Attention Deficit Disorders

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - James Vardeman, Nathan Smith, Kim Jackson, Shaimaa Eldib, Rucha Gadgil, Uchechukwu Chukwuemeka, Vidya Acharya, Shreya Pavaskar, Elaine Lonnemann, WikiSysop, Simisola Ajeyalemi, Eugenie Lamprecht and 127.0.0.1  

Definition/Description

The attention deficit disorder/ hyperactivity disorder (ADHD) is the most prevalent neuropsychiatric disorder, affecting 5-10% of children in school age, and continuing through adolescence and adulthood in about 30-50% of them. Attention deficit hyperactivity disorder (ADHD) is a neurobiological condition characterized by developmentally inappropriate and impairing patterns of inattention, hyperactivity, and impulsivity.

According to the National Institute of Mental Health, Attention-deficit/hyperactivity disorder (ADHD) is defined as “a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development”. In adults, this disorder may cause trouble getting organized, remembering appointments, or even have trouble keeping a job. Activities of Daily Living are affected due to the inability to keep attention on one task at a time. Chronic conditions affecting millions of children and often continues into adulthood.

Children with ADHD may also struggle with low self-esteem, troubled relationships, and poor performance in school. Symptoms experienced by these individuals sometimes diminish as one age. For those who's symptoms persists, coping strategies can be learned in order to be successful

Prevalence

• The onset of this condition typically occurs according to a common trend in children, with boys being more likely to show signs and symptoms.
  Average age of onset: 7 years old
  12 month prevalence: 4.1% of U.S adult population

Prevalence of ADHD

Percentage of children 5-17 years old diagnosed	10.2%
Percentage of boys 5-17 years old diagnosed	14.1%
Percentage of girls 5-17 years old diagnosed	6.2%

Etiology/Causes

The exact cause of ADHD is not clear but research continues on the topic. Sugar is a suspect in causing hyperactivity, but there is no reliable proof that this directly causes ADHD. Although it may play a role in one’s sustain attention, it is not considered to be a cause of ADHD.

Factors

Possible factors that are thought to play a role include:

• Genetics: ADHD can run in families, and studies show that genes may play a role.
• Environment: Factors, such as lead exposure may increase the risk during early childhood
• Development: Problems with the central nervous system at key moments of development may play a role.

Other risk factors for ADHD may include:

• Blood relatives with ADHD or other mental health disorders
• Maternal drug use such as alcohol or tobacco use during pregnancy.
• Premature birth/Low Birth Weight

Pathophysiology

ADHD is associated with cognitive and motivational problems as well as resting-state abnormalities, associated with impaired brain activity in distinct neuronal networks.

More recent theoretical approaches integrate clinical symptoms and neuropsychological difficulties hypothesizing that cognitive deficits may emerge from dysfunctions particularly in fronto-striatal or meso-cortical brain networks, while problems with reward processing may be associated with dysfunctions in the mesolimbic dopaminergic system. More fundamental neuronal network approach suggests that in ADHD particularly Default-Mode-Network (DMN) activity (usually prominent during rest) may interfere with activity in neuronal networks engaged in task processing, leading to difficulties in state regulation and periodic attentional lapses.

The neurotransmitters dopamine (DA) and norepinephrine (NE) are implicated in the pathophysiology of ADHD. Dopamine is a neurotransmitter involved in reward, risk taking, impulsivity, and mood. Norepinephrine modulates attention, arousal, and mood. Studies on individuals with ADHD suggest a defect in the dopamine receptor D4 (DRD4) receptor gene and overexpression of dopamine transporter-1 (DAT1). The DRD4 receptor uses DA and NE to modulate attention to and responses to one's environment. The DAT1 or dopamine transporter protein takes DA/NE into the presynaptic nerve terminal so it may not have sufficient interaction with the postsynaptic receptor. Though these implications need further studies, the involvement of neurotransmitters cannot be ignored.

Characteristics/Clinical Presentation

ADHD symptoms start before the age of 12, and sometimes as noticeable as young as 3 years. Symptoms can range from mild to severe and can continue into adulthood

Symptoms of ADHD in Children

In children, symptoms include:

• These symptoms get in the way of functioning or development. People who have ADHD have combinations of these symptoms:
  1. Overlook or miss details, make careless mistakes in schoolwork, at work, or during other activities.
  2. Have problems sustaining attention in tasks or play, including conversations, lectures, or lengthy reading.
  3. Seem to not listen when spoken to directly.
  4. Fail to not follow through on instructions, fail to finish schoolwork, chores, or duties in the workplace, or start tasks but quickly lose focus and get easily distracted .
  5. Have problems organizing tasks and activities, such as doing tasks in sequence, keeping materials and belongings in order, keeping work organized, managing time, and meeting deadlines.
  6. Avoid or dislike tasks that require sustained mental effort, such as schoolwork or homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers.
  7. Lose things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones.
  8. Become easily distracted by unrelated thoughts or stimuli.
  9. Forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments.
• Signs of hyperactivity and impulsivity may include:
  1. Fidgeting and squirming while seated.
  2. Getting up and moving around in situations when staying seated is expected, such as in the classroom or in the office.
  3. Running or dashing around or climbing in situations where it is inappropriate, or, in teens and adults, often feeling restless.
  4. Being unable to play or engage in hobbies quietly.
  5. Being constantly in motion or “on the go,” or acting as if “driven by a motor”.
  6. Talking nonstop.
  7. Blurting out an answer before a question has been completed, finishing other people’s sentences, or speaking without waiting for a turn in conversation.
  8. Having trouble waiting his or her turn.
  9. Interrupting or intruding on others, for example in conversations, games, or activities.

Presentation of ADHD

ADHD usually presents in 3 different ways in children:

• Predominantly Inattentive: difficulty sustaining focus, dis-organized, easily distracted or forgets details of daily routines.
• Predominantly Hyperactive-Impulsive: hyperactivity means a person moves constantly or is restless. Impulsivity means a person makes hasty actions that occur at the moment.
• Combined :it includes symptoms of both but presentation may incline towards one as the child grows.

To be diagnosed with ADHD as an adult, several factors must be taken into account.

Factors

According to the National Institute of Mental Health, four factors must be taken into consideration:

• Several symptoms must be present before the age of twelve.
• A person must have at least five symptoms of either inattention and/or hyperactivity-impulsivity.
• The symptoms must be present in two or more settings, such as at home and at work
• There must be evidence the symptoms interfere with the person’s functioning in these settings.

Symptoms of ADHD in adults

• Failure to pay attention to details/makes careless mistakes.
• Difficulty keeping attention on tasks.
• Difficulty organizing tasks and activities.
• Avoids activities requiring sustained mental effort.
• Easily distracted.
• Forgetfulness in activities of daily living.
• Fidgety/squirms.
• Unable to remain still for extended periods of time.

Associated Co-morbidities

There are multiple comorbidities associated with ADHD.

• There is a high rate of anxiety in those diagnosed with ADHD, along with depressive disorder. Having the diagnosis of ADHD doubles the likelihood of having depression. The bipolar disease has a growing association as well, with 22% of those with ADHD having bipolar disorder as well.
• A group of comorbidities for which turns special attention that is found between ADHD and motor problems, also referred to the Co-ordination Development Disorder (CDD)
• ADHD is associated with accidental injuries. Literature suggests increased risk of bone fractures in children with ADHD. A recent meta-analysis revealed the prevalence of fractures among children and adolescents diagnosed with ADHD is 4.83 % (95 % CI: 3.07 to 6.58). The other findings which the study showed were children with ADHD had a 2.55-fold increase in the prevalence of fractures than those without ADHD and the distribution of fractures among the population with ADHD to be in the upper limb (69.62 %), lower limb (22.85 %), and other anatomic regions (7.53 %).
• There is data to indicate that youth with ADHD are at an increased risk for cigarette smoking and substance abuse during their teenage years, and are twice as likely as their non-ADHD counterparts for this to occur. Those with this disorder also tend to maintain their addictions for longer.
• Children with ADHD have been reported to have impaired handwriting and impaired balance.

Medications

Stimulants

Several heart-related deaths have occurred in children and teenagers taking stimulants. Although unproven at this point as to why this is, it’ believed that people who already have heart disease or heart defect are at greater risk for this

Class: Amphetamines

• Adderall (mixed amphetamine salts)
• Adderall XR (Extended release mixed amphetamine salts)
• Dexedrine (Dextroamphetamine)
• Dexedrine Spansule (Dextroamphetamine)
• Vyvanse (Lisdexamfetamine (extended release))

Class: Methylphenidate

• Concerta (Methylphenidate)
• Daytrana (Methylphenidate (patch))
• Focalin (dexmethylphenidate)
• Focalin XR (extended release dexmethylphenidate)
• Metadate ER extended release methylphenidate)
• Metadate CD (extended release methylphenidate)
• Methylin (Methylphenidate hydrochloride)
• Quillivant XR (extended release methylphenidate)
• Ritalin (Methylphenidate)
• Ritalin LA (extended release methylphenidate)
• Ritalin SR (extended release methylphenidate)

Non-Stimulants

Concerns have been raised threat there may be a slightly increased risk of suicidal thoughts in children and teenagers taking non-stimulant medication or antidepressants. Contact your child’s doctor if you notice any signs of depression or suicidal thoughts.

Class: Norepinephrine Uptake Inhibitor

• Strattera (Atomoxetine)

Class: Alpha Adrenergic Agents

• Intuniv (extended-release guanfacine)
• Kapavay (extended-release clonidine)

Diagnostic Tests/Lab Tests/Lab Values

• First off, a child should only receive a diagnosis of ADHD if the core symptoms start before the age of 12 and create significant problems at home and at school repeatedly.
• Also, to be diagnosed with ADHD, a person must show symptoms for more than six months, and in more than one setting. Although the signs and symptoms of ADHD can sometimes manifest themselves in children of preschool age or even younger, diagnosis at a very young age is difficult. The reason for this is because developmental problems, like language delays, can be mistaken for ADHD. Therefore, children at the preschool age or younger suspected of having ADHD are more likely to need an evaluation from a specialist (ie psychologist, psychiatrist, speech pathologist, developmental paediatrician). 
• Although there is no specific diagnostic test for ADHD, the diagnosis will usually include:

1. medical exam: ruling out other possible causes of the symptoms.
2. medical history: school records, and subjective history.
3. interviews/questionnaires: distributed to family members, teachers, and others who know the child well (coaches, babysitters, etc.
4. DSM-5: ADHD Criteria from the diagnostic and statistical manual of mental disorders.
5. ADHD rating scales- parent, therapist, teacher administered.

Differential Diagnosis

Medical conditions that can mimic ADHD include:

• Learning/language problems
• Mood disorders (depression, anxiety)
• Psychiatric disorders
• Seizure disorders
• Vision/hearing problems
• Tourette’s Syndrome
• Cognitive and behavioural disorders
• Sleep disorders
• Thyroid issues
• Substance abuse
• Brain injury

Medical Management

Treatment varies with the age of individuals with ADHD. For children 4 to 5 years old, treatment consists of parent and/or teacher administered behaviour therapy.

If the symptoms have a well-founded manifestation, the doctor may prescribe medication, although this is not the most desirable course of action. Initially, attempting behavioural therapy can give the parents skills and strategies to help their child, relatively no side effects in comparison to medication prescription, and the long term effects of ADHD medication on young children have not been widely studied.

ADHD medications can cause sleeping problems, decreased appetite, delayed growth, headaches/stomachaches, rebound irritability, tics, and moodiness/irritability. For children who are 6-11 years of age, then the physician should prescribe medication (usually stimulant medications), along with possible parent and/or teacher behavioural therapy. The medication is more important here, although behavioural therapy is an important part of management as well.

For adolescents who are defined as 12-18 yrs old, medication is the primary method of management. It is also recommended that behaviour therapy is also prescribed.

Stimulant medications are highly effective in reducing ADHD symptoms. Other medications including selective norepinephrine-reuptake inhibitors and selective alpha-adrenergic agonists have also been shown to be effective.

Behaviour therapy is a broad, non-specific intervention. Its goal is to modify both the physical and social environment to change the behaviours of those with ADHD. This is done by using rewards and consequences for certain behaviours. 

Peer interventions include social skills training and time-intensive, adult-mediated interactions to improve social behaviors.

Physical Therapy Management

Physical activity and exercise have been shown to reduce stress, anxiety, and depressive symptoms as well as improve cognitive function. Research exists to show that regular exercise can alter brain functions both emotionally and cognitively.

For those with ADHD, it has been shown that moderate to high-intensity exercise improved parent-teacher behaviour reports and levels of information processing. With moderate to high-intensity training, it has also been shown that motor performance was improved as well. Physical activity improves social skills and behaviour as well in those with ADHD, especially children. The ability to maintain attention is improved with physical exercise as well, with better sustained auditory attention.
Another possible intervention for those with ADHD is yoga. Studies have been conducted that show that an eight-week yoga intervention improved both selective and sustained attention in children with ADHD. It has also been suggested by studies that yoga can reduce impulsivity, anxiety, and social problems in all individuals with ADHD.

Techniques like massage therapy, breathing exercises, and aquatic therapy have been shown to reduce anxiety, stress, muscle tension caused by ADHD and further promote relaxation and improve the quality of life.

Research has shown that techniques like Watsu decrease the muscle tension and pain, by affecting all physical, psychological, and emotional levels, and also reduces stress, anxiety, and fatigue. Accordingly, Watsu is useful for children, because it is fun, allowing facilitating the movement, stimulating further the child to treatment.

Executive Function (EF) training program was feasible and acceptable to children with ADHD and parents. This type of training with multiple EF focus and parent involvement in real-life activities could be a potentially promising intervention associated with significant EF and ADHD symptoms improvements. Specifically, for children with ADHD, it is important and useful to reduce the EF developmental gap by teaching the children to appropriate coping skills and strategies.

Related Research

• Significant differences in hematologist parameters in terms of Vitamin D and Vitamin B12 in those who have been diagnosed with ADHD or ASD (Autism Spectrum Disorder). In ADHD group, the negative correlation between both vitamins and mean platelet volume. Therefore, both ADHD and ASDs may accompany the increased risk for cardiovascular disease due to the presence of vitamin deficiencies.

• Methylphenidate treatment exceeding 180 days or greater was linked to nearly 25% lower risk for fracture comparing to those who never received methylphenidate. Also, shorter duration of medical treatment doesn’t mitigate the risk for fracture. Although the foregoing collection of observations suggests that psychostimulant prescription mitigates the risk for fracture, data wasn’t provided on whether the treatment duration further moderated risk reduction. The high lifetime prevalence and persistence of ADHD, as well as personal costs associated with fracture and other unintentional injuries, underscores the public health significance of this topic.

• Sleep promotes the consolidation of declarative memory in healthy children but not in children with ADHD. Sleep seems to foster the consolidation of rewarded behaviour in healthy children but not in children suffering from ADHD+CD/ODD (contact disorder; oppositional defiant disorder). Severely affected patients pose a great challenge for therapeutic and pedagogical interventions. Behavioural therapy using reward is the main approach in these patients. Therefore, the consolidation of behaviour learned by reward is a topic of high clinical relevance. In conclusion, healthy children consolidate rewarded behaviour better. Night of sleep than during a day of awake. Sleep dependent consolidation of rewarded behaviour is diminished in children with ADHD and doesn’t correlate with sleep. This helps explain why children suffering from ADHD often display impaired learning and memory and are at risk of school failure. Take into account poor sleep quality when treating children with ADHD and a co-morbid disorder of social behaviour. Sleep hygiene training might help to improve both sleep as well as social behaviour in children with ADHD.

• The classroom is a predominantly verbal environment, placing a heavy demand on children to retain spoken or written instruction. Teacher demonstration may improve the retention of important information both for children with and without developmental difficulties. This provides a possible target for training and intervention.

• Significantly increased overall risk of arrhythmia she associated with treatment with methylphenidate in children with ADHD. Risk of MI not significant overall; but, increased risk after the first week of treatment, remaining significantly raised for the first two months of continuous treatment.

• Physiotherapy management using multiple approaches namely motor perception, sensory integration therapy, kinesiotherapy, neurobehavioral performance, and a motor intervention program showed significant improvements in balance, fine motor skills, body image, and temporal organization in children with ADHD.

• The National Institute for Health and Care Excellence (NICE) has recently published guidelines for diagnosis and management of Attention Deficit Hyperactivity Disorder (ADHD) in 2018 which aim to improve the lives of people with ADHD by providing detailed information on common symptoms, diagnostic criteria and multi-agency management with the importance of adherence to medication when prescribed, the importance of a balanced diet and the role of diary, the role of a healthy lifestyle and exercise highlighted with links to supporting evidence.

• Dietary alterations- Although very few studies have been carried out in this area, elimination diets and fish oil supplementation seem to be the most promising dietary interventions for a reduction in ADHD symptoms in children. it has been found that a wholesome diet instead of supplementary items are beneficial to ADHD.