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Attention Deficit Hyperactivity Disorder

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Attention Deficit Hyperactivity Disorder or ADHD, is a neurodevelopmental disorder characterized by inattention, impulsivity, or hyperactivity1. This disorder effects somewhere between 2 and 18% of those between the ages of 6 and 17 years old and 4% of adults. ADHD is more commonly diagnosed in boys (13%) than in girls (4%). Some risk factors for ADHD are neglect or abuse, low birth weight, and the mother’s use of alcohol or tobacco during pregnance.

Diagnosis of ADHD requires that symptoms are present before the age of 12 in multiple settings and interfere with quality of life1. ADHD is classified into three subtypes based on the symptoms present. The first type is predominantly hyperactive impulsive. To be diagnosed with this subtype, a patient must meet six of the symptoms that fall under the hyperactivity category. These symptoms include fidgeting, leaving seat when expected to remain, often on the go, or excessive talking1. A meta analysis predicted about .8% of cases fell in this category based on parent and teacher reports. The second subtype is predominantly inattentive, estimated to be 1.8% of cases. This subtype is for patients who meet six or more of the criteria under the inattentive category, such as easily distracted, unorganized, or failure to follow directions1. The final category is combined presentation, in which a patient meets six or more criteria from both hyperactivity-impulsivity and inattention, representing about 3.4% of the cases. The CDC recommends that for diagnosis, doctors collect reports from parents, teachers, and mental health providers and exclude other explanations5. A self-report study reported 80% collected parent and teacher ratings, however, in a review of 188 practitioners and 1098 patient charts, just over 50% of pediatricians used ratings6.

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Typically, ADHD is first diagnosed in elementary school, though imperceptible signs may appear in toddlers1. When children enter elementary school they are expected to be able to sit at a desk paying attention for a larger chunk of the day than they were in preschool, which for some may only have been half days. It is at this point that the inattentive symptoms in ADHD first begin to have a detrimental effect on a child. It is common for children with ADHD to develop conduct problems. We can infer why children with ADHD tend to be left out or teased in classrooms, when we consider that they both perform poorly and act out in class.

Upon the shift into adolescence, there is a change in presentation, hyperactivity remains persistent but is less noticeable. However, other problems emerge, such as antisocial personalities, which may stem from the teasing of classmates. Childhood-limited ADHD has been linked to the early use of alcohol and marijuana. One study found that if ADHD persisted into adolescence there was a higher likelihood of substance abuse.

Children and adolescence overall deal with many challenges because of this disorder. They have problems with grades, lower self-esteem, and greater risk of anxiety and depression2. They also are more likely to be in motor vehicle accidents, contract sexually transmitted diseases, or get pregnant. These problems shift in adulthood to job performance and marital problems. Adults that are living with ADHD are more likely to be unemployed males, who are divorced.

Physiologically, ADHD causes multiple changes in the brain effecting executive functioning. Studies have found reduced volume in and less activity in the prefrontal cortex and the cerebellum. The smaller prefrontal cortex may be what leads to the impulsive nature of ADHD, as this is where decisions are made. Neurocognitive testing in athletes using the Immediate Post Concussion Assessment and Cognitive Testing test, that looks at memory and reaction has shown a correlation between ADHD and both verbal and visual memory8.

Treatment for ADHD, mostly involves the use of medication. There is a great variance in which medication is used though. A study reviewing patient files reported that 93% of patients were prescribed a medication. The most commonly medication prescribed to adolescence is Ritalin, which is believed to lower aggressiveness, as with most drugs, there are side effects including decreased blood flow to the brain and insomnia. Ritalin was then adapted into an extended release medication called Concerta. Concerta showed presented less side effects with use. Both of these are stimulants, like the better-known Adderall. Adderall is an amphetamine unlike Concerta and Ritalin, which are methylphenidates. One problem with Adderall is that it is commonly abused by college students to stay up all night3. The other category that ADHD medication falls under is the non-stimulant. One of these is Strattera, or atomoxetine, studies have shown that it helps in symptom control of ADHD as well as reducing tics and anxiety. There are several concerns with this medication as some cases of liver damage have occurred along with the less severe side effects of nausea, vomiting, or fatigue. Stimulants in general take less time to show improvement and take effect in comparison to non-stimulants, however the risk of substance abuse is higher.

In the recommendations of the CDC on the treatment of ADHD while medication has shown strong effects that both medication and behavior therapy both in school and at home also be used5. In the study looking at patient cases in pediatric clinics, only 13% of cases were recommended psychological treatment6. Much of the research on ADHD involves family therapy for both children and adolescents. One such study combined the use of motivational interviewing with family therapy, the outcome was improvement in organization and time management, reduction of symptom severity, and disruptive behavior.

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