ADHD
(Attention Deficit Hyperactivity Disorder)
ADHD is a brain-based syndrome, highly genetic, which deal with specific brain functions and related behaviors.
Attention, Memory, Motivation, Impulsivity, the ability to learn from mistakes, Hyperactivity, Social skills and Organization are typical brain operations that measure the functioning abilities of any human being. Many contributing factors will play an essential role especially when there is a chemical and structural imbalance.
It is believed that 5 % of adults have ADHD, representing 11,000,000 in the USA. Women and men appear to be equally exposed although the symptoms will last forever because it is not limited to childhood and most will not outgrow it.
ADHD is described as a neuro-behavioral condition with no cure. The symptoms can appear as early as between the age of 3 and 6 to continue through adolescence and adulthood. About 2/3 of children with ADHD will continue to have symptoms in their adult life until they require treatment. Some studies have shown a mild male predominance probably because more boys or men are referred for ADHD testing and treatment. It makes it difficult to have a true male to female ratio. It is agreed that the disease is underdiagnosed in women, leaving a majority undertreated especially when hyperactivity or behavior problems are encountered. Conduct disorder, depression and substance abuse are also common. Many patients suffering from ADHD will demonstrate a different subtype in Inattentiveness, Hyperactivity or Behavior problem not always similar. Adults misdiagnosed with ADHD may show poor academic performance, problems at work, and difficulty in their relationships. ADHD symptoms can change with a person becoming older. In the young children with ADHD, hyperactivity-impulsivity are the predominant symptoms. In the adolescence, hyperactivity brings restlessness, but the inattention and the impulsivity remain until adulthood. Many will struggle with relationships to exhibit antisocial behaviors.
Scientists are not sure on what cause ADHD. Many factors have been blamed like Cigarette smoking, Alcohol use and drugs during Pregnancy, Genes, Exposure to toxins, low birth rate, high level of lead and even Brain injury has been blamed to induce the disease.
The American Psychological Association has outline ADHD like a lifelong pattern of inattention and /or hyperactivity-Impulsivity that interferes with development and functioning. The diagnosis requires the following criteria:
1- Inattention: Present at least for the last 6 months showing careless mistakes, failure to give close attention to details, Trouble in holding attention on tasks related to schoolwork, work or other activities, in following instructions, in finishing schoolwork or duties, troubles in organizing activities. They often avoid or dislike or become reluctant to do tasks requiring mental effort. Often, they lose things like wallets, keys, passport, eyeglass, telephone etc.
2- Hyperactivity and Impulsivity: Present at least for 6 months to an extent that is disruptive and inappropriate. Often fidgets with or taps hands and feet or squirms in seat. Often leaves assigned seat or runs about or climb feeling restless. Often unable to play quietly. Often on the go like driven by a motor. Often talk excessively or blurts an answer before a question is completed. Often has trouble in waiting for his/her turn. Often interrupts or intrudes on other conversations or games
Other conditions must be met:
- Hyperactive-Impulse symptoms with Inattentiveness present before the age of 12 in different setting (Home, Work, School with friends and relatives).
- Symptoms interfere with or reduce social, school or work functioning
- Symptoms not associated with other mental disorders like Mood, Anxiety, Dissociative or Personality.
The ADHD diagnosis is further broken down into one of three subtypes
Combined Presentation: symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months;
Predominantly Inattentive Presentation: predominant symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months; and
Predominantly Hyperactive-Impulsive Presentation: predominant symptoms of hyperactivity-impulsivity but not inattention was present for the past six months.
.(American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.)
What is the difference between ADD and ADHD.
The current terms ADD (Attention Deficit Disorder) and ADHD (Attention Deficit Hyperactivity Disorder) are often used interchangeably.
The name “ADHD” was recorded as early as 1700 in the medical research under the name of “Minimal Brain Dysfunction” but has evolved interchangeably with ADD (Attention Deficit Disorder). The most recent description breaks Attention/Hyperactivity Disorder and Combined presentation to reflect the most common form of the condition. ADHD/ADD is not cause by poor parenting or Traumatic brain injury nor by food allergies or lack of physical activities or even excess of sugar. History of head injury has been disproved as well for any chemical and structural imbalance in the brain mostly as the result of a genetic defect in the way the Neurotransmitters Dopamine and Norepinephrine interact at the level of the neurons to facilitate Brain Function. Researchers Volkow et al in 2009 have found a deficient pathway in the brains of patients suffering of ADHD possibly affecting the modulation and regulation of the Dopamine system.
Ongoing researches with McCarthy et al 2013, Metin et al, 2014, Uddin et al 2008-2009; Zametkin 1990 etc., with the use of Pet Scans on patients with ADHD, have shown a significantly reduced activity around the brain responsible for motor activity and attention capacity (Pre-motor and pre-frontal cortex). Other studies have demonstrated a decrease in the blood flow through the brain through the entire brain with poor connectivity.
Several genes have been implicated in the ADHD including Dopamine receptor genes DRD4 and D2 as well as a Dopamine Transport gene DAT1. Possibly a gene impacting Serotonin Activity may play a role affecting 40-60% 0f patients with ADHD, children or adults (Meldine et al 2003, Barkley 2008).
ADHD can be diagnosed via extensive interviews, observations and comprehensive history. Comprehensive Neuropsychological and psychoeducational testing can occasionally bring benefits in learning to live with the disease. Those tests become important in the process of obtaining academic or standardized testing for workplace and school activities. Family members, teachers, spouses are often asked to provide a third-party observation or a behavior rating to verify symptoms. Psychologist, Psychiatrist or psychotherapist specializing in ADHD can better face these challenges. Teachers and coaches are not qualified to make such diagnosis nor even a family practice physician who can refer the patient to one of the specialist cited above.
Treatment of ADHD
The best way to treat ADHD is with a combination of medication and therapy. The treatment aims at managing brain base functions and therapy to deal with the daily behavior and thoughts. Cognitive therapy is certainly the most effective approach to the various problems.
A new mode of treatment has shown good results using dialectical behavioral therapy which looks for internal and external to adaptive coping behaviors and works at developing new actions and skills. An experienced ADHD therapist look for this opportunity to help building new skills in improving the emotional and interpersonal effects of the disease via coaching sessions and group therapy programs or peer support group.
Medication is often used to normalize the brain activity and must be carefully prescribed and monitored by a psychiatrist or a primary care physician who knows well ADHD:
Stimulant Medication like Ritalin, Concerti, Adderall XR, Vyvanse and Focalin XR have shown effectivity in the treatment. Some adults will prefer long-acting medications while others respond better to short-acting or a combination of both. Adjustments are needed because not all patients will respond well to the stimulants. Other medications like Strattera, Intunity, Wellbutrin can be added to the regimen.
Conclusions:
In conclusion, ADHD is considered as a disability. Any patient suffering from this disease may require accommodations in school or in the workplace. I met so many young and older suffering with this “genetic disease” and understand your world with the problems that I can see now with a different eye. I urge you to know that I finally understood what it takes to live with Attention Deficit Hyperactive Disorder.
Maxime Coles MD
References:
1- Attention Deficit Hyperactivity Disorder. NIH Archived Documents 2016
2- Symptoms and Diagnosis in Attention Deficit /Hyperactivity Disorder (ADHD) CDC Archived Documents 2014
3- American Psychiatric Association 2013. Diagnosis and Statistical Manual of Mental Disorders.
4- Current and Investigational Medication delivery systems for treating ADHD. The PCP companion for CNS Disorders. 18 (4)
5- Disease and Injury Incidence and Prevalence, Collaborators Oct 2016. Global Regional and National Incidence and Prevalence.1990-2015.
6- Inattentiveness in ADHD. Neuroscience Bulletin 29 (1).
7- Drug and other Physical treatments. Shorter Oxford Textbook of Psychiatry p 546
8- Epidemiology of ADHD. In Tsuang, MT; Tohen. M Jones. Textbook of Psychiatric Epidemiology p 450
9- ADHD, a women’s issue. Feb 2003 Monitor on Psychological Association April 2017. 34 (2)
10- Pharmacological Treatment: ADHD: Diagnosis and Management in children, young persons and adults. NICE Clinical Guidelines. 72.
11- ADHD Recommendations CDC June 2015
12- Lange, KW: Reichl, S: Lange, KM: History of ADHD.
13- Bendz,LM, Scates AC. Melatonin Treatment for Insomnia in pediatric patients with ADHD. Annals of Pharmacotherapy, 44 (1) pp 185-191.
14- Baud P, Perroud, N Aubry, (June 2011); Bipolar Disorder and ADHD in adults. 7 (297: pp 1912-1922.