diagnosed childhood psychiatric disorders. Estimates indicate that anywhere from 6 to 11 percent of children and adolescents in the United States are affected by ADHD.

It was not until the mid-1950s that American physicians began to classify as “mentally deficient” individuals who had difficulty paying attention on demand. Various terms were coined to describe this behaviour, among them minimal brain damage and hyperkinesis. In 1980 the American Psychiatric Association (APA) replaced these terms with attention deficit disorder (ADD). Then in 1987 the APA linked ADD with hyperactivity, a condition that sometimes accompanies attention disorders but may exist independently. The new syndrome was named attention-deficit/hyperactivity disorder, or ADHD.

Symptoms

ADHD does not have easily recognizable symptoms or definitive diagnostic tests. Physicians may distinguish between three subtypes of the disorder: predominantly hyperactive-impulsive, predominantly inattentive, and combined hyperactive-impulsive and inattentive. Children and adults are diagnosed with ADHD if they persistently show a combination of traits including, among others, forgetfulness, distractibility, fidgeting, restlessness, impatience, difficulty sustaining attention in work, play, or conversation, or difficulty following instructions and completing tasks. According to criteria issued by the APA, at least six of these traits must be present “to a degree that is maladaptive,” and these behaviours must cause “impairment” in two or more settings—e.g., at school, work, or at home. Studies have shown that more than a quarter of children with ADHD are held back a grade in school, and a third fail to graduate from high school. The learning difficulties associated with ADHD, however, should not be confused with a deficient intelligence.

Treatment

The most common medication used to treat ADHD is methylphenidate (e.g., Ritalin™), a mild form of amphetamine. Amphetamines increase the amount and activity of the neurotransmitter norepinephrine (nonadrenaline) in the brain. Although such drugs act as a stimulant in most people, they have the paradoxical effect of calming, focusing, or “slowing down” people with ADHD. Ritalin was developed in 1955, and the number of children with ADHD taking this and related medications has increased steadily ever since. Mixed salts of amphetamine (e.g., Adderall) and the drug dextroamphetamine (e.g., Dexedrine) are other stimulants that may be used to treat ADHD. These drugs may be prescribed in a short-acting form, the effects of which last about four hours, or a long-acting form, with effects lasting anywhere from six to 12 hours.

The fact that many people diagnosed with ADHD experience fewer problems once they start taking stimulants such as Ritalin may confirm a neurological basis for the condition. Ritalin and similar medications help people with ADHD to concentrate better, which helps them get more work done and, in turn, reduces frustration and increases self-confidence. ADHD may also be treated with a nonstimulant drug such as bupropion or atomoxetine (Strattera®). Such drugs work by inhibiting the reuptake of norepinephrine from nerve terminals, thereby increasing the amount of the neurotransmitter available in the brain.

Medications used to treat ADHD are associated with various side effects, including decreased appetite, involuntary tics (repetitive movements), headache, irritability, and insomnia. Mood swings and hyperactivity or fatigue can develop as the effects of medication lessen over the duration of a dose. Patients who take amphetamines for ADHD may experience an increase in risk of psychotic events.

Another form of treatment, often used in conjunction with drug therapy, is cognitive behavioral therapy, which focuses on teaching affected individuals to learn to monitor and control their emotions. Behavioral therapy has proved beneficial in helping patients to establish structured routines and to set and achieve clearly defined goals.

ADHD patients who cannot take medication may be eligible for therapy involving mild nerve stimulation. In this therapy, low-level electrical pulses are used to stimulate the trigeminal nerve, resulting in increased activity in brain areas implicated in the regulation of attention and behaviour. Mild nerve stimulation is applied while the patient is asleep and is monitored by a caretaker.

Causes

The cause of ADHD is believed to be a combination of both inherited and environmental factors. There have been numerous theories regarding causation; however, many suffer from a lack of evidence (for example, theories involving bad parenting; brain damage due to head trauma, infection, or exposure to alcohol or lead; food allergy; and too much sugar). ADHD is thought to be at least partly hereditary. About 40 percent of children with the condition have a parent who has ADHD, and 35 percent have a sibling who is affected. About 15 percent of persons with ADHD appear to carry chromosomal abnormalities known as copy number variants. These defects consist of deletions and duplications of segments of chromosomes and have been implicated in other disorders, including autism and schizophrenia.

Using imaging technologies such as positron emission tomography and functional magnetic resonance imaging (fMRI), neurobiologists have found subtle differences in the structure and function of the brains of people with and without ADHD. One study, which compared the brains of boys with and without ADHD, found that the corpus callosum, the band of nerve fibres that connects the two hemispheres of the brain, contained slightly less tissue in those with ADHD. A similar study discovered small size discrepancies in the brain structures known as the caudate nuclei. In boys without ADHD, the right caudate nucleus was normally about 3 percent larger than the left caudate nucleus; this asymmetry was absent in boys with ADHD.

Other studies have detected not just anatomic but functional differences between the brains of persons with and without ADHD. One research team observed decreased blood flow through the right caudate nucleus in adults with ADHD. Another study showed that an area of the prefrontal cortex known as the left anterior frontal lobe metabolizes less glucose in adults with ADHD, an indication that this area may be less active than in those without ADHD. Still other research showed higher levels of the neurotransmitter norepinephrine throughout the brains of people with ADHD and lower levels of another substance that inhibits the release of norepinephrine. Metabolites, or broken-down products, of another neurotransmitter, dopamine, have also been found in elevated concentrations in the cerebrospinal fluid of boys with ADHD. Increases in dopamine concentrations may be related to a deficiency of neuronal dopamine receptors and transporters in persons affected by ADHD. Dopamine plays a central role in the reward system in the brain; however, the absence of receptors and transporters prevents cellular uptake of the neurotransmitter, which renders the neural reward circuit dysfunctional. This in turn leads to significant alterations in mood and behaviour.

These anatomic and physiological variations may all affect a sort of “braking system” in the brain. The brain is constantly coursing with many overlapping thoughts, emotions, impulses, and sensory stimuli. Attention can be defined as the ability to focus on one stimulus or task while resisting focus on the extraneous impulses; people with ADHD may have reduced ability to resist focus on these extraneous stimuli. The cortical-striatal-thalamic-cortical circuit, a chain of neurons in the brain that connects the prefrontal cortex, the basal ganglia, and the thalamus in one continuous loop, is thought to be one of the main structures responsible for impulse inhibition.

The size and activity differences found in the prefrontal cortex and basal ganglia of people with ADHD may be evidence of a delay in the normal growth and development of this inhibitory circuit. If this supposition is true, it would help explain why the symptoms of ADHD sometimes subside with age. The cortical-striatal-thalamic-cortical circuit in the brains of people with ADHD may not fully mature—providing more normal levels of impulse inhibition—until the third decade of life, and it may never do so in some people. This developmental lag may explain why stimulant medications work to enhance attention. In one study, treatment with Ritalin restored average levels of blood flow through the caudate nucleus. In other trials, dopamine levels, which normally decrease with age but remain high in people with ADHD, fell after treatment with Ritalin. The hypothesis would coincide, finally, with observations that the social development of children with ADHD progresses at the same rate as that of their peers but with a lag of two to three years.

Controversy—mental disorder or state of mind?

ADHD has been a subject of great controversy and debate. A number of people who have been diagnosed with the syndrome—some of them psychologists and psychiatrists—have challenged the notion that personality traits such as inattentiveness, impulsivity, and distractibility deserve the label symptoms. They contend that many people labeled as having ADHD are neither “deficient” nor “disordered”—they are simply different. ADHD, this vocal minority argues, is not a mental disorder at all but a different state of mind, and it is because of this difference that people with ADHD often do not function well in standard learning or work environments. It is society and its expectations that have to change, they claim, not persons with short attention spans and high energy.

Indeed, the view of ADHD as a problem requiring medical intervention is highly culture-bound, being largely peculiar to the United States and Canada. This is not to say that the behaviours characteristic of ADHD are absent from children in other nations. The larger question is whether children in other countries are identified by their parents, teachers, and physicians as having a problem. In Great Britain and France only about 1 percent of children are diagnosed with “hyperkinetic disorder,” the closest equivalent to ADHD in the World Health Organization’s International Classification of Diseases (the diagnostic system used by most medical professionals outside North America). And the British medical establishment hopes this number will remain comparatively low. The British Psychological Society suggested in a 1997 report that physicians and psychiatrists should not follow the American example of applying medical labels to such a wide variety of attention-related disorders: “The idea that children who don’t attend or who don’t sit still in school have a mental disorder is not entertained by most British clinicians.”

Emerging scientific evidence about the causes and consequences of ADHD lends some plausibility to this viewpoint. As noted above, neurologists are finding that the anatomic and physiological differences underlying ADHD appear to be mere variations in the timing of brain development, not outright defects. Other researchers suggest that the behaviours characteristic of ADHD may once have conferred an evolutionary advantage, which would explain why their underlying genetic components have been conserved in the human gene pool.

Nevertheless, the majority of American medical professionals are certain that ADHD is a disorder and not just a normal variance. Indeed, some argue that the categorization of ADHD as a neurobiological disorder was an important step forward, since it clearly distinguished the ability to pay attention or control one’s impulses from other mental capacities such as innate intelligence. Once ADHD was acknowledged as a disorder, impulsive or inattentive people could no longer be dismissed as “slow” or “stupid.” Instead, the disorder could be managed with an appropriate treatment regimen—usually including medication but also incorporating certain organizing techniques—that would allow a person with ADHD to develop to the full extent of his or her intelligence.

cryptonian · 2023-06-29 21:53:21

wow. I never thought about it.

Bob · 2023-06-30 01:23:22

hi Ganesh,

There have been two new posters recently, writing about ADHD. At first glance all very interesting but, I followed the links, and it turned out to be just an advert for a 'wonder cure'. After I removed the first, another appeared, almost identical. As we are not a free site for anyone's questionable 'products' I have deleted both.

Your explanation should mean there is no excuse for anyone else to infiltrate our site like this.

Best wishes,

Bob

Jai Ganesh · 2023-06-30 13:13:46

Hi Bob,

Thanks!

JCBayley · 2024-04-01 22:13:55

I really appreciate you shedding light on ADHD. It's a condition that affects so many people in various ways. Personally, I've seen friends and family members struggle with it, and I've witnessed how it can impact their daily lives.

If you're thinking about therapy or treatment for ADHD, it's worth exploring your options. I've heard that therapy can be really helpful for managing symptoms and finding coping strategies.

Jai Ganesh · 2024-04-01 23:12:25

Hi JCBayley,

Thanks!

Coralie L · 2024-11-25 02:07:16

Probably the most complete and efficient post I've read about ADHD !

Jai Ganesh · 2024-11-25 13:21:14

Hi Coralie L,

Thanks!

Math Is Fun Forum

#1 2023-05-16 21:59:53

Attention Deficit Hyperactivity Disorder (ADHD)

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