Attention Deficit Hyperactivity Disorder

Summary

ADHD is a disorder characterised by three primary symptoms: hyperactivity, impulsivity and inattention (difficulty focusing and sustaining attention).

There are three types; inattentive type, impulsivity-hyperactivity type and a combination type including both inattention and impulsivity-hyperactivity.

ADHD is a neurological condition and runs in families.

Diagnosis requires a comprehensive assessment and involves a team of professionals.

Treatment includes medical, psychological and educational intervention as well as behavioural management.

With appropriate intervention and support, people with ADHD can function successfully in society.            

What is attention-deficit hyperactivity disorder (ADHD)?

Occasionally, we may all have difficulty sitting still, paying attention or controlling impulsive behaviour. For a person with ADHD, though, these problems become so pervasive and persistent that their ability to function effectively in daily life is compromised.

ADHD is a neurological syndrome, found in children as well as adults, that is characterised by poor concentration and organisational skills, easy distractibility, low tolerance for frustration or boredom, a greater tendency to say or do whatever comes to mind (impulsivity) and a predilection for situations with high intensity.

The name Attention-Deficit Hyperactivity Disorder reflects the importance of the inattention/ distraction aspect of the disorder as well as the hyperactivity/ impulsivity aspect. The disorder ADHD symptoms arise in early childhood, unless associated with some type of brain injury later in life.

What causes ADHD?

ADHD is caused by differences in neurotransmitter patterns in certain parts of the brain. Neurotransmitters are chemicals that make it possible for nerve impulses to travel from one nerve cell to another, and therefore play an essential role in the functioning of the brain. The brain performs a vast range of tasks or functions, allowing us, for instance, to see, hear, think, speak and move. Each function is performed by a different part of the brain. In individuals with ADHD there are lower than normal levels of certain neurotransmitters (especially dopamine) in the regions of the brain that are responsible for regulating behaviour and attention. Research also confirms that the Norepinephrine system is also involved in some patients.

ADHD has a genetic component and a group of genes involved has been identified. The genetic component is confirmed with epidemiological studies looking at family groups. Research has shown that in the case of identical twins, if one of the twins has ADHD there is an almost 100% chance that the other twin will show symptoms of ADHD.

ADHD can also be present in some patients with neurological damage occurring either before or after birth. Certain developmental disorders or syndromes, like Foetal Alcohol Syndrome, are associated with a higher incidence of ADHD.

Diet is often cited as the cause for ADHD. Patients with malnutrition or a poor diet may manifest some of the symptoms. In a small subgroup dietary factors may play a role in the worsening of symptoms, especially that of impulsivity/hyperactivity in younger children. Ongoing research is looking at the role that essential fatty acids play in some patients. Poisoning with heavy metals like lead will create a similar clinical picture in some patients.

Although environmental factors do not play a causal role in ADHD, a disorganised, chaotic and stressful environment can cause behaviour which mimics that of ADHD.

Symptoms

There are three primary subtypes of ADHD:

ADHD primarily inattentive type

• Fails to give close attention to details or makes careless mistakes.
• Has difficulty sustaining attention.
• Does not appear to listen.
• Struggles to follow through on instructions.
• Has difficulty with organisation.
• Avoids or dislikes tasks requiring sustained mental effort.
• Is easily distracted.
• Is forgetful in daily activities.

Clinically they present as the classical dreamers, disorganised and often living in their own little world. This leads to major problems with planning and task completion.

ADHD primarily hyperactive/impulsive type

• Fidgets with hands or feet or squirms in chair.
• Has difficulty remaining seated.
• Runs about or climbs excessively.
• Difficulty engaging in activities quietly.
• Acts as if driven by a motor.
• Talks excessively.
• Blurts out answers before questions have been completed.
• Difficulty waiting or taking turns.
• Interrupts or intrudes upon others.

The classical hyperactive group are often a danger to themselves because of the impulsive behaviour.

ADHD combined type

The individual meets both sets of inattention and hyperactive/impulsive criteria, constantly fidgeting and busy with something other than what it expected of them at that moment.

Coexisting disorders

In studies as many as 60 percent of individuals with ADHD present with at least one other major disorder. The most common of these coexisting disorders are briefly described below.

Disruptive Behaviour Disorders

Oppositional-Defiant Disorder (ODD) and Conduct Disorder (CD): ODD involves a pattern of arguing with multiple adults, losing one's temper, refusing to follow rules, blaming others, deliberately annoying others, and being angry, resentful.
CD is associated with efforts to break rules without getting caught. Such children may be aggressive to people or animals, destroy property, lie or steal things from others, run away, be truant from school, or break curfews. CD is often described as delinquency.

Mood Disorders

Depression
ADHD is often associated with depression, which usually appears after ADHD has developed. Depression is characterised by sadness (a child may cry frequently, and for no apparent reason), social withdrawal, loss of appetite, self recrimination, insomnia or excessive sleeping, and a loss of interest in activities that were previously enjoyed.

Mania/Bipolar Disorder
Bipolar Disorder may present with symptoms of ADHD in the pre-pubertal child. A family history of bipolar disorder is an important indicator. This disorder takes the form of periods of abnormally elevated mood (mania) alternating with episodes of depression. In children, the manic phase can manifest as pervasive irritability and unprovoked aggression.
The manic phase in adults is usually characterised by an expansive mood, such that the person feels euphoric and extremely confident. The manic individual may go for days without sleeping, tends to speak rapidly and incessantly, and is inclined to behave inappropriately in social settings (having lost their normal inhibitions). During a manic phase people often develop an unrealistic belief in their capabilities, as a result of which they engage in activities or projects which are doomed to failure and which often lead them into financial or other difficulties.

Anxiety

Approximately one third of children with ADHD will also have an anxiety disorder. People with anxiety disorders often worry excessively about a number of things and may feel edgy, stressed out or tired, tense, and have trouble getting restful sleep. A small number of patients may report brief episodes of severe anxiety (panic attacks) with complaints of pounding heart, sweating, shaking, choking, difficulty breathing, nausea or stomach pain, dizziness, and fears of going crazy or dying. These episodes may occur for no reason.

Tourette's Disorder

About seven percent of those with ADHD have Tourette's Disorder. This disorder involves movements and vocal tics. Tics are sudden, rapid, recurrent, non-rhythmic, involuntary movements or vocalisations. The diagnosis of ADHD may precede the onset of tics.

Learning Disabilities

Up to 60 percent of individuals with ADHD have some form of learning disability. Learning disabled persons may have a specific problem reading or calculating, but usually have normal IQ. Dyslexia may have a major impact.

Substance Abuse

Recent research suggests that adolescents with ADHD are at increased risk for very early cigarette use, which is likely to be followed by alcohol and drug abuse if their symptoms are not controlled.

Who gets ADHD?

Three to five percent of children are affected by ADHD. Until recent years, it was believed that children outgrow ADHD in adolescence. Hyperactivity often does diminish during the teen years, but it is now known that symptoms can continue into adulthood. In fact, up to 65 percent of children with ADHD will continue to exhibit symptoms in adulthood and in a major proportion it may still have a negative impact on their functioning in all aspects of life and society.

Males are far more likely to get ADHD, with the ratio of males to females with ADHD being 3 to 1. However, ADHD tends to be under-diagnosed in girls as they more frequently present with the inattentive type, which is more difficult to identify than the hyperactive-impulsive type.

In certain conditions a higher incidence of ADHD are found i.e. Tourette’s syndrome or Foetal Alcohol Syndrome.

How is ADHD diagnosed?

There is no single test to diagnose ADHD. Instead, a comprehensive evaluation is necessary to:

• reach a diagnosis rule out other causes for the symptoms
• establish whether coexisting conditions are present.

Such an evaluation requires time and effort and should include a clinical assessment of the individual’s academic, social and emotional functioning. In children, a careful history should be taken from parents and teachers. Often, both a psychologist and a medical practitioner, usually a psychiatrist or a paediatrician, should be involved in the assessment process.

Before reaching a diagnosis, it is important to rule out the following conditions, which usually manifest similar symptoms to those of ADHD.

• Emotional difficulties/social and environmental problems.
• Low Muscle Tone – some children have to focus so hard on sitting up straight that they fidget more.
• Motor-co-ordination difficulties – if present this often leads to problems with task completion and the quality of work presented. It often coexists in patients with ADHD.
• Sensory Modulation Disorders – These children have problems being tactile or light defensive. The noise defensive child has difficulty blocking out background noise when having to pay attention.
• Global development delay - concentration and functioning should be evaluated according to functional, not chronological age.
• Absence Epilepsy - often presents between ages six - 10 years.

It is important to realise that some of the above can also be present in patients with a classical picture of ADHD. Other problems may present with symptoms suggestive of ADHD but often leads to a later diagnosis because the interaction with concentration problems is not explored. They often coexist.

In order for a diagnosis of ADHD to be made the following conditions should be met

• Some symptoms must have appeared by the age of seven.
• At least six symptoms must be present and must have persisted for at least six months.
• Symptoms must occur in at least two different settings (for example, at school and at home).
• The symptoms must cause significant impairment of social and academic functioning.

How is ADHD treated?

It is imperative that children who present with ADHD receive appropriate and adequate treatment.

Treating ADHD in children requires medical, psychological and educational intervention, as well as behavioural management. It therefore requires a team approach and also includes parent training. Parents need to be educated on how to cope with and assist a child with ADHD. Parental support is a crucial component in any successful treatment programme. Positive reinforcement, in which desired behaviour is rewarded, is the most appropriate and effective form of behavioural management. It is important that reinforcement is consistently applied.

Many children with ADHD can be taught in a regular classroom with minor adjustments to the environment, but some children require additional assistance using special educational services, especially if they have complex learning difficulties.

Treatment for adults with ADHD involves medical intervention and psychotherapy. Psychotherapy is important because adults with ADHD need to be helped to understand that their educational, vocational and/or personal difficulties are not the result of an irremediable personality flaw.

Patients with ADHD often present with emotional difficulties and problems due to the negative impact of ADHD on their lives. Psychotherapy and coaching helps with understanding the condition, taking control of the symptoms and making better choices.

Medication

For most children and adults with ADHD, medication is an integral part of treatment. Medication is not used to control behaviour. Medication is used to improve the symptoms of ADHD. This leads to success in controlling the core symptoms of the disorder and, especially in younger children. learning from positive feedback and experiences.

Between 70-80 percent of children with ADHD respond positively to these medications. Attention span, impulsivity and on-task behaviour improve, especially in structured environments. Some children also demonstrate improvements in frustration, tolerance and compliance, even handwriting, as it can assist with fine-motor control and visual-motor co-ordination. Relationships with parents, peers and teacher may also improve.

Stimulant medication can also be effective in adults who have ADHD. The reaction to these medications can be similar to that experienced by children with ADHD - a decrease in impulsivity and an increase in attention. Many ADHD adults treated with a stimulant medication report that they are able to bring more control and organisation to their lives.

Medical management of ADHD involves medication that has an influence on the neurotransmitters involved :

• 1. Stimulants : Methylphenidate
• 2. Nonstimulants : (a ) Atomoxetine (b) Tricyclics
• 3. Other

1.  Methylphenidate

Methylphenidate (MPH) acts on Dopamine levels in certain areas of the brain, especially those involved with executive function in the prefrontal areas. There is an inhibition in the reuptake of the neurotransmitter, and thus an increase in the levels of dopamine, causing an improvement in the core symptoms of the individuals ADHD.

MPH acts immediately when taken and the effect disappears when serum levels drop. Different preparations and release forms thus lead to a choice of medications with a difference in the period of efficacy.

• Ritalin IR 10mg 4 hours (a generic is available)
• Ritalin LA 20/ 30/ 40 mg 8 hours
• Concerta 18/ 27/ 36/ 54 mg 12 hours

There is a wide variation in response to dosage of medication, so the appropriate dose needs to be carefully determined for each individual. This is achieved through a medication trail, which begins with a low dose that is gradually increased until clinical benefits are achieved.

Effects of stimulant medications have been well researched for the past 50-60 years, making them among the most studied medications in pharmacological history.

Side effects of stimulant medication

Most immediate side effects related to these medications are mild and tend to diminish over time. The most common side effects are initially headaches and abdominal pain. Reduction in appetite when medication is active especially affects midday eating patterns. Problems may develop with sleep onset. If side effects continue after two to three weeks, adjustment in dosage, or change in release form may improve side effects.

Some children experience a negative mood or an increase in activity (rebound) when the effect of the medication is beginning to wear off. This problem can usually be remedied by using a sustained-release form of medication. This allows the medication to be released at a steady rate, so that the level of medication in the bloodstream does not rise and fall to the same extent as it does with the ordinary form of medication. There is a small subgroup where a consistent negative mood and, at times, increase of anxiety may lead to the use of alternative medication.

Use of stimulant medications can, initially, cause a slight decrease in the height and weight of some children, but research suggests that the ultimate height and weight are not affected. Concerns regarding the possible cardiac effects of MPH have led to an extensive review and at present there are no increased clinical concerns. In patients with cardiac problems the use of stimulants is not advocated.

In patients with Tic Disorders use of a stimulant may improve tics in a third, worsen tics in a third or make no difference.

Research has shown that substance abuse is not linked to the use of stimulant medication, but to ADHD and poor control of symptoms.

2.  Atomoxetine (Strattera)

Atomoxetine acts on the Norepinephrine neurotransmitters in areas of the brain and thus leads to improvement in the symptoms of ADHD. As there is little or no action on the dopamine system it can be classified as a non-stimulant.

Atomoxetine has a clinical effect that lasts for 24 hours. Its effect takes 6-8 weeks to develop and medication needs to be taken consistently on a daily basis after a meal. Dosage is 1.2-1.8 mg per kg and incremental increases are suggested in the first two weeks. Atomoxetine 10/ 18/ 25/ 40/ 60/ mg is available. A very small subgroup may be poor metabolizers and a lower dose may be used.

Side Effects of Atomoxetine

Abdominal pain, nausea and heartburn may be the most frequent problem, causing a need for discontinuation. Other complaints include headaches, dizziness, sleep disturbances and appetite changes

Concerns about hepatic effects have proven to be of little clinical concern, as has a possibility of increased suicidality.

Because of a possible lesser effect on tics, in may be the preferred option in patients with Tic Disorders.

3.  Tricyclics

Tricyclics were developed as an antidepressant, but because of its effect on the Norepinephrine system, researched and used in patients with ADHD. It can also be used for anxiety symptoms and sleep disorders. Its effect on ADHD symptoms may not be as robust.

Individual dosages need to be determined per patient. it has a 24 hour action and thus is taken once daily. Tofranil is available as 10/ 25 mg tablets.

Tricyclics are used infrequently in ADHD, but may be indicated if contraindications to the other medications exist, if there are unacceptable side effects, or other medications prove to be ineffective.

Side effects of tricyclics:

abdominal pain, constipation, and headaches are most problematic. Emotional effects have to be watched. Sleepiness may occur. Overdose may have serious cardiac effects.

Other medications

Clonidine: this can be used in ADHD, but it has a primary effect on impulsive and intrusive behaviours.

Supplements: many vitamins, especially B6 and B12, as well as essential fatty acids Omega 3 and 6 are sold as treatments for ADHD. Research has shown some benefit in a group of patients with ADHD for the Omega oils.

Coexistent conditions may need treatment with specific medications to improve SSRI's for depression and/or anxiety. These may have to be used in combination with specific treatments for ADHD.

Other treatments

Specific coexistent problems need to be addressed with the appropriate therapy ie Occupational Therapy for coordination and sensory modular problems and Remedial Teaching for specific learning problems.
Training in specific techniques and strategies may help patients to take control of the symptoms. A Psychologist/life coach may be invaluable here. A full educational evaluation is needed of hearing problems are present.

What is the outcome of ADHD?

Although individuals with ADHD can be very successful in life, without identification and proper treatment ADHD can have serious consequences, including failure at school, low self esteem, depression, behavioural problems and substance abuse. Early identification and treatment increases the likelihood of a positive long-term outcome. Up to 65 percent of children with ADHD will continue to present symptoms in adulthood.

It is important to note that, despite their difficulties, people with ADHD possess positive personality characteristics, particularly those who receive appropriate intervention and support. People with ADHD can be

• Intelligent, imaginative, creative and original.
• Inquisitive, exploratory, and open to new experiences.
• Active and energetic.
• Enthusiastic, spontaneous, and keen to try out new things.
• Entertaining and interesting to talk to and be with.

When to see your doctor

If you notice that your child is exhibiting some of the symptoms described in this article, if your child's teacher tells you that your child is negatively influenced by his/her concentration problems and is difficult or disruptive at school - then seek a medical and psychological opinion. Emotional and other behavioural issues may stem from the individual's inability to cope and full evaluation may determine whether ADHD is the issue, or part of the problem.

Reviewed by Dr A van der Walt, MMed (Paed) BSc Hon (Human Genetics),
May 2007 and July 2010.

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