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Attention Deficit Disorders

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

Top Contributors - James Vardeman, Uchechukwu Chukwuemeka, Nathan Smith, Kim Jackson, Shaimaa Eldib, Jess Bell, Rucha Gadgil, Shreya Pavaskar, Vidya Acharya, Ahmed M Diab, Elaine Lonnemann, Simisola Ajeyalemi, WikiSysop, Eugenie Lamprecht, Khloud Shreif, Ewa Jaraczewska and 127.0.0.1

Definition/Description

Attention deficit disorder/ hyperactivity disorder (ADHD) is a complex neurodevelopmental condition that can affect people throughout their life.[1][2]

It "is primarily characterized by developmentally inappropriate, persistent, and impaired levels of inattention, hyperactivity, and impulsivity."[1] ADHD can affect a person's mental and physical health, as well as their academic and work performance.[1][3]

Symptoms vary depending on the type of ADHD a person has. There are three subtypes of ADHD: (1) predominantly inattentive, (2) predominantly hyperactive/impulsive (3) combined presentation. ADHD can affect mental and physical health and academic and work performance.[1][4]

Prevalence

ADHD is the most prevalent childhood behavioural disorder.[5] The global estimated prevalence of ADHD in children and adolescents is 8.0%. The inattentive subtype of ADHD occurs most frequently, followed by hyperactive/impulsive and then combined presentations.[1] Boys are two times more likely to be affected than girls.[1] For around 30-50% of people with ADHD, symptoms persist through adolescence and into adulthood in a way that meets full diagnostic criteria.[6][7]However, many others experience a shift or reduction in symptoms-such as hyperactivity turning into restlessness or inattention while retaining residual traits that can still affect daily functioning, indicating ADHD often remains a lifelong condition.[8][9]

It has been found that using DSM-V (Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria results in higher ADHD prevalence rates in young people compared with earlier diagnostic frameworks.[10] Please click here to see a comparison between the DSM-IV and DSM-V for ADHD.

The prevalence of ADHD shifts somewhat in adulthood, with global estimates suggesting that approximately 3.1% of adults live with ADHD. Similar to younger populations, the inattentive subtype is the most common, followed by hyperactive/impulsive and combined ADHD.[11]

Aetiology/Causes

The aetiology of ADHD remains incompletely understood despite ongoing research. However, several factors are believed to be associated with ADHD.[12] Genetic predisposition appears significant, as ADHD frequently demonstrates familial patterns.[13][14] Environmental exposures, particularly early childhood lead exposure, may increase risk.[15][16] Neurodevelopmental disruptions during critical periods of central nervous system formation likely play a crucial role.[17][18] While sugar consumption has been popularly associated with hyperactivity, scientific evidence does not support it as a direct cause of ADHD, though it may temporarily affect attention in some individuals.[19]

Additional risk factors include having blood relatives with ADHD or other psychiatric disorders,[18][20] maternal substance use during pregnancy, including alcohol and tobacco,[21] and complications such as premature birth or low birth weight.[22][23]

Pathophysiology

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

Recent theories about ADHD focus on how brain networks function. Scientists think cognitive problems in ADHD may come from issues in the brain's front region and its connections (fronto-striatal networks) or other important brain pathways (meso-cortical networks). Problems with processing rewards might be linked to issues in another brain system that uses the chemical dopamine (mesolimbic system).[24]

A newer theory suggests that in people with ADHD, the brain's "default mode network", which is normally active during rest, may interfere with brain networks needed for tasks. This interference can make it hard to maintain a proper mental state and cause periodic lapses in attention.[25]

Additionally, two important brain chemicals, dopamine and norepinephrine, are thought to play roles in ADHD. Dopamine affects reward feelings, risk-taking, impulsivity, and mood. Norepinephrine affects attention, alertness, and mood. Research on people with ADHD points to possible issues with certain genes related to dopamine receptors (DRD4) and too much of a protein that transports dopamine (DAT1). The DRD4 receptor uses both dopamine and norepinephrine to help people pay attention to their environment and respond appropriately. The DAT1 protein removes these chemicals too quickly, possibly preventing them from working properly in the brain. While we need more research in this area, these brain chemicals clearly play an important role in ADHD.[17][26]

Characteristics/Clinical Presentation

ADHD symptoms start before the age of 12, and are sometimes noticeable as young as 3 years. Symptoms can range from mild to severe and may continue into adulthood.[27]

Symptoms of ADHD in Children

  • Children with attention disorders may encounter a variety of symptoms that disrupt their development and daily functioning[28]. They frequently miss details, make casual blunders, and struggle to stay focused during tasks, discussions, or reading. When spoken to directly, they may appear not to listen. They frequently struggle to follow directions, accomplish schoolwork or tasks, and lose focus fast due to distractions. Organising tasks and materials provides numerous obstacles, including difficulty sequencing activities, keeping possessions organised, and meeting deadlines. These children tend to avoid tasks that require continuous mental effort, such as homework or lengthy reading. They frequently misplace important objects such as school materials, books, and personal belongings. Unrelated ideas or external stimuli can quickly divert their attention, and they frequently forget daily.
  • In adults, the symptoms include:
    • Difficulty keeping attention on tasks.
    • Failure to pay attention to details/makes careless mistakes.
    • Difficulty organising 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.
  • Signs of hyperactivity and impulsivity may include:
    • Fidgeting and squirming while seated.
    • Getting up and moving around in situations where staying seated is expected, such as in the classroom or the office.
    • Running or dashing around or climbing in situations where it is inappropriate, or, in teens and adults, often feeling restless.
    • Being unable to play or engage in hobbies quietly.
    • Being constantly in motion or “on the go,” or acting as if “driven by a motor”.
    • Talking nonstop.
    • Blurting out an answer before a question has been completed, finishing other people’s sentences, or speaking without waiting for a turn in a conversation.
    • Having trouble waiting his or her turn.
    • Interrupting or intruding on others, for example, in conversations, games, or activities.
  • ADHD usually presents in 3 different ways:[29]
    • Predominantly Inattentive: difficulty sustaining focus, disorganised, 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.

Diagnosis

According to the National Institute of Mental Health, to be diagnosed with ADHD as an adult, these four factors must be taken into consideration:[30]

  • 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 work
  • There must be evidence that the symptoms interfere with the person’s functioning in these settings.

This criterion also applies in children, except for the first point, as ADHD could be seen and diagnosed as early as 3 years of age. 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 school repeatedly. Also, to be diagnosed with ADHD, a person must show symptoms for more than six months, and in more than one setting.[20] 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 that developmental problems, like language delays, can be mistaken for ADHD.

Therefore, the diagnosis of ADHD is made after a holistic evaluation from a specialist (ie psychologist, psychiatrist, speech pathologist, developmental paediatrician).[31]

Although there is no specific diagnostic test for ADHD, the procedure for the diagnosis will usually include:[32]

  • Medical examination to rule out other possible causes of the symptoms.
  • Medical history such as school records, and subjective history.
  • Interviews/questionnaires distributed to family members, teachers, and others who know the child well (coaches, babysitters, etc.
  • DSM-5: ADHD Criteria from the Diagnostic and Statistical Manual of Mental Disorders.
  • ADHD rating scales that could be parent, therapist, or teacher administered.

Recognising ADHD symptoms

Watch this video to understand how to recognise ADHD in children.

[33]

Differential Diagnosis

Medical conditions that can mimic ADHD include:[30]

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.[2] Also, a group of comorbidities for which special attention is found between ADHD and motor problems, referred to the Co-ordination Development Disorder (CDD).[34]

Moreover, ADHD is associated with accidental injuries. Literature suggests an increased risk of bone fractures in children with ADHD.[35] A recent meta-analysis[36] 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 that 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 was 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.[37] Those with this disorder also tend to maintain their addictions for longer.[38][39] Additionally, children with ADHD have been reported to have impaired handwriting[40]and impaired balance.[41]

Medical Management

ADHD treatment approaches vary by age group, with consideration for both behavioural therapy and medication. This guide outlines evidence-based strategies for managing ADHD across different age groups, focusing on effectiveness and safety.

Treatment by Age Group

Children 4-5 Years Old

For children aged 4-5 years, treatment primarily consists of parent and/or teacher-administered behavioural therapy. Medication is reserved only for cases where symptoms demonstrate significant and persistent manifestation. The preference for behavioural approaches stems from their minimal side effect profile compared to pharmacological interventions. Behavioural therapy provides parents with practical skills and strategies to help their child without the risks associated with medication. It is particularly important to note that the long-term effects of ADHD medications on young children have not been extensively studied, which further justifies the cautious approach to medication in this age group.[42]

Children 6-11 Years Old

For children between 6-11 years of age, physicians typically recommend a combined approach. This involves FDA-approved stimulant medications alongside parent and/or teacher behavioural therapy. Research demonstrates that this combination often yields better outcomes than either treatment modality alone. The behavioural component helps children develop self-regulation skills while medication addresses the neurobiological aspects of the condition. This dual approach addresses both the biological and environmental factors that contribute to ADHD symptoms.[27][43]

Adolescents 12-18 Years Old

When treating adolescents between 12-18 years old, medication serves as the primary method of management. Stimulant medications are most commonly prescribed, though other options may be considered based on individual response and tolerance. While medication takes precedence in this age group, behavioural therapy is still strongly recommended as a complementary approach. The behavioural component for adolescents often focuses on developing self-management strategies, academic support, and addressing the unique social challenges that emerge during teenage years.[27]

Adults with ADHD

For adults with ADHD, treatment typically follows a multimodal approach similar to that used for adolescents. Medication remains the cornerstone of treatment, with stimulants generally considered firstline pharmacotherapy due to their robust efficacy. Non-stimulant medications may be appropriate for adults who cannot tolerate stimulants or have comorbid conditions where stimulants are contraindicated. Alongside medication, cognitive-behavioural therapy specifically adapted for adult ADHD has shown effectiveness in addressing executive functioning deficits, organisational challenges, and emotional regulation.[44] Adults with ADHD often benefit from psychoeducation about the condition, which helps them understand how ADHD affects their daily functioning and relationships. Additionally, coaching focused on developing compensatory strategies for workplace functioning, time management, and interpersonal skills forms an important component of comprehensive adult ADHD management.[45] Regular monitoring is essential, as adults may experience different medication side effects and may require dosage adjustments to balance symptom control with tolerance.[43]

Medication Options

Stimulant Medications

Stimulant medications have demonstrated high effectiveness in reducing core ADHD symptoms across numerous clinical trials. These medications include methylphenidate-based and amphetamine-based formulations, available in various delivery systems such as immediate-release and extended-release options. The choice between these formulations depends on the individual's symptom pattern, daily routine, and response to treatment. Stimulants work by increasing the availability of certain neurotransmitters in the brain, which helps improve attention and reduce hyperactivity and impulsivity.[43]

Non-Stimulant Alternatives

For individuals who do not respond adequately to stimulants or experience intolerable side effects, non-stimulant medications offer alternative options. These include selective norepinephrine reuptake inhibitors and selective alpha adrenergic agonists. While generally considered second line treatments, these medications have shown efficacy in reducing ADHD symptoms and may be particularly useful for patients with certain comorbid conditions or those who experience significant adverse effects with stimulants.[46]

Potential Medication Side Effects

ADHD medications, particularly stimulants, can cause several side effects that require monitoring. These include sleep disturbances, decreased appetite, delayed growth, headaches and stomachaches, rebound irritability as medication wears off, tics, and changes in mood, including irritability. The presence and severity of these side effects vary considerably between individuals and often influence medication choice and dosing strategies. Regular monitoring can help identify and manage these side effects effectively.[47][27]

Behavioural Interventions

Behaviour Therapy Approach

Behaviour therapy represents a structured intervention designed to modify both the physical and social environments that influence a child's behaviour. This approach employs clear systems of rewards and consequences to encourage positive behaviours and discourage problematic ones. Although characterised as a broad, non-specific intervention, behaviour therapy provides concrete strategies for parents, teachers, and caregivers to help children with ADHD develop better self-regulation skills. The therapy focuses on consistency, positive reinforcement, and clear expectations across different settings.[27]

Peer-Based Interventions

Peer interventions form another important component of comprehensive ADHD management. These include dedicated social skills training and time-intensive, adult-mediated interactions specifically designed to improve social behaviours. Such interventions help address the social difficulties many children with ADHD experience, including problems with peer relationships and social cue interpretation.[48] These structured settings allow children to practice appropriate social responses and receive immediate feedback, gradually building their social competence.[49]

Treatment Monitoring

Effective ADHD management requires regular assessment of symptom control, medication effectiveness, and potential side effects. Healthcare providers should conduct periodic evaluations to determine whether treatment adjustments are necessary. These assessments may include feedback from parents, teachers, and the individual with ADHD. The goal is to optimise functioning while minimising adverse effects, recognising that treatment needs may change over time as the individual develops and their circumstances evolve.[27][47]

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 is believed that people who already have heart disease or a heart defect are at greater risk for this[12]

Class: Amphetamines[50]

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

Class: Methylphenidate[50]

  • 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 that 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[50][12].

Class: Norepinephrine Uptake Inhibitor

  • Strattera (Atomoxetine)

Class: Alpha Adrenergic Agents

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

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[29]. 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 in those with ADHD, especially children. The ability to maintain attention is improved with physical exercise as well, with better sustained auditory attention[51].
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 [52]. It has also been suggested by studies that yoga can reduce impulsivity, anxiety, and social problems in all individuals with ADHD[53].

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[54][55].

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[56][57].

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 [58]. 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[2].

A study reveals neurodivergent adults (with autism, ADHD, or tic disorders) have significantly higher rates of joint hypermobility (51%) compared to the general population (20%). They also experience more orthostatic intolerance and musculoskeletal pain, with joint hypermobility mediating these physical symptoms. For physiotherapists, this suggests the importance of screening neurodivergent patients for hypermobility and adapting treatment approaches to address joint stability, orthostatic symptoms, and pain management specifically for this population. Recognising this connection could substantially improve care outcomes and quality of life for neurodivergent individuals[59].

Additionally, another research suggests neurodivergent individuals may experience emotional dysregulation due to imprecise processing of proprioceptive signals, particularly when they have variant connective tissue and joint hypermobility. For physiotherapy, this implies that treatments should address the neurological-emotional connection by adapting techniques for different proprioceptive processing patterns, potentially improving physical symptoms and emotional regulation in neurodivergent patients with hypermobility.[60]

Related Research

  • Significant differences in Vitamin D and B12 levels in ADHD/ASD and a negative correlation between vitamins and platelet volume in ADHD group have been reported. Both conditions may increase cardiovascular disease risk due to vitamin deficiencies.[12]
  • Methylphenidate treatment of >180 days has been linked to 25% lower fracture risk. But shorter treatments don't reduce risk. High prevalence of ADHD and personal costs of fractures underscore public health significance.[61]
  • Although sleep promotes memory consolidation and fosters rewarded behaviour in healthy children but not in ADHD+CD/ODD patients. Poor sleep quality contributes to learning impairment.[62] Therefore, sleep hygiene training is recommended.[2]
  • Verbal classroom environments create heavy demands on information retention.[63] Teacher demonstrations improve retention for all children, providing potential intervention targets.[64]
  • Methylphenidate treatment has been associated with a significantly increased risk of arrhythmia. Myocardial infarction risk increases after first week, remaining high for first two months of continuous treatment.[27][65]
  • Multiple physiotherapy approaches show significant improvements in balance, fine motor skills, body image, and temporal organisation in ADHD children.[66][67]
  • 2018 NICE guidelines aim to improve ADHD patients' lives through detailed symptom information, diagnostic criteria, multi-agency management, medication adherence, balanced diet, and healthy lifestyle recommendations.[29]
  • Limited research suggests elimination diets and fish oil supplementation are promising for reducing ADHD symptoms. Wholesome diets preferred over supplements.[68]

References

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