Introduction

Attention deficit hyperactivity disorder is a widely known neurodevelopmental disorder with onset during the developmental period. It is usually first diagnosed during childhood and persists till adulthood. ADHD is characterized by the presence of inattention, hyperactivity, and impulsivity. ADHD affects school life and hinders the ability to attain goals. The children with ADHD face difficulty in maintaining interpersonal relationships and achieving academic excellence in comparison to typically developing children, resulting in low self-esteem.

In children and adolescents ( <18 years), the global prevalence of ADHD is found to be 2.2 percent (range, 0.1–8.1 percent). The overall prevalence of ADHD in adults (aged 18–44 years) from Asia, Europe, the Americas, and the Middle East was reported to be 2.8 percent (range: 0.6–7.3 percent).

International Classification of Diseases 11 has mentioned Attention deficit hyperactivity disorder under neurodevelopmental disorders which is characterized by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity that has a direct negative impact on academic, occupational, or social functioning.

 

Inattention

Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility, and problems with organization.

Hyperactivity

Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioral self-control.

Impulsivity

Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences.

Although little kids are highly active and are easily distracted the degree of inattention and hyperactivity in ADHD-affected children is beyond the normal range.  The main difference between a normally active child and one with ADHD is that the symptoms of ADHD interfere with the normal routine functioning of a child at social settings like school, etc.

 

Types of ADHD

Predominantly inattentive type:

In this the symptoms of inattention like distractibility, failure to look into details, forgetting daily routine task, difficulty in the organization, etc is predominant. The symptoms of hyperactivity are not present in this type.

predominantly hyperactive type:

In this predominant symptoms are hyperactivity and impulsivity which is characterized by excessive talk, unnecessary interruption in other’s task, constant running and jumping, restlessness, inability to sit still, reckless play, etc.

combined type:

In this the symptoms of both inattention and hyperactivity are present.

Clinical Features

Symptoms of inattention

• Has poor attention to detail and makes careless errors.
• Has a hard time paying focus for long periods of time
• Doesn’t seem to be paying attention.
• Fails to follow through on instructions or complete assignments
• Organizing tasks is a challenge
• Tries to stay away from tasks that require mental effort.
• Frequently misplaces goods needed to complete a task and is easily sidetracked.

Symptoms of hyperactivity

• Restlessness
• Fidgets and squirm extensively
• Difficulty in sitting at one place quietly
• Leaves seat when inappropriate
• Hyperactive at inappropriate places often found running and climbing unnecessarily
• Unable to play quietly
• Talks excessively
• Blurts out answers before the question is finished
• Face difficulty when waiting for their turn
• Interrupts or intrudes on others

Other associated symptoms

• Sensitive to stimuli, easily upset by noise, light, temperature, and other environmental changes
• Impulsivity.
• Memory and thinking deficits
• Specific learning disabilities
• Sleep problems
• Explosive or irritable.
• The mood is unpredictable.
• Often engages in physically dangerous activities without considering possible consequences (for example, runs into street without looking).

Etiology/ Causes

Genetic factors

• Monozygotic twins have a higher risk than dizygotic twins.
• Siblings of hyperactive children have nearly twice the risk of having the disorder
• Biological parents of children with the disorder have a higher incidence of ADHD than adoptive parents

Neurotransmitters

•  In ADHD, dopamine and norepinephrine level is low. Norepinephrine is thought to be involved in executive functions like analysis and reasoning, as well as the cognitive alertness required for processing stimuli and maintaining attention and thought. Dopamine is involved in sensory filtering, memory, concentration, controlling emotions, locomotor activity, and reasoning.
• Children with ADHD have lower levels of serotonin

Functional areas of the brain affected

• Prefrontal cortex: This part of the brain is responsible for maintaining attention, organizing, and executive function.

• Basal ganglia: Involved in high-level movement regulation. Inattention or impulsivity can be caused by disruptions in these circuits.

• Hippocampus: This part of the brain is involved in learning and memory.

• Limbic system: Emotional regulation. Restlessness, inattention, or emotional volatility can all be symptoms of a neurotransmitter imbalance in this area.

Prenatal, perinatal, and postnatal factors

Prenatal toxic exposure, prenatal factors that cause injury to the fetal brain, Prematurity, fetal distress, precipitated or prolonged labor, perinatal asphyxia, Postnatal infections, CNS abnormalities resulting from trauma, etc.

Environmental influences

Environmental lead exposure, food additives, colored preservatives, and sugar have also been postulated as probable causes of hyperactivity, although no conclusive evidence exists.

Psychosocial factors

Emotional deprivation for a prolonged time, stressful situation, and family dispute are often associated with ADHD

 

Treatment of ADHD

There is no exact line of treatment that can completely cure ADHD, but mental health experts suggests that a multimodal approach is best to deal with it. A combination of medicines and psychotherapy like behavior management is proved to be effective for controlling the symptoms of ADHD. The important factor to treat ADHD is the cooperation among family members and mental health care professionals.

Medicines for ADHD

CNS Stimulants

Stimulants are most common treatment choice for ADHD. Stimulants act by increasing the level of dopamine and norepinephrine. The use of stimulants help ADHD affected person to manage their symptoms that hinder them in performing daily activities. Stimulants provide a calming effect which reduces symptoms of hyperactivity and improves span of attention. Methylphenidate, Amphetamines (dextroamphetamine, Lisdexamfetamine), and Dexmethylphenidate are some of the most common CNS stimulants that are utilized for treating ADHD.

Non Stimulants

Non stimulants increases the norepinephrine level hence helps in relieving ADHD symptoms. These drugs are used when stimulants are not effective in controlling symptoms or are causing side effects. Atomoxetine, Guanfacine XR, and Clonidine XR 

Other Drugs

Antidepressants (e.g., bupropion), atypical antipsychotics (e.g., risperidone), and mood stabilizers (e.g., carbamazepine) are used to deal with comorbid conditions.

Psychosocial Intervention

Along with medication psychosocial interventions like behavior therapy has shown improvement in social skills, impulsive behaviour and academic performance. Common psychosocial interventions are cognitive behavior therapy, parents behavior management training and behavior therapy.

Behavior therapy

Behavior therapy is mostly used for children which aims toward correcting maladaptive behavior of ADHD affected child. Behavior therapy addresses the problems like lack of attention, inability to follow instruction and failure to follow schedule.

The vital components of an effective behavior therapy plan includes the following:

• Assessing and preventing triggers for maladaptive behavior.
• Appropriate reward system to reinforce good behavior.
• Decreasing frequency of negative behavior by ignoring.
• Appropriate negative punishment to decrease bad behavior

 

Specific behavioral therapy techniques include:

Positive reinforcement:
In this the behaviour is moulded by rewarding the desirable behaviour and strengthening the chance of repetition of such behaviour.
Example: A child with hyperactivity is offered to watch his favourite cartoon if he remains seated at one place for10 minutes without fidgeting.

Response cost:
In this technique child is made aware of the fact that the undesirable behaviour on his part will make him lose the reward.
Example: A child is told to be seated for 10 minutes without fidgeting and is offered to watch his favorite cartoon. In response cost the privilege of watching favourite cartoon will be exempted if the child fails to follow the instruction properly.

Time out:
This technique is usually used when the child show maladaptive behaviour like excessive hyperactivity, shouting and aggressive act, etc. The child is deprived of the environmental stimulation by making him sit alone quietly for some time after he shows bad behaviour.

Parents behaviour management training

Parents of ADHD affected child in this are taught the techniques to mold their child’s behavior. Parents are taught to assess the triggers for undesirable behavior and how to deal with the undesirable behavior. Techniques like positive reinforcement, time out and negative punishment are applied by parents in home setting to get desirable behavior outcome.

Cognitive Behavioral Therapy

This therapy is appropriate for adolescents and adults affected by ADHD. In this therapy negative cognition of client is reframed into positive cognition. Although CBT can’t target the core symptoms of ADHD but it aids in lessening the impairments associated with ADHD like procrastination.

Occupational therapy

Occupational therapy helps in improving social skills of ADHD child by teaching how to organize a task, improving motor coordination, teaching activities of daily life (bathing, brushing, making own backpack, etc.), and providing sensory stimulation to reduce hyperactive behavior.

 

ADHD is a common disorder which affects the growing years of a child. A person with ADHD face problems in paying attention to details and show hyperactive behavior. Biological and psychosocial factors all plays a dynamic role in causing ADHD although the exact cause is still unknown. The problems faced by an ADHD affected child makes it difficult for the child to meet social demands. Medication along with specific psychosocial interventions are proved to be effective in managing core symptoms of ADHD. The lack of awareness related to ADHD leads to late diagnosis of disease hence, it is necessary for parents and teachers to know ADHD as they are the one who can detect the symptoms at early stages.