Attention Deficit Hyperactivity Disorder in Children, Adolescents and Adults.
DEFINITION:
Attention deficit hyperactivity disorder (ADHD), one of the most common neuropsychiatric disorders of childhood and adolescence, often persists into adulthood. It manifests in childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning.
ADHD in adults is characterized by symptoms of inattention, impulsivity, and restlessness, resulting in functional impairment. Emotional dysregulation is often seen in these patients.
EPIDEMIOLOGY AND PATHOGENESIS:
The prevalence of ADHD is estimated to be between 8 and 10 percent in school-age children, making it one of the most common disorders of childhood. It is more common in males than females.
Children and adolescents with ADHD frequently have comorbid psychiatric disorders, including oppositional defiant disorder (ODD), conduct disorder, depression, anxiety disorder, and learning disabilities.
The pathogenesis of ADHD is not definitively known. A genetic imbalance of catecholamine metabolism in the cerebral cortex appears to play a primary role.
Prenatal exposure to tobacco and prematurity/low birth weight are associated with development of ADHD.
CLINICAL FEATURES AND DIAGNOSIS:
CHILDREN AND ADOLESCENTS:
Hyperactive and impulsive behaviors almost always occur together in young children. Hyperactive and impulsive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years, peaking in severity when the child is seven to eight years of age. After seven to eight years of age, hyperactive symptoms begin to decline;by the adolescent years, they may be barely discernible to observers, although the adolescent may feel restless or unable to settle down. In contrast, impulsive symptoms usually persist throughout life. Symptoms of impulsivity in adolescents include substance use, risky behavior, and impaired driving.
Symptoms of hyperactivity and impulsivity:
- Excessive fidgetiness (eg, tapping the hands or feet, squirming in seat).
- Difficulty remaining seated when sitting is required.
- Feelings of restlessness (in adolescents) or inappropriate running around or climbing in younger children.
- Difficulty playing quietly.
- Excessive talking.
- Difficulty waiting turns.
- Blurting out answers too quickly.
- Interruption or intrusion of others.
Inattention: Children with the inattentive subtype often are described as having a sluggish cognitive tempo and frequently appear to be daydreaming. Similar to the pattern of impulsivity, symptoms of inattention usually are a lifelong problem. In adolescents, symptoms of inattention may result in academic difficulty.
Symptoms of inattention:
- Failure to provide close attention to detail, careless mistakes.
- Difficulty maintaining attention in play, school, or home activities.
- Seems not to listen, even when directly addressed.
- Fails to follow through (eg, homework, chores, etc).
- Difficulty organizing tasks, activities, and belongings.
- Avoids tasks that require consistent mental effort.
- Loses objects required for tasks or activities (eg, school books, sports equipment, etc).
- Easily distracted by irrelevant stimuli.
- Forgetfulness in routine activities (eg, homework, chores, etc).
Impaired functioning:To meet criteria for ADHD, core symptoms must impair function in academic, social, or occupational activities. Social skills in children with ADHD often are significantly impaired, making it difficult to form friendships. Hyperactive and impulsive behaviors may result in peer rejection. The negative consequences of impaired social function (eg, poor self-esteem, increased risk for depression and anxiety) may be long standing.
ADULTS:
Adult ADHD is often co-morbid with other psychiatric disorders: Mood disorders, anxiety disorders, substance use disorders, and intermittent explosive disorder. The rate of comorbid psychiatric disorders in adults with ADHD tends to increase with age. As people with ADHD age, the likelihood of anxiety, depression,substance use disorder, and antisocial personality disorder increases and often becomes more evident, while the underlying ADHD becomes less evident. Adults with ADHD are commonly diagnosed and treated for a comorbid condition, while ADHD is often unrecognized and untreated. ADHD can run in families. Some adults figure out that they have ADHD only after their child is diagnosed with it.
inattention problems characteristic of adult ADHD:
- Procrastination.
- Difficulty making decisions.
- Poor time management (eg, missing appointments or deadlines).
- Difficulty in organizing and prioritizing activities.
- Forgetfulness.
- Increased problems related to driving.
Impulsivity in adult ADHD is characterized by excessive involvement in activities or speech that has a high potential for consequences (premature termination of relationships or quitting jobs without having any alternative). Impulsivity can contribute to the driving errors, traffic tickets, and speeding.
Hyperactivity (restlessness): Rather than overly hyperactive, adults with ADHD will seem or report feeling fidgety or restless, talking too much and/or interrupting others.
Emotional dysregulation: Mood lability, irritability, anger outbursts, low frustration tolerance, and motivational deficits are commonly seen in adults with ADHD. Inability to manage uncomfortable emotions when necessary, and to engage in appropriate behavior (eg, go to work, engage in social relationships) when distressed.
Occupational effects, health and social problems: Adults with ADHD have higher levels of unemployment. Adults with ADHD who are employed experience workplace impairment and reduced productivity; they are also at increased risk of accidents and workplace injuries, particularly traffic accidents. Other problems associated with adult ADHD include reduced educational achievement and increased rates of substance abuse and criminality. ADHD-related impairments from childhood – such as educational difficulties, problems with self-esteem, significantly impaired family and peer relationships – are believed to contribute to these behavioral problems of adults.
EVALUATION:
Evaluation for ADHD should be initiated in children ≥4 years of age who have symptoms of inattention, hyperactivity, or impulsivity or who have complaints frequently associated with ADHD (eg, poor school performance, difficulty making and keeping friends, difficulty with team sports). Evaluation for ADHD requires comprehensive medical, developmental, educational, and psychosocial evaluation.
TREATMENT:
ADHD is a chronic condition. In addition to regularly monitoring the effectiveness of therapeutic interventions, it is important to provide information to the family and child about ADHD, help the family set specific treatment goals, and offer information regarding local support groups.
Regular communication between the parents and the teachers is important. This can occur through a daily report card or a weekly communication book.
Treatment of ADHD may involve behavioral interventions, medication, school-based interventions, or psychologic interventions alone or in combination.
The management of children with ADHD centers upon the achievement of target outcomes that are realistic, achievable, and measurable.
Examples of target outcomes include:
-Improved relationships with parents, teachers, siblings, or peers (eg, plays without fighting).
-Improved academic performance (eg, completes academic assignments).
-Improved rule following (eg, does not talk back to the teacher).
Behavior therapy and environmental changes that can be used by parents or teachers to shape the behavior of children with ADHD include:
- Maintaining a daily schedule.
- Keeping distractions to a minimum.
- Providing specific and logical places for the child to keep his or her schoolwork, toys, and clothes
- Setting small, reachable goals.
- Rewarding positive behavior (eg, with a "token economy").
- Identifying unintentional reinforcement of negative behaviors.
- Using charts and checklists to help the child stay "on task".
- Limiting choices.
- Finding activities in which the child can be successful (eg, hobbies, sports).
- Using calm discipline (eg, time out, distraction, removing the child from the situation).