Attention deficit hyperactivity disorder

The terms "attention deficit hyperactivity disorder" and "developmental disorders" describe clinical phenomena rather than being names of independent diseases. Much effort has been made to identify individual nosological entities within these conditions that have specific etiology and pathogenesis. An example is fragile X syndrome, which often includes mental retardation, hyperactivity, and autism.

Attention deficit hyperactivity disorder (ADHD) is a frequently diagnosed condition that accounts for a significant portion of the daily clinical practice of child psychiatrists and neurologists. ADHD is also frequently treated by pediatricians, who typically refer patients to specialists when psychostimulants are ineffective. Symptoms of ADHD can persist throughout the patient's life, and therefore ADHD can be considered a developmental disorder ("dysontogenetic disorder"). ADHD in adults has recently received more attention, but the pathogenesis, clinical picture, and treatment of this condition remain poorly understood. Autism is considered a very intriguing, somewhat "otherworldly" pathology and occupies the minds of the best child and adolescent psychiatrists. At the same time, specialists dealing with the problem of mental retardation complain about their relatively low position in the professional "table of ranks", which probably reflects the position of this group of patients in society.

Psychopharmacology is only one area of treatment for ADHD and other developmental disorders, albeit a very important one. No less important is the implementation of a comprehensive "biopsychosocial-educational" approach to the treatment of these conditions, which requires the joint efforts of specialists from different specialties. Treatment of developmental disorders requires the development of new drugs. Apart from psychostimulants, few drugs have been adequately tested, but the emergence of a new generation of atypical antipsychotics inspires some optimism. Clinical trials of psychopharmacological agents in children are somewhat delayed in relation to studies in adults, which is explained by the special caution when using drugs that are not formally approved for use in a particular condition.

Psychopharmacotherapy is an effective tool in the hands of a doctor who has modern information about the brain mechanisms that regulate behavior and psychotherapeutic methods that have a beneficial effect on the affective state of patients and their daily activities. The effectiveness of psychopharmacotherapy for attention deficit hyperactivity disorder and other developmental disorders is significantly enhanced if the doctor sincerely sympathizes with his patients and constantly asks himself the question: "Would I like a member of my family to be treated in the same way?"

Attention deficit hyperactivity disorder (ADHD) is a syndrome involving inattention, hyperactivity, and impulsivity. There are three main types of ADHD: attention-deficit predominant, hyperactivity-impulsivity predominant, and mixed. Diagnosis is based on clinical criteria. Treatment typically includes medication with psychostimulant drugs, behavioral therapy, and school modification.

Attention deficit hyperactivity disorder (ADHD) is classified as a developmental disorder, although it is increasingly considered a behavioral disorder. ADHD is estimated to affect 3% to 10% of school-aged children. However, many experts believe that ADHD is overdiagnosed, largely because criteria are not applied precisely. According to the Diagnostic and Statistical Manual, Edition IV, there are three types: attention-deficit, hyperactivity-impulsivity, and mixed. Hyperactivity-impulsivity ADHD is 2 to 9 times more common among boys, while attention-deficit ADHD is about equally common among boys and girls. ADHD tends to run in families.

There is currently no known single cause for ADHD. Potential causes include genetic, biochemical, sensorimotor, physiological, and behavioral factors. Risk factors include birth weight less than 1,000 g, head trauma, lead exposure, and maternal smoking, alcohol use, and cocaine use. Less than 5% of children with ADHD have other symptoms and signs of neurological damage. There is growing evidence that abnormalities in the dopaminergic and noradrenergic systems are involved, with decreased activity or stimulation in the upper brainstem and frontal-midbrain pathways.

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Causes of Attention Deficit Hyperactivity Disorder

The cause of ADHD remains unknown. Similar clinical manifestations are seen in fragile X syndrome, fetal alcohol syndrome, very low birth weight infants, and very rare hereditary thyroid disorders; however, these conditions account for only a small proportion of ADHD cases. The search for the causes of ADHD is being conducted in various directions, using genetic, neurochemical, structural and functional neuroimaging studies, etc. For example, patients with ADHD have a decreased size of the anterior corpus callosum. Single-photon emission computed tomography (SPECT) has revealed focal hypoperfusion in the striatum and hyperperfusion in the sensory and sensorimotor cortex.

Attention Deficit Hyperactivity Disorder - Causes

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Symptoms of Attention Deficit Hyperactivity Disorder

The first symptoms usually appear before age 4 and always before age 7. The peak age for ADHD diagnosis is between ages 8 and 10; however, in attention-focused ADHD, the diagnosis may not be made until late adolescence.

The main symptoms and signs of ADHD are inattention, hyperactivity, and impulsivity that are more severe than expected for the child's developmental level; poor school performance and impaired social functioning are common.

Attention deficits often manifest when the child is involved in activities that require attention, rapid reaction, visual or perceptual search, systematic or prolonged listening. Attention deficits and impulsivity interfere with the development of school skills and thinking, as well as the rationale for action tactics, motivation to attend school, and adaptation to social demands. Children with ADHD with a predominance of attention deficits tend to be students who require constant supervision, who have difficulty with passive learning, which requires prolonged concentration and task completion. Overall, about 30% of children with ADHD have learning disabilities.

Behavioral history may reveal low tolerance for frustration, opposition, temper tantrums, aggressiveness, poor social skills and peer relationships, sleep disturbances, anxiety, dysphoria, depression, and mood swings. Although there are no specific physical or laboratory findings in these patients, symptoms and signs may include mild incoordination or clumsiness; non-localizing, “soft” neurologic symptoms; and perceptual-motor dysfunction.

The American Academy of Pediatrics has published guidelines for the diagnosis and treatment of ADHD.

Attention Deficit Hyperactivity Disorder - Symptoms

Diagnosis of Attention Deficit Hyperactivity Disorder

Diagnosis is clinical and based on a complete medical, psychological, developmental and school skills examination.

The DSM-IV diagnostic criteria include 9 symptoms and signs of inattention, 6 of hyperactivity, and 3 of impulsivity; a diagnosis using these criteria requires the presence of these symptoms in at least two settings (e.g., home and school) in a child younger than 7 years of age.

Differential diagnosis between ADHD and other conditions can be difficult. Overdiagnosis should be avoided and other conditions should be properly identified. Many of the signs of ADHD that appear in preschool years may also indicate communication impairments that may occur in other developmental disorders (e.g., pervasive developmental disorders) as well as specific scholastic acquisition disorders, anxiety disorders, depression, or conduct disorders (e.g., conduct disorders). As children get older, signs of ADHD become more definite; these children exhibit constant lower extremity movements, motor inconsistency (e.g., purposeless movements and small, constant hand movements), impulsive speech, and seem inattentive or even careless about their surroundings.

DSM-IV ADHD Criteria ¹

Symptom class	Individual symptoms
Attention deficit disorder	Doesn't pay attention to details Difficulty maintaining attention at school is noted Doesn't listen attentively when spoken to. Does not follow instructions to complete the task Has difficulty organizing activities and completing tasks Avoids, dislikes, or is reluctant to perform tasks that require long periods of time Mental stress Often loses things Easily distracted Forgetful
Hyperactivity	Often makes fidgety, nervous movements with his hands and feet Frequently gets up from his seat in class or other places Often runs back and forth or climbs up and down stairs It's hard for him to play calmly. Constantly in motion, as if it had a motor Often talks too much
Impulsiveness	Often answers a question without listening to the end It's hard for him to wait his turn. Often interrupts and interferes in other people's conversations

ADHD - Attention Deficit Hyperactivity Disorder.

¹ A diagnosis according to DSM-IV criteria requires the presence of symptoms in at least two situations by age 7 years. For a diagnosis of the predominantly inattention-impaired type, at least 6 of the possible 9 symptoms of inattention are required. For a diagnosis of the hyperactive-impulsive type, at least 6 of the possible 9 symptoms of hyperactivity and impulsivity are required. For a diagnosis of the mixed type, at least 6 symptoms of inattention and 6 symptoms of hyperactivity-impulsivity are required.

The medical evaluation focuses on identifying treatable conditions that may contribute to or worsen ADHD symptoms. The developmental assessment focuses on determining the onset and progression of symptoms and signs. The school assessment focuses on documenting key symptoms and signs; it may include review of school records and administration of scales or tests. However, scales and tests alone are not always sufficient to differentiate ADHD from other developmental or behavioral disorders.

Attention Deficit Hyperactivity Disorder - Diagnosis

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Treatment of attention deficit hyperactivity disorder

Randomized controlled trials have shown that behavioral therapy alone is less effective than treatment with psychostimulant medication alone; mixed results have been obtained with combination therapy. Although neurophysiological differences in patients with ADHD are not corrected with medication, medications are effective in reducing ADHD symptoms and allowing the patient to engage in activities that were previously inaccessible due to poor attention and impulsivity. Medications often interrupt episodes of abnormal behavior, enhancing the effects of behavioral therapy and school interventions, motivation, and self-esteem. Treatment of adults follows the same principles, but recommendations for drug selection and dosage are still being developed.

Medications: Psychostimulant medications, including methylphenidate or dextroamphetamine, are most widely used. Response to treatment varies widely, and the dose depends on the severity of the behavioral disorder and the child's tolerance of the drug.

Methylphenidate is usually started at a dose of 5 mg orally once daily (immediate-release form), which is then increased weekly, usually to a dose of 5 mg three times daily. The usual starting dose of dextroamphetamine (either alone or in combination with amphetamine) is 2.5 mg orally once daily in children under 6 years of age, which can be gradually increased to 2.5 mg twice daily. In children over 6 years of age, the starting dose of dextroamphetamine is usually 5 mg once daily, gradually increasing to 5 mg twice daily. A balance between effect and side effects can be maintained as the dose is increased. In general, dextroamphetamine doses are approximately 2/3 of the dosemethylphenidate. With both methylphenidate and dextroamphetamine, once the optimal dose is reached, an equivalent dose of the same drug in a slow-release form is given, with the goal of avoiding school administration. Learning often improves with low doses, but higher doses are often needed to correct behavior.

Psychostimulant dosing regimens may be adjusted to provide more effective effects on certain days or time periods (e.g., school time, homework time). Drug breaks may be tried on weekends, holidays, and during summer vacations. Periodic placebo periods (5-10 school days to ensure the reliability of observations) are also recommended to determine whether further drug use is necessary.

Common side effects of psychostimulants include sleep disturbances (insomnia), depression, headache, abdominal pain, decreased appetite, and increased heart rate and blood pressure. Some studies have shown growth retardation with stimulant use for 2 years, but it is unclear whether this persists over longer periods of treatment. Some patients who are sensitive to the effects of psychostimulants may appear overly focused or lethargic; reducing the dose of the psychostimulant or changing the drug may be helpful.

Atomoxetine, a selective norepinephrine reuptake inhibitor, is also used. This drug is effective, but the data on its effectiveness are mixed compared with the results of psychostimulants. Many children experience nausea, irritability, and angry outbursts; severe hepatotoxicity and suicidal ideation have been observed rarely. Atomoxetine should not be considered a first-line drug. The usual starting dose is 0.5 mg/kg orally once daily, gradually increasing weekly to a dose of 1.2 mg/kg. The long half-life allows the drug to be given once daily, but continuous administration is necessary to achieve an effect. The maximum daily dose is 60 mg.

Antidepressants such as bupropion, alpha-2 agonists such as clonidine and guanfacine, and other psychotropic medications are sometimes used when stimulant medications are ineffective or have unacceptable adverse effects, but they are much less effective and are not recommended as first-line treatments. Pemoline is no longer recommended.

Behavioral therapy: Counseling, including cognitive behavioral therapy (e.g., goal setting, self-monitoring, modeling, role-playing), is often effective in helping the child understand ADHD. Structure and routine are essential.

Behavior in school often improves with control of noise and visual stimuli, task duration appropriate to the child's abilities, task novelty, practice, and teacher proximity and accessibility.

If difficulties are noted at home, parents should be encouraged to seek additional professional help and training in behavioral therapy. Additional incentives and symbolic rewards reinforce behavioral therapy and are often effective. Children with ADHD who are hyperactive and impulsive can often be helped at home if parents establish consistent and structured rules and well-defined limits.

Elimination diets, high-dose vitamins, antioxidants, and other supplements, as well as dietary modification and biochemical correction, have had significantly less effect. Biofeedback has not been proven to be valuable. Most studies have shown minimal behavioral changes and no long-term results.

Attention Deficit Hyperactivity Disorder - Treatment

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Attention deficit hyperactivity disorder prognosis

Traditional schooling and activities often exacerbate symptoms in children with untreated or inadequate ADHD. Social and emotional immaturity may persist. Poor peer acceptance and loneliness tend to increase with age and with obvious signs of ADHD. Concomitant low intelligence, aggression, social and interpersonal problems, and parental psychopathology predict poor outcomes in adolescence and adulthood. Problems in adolescence and adulthood manifest primarily as academic failure, low self-esteem, and difficulty developing appropriate social behavior. Adolescents and adults with predominantly impulsive ADHD may have increased rates of personality disorders and antisocial behavior; many persist with impulsivity, agitation, and poor social skills. Individuals with ADHD adjust better to work than to school or home life.

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