Attention-DEFICIT/hyperactivity disorder (ADHD)
what is adhd?
Attention-deficit/hyperactivity disorder (ADHD) is a frequently occuring, brain-based, neurodevelopmental disorder with substantial negative consequences for individual and public health. Once viewed as a childhood condition, it is now recognized that a majority of cases persist throughout adolescence and adulthood. The lifelong impact of ADHD often extends beyond the disorder’s defining features of developmentally inappropriate levels of inattention and/or hyperactivity and impulsivity.
Misinformation about ADHD abounds. Some assert that ADHD is not real. Critics variably maintain that childhood inattention and hyperactivity are normal, the diagnosis is subjective, behaviors attributed to ADHD arise when parents and teachers fail to maintain appropriate discipline, older students fake symptoms to obtain academic advantages or performance-enhancing drugs, adults are similarly drug-seeking or looking to excuse various life failures, or that the condition represents a conspiracy by pharmaceutical companies and organized psychiatry to increase medication sales.
This could not be further from the truth. Indeed, ADHD is among the most scientifically validated psychiatric disorders. Its diagnostic reliability is well demonstrated and on par with many conditions in general medicine. Medications for ADHD have been used for over 70 years in millions of individuals annually, creating an indisputable record of real-world safety and positive result.
Having ADHD is associated with significant added risk for developing other mental health disorders, as well as functional impairments, across a range of life domains. These domains include educational attainment, social skills, occupational success, personal relationships, parenting, personal safety, and general health. ADHD is associated with increased lifetime risk for anxiety, depression, substance abuse, and impulse control disorders. Children with ADHD have increased rates of learning disabilities, oppositional defiant disorder, conduct disorder, depression, anxiety, and other conditions, compared with unaffected children.
ADHD occurs in all racial, ethnic, and socioeconomic groups and is not a function of intellectual ability.
what are the causes of adhd?
Like many psychiatric conditions, the causes of ADHD are multifactorial, involving an interaction of multiple genes and environmental factors. The biological basis of ADHD is strongly evidenced in genetic and brain imaging studies.
There is growing appreciation of the extent to which interactions between genetic and environmental factors increase disease risk. Although both genetic and environmental ADHD risk factors (maternal smoking, increased maternal age, prematurity,parenting style, parenting conflict, family stress,…) are identified, none is causal and many individuals with them do not develop the disorder. Evidence suggests that underlying ADHD genetic risks have greater expression in the context of high environmental adversity and are attenuated with increased psychosocial stability.
Neuropsychological models emphasize deficits in cognitive function that are consistent with brain imaging abnormalities. One popular neuropsychological model suggests that ADHD arises from primary deficits in executive functions (EFs), generally defined as cognitive processes that support appropriate problem-solving skills aimed towards achieving future goals. Specifically, EFs maintain information about possible choices in working memory and facilitate integration with other relevant information from the current environmental context in order to make optimal choices in a given situation. EF deficits in ADHD include working memory, response inhibition, and general weaknesses in executive control. Executive function (EF) processes are largely function of the prefrontal lobes, which are implicated further with behavioral hyperactivity, impulsivity, and inattention. Impaired EF appears to play an important role in the complex neuropsychology of ADHD, but it does not adequately explain all cases of the condition.
what is the diagnostic criteria for adhd?
Despite demonstrated biological difference in groups with and without ADHD, the condition remains a behaviorally defined syndrome diagnosed by careful assessment of symptoms and clinical history, not by laboratory tests or brain imaging.
ADHD is diagnosed on the basis of persistent difficulties from symptoms of inattention and/or hyperactivity-impulsivity that occur to a greater degree than expected for an individual’s developmental level.
DSM-5 retains the same set of 18 ADHD symptoms used in DSM-IV, nine inattentive and nine hyperactive/impulsive.
adhd inattentive symptoms:
Careless or inaccurate work
Trouble staying focused on boring work
Difficulty focusing on what people say
Has difficulty finishing tasks, easily sidetracked
Procrastinates, trouble completing tasks
Delays or avoids activities that are boring
Often misplaces things required at work or home
Distracted by surrounding noises or activities
Trouble remembering appointments/obligation
Fails to notice details; makes careless errors
Trouble maintaining attention
Appears not to listen when spoken to
Trouble completing tasks
Difficulty with organization
Avoids activities that require attention
Loses or misplaces things
Distracted easily by extraneous stimulating activities
Adhd hyperactivity-impulsive symptoms:
Often restless of fidgety
Often leaves seat at meetings
Feels internally restless
Often louder than appropriate
Has trouble unwinding or relaxing
Talks too much in social situations
Finishes others' sentence
Difficulty standing in line or waiting turn
Interrupts others' conversations or activities
Frequently fidgets, taps hands or feet
Frequently gets out of seat
Runs and climbs when inappropriate
Unable to play quietly
Frequently “on the go”
Talks to excess
Blurts out answers
Trouble waiting turn or in line
Frequently interrupts or intrudes
According to the criteria in the DSM-5, persistent impaired behavior for a minimum of 6 months that exceeds what is expected for an individual’s developmental level and is characterized by at least 6 or 9 inattentive and/or 6 or 9 hyperactive-impulsive symptoms is required to make an ADHD diagnosis. If the individual is 17 years of age or older, only 5 of 9 symptoms are required.
The person also must show some history of symptoms before age 12 and at least several symptoms must occur in more than one setting (e.g., home, school, social relations, work, recreational activities, etc.). The symptoms also must result in clinically meaningful impairment in social, academic, or occupational functioning (for example the individual had a negative job performance review).
what is the treatment of adhd?
Treatment of ADHD in children and adolescents usually requires a team approach that coordinates various interventions in office, family, and school settings. This includes services by physicians, psychologists, teachers, and other mental or behavioral health professionals.
The multi-modal approaches to ADHD treatment in children and adolescents have proven successful in maximizing improved global functioning. These domains include Psycho-education, Family-Focused interventions, School-Focused interventions (section 504 plans, standardized testing accommodations, behavioral classroom management), and Patient-Focused interventions (pharmacotherapy, social skills training, individual psychotherapy).
Pharmacotherapy is the only intervention to yield large treatment effects on core ADHD symptoms. Optimal ADHD management usually combines medication treatment with psycho-social interventions that target patient-specific difficulties.
For adults, preliminary evidence supports a potential role for psycho-social interventions, including psycho-education, cognitive behavioral (CBT) and other therapies, school and workplace accommodations, coaching, and support groups. Optimal treatment generally combines medication management with problem-specific interventions selected for individual patients. The most useful interventions tend to be brief, well-structured, skill-oriented, and specific to ADHD.
Treatment algorithms for medication selection in adults are less established than those for younger individuals. The FDA has approved both stimulant and non-stimulant medications for adults. As with children, adult clinical trials consistently show larger treatment effect sizes for stimulants versus non-stimulants. Potential benefits of any stimulant are easily assessed with short-term titration. Larger effect sizes, safety, and ease of titration support the recommendation to use stimulants as first-line adult treatments, similar to pediatric ADHD. Atomoxetine (Strattera) is also indicated for adults and provide a second-line alternative if stimulants prove unsatisfactory.
The FDA-Approved Medications for ADHD include the 1) stimulants: Methylphenidates, D-Methylphenidates, D-Amphetamines, Mixed Amphetamine Salts (Adderall) and Lisdexamfetamine (Vyvanse); and the 2) nonstimulants: Atomoxetine and Extended-release alpha-2 agonists. The FDA-Approved Methylphenidate (MPH) and Amphetamine (AMPH) formulations are produced in immediate release, sustained release and extended release.