Attention deficit hyperactivity disorder (ADHD)

by Eesha Madan

1) Abstract

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood neurodevelopmental disorders that impacts the parts of the brain that help us plan, focus on, and execute tasks. ADHD symptoms vary by sub-type — inattentive, hyperactive, or combined — and are often more difficult to diagnose in girls and adults. Here, we review the symptoms, causes, types, and treatments associated with ADHD.

 2) Understanding Attention-deficit/hyperactivity

 disorder: ADHD, attention deficit hyperactivity disorder, is a developmental condition of inattention and distractibility, with or without accompanying hyperactivity. It is one of the most common neurodevelopmental disorders affecting children. The signs of ADHD start early in childhood. But some people don’t find out they have it until they are older. Individuals suffering from this disorder show patterns of developmentally inappropriate levels of inattentiveness, hyperactivity, or impulsivity. Scientists have discovered there are differences in the brains, nerve networks and neurotransmitters of people with ADHD. It can limit a person’s ability to study or work, and it can lead to stress, anxiety, and depression. This disorder includes Autism Spectrum, Intellectual Disability and Specific Learning Disorders. These disorders if not attended to can lead to more serious and chronic disorders in adulthood.  An article published in “India Today” mentioned that it is estimated that 10 million Indian children are diagnosed with ADHD annually. 

3) Signs of ADHD

All kids struggle at times to pay attention, listen and follow directions, sit still, or wait their turn. But for kids with ADHD, the struggles are harder and happen more often.

Kids with ADHD can show signs in different areas. They might be:

• Inattentive: Kids who are inattentive (easily distracted) have trouble focusing their attention, concentrating, and staying on task. They may not listen well to directions, may miss important details, and may not finish what they start. They may daydream or dawdle too much. They may seem absent-minded or forgetful and may lose track of their things.
• Hyperactive: Hyperactive Kids are fidgety, restless, and easily bored. They may have trouble sitting still, or staying quiet when needed. They may rush through things and make careless mistakes. They may climb, jump, or roughhouse when they shouldn’t. Without meaning to, they may act in ways that disrupt others.
• Impulsive: Kids who are impulsive act too quickly before thinking. They often interrupt, might push or grab, and find it hard to wait. They may do things without asking for permission, take things that aren’t theirs, or act in ways that are risky. They may have emotional reactions that seem too intense for the situation.

Sometimes parents and teachers notice signs of ADHD when a child is very young. But it’s normal for little kids to be distracted, restless, impatient, or impulsive — these things don’t always mean that a child has ADHD. Attention, activity, and self-control develop little by little, as children grow. Kids learn these skills with help from parents and teachers. But some kids don’t get much better at paying attention, settling down, listening, or waiting. When these things continue and begin to cause problems at school, home, and with friends, it may be ADHD.

Some people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. Symptoms can range from mild to severe.

Many adults with ADHD aren’t aware they have it — they just know that everyday tasks can be a challenge. Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger.

Adult ADHD symptoms may include:

• Impulsiveness
• Disorganization and problems prioritizing
• Poor time management skills
• Problems focusing on a task
• Trouble multitasking
• Excessive activity or restlessness
• Poor planning
• Low frustration tolerance
• Frequent mood swings
• Problems following through and completing tasks
• Hot temper
• Trouble coping with stress

4) What causes ADHD?

Despite how common ADHD is, doctors and researchers still are not sure what causes the condition. The exact cause of ADHD is unknown, but the condition has been shown to run in families. While there is growing evidence that genetics contribute to ADHD and several genes have been linked to the disorder, no specific gene or gene combination has been identified as the cause of the disorder.

However, some research suggests that the following factors may play a role in developing ADHD:

• Genetics: Around 3 out of 4 children with ADHD have a relative with the condition.
• Premature birth: Infants born even 1 month prematurely may face an increased risk of developing ADHD.
• Low birth weight: Results of one meta-analysisTrusted Source suggest a small but significant link between low birth weight and the development of ADHD.
• Stress and other lifestyle factors during pregnancy: Findings of a study from 2012 support a previously established connection between maternal stress during pregnancy and the development of ADHD. The authors of this study conclude that smoking tobacco and drinking alcohol during pregnancy may also increase the child’s risk of developing the disorder.
• Traumatic brain injury: In 2015, researchers found a possible linkTrusted Source between mild traumatic brain injury and ADHD in student athletes. However, the causal relationship was unclear.

ADHD is not caused by too much screen time, poor parenting, or eating too much sugar.

5) Types of ADHD:

According to DSM-5, the 3 types of attention-deficit/hyperactivity disorder (ADHD) are (1) predominantly inattentive, (2) predominantly hyperactive/impulsive, and (3) combined. The specific criteria for attention-deficit/hyperactivity disorder are as follows:

5.1 Inattentive:   

This must include at least 6 of the following symptoms of inattention that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen to what is being said
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions)
• Often has difficulties organizing tasks and activities
• Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
• Often loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys)
• Often is easily distracted by extraneous stimuli
• Often forgetful in daily activities

5.2 Hyperactivity/impulsivity:     

This must include at least 6 of the following symptoms of hyperactivity-impulsivity that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

• Fidgeting with or tapping hands or feet, squirming in the seat
• Leaving seat in the classroom or in other situations in which remaining seated is expected
• Running about or climbing excessively in situations where this behaviour is inappropriate (in adolescents or adults, this may be limited to subjective feelings of restlessness)
• Difficulty playing or engaging in leisure activities quietly
• Unable to be or uncomfortable being still for extended periods of time (may be experienced by others as “on the go” or difficult to keep up with)
• Excessive talking
• Blurting out answers to questions before the questions have been completed
• Difficulty waiting in lines or awaiting turn in games or group situations
• Interrupting or intruding on others (for adolescents and adults, may intrude into or take over what others are doing)

In addition, attention-deficit/hyperactivity disorder is specified by the severity based on social or occupational functional impairment: mild (minor impairment), moderate (impairment between “mild” and “severe”), severe (symptoms in excess of those required to meet diagnosis; marked impairment).

5.3

Inattention-Impulsivity (Combined):

This type of ADHD is diagnosed when both criteria for both inattentive and hyperactive/impulse types are met.

ADHD is typically diagnosed by mental health providers or primary care providers. A psychiatric evaluation will include a description of symptoms from the patient and caregivers, completion of scales and questionnaires by patient, caregivers and teachers, complete psychiatric and medical history, family history, and information regarding education, environment, and upbringing. It may also include a referral for medical evaluation to rule out other medical conditions.

It is important to note that several conditions can mimic ADHD such as learning disorders, mood disorders, anxiety, substance use, head injuries, thyroid conditions, and use of some medications such as steroids (Austerman, 2015). ADHD may also co-exist with other mental health conditions, such as oppositional defiant disorder or conduct disorder, anxiety disorders, and learning disorders (Austerman, 2015). Thus, a full psychiatric evaluation is very important. There are no specific blood tests or routine imaging for ADHD diagnosis. Sometimes, patients may be referred for additional psychological testing (such as neuropsychological or psychoeducational testing) or may undergo computer-based tests to assess the severity of symptoms.

5.4 Autism spectrum disorder (ASD)

Autism spectrum disorders (ASD) are a diverse group of conditions. They are characterized by some degree of difficulty with social interaction and communication. Other characteristics are atypical patterns of activities and behaviours, such as difficulty with transition from one activity to another, a focus on details and unusual reactions to sensations.

The American Academy of Pediatrics (AAP) recommends that all children be screened for autism spectrum disorder at their 18- and 24-month well-child checkups

5.5: Intellectual disability

Intellectual disability is a term used when a person has certain limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills. Intellectual disability is when an individual’s IQ is 70 or below 70. These are manifested before the age of 18 years.

5.6 Specific learning disorder: 

When an individual experiences difficulty in perceiving or processing information Efficiently and accurately. The individual also encounters problems in basic skills like reading. These get manifested during early school years.

6) Treatment:

There are 2 types of treatments.

6.1) behavioural:

ADHD affects not only a child’s ability to pay attention or sit still at school but also affects relationships with family and other children. Children with ADHD often show behaviors that can be very disruptive to others. Behaviour therapy is a treatment option that can help reduce these behaviours and can help increase self-regulation skills. it is often helpful to start behaviour therapy as soon as a diagnosis is made. 

The following are suggestions that may help with your child’s behaviour:

•  Create a routine: try to follow a routine from day to bedtime every day. 

• Get organized: Try to make your children do basic stuff like- putting school bags themselves and toys in the same place etc.

• Manage distractions. Turn off the TV and social media, limit noise, and provide a clean workspace

• Limit choices. To help someone not feel overwhelmed or overstimulated, offer choices with only a few options. For eg: this or that.

• Be clear and specific when you talk: Give them clear instructions or guidelines on how to do specific tasks.

• Help them plan. Break down complicated tasks into simpler, shorter steps. For long tasks, starting early and taking breaks may help limit stress.
• Provide a healthy lifestyle. Nutritious food, lots of physical activity, and sufficient sleep are important; they can help keep ADHD symptoms from getting worse.

6.2) medications

6.2.1 Stimulants 

Stimulant medications reduce the reabsorption of brain messengers like dopamine and norepinephrine, which increases their levels in the brain. They are commonly used for adult ADHD symptoms.

Common stimulant medications for ADHD include:

• amphetamine
• dextroamphetamine
• lisdexamfetamine
• methylphenidate
• dexmethylphenidate

6.2.2 Non- Stimulants

Certain non-stimulant medications work by increasing the levels of norepinephrine in the brain. Norepinephrine is thought to help with attention and memory.

Possible non-stimulant medications for ADHD include:

• atomoxetine
• guanfacine ER
• clonidine ER 

7) side effects of treatments: 

 Possible side effects of ADHD medications may include:

• headache
• trouble sleeping
• stomach upset
• nervousness
• irritability
• unwanted weight loss
• dry mouth

Serious side effects are rare but still possible:

       For stimulants, serious side effects may include:

• hallucinations (seeing, sensing, or hearing things that aren’t there)
• increased blood pressure
• allergic reactions
• thoughts of death and suicide

And for non-stimulants:

• seizures
• nausea and vomiting
• thoughts of death and suicide

CITATIONS: 

• “What is ADHD” written by Scott Benson, M.D. Pediatric Psychiatrist, Pensacola, Fla.
• “Attention Deficit Hyperactivity Disorder” written by Warren Magnus; Saad Nazir; Arayamparambil C. Anilkumar; Kamleh Shaban.
• “What to know about ADHD” Written by Rachel Nall, MSN, CRNA

• “Millions of Indian Children (and Parents) Struggle with ADHD” written by D’Laarni Ortiz 

• “ADHD Treatment Options for Children and Adults” written by Sandra Silva
• “Treatment of ADHD” written by CDC
• “Attention Deficit Hyperactivity Disorder (ADHD) Treatment & Management” written by Stephen Soreff, MD
• Google.com
• 12th ncert 
• “ADHD In Kids” written by  Shirin Hasan
• “Attention Deficit Hyperactivity Disorder (ADHD)” written by WebMD Editorial Contributors
• “Attention-Deficit/Hyperactivity Disorder (ADHD)” by Cleveland Clinic
•  “Attention-Deficit/Hyperactivity Disorder” by NIH
• “Everything You Need to Know About ADHD” written by Traci Angel
•  “Attention Deficit Hyperactivity Disorder (ADHD)” written by Stephen Soreff
• “What to know about inattentive ADHD” written by Hannah Nichols
• “What Is ADHD? Symptoms, Subtypes & Treatments” written by ADDitude Editors
• “Attention deficit hyperactivity disorder” by National Library of Medicine 
• “ADHD” by TeensHealth
• “Diseases & Conditions Adult attention-deficit / hyperactivity disorder (ADHD)” by Mayo Clinic 
• “What is ADHD?” by American Psychiatric Association 
• “Attention deficit hyperactivity disorder (ADHD)” by NHS
• “Attention Deficit Hyperactivity Disorder” by National Library of Medicine
• “What is Intellectual Disability?” by Special Olympics