ADHD: Diagnosis, Types and Treatment

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by difficulties that interfere with effective goal-oriented behaviour in children. This includes impulsivity, and excessive or exaggerated motor activity, such as running aimlessly or fidgeting with surrounding objects. Additionally, individuals with ADHD struggle with sustaining attention across various domains, such as in school or workplace settings.

Children with ADHD get distracted easily and often fail to follow instructions or respond to demands placed on them. Thus, due to their behavioural issues, children with ADHD are often lower in intelligence, usually about 7 to 15 IQ points below the average range of peers of the same age and sex. Children with ADHD also tend to talk excessively and have intrusive and immature social behaviours. Children with ADHD show marked deficits on neuropsychological testing that are related to poor academic functioning. 

Children with ADHD generally have many social problems because of their impulsivity and hyperactivity. Hyperactive children usually have great difficulty in getting along with their parents because they do not obey rules and follow their instructions. Hyperactivity, restlessness, and distractibility are often manifested as indicators of anxiety among ADHD children, however, research portrays that they are generally not anxious.

Their poor performance in school often depicts specific learning disabilities such as difficulties in reading or learning (dyslexia) and other basic school subjects like mathematics (dyscalculia). ADHD has also been found to be comorbid with other disorders such as oppositional defiant disorder (ODD) where children find it difficult to conform to those individuals who have authority like parents. Some residual effects, such as attention difficulties, may persist into adolescence or adulthood impairing the social, interpersonal and occupational lives of the affected. 

Read More: Understanding the Learning Disabilities During Childhood

Casual factors in ADHD:

It remains unclear to what extent ADHD results from environmental or biological factors. Recent research, however, points to both genetic and social-environmental precursors contributing to an individual acquiring the disorder. Many researchers believe that biological factors such as genetic inheritance will turn out to be important precursors to the development of ADHD (attention-deficit hyperactivity disorder), although further research needs to be conducted in this arena.

The search for psychological causes of ADHD has yielded similarly inconclusive results, although temperament and learning styles appear likely to be factors resulting in children contracting ADHD. It often runs in families and is inherited, some studies show that if a parent has ADHD, there is a higher likelihood their child will also have it. Moreover, gene mutations associated with the dopamine regulation pathway might result in the individual acquiring ADHD as dopamine is a neurotransmitter responsible for attention.

The prefrontal cortex in the brain is responsible for executive functions like planning, organizing, and impulse control. People with ADHD may have a less functional prefrontal cortex or impairments in the surrounding regions. Moreover, reduced levels of dopamine and norepinephrine also contribute to contracting ADHD as these neurotransmitters are responsible for attention and impulse control. Research studies portray that toxins exposed during the gestation period like drugs, alcohol or stimulants increase the risk of ADHD.

Additionally, maternal stress and malnutrition may also contribute to the same. The cognitive processes in the brain may be disinhibiting the child’s behaviour. To support this view, some research has found different EEG patterns in children with ADHD compared to those without the disorder. Early childhood factors like traumatic brain injuries, and exposure to toxins like lead and mercury might result in children acquiring ADHD. Inconsistent parenting, stressful environments, childhood neglect and isolation can be varying causes that may culminate in a person acquiring ADHD. 

Symptoms of ADHD across ages:

• Children: Difficulty in concentrating in school, hyperactivity like running around, difficulty in sitting in one place, especially during class hours
• Teenagers: Poor academic performance due to inattention, forgetfulness and impulsive behaviours
• Adults: Difficulty in managing time, staying organized and maintaining relationships. 

According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), ADHD is defined by a consistent pattern of behaviours that significantly disrupt effective functioning or developmental progress. Individuals may display symptoms predominantly in one domain or a combination of both namely inattention and hyperactivity-impulsivity.

At least six of the following symptoms in each domain namely – “inattention” and “hyperactivity-impulsivity” must be present for a minimum of six months, occurring at a level that is not consistent with the behaviour of peers of the same age and gender. This further causes impairment in their occupational, academic, social and interpersonal life significantly. 

Inattention:

1. Often fail to give adequate attention to details or make careless mistakes at the workplace or in school where they overlook important entities. 
2. Often has difficulty sustaining attention in tasks or play activities where one is unable to maintain a long conversation with a peer or remain in class concentrating on the lecture being given.
3. Often, the individual does not seem to listen when spoken to directly, even in situations where there are no distractions, as their mind tends to wander elsewhere.
4. Often have difficulty following rules, instructions and regulations given to them in the workplace setting or in school. They may initiate the tasks assigned but due to lack of focus, they are sidetracked towards another activity.   
5. Often have difficulty organizing schedules and activities and they are unable to meet the deadlines at the workplace due to their inefficiency in time management. Moreover, they also face difficulty where tasks are given in a sequential format. They have trouble keeping their belongings in order. 
6. Frequently avoids, dislikes, or shows reluctance to engage in activities that demand prolonged mental focus, such as completing forms or reviewing articles.
7. Often lose things necessary for tasks or activities like children losing their stationery items like pencils, scales and erasers in school or paperwork and spectacles in the workplace. 
8. Is often easily distracted by external stimuli which prevents them from concentrating on tasks assigned at present. 
9. Is often forgetful in daily activities like going for errands, buying groceries, paying electric bills or house rent 

Hyperactivity and impulsivity: 

• Inability to remain physically still due to restlessness like continuously tapping feet or fingers on the desk and frequently shifting postures or positions during times where stillness is required. 
• Individuals struggle to sit in structured environments such as walking around in the classroom setting or getting up during work meetings.
• Individual behaves or act in socially or contextually unsuitable ways like climbing on furniture or equipment placed in the surroundings or running in hallways. This behaviour elicits excessive activity. 
• Engaging in calm, quiet and leisure activities is difficult. 
• Individuals are in a perpetual state of motion where they are unable to relax or stay still, like constant pacing or shifting positions during meals at restaurants. 
• Individuals might talk incessantly where they can speak without pauses for an extended period  
• Individuals are impatient and often answer a question before it is even posed fully, where they speak before hearing the question fully. This demonstrates impulsivity which is often manifested by completing other people’s sentences which might be inaccurate as well. 
• Individuals struggle to wait in line reflecting impatience where they show frustration or agitation when they have to wait for a longer duration for their turn.
• Individuals interrupt a conversation without being invited into one, they intrude on activities without permission. 

Moreover, neither of the above symptoms occurs due to oppositional defiant disorder, hostility, or under the influence of psychoactive substances such as drugs or alcohol. Additionally, they are not manifested during mood, personality, anxiety, or psychotic disorders. Many of these symptoms were present in the individual but remained undiagnosed before the age of 12, significantly impairing more than two areas such as the workplace, academic setting, or social gatherings.

Furthermore, for individuals above the age of 17, only 5 symptoms need to be present in both domains of the DSM-5 criteria, compared to 6 or more symptoms required for children or adolescents under 17. Research reports indicate that ADHD is more prevalent in boys than girls assigned at birth.

Treatment of ADHD:

Medicines:

Despite several arguments and disagreements around the globe regarding to use of medications to calm down an ADHD child, this approach is used to treat children with ADHD. One survey found that 40% of junior high school children and 15% of high school children with emotional and behavioural problems and ADHD are prescribed medication, mostly Ritalin (methylphenidate). It is an amphetamine; despite its stimulating properties, it has been effective in treating ADHD, especially in children reducing their hyperactivity symptoms and eliciting alertness.

Moreover, studies conducted with this drug of choice have proven that it reduces the aggressive behaviour of the child as well. But, Ritalin decreases the blood flow to the brain, which results in impaired thinking ability and memory loss. Additionally, disruption of growth hormone leads to suppression of growth in the body and brain of the child along with insomnia and psychotic symptoms. Although amphetamines do not cure ADHD solely, they have reduced the behavioural symptoms in about one-half to two-thirds of the cases in which it was administered.

Over the years, Pemoline another chemical substance has proven to be effective in treating ADHD via enhancing cognitive processing and has fewer adverse effects on health. Strattera is a stimulant that is used to reduce the symptoms of ADHD but causes decreased appetite, vomiting, fatigue and nausea. Furthermore, the FDA reported that usage of this drug might cause liver damage. Another drug that reduces symptoms of impulsivity and hyperactivity in children with attention-deficit/hyperactivity disorder is Adderall. However, research has suggested that Adderall has no advantage or improvement over the effects of Ritalin or Strattera.

Psychological interventions:

Reinforcements in a classroom setting along with behavioural interventions are used to maximize immediate feedback and success rate in children affected with ADHD. Moreover, an integrated therapy approach is used where the child along with their parents are given psychoeducation on ADHD. It is a holistic approach used to address the fatigue faced by the parents and help the child alleviate the hyperactive and impulsive symptoms manifested because of ADHD.

Research studies have portrayed that positive reinforcement prevents disruptive behaviour in the classroom setting at the elementary level. Individualized Education Programs (IEPs) are implemented in schools to administer ADHD-friendly environments like breaks or extended time during tests. Parent-Child Interaction Therapy (PCIT) helps to address these issues for parents without blaming the children and encourages them to help their children via learning effective strategies. It enhances the bond between the parent and the child.

Social skills training is offered to children and individuals affected with ADHD to help them build healthy relationships by improving their interactions with family, peers and coworkers. Relaxation techniques like yoga and meditation help with improving the focus and attention span of an individual. Support groups help reduce the stigma related to the disorder and reduce the feelings of isolation. Moreover, lifestyle changes like a healthy diet, a strict exercise regime and structured routines enforce stability and organization in one’s life. 

ADHD across the lifespan: 

A lot of changes were made in the DSM-5 criteria across the editions to expand the diagnoses over the life span of a human. Reports have shown that many symptoms of ADHD are retained in adulthood. As a result, in the late adolescent or early adulthood period, individuals tend to be associated with aggressive behaviour and substance-use disorders. In boys, ADHD is often manifested as a risk of adult criminality whereas in girls, the same is observed as a high risk of exhibiting antisocial, mood, eating and anxiety disorders.