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Attention Deficit Hyperactivity Disorder

ADHD is one of the most common but also one of the most treatable psychiatric disorders. Although it has traditionally been thought of as a childhood disorder, ADHD actually has life-long implications. It is most commonly first identified with attention problems in the early school years, but in retrospect, parents often remember the affected child having extra energy as a toddler. These children have difficulty staying with a single activity for more than a few minutes and frequently leave projects unfinished. They appear not to listen when spoken to and are constantly moving: running, jumping, climbing, and unable to sit still.

The tendency towards hyperactivity is more prominent in younger children and tends to subside as patients age. This is replaced by restlessness and impulsivity in adolescents and adults, while attention problems tend to persist after they appear in the elementary school years. Inattention presents a major hurdle for these children when they are presented with academic challenges. They have trouble organizing their work and remaining focused in class. They also frequently have social issues because they miss social cues, interrupt often, and have trouble taking turns.

Affected adults have similar problems in the workplace that affected children have in school. They miss work more often, perform less efficiently at their jobs, and have more trouble staying employed. They are easily distracted, take a long time to get back on task, and have difficulty organizing and finishing work-related projects. These issues, unfortunately, lead supervisors to see them as lazy and not dedicated to their work. Adults with ADHD are also more prone to distracted driving and subsequent accidents. They have trouble managing their finances and impulsive spending can leave people with little savings. Social issues also plague these adults who have difficulty communicating effectively in relationships and have problems maintaining a solid peer circle because of the social skills they did not develop as adolescents with ADHD.

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Causes and Risk Factors

Rates

ADHD is one of the most common childhood psychiatric disorders, appearing in about 5% of children and in about half as many adults. It is two-to-three times more common in males than in females. Men are more likely to have hyperactive features of the disorder while women tend to have inattentive symptoms.

Powerful genetics

Compared to most other mental health disorders, ADHD has one of the strongest genetic components. Genes account for 60 to 76% of the risk of developing ADHD. ADHD in one family member increases the risk by eight times in first-degree family members (siblings, parents, and children).

Childhood trauma

Although an impoverished childhood and a family home life fraught with conflict are often blamed for ADHD, it is difficult to parse out which causes which. This is because having a child with ADHD can be stressful by itself and lead to trouble in the family unit. However, studies looking at adopted children found that a severe lack of physical and emotional contact very early in life is a definite risk factor for ADHD.

Pregnancy and birth related risks

Children whose mother smoked during pregnancy are over twice as likely to develop ADHD, and this likelihood increases as the degree of smoking increases. The inattentive type of ADHD is also more than twice as likely to appear in children who had low weight at birth and were premature.

Toxic chemical exposures

Exposure to pesticides, lead, and polychlorinated biphenyls (PCBs, a formerly common chemical in plastics) starting as early as before birth and up to adolescence can up to double the chances of developing ADHD. PCBs and lead specifically reduce short term memory and increase distractibility.

Learning and behavioral problems

ADHD frequently co-occurs with multiple different learning disorders. These can include problems in the development of reading, writing, spoken language, and motor capabilities. These patients can have intellectual disability and Autism Spectrum Disorders as well. ADHD shares a genetic basis with Autism Spectrum Disorders as well as with Conduct Disorder, Antisocial Personality Disorder, Substance Use Disorders, and mood disorders.

Diagnosing ADHD

Inattention and hyperactivity are the two categories of symptoms that form the core of ADHD. One or both must be present and be intense enough to disrupt functioning in social, work, or academic areas to make the diagnosis.

Inattention

Inattention generally consists of trouble focusing and disorganization that is not attributable to a behavioral issue. This requires at least six of nine symptoms that have lasted for at least six months.

  1. Makes simple, careless mistakes in work and lacks focus on details.
  2. Problems sustaining focus, such as in class or while reading.
  3. Difficulty with focusing in conversations, does not appear to attend to who is speaking.
  4. Starts projects but has trouble finishing them.
  5. Generally disorganized, bad time management.
  6. Avoids work that needs sustained focus.
  7. Frequently misplaces things.
  8. Easily distracted.
  9. Forgetful of appointments and tasks.

Hyperactivity and Impulsivity

These make up the second piece of ADHD. Hyperactivity comprises increased energy and movement, like squirming, rocking, or running around. Impulsivity refers to acting or speaking without thinking and difficulty delaying gratification. It requires at least six of nine symptoms over six months.

  1. Frequent movement and fidgeting, unable to sit still.
  2. Unable to remain seated for extended periods, gets up in inappropriate situations like meetings or class.
  3. Feels restless, runs around at inappropriate times.
  4. Cannot play or recreate quietly.
  5. Frequent excess energy.
  6. Talks excessively.
  7. Impulsively speaks before it is appropriate.
  8. Trouble waiting and taking turns.
  9. Interrupts others’ conversations and activities.

Although there is no age cutoff for the disorder, at least some symptoms of inattention or hyperactivity must have appeared before age 12. Symptoms must be present in at least two different types of situations, such as at home, at school, at work, or with family or friends.

Treating ADHD

Behavior therapy

Behavior therapy alone is the first choice treatment for ADHD in children under the age of six and can be combined with medication in those six and older. It involves not only affected children but also their families and teachers working together in a coordinated effort. It begins by a therapist assessing the patient’s current problems at school, in their social life, and at home by meeting with the child and parents and communicating with teachers. The therapist identifies specific problems in these areas of the child’s life that are caused by ADHD and determines skills the child needs to develop and unwanted behaviors that need to be extinguished. The therapist works with the child to help them learn these skills and teaches the parents and teachers how to reinforce the desired behaviors in a consistent manner.

Treatment in adulthood is similar except it is combined with medication frequently. Adults usually participate in Cognitive Behavioral Therapy that is customized to ADHD. These programs address the organizational issues that plague people with ADHD. They engage similar skills that the child behavior therapy programs use, except that adults are able to manage their own behaviors rather than having parents regulate them. CBT can also help with the depression and anxiety that frequently coexist with ADHD in adults.

Medications

Stimulant medications have been the mainstay drugs used to treat ADHD for decades because up to 80% of patients respond positively to them. Although it may seem counterproductive to give something called a “stimulant” to people who already tend to have excess energy, that is not the effect these drugs actually have on these patients. In fact, these drugs work by increasing connectivity in the areas of the brain that deal with organization, attention, and memory.

The most well known medications in this category are Ritalin/Concerta/Focalin (methylphenidate) and Adderall (amphetamine). These work immediately but only on the days that they are taken. They do not need any build up time and have no carry-over effect.

Strattera (atomoxetine) is the first non-stimulant medication approved by the Food and Drug Administation to treat ADHD. It is not a controlled substance like stimulants, and there is much lower risk of patients abusing it or illegally selling to others. Unlike stimulants, these take 3-4 weeks to work but have fewer undesirable side effects.

Managing ADHD

Starting treatment

Treatment should start as soon as the diagnosis is made. Children with ADHD who receive treatment as early as possible have fewer problems in school, with friends, and at home. These children grow into adults who are less impaired by their ADHD as well.

Alleviating medication concerns

Stimulant medications for ADHD are some of the most studied drugs in existence. To address fears that these medications could lead to substance use problems, decade-long studies found that treating ADHD with them actually reduced the risk of substance abuse. In fact, children who don’t receive stimulant treatment for ADHD are at higher risk of substance use disorders in adulthood. However, they should be avoided in adolescents and adults who show signs of substance use problems. They can also worsen the symptoms of coexisting anxiety and bipolar disorders.

Tics Disorders, which include Tourette’s Disorder, consist of repetitive, unintentional movements or sounds. These start in childhood and frequently coexist with ADHD. Stimulant medications do not cause tics, but they can bring them out earlier than when they would have naturally developed. Non-stimulant medication is a good alternative in these situation.

Practical approaches

Creating structure is the most important part of self-management of ADHD. In children with ADHD, parents help to create this structure by setting rules, bed times, and rewarding desired behaviors. Adults with ADHD have to police themselves. In the process of getting organized, list making is an excellent start. Multitasking is not.  The ADHD brain is not built for it. Using a to-do list to break things down into a sequence is very helpful. Simplifying and consolidating finances as much as possible can often stop money troubles . Trading a credit card for a debit card can allow one to better manage payment of monthly bills. Finally, eliminating distractions when trying to get work done is extremely helpful.

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References
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