Attention Deficit – Hyperactivity Disorder (ADHD)

• Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood.
• According to the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV), ADHD is characterized by inattention, including increased distractibility and difficulty sustaining attention; poor impulse control and decreased self-inhibitory capacity; and motor overactivity and motor restlessness.
• These symptoms are pervasive and interfere with the individual’s ability to function under normal circumstances.

• DSM-IV identifies three types of ADHD:
  • Predominantly hyperactive-impulsive symptoms
  • Predominantly inattentive symptoms
  • Combined type
• Affected children commonly experience problems with academic underachievement, interpersonal relationships with family members and peers, and low self-esteem.
• ADHD frequently co-occurs with other emotional, behavioral, language, and learning disorders.

Five criteria (A – E) used to classify ADHD

Criterion A: Symptoms

A clinician must document the presence of at least six out of nine hyperactive-impulsive and/or at least six of nine inattentive symptoms. Preferably, assessing these symptoms should be done using both rating scales and clinical interviews.

Symptoms for inattention

1. Often fails to give close attention to details or makes careless mistakes
2. Often has difficulty sustaining attention
3. Often does not seem to listen
4. Often does not follow through on instructions, and fails to finish tasks
5. Often has difficulty organizing activities
6. Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained attention
7. Often loses things necessary for tasks or activities
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities

Symptoms for Hyperactivity/Impulsivity

For the diagnosis of Hyperactivity/impulsivity type of ADHD, a minimum of six out of the following nine symptoms must be present:

1. Often fidgets with hands or feet
2. Often leaves seats in situations where remaining seated is expected
3. Often runs about or climbs excessively
4. Often has difficulty engaging in leisure activities quietly
5. Is often “on the go” or acts as if “driven by a motor”
6. Often talks excessively
7. Often blurts out answers before questions have been completed
8. Often has difficulty waiting turn
9. Often interrupts or intrudes on others

Criterion B: Age of Onset

The DSM-IV-TR criteria stipulate that there must be evidence of clinically impairing symptoms prior to the age of 7 years, although there is controversy over the validity of this criterion.

Clinically, it is critical to establish chronicity of the disorder.

Criterion C: Pervasiveness

• DSM-IV-TR requires that the symptoms are pervasive (i.e. evident in at least two settings).
• In the strict sense, ADHD is not a school-based disorder, nor is it confined to the workplace for adults.
• Careful assessment of pervasiveness can include the collection of data (often via rating scales) from multiple sources.
• For children and adolescents, these sources most typically include a parent and a teacher, but can also include coaches, youth leaders, close adult relatives, or other individuals who spend considerable time with the patient.

Criterion D: Clinically significant impairment

In order to meet the criteria for ADHD, the symptoms exhibited (and documented in Criterion A) must cause clear, clinically significant impairment in major role functions of the patient.

For the child or adolescent, this typically refers to social, academic, and/or home functioning. In adolescents and adults, impairment can extend to occupational/vocational settings.

Criterion E: Ruling out Additional Disorders/Differential Diagnosis

• It is critical to make sure that the symptoms observed in the patient are not better accounted for by other psychiatric or medical conditions.
• A number of the symptoms of ADHD are also present in a range of other psychiatric conditions, including depression, bipolar disorder, anxiety disorders, and substance abuse disorders.

• More evidence now suggests that ADHD does not stem from home environment, but from biological causes.
• Knowing this can remove a huge burden of guilt from parents who might blame themselves for their child’s behavior.
• Over the last few decades, scientists have come up with possible theories about what causes ADHD.
• Some of these theories have led to dead ends, some to exciting new avenues of investigation.

Environmental Agents:

• Use of cigarettes and alcohol during pregnancy
• High levels of lead in the bodies of young preschool children

Brain Injury:

One early theory was that attention disorders were caused by brain injury. Some children who have suffered accidents leading to brain injury may show some signs of behavior similar to that of ADHD, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

Food Additives and Sugar:

It has been suggested that attention disorders are caused by refined sugar or food additives, or that symptoms of ADHD are exacerbated by sugar or food additives (Proven wrong).

Genetics:

• Attention disorders often run in families.
• Studies indicate that 25 percent of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5 percent in the general population.
• Many studies of twins now show that a strong genetic influence exists in the disorder.

Current Studies on Aetiolopathology

As a group, the ADHD children showed 3 – 4 percent smaller brain volumes in all regions – the frontal lobes, temporal gray matter, caudate nucleus, and cerebellum.

• Medicinal
• Non-medicinal

Considerations in Medication Selection in the Treatment of ADHD

• Age and individual variation
• Duration of effect
• The speed of action of the medication
• ADHD subtypes
• Comorbid symptom profile
• Comorbid psychiatric disorder
• History of earlier medication use
• Attitudes towards medication use
• Affordability
• Medical problems and other medications
• Associated features similar to medication side effects
• Combining stimulants with other medications
• Physician attitude towards ADHD medications

Drugs Used

• Amphetamine
• Dextro-amphetamine
• Methylphenidate
• Atomoxetine
• Isdexamfetamine dimesylate
• etc.

Psychosocial Intervention Overview

• Psychoeducation: is most relevant for individuals eight years and older and is designed to empower the patient and his/her supports with knowledge about the disorder, its impacts and how to function optimally while having ADHD.
  • These approaches can also include strategy instruction, self-talk, and organizational skill development.
  • Topics might include information on sleep management, anger, organizational skills, etc.
• Behavioural Interventions: Can be implemented at any age.
  • These include the thoughtful application of rewards, consequences, response cost, point systems, token economies (in group settings such as classrooms), environmental management, ADHD coaching, and lifestyle change (diet, exercise, sleep).
• Social Interventions: are useful across the lifespan and include social skills training, anger management, supervised recreation, and parent training.
• Psychotherapy: for adolescent and adult ADHD with/without comorbid conditions (such as poor self-esteem, depression, and anxiety) includes: self-talk, cognitive-behavioral therapy, expressive arts therapy, play therapy, and supportive counseling (typically for adjustment problems and less severe emotional concerns).
• Educational/vocational accommodation: include academic remediation, specialized educational placements, and workplace interventions.

Assessment

• Conner's Rating Scales

Conners-3 Rating Scales (Conners-3): A comprehensive set of rating scales used to assess ADHD symptoms in children and adolescents aged 6-18 years. It includes parent, teacher, and self-report forms that assess inattention, hyperactivity-impulsivity, and emotional problems.

Conners’ Adult ADHD Rating Scales (CAARS): A set of rating scales designed to assess ADHD symptoms in adults aged 18-80 years. It includes informant and self-report forms that assess inattention, hyperactivity-impulsivity, and emotional dysregulation.

• Vanderbilt ADHD Rating Scale (VANDERS)

A widely used rating scale for assessing ADHD symptoms in children and adolescents aged 6-12 years. It is completed by parents and teachers and assesses six core ADHD symptoms, as well as oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms.