ADHD (Attention deficit hyperactivity disorder) is a mental disorder of the neurodevelopmental type. It is characterized by problems paying attention, excessive activity, or difficulty controlling behavior that is not appropriate for a person’s age. The symptoms appear before a person is twelve years old, are present for more than six months, and cause problems in at least two settings (such as school, home, or recreational activities). In children, problems paying attention may result in poor school performance. Although it causes impairment, particularly in modern society, many children with ADHD have a good attention span for tasks they find interesting.
Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. People with ADHD experience an ongoing pattern of the following types of symptoms:
- Inattention means a person may have difficulty staying on task, sustaining focus, and staying organized, and these problems are not due to defiance or lack of comprehension.
- Hyperactivity means a person may seem to move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks. In adults, hyperactivity may mean extreme restlessness or talking too much.
- Impulsivity means a person may act without thinking or have difficulty with self-control. Impulsivity could also include a desire for immediate rewards or the inability to delay gratification. An impulsive person may interrupt others or make important decisions without considering long-term consequences.[rx]
Types of ADHD
Using the above criteria, a health professional can determine the type of ADHD a child has. Types of ADHD include:
- ADHD combined type – if the child meets the criteria for both inattention and hyperactivity-impulsivity for the past six months
- ADHD predominantly inattentive type – if the child meets the criteria for inattention, but not the criteria for hyperactivity-impulsivity, for the past six months
- ADHD predominantly hyperactive-impulsive type – if the child meets the criteria for hyperactivity-impulsivity, but not the criteria for inattention, in the past six months.
Causes of ADHD
The cause of ADHD isn’t known. Researchers say several things may lead to it, including
- Heredity – ADHD tends to run in families.
- Chemical imbalance – Brain chemicals in people with ADHD may be out of balance.
- Genetics – ADHD can run in families, and studies indicate that genes may play a role.
- Environment – Certain environmental factors also may increase risk, such as lead exposure as a child.
- Neurophysiology – which includes differences in brain anatomy, electrical activity, and metabolism
- Drugs – the child’s mother having used nicotine or cocaine during pregnancy
- Lead – chronic exposure to low levels of the metal lead may influence behavior and brain chemistry
- Lack of early attachment – if a baby does not bond with their parent or caregiver, or has traumatic experiences related to the attachment, this can contribute to their inattention and hyperactivity
- Childhood post-traumatic stress disorder – a child with this disorder may have symptoms similar to ADHD but will need different treatment.
- Problems during development – Problems with the central nervous system at key moments in development may play a role.
- Brain changes – Areas of the brain that control attention is less active in children with ADHD.
- Poor nutrition, infections, smoking, drinking, and substance abuse during pregnancy – These things can affect a baby’s brain development.
- Toxins, such as lead – May affect a child’s brain development.
- A brain injury or a brain disorder – Damage to the front of the brain, called the frontal lobe, can cause problems with controlling impulses and emotions.
ADHD also isn’t caused by watching too much TV, a poor home life, poor schools, or food allergies.
Symptoms of ADHD
According to the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), symptoms must be present for six months or more to a degree that is much greater than others of the same age and they must cause significant problems functioning in at least two settings (e.g., social, school/work, or home). The full criteria must have been met prior to age twelve in order to receive a diagnosis of ADHD.
ADHD is divided into three subtypes – predominantly inattentive (ADHD-PI or ADHD-I), predominantly hyperactive-impulsive (ADHD-PH or ADHD-HI), and combined type (ADHD-C).
A child with ADHD inattentive type has most or all of the following symptoms, excluding situations where these symptoms are better explained by another psychiatric or medical condition
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty maintaining focus on one task
- Become bored with a task after only a few minutes, unless doing something they find enjoyable
- Have difficulty focusing attention on organizing or completing a task
- Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
- Appear not to be listening when spoken to
- Daydream, become easily confused and move slowly
- Have difficulty processing the information as quickly and accurately as others
- Struggle to follow instructions
- Have trouble understanding details; overlooks details
A child with ADHD hyperactive-impulsive type has most or all of the following symptoms, excluding situations where these symptoms are better explained by another psychiatric or medical condition
- Fidget or squirm a great deal
- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school, doing homework, and storytime
- Be constantly in motion
- Have difficulty performing quiet tasks or activities
- Be impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
- Have difficulty waiting for things they want or waiting their turn in games
- Often interrupt conversations or others’ activities
Girls tend to have less hyperactivity, inattention, and impulsivity but greater symptoms pertaining to inattention and distractibility. Symptoms of hyperactivity tend to go away with age and turn into “inner restlessness” in teens and adults with ADHD
Adult ADHD symptoms may include
- Impulsiveness
- Disorganization and problems prioritizing
- Poor time management skills
- Problems focusing on a task
- Trouble multitasking
- Excessive activity or restlessness
- Poor planning
- Low frustration tolerance
- Frequent mood swings
- Problems following through and completing tasks
- Hot temper
- Trouble coping with stress
| ADHD symptoms which are related to other disorders | |||
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| Depression | Anxiety disorder | Bipolar disorder | |
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Inattention
People with symptoms of inattention may often:
- Overlook or miss details and make seemingly careless mistakes in schoolwork, at work, or during other activities
- Have difficulty sustaining attention during play or tasks, such as conversations, lectures, or lengthy reading
- Not seem to listen when spoken to directly
- Find it hard to follow through on instructions or finish schoolwork, chores, or duties in the workplace, or may start tasks but lose focus and get easily sidetracked
- Have difficulty organizing tasks and activities, doing tasks in sequence, keeping materials and belongings in order, managing time, and meeting deadlines
- Avoid tasks that require sustained mental effort, such as homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers
- Lose things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones
- Be easily distracted by unrelated thoughts or stimuli
- Be forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments
Hyperactivity-Impulsivity
People with symptoms of hyperactivity-impulsivity may often:
- Fidget and squirm while seated
- Leave their seats in situations when staying seated is expected, such as in the classroom or the office
- Run, dash around, or climb at inappropriate times or, in teens and adults, often feel restless
- Be unable to play or engage in hobbies quietly
- Be constantly in motion or on the go, or act as if driven by a motor
- Talk excessively
- Answer questions before they are fully asked, finish other people’s sentences or speak without waiting for a turn in a conversation
- Have difficulty waiting for one’s turn
- Interrupt or intrude on others, for example in conversations, games, or activities
Primary care providers sometimes diagnose and treat ADHD. They may also refer individuals to a mental health professional, such as a psychiatrist or clinical psychologist, who can do a thorough evaluation and make an ADHD diagnosis.
For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind typical development for their age. Stress, sleep disorders, anxiety, depression, and other physical conditions or illnesses can cause similar symptoms to those of ADHD. Therefore, a thorough evaluation is necessary to determine the cause of the symptoms.
Most children with ADHD receive a diagnosis during the elementary school years. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before age 12.
ADHD symptoms can appear as early as between the ages of 3 and 6 and can continue through adolescence and adulthood. Symptoms of ADHD can be mistaken for emotional or disciplinary problems or missed entirely in children who primarily have symptoms of inattention, leading to a delay in diagnosis. Adults with undiagnosed ADHD may have a history of poor academic performance, problems at work, or difficult or failed relationships.
ADHD symptoms can change over time as a person ages. In young children with ADHD, hyperactivity-impulsivity is the most predominant symptom. As a child reaches elementary school, the symptom of inattention may become more prominent and cause the child to struggle academically. In adolescence, hyperactivity seems to lessen and symptoms may more likely include feelings of restlessness or fidgeting, but inattention and impulsivity may remain. Many adolescents with ADHD also struggle with relationships and antisocial behaviors. Inattention, restlessness, and impulsivity tend to persist into adulthood.
Diagnosis of ADHD
Diagnostic criteria (DSM-5)
According to DSM-5, the 3 types of attention-deficit/hyperactivity disorder (ADHD) are
- Predominantly inattentive,
- Predominantly hyperactive/impulsive, and
- Combined – The specific criteria for attention-deficit/hyperactivity disorder are as follows
Inattentive
This must include at least 6 of the following symptoms of inattention that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level
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Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
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Often has difficulty sustaining attention in tasks or play activities
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Often does not seem to listen to what is being said
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Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
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Often has difficulties organizing tasks and activities
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Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
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Often loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys)
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Often is easily distracted by extraneous stimuli
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Often forgetful in daily activities
Hyperactivity/impulsivity
This must include at least 6 of the following symptoms of hyperactivity-impulsivity that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
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Fidgeting with or tapping hands or feet, squirming in seat
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Leaving seat in classroom or in other situations in which remaining seated is expected
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Running about or climbing excessively in situations where this behavior is inappropriate (in adolescents or adults, this may be limited to subjective feelings of restlessness)
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Difficulty playing or engaging in leisure activities quietly
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Unable to be or uncomfortable being still for extended periods of time (may be experienced by others as “on the go” or difficult to keep up with)
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Excessive talking
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Blurting out answers to questions before the questions have been completed
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Difficulty waiting in lines or awaiting turn in games or group situations
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Interrupting or intruding on others (for adolescents and adults, may intrude into or take over what others are doing)
Diagnostic criteria
- ADHD — The American Psychiatric Association has defined consensus criteria for the diagnosis of ADHD, which are published in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) .
- For children <17 years, the DSM-5 diagnosis of ADHD requires ≥6 symptoms of hyperactivity and impulsivity or ≥6 symptoms of inattention.
- For adolescents ≥17 years and adults, ≥5 symptoms of hyperactivity and impulsivity or ≥5 symptoms of inattention are required.
The symptoms of hyperactivity/impulsivity or inattention must
Occur often
- Be present in more than one setting (eg, school and home)
- Persist for at least six months
- Be present before the age of 12 years
- Impair function in academic, social, or occupational activities
- Be excessive for the developmental level of the child
In addition, other physical, situational, or mental health conditions that could account for the symptoms must be excluded.
Adherence to the DSM-5 criteria can help to minimize over- and under-diagnosis of ADHD. The diagnostic criteria have high interrater reliability for individual items and for overall diagnosis even though the behavioral characteristics specified in the definition are subject to different interpretation by different observers.
Limitations of the DSM-5 criteria include their derivation from studies of children who were evaluated in psychiatric rather than primary care settings and lack of data supporting the number of items required for diagnosis. In addition, the criterion that symptoms of hyperactivity/impulsivity or inattention be present before the age of 12 years is controversial.
The response to stimulant medication cannot be used to confirm or refute the diagnosis of ADHD . Stimulant medications improve behavior in children with ADHD, children with conditions other than ADHD (eg, learning disabilities, depression), and normal control children .
ADHD subtype of ADHD
Depending upon the predominant symptoms, ADHD can be categorized into one of the three subtypes listed below . The subtype of ADHD in a given patient can change from one to another over time .
- Predominantly inattentive – ≥6 symptoms of inattention for children <17 years; ≥5 symptoms for adolescents ≥17 years and adults
- Predominantly hyperactive-impulsive – ≥6 symptoms of hyperactivity-impulsivity for children <17 years; ≥5 symptoms for adolescents ≥17 years and adults
- Combined – ≥6 symptoms of inattention and ≥6 symptoms of hyperactivity-impulsivity for children <17 years; ≥5 symptoms in each category for adolescents ≥17 years and adults
- Hyperkinetic disorder – In Europe, the diagnosis of hyperkinetic disorder (HKD) is defined by the International Classification of Diseases (10th edition, ICD-10) criteria . The ICD-10 criteria for HKD are more restrictive than the DSM-5 criteria for ADHD, requiring that at least six symptoms of inattention, at least three symptoms of hyperactivity, and at least one symptom of impulsivity are present in more than one setting . HKD is subdivided into HKD with and without conduct disorder.
- Diagnosis in preschool children – The diagnostic criteria for ADHD (without subtyping) can be applied to children as young as four years of age. Longitudinal studies suggest that severe hyperactivity, which is present in only a small subset of preschool children, persists into the school years .
Treatment of ADHD
Medications called stimulants can help control hyperactive and impulsive behavior and increase attention span. They include:
- Dexmethylphenidate
- Dextroamphetamine
- Lisdexamfetamine
- Methylphenidate
Stimulant medications don’t work for everyone with ADHD. Non stimulant medications may be prescribed for people older than 6. These include
- Stimulants – such as products that include methylphenidate or amphetamine, are typically the most commonly prescribed medications for ADHD, but other drugs may be prescribed. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters.
- Other medications – used to treat ADHD include the non-stimulant atomoxetine (Strattera) and certain antidepressants such as bupropion (Wellbutrin, others). Atomoxetine and antidepressants work slower than stimulants do, but these may be good options if you can’t take stimulants because of health problems or a history of substance abuse or if stimulants cause severe side effects.
The right medication and the right dose vary among individuals, so it may take time to find out what’s right for you. Tell your doctor about any side effects.
Psychological counseling of ADHD
Counseling for adult ADHD generally includes psychological counseling (psychotherapy), education about the disorder and learning skills to help you be successful.
Psychotherapy may help you
- Improve your time management and organizational skills
- Learn how to reduce your impulsive behavior
- Develop better problem-solving skills
- Cope with past academic, work or social failures
- Improve your self-esteem
- Learn ways to improve relationships with your family, co-workers and friends
- Develop strategies for controlling your temper
Common types of psychotherapy for ADHD include
- Cognitive-behavioral therapy – This structured type of counseling teaches specific skills to manage your behavior and change negative thinking patterns into positive ones. It can help you deal with life challenges, such as school, work or relationship problems, and help address other mental health conditions, such as depression or substance abuse.
- Marital counseling and family therapy – This type of therapy can help loved ones cope with the stress of living with someone who has ADHD and learn what they can do to help. Such counseling can improve communication and problem-solving skills.
Many symptoms of ADHD can be managed with medication and therapy.
- Atomoxetine
- Clonidine
- Guanfacine
Dietary supplements with omega 3s have shown some benefits. Vayarin, a non-pharmaceutical supplement that contains omega-3s, is available by prescription only.
Therapy – These treatments focus on changing behavior.
- Special education – helps a child learn at school. Having structure and a routine can help children with ADHD a lot.
- Behavior modification teaches ways to replace bad behaviors with good ones.
- Psychotherapy (counseling) – can help someone with ADHD learn better ways to handle their emotions and frustration. It can also help improve their self-esteem. Counseling may also help family members better understand the child or adult with ADHD.
- Social skills training – can teach behaviors, such as taking turns and sharing.
- Support groups – of people with similar problems and needs can help with acceptance and support. Groups also can provide a way to learn more about ADHD. These groups are helpful for adults with ADHD or parents of children with ADHD.
- Family and marital therapy can help family members and spouses find productive ways to handle disruptive behaviors, encourage behavior changes, and improve interactions with the person with ADHD.
- Parenting skills training (behavioral parent management training) teaches parents skills for encouraging and rewarding positive behaviors in their children. Parents are taught to use a system of rewards and consequences to change a child’s behavior, to give immediate and positive feedback for behaviors they want to encourage, and to ignore or redirect behaviors they want to discourage.
- Specific behavioral classroom management interventions and/or academic accommodations for children and teens have been shown to be effective for managing symptoms and improving functioning at school and with peers. Interventions may include behavior management plans or teaching organizational or study skills. Accommodations may include preferential seating in the classroom, reduced classwork load, or extended time on tests and exams. The school may provide accommodations through what is called a 504 Plan or, for children who qualify for special education services, an Individualized Education Plan (IEP). To learn more about the Individuals with Disabilities Education Act (IDEA), visit the U.S. Department of Education’s IDEA website.
- Stress management techniques can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behavior.[rx]
Lifestyle and home remedies of ADHD
Because ADHD is a complex disorder and each person is unique, it’s hard to make recommendations for all adults who have ADHD. But some of these suggestions may help:
- Make a list of tasks – to accomplish each day. Prioritize the items. Make sure you’re not trying to do too much.
- Break down tasks – into smaller, more manageable steps. Consider using checklists.
- Use sticky pads to write notes to yourself. Put them on the fridge, on the bathroom mirror, in the car or in other places where you’ll see the reminder.
- Keep an appointment book – or electronic calendar to track appointments and deadlines.
- Carry a notebook or electronic device with you – so that you can note ideas or things you’ll need to remember.
- Take time to set up systems to file and organize information – both on your electronic devices and for paper documents. Get in the habit of using these systems consistently.
- Follow a routine – that’s consistent from day to day and keep items, such as your keys and your wallet, in the same place.
- Ask for help – from family members or other loved ones.
References
