Attention-Deficit Hyperactivity Disorder

Attention Deficit/Hyperactivity Disorder (ADHD) is the most common childhood behavioural disorder. It is a chronic disorder which may cause impairment into adolescence and adulthood.

Attention Deficit/Hyperactivity Disorder is described by the American Psychiatric Association (APA) in fifth edition of Diagnostic and Statistical Manual-5 (DSM-5) as a pattern of inattentive and/or hyperactive-impulsive behaviour inconsistent with developmental level which interferes with functioning in educational, social, or work settings.

DSM-5 delineates six neuro-developmental disorders including ADHD. These are

  • Communication disorder
  • Attention-Deficit Hyperactivity Disorder (ADHD)
  • Intellectual Disabilities
  • Autism Spectrum Disorder
  • Specific Learning Disorder (SLD): SLD describes persistent and impairing problems in acquiring and using the cultural symbols that are required for reading, writing, and arithmetic. SLD has high co-morbidities rates, in which ADHD is most common.
  • Motor Disorders

 

References

Shaikh Aasef G, Rufa Alessandra. Ocular Motor and Vestibular Function in Neurometabolic, Neurogenetic, and Neurodegenerative Disorders. Frontiers Media SA 2007-2018. P 104.

Adler Lenard A, Spencer Thomas J, Wilens Timothy E. Attention-Deficit Hyperactivity Disorder in Adults and Children. Cambridge University Press 2015. P 151-160.

Johnson Sandra. A Clinical Handbook on Child Development Paediatrics. Churchill Livingstone, is an imprint of Elsevier Australia 2012. P 145-165.

Sadock Benjamin James, Sadock Virginia Alcott. Kaplan & Sadock’s Synopsis of Psychiatry- Behavioral Sciences/Clinical Psychiatry Tenth Edition. Lippincott Williams & Wilkins, a Wolters Kluwer Business 2007. P 1206-1217.

https://pubmed.ncbi.nlm.nih.gov/28361657/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4690612/  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081050/   

https://www.cdc.gov/ncbddd/adhd/features/adhd-and-school-changes.html

https://pubmed.ncbi.nlm.nih.gov/14643117/

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33004-1/fulltext

https://onlinelibrary.wiley.com/doi/full/10.1002/hbm.25029

Levin Alex V, Enzenauer Robert W. The Eye in Pediatric Systemic Disease. Springer International Publishing Switzerland 2017. P 584-585.

Sadock Benjamin James, Sadock Virginia Alcott, Ruiz Pedro. Kaplan & Sadock’s Comprehensive Text Book of Psychiatry Tenth Edition Volume I & II. Wolters Kluwer 2017. P 9141-9185.

 

Most children with ADHD are referred for impairment in family, academic, and/or peer relationship functioning. Symptoms of over-activity, inattention, and impulsivity drive this impairment even later.

General symptoms

1. Symptoms of Inattention:

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g. misses or overlooks details, and work is inaccurate).

b. Often has difficulty in sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, lengthy reading, or conversations).

c. Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork, duties in the work place, or chores (e.g. starts task but quickly loses focus and is easily sidetracked/ distracted).

e. Often has difficulty organising tasks and activities (e.g. difficulty in keeping belongings and materials in order, disorganised work, messy, difficulty in managing sequential tasks, fails to meet deadlines, and has poor time management).

f. Often dislikes, avoids, or is reluctant to engage in tasks that require sustained mental effort: (e.g. school or homework: for older adolescents and adults, preparing reports, reviewing lengthy papers, and completing forms).

g. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

h. Often loses things necessary for tasks or activities (e.g. books, tools, pencils, school material, paperwork, wallets, keys, mobile phones, or glasses).

i. Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, paying bills, returning calls, or keeping appointments).

2. Symptoms of Hyperactivity and Impulsivity:

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected (e.g. leaves his or her place in the classroom, in office, at workplace, or in other situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate (in adolescents or adults, it may be limited to feeling restless).

d. Often unable to play or engage in leisure activities quietly.

e. Is often ‘on the go’, acting as if ‘driven by a motor’ (e.g. is unable to be or uncomfortable being still for extended time, as in meetings, restaurants. It is experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.

g. Often has difficulty waiting his or her turn (e.g. while waiting in line).

h. Often blurts out an answer before a question has been completed (e.g. cannot wail for turn in conversation, or completes sentences of people).

i. Often interrupts or intrudes on others (e.g. butts into conversation, activities, or games. Child may start using things of others, without asking or without taking permission. For adolescents and adults, may intrude into or take over what others are doing).

Other symptoms not specified in DSM-5 criteria, may include

  • Difficulty in management of time
  • Do not develop internal sense of pace in planning tasks
  • Problems in regulation of emotions

 

The aetiology of ADHD is yet to be determined.

There is no one cause for ADHD and it appears to be the result of multiple genetic and environmental factors.

There is consensus that the condition involves anatomical and functional dysfunction in cortico-basal ganglia/thalamo-cortical circuit of brain.

 

Systemic features

The principal features of ADHD are inattention, hyperactivity, and impulsiveness in some combination that impair basic everyday function. It often interferes with establishing friendships, limiting academic progress and in later life may result in financial and social burdens. The manifestations are seen to some degree in normal child development and thus to make the diagnosis they need to be severe and out of proportion to normal age expectations. There are no definite biomarkers.

There is evidence that the effects of ADHD continue to have impact in adult life.

The Diagnosis of ADHD is based on clinical features in context of the features in diagnostic criteria.

Attention Deficit/Hyperactivity Disorder is defined by the American Psychiatric Association (APA) in fifth edition of Diagnostic and Statistical Manual-5 (DSM-5) as

A.  A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterised 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:

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g. misses or overlooks details, and work is inaccurate).

b. Often has difficulty in sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, lengthy reading, or conversations).

c. Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork, duties in the work place, or chores (e.g. starts task but quickly loses focus and is easily sidetracked/ distracted).

e. Often has difficulty organising tasks and activities (e.g. difficulty in keeping belongings and materials in order, disorganised work, messy, difficulty in managing sequential tasks, fails to meet deadlines, and has poor time management).

f. Often dislikes, avoids, or is reluctant to engage in tasks that require sustained mental effort: (e.g. school or homework: for older adolescents and adults, preparing reports, reviewing lengthy papers, and completing forms).

g. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

h. Often loses things necessary for tasks or activities (e.g. books, tools, pencils, school material, paperwork, wallets, keys, mobile phones, or glasses).

i. Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, paying bills, returning calls, or 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:

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected (e.g. leaves his or her place in the classroom, in office, at workplace, or in other situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate (in adolescents or adults, it may be limited to feeling restless).

d. Often unable to play or engage in leisure activities quietly.

e. Is often ‘on the go’, acting as if ‘driven by a motor’ (e.g. is unable to be or uncomfortable being still for extended time, as in meetings, restaurants. It is experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.

g. Often has difficulty waiting his or her turn (e.g. while waiting in line).

h. Often blurts out an answer before a question has been completed (e.g. cannot wail for turn in conversation, or completes sentences of people).

i. Often interrupts or intrudes on others (e.g. butts into conversation, activities, or games. Child may start using things of others, without asking or without taking 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 school, home, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of academic, social, 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, dissociative disorder, anxiety disorder, personality disorder, substance intoxication or withdrawal).

 

DSM-5 Diagnostic criteria:

There are three types of presentations based on nine symptoms each of inattention and hyperactivity/impulsivity as mentioned above.

  • ADHD predominantly inattentive presentation: Children have six or more symptoms of inattention and fewer than six symptoms of hyperactivity/impulsivity.
  • ADHD predominantly hyperactivity/impulsivity presentation: Children have six or more symptoms of hyperactivity/impulsivity and fewer than six symptoms of inattention.
  • ADHD combined presentation: It is diagnosed when full criteria from both the lists are met.

Older adolescents and adults require only five symptoms from either (or both) of the two criteria lists.

 

Differential diagnosis

  • Special learning disorders
  • Mood disorders
  • Sleep disorders
  • Depression
  • Anxiety
  • Substance use
  • Rare genetic disorders e.g. tuberous sclerosis, neurofibromatosis type 1, and Turner syndrome

 

Behavioural and pharmacologic interventions are used in the management of ADHD.

Pharmacologic interventions:

Evidence suggests that Stimulants are more effective than Non- stimulants.

  • Stimulants: Amphetamines and Methylphenidate (MPH). Stimulants are considered first-line agents to treat ADHD. These increase the central nervous system (CNS) activity in brain. The exact mechanism of action is not known.
  • Non- stimulants: Non-responders or those who experience adverse effects to stimulants may be prescribed non-stimulants. Guanfacine, Clonidine, and atomoxetine are the approved drugs for ADHD treatment. Guanfacine and Clonidine are long-acting alpha-adrenergic agonist agents which have been used as monotherapy or as an adjunctive therapy. Immediate-release Guanfacine and Clonidine are not approved in the treatment of ADHD.

Other medications

  • Tricyclic antidepressants (TCAs): TCAs are used infrequently as they have more serious side-effects.

Co-morbid conditions such as anxiety, mood, and seizure disorders should be treated accordingly.

American Academy of Paediatrics guidelines for the management of ADHD, recommends that pharmacologic intervention should be the first line of treatment in most cases.

Behavioural interventions: It includes

  • Behavioural classroom management
  • Behavioural peer interventions
  • Behavioural parent training (family therapy)

 

Prognosis

About 60% of children with ADHD continue to be impaired well into adult life with estimates suggesting that 4% of adults may suffer from ADHD.

 

  • PUBLISHED DATE : May 31, 2022
  • PUBLISHED BY : NHP Admin
  • CREATED / VALIDATED BY : Dr. S. C. Gupta
  • LAST UPDATED ON : May 31, 2022

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