What is ADHD?
Attention deficit hyperactivity disorder (ADHD) is a very common condition, usually present in childhood and often continuing through adulthood. Deficit in paying attention is the most common feature. However, hyperactivity and impulsiveness are also present to a lesser degree. ADHD is NOT antisocial behavior such as defiance or aggressiveness but is more like a related disorder, deficient emotional self-regulation (DESR).
Classic ADHD symptoms are trouble paying attention, excessive physical activity and poor impulse control. ADHD patients also display brief anger, impatience and frustration in response to minor inconveniences or disappointments which other people would show less extreme reactions to. These types of reactions make ADHD more similar to DESR, but differentiate ADHD from mood disorders which are characterized by pervasive and specific emotions.
The disorder used to be called attention deficit disorder (ADD) but was changed to the current term in 1994 by The American Psychiatric Association (APA). Europeans and others that use the World Health Organization (WHO) classification system, call it hyperkinetic disorder (HKD) or deficits in attention, motor control and perception (DAMP).
The new term, ADHD, is a generic or umbrella term, divided into types:
- predominantly inattentive
- predominantly hyperactive/impulsive
- combined inattentiveness and hyperactivity.
Sub-threshold types, including distractibility, may occur as well. Mainly though, this neuropsychological disorder is primarily one of lack of focus or paying attention. Over time, even those with a hyperactive component will gradually overcome or lose the hyperactivity, while inattentiveness will persist.
Not being able to pay attention to tasks or to people confers a significant disability, both as children and as adults. This functional impairment can create havoc for the individual, the family, the school and work environment. Because of the social stigma, individuals may feel shame or worthlessness, and develop anxiety or other mood disorders in addition to the ADHD. Because ADHD often begins in childhood and persists into adulthood, the disorder is considered chronic and must be managed lifelong for a large majority of sufferers.
However, new research suggests that this chronic, social stigma-bearing disorder may be misinterpreted. The “disorder” may be a variant in temperament and not a defect. Research in 2006 showed individuals with ADHD had higher levels of creativity than others. This scientific research was conducted using laboratory measures of creativity. Researchers have now expanded the study to include real life achievements. They have found that people with ADHD think differently than others and prefer to generate ideas rather than carry them out. This new interpretation may be useful for ADHD patients in changing perceptions of themselves. The new findings may also reduce medication use and encourage schools and workplaces to find better ways to use the talents of hyperkinetic people.
Attention Deficit Disorder Epidemiology
Population studies in different countries have found similar prevalence rates. Adults are diagnosed at a rate of 3-6 percent. Children are diagnosed at a rate of 3-8 percent of the general population. Males are more often diagnosed than females. Research suggests this disparity is due to the disruptive, attention gaining behavior of boys which brings them into the spotlight and into the clinician’s office. Girls, in contrast, are more likely to be inattentive, which keeps them below the radar, but still quietly suffering. A U.S. study showed that out of the diagnosed cases of adult ADHD, only 39 percent were female, while 61 percent were male. Most ADHD cases are in the 18-24 year old age group, or 1 in 2 of all diagnosed cases.
Ethnic rates may be unclear. In America, black children are more likely than white children to be diagnosed, while Hispanic children have the least incidence. These rates may be due to economic conditions, insurance status and access to care. Rates according to country are also unclear due to the differing manner of characterizing and classifying the disorder.
ADHD seems to be a heritable disorder or a genetic predisposition. Genes thought to be responsible are dopamine and serotonin genes including:
- D2, D4, D5 dopamine receptor genes
- dopamine beta-hydroxylase gene
- dopamine transporter gene
- SNAP-25 gene
- serotonin transporter gene
The shape and function of some brain regions including the parietal cortex, inferior parietal lobe, superior temporal sulcus, and reticular activating system have differences compared to “normal” brains. The prefrontal cortex in the brain downregulates or reduces the production and/or transport of the neurotransmitters dopamine and norepinephrine (noradrenaline). The premotor cortex and the superior prefrontal cortex show deficits in glucose metabolism. The anterior cingulate demonstrates reduced activation as well. Children with a smaller caudate nucleus in the subcortical region of the brain have ADHD symptoms.
The combination of ADHD and poor emotional control, acts to functionally impair individuals in their tasks and their relationships with others. ADHD becomes more and more isolating and frustrating as the impairment and the person develops over time.
ADHD causes functional impairment including:
- Verbal learning
- Non-verbal memory
- Paying bills on time
- Problem solving
- Risk taking – gambling and sexual escapes.
- Substance abuse – females especially, and males of all races are 2-3 times more likely to use cigarettes, alcohol and drugs.
- Accidents and motoring offences – reductions in vigilance, motor inhibition and hyperactivity make ADHD patients dangerous on the roads.
- Lower occupational status and less productivity – workers with ADHD produce about 22 less days per year of work. Restlessness may cause people to seek more menial, low-paying but active jobs.
- Lower educational level – ADHD can delay entrance into kindergarten which sets the tone for a lifetime of underachievement. Those with ADHD symptoms are less likely to complete secondary school, have lower levels of completed education, and spend a longer time achieving degrees.
- Criminal offenses – as many as 25% of criminal offenses may be perpetrated by ADHD patients due to the stress of having ADHD and environmental factors.
Poor emotional control causes relationship difficulties including:
- Listening – other people may feel frustrated by the inattentiveness.
- Being oppositional or defiant – teachers, bosses and co-workers often bear the brunt of ADHD behavior.
- Difficulties making friends.
- Isolation stress – overreactions and temper flares cause others to back away.
- Marital problems – partners can become stressed, arguments ensue, and conflict is poorly managed.
- Family stress – parents and siblings experience stress from the chaos, strife and social stigma.
Most ADHD sufferers also have accompanying psychological disorders. The disorders may exist alongside of ADHD or develop because of ADHD:
- Depression – ADHD patients have up to 6 times the risk of developing depression, along with suicidal ideation and completion.
- Bi-polar – periods of mania mixing with depression.
- Anxiety – general anxiety or panic attacks.
- Sleep disorders – insomnia, nightmares, and early waking.
- Eating disorders – impulsivity and low self-esteem may invite problems with food.
- Dementia – ADHD patients are 3 times as likely to develop degenerative dementia as the aging process unfolds.
ADHD Risk Factors
These factors are associated with ADHD:
- Male sex – 61% of all ADHD cases are male. Some reports suggest that as many as 9 out 10 cases are male.
- Family History – the genetic component and reports of diagnosed cases running in families is a strong association with ADHD.
- Health problems – people with hypertension and anemia are more likely to have ADHD symptoms.
- Psychosocial adversity – exceptional adversity as a youth.
- Lower socioeconomic status – poverty, low family income, and low social class.
- Dysfunctional parent-child relationship
- Spousal separation
- Parental mental health disorders
- Parental stress
- Multiple life failures
- Legal violations
- Low birth weight, pregnancy and delivery complications.
- Childhood lead exposure
- Maternal exposure to lead, alcohol, smoking and drug use.
- Previously married
- ADHD symptoms onset prior to age 7 years
- Past or present academic dysfunction
- racing or wandering thoughts
- easily distracted
- unable to complete a task
- easily bored
- mental confusion
- poor memory retrieval
- excessive talking
- low mental energy
- inability to relax
- being late
- rigid thinking
- lack of perseverance
- drug and alcohol abuse
- eating disorder
- smoking cigarettes
- criminal behavior
- sleep problems
- difficulty waiting
- interrupting others
- losing things
- problems listening
Attention Hyperactivity Deficit Disorder Diagnosis
Screening for ADHD can be performed at any age as part of regular checkups with a family physician, at a psychiatric interview or in the presence of symptoms indicating ADHD. Studies have shown that primary care physicians are less suitable than psychiatrists to diagnose ADHD. However, because of the nature of ADHD, its chronic course and its impairment in different settings, a team approach is often necessary and includes the patients, parents, siblings, life partners, the pediatrician or physician, therapists, teachers and employers.
Multiple screening instruments can help differentiate symptoms, subtypes and identify accompanying mood disorders. Self-screening tools are also available but they cannot take the place of a proper evaluation by a qualified psychiatrist. Discovery of patterns of ADHD episodes over the lifetime can alert a physician more than screening methods. Typical questions include the age at onset, the course of the illness, episode characteristics, and family history. Screening instruments may include but are not limited to:
- ADHD Rating Scale
- Conners Adult ADHD Rating Scale
- Brown Attention Deficit Disorder Scale
- WHO Adult ADHD Self-Report Scale
- Adult ADHD Self-Report Scale
- Wender Utah Rating Scale
- Mood Disorder Questionnaire (MDQ)
- Bipolarity Index
- Composite International Diagnostic Interview (CIDI)
- Bipolar Spectrum Diagnostic Scale (BSDS)
- Primary Care Evaluation of Mental Disorders (PRIME-MD)
- Patient Health Questionnaire (PHQ-9)
- Patient Health Questionaire (PHQ-2)
ADHD is diagnosed based on clinical history and not psychological testing because the disorder is functional/dysfunctional in nature and not mood related primarily. Factors for proper diagnosis for adults or children depending on the situation include:
- Presence of risk factors.
- Functional impairment across 2 or more settings (school and home) – impairment criteria must be met for a diagnosis of ADHD.
- ADHD symptoms onset prior to age 7 years – children often display symptoms before the age of seven and as young as 2 or 3 with hyperactive symptoms. Inattentiveness is apparent when the child begins school.
- Past or present academic or work dysfunction – students or workers who achieve below their capabilities, have low grades or performance reports, and disciplinary problems.
- Clinical history – includes reports from parents, teachers, co-workers and employers.
- Screening questionaires – parents and teachers can fill out these questionaires.
- Self-reports and testing – adult people with ADHD report that they are disorganized and unfocused. Testing for short-term memory, long-term memory and word-finding abilities can confirm in adults or children. A history can be obtained from the patient including childhood conditions and impairments, but patients often overestimate inattention. Confirmation from a living relative or sibling is necessary or the patient’s self-report is taken less seriously.
- Time Course – the impairment and symptoms can be identified over time. If life stresses, mood symptoms or other mitigating factors are found during the time of the ADHD symptoms, then ADHD is placed lower in significance. Specific mood disorders, health disorders or life stresses are identified and treated first before the ADHD.
- Neuropsychological testing – not diagnostic in and of itself, but as an adjunct and useful in isolating attentional impairment by ruling out cognitive or mood deficits, identify processing deficits, intelligence level and learning disabilities.
- Medical testing – not diagnostic, but useful for identifying medical conditions like anemia or hypertension which may cause ADHD. Blood and urine can be useful in identifying substance abuse. EEG and brain imaging tests are used to identify seizures and head trauma.
These symptoms, conditions and disorders may accompany ADHD but are not primary symptoms and indicate a cause other than ADHD:
- Aggression that hurts people or animals.
- Compulsive behaviors
- Delusions – false beliefs
- Depression – chronic depressed mood or a loss of interest in usual activities.
- Destruction of property
- Excessive guilt
- Excessive worry
- Language disorder – language expression or comprehension, limited vocabulary, poorly organized speech, pronunciation difficulties, stuttering, lisping, or erratic speech rhythm.
- Learning disorder – difficulties with reading, math or written expression.
- Leg muscle soreness
- Lying or stealing
- Medication side effects
- Mental retardation – IQ of 70 or less.
- Mood instability – alternating periods of depression and euphoria.
- Muscle tension
- Obsessive thoughts
- Odd or strange ideas
- Openly rebellious
- Poor work performance
- School dropout
- Seizure disorder – sudden loss of consciousness followed by intense motor activity or vocalization.
- Serious rule violations
- Sleep disorder
- Social isolation
- Spending sprees
- Substance abuse
- Suicidal ideation
- Traumatic brain injury
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. These criteria are for childhood ADHD persisting into adulthood:
Six or more of the following symptoms of inattention have been present for at least 6 months, are maladaptive and inappropriate.
- 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 when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
- Often has difficulty organizing tasks and activities.
- Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
- Often loses things necessary for tasks and activities (toys, school assignments, pencils, books, tools).
- Is often easily distracted by other stimuli.
- Is often forgetful in daily activities.
Six or more of the following symptoms of hyperactivity/impulsivity have persisted for at least 6 months to a degree that is maladaptive and inappropriate.
- Often fidgets with hands or feet, or squirms in seat.
- Often leaves seat in classroom or in other situations in which remaining in seat is expected.
- Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, it may be limited to subjective feelings of restlessness).
- Often has difficulty playing or engaging in leisure activities quietly.
- Is often “on the go” or often acts as if “driven by a motor.”
- Often talks excessively.
- Often blurts out answers before questions have been completed.
- Often has difficulty waiting their turn.
- Often interrupts or intrudes on others (butts into conversations or games).
Three (3) specific subtypes of ADHD are:
- ADHD, combined type: if both criteria IA and IB are met for the past 6 months.
- ADHD, predominantly inattentive type: if criterion IB is not met for the past 6 months.
- ADHD, predominantly hyperactive-impulsive type: if criterion IB is met, but criterion IA is not met for the past 6 months.
ADHD in partial remission – those who have overcome some aspects of the disorder but retain some symptoms.
ADHD not otherwise specified – impairment is significant but does not meet full criteria and patient can benefit from treatment.
A greater awareness about ADHD can include personnel at school, work, family relationships, friendships, and activities. Early identification and treatment is important to increase the chances in school and work, and to limit developing emotional and conduct disorders. Treatment is often individualized and will change over time according to developmental stages. Treatment advice for a child will differ than for a teenager. For example, a teenager should be able to pay attention longer or sit in the chair longer than a pre-schooler and treatment advice is adjusted accordingly. Treatment is also monitored and adjusted for maximum efficiency and compliance, with a limitation of side effects.
A first line treatment for patient, family, school personnel and workplace, especially for preschoolers before medication is tried. Everyone is informed of symptoms, probable course of the disorder, and options for treatment. Discussions include the types of accommodations and individualized plans that will be made for a student or worker. Psychoeducation offers clear, non-technical language and proven strategies for accommodations.
Dosing starts at the lowest level possible with monitoring to determine efficacy, side effects and addiction. Preparations can be increased in dosage if necessary. Long-acting doses are preferred in order to have a smooth uptake and measured release over the course of the day. Long-acting doses are usually given once a day and reduce the need to take medication at school or work, and increase compliance by not needing to remember many doses.
Medications may become less efficient over time. Individuals will vary in reaction to medication according to metabolism, absorption and sensitivity, so weight or size is just a beginning in determining dosage. The delivery will also vary according to medication, manufacturer, and delivery mechanism.
Medication type can be switched if necessary and multiple attempts at pharmacological intervention often occur, especially in the cases of accompanying psychological disorders.
Medication is sometimes stopped after 6 months to reevaluate the patient, and resumed if necessary. The following medications are listed in order of preference for treatment of ADHD, although individual doctors may prefer a different order:
1/ Methylphenidate (brand names Ritalin or Concerta) and Amphetamine (brand name Adderall) – first-line pharmacological agents of choice. Stimulants are favored over behavioral therapy according to large scale, repeated studies. Most patients (65-75%) respond to these agents because of their calming and focusing effect. They work by restoring dopamine levels and efficiency in the brain.
2/ Atomoxetine – a non-stimulant medication with a low abuse or addiction potential. It works by inhibiting noradrenaline reuptake. Dosing is once or twice daily but can take several weeks for the full effects to be seen. A very small risk of suicidal ideation is documented but no completed suicides. Some cases of liver damage have been reported, as well as increases in heart rate and blood pressure.
3/ Alpha-2-adrenergic agonists – used to treat symptoms of ADHD, comorbid aggression, stimulant-induced tics and insomnia and are usually are more effective for the hyperactive-impulsive ADHD than for inattentive ADHD. Heart and blood pressure should be monitored and side effects may include sleepiness, dry mouth, and dizziness.
4/ Tricyclic antidepressants (TCAs) – may be counterindicated for those with bi-polar co-morbidity. Cardiotoxicity, sleepiness, and constipation are among the side effects. Overdoses can be fatal so those with suicidal ideation should not take TCAs.
5/ Bupropion (brand name Wellbutrin) – those with seizure risks should not take this medication. Doses are often divided to enhance safety.
Medication combined with strategies for the patient, parents and families may provide optimum treatment for ADHD. Patients with accompanying psychological disorders, life stresses and substance abuse may be particularly receptive to behavioral therapy. Coordination with school and work includes communication, positive feedback, and negative consequences like time-outs. One such program for children is called The Incredible Years, a basic parent training program.
Talking to a counselor may help sort through the emotional issues that accompany ADHD, especially since ADHD often interferes with social relationships. Family and life partners may be brought into therapy as an intervention with family members can be very helpful to increase positive outcomes. Patients need to interview potential therapists in order to find one they feel comfortable with. One form of therapy is not better than another but rather depends on the personalities of the therapist and patient meshing together.
Patients on medication should follow up with the physician on a regularly scheduled basis, weekly or bi-weekly initially, monthly or quarterly thereafter. Medication efficacy, side effects, mood, substance abuse and relationship issues can be addressed during these appointments, as well as any new issues or developmental changes.
- Changes might include the onset of puberty, pregnancy or other medical issues.
- Medication issues may include mania, insomnia, or heart problems.
- Co-morbid conditions may include depression, eating disorders and substance abuse.
Interventions which enhance organization, time management, planning skills and problem solving can be helpful. While most people have time management issues and can learn better skills, targeted programs for adult ADHD patients show success in diminishing ADHD symptoms. In addition, people with ADHD can focus and pay attention to things that they like to do, so pursuing schooling, work or activities with a perceived high reward is an excellent strategy.
Social buffering and an emphasis on important personal relationships can provide a positive effect on ADHD symptoms. Informal networks of family members, co-workers, friends and religious counselors can provide support and help in meeting life satisfaction goals.
Even a small amount of sleep deprivation causes children with ADHD to lose focus. Scientists have found that even one hour of sleep loss per week can impact a child’s ability in many measures of ADHD symptoms. Current recommendations for sleep vary with age, but are generally within a 7-9 hours of sleep per night.
Currently, advice is mixed on the elimination of sugar and food dyes from the dietary intake. Some studies and some experts recommend elimination of sugar and dyes, while others disagree. More studies are needed to elicit agreement. However, elimination is not harmful and can be helpful.
No dietary strategies are proven to help with ADHD symptoms. However, anemia is considered a causative agent for ADHD, so a diet rich in bioavailable iron is recommended. A balanced diet is important for all ages, especially for children and adolescents. Omega 3 fatty acids supplementation may be moderately effective.
Exercise increases cognitive skills for people of all ages. Task perseverance and memory increases immediately after exercise and may have long-term benefits as well. Children who exercise show lower symptoms of ADHD. Exercise increases a sense of mastery and a sense of self-worth, and gives a natural lift in mood. Yoga, strength training, balance exercise and even massage can reduce tension, fatigue and anxiety.
Behaviors to Avoid
Alcohol, cigarettes and drug use is common in ADHD patients of all subtypes, ages, and races. Elimination of substance use may decrease symptoms, increase medication efficiency and increase long-term health outcomes.
Barriers to Treatment
Many patients under medical or psychiatric care do not take their medications as directed. Stopping medications or taking medication inappropriately may reduce positive outcomes and cause a return of the symptoms of ADHD. Regular visits with the physician are necessary to monitor medications, adjust dosage and monitor for side effects.
The prognosis for ADHD patients is very good with medication, life skills training, parent education and support. Even those patients with accompanying mood disorders improve with treatment. While the quality of life depends on the severity of symptoms, treatment is effective in a majority of cases.
Green Play Therapy
A new study reports that children who play in surroundings approximating nature, have less severe ADHD symptoms. Children who have opportunities to spend time in landscapes filled with trees and grass can improve concentration and impulse control.
A very small quasi-experimental study has demonstrated a novel form of therapy for children. Five children aged 10-11 years old with ADHD participated in horseback riding for one hour, twice a week for eight weeks. Subjects improved in measures related to social relationships, quality of life, and motor performance.
A new way to identify ADHD patients has been found in unintentional and unnecessary movements. ADHD patients were filmed while being asked to tap the fingers of their dominant hand. Patients with ADHD had fifty times the amount of movement in the same muscles on the opposite side of the body, as compared to normal subjects.
Saliva testing is new non-invasive method for testing for ADHD by measuring oxidative stress. Patients with ADHD had higher levels of salivary protein thiols and pseudocholinesterase levels compared to controls. Magnesium levels in ADHD patients are decreased in comparison to controls.
- Depression – a persistent negative mood with learned helplessness attitudes.
- Generalized Anxiety Disorder – characterized by a lack of control in managing worry and tension.
- Bi-polar Disorder – alternating moods between mania and depression, but never a normal mood.
- Social Anxiety Disorder – the presence of other people causes persons with this disorder to become overvigilant to their own performance, which leads them to avoid social situations.
- Personality Disorders – types of personality that feature a narrow range of feelings, thoughts, and behaviors that do not show adaptability in most situations. A personality becomes fixed in a particular maladaptive psychiatric condition.
- Dementia – cognitive deficits of confusion, poor memory and concentration difficulties that occurs in aging adults.