Despite being the most commonly studied and diagnosed psychiatric disorder in children and adolescents, the cause in the majority of cases is unknown. It affects about 6–7% of children when diagnosed via the DSM-IV criteria and 1–2% when diagnosed via the ICD-10 criteria. Rates are similar between countries and depend mostly on how it is diagnosed. ADHD is diagnosed approximately three times more in boys than in girls. About 30–50% of people diagnosed in childhood continue to have symptoms into adulthood and between 2–5% of adults have the condition. The condition can be difficult to tell apart from other disorders as well as that of high normal activity.
ADHD management usually involves some combination of counseling, lifestyle changes, and medications. Medications are only recommended as a first-line treatment in children who have severe symptoms and may be considered for those with moderate symptoms who either refuse or fail to improve with counseling.:p.317 Long term effects of medications are not clear and they are not recommended in preschool-aged children. Adolescents and adults tend to develop coping skills which make up for some or all of their impairments.
ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media. Topics include ADHD's causes, and the use of stimulant medications in its treatment. Most healthcare providers accept ADHD as a genuine disorder with debate in the scientific community mainly around how it is diagnosed and treated.
Inattention, hyperactivity (restlessness in adults), disruptive behavior, and impulsivity are common in ADHD. Academic difficulties are frequent as are problems with relationships. The symptoms can be difficult to define as it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring interventions begin.:p.26
Based on the presenting symptom ADHD can be divided into three subtypes—predominantly inattentive, predominantly hyperactive-impulsive, or combined if criteria for both types are met.:p.4
An individual with inattention may have some or all of the following symptoms:
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 enjoyable
Have difficulty focusing attention on organizing and completing a task or learning something new
Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
Not seem to listen when spoken to
Daydream, become easily confused, and move slowly
Have difficulty processing information as quickly and accurately as others
Struggle to follow instructions
An individual with hyperactivity may have some or all of the following symptoms:
Fidget and squirm in their seats
Dash around, touching or playing with anything and everything in sight
Have trouble sitting still during dinner, school, doing homework, and story time
Be constantly in motion
Have difficulty doing quiet tasks or activities
Note: These hyperactivity symptoms tend to go away with age and turn into "inner restlessness" in teens and adults with ADHD.
An individual with impulsivity may have some or all of the following symptoms:
Be very 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 turns in games
Often interrupts conversations or others' activities
People with ADHD more often have difficulties with social skills, such as social interaction and forming and maintaining friendships. About half of children and adolescents with ADHD experience social rejection by their peers compared to 10–15% of non-ADHD children and adolescents. People with ADHD have attention deficits which cause difficulty processing verbal and nonverbal language which can negatively affect social interaction. They also may drift off during conversations, and miss social cues.
Difficulties managing anger are more common in children with ADHD as are poor handwriting and delays in speech, language and motor development. Although it causes significant impairment, particularly in modern society, many children with ADHD have a good attention span for tasks they find interesting.
In children ADHD occurs with other disorders about ⅔ of the time. Some of the commonly associated conditions include:
Learning disabilities have been found to occur in about 20–30% of children with ADHD. Learning disabilities can include developmental speech and language disorders and academic skills disorders. ADHD, however, is not considered a learning disability but it can still significantly impact academic performance.
Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.
Substance use disorders. Adolescents and adults with ADHD are at increased risk of developing a substance use problem. This is most commonly with alcohol or cannabis. The reason for this may be due to an altered reward pathway in the brains of ADHD individuals. This makes the evaluation and treatment of ADHD more difficult, with serious substance misuse problems usually treated first due to their greater risks.:p.38
Sleep disorders and ADHD commonly co-exist. They can also occur as a side effect of medications used to treat ADHD. In children with ADHD, insomnia is the most common sleep disorder with behavioral therapy the preferred treatment. Problems with sleep initiation are common among individuals with ADHD but often they will be deep sleepers and have significant difficulty getting up in the morning.Melatonin is sometimes used in children who have sleep onset insomnia.
The cause of most cases of ADHD is unknown; however, it is believed to involve interactions between genetic and environmental factors. Certain cases are related to previous infection of or trauma to the brain.
Twin studies indicate that the disorder is often inherited from one's parents with genetics determining about 75% of cases. Siblings of children with ADHD are three to four times more likely to develop the disorder than siblings of children without the disorder. Genetic factors are also believed to be involved in determining whether or not ADHD persists into adulthood.
Natural selection may have favored the traits of ADHD as, at least individually, they may have provided a survival advantage, becoming dysfunctional only when combined. Additionally, some women may be more attracted to males who are risk takers, increasing the frequency of genes that predispose to ADHD in the gene pool. As it is more common in children of anxious or stressed mothers, some argue that ADHD is an adaptation that helps children face a stressful or dangerous environment with, for example, increased impulsivity and exploratory behavior.
Hyperactivity might have been beneficial, from an evolutionary perspective, in situations involving risk, competition, or unpredictable behavior (i.e. exploring new areas or finding new food sources). In these situations, ADHD could have been beneficial to society as a whole even while being harmful to the individual. Additionally, in certain environments it may have offered advantages to the individuals themselves, such as quicker response to predators or superior hunting skills.
Environmental factors are believed to play a lesser role. Alcohol intake during pregnancy can cause fetal alcohol spectrum disorder which can include symptoms similar to ADHD. Exposure to tobacco smoke during pregnancy can cause problems with central nervous system development and can increase the risk of ADHD. Many children exposed to tobacco do not develop ADHD or only have mild symptoms which do not reach the threshold for a diagnosis. A combination of a genetic predisposition with tobacco exposure may explain why some children exposed during pregnancy may develop ADHD and others do not. Children exposed to lead, even low levels, or polychlorinated biphenyls may develop problems which resemble ADHD and fulfill the diagnosis. Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not conclusive.
A small number of children may react negatively to food dyes or preservatives. It is possible that certain food coloring may act as a trigger in those who are genetically predisposed. The United Kingdom and European Union have put in place regulatory measures based on these concerns. Dietary sugar and the artificial sweetener aspartame appears to have little to no effect, except possibly in children under six years of age where sugar may increase inattention.
The diagnosis of ADHD can represent family dysfunction or a poor educational system rather than an individual problem. Some cases may be explained by increasing academic expectations, with a diagnosis being a method for parents in some countries to get extra financial and educational support for their child. The youngest children in a class have been found to be more likely to be diagnosed as having ADHD possibly due to their being developmentally behind their older classmates. Behavior typical of ADHD occur more commonly in children who have experienced violence and emotional abuse.
Per social construction theory it is societies that determine the boundary between normal and abnormal behavior. Members of society: including physicians, parents, and teachers determine which diagnostic criteria are used and, thus, the number of people affected. This leads to the current situation were the DSM-IV arriving at levels of ADHD three to four times higher than those obtained with the ICD 10.Thomas Szasz, a supporter of this theory, has argued that ADHD was "invented and not discovered."
Diagram of the human brain
The pathophysiology of ADHD is unclear with there being a number of competing explanations. In children with ADHD there is a general reduction of brain volume, with a proportionally greater decrease in the volume in the left-sided prefrontal cortex. The brain pathways connecting the prefrontal cortex and the striatum also appears to be involved. This suggest that inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction, with addition brain regions such as the cerebellum also being implicated. Other brain systems related to attention have also been found to differ between people with and without ADHD.
Previously it was thought that the elevated number of dopamine transporters in people with ADHD was part of the pathophysiology but it appears that the elevated numbers are due to adaptation to exposure to stimulants. People with ADHD may have a low arousal threshold and compensate for this with increased stimuli, which in turn results in disruption of attention and increases hyperactive behavior. The reason for this is due to abnormalities in how the dopamine system responds to stimulation. There may additionally be abnormalities in the adrenergic, serotoninergic and cholinergic or nicotinergic pathways.Glutaminergic neurotransmission seems to be also involved.
One theory of suggests that the symptoms arise from a difficulty in executive functions. Executive functions refers to a number of mental processes that are required to regulate, control, and manage daily life tasks. Some of these impairments include: problems with organizational skills, time keeping, excessive procrastination, concentration problems, processing speed, regulating emotions, using working memory and short-term memory problems. People usually have decent long-term memory. The criteria for an executive function deficit are met in 30–50% of children and adolescents with ADHD. One study found that 80% of individuals with ADHD were impaired in at least one EF task, compared to 50% for individuals without ADHD. Due to the rates of brain maturation and the increasing demands for executive control as a person gets older ADHD impairments may not fully manifest themselves until adolescence or even early adulthood.
ADHD is diagnosed by an assessment of a person's childhood behavioral and mental development, including ruling out the effects of drugs, medications and other medical or psychiatric problems as explanations for the symptoms.:p.19–27 It often takes into account feedback from parents and teachers with most diagnoses begun after a teacher raises concerns. It may be viewed as the extreme end of one or more continuous human traits found in all people.:p.130 Whether someone responds to medications does not confirm or rule out the diagnosis. As imaging studies of the brain do not give consistent results between individuals, they are only used for research purposes and not diagnosis.
Associated conditions that should be screened for include anxiety, depression, oppositional defiant disorder, conduct disorder, and learning and language disorders. Other conditions that should be considered are other neurodevelopmental disorders, tics, and sleep apnea.
ADHD predominantly inattentive type (ADHD-PI) presents with symptoms including being easily distracted, forgetful, daydreaming, disorganization, poor concentration, and difficulty completing tasks. Often people refer to ADHD-PI as "attention deficit disorder" (ADD), however, the latter has not been officially accepted since the 1994 revision of the DSM.
ADHD, predominantly hyperactive-impulsive type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behavior; destructive behaviors may also be present.
ADHD, combined type is a combination of the two other subtypes.
This subdivision is based on presence of at least six out of nine long-term (lasting at least six months) symptoms of inattention, hyperactivity–impulsivity, or both. To be considered, the symptoms must have appeared by the age of six to twelve and occur in more than one environment (e.g. at home and at school or work). The signs must be not appropriate for a child of that age and there must be evidence that it is causing social, school or work related problems.
Most children with ADHD have the combined type. Children with the inattention subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but without paying attention resulting in the child difficulties being overlooked.
Adults with ADHD are diagnosed under the same criteria, including that their signs must have been present by the age of six to twelve. Questioning parents or guardians as to how the person behaved and developed as a child may form part of the assessment; a family history of ADHD also adds weight to a diagnosis. While the core symptoms of ADHD are similar in children and adults they often present differently in adults than in children, for example excessive physical activity seen in children may present as feelings of restlessness and constant mental activity in adults.
ADHD symptoms which may be related to other disorders
Primary sleep disorders may affect attention and behavior and the symptoms of ADHD may affect sleep. It is thus recommended that children with ADHD be regularly assessed for sleep problems. Sleepiness in children may result in symptoms ranging from the classic ones of yawning and rubbing the eyes, to impulsivity, hyperactivity, aggressiveness, mood swing and inattentiveness.Obstructive sleep apnea, can also cause ADHD type symptoms.
The management of ADHD typically involves counseling or medications either alone or in combination. While treatment may improve long term outcomes it does not get rid of negative outcomes entirely. Medications used include stimulants, atomoxetine, alpha-adrenergic agonists and sometimes antidepressants. They have at least some effect in about 80% of people. Dietary modifications may also be of benefit with evidence supporting free fatty acids and reduced exposure to food coloring. Removing other foods from the diet is not currently supported by the evidence.
Training in social skills, behavioral modification and medication may have some limited beneficial effects. The most important factor in reducing later psychological problems, such as major depression, criminality, school failure, and substance use disorders is formation of friendships with people who are not involved in delinquent activities.
Stimulant medications are the pharmaceutical treatment of choice and improve symptoms, at least in the short term. There are a number of non-stimulant medications, such as atomoxetine, bupropion, guanfacine and clonidine that may be used as alternatives. There are no good studies comparing the various medications; however, they appear more or less equal with respect to side effects. Stimulants but not atomoxetine appear to improve academic performance. There is little evidence on their effects on social behaviors. Medications are not recommended for preschool children, as the long-term effects in this age group are not known. The long-term effects of stimulants generally are unclear with one study finding benefit, another finding no benefit and a third finding evidence of harm. Their long term use does; however, appear to normalize brain structure. Atomoxetine, due to its lack of abuse potential, may be preferred in those who are at risk of abusing stimulant medication.Guidelines on when to use medications vary by country, with the United Kingdom's National Institute of Clinical Excellence recommending use only in severe cases, while most United States guidelines recommend medications in nearly all cases.
While stimulants and atomoxetine are usually safe, there are side-effects and contraindications to their use. Stimulants may result in psychosis or mania; however, this is relatively uncommon. Regular monitoring has been recommended in those on long term treatment. Stimulant therapy should be stopped from time to time to assess for continuing need for medication. Stimulant medications have the potential for abuse and dependence and while people with ADHD have an increased risk of substance abuse, the use of stimulants generally appears to either reduce this risk or have no effect on it. The safety of these medication in pregnancy is unclear.
Zinc deficiency has been associated with inattentive symptoms and there is evidence that zinc supplementation can benefit children with ADHD who have low zinc levels. Iron, magnesium and iodine may also have an effect on ADHD symptoms. There is evidence of a modest benefit of omega 3 supplementation, but it is not recommended in place of traditional medication.
An 8-year follow up of children diagnosed with ADHD (combined type) found that they often have difficulties in adolescence, regardless of treatment or lack thereof. In the US, less than 5% of individuals with ADHD get a college degree, compared to 28% of the general population aged 25 years and older. The proportion of children meeting criteria for ADHD drops by about half in the three years following the diagnosis and this occurs regardless of treatments used. ADHD persists into adulthood in about 30–50% of cases. Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous symptoms.
ADHD is estimated to affect about 6–7% of people aged 18 and under when diagnosed via the DSM-IV criteria. When diagnosed via the ICD-10 criteria rates in this age group are estimated at 1–2%. Children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East; this is believed to be due to differing methods of diagnosis rather than a difference in underlying frequency. If the same diagnostic methods are used rates are more or less the same between countries. It is diagnosed approximately three times more often in boys than in girls. This difference between sexes may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.
Rates of diagnosis and treatment have increased in both the United Kingdom and the United States since the 1970s. This is believed to be primarily due to changes in how the condition is diagnosed and how readily people are willing to treat it with medications rather than a true change in how common the condition is. It is believed that changes to the diagnostic criteria in 2013 with the release of the DSM V will increase the percentage of people with ADHD especially among adults.
Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An inquiry into the nature and origin of mental derangement written in 1798. ADHD was first clearly described by George Still in 1902. The terminology used to describe the condition has changed over time and has included: in the DSM-I (1952) "minimal brain dysfunction", in the DSM-II (1968) "hyperkinetic reaction of childhood", in the DSM-III (1980) "attention-deficit disorder (ADD) with or without hyperactivity". In 1987 this was changed to ADHD in the DSM-III-R and the DSM-IV in 1994 split the diagnosis into three subtypes, ADHD inattentive type, ADHD hyperactive-impulsive type and ADHD combined type. These terms were kept in the DSM-V in 2013. Other terms have included "minimal brain damage" used in the 1930s.
The use of stimulants to treat ADHD was first described in 1937. In the 1930s, Benzedrine became the first amphetamine medication approved for use in the United States. Methylphenidate was introduced in the 1950s, and enantiopure dextroamphetamine in the 1970s.
ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media. Positions regarding ADHD range from believing it is simply the far end of a normal range of behavior:p.23 to considering that it is the result of an underlying genetic condition. Other areas of controversy include the use of stimulant medications and specifically their use in children, as well as the method of diagnosis and the possibility of overdiagnosis. The National Institute for Clinical Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature.:p.133
With widely differing rates of diagnosis across countries, states within countries, races, and ethnicities, some suspect factors other than the presence of the symptoms of ADHD are playing a role in diagnosis. Some sociologists consider ADHD to be an example of the medicalization of deviant behavior, or in other words, the turning of the previously non medical issue of school performance into a medical one. Most healthcare providers accept ADHD as a genuine disorder, at least in the small number of people with severe symptoms. Among healthcare providers the debate mainly centers around diagnosis and treatment in the much larger number of people with less severe symptoms.
As of 2009[update], 8% of all United States Major League Baseball players had been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants, which has raised concern that some players are mimicking or falsifying the symptoms or history of ADHD to get around the ban on the use of stimulants in sport.
A number of notable individuals have given controversial statements regarding ADHD. Tom Cruise has referred to the medications Ritalin and Adderall as "street drugs". Ushma S. Neill criticized this view, stating that the doses of stimulants used in the treatment of ADHD do not cause behavioral addiction and that there is some evidence of a reduced risk of later substance addiction in children treated with stimulants. In England, Susan Greenfield spoke out publicly in 2007 in the House of Lords about the need for a wide-ranging inquiry into the dramatic increase in the diagnosis of ADHD in the UK and possible causes. Her comments followed a BBC Panorama program that highlighted research that suggested medications are no better than other forms of therapy in the long term. In 2010, the BBC Trust criticized the 2007 BBC Panorama program for summarizing the research as showing "no demonstrable improvement in children's behavior after staying on ADHD medication for three years" when in actuality "the study found that medication did offer a significant improvement over time" although the long-term benefits of medication were found to be "no better than children who were treated with behavior therapy."
It is estimated that between 2–5% of adults have ADHD. Around half of children with ADHD continue to have ADHD as adults. Of those who continue to have symptoms approximately 25% have the full disorder and 75% partially 'grow out' of it. Most adults remain untreated. Many have a disorganized life and use non-prescribed drugs and alcohol as a coping mechanism. Other problems may include relationship and job difficulties, and an increased risk of criminal activities. Associated mental health problems include: depression, anxiety disorder, and learning disabilities.
Some ADHD symptoms in adults differ from those seen in children. While children with ADHD may climb and run about excessively, adults may experience an inability to relax or talk excessively in social situations. Adults with ADHD may start relationships impulsively, display sensation-seeking behavior, and be short-tempered. Addictive behavior such as substance abuse and gambling are common. The DSM-IV criteria have been criticized for not being appropriate for adults; those who present differently may lead to the claim that they outgrew the diagnosis.
Children with high IQ scores
The diagnosis of ADHD and the significance of its impact on children with a high intelligence quotient (IQ) is controversial. Most studies have found similar impairments regardless of IQ, with higher rates of repeating grades and having social difficulties. Additionally, more than half of people with high IQ and ADHD experience major depressive disorder or oppositional defiant disorder at some point in their lives. Generalised anxiety disorder, separation anxiety disorder and social phobia are also more common. There is some evidence that individuals with high IQ and ADHD have a lowered risk of substance abuse and anti-social behavior compared to children with low and average IQ and ADHD. Children and adolescents with high IQ can have their level of intelligence mismeasured during a standard evaluation and may require more comprehensive testing.
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