ADHD management

Attention Deficit Hyperactivity Disorder (ADHD):

Treatment and Management

 

Attention deficit-hyperactivity disorder (ADHD) or Attention deficit disorder (ADD) is a neurobehavioral disorder characterized by either significant difficulties of inattention or hyperactivity and impulsiveness or a combination of the two. ADHD impacts school-aged children and results in restlessness, acting impulsively, and lack of focus which impairs their ability to learn properly.

Symptoms emerge before seven years of age. It is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 percent of children globally, and is diagnosed in about 2 to 16 percent of school-aged children. ADHD is about three times more common among boys than girls. It is a chronic disorder with 30 to 50 percent of those individuals diagnosed in childhood continuing to have symptoms into adulthood. Adolescents and adults with ADHD tend to develop coping mechanisms to compensate for some or all of their impairments.

There are three subtypes of the disorders

1. Predominantly inattentive (ADHD-PI or ADHD-I) or "attention deficit disorder" (ADD)
2. Predominantly hyperactive-impulsive (ADHD-HI or ADHD-H)
3. Combined (ADHD-C)

 

Signs and symptoms

Inattention, hyperactivity, disruptive behavior, and impulsivity are common features of ADHD.

Symptoms of Inattention:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

Symptoms of Hyperactivity:

• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which remaining seated is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Is often "on the go" or often acts as if "driven by a motor"
• Often talks excessively

Symptoms of Impulsivity:

• Often blurts out answers before questions have been completed.
• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

Impulsivity may lead to accidents such as knocking over objects or banging on people. Children with ADHD may also engage in potentially dangerous activities without considering the consequences. For instance, they may climb to precarious positions.

Symptoms must have persisted for at least 6 months. Some of these symptoms need to have been present as a child, at 7 years old or younger. The symptoms also must exist in at least two separate settings (for example, at school and home). The symptoms should be creating significant impairment in social, academic, or occupational functioning or relationships. About half of children and adolescents with ADHD experience rejection by their peers compared to 10-15 percent of non-ADHD children and adolescents. Adolescents with ADHD are more likely to have difficulty making and keeping friends due to impairments in processing verbal and nonverbal language.

Handwriting difficulties seem to be common in children with ADHD. Delays in speech and language as well as motor development occur more commonly in the ADHD population. A study found that children with ADHD move around a lot because it helps them stay alert enough to complete challenging tasks.

 

Associated disorders:

Inattention and hyperactive behavior are not necessarily the only problems in children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it. The combination of ADHD with other conditions can greatly complicate diagnosis and treatment. Many co-existing conditions require other courses of treatment and should be diagnosed separately instead of being grouped in the ADHD diagnosis.

Some of the associated conditions are:

• Oppositional defiant disorder and conduct disorder
• Borderline personality disorder
• Primary disorder of vigilance
• Mood disorders and Major depressive disorder
• Borderline personality disorder
• Anxiety disorders
• Obsessive-compulsive disorder
• Substance use disorders

Cause:

The specific causes of ADHD are not known. There are, however, several factors that may contribute to, or exacerbate ADHD. They include genetics, diet, and social and physical environments.

As with all mental disorders, the exact cause of attention deficit disorder (ADHD) is unknown, so parents should not blame themselves for this problem. Instead, parents should focus on how best to help their child with ADHD. Experts hope that someday, understanding the causes of the condition will lead to effective therapies, and evidence is building on the side of genetic causes for ADHD rather than elements of the home environment. Certain aspects of a child’s environment may, however, affect the symptom severity of ADHD once it is established.

Possible causes of ADHD include:

Genes

ADHD has a strong genetic basis in the majority of cases, as a child with ADHD is four times as likely to have had a relative who was also diagnosed with attention deficit disorder. People with ADHD seem to have lower levels of dopamine in the brain. Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. Research into this gene has shown that the differences are not permanent, however. As children with this gene grow up, their brains develop to a normal level of thickness and most ADHD symptoms subsided.

Nutrition and Food

Certain components of the diet, including food additives and sugar, can have clear effects on behavior. Some experts believe that food additives may exacerbate ADHD. A popular belief is that refined sugar may be to blame for a range of abnormal behaviors. Most experts now believe that the link is not a strong one. Simply removing sugar from a child’s diet is unlikely to significantly impact their ADHD behavior.

Some studies also suggest that a lack of omega-3 fatty acids is linked to ADHD symptoms. These fats are important for brain development and function, and there is plenty of evidence suggesting that a deficiency may contribute to developmental disorders including ADHD. Fish oil supplements appear to alleviate ADHD symptoms, at least in some children, and may even boost their performance at school.

The Environment

There may be a link between ADHD and maternal smoking. However, women who suffer from ADHD themselves are more likely to smoke, so a genetic explanation cannot be ruled out. Nevertheless, nicotine can cause hypoxia (lack of oxygen) in the fetus. Lead exposure has also been suggested as a contributor to ADHD. Although paint no longer contains lead, preschool children who live in older buildings may be exposed to toxic levels of lead from old paint or plumbing that has not been replaced.

Brain Injury

Brain injury may also be a cause of attention deficit disorder in some very small minority of children. This can come about following exposure to toxins or physical injury, either before or after birth. Experts say that head injuries can cause ADHD-like symptoms in previously unaffected people, perhaps due to frontal lobe damage.

Other Possible Causes

ADHD researchers are currently investigating the frontal lobes of the brain — the areas controlling problem-solving, planning, understanding other people’s behavior, and restraining our impulses. A 2002 study found that children with ADHD had 3-4 percent smaller brain volumes in all the brain regions measured. But children on ADHD medication had similar brain volumes to unaffected children, in some of the areas measured. One big difference was the amount of “white matter” — long-distance connections between brain regions that normally become stronger as a child grows up. Children with ADHD who had never taken medication had an abnormally small volume of white matter.

Management

Methods of treatment often involve some combination of Positive behavior support (PBS), lifestyle changes, counseling, psychotherapy, Hypnotherapy, and medication. Medical management and behavioral treatment are the most effective ADHD management strategies.  Medications have at least some effect on about 80% of people. Dietary modifications may also be of benefit.

Psychosocial

The evidence is strong for the effectiveness of behavioral treatments in ADHD. It is recommended first line in those who have mild symptoms and in preschool-aged children. Psychological therapies used include psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training, parent management training, neurofeedback, and nature exposure. Parent training and education have been found to have short-term benefits. Hypnotherapy helps a lot to change unwanted habits.

Medication

Stimulant medications are the medical treatment of choice in allopathy. There are several non-stimulant medications, such as atomoxetine, that may be used as alternatives.  Medications are not recommended for preschool children, as their long-term effects on such young people are unknown. There is very little data on the long-term benefits or adverse effects of stimulants for ADHD. Any drug used for ADHD may have adverse drug reactions such as psychosis and mania. Tolerance to the therapeutic effects of stimulants can occur,[90] and abrupt withdrawal is not recommended.  People with ADHD have an increased risk of substance abuse, and stimulant medications reduce this risk. Stimulant medications themselves however have the potential for abuse and dependence.

Homeopathic medicines have a significant effect on ADHD children. Regular homeopathic treatment along with psychological therapies brings significant and positive change in patients with ADHD.

Prognosis

Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment. In the United States, 37 percent of those with ADHD do not get a high school diploma even though many of them will receive special education services. Almost half of all ADHD students never finish high school and less than 5 percent of individuals with ADHD get a college degree compared to 28 percent of the general population. ADHD persists into adulthood in about 30 to 50 percent of cases. Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.

Between one-third and up to 80 percent of the children diagnosed with ADHD continue having symptoms well into adulthood. Many adults, however, remain untreated. Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized, and may rely on non-prescribed drugs and alcohol to get by. They often have such associated psychiatric co-morbidities as depression, anxiety disorder, substance abuse, or a learning disability.

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