Overview
Attention-Deficit/Hyperactivity Disorder, referred to more commonly as its abbreviation โADHDโ, is a neurodevelopmental disorder that is characterized by inattention, commonly observed through behaviors such as leaving tasks midway and getting occupied by something else, inability or difficulty paying attention, and lacking persistence, and hyperactivity, observed through behaviors such as extreme restlessness, excessive fidgeting or tapping, talking excessively, and so on.
The disorder may manifest as a combination of both inattention and hyperactivity, or symptoms of either of the two. The occurrence of ADHD can significantly impair functionality, especially academic, occupational, and social aspects.
The disorder presents with a male predominance, but may be underdiagnosed in females due to a higher tendency of internalized presence of symptoms. The onset of the disorder is in childhood, even though it may be diagnosed in adulthood. The aetiology of the disorder is not yet concretely determined, but the interaction of genetic and environmental factors, developmental delays, and neurobiological correlates are usually considered as correlates.
The treatment of the disorder is primarily pharmacological, including management through both stimulant and non-stimulant medication. The use of medication in ADHD management must be done carefully, owing to the significant risk of side effects. Psychosocial treatments are also implemented.
Signs and Symptoms
The signs and symptoms of ADHD may include:
a. Inattention
- Making careless mistakes in work or other activities
- Failing to pay attention to details
- Difficulty remaining focused in class or lectures, conversations, or lengthy reading
- Inattentiveness when spoken to directly, even in the absence of distractions
- Failure to follow through on instructions
- Difficulty organizing tasks and activities
- Avoiding tasks requiring sustained mental effort
- Losing things necessary for certain tasks or activities (for e.g. books, wallet, keys, phones, etc.)
- Being easily distracted by extraneous stimuli or by own unrelated thoughts
- Forgetfulness in daily activities
b. Hyperactivity and Impulsivity
- Feelings of restlessness
- Signs of restlessness such as fidgeting, tapping, or squirming in seat
- Leaving seat often in situations where one must remain seated and wandering around
- Climbing or running around in situations where it is inappropriate (for children)
- Inability to remain quiet while engaging in play or leisurely activity
- Uncomfortable being still for long periods of time, always on the go
- Talking excessively
- Interrupting people while they talk or not waiting for others to finish questions or statements
- Difficulty in waiting for own turn, impatience
- Intruding on others
Risk Factors
Attention-Deficit/Hyperactivity Disorder presents with a male predominance in prevalence, and females with the disorder are more likely to present with inattentive features. The symptoms of the disorder manifest in childhood, but depending on the severity, the disorder itself may not be diagnosed until adulthood.
The exact aetiology of ADHD is yet largely unknown, though the complex interaction of genetics, biological and environmental factors is often considered. A strong overlap has been identified in the genetic risks of ADHD with health risk behaviors. A significant heritability quotient is also taken into account, and studies show an association between the disorder and genes that are involved in dopamine and serotonin pathways.
It is the action of environmental factors upon this genetic vulnerability in certain ways that leads to a susceptibility to ADHD. Perinatal factors, such as smoking during pregnancy and low birth weight have been linked to the disorder. Childhood maltreatment, exposure to toxins, infections, and placement in several foster homes have also been identified as common factors in some cases. The occurrence of ADHD is also elevated among individuals that have suffered some form of head trauma.ย
Developmental factors are also linked to the manifestation of the disorder. Delays in the maturation of the brain, seen most prominently in the prefrontal regions, caudate, and cerebellum have been identified. These are the areas that together control processes such as attention, thoughts, emotions, behavior, and actions. Many theoretical frameworks explain the disorder as stemming from disruptions in executive functions such as self-regulation, arousal, speech-internalization, and so on.
There is a high likelihood of comorbidities among individuals with ADHD. Oppositional defiant disorder is likely to be concurrent among 50% of children with both inattention and hyperactivity or impulsivity symptoms, and conduct disorder is concurrent among 25%. Disruptive mood dysregulation, specific learning disorder, anxiety disorders, major depressive disorder, obsessive-compulsive disorder, tic disorders, autism spectrum disorder, intermittent explosive disorder, substance use disorders, and personality disorders may be identified as comorbidities.
Diagnosis
The diagnosis of ADHD is a complex process, and involves an exhaustive clinical assessment that makes use of diagnostic criteria and rating scales, and collects a detailed history from the individual as well as their close ones.
The disorder is most commonly identified in elementary school years, as the functional consequences of inattention and hyperactivity become more evident. Academic performance and social interaction is likely to be significantly affected. In adolescence, outward manifestations of hyperactivity may be less common, and concealed feelings of jitteriness or restlessness may be present.
It is important to look out for impulsiveness among adults. The disorder may be underdiagnosed in girls due to a reported tendency to present with internalized symptoms such as forgetfulness and difficulty sustaining attention.
Rating scales consist of both self-report measures, which are administered to adolescent and adult populations, as well as reports that may be filled out by parents or caregivers and teachers. The Conners Rating Scales โ Revised, Innatention/ /Overactivity With Aggression (IOWA), Conners Teacher Rating Scale; Swanson, Nolan, and Pelham-IV (SNAP-IV) Questionnaire; Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP) rating scale; ADHD Rating Scale-IV; Vanderbilt ADHD Rating Scale; and ADHD Symptom Rating Scale may be used.
The DSM-5 contains the following diagnostic criteria for ADHD:
A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily side-tracked).
- Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
- Often fidgets with or taps hands or feet or squirms in seat.
- Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
- Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
- Often unable to play or engage in leisure activities quietly.
- Is often โon the go,โ acting as if โdriven by a motorโ (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- Often talks excessively.
- Often blurts out an answer before a question has been completed (e.g., completes peopleโs sentences; cannot wait for turn in conversation).
- Often has difficulty waiting his or her turn (e.g., while waiting in line).
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other peopleโs things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
The diagnosis of ADHD may be specified as a combined presentation, including signs of both inattention and hyperactivity-impulsivity, or as predominantly inattentive or predominantly hyperactive-impulsive presentation.
Differential Diagnosis
1. Oppositional defiant disorder: Children with ODD refuse to conform to norms and demands using hostility and defiance. Whereas in ADHD, the child faces mental difficulty understanding and executing the task. Children with ADHD may develop secondary ODD if the difficulties persist.
2. Intermittent explosive disorder: It involves a high level of impulsivity and aggression towards others which are not the characteristics of ADHD. Children with intermittent explosive disorder do not have problems with attention.
3. Autism spectrum disorder: CHildren with autism spectrum disorders do exhibit ADHD symptoms and behaviours but the triggers, consistency and other behaviour patterns vary prominently.
4. Intellectual disability: Children who lack the intellectual ability to fit into a common academic setting often are diagnosed with ADHD. But, they lack the inattention and hyperactivity that distinctly portray ADHD.
5. Anxiety disorders: ADHD shares symptoms with anxiety disorders. Although the worry and fixation common in the anxiety disorders is not a characteristic of ADHD.
6. Reactive attachment disorder: Children with RAD show social disinhibition and lack the ability to maintain social relationships. Both of which do not indicate ADHD symptoms.
7. Depressive disorder: Individuals with depressive disorder exhibit lack of concentration but only during the depressive episodes.
8. Bipolar disorder: The common symptoms between bipolar disorder and ADHD are only episodic in the case of bipolar disorders. Also, bipolar is a rare occurrence in children and adolescents in spite of them having extreme mood changes within one day.
9. Other neurodevelopmental disorders: ADHD involves increased motor activity whereas neurodevelopmental disorder involves repetitive patterns of the same activity.
10. Disruptive mood dysregulation disorder: DMDD does include irritability, frustration and intolerance, but impulsiveness and inattention are not a part of it. However, both the disorders are often diagnosed separately in one individual.
11. Specific learning disorder: Children with specific learning disorder show inattentiveness because of lack of interest, limited understanding or frustrations.
12. Personality disorders: It may be difficult to distinguish ADHD from borderline, narcissistic, and other personality disorders. All these disorders tend to share the features of disorganization, social intrusiveness, emotional dysregulation, and cognitive dysregulation.
However, ADHD is not characterized by fear of abandonment, self-injury, extreme ambivalence, or other features of personality disorder. It may take extended clinical observation, informant interview, or detailed history to distinguish impulsive, socially intrusive, or inappropriate behavior from narcissistic, aggressive, or domineering behavior to make this differential diagnosis.
13. Psychotic disorders: If inattention and hyperactivity are present only during psychotic episodes, it does not amount to a diagnosis of ADHD.
14. Neurocognitive disorders: Major or mild neurocognitive disorders share similar symptoms to ADHD but can be distinguished by the late onset of neurocognitive disorders.
15. Substance use disorders: Differentiating between inattentiveness and impulsivity caused by substance intoxication. Unless there is clear evidence of ADHD symptoms before the onset of substance use, ADHD diagnosis would be unjustified.
Treatment
Treatment of ADHD depends greatly on pharmacological modalities, though the use of medication in management of symptoms remains largely disputed. Psychosocial interventions are also largely relied on, and sometimes preferred by parents and caregivers for treatment of children due to the significantly lower risk as compared to pharmacological treatment. Ultimately, the mode of treatment depends greatly on symptoms exhibited, and a combined approach may produce maximum efficacy.
The most common type of pharmacological drug used in the treatment of ADHD are stimulants. Amphetamines, such as Adderall, and Methylphenidates, such as Ritalin, are prescribed in order to reduce the severity of inattention, hyperactivity, and impulsivity. Non-stimulants may include atomoxetine, extended-release clonidine, and extended-release guanfacine. Dosages of the medication vary from person to person, and certain side effects may be experienced.
Psychosocial interventions include behavioral interventions as well as cognitive training, and may make use of eclectic modes. Family-bases and parent training may involve caregivers in order to optimize behaviors through parental guidance. Methods such a positive reinforcement may be implemented through rewarding positive behaviors and coping mechanisms.
Interventions may also be adapted to school settings, wherein positive reinforcement takes place when positive classroom behaviors are carried out, which may lead to a reduction in disruptive behaviors in the academic setting. Further, psychotherapy, or talk therapy, may be helpful in alleviating psychological stress experienced by patients as a result of their symptoms.
In Conclusion
ADHD or Attention Deficit Hyperactivity Disorder affects important aspects of life and causes major hindrances in the overall growth of a person. Although it is common in early childhood, it can also occur in adulthood. If you observe the symptoms of ADHD, please consult a professional, seek therapy and proper treatment.
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