Attention deficit hyperactivity disorder (ADHD) is a syndrome that includes inattention, hyperactivity, and impulsivity. The three main types of ADHD are inattention, hyperactivity/impulsivity, and a combination of the two. Diagnosis is based on clinical criteria. Treatment often includes psychotropic drug therapy, behavioral therapy, and educational interventions.
ADHD is considered a neurodevelopmental disorder. Neurodevelopmental disorders are neurological conditions that appear early in childhood, often before starting school, and impair the development of personal, social, academic, and/or functioning. or profession. They often involve difficulties acquiring, maintaining, or applying specific skills or information. Neurodevelopmental disorders may involve dysfunction in one or more of the following: attention, memory, cognition, language, problem solving, or social interaction. Other common neurodevelopmental disorders include autism spectrum disorder , learning disorders (e.g., dyslexia ), and mental retardation .
Some experts have previously considered ADHD to be a behavioral disorder, possibly because children often exhibit inattentive, impulsive, and hyperactive behavior and because of comorbid behavioral disorders, especially Oppositional defiant disorder and conduct disorder , are common. However, ADHD has a well-established neurological basis and is not simply “misbehavior”.
ADHD affects approximately 5 to 15% of school-aged children ( 1 ). However, many experts say ADHD is often overdiagnosed, largely because the criteria are applied incorrectly. According to the Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5), there are 3 types:
- Reduced attention
- Hyperactivity/impulsivity
- mixed cells
In general, the rate of ADHD in boys is about twice higher than in girls, this rate varies by type. Hyperactivity/impulsivity mainly occurs in boys 2 – 9 times more often than in girls; Inattention occurs at equal rates in both sexes. ADHD runs in families.
ADHD has no specific cause. Potential causes of ADHD include genetic, biochemical, sensorimotor, physiological, and behavioral factors. Some risk factors include: birth weight < 1500 g, head trauma, iron deficiency , obstructive sleep apnea , and prenatal exposure to lead as well as alcohol, tobacco, and cocaine . ADHD is also associated with adverse childhood experiences (ACEs; 2 ). Less than 5% of children with ADHD have evidence of neurological damage. There is increasing evidence suggesting differences in the dopaminergic and noradrenergic systems with reduced activity or arousal in the upper brainstem and forebrain-midbrain regions.
General references
- 1. Boznovik K, McLamb F, O’Connell K, et al : US national, regional, and state‑specific sociometric factors correlated with child and adolescent ADHD diagnoses. Sci Rep 11:22008, 2021. doi: 10.1038/s41598-021-01233-2
- 2. Brown N, Brown S, Briggs R, et al : Associations between adverse childhood experiences and ADHD diagnosis and severity. Acad Pediatr 17(4):349–355, 2017. doi: 10.1016/j.acap.2016.08.013
ADHD in adults
Although ADHD is considered a childhood disorder and always begins during childhood, basic neurophysiological differences persist into adult life and behavioral symptoms continue to manifest. is apparent by adulthood in about half of cases. Although the diagnosis may sometimes not be recognized until adolescence, some manifestations are present before age 12.
In adults, symptoms include:
- Difficulty concentrating
- Difficulty completing work
- Easily changes mood
- Impatient
- Difficulty maintaining relationships
Hyperactivity in adults often manifests as restlessness and anxiety rather than the hyperactivity that occurs in young children. Adults with ADHD are at increased risk of unemployment, decreased educational achievement, and increased rates of substance abuse and crime. More common are traffic accidents and breaking the law.
ADHD in adults is often more difficult to diagnose. Symptoms can include mood changes , anxiety disorders , and substance use disorders . Because children’s self-reported symptoms are unreliable, clinicians should ask additional questions from school or family members to confirm the existence of symptoms before the child is 12 years old.
Adults with ADHD can use the same psychotropic medications as children with ADHD. They can also improve their time management and other similar skills with counseling.
Symptoms and signs of ADHD
Onset usually occurs before age 4 and remains constant before age 12. The highest age for diagnosis is 8 – 10 years old; However, children with inattentiveness may not be diagnosed until after adolescence.
Key ADHD symptoms and signs include:
- Loss of attention
- Hasty, impulsive
- Hyperactivity
Inattention tends to appear when children engage in tasks that require systematic and continuous attention, quick reaction times, observation and recognition, and listening.
Impulsivity refers to hasty actions that have the potential to lead to negative outcomes (e.g., in children, running across the street without looking; in adolescents and adults, suddenly missing school or quit your job without thinking about the consequences).
Hyperactivity includes excessive physical activity. Children, especially young ones, may have difficulty sitting still (for example, at school or church). Elderly patients may simply be restless, restless or talkative – sometimes to the point of tiring those around them.
Inattention and impulsivity hinder the development of the ability to learn, think and reason, develop in school and meet the demands of society. Children with inattentive ADHD tend to learn hands-on, so they often have difficulty with passive learning that requires constant practice and completion of assignments.
In general, about 20 – 60% of children with ADHD have reduced learning ability. For most children with ADHD, some skills are lost in school because of inattention (forgetting details) and impulsivity (answering without thinking).
Children may have a history of behavior such as poor tolerance, resistance, anger, aggression, poor social skills and peer relationships, sleep disorders, anxiety. , irritability, depression, and mood swings.
Although there are no specific tests or test results associated with ADHD, signs may include:
- Loss or disorder of movement coordination
- What are the disinhibiting, “soft” neurological outcomes?
- Loss of sensory and motor function
Diagnosis of ADHD
- Clinical criteria are based on DSM-5
Diagnosis is clinical and based on comprehensive medical, developmental, educational, and psychological assessment (see also American Academy of Pediatrics ADHD: 2019 clinical practice guideline for the diagnosis, assessment, and Evaluation and treatment of attention deficit hyperactivity disorder in children and adolescents).
DSM-5 diagnostic criteria for ADHD
DSM-5 diagnostic criteria include 9 symptoms and signs of inattention and 9 of hyperactivity and impulsivity. Diagnosis using these criteria requires ≥ 6 symptoms and signs from one or each group. In addition, the symptoms should be
- Frequently persists for ≥ 6 months
- Symptoms and signs appear clearly but are not appropriate for the child’s age
- Occurs in at least 2 situations (e.g., home and school)
- Appears before age 12 (at least some symptoms)
- Interference with activities at home, school or work
Symptoms of inattention:
- Reduced attention to details or causes errors in learning and activities
- Difficulty maintaining attention during schoolwork or while playing
- Seems not paying attention when speaking in person
- Failure to follow instructions or complete assignments
- Difficulty organizing activities and doing homework
- Avoids, dislikes, or is unwilling to engage in tasks that require sustained concentrated effort over a long period of time
- Often loses things needed for class assignments and school activities
- Easily distracted
- Forgetfulness of daily activities
Symptoms of hyperactivity, haste and impulsivity:
- Frequently restless hands and feet, confused
- Often skips positions in the classroom or other places
- Frequently running or climbing excessively when operating in places where it is not allowed
- Difficulty playing quietly
- Frequently moving and active
- Usually talks a lot
- Often blurts out answers without waiting for the question to finish
- Difficulty waiting your turn
- Frequently interrupts or interrupts others
Diagnosis of inattentive form requires ≥ 6 symptoms and signs. Diagnosis of the hyperactive/impulsive type requires ≥ 6 symptoms and signs. Diagnosis of the combined type requires ≥ 6 symptoms and signs of each type above.
Other diagnoses
There is difficulty in differentiating ADHD from other disorders. Overuse of the diagnosis of ADHD must be avoided, and other disorders should be diagnosed accurately. Many signs of attention-deficit/hyperactivity disorder (ADHD) that occur before school age may indicate communication problems that may occur in other neurodevelopmental disorders (eg, autism spectrum disorders) . autism ) or in certain learning disorders , anxiety , depression , or behavioral disorders (eg, conduct disorder ).
Clinicians should consider whether the child is distracted by external factors (eg, environmental inputs) or by internal factors (eg, child anxiety, rumination). However, after childhood, symptoms of ADHD in children become more obvious; Children with hyperactive/impulsive, impulsive or combined types often move constantly (e.g., aimless movements, hands not staying still), talk hastily, impulsively and seem to lack awareness of environment. Children with the inattentive form may have no physical signs.
Evaluation focuses on identifying potentially treatable patterns that may contribute to or worsen symptoms and signs. Evaluation includes a history of prenatal exposures (eg, drugs, alcohol, tobacco), perinatal complications or infections, CNS infections, traumatic brain injury, cardiac disease, apnea when sleeping, not eating well and/or dieting, and a family history of ADHD.
Developmental assessment focuses on determining the onset and course of symptoms and signs. This assessment includes testing for developmental milestones, especially language milestones, and using ADHD-specific assessment scales (eg, Vanderbilt Rating Scale , Conners Comprehensive Behavioral Assessment Scale, ADHD assessment IV). Versions of these scales are available for both families and school personnel, allowing for assessment of various situations according to DSM-5 standards. Note that the scale should not be used for diagnosis.
Educational assessment focuses on documenting baseline symptoms and signs; it may involve reviewing educational records and using rating scales or checklists. However, rating scales and checklists often cannot distinguish ADHD from other developmental or behavioral disorders.
Prognosis of ADHD
Traditional classrooms and routine activities often worsen symptoms and signs in children with untreated or inadequately treated ADHD. Social and emotional adjustment problems may persist. Disapproval from peers and loneliness tend to increase with age and become more obvious. Substance abuse can occur if ADHD is not adequately diagnosed and treated because many adolescents and adults with ADHD self-administer legal (e.g., caffeine) and illegal (e.g., cocaine, amphetamines).
Although hyperactivity symptoms and signs tend to decrease with age, adolescents and adults may have more difficulty presenting. Possible consequences in adolescents and adults include:
- Reduced intelligence
- Rampage
- Personal and social issues
- Mental disorders during pregnancy
Problems in adolescence and adulthood manifest primarily as academic failure, low self-esteem, and difficulty learning appropriate social behavior. Adolescents and adults with predominantly impulsive ADHD may have increased rates of personality disorder and antisocial behavior; Many people continue to exhibit haste, impulsivity, restlessness, and poor social skills. People with ADHD seem to adjust better to work, especially if they can find work that doesn’t require much attention to perform.
Treatment of ADHD
- Behavioral therapy
- Pharmacological treatment, usually with psychotropic drugs such as methylphenidate or dextroamphetamine (short- and long-acting)
Anecdotally, case-control studies indicate that behavioral therapy alone is less effective than when combined with medication for school-age children, but behavioral therapy or combination therapy is often used. for younger children. Although correction of ADHD patients’ neuropathological differences does not occur with drug treatment, medications are effective in reducing ADHD symptoms and allowing patients to participate in activities. Previously inaccessible due to reduced attention and haste and impulsivity. Medication often interrupts inappropriate behavior, enhancing behavior, learning, development, and self-esteem.
Treatment of adults follows the same principles, but drug choice and dosage are determined on an individual basis, depending on different medical conditions.
Psychotropic drugs
Preparations consisting of salts of methylphenidate or amphetamine are widely used. Response is variable, and dosage depends on the severity of the behavior and the child’s tolerance to the medication. Dosage is adjusted for frequency and amount until an optimal balance between response and side effects is achieved.
Methylphenidate is usually started at a dose of 0.3 mg/kg/day (immediate-release formulation) and increased in frequency weekly, usually to approximately 2 to 3 times daily or every 4 hours while awake; Many clinicians use morning and noon doses. If there is no response but the drug is tolerated, the dose can be increased. Most children have an optimal balance of benefits and harms at individual doses between 0.3 – 0.6 mg/kg. The dextro isomers of methylphenidate are the active molecules and are available in prescription half doses.
Dextroamphetamine is usually started (often in combination with amphetamine) at a dose of 0.15 – 0.2 mg/kg orally once daily, which may then be increased to 2 or 3 times daily or every 4 hours during waking hours. Specific doses in the range of 0.15 – 0.4 mg/kg are usually effective. Dosage should balance effectiveness against side effects; Actual doses vary significantly between individuals, but in general, higher doses increase the likelihood of unwanted side effects. Overall, the dextroamphetamine dose is about two-thirds that of the methylphenidate dose.
For methylphenidate or dextroamphetamine, once the optimal dose has been achieved, an equivalent dose of the same drug in the extended-release formulation is often substituted to avoid the need for repeated dosing at school. Long-acting preparations include tablets, biphasic capsules containing 2 doses, delayed-release tablets, and skin patches that last up to 12 hours. Currently, there are two types of preparations available: short-acting and long-acting. Purified dextro preparations (eg, dextromethylphenidate) are often used to reduce side effects such as anxiety; The usual dose is half of the mixed preparations. Sometimes experimental drug preparations are also used because of their faster release, longer duration of action, fewer side effects, and lower abuse potential. Learning is often enhanced by low doses, but behavioral improvements often require higher doses.
Dosage changes can be adjusted to suit specific times and days (eg, during school hours, while doing homework). You can stop taking the medicine on weekends, holidays, or during summer vacation. A placebo period (5 – 10 school days to ensure reliability of observations) is recommended to determine whether medication is necessary.
Common side effects of psychotropic medications include
- Sleep disorders (eg, insomnia)
- Headache
- Stomachache
- Reduced appetite
- Increased heart rate and blood pressure
Depression is a less common adverse effect and can often manifest as an inability to easily shift focus (overconcentration). This may manifest as a lethargic demeanor (sometimes described by families as zombie-like) rather than actual clinical childhood depression . In fact, stimulant medications are sometimes used as an adjunctive treatment for depression. Sometimes drowsiness can be resolved by cutting back on stimulant medication or trying a different medication.
Studies have shown that height growth slows within 2 years of stimulant use, and the slowing appears to persist into adulthood with continued long-term stimulant use.
Non-psychotropic drug group
Atomoxetine, a selective norepinephrine reuptake inhibitor, is also used. The drug is effective, but its effectiveness is often mixed with that of psychotropic drugs. Some children show signs of nausea, sedation, irritability, and impatience; Hepatotoxicity and suicidal ideation rarely occur. Typical starting dose is 0.5 mg/kg/time/day, increasing weekly to 1.2 -1.4 mg/kg/time/day. The half-life is long so the drug is used once a day but must be used continuously to be effective. The maximum recommended dose is 100 mg/day.
Selective norepinephrine reuptake inhibitor antidepressants such as bupropion and venlafaxine, alpha-2 agonists such as clonidine and guanfacine, and other psychoactive drugs are sometimes used in cases where stimulants are ineffective or Side effects are unacceptable, but such drugs are less effective and are not recommended as first-line drugs. Sometimes these drugs are used in combination with psychotropic drugs for synergistic effects; Close monitoring of drug side effects is required.
Adverse drug interactions are a concern with ADHD treatment. Drugs that inhibit the metabolic enzyme CYP2D6, including some selective serotonin reuptake inhibitors (SSRIs) sometimes used in patients with ADHD, may increase the effects of stimulant drugs. Reviewing potential drug interactions (often using a computer program) is an important part of the pharmacological management of patients with ADHD.
Behavior management
Counseling, including cognitive behavioral treatment (eg, goal setting, self-monitoring, modeling, role-playing) is often effective and helps children understand ADHD. Self-organization and habit formation are essential.
Classroom behavior is often improved by controlling noise and visual stimulation, teachers need to assign exercises that are of appropriate length, varied and more personal to the child.
When difficulties at home continue, parents should seek professional support and training in behavior management skills. For behavior management to be enhanced and effective, children need to be encouraged and rewarded. Children with mainly hyperactive ADHD often need help from their families.
Diet, use of drugs rich in vitamins, antioxidants or other compounds, and nutritional and biochemical interventions have had certain effects. In some cases, biofeedback is beneficial but it is not recommended for daily use because there is no clear evidence.
Main attractions
- ADHD includes forms of inattention, hyperactivity/impulsivity, impulsivity, or a combination of both; It usually appears before age 12, including in preschool children.
- Currently, the cause of the disease is unknown, but there are many risk factors.
- Diagnose using clinical criteria and other disorders that may present similarly (eg, autism, conduct disorders, anxiety, depression).
- Symptoms tend to decrease with age, and adolescents and adults may have more difficulty experiencing symptoms.
- Treatment with psychotropic drugs and cognitive-behavioral therapy; Individual behavioral therapy may be appropriate for preschool-aged children.
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