Attention Deficit Hyperactivity
Disorder
Author - RajveeR Makwana
Abstract
Attention Deficit Hyperactivity Disorder or also called ADHD is one of the most common
mental disorders affecting children. The man cause for ADHD is still being researched on but
although not the case for every time, history shows that ADHD tends to run in families and in
most cases it's thought that the genes you inherit from your parents are a significant factor in
developing the condition. Research suggests that parents and siblings of someone with
ADHD are more likely to have ADHD themselves. There is no permanent cure for ADHD
yet, but medication, education, skills training and psychological counselling a combination of
these is most effective treatment that can help to manage the symptoms of ADHD. In this
article we will tale about the history, characteristics, Treatment, Current state of research of
ADHD.
The article reviews the current state of research on ADHD, including its etiology, prevalence,
and treatment. The review highlights the ongoing debates and controversies surrounding the
diagnosis and treatment of ADHD. Overall, this review article aims to provides balanced
understanding of the complex and evolving history of ADHD, and to shed light on the
challenges and opportunities for the diagnosis and treatment of there for stigmatized disorder.
Keywords - Attention Deficit Hyperactivity Disorder, ADHD, Attention deficit disorder.
Introduction
Attention deficit hyperactivity disorder (ADHD) is a common mental
health disorder that affects an estimated 3.6 % of children and 2.5 %
of adults in the UK. The disorder is well established in childhood,
with rapid service development since the mid-1990s. As a result,
almost all regions of the UK have child and adolescent mental health
or paediatric services with expertise in the diagnosis and treatment of
ADHD in young people. Depending on the severity of the condition
and co-occurring mental health or psychosocial problems, these
young people generally will receive medical, social, and educational
interventions. Follow-up studies of children with ADHD indicate that
approximately 15 % retain the full ADHD diagnosis at age 25, and a
further 50 % remain in partial remission, with persistence of some
symptoms associated with significant impairments. Yet until recently,
adult services have been poorly developed in the UK and other parts
of Europe, despite the known impact that ADHD has on adult mental
health.
Epidemiology
The subtypes of attention deficit disorders are found to have a
different rate of prevalence in a group of individuals suffering from
the disorders. It is found that the inattentive subtype is prevalent in
about 18.3% of the total patients while hyperactive/impulsive and
combined represent 8.3% and 70%, respectively. It is also found that
the inattentive subtype is more common amongst the female
population. The disorders (collectively) are found in a 2:1 male to
female ratio as per different researches. It is prevalent in around 3%-
6% of the adult population. It is one of the most prevalent disorders
found in childhood. There is some evidence that ADHD is more
prevalent in the United States than in other developed countries.
Etiology
The etiology of ADHD is related to a variety of factors that include
both a genetic and an environmental component. It is one of the most
heritable conditions in terms of psychiatric disorders. There is a much
greater concordance in monozygotic twins than dizygotic. Siblings
have twice the risk of having ADHD than the general population.
Similarly, viral infections, smoking during pregnancy, nutritional
deficiency, and alcohol exposure in the fetus have also been explored
as possible causes of the disorder. There are no consistent findings on
brain imaging of patients with ADHD. The number of dopaminergic
receptors has also been implicated in the development of the disorder
whereby research has shown that the receptors are decreased in the
frontal lobes in individuals with ADHD. There is also evidence for
the role of noradrenergic receptor involvement in ADHD.
Clinical Manifestation
The DSM-IV recognizes three subtypes of ADHD: a predominantly
inattentive subtype, a predominantly hyperactive-impulsive subtype,
and a combined subtype (American Psychiatric Association 1994).
These categories acknowledge clinical heterogeneity and reflect a
change in emphasis from earlier definitions that stressed motoric
symptoms to the current nosology, which emphasizes deficits in the
regulation of cognitive function. These changes have particular
relevance to adult ADHD because
Family history
Because genes affect one’s susceptibility to ADHD (Faraone and
Biederman 1999), family studies provide a method of assessing the
validity of adult ADHD. If ADHD persists into adulthood, then the
parents of ADHD children and the children of ADHD adults should
show an increased risk for ADHD. Many case-control family studies
show that the former prediction is true. The parents of ADHD
children are more likely to have ADHD than are the parents of non-
ADHD children (Faraone and Biederman 1994).
In Treatment response
An overwhelming amount of data from close to 200 controlled
clinical trials unequivocally documents the efficacy of stimulant
medications in the treatment of children and adolescents with ADHD
(Spencer et al 1996). Because approximately 70% of ADHD children
show a therapeutic response to stimulant medication, some
researchers have looked to studies of stimulant drugs in adult ADHD
in the hope that a clear-cut response to stimulant medication would
clarify the validity of adult ADHD.
Four initial Laboratory studies
Although there is no laboratory test of ADHD for either children or
adults, laboratory measures provide useful clues about the etiology of
adult ADHD and its validity as an outcome of the childhood disorder.
This section examines three laboratory approaches that have been
applied to adult ADHD: molecular genetics, neuropsychologic
assessment, and neuroimaging.
Course and outcome
Do ADHD children grow up to become ADHD adults? If adult
ADHD is a valid disorder, then follow-up studies of ADHD children
should show that they grow up to become ADHD adults and that their
persistence of ADHD symptoms exceeds that seen in an appropriate
control group. Prospective follow-up studies are not clouded by the
ambiguities of retrospective reports. Thus, they are an essential for
validating the adult ADHD diagnosis. If prospective studies do not
find ADHD persisting into adulthood.
Pathophysiology
Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset,
clinically heterogeneous disorder of inattention, hyperactivity, and
impulsivity. Its impact on society is enormous in terms of its financial
cost, stress to families, adverse academic and vocational outcomes,
and negative effects on self-esteem. Children with ADHD are easily
recognized in clinics, in schools, and in the home. Their inattention
leads to daydreaming, distractibility, and difficulties in sustaining
effort on a single task for a prolonged period. Their impulsivity makes
them accident prone, creates problems with peers, and disrupts
classrooms. Their hyperactivity, often manifest as fidgeting and
excessive talking, is poorly tolerated in schools and is frustrating to
parents, who can easily lose them in crowds and cannot get them to
sleep at a reasonable hour. In their teenage years, symptoms of
hyperactivity and impulsivity diminish, but in most cases the
symptoms and impairments of ADHD persist. The teen with ADHD is
at high risk of low selfesteem, poor peer relationships, conflict with
parents, delinquency, smoking, and substance abuse. The validity of
diagnosing ADHD in adults has been a source of much controversy.
Some investigators argue that most cases of ADHD remit by
adulthood, a view that questions the validity of the diagnosis in
adulthood. Others argue that the diagnosis of ADHD in adults is both
reliable and valid. These investigators point to longitudinal studies of
children with ADHD, studies of clinically referred adults, family-
genetic studies, and psychopharmacologic studies. Longitudinal
studies have found that as many as two thirds of children with ADHD
have impairing ADHD symptoms as adults. Studies of clinically
referred adults with retrospectively defined childhood-onset ADHD
show them to have a pattern of psychosocial disability, psychiatric
comorbidity, neuropsychological dysfunction, familial illness, and
school failure that resemble the well known features of children with
ADHD. Throughout the life cycle, a key clinical feature observed in
patients with ADHD is comorbidity with conduct, depressive, bipolar,
and anxiety disorders. Although spurious comorbidity can result from
referral and screening artifacts, these artifacts cannot explain the high
levels of psychiatric comorbidity observed for ADHD. Notably,
epidemiologic investigators find comorbidity in unselected general
population samples, a finding that cannot be caused by the biases that
inhere in clinical samples. Moreover, as we discuss later, family
studies of comorbidity dispute the notion that artifacts cause
comorbidity; instead, they assign a causal role to etiologic
relationships among disorders.
Risk Factors
Although ADHD is a multifaceted condition that has different types
of behavioural symptoms, the popular view of symptoms as mainly
related to hyperactivity has led to under-diagnosis in certain
populations. This chapter looks at the evidence for increased risk of
ADHD in certain populations. Here risk refers to populations in which
ADHD occurs at higher rates than in the general population, and
where practitioners need to be alert to the diagnosis of ADHD.
There are two main reasons to raise awareness of ADHD in
populations at high risk of ADHD. First, the overlap of symptoms
with other neurodevelopmental and mental health problems can lead
to diagnostic overshadowing and a failure to appropriately diagnosis
and treat ADHD. Another problem is failure to identify and treat
conditions co-existing with ADHD.
The findings on risk are therefore intended to identify the populations
in which practitioners need to pay particular attention to the
possibility of ADHD. Here screening for ADHD or how best to
diagnose ADHD in the presence of co-existing conditions is not
considered, the aim is to raise awareness among practitioners of the
circumstances under which there is an increased risk of ADHD.
Diagnosis
Search strategy
The evidence on ADHD prevalence and comorbidities was gathered
from published literature identified through searches of MEDLINE
and PsycINFO databases, reference lists in review articles, and from
10 behavioral rating scale manuals. Articles on medical screening
tests were identified through searches of MEDLINE. Additional
articles that met eligibility criteria but were not yet listed in
MEDLINE were identified by experts.
Selection criteria
The diagnosis of ADHD was based on criteria in one of the diagnostic
reference standards. Study populations were limited to boys and girls
6 to 12 years of age. Only studies using general, unselected
populations in communities or schools or pediatric/family practice
clinics were used to address the prevalence questions. Data on the
performance of screening tests could come from studies conducted in
any setting. Two types of scales were examined for this report:
“ADHD-specific,” designed to target ADHD symptoms only, and
“broad-band,” designed to screen for various symptoms, including the
symptoms found in ADHD patients. Data sought from medical tests
included the prevalence of abnormal findings among children
diagnosed with ADHD. Evidence was admissible if the study from
which it came had representative study populations, comparable
control groups and adequate description of demographic information.
Only articles published in English between 1980 and 1997 were used
in the analysis.
Data collection and analysis
Two trained specialists independently read each of the retrieved
articles and completed a form which characterized the type of
information in the article. The articles accepted for analysis were each
abstracted by trained personnel and the subject specialist
independently abstracted each article. The resulting sets of
abstractions (2 abstractions per article) were compared, with
differences discussed and resolved. A multiple logistic regression
model with random effects was used to analyze simultaneously for the
effect of age, gender, diagnostic tool, and setting. The analysis was
done using the EGRET software Appropriate quality checks were
performed.
Main results
Prevalence of ADHD ranged from 4 to 12 percent in the general,
unscreened, school-age U.S. population. Gender, diagnostic tool, and
setting are significant factors in the prevalence of ADHD, but age is
not significant. Boys have higher rates of ADHD than in girls for all
types of ADHD, with the inattentive type most common. Up to one-
third of children diagnosed with ADHD also qualify for one of the
five conditions most commonly comorbid with ADHD: oppositional
defiant disorder, conduct disorder, anxiety disorder, depressive
disorder or learning disorders. The prevalence of ADHD in a pediatric
clinic setting varies between two percent of children and five percent
depending on the study. Coexistence of ADHD with other disorders in
children seen by a pediatrician was found in the one study to be 59
percent and in a second to range from 8 to 20 percent, depending on
the comorbid condition and whether the informant was the parent or
the child. Studies of behavioral rating scales showed that the Conners
Rating Scale of 1997, contains two highly effective indices for
discriminating between children with ADHD and normal controls 94
percent of the time. The Barkley School Situations Questionnaire was
86 percent effective. Medical screening tests to detect a relationship
between ADHD and lead levels, abnormal thyroid function, imaging
of brain structures, or EEG abnormalities have not shown any
relationship with ADHD.
Treatment
Pharmacological therapy remains the mainstay of treatment for
patients who have ADHD. It is divided into two major categories,
which fall into stimulants or non-stimulants. Stimulants are further
broken into amphetamines and methylphenidates. Both types of
stimulants block the reuptake of dopamine at the presynaptic
membranes and postsynaptic membranes. Amphetamines also directly
release dopamine. Stimulants are the mainstay of treatment for
ADHD. They are effective in about 70% of patients. There is a
number needed to treat of 2. There are multiple formulations of each
subtype of stimulants, including immediate-release and extended-
release, long-acting, or sustained release. Side effects of stimulants
include changes in blood pressure, decreasing appetite and sleep, and
risk of dependency. However, there is an increased risk of substance
use in patients with ADHD and studies show treating with a stimulant
decreases their overall lifetime risk of substance abuse. Because
stimulants are controlled substances, providers often are hesitant to
use them. However, repeated evidence has shown how imperative it is
to try stimulants in ADHD.
There have been concerns regarding stimulant use in patients with
seizures. However, recent studies showed that stimulant use for
ADHD is safe in epilepsy.
There can be an increase in the frequency of tics in patients with
ADHD and Tic disorders. Adding alpha agonists may help to reduce
tics.
Of the non-stimulant option, there are also two types: antidepressants
and alpha agonists. Within the antidepressant category, atomoxetine is
is the best known and works as a selective norepinephrine reuptake
inhibitor. It is known to be effective in many trials as a treatment
option for ADHD, though not nearly as effective as stimulants. It also
has minimal antidepressant effects. It is often used in children who
don't tolerate stimulants or have anxiety. Other antidepressants
include bupropion, which targets dopamine and serotonin, and TCAs,
which are the last choice options. These work by targeting
norepinephrine.
Lastly, alpha agonists such as clonidine and guanfacine can be used as
an effective treatment for ADHD. However, these are associated with
multiple cardiovascular effects like lowering blood pressure, sedation
(clonidine more than guanfacine), weight gain, dizziness, etc. They
are found to be more effective in younger children than adults.
Psychosocial treatment is the other form of treatment that is used for
individuals suffering from the disorder. This form of treatment
includes psycho-education for the family and patient and cognitive-
behavioral training programs designed specifically for the patient to
achieve short and long-term goals. Research has found that these
training programs prove to be very effective when used along with
pharmacotherapy. However, unlike other psychiatric disorders, there
is strong evidence for medication management without therapy as
being the most efficacious.
The FDA has just approved the trigeminal nerve stimulation system
for children not on medications. The device generates a low-level
electrical pulse which suppresses hyperactivity.
There is no diet that has been found to improve ADHD.
Conclusion
Attention Deficit Hyperactivity Disorder (ADHD) remains a
significant mental health challenge affecting both children and adults
worldwide. It is characterized by a complex interplay of genetic and
environmental factors, leading to impairments in attention,
hyperactivity, and impulsivity. Despite ongoing debates about its
diagnosis and treatment, current research underscores the validity of
ADHD as a neurodevelopmental disorder with lifelong implications.
The disorder manifests differently across the lifespan, with childhood
symptoms often persisting into adulthood, albeit with varying
intensity. While pharmacological interventions, particularly stimulant
medications, have proven efficacy in managing symptoms,
comprehensive treatment strategies combining medication with
psychosocial interventions yield the best outcomes.
Further advancements in understanding ADHD's etiology, such as
genetic studies and neuroimaging, continue to refine diagnostic
approaches and therapeutic interventions. However, challenges
remain in addressing comorbid conditions and optimizing treatment
for diverse populations.
In conclusion, ADHD necessitates a holistic approach encompassing
medical, educational, and psychosocial support to mitigate its impact
on individuals and society. Continued research and awareness are
crucial in enhancing our understanding and management of this
complex disorder.
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