What is attention deficit hyperactivity disorder (ADHD)?

Causes and Symptoms

Studies indicate that 2 to 10 percent of children may have attention deficit hyperactivity disorder (ADHD), depending on the diagnostic criteria used and the population studied. The cause of ADHD is unknown, although the fact that it often occurs in families suggests some degree of genetic inheritance. Boys are two times more likely to be affected than girls. ADHD is usually diagnosed when a child enters school, but it may be discovered earlier. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association in 2013, several of an individual's symptoms must be present prior to the age of twelve years for the diagnosis of ADHD.

An abnormality in the central dopaminergic and noradrenergic tone is thought to be the pathophysiologic basis for ADHD. Some genetic causes of ADHD that have been suggested include a possible mutation of the dopamine D4 receptor (DRD4) gene or a phenotypic variation in the catechol-O-methyltransferase (COMT) gene. Other risk factors being explored include head injury before the age of two years; exposure to emotionally traumatic situations such as abuse, neglect, or violence; and childhood exposure to environmental contaminants such as lead and organophosphate pesticides, substances such as alcohol and nicotine in utero, or secondhand smoke in childhood. Some studies have suggested that a high level of television viewing between the ages of one and three years is modestly associated with ADHD. Other studies suggest that food dyes and preservatives such as artificial colors or sodium benzoate may increase hyperactivity. Other possible factors that may increase the risk of ADHD include maternal urinary tract infection during pregnancy, premature birth, complex congenital heart disease, and Turner syndrome.

Individuals who do not have ADHD may, at times, display some of the symptoms of this disorder, but those who are diagnosed with ADHD must display symptoms most of the time and across multiple settings—in school, at home, and/or during other activities. According to the DSM-5, a child must display six or more ADHD symptoms for six months or longer to be diagnosed with the disorder, while adults must display five or more symptoms to be eligible for diagnosis. Prior to diagnosis, the referring pediatrician and specialist should rule any undetected hearing or vision problems, any learning disabilities, undetected seizures, and anxiety and depression that may be causing ADHD-like symptoms. The symptoms of ADHD are usually grouped into three main categories: inattention, hyperactivity, and impulsiveness.

Individuals who have symptoms of inattention often make careless mistakes or do
not pay close attention to details in school, social settings, or at work. They
may have problems sustaining attention over time and frequently do not seem to
listen when spoken to, especially in groups. Individuals with ADHD have difficulty
following instructions and often fail to finish chores or schoolwork. They do not
organize well and may have messy rooms and desks at school. They also frequently
lose things necessary for school, work, or other activities. Because they have
trouble sustaining attention, individuals with ADHD dislike tasks that require
this skill and will try to avoid them. One of the key symptoms is distractibility,
which means that people with ADHD are often paying attention to extraneous sights,
sounds, smells, and thoughts rather than focusing on the task that they should be
doing. ADHD may also be characterized by forgetfulness in daily activities,
despite numerous reminders about such common, everyday activities as dressing,
hygiene, manners, and other behaviors. People with ADHD seem to have a poor sense
of time; they are frequently late or think that they have more time to do a task
than they really do.

Not all individuals with ADHD have symptoms of hyperactivity, but many have
problems with fidgeting, or squirming. It is common for these individuals to be
constant talkers, often interrupting others. Other symptoms of hyperactivity
include leaving their seat in school, work, church, or similar settings and moving
around excessively in situations where they should be still. Some people with ADHD
seem to be driven by a motor or are continuously on the go.

Individuals with ADHD may also have some symptoms of impulsiveness, such as
blurting out answers before questions are completed. Another example of
impulsiveness would be or intruding upon others in conversation or in some
activity. They may also have difficulty standing in lines or waiting for their
turn.

It is important to recognize that children with ADHD are not bad children who are
hyperactive, impulsive, and inattentive on purpose. Rather, they are usually
bright children who would like to behave better and to be more successful in
school, in social life with peers, and in family affairs, but they simply cannot.
One way to think about ADHD is to consider it a disorder of the ability to inhibit
impulsive, off-task, or undesirable attention. Consequently, an individual with
ADHD cannot separate important from unimportant stimuli and cannot sort
appropriate from inappropriate responses to those stimuli. It is easy to
understand how someone whose brain is trying to respond to a multitude of stimuli,
rather than sorting stimuli into priorities for response, will have difficulty
focusing and maintaining attention to the main task.

Individuals with ADHD may also have a short attention span, particularly for
activities that are not fun or entertaining. They will be unable to concentrate
because they will be distracted by peripheral stimuli. They may also have poor
impulse control so that they seem to act on the spur of the moment. They may be
hyperactive or clumsy, resulting in their being labeled “accident-prone.” They may
also have problems completing tasks that require a lot of organization and
planning—often first seen when the individual is in the third grade or beyond.
They may display attention-demanding behavior and/or show resistant or
overpowering social behaviors. Last, children with ADHD often act as if they were
younger, and “immaturity” is a frequent label. Along with this trait, they have
wide mood swings and are seen as emotional.

Many experts think that ADHD may be related to problems with brain development. Studies have shown that the prefrontal cortex, striatum, and cerebellum in the brains of individuals with ADHD are less activated on functional magnetic resonance imaging (fMRI) than age-matched controls without ADHD. These regions of the brain are rich in dopaminergic and noradrenergic pathways and are associated with executive function. Other researchers have proposed the hypothesis that a developmental abnormality of the inferior frontal gyrus might cause the inhibition difficulties seen in ADHD.

Hyperactive symptoms may improve in adolescence, although adolescents with ADHD may continue to have problems with impulsive behavior and inattention. They may have considerable difficulty complying with rules and following directions. They may be poorly organized, causing problems both with starting projects and with completing them. Adolescents with ADHD may have problems in school in spite of average or above-average potential. They may have poor self-esteem and a low frustration tolerance. Because of these and other factors related to ADHD, they may also be at greater risk of developing substance use problems and other mental health problems. ADHD may also persist into adulthood, in which case it is referred to as adult ADHD. The same diagnostic criteria apply, including the presence of the disorder since childhood.

Several other neurologic or psychiatric disorders have symptoms that can overlap with ADHD, so accurate diagnosis can be difficult. When an individual is suspected of having ADHD, he or she should have a thorough medical interview with, and physical examination by, a physician familiar with child development, ADHD, and related conditions. A psychological evaluation to determine intelligence quotient (IQ) and areas of learning and performance strengths and weaknesses should be obtained. A thorough family history and a discussion of family problems such as divorce, violence, alcoholism, or drug abuse should be part of the evaluation, as symptoms of ADHD may arise after a significant and sudden change in a child's life. Other conditions that might be found to exist along with ADHD, or to be the underlying cause of symptoms thought to be ADHD, include oppositional defiant disorder, conduct disorder (usually seen in older children), depression, anxiety, or a substance abuse disorder.

"Attention-deficit disorder (ADD) with or without hyperactivity" was first defined
in the third edition of the American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders (1980), or DSM-III, and its
definition has evolved since then. The name ADD was changed to ADHD in the revised
edition of the DSM-III-R (1987). In 1998, the National Institutes of Health
(NIH) held a Consensus Development Conference on the
Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. While most
experts supported the ADHD diagnosis criteria, the final report noted a need for
further research into the validity of the diagnosis. The fifth edition of the
DSM(DSM-5), published in 2013, updated the definition of ADHD
to reflect the growing body of evidence that shows the condition can last beyond
childhood in order to help clinicians diagnose and treat adults with ADHD.
Approximately 50 percent of children with ADHD continue to have ADHD into
adulthood.

Treatment and Therapy

Treatment and therapy for ADHD will usually begin with the diagnostic process. Generally, treatment will begin with some combination of counseling, education, and behavioral therapy. Behavioral therapy may be administered by a parent, teacher, or counselor. In some cases, family counseling may be indicated. This counseling may be help family members learn about ADHD. Parent training interventions may help to improve some symptoms of ADHD in children. Family counseling also may be recommended when family issues are thought to be related to the type or severity of symptoms that the child may be experiencing. For instance, if the family is undergoing a stressful event, such as a divorce, serious loss, or death, or other problems such as economic stress, then the symptoms of ADHD may worsen. Therefore, treatment may focus on trying to minimize the impact of such stressors on the child. In addition, neurofeedback may reduce inattentive behaviors and impulsivity.

If behavioral and nonpharmacologic interventions do not lead to improvement and if there is a moderate to severe functional disturbance caused by ADHD, medications may be considered. Stimulants have the best evidence for the treatment of ADHD; stimulant medications include methylphenidate (Ritalin), extended-release dexmethylphenidate (Focalin), and amphetamines (Adderall). These medications are generally thought to be safe and effective, although they can have such adverse effects as headache, stomachache, mood changes, heart rate changes, appetite suppression, and interference with falling asleep. All children receiving medication must be monitored at regular intervals by a physician.

Nonstimulant medications are the second-line pharmacological treatment of ADHD,
especially if stimulant medications are ineffective or poorly tolerated. Other
medications that may be used for ADHD include atomoxetine (Strattera),
antidepressants such as desipramine or bupropion, and alpha-2 adrenergic agonists
such as clonidine and extended-release guanfacine.

Costs and risks for adverse effects should be discussed with the physician who has
made the diagnosis of ADHD before implementing any treatment, to ensure safety and
a reasonable expectation of efficacy.

Perspective and Prospects

Attention deficit hyperactivity disorder remains controversial due to the subjective nature of its symptoms and the possible overdiagnosis and overtreatment of the disorder. Historically, experts have estimated that ADHD affects between 2 and 10 percent of the general population. However, in March 2013, the New York Times reported that data from the Centers for Disease Control and Prevention showed that approximately 11 percent of children between the ages of four and seventeen have been diagnosed with ADHD, representing a 16 percent increase since 2007 and a 53 percent rise over the last decade. This follows a general increase in rates of diagnosis beginning in the 1970s. ADHD experts caution against attributing the increase to a single factor, including misdiagnosis and increased pharmacological treatment of milder forms of the disorder.

Many experts also suggest that shifts in how ADHD is diagnosed, increasing tendencies to prescribe medications, and a rise in public awareness and media attention have all contributed to an increase in diagnoses if not an increase in actual cases. These trends have also led some researchers to warn against overdiagnosis of ADHD, cautioning that not all children with high energy or difficulty focusing necessarily have the disorder, especially at very young ages. Some even challenge the concept of ADHD altogether, claiming that it is a case of applying a medical diagnosis to a range of behaviors that may go against social norms but have historically not been seen as a medical issue. Still, the majority of medical professionals do recognize ADHD as a legitimate condition, if one surrounded by continued controversies and misunderstandings.

For individuals with ADHD, the disorder is a real issue that can cause great harm
and impairment if not recognized and managed correctly. Diagnosis should be based
on family history, careful examination, and thorough psychological assessment.
Treatment should always begin with behavioral interventions before medication.

Individuals with ADHD in the United States can share experiences and resources
through organizations that assist families dealing with attention deficit
hyperactivity disorder. The national organization Children and Adults with
Attention Deficit/Hyperactivity Disorder (CHADD) has state and local chapters
helping individuals and families cope with the condition. CHADD chapters often
have libraries and provide resources on ADHD management. The Learning Disabilities
Association of America (LDA) also has state and local chapters helping schools and
families cope with a wide range of learning disabilities, including ADHD.

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