ADHD, or attention deficit hyperactivity disorder, is a common genetic neurodevelopmental disorder that affects executive functioning skills, such as attention, concentration, memory, motivation and effort, learning from mistakes, impulsivity, hyperactivity, organization, and social skills. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active. There is no cure for ADHD, but it can be successfully managed and some symptoms may improve as the child ages. ADHD occurs in most cultures in about 5% of children and about 2.5% of adults.
Symptoms of ADHD
ADHD begins in childhood. People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with proper functioning or development (American Psychiatric Association, 2013).
Inattention manifests behaviorally in ADHD as:
- Wandering off task on hand
- Lacking persistence
- Difficulty in sustaining focus
- Being disorganized
- And NOT due to lack of comprehension or defiance.
Hyperactivity manifests as:
- Inappropriate excessive motor activity (such as running about)
- Excessive fidgeting
- Extreme restlessness or wearing others out with their activity, in adults
Impulsivity could be due to a desire for immediate rewards or an inability to delay gratification. It manifests as:
- Hasty actions in the spur of the moment without much forethought, which have a high potential for harm (e.g., darting into the street without looking)
- Social intrusiveness (such as interrupting others often)
- Making important decisions without proper consideration of the consequences (such as taking up a job without enough information)
Nonspecific mild delays in language, motor, or social development can co-occur, presenting as low frustration tolerance, irritability, or mood lability. Performance at school or work is impaired. ADHD patients could exhibit problems with attention, memory, thinking, and reasoning on tests of attention, executive function, or memory. If there is comorbid mood, conduct, or substance use disorder, then ADHD in early adulthood can present an increased risk of suicide attempt.
Children with ADHD are significantly more likely than their peers to develop conduct disorder in adolescence and antisocial personality disorder in adulthood, resulting in a higher likelihood of substance use disorders and imprisonment. In adults with ADHD, there will be poorer occupational performance, attainment, attendance, and higher probability of unemployment as well as elevated interpersonal conflict.
Regarding the course of ADHD, DSM-5 has this to say: “A substantial proportion of children with ADHD remain relatively impaired into adulthood. In preschool, the main manifestation is hyperactivity. Inattention becomes more prominent during elementary school. During adolescence, signs of hyperactivity (e.g., running and climbing) are less common and may be confined to fidgetiness or an inner feeling of jitteriness, restlessness, or impatience. In adulthood, along with inattention and restlessness, impulsivity may remain problematic even when hyperactivity has diminished.” (American Psychiatric Association, 2013)
Causes of ADHD
Attention Deficit Disorder Association notes that “ADHD is NOT caused by poor parenting, falls or head injuries, traumatic life events, digital distractions, video games and television, lack of physical activity, food additives, food allergies, or excess sugar.”
Possible causes and risk factors of ADHD include:
- Genetics: ADHD risk is elevated in the first-degree biological relatives of individuals with ADHD.
- Brain injury
- History of child abuse, neglect, multiple foster placements
- Exposure to environmental neurotoxins (e.g., lead) during pregnancy or at a young age
- Exposure to infections (e.g., encephalitis)
- Alcohol and tobacco use during pregnancy
- Premature delivery
- Very low birth weight (< 1500 grams): A two- to three-fold increased risk for ADHD.
Diagnosis of ADHD: DSM-5 Criteria for ADHD
DSM-5 lists these diagnostic criteria for ADHD (American Psychiatric Association, 2013):
- Inattention: Six or more of the following symptoms of inattention, inappropriate for developmental level, have been present for at least 6 months for children up to age 16 years (five or more symptoms for adolescents age 17 and older and adults):
- Often fails to pay close attention to details or makes careless mistakes in schoolwork, at work, or in other activities.
- Often has trouble holding on to attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- Often has problems with organizing tasks and activities.
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a prolonged period (e.g., schoolwork or homework).
- Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by irrelevant stimuli
- Is often forgetful in daily activities.
- Hyperactivity and Impulsivity: Six or more of the following symptoms of hyperactivity-impulsivity which have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level for children up to age 16 years (five or more symptoms for adolescents age 17 and older and adults):
- Often fidgets with or taps hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is not appropriate (adolescents or adults may merely feel restless).
- Often unable to play or take part in leisure activities quietly.
- Is often “on the go” acting as if “driven by a motor”.
- Often talks excessively.
- Often blurts out an answer before a question has been completed.
- Often has trouble waiting his/her turn.
- Often interrupts or intrudes on others (e.g., in conversations or games)
In addition, the following conditions must be met:
- Several inattentive or hyperactive-impulsive symptoms were present before age 12.
- Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or job functioning.
- The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
- Combined Presentation: if enough symptoms of both inattention and hyperactivity-impulsivity criteria were present for the past 6 months
- Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past 6 months
- Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past 6 months.
Based on the severity of symptoms and functional impairment, ADHD can be classified as:
Mild: Only minimal symptoms required to make the diagnosis are present, resulting in only minor impairments in social or occupational functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: More symptoms are present than required to make the diagnosis, or several severe symptoms are present, or the symptoms cause marked impairment in social or occupational functioning.
Treatment of ADHD (CDC, 2019)
In most cases, ADHD is best treated with a combination of behavior therapy and medication. The first-line treatment recommended for preschool-aged children (4-5 years of age) with ADHD is behavior therapy, particularly training for parents. What works best is subject to variation and hence the need for close monitoring, follow-ups, and making changes, if needed, along the way.
Behavior Therapy, Including Training for Parents
The goals of behavior therapy are to make them learn or strengthen positive behaviors and eliminate unwanted or problem behaviors. Behavioral therapy can help reduce certain behaviors in young children, such as inability to pay attention or sit still at school, behaviors that are disruptive to others, and also improve relationships with family and other children. Alongside, parent training in behavior management gives parents the skills and strategies to help their child. This has been shown to work as well as medication for ADHD in young children. Also, medications are not first-line therapy in younger children because they have more side effects in them than in older children.
Behavior therapies effective in older children and adolescents include:
- Parent training in behavior management;
- Behavioral interventions in the classroom;
- Peer interventions that focus on behavior; and
- Organizational skills training.
Medication can help children manage their ADHD symptoms in their everyday life and can help them control the behaviors that cause difficulties with family, friends, and at school. Several different types of medications are FDA-approved for use in children 6 years or older with ADHD:
- Stimulants: They are fast-acting medications, most widely used in ADHD, and are helpful in symptom-relief in 70-80% of children with ADHD. Stimulants are thought to help by increasing the levels of the brain chemical dopamine, which plays essential roles in thinking and attention. Stimulant medications are methylphenidate (Ritalin, Concerta), Amphetamine/dextroamphetamine (Adderall, Adderall XR), lisdexamfetamine (Vyvanse), and dexmethylphenidate (Focalin XR).
- Nonstimulants: They were approved for the treatment of ADHD in 2003. They are slow-acting, but their effect can last up to 24 hours. They can improve focus, attention, and impulsivity in a person with ADHD. Examples of non-stimulants include atomoxetine and guanfacine.
Antidepressants are sometimes used to treat adults with ADHD, though they are not FDA-approved for ADHD. Older antidepressants, called tricyclics, help by affecting the brain chemicals norepinephrine and dopamine.
Coping with ADHD
The following are tips for parents that may help them modify and manage their child’s behavior:
- Create a routine.Follow the same schedule every day.
- Get organized. Teach and encourage the child to put away their things in the same place every day.
- Manage distractions.Turn off the TV. Limit noise. Play background music if that helps the child.
- Limit choices.To avoid overwhelmed feeling or overstimulation, offer choices with only a few options.
- Be clear and specific when you talk with your child.Repeat back to your child what they say. Use clear and brief directions.
- Help your child plan. Break down complicated tasks into simpler, shorter steps. Let them take breaks on longer tasks.
- Use goals and praise or other rewards.Use a chart to list realistic goals and track positive behaviors, and reward upon successful completion.
- Discipline effectively.Respond to inappropriate behavior not with scolding, yelling, or spanking, but with time-outs or removal of privileges.
- Create positive opportunities.Find out and encourage what your child does well.
- Provide a healthy lifestyle. Proper food, exercise, and sleepcan help keep ADHD symptoms from getting worse.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.
CDC, 2019. Treatment of ADHD. [Online]
Available at: https://www.cdc.gov/ncbddd/adhd/treatment.html
[Accessed 15 Nov 2019].