Attention Deficit Hyperactivity Disorder

ADHD is not a clinically definable disease

Rather, as of December 2003, ADHD is a diagnosis given to children and adults who exhibit certain behaviors over an extended period of time. The most common of these behavioral criteria are inattention, hyperactivity, and severe impulsivity.

The European description of ADHD places this disorder in a subset of the so-called hyperkinetic disorders (the hallmarks are inattention and over-activity).

Description


ADHD is also known as attention deficit disorder (ADD), attention deficit disorder with and without hyperactivity, hyperkinesis, hyperkinetic impulse disorder, hyperactive syndrome, childhood hyperkinetic response, minimal brain damage, and minimal brain dysfunction.

For many people with ADHD, life is a never-ending transition from one activity to another. It is impossible to focus on any one topic long enough to conduct a detailed assessment. The constant processing of information can also be distracting, making it difficult for a person with ADHD to direct their attention to whoever is talking to them. This struggle for focus can cause great chaos that can wreak havoc and low self-esteem.

The neurological manifestations of ADHD are disorders of the so-called executive functions. In particular, six executive functions affected:

  • the ability to organize thinking;

  • the ability to change the way of thinking;

  • short term memory;

  • the ability to distinguish between emotional and logical reactions;

  • the ability to make a reasoned decision;

  • the ability to set a goal and plan how to achieve this goal.

Causes and symptoms


For many years, it was thought that ADHD developed after a physical blow to the head or due to infection in early childhood, leading to the terms “minimal brain damage” and “minimal brain dysfunction.” However, these definitions only apply to a very small number of people diagnosed with ADHD and have therefore been rejected as the main cause.

Another once prevalent theory was that eating refined sugar or chemical additives causes hyperactivity and inattention. While sugar can induce behavioral changes, the data do not support this alleged link.

ADHD symptoms can sometimes be alleviated by using stimulants that increase levels of a chemical called dopamine. This chemical has the function of transmitting impulses from one neuron to another. Too little dopamine can reduce motivation and alertness. These observations led to the popular “dopamine hypothesis” for ADHD, which suggested that ADHD results from insufficient supply of dopamine to the central nervous system.

Observations have shown that ADHD may be of genetic origin. Twin studies have shown that the occurrence of ADHD in one of the twins is more likely to be reflected in identical twins (with the same genetic makeup) than in fraternal twins (whose genetic makeup is similar, but not identical).

The development of ADHD can be influenced by environmental factors. Some people with ADHD are associated with complications during pregnancy and childbirth, excessive use of marijuana, cocaine and / or alcohol (especially by pregnant women), family or marital stress, and poverty. However, many other ADHD sufferers do not exhibit any of these associations.

Heavy alcohol use by a pregnant woman can lead to malformations of nerve cells in the fetus, which can lead to the birth of a baby with a lower than usual weight and intellectual disability. This condition, called fetal alcohol syndrome, can also manifest as ADHD-like hyperactivity, inattention, and impulsive behavior.

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Diagnostics


ADHD is sometimes difficult to diagnose. Unlike the flu or a fractured limb, ADHD has no symptoms that can be found on a physical examination or chemical test. Rather, the diagnosis of ADHD is based on the presence of a number of characteristic behaviors over an extended period of time. Often the child will be observed by the specialist during periods of intense irritation, such as at a birthday party, and during quieter periods of concentrated concentration.

The criteria for either inattention or hyperactivity / impulsive behavior must be met. These criteria are usually reached by age seven and are not limited to one particular social setting, such as school. These benchmarks must be present for an extended period of time, at least six months or more. There are nine separate criteria for each category. Six of the nine criteria must be met for a diagnosis.

Examples of diagnostic signs of inattention include difficulty maintaining focus on a task, failure to follow instructions, difficulty organizing approaches to tasks, repeated misuse of the tools needed to complete tasks, and a tendency to be easily distracted. Examples of hyperactivity or impulsive behavior include fidgeting with arms or legs, restlessness, difficulty playing quietly, excessive talking, etc.

Because ADHD can be associated with the use of certain drugs or supplements, diagnosis includes screening for past or present use of drugs, such as anticonvulsants or antihypertensive drugs, and drugs containing caffeine.

Diagnosis of ADHD can also be complicated by the concurrent presence of another medical condition. Diagnosis includes screening for bipolar disorder, depression, eating disorder, learning disability, panic disorder (including agoraphobia), sleep disturbance, substance abuse, or Tourette’s syndrome. Nearly half of all children (mostly boys) with ADHD exhibit what has been termed “oppositional defiant behavior.” These children tend to be stubborn, temperamental, aggressive, and may lash out at others through minor provocation. Without intervention, these children can move on to more serious hardships such as property destruction, theft, arson and unsafe driving.

A complete physical examination is recommended as part of the diagnosis. The examination gives the doctor the opportunity to observe a person’s behavior. More specific tests can also be performed. Children can be assessed using the Conner Parent-Teacher Scale. The brown Attention Deficit Disorder Scale can be used to assess adolescents and adults. Impulsive and inattentive behavior can be assessed using Conner’s Continuous Performance Test (CPT) or Integrated Visual and Auditory CPT. Girls can be specifically assessed using the Nade / Quinn / Littman ADHD Self-Assessment Scale.

Treatment


Behavioral therapy can consist of monitoring school performance and using standardized assessment tests. For older children, adolescents, and adults, support groups can be helpful. In addition, ADHD patients can learn behavioral techniques that are useful for self-monitoring their behavior and making appropriate changes (such as a timeout). Behavioral treatment is useful in combination with drug therapy or as a stand-alone treatment in cases where drug use is not tolerated or preferred.

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Medical treatment may consist of drugs such as Ritalin, which are used to correct excessive behavior, or other drugs that have different potencies. Psychostimulants such as Ritalin, Zilert, and Dexedrine increase brain activity by increasing the concentration of chemicals in the brain, such as dopamine, that are involved in impulse transmission, or by stimulating receptors that the chemicals bind to.

Stimulants can sometimes disrupt sleep, reduce appetite, cause stomach pains and headaches, and cause feelings of anger and anxiety, especially in people with mental illness such as bipolar disorder or depression. For many people, the side effects are minor and may become even milder with long-term use of the drugs.

Antidepressants such as imipramine work by slowing the absorption of chemicals involved in impulse transmission. Central alpha agonists are especially used in the treatment of hyperactivity. By limiting the presence of chemical neurotransmitters between neurons, drugs such as clonidine and guanfacine restrict the flow of information from one neuron to another. Four sudden deaths have been reported in people taking clonidine in combination with the drug methylphenidate (Ritalin), and non-fatal heart problems have been reported in people taking clonidine alone.

Finally, drugs known as selective norepinephrine reuptake inhibitors limit the production of norepinephrine between neurons, which suppresses the sudden and often hyperactive fight-or-flight response.

Recovery and rehabilitation


After stabilization of the patient’s condition, usually taking medication, it is recommended to see a doctor every few months for the first year.

Convalescence and rehabilitation are not ADHD. Rather, the child with ADHD can receive optimal care. Assistance can take the form of special education for those who are too hyperactive to function in a regular classroom, the child can sit in a quieter place in the classroom, or use a system of rules and rewards for appropriate behavior. Children and adults can also learn strategies for maximum concentration (such as making lists) and strategies for monitoring and controlling their behavior.

Forecast


The outlook for a patient with ADHD can be excellent if the treatment regimen is adhered to and other existing conditions and disabilities are identified and treated. Methylphenidate, the main psychostimulant used in the treatment of ADHD, has been prescribed since the 1960s. The experience gained during this time has shown that the drug is one of the safest medicines for children. Indeed, intervention can be beneficial. In 1999, researchers at Massachusetts General Hospital reported that drug treatment for children diagnosed with ADHD could significantly reduce the risk of future substance abuse.

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