Attention Deficit Hyperactivity Disorder

The terms "attention deficiency with hyperactivity" and "developmental disorders" rather describe the clinical phenomenon rather than the name of independent diseases. Many efforts have been made to separate separate nosological units with specific etiology and pathogenesis within these states. An example is the syndrome of a fragile X chromosome, in which mental retardation, hyperactivity and autism are common.

Attention Deficit Hyperactivity Disorder (ADHD) is an often diagnosed condition that accounts for a significant proportion of the daily clinical practice of children's psychiatrists and neurologists. Deficiency of attention with hyperactivity is often treated and pediatricians, who usually refer patients to specialists with ineffective psychostimulants. Symptoms of attention deficit hyperactivity may persist throughout the life of the patient, in this regard, attention deficit hyperactivity can be considered as a developmental disorder ("dysontogenetic disorder"). To the manifestation of attention deficit hyperactivity in adults recently began to pay more attention, but the pathogenesis, clinical picture and treatment of this condition remain poorly studied. Autism is considered very intriguing, a kind of "otherworldly" pathology and takes the minds of the best children and adolescent psychiatrists. At the same time, specialists dealing with the problem of mental retardation complain that they occupy a relatively low position in the professional "table of ranks", which probably reflects the situation in the society of this group of patients.

Psychopharmacology is only one of the areas of attention deficit management with hyperactivity and other developmental disorders, although very important. No less important is the implementation of a comprehensive "biopsychosocial-educational" approach to the treatment of these conditions, which requires joint efforts of specialists of different specialties. Treatment of developmental disorders requires the development of new medicines. In addition to psychostimulants, only a 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 go with a certain delay in relation to research in adults, which is explained with extreme caution in the use of drugs that are formally not approved for use in this or that condition.

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

Attention Deficit Hyperactivity Disorder (ADHD) is a syndrome that includes inattention, hyperactivity and impulsivity. There are three main types of ADHD: with a predominance of impaired attention, with a predominance of hyperactivity-impulsivity and a mixed one. The diagnosis is based on clinical criteria. Treatment usually includes medical therapy with the use of psychostimulating drugs, behavioral therapy and modification of school activities.

Attention Deficit Hyperactivity Disorder (ADHD) is classified as a developmental disorder, although it is increasingly considered a behavioral disorder. ADHD is estimated to occur in 3-10% of school-age children. Nevertheless, many experts believe that there is a hyperdiagnosis of ADHD largely due to the fact that the criteria are applied inaccurately. According to the Manual on Diagnosis and Statistical Processing (Edition IV), three types are distinguished: with a predominance of attention deficit, with a predominance of hyperactivity-impulsivity and a mixed one. ADHD with a predominance of hyperactivity-impulsivity is 2-9 times more common among boys, while ADHD with a predominance of impaired attention is approximately equally common in boys and girls. Family cases are characteristic of ADHD.

To date, there is no specific, single cause of ADHD. Potential causes include genetic, biochemical, sensory-motor, physiological, and behavioral factors. The risk factors include body weight at birth of less than 1000 g, head injuries, exposure to lead, and smoking and drinking by a pregnant woman alcohol, cocaine. Less than 5% of children with ADHD have other symptoms and signs of neurological damage. More and more evidence appears about the involvement of disorders in the dopaminergic and noradrenergic systems with a decrease in activity or stimulation in the upper parts of the brainstem and the front-median brain path.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Causes of Attention Deficit Hyperactivity Disorder

The causes of attention deficit hyperactivity remain unknown. Similar clinical manifestations are found in the syndrome of fragile X chromosome, alcoholic fetal syndrome, in children born with very low weight, and also with very rare hereditary thyroid diseases; but these conditions are revealed only in a small part of cases of attention deficit hyperactivity disorder. The search for the causes of attention deficit hyperactivity are conducted in different directions with the help of genetic, neurochemical studies, methods of structural and functional neuroimaging, etc. For example, in patients with attention deficit hyperactivity, the size of the anterior parts of the corpus callosum has decreased. Single-photon emission computed tomography (SPECT) revealed focal hypoperfusion in the striatum zone and hyperperfusion in the sensory and sensorimotor cortex areas.

Attention Deficit Hyperactivity Disorder - Causes

[12], [13], [14], [15], [16], [17], [18]

Symptoms of attention deficit hyperactivity disorder

The first manifestations, as a rule, appear up to 4 years of age and always - up to 7 years of age. The peak of diagnosis of ADHD falls on the age between 8 and 10 years; However, with ADHD with a predominance of attention impairment, the diagnosis can not be detected until the adolescent period ends.

The main symptoms and signs of ADHD are inattention, hyperactivity and impulsiveness, which are more than expected, taking into account the level of development of the child; often there is a decline in school performance and a violation of social functions.

Violation of attention is often manifested when a child participates in activities requiring attention, rapid reaction, visual or perceptual search, systematic or prolonged listening. Violation of attention and impulsiveness complicates the development of school skills and thinking, as well as the rationale for tactics of action, motivation for attending school, and adaptation to social requirements. Children with ADHD with a predominance of attention impairment tend to be students who need constant supervision, who have difficulties with passive learning, when long-term concentration and completion of the task is required. In general, about 30% of children with ADHD are experiencing learning disabilities.

Behavioral history may reveal low tolerance of dissatisfaction of needs, resistance, outbursts of anger, aggressiveness, low social skills and poor relationships with peers, sleep disorders, anxiety, dysphoria, depression and sudden mood changes. Although there are no specific signs for a physical or laboratory examination of such patients, the symptoms and symptoms may include minor impairment of coordination or embarrassment; non-localized, "soft" neurological symptoms and perceptive motor dysfunction.

The American Pediatric Academy has published a guide to diagnosing and treating ADHD.

Attention Deficit Hyperactivity Disorder - Symptoms

Attention Deficit Hyperactivity Disorder

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

Diagnostic criteria for DSM-IV include 9 symptoms and signs of attention disorder, 6 - hyperactivity, 3 - impulsivity; For diagnosis using these criteria, these symptoms must be present in at least two situations (for example, at home and at school) in a child under 7 years of age.

There is a difficult differential diagnosis between ADHD and other conditions. It is necessary to avoid overdiagnosis and properly identify other conditions. Many of the signs of ADHD that occur at preschool age may also indicate communication disorders that may occur in other developmental disorders (for example, general developmental disorders), as well as certain disorders in acquiring school skills, anxiety disorders, depression or behavioral disorders (eg, conductive disorder). In the older age, signs of ADHD become more specific; such children demonstrate constant movements of the lower extremities, motor inconstancy (for example, aimless movements and small constant movements of the hands), impulsive speech, seem insufficiently attentive and even careless towards the surrounding.

ADHD Criteria for DSM-IV ¹

Class of symptoms	Individual Symptoms
Violation of attention	Does not pay attention to details There are difficulties with maintaining the school's attention Inattentively hears when they talk to him Do not follow the instructions to complete the task Has difficulties with the organization of activities and tasks Avoids, dislikes or reluctantly tasks that require a long Mental stress Often loses things Easily distracted Forgetful
Hyperactivity	Often he makes fussy nervous movements with his hands and feet Often rises from a place in the classroom or other places Often runs back and forth or scrambles up and down the stairs He finds it difficult to play calmly Constantly in motion, as if he has a motor Often says too much
Impulsiveness	Often answers the question, to the end of it not having listened to He finds it difficult to wait his turn Often interrupts and intervenes in someone else's conversation

ADHD is attention deficit hyperactivity disorder.

¹ Diagnosis by DSM-IV criteria requires the presence of symptoms in at least two situations before the age of 7 years. For diagnosis of a type with a predominance of attention deficit, at least 6 of the 9 possible symptoms of attention disturbance are necessary. To diagnose a hyperactive-impulsive type, at least 6 of the 9 possible symptoms of hyperactivity and impulsivity are necessary. For the diagnosis of a mixed type, at least 6 symptoms of impaired attention and 6 symptoms of hyperactivity-impulsivity are necessary.

The medical examination focuses on identifying potentially treatable conditions that can participate in development or weight the symptoms of ADHD. Evaluation of the level of development is concentrated on determining the onset and progression of symptoms and signs. Assessment of school skills is aimed at fixing key symptoms and signs; it can include the study of school records and the use of different scales or verification tasks. However, the use of only scales and verification tasks is not always enough to distinguish ADHD from other developmental disorders or behavioral disorders.

Attention Deficit Hyperactivity Disorder - Diagnosis

[19], [20], [21], [22], [23]

Attention Deficit Hyperactivity Treatment

Randomized controlled trials have shown that isolated behavioral therapy is less effective than isolated psychostimulating medication; mixed results were obtained with combined therapy. Although the correction of neurophysiological differences in patients with ADHD does not occur with drug therapy, the drugs are effective in alleviating the symptoms of ADHD and allow the patient to participate in activities that were previously inaccessible to him due to low attention and impulsiveness. Drugs often interrupt episodes of abnormal behavior, enhancing the effect of behavioral therapy and activities in school, motivation and self-esteem. Adult patients are treated according to the same principles, but recommendations for drug selection and dosage are still being developed.

Preparations. Psychostimulating drugs, including methylphenidate or dextroamphetamine, are used most widely. The response to treatment varies widely, and the dose depends on the severity of the behavioral disorder and the tolerability of the drug by the child.

Methylphenidate is usually prescribed at the starting dose of 5 mg orally once a day (immediate release forms), which is then increased weekly, reaching, as a rule, 5 mg 3 times a day. The usual starting dose of dextroamphetamine (either alone or in combination with amphetamine) is 2.5 mg by mouth once a day in children less than 6 years old, which can be gradually increased to 2.5 mg twice a day. In children older than 6 years, the starting dose of dextroamphetamine is usually 5 mg once a day, with a gradual increase to 5 mg 2 times a day. With increasing doses, you can balance the effect with side effects. In general, the dose of dextroamphetamine is approximately 2/3 of the dosemethylphenidate. In both methylphenidate and dextroamphetamine treatment, once the optimal dose is reached, an equivalent dose of the same drug in a slow release form is administered, which is done to avoid taking the drug in school. Training is often improved at low doses, however, the administration of higher doses is often necessary to correct behavior.

Patterns of prescribing psychostimulants can be corrected for the purpose of more effective exposure to certain days or periods of time (for example, school time, time of homework). Breaks in taking the drug can be tried on weekends, holidays and during the summer holidays. It is also recommended to periodically apply the periods of taking placebo (during 5-10 school days to ensure the reliability of observations) to determine the need for continued use of the drug.

Common side effects of psychostimulants are sleep disorders (insomnia), depression, headache, abdominal pain, decreased appetite, increased heart rate and blood pressure. In some studies, it has been shown that with the use of stimulants for 2 years, there is a delay in growth, but it remains unclear whether this disturbance persists for a longer duration of treatment. Some patients, sensitive to the effect of stimulants, may seem overly focused or lethargic; a decrease in the dose of the stimulant or a change in the drug can be effective.

Also used are atomoxetine, a selective norepinephrine reuptake inhibitor. This drug is effective, but the data on its effectiveness are heterogeneous in comparison with the results of using psychostimulants. Many children experience nausea, irritability, outbursts of anger; rarely expressed hepatotoxicity and suicidal ideation. Atomoxetine should not be considered as a first-line drug. Usually the starting dose is 0.5 mg / kg orally once a day, with a gradual weekly increase to a dose of 1.2 mg / kg. A prolonged half-life allows you to prescribe the drug once a day, but you need a drip drug to achieve the effect. The maximum daily dose is 60 mg.

Antidepressants, such as bupropion, alpha-2 agonists, for example clonidin and guanfacine, as well as other psychotropic drugs, are sometimes used in the case of ineffective psychostimulating drugs or unacceptable adverse effects in their use, but they are much less effective and are not recommended as drugs first line. Pemoline is no longer recommended for use.

Behavioral therapy. Counseling, including cognitive-behavioral therapy (for example, goal setting, self-observation, modeling, role-playing), is often effective and helps the child understand ADHD. Structuredness and observance of the established order are necessary.

Behavior in school often improves with monitoring of the level of noise and visual stimuli corresponding to the child's abilities in the duration of tasks, their novelty, training and proximity and the availability of teacher's help.

If difficulties are noted at home, parents should focus on seeking additional professional help and teaching behavioral therapy. Additional incentives and symbolic rewards reinforce behavioral therapy and are often effective. Children with ADHD who are dominated by hyperactivity and impulsiveness can often be helped at home if parents establish permanent and structured rules and well-defined restrictions.

Elimination diet, the use of vitamins in large doses, antioxidants and other components, as well as changes in nutrition and biochemical correction have significantly less effect. The value of biofeedback is not proven. Most studies have shown minimal behavioral changes and a lack of long-term results.

Attention Deficit Hyperactivity Disorder - Treatment

[24], [25], [26], [27], [28], [29]

Forecast of attention deficit hyperactivity disorder

Traditional lessons and school activities often increase symptoms in children in the absence or inadequate treatment of ADHD. Social and emotional immaturity may persist. Poor peer acceptance and loneliness tend to increase with age and with obvious signs of ADHD. Associated low intelligence, aggressiveness, social and interpersonal problems, psychopathology in parents are predictors of adverse outcomes in adolescence and adulthood. Problems in adolescence and adulthood are manifested primarily as academic underachievement, low self-esteem, difficulties with the development of proper social behavior. Adolescents and adults predominantly with impulsive type of ADHD may have an increased incidence of personality disorders and antisocial behavior; many remain impulsive, excited and low social skills. Individuals with ADHD better adapt to work than to study or home life.

[30], [31], [32]