Attention Deficit Hyperactivity Disorder Analysis

Introduction

Although attention deficit hyperactivity disorder (ADHD) is largely believed to be a childhood behavioral disorder, it is now considered a lifespan disorder, and in 60%–70% of cases, it can persist into young adulthood. First, ADHD in children is considered, followed by adult ADHD.

DSM-IV Diagnostic Criteria for ADHD

Although the DSM-IV Diagnostic Criteria for ADHD in children is clear, there is no such clear consensus on the diagnostic criteria for adult ADHD at present (McGough & Barkley, 2004.)

The DSM-IV Diagnostic Criteria for ADHD in children is as follows (American Psychiatric Association, 1994.)

• Either (1) or (2):

1. Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

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.

2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

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.

Impulsivity

1. often blurts out answers before questions have been completed.
2. often has difficulty awaiting turns.
3. often interrupts or intrudes on others (e.g., butts into conversations or games).

• B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
• C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
• D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Although the DSM-IV classification meant for children for ADHD can also be used for adults, the minor differences of symptoms in adults have led to the existing criteria being modified. For example, instead of applying six DSM-IV symptoms of inattention or hyperactivity, adults may require only five such behaviors to be present (Searight, Burke, Rottnek, 2000). The Utah classification is one such modified diagnostic criterion for ADHD for adults and is as follows: (Searight, Burke, Rottnek, 2000).

1. Childhood history consistent with ADHD.
2. Adult symptoms: poor concentration and hyperactivity along with two of the following: impulsivity, hot temper, affective lability, not able to complete tasks and disorganization, and stress intolerance.

The Copeland symptom checklist for ADHD is another model, and it has eight dimensions: “inattention and distractibility; impulsivity; activity level problems; noncompliance; underachievement, disorganization and learning problems; emotional difficulties; poor peer relations; and impaired family relationships” (Searight, Burke, Rottnek, 2000).

Signs and symptoms in children

Although ADHD is present at birth, the problems usually do not become obvious until later in childhood (Selikowitz, 2004.)

Features of the inattentive type

• Poor concentration: since the attentional mechanisms in the brains of these children are not efficient, they often have the poor concentration for schoolwork. There may be many careless errors, lack of precision, and attention to detail. Since a setting like a classroom has many distractions, they have difficulty in maintaining attention in the classroom. More often, the difficulty is in concentrating on things they have to listen to rather than things they have to look at (Selikowitz, 2004). In milder cases, highly interactive and motivating activities like video games hold their attention. Although they are able to cope relatively well in the first half of the school day, in the second half, there is a marked fall in their performance (Selikowitz, 2004). Following the effort of focusing in the class, such children may be very tired and emotionally drained when they return from school. They procrastinate very often for work assignments, homework, or revisions (Selikowitz, 2004). A child with severe ADHD is unable to stay on any task for a period of time and flit from one activity to another (Selikowitz, 2004.)
• Task persistence: these children do not complete tasks, and more closer supervision is, therefore, required from their parents. As a result, schoolwork is affected and the academic results are affected (Selikowitz, 2004.)
• Disorganization: such children require supervision since they find it very difficult to follow sequences. Whenever such supervision is not available, they tend to become disorganized (Selikowitz, 2004.)
• Forgetfulness: although they are able to recollect multiplication or spelling list shortly after it has been taught, they are unable to do so the very next day. Whenever they have to follow an instruction with more than one part, they find it very difficult; tending to get lost midway or become abstracted. Although they are very absent-minded, they are able to recall events that happened long back (Selikowitz, 2004.)

Features of the hyperactive-impulsive type

Impulsivity and overactivity: children with ADHD often tend to do the first thing that comes to their minds. In the classroom, they blurt out answers, say things without any tact, take many risks, etc. They often do not learn from their mistakes, and lack self-control (Selikowitz, 2004). They tend to be very restless, and cannot remain still even for a few moments (Selikowitz, 2004.)

Noisiness: it is very difficult for such children to be engaged in quiet activities, tend to be boisterous, loud, talk excessively, and make repetitive noises (Selikowitz, 2004.)

Features that may be present in either type of ADHD

Performance inconsistency and low self-esteem: this is especially marked in ADHD children. Although it is possible for them to concentrate or stop and think before acting with an effort, it is not possible for them to maintain this effort (Selikowitz, 2004). It is possible for these children to perform well under close supervision in a one-to-one setting, or in a novel situation (Selikowitz, 2004). They suffer from low self-esteem and say things like “I am dumb,” get easily offended and cry easily. Even after succeeding in something, they may not be satisfied with themselves (Selikowitz, 2004.)

Poor working memory and poor incentives motivation: they have impaired working memory (a type of short-term memory). It is difficult for them to keep any set of instructions or sequenced information in their mind (Selikowitz, 2004). Impaired working memory also results in learning difficulties like reading comprehension, sequencing, and written expression (Selikowitz, 2004). In addition, they also have behavioral problems like lack of foresight or failure to learn from experience (Selikowitz, 2004). The ability to work for future rewards is known as incentive motivation. They find it difficult to make any kind of sacrifice for a deferred reward (like studying regularly for good marks) (Selikowitz, 2004.)

Clumsiness: although some are good athletes, most are poorly coordinated. Many children have low muscle tone and poorly coordinated running (Selikowitz, 2004). Social clumsiness includes saying tactless things without knowing the effects it could have, and behaving inappropriately in front of others for children their age. They are unable to pick cues or read facial expressions and find it difficult to predict the consequences of their actions and respond appropriately to the occasion (Selikowitz, 2004.)

Learning difficulties and inflexibility: they are academic underachievers. In primary school, they face difficulties with skills like reading, spelling, and mathematics, as well as have bad handwriting (Selikowitz, 2004). They are very inflexible after they have made up their mind. They become fixated on certain rules and follow these rigidly (Selikowitz, 2004.)

Insatiability, defiant behavior, and sleep problems-they may be insatiable in their activities, and not know when to stop. During play, they become overexcited and are unable to calm down, becoming more excited, non-compliant, defiant, and provocative (Selikowitz, 2004). They are hard to discipline and do not obey reasonable rules and regulations. Later, as they get older, they might steal and display other anti-social behavior (Selikowitz, 2004). They have problems in falling asleep but once asleep they may become very restless. Others exhaust themselves so much during the day that they fall asleep very soundly at night. Many may sleepwalk, persist with bedwetting, and have nightmares (Selikowitz, 2004.)

Associated (co-morbid) conditions in children include tic disorder, dyslexia, conduct disorder, anxiety, depression, Asperger syndrome, obsessive-compulsive disorder, and bipolar disorder (Selikowitz, 2004.)

Adults have comorbidities like anxiety disorders, personality disorders, sleep problems, substance use, learning disabilities, and oppositional defiant disorder (Newcorn, Weiss, Stein, 2007.)

Substance abuse includes the use of alcohol, cannabis, cocaine, and cigarette smoking. Substance abuse is more prevalent with the presence of comorbid conduct or bipolar disorder (Newcorn, Weiss, Stein, 2007.)

Signs and symptoms in adults

Although the symptom of hyperactivity is common in children, it may not be very obvious in adults. Adults may complain of an inability to relax, and restlessness. As daily responsibilities increase in late adolescence and early adulthood, poor attention and concentration become more obvious and apparent (Searight, Burke, Rottnek, 2000). They easily forget social commitments, deadlines, and appointments. Impulsive behavior is seen in the form of rude or insulting remarks. They are unorganized, unable to prioritize (Searight, Burke, Rottnek, 2000).

Affective lability is “brief, intense affective outbursts ranging from euphoria to despair to anger”(Searight, Burke, Rottnek, 2000). Hot temper is characterized by “frequent angry eruptions out of proportion to the precipitants”(Searight, Burke, Rottnek, 2000).

Physiological/psychological/sociological factors underlying ADHD

Physiological factors

Although many theories of ADHD have been proposed, the dopamine deficit theory is the most favored of the lot (Swanson et al., 2007). ADHD and other major mental disorders are considered to be due to defects in the basal ganglia and their related nuclei. The basal ganglion is a part of the forebrain system. It functions by collecting signals from a large area of the neocortex, redistributing and focusing it into specific areas of the frontal lobes and brainstem (involved in motor planning and motor memory) (Swanson et al., 2007).

One important pathophysiological component of ADHD involves the imbalance of basal ganglia neurocircuitries, which are induced by dopamine. As a result of the lack of dopaminergic nigrostriatal input, the positive feedback via the direct system is reduced while the negative feedback via the indirect system is increased. The net result is an overactivity of the basal ganglia output sites along with an inhibition of the thalamocortical drive (Mehler-Wex, Riederer, Gerlach, 2006.)

Other than dopamine, deficiencies in norepinephrine and serotonin are also implicated in ADHD. Norepinephrine functions by modulating other neurotransmitters like dopamine and have a role in alertness and environmental sensitivity. Whenever the level of norepinephrine falls, it leads to depression, while excess levels of norepinephrine can cause mania and ADHD symptoms. Norepinephrine activates serotonin nerves, and conversely, serotonin inhibits norepinephrine (Teeter, Ellison, Goldstein, 2000.)

Although the primary gene involved in ADHD has not yet been isolated (Teeter, Ellison, Goldstein, 2000), genetic factors are important in the etiology of ADHD, and the disorder may be polygenic (Coffey & Brumback, 2005). By means of genetic studies, the association between ADHD and genes involved in dopaminergic neurotransmission (DRD4, DRD5, DAT1) has been shown (Coffey & Brumback, 2005). Other specific gene associations in ADHD include the human thyroid receptor-β gene (Wolraich, 2003). Imaging studies in ADHD patients have shown an increased density of DAT in the striatum (Mehler-Wex, Riederer, Gerlach, 2006.)

Many chromosomal regions containing potential ADHD predisposing loci have been identified, following family-based linkage studies. Some of these loci have been found to overlap in two or more studies; these include 5p, 6q, 7p, 11q, 12q, and 17p (Elia & Devoto, 2007). In the case of the inattentive subtype of ADHD, a variation in the HTR1B gene may be the primary cause (Smoller et al., 2006).

ADHD may also occur after brain injury or frontal-subcortical system dysfunction. Prenatal factors that have been implicated in ADHD include fetal alcohol syndrome and maternal cigarette smoking (Coffey & Brumback, 2005). Other conditions associated with ADHD include celiac disease, prematurity, epilepsy, Pediatric Autoimmune Neuropsychiatric Disorders Associated With streptococcus (PANDAS), and phenylketonuria. Environmental toxins, especially lead may contribute to ADHD (Coffey & Brumback, 2005.)

Research on subjects with ADHD has shown that, anatomically, they have smaller anterior right frontal regions and asymmetrical caudate nucleus; this suggests frontal-striatal system anomalies (Teeter, Ellison, Goldstein, 2000). The corpus callosum and posterior-occipital regions (involved in attentional control, executive control, and motor planning) also show an anomalous morphology (Teeter, Ellison, Goldstein, 2000).

The other changes that have been observed include: hypoperfusion (low arousal) pattern in the mesial frontal areas, increased arousal in the sensory and sensorimotor regions, and decreased metabolic activity in cortical areas (Teeter, Ellison, Goldstein, 2000). Studies have also shown an association between neurochemical activity, neuroanatomical arousal, and behavioral symptoms in children with ADHD (Teeter, Ellison, Goldstein, 2000.)

Several brain studies (neurophysical studies, neuroimaging studies, and animal models) have provided information about the probable locus of the brain pathophysiology of ADHD (Davis, Charney, Coyle, 2002). Neurophysiological studies point out to the orbitofrontal and dorsolateral prefrontal cortex or regions projecting to these regions (Davis, Charney, Coyle, 2002); the monkey model implicates frontal-striatal neural networks; structural neuroimaging studies implicates frontal cortex (usually right side), cerebellum, globus pallidus, caudate and corpus callosum; functional neuroimaging studies have shown hypoactivity of the frontal cortex, anterior cingulated cortex and subcortical structures (Davis, Charney, Coyle, 2002.)

Findings from these studies together suggest that ADHD could probably be due to the dysregulation of the frontal cortex, subcortical structures, and the networks that connect them (Davis, Charney, Coyle, 2002.)

Psychosocial factors

Many environmental theories were proposed over the years but they were not adequately researched and hence received little support. Willis and Lovas claimed that hyperactive behavior was the result of poor stimulus control by maternal commands and that this poor regulation of behavior arose from poor parental management of the children (Barkley & Murphy, 2005.)

The mother’s use of inappropriate control strategies with children, lack of affection and approval of their children, etc are associated with ADHD symptoms (Eisen, 2008). Other studies have reported higher levels of control and emotional overinvolvement and lower levels of acceptance and psychological independence among parents of anxious children than among those of controls (Eisen, 2008).

The attachment theory tries to explain how early parent-child relationships may serve as a protective or risk factor for mental illness (Eisen, 2008). Some studies have indicated that attachment issues among children with ADHD are linked to stress-related to a mother’s pregnancy and the child’s first year of life (Eisen, 2008).

Some examples of factors, which negatively impact child-parent attachment is insecurity about parenting, lack of significant other/familial support, and the mother’s negative views of the father’s behavior, significant life stressors, and pregnancy/birth complications (Eisen, 2008). Attachment theories propose that ADHD symptoms are linked to the poor attachment between mothers and their children because the disrupted attachment pattern, in part, leads to impairments in children’s regulation and interpersonal functioning (Eisen, 2008)

There is a higher risk for developing ADHD in children who have been brought into an environment of paternal criminality, maternal psychopathology, and poverty (Teeter, Ellison, Goldstein, 2000). Other implicated factors include large family size and foster placement. It is probably an aggregation of these factors, rather than any single factor, which impairs development (Davis, Charney, Coyle, 2002.)

Treatment approaches

Traditional

Two of the most commonly used medications in ADHD are the stimulants methylphenidate (MPH) and amphetamine. Other medications, which have been reported to be both efficacious and tolerable include dexmethylphenidate (active D-isomer of MPH), mixed amphetamine salts (MMAS-XR), and lisdexamfetamine dimesylate (LDX)-a prodrug of d-amphetamine (Findling, 2008). Desipramine is effective while an inconsistent efficacy has been reported with imipramine (Findling, 2008).

For ADHD in children 6 years of age and in adolescents, a non-stimulant drug called atomoxetine has been used; this is the first such non-stimulant drug to be approved (Gaillez, Sorbara, Perrin, 2007). It is a “highly specific inhibitor of the presynaptic norepinephrine transporter, with minimal affinity for other transporters or other neurotransmitter receptors”(Gaillez, Sorbara, Perrin, 2007). It is also potentially beneficial in the management of ADHD with comorbid conditions like oppositional-defiant disorder, conduct disorders, and tic disorders (Gaillez, Sorbara, Perrin, 2007.)

One novel medication, which supposedly promotes wakefulness, is modafinil. Compared to placebo treatment, modafinil has shown greater efficacy in ADHD in children and adults. Nevertheless, more studies are required before its use can be confirmed (Turner, 2006).

In adults with ADHD, the pharmacotherapy is the same. Stimulants are the most commonly used medications. They include: methylphenidate, pemoline, dextroamphetamine, methamphetamine, desipramine, imipramine, nortriptyline, and bupropion (Searight, Burke, Rottnek, 2000.)

The FDA has approved two stimulants for use in adult ADHD: lisdexamfetamine dimesylate and extended-release mixed amphetamine salts (Stephen & Kevin, 2008.)

Atomoxetine may be especially useful for adult ADHD along with comorbid depression or for adult ADHD with comorbid substance use disorder addictive potential (Stephen & Kevin, 2008.)

In adults, with age, the adherence to stimulant medications may decrease, and thus efforts should be directed to prevent this. Another problem is stimulant misuse and/or diversion, especially in those adults with comorbid conduct disorder or substance abuse diagnosis (Stephen & Kevin, 2008.)

Psychosocial treatment interventions for children

Behavioral strategies: this involves parent training, contingency management, cognitive-behavioral treatment, and clinical behavior therapy. Contingency management is typically done in the child’s classroom and involves strategies like timeout, response cost, point/token reward systems, etc. Parent training involves teaching parent-child management skills (Roth, Fonagy, Parry, 2005).

In clinical behavior therapy, either the teacher or parent, or both are taught how to use contingency management procedures. Cognitive-behavioral treatment involves the use of self-reinforcement, self-monitoring, problem-solving strategies, and verbal self-instruction (Roth, Fonagy, Parry, 2005).

However, cognitive-behavioral treatment has not been found to be beneficial in ADHD children. Parent training, contingency management, and clinical behavior therapy have been found to be beneficial (Roth, Fonagy, Parry, 2005). Some studies have compared the efficacy of stimulants versus the psychosocial treatment and found that stimulants are more effective (HSTAT). A few approaches have scant supporting evidence for their use; these include: systemic and psychodynamic therapy, CBT offered alone, and social skills training (Roth, Fonagy, Parry, 2005).

For adults with ADHD, the use of structured, skills-based psychosocial interventions has been advocated (Knouse et al., 2008). Some of the components of such interventions include training in skills (e.g., organization and planning strategies), psychoeducation, and emphasis on outside practice and maintenance of these strategies in daily life (Knouse et al., 2008). Other methods include appropriate use of technological tools and devices, coaching, advocacy, and reasonable school or workplace accommodations (Murphy, 2008)

Self-Management Strategies for Adults

A direct education about their disorder can help adults with ADHD, and any information about their deficits helps them to make compensatory strategies. By making lists and using computerized schedules, they can improve their planning and organizational abilities (Searight, Burke, Rottnek, 2000). In order to improve their memory for important dates and deadlines, they can place a marked calendar in a prominent location at home or the workplace.

Daily distractions can be avoided by having a windowless office, a clutter-free desk, etc (Searight, Burke, Rottnek, 2000). A systematic breakdown of large projects into smaller ones with their own deadline can improve task completion (Searight, Burke, Rottnek, 2000). In order to reduce their risk for drug and alcohol dependence, adults with ADHD are asked to abstain from drinking or to drink in moderation (Searight, Burke, Rottnek, 2000).

Psychotherapy in adults

In addition to pharmacotherapy and skill training, adults can benefit from marital and individual counseling and participation in self-help groups (Searight, Burke, Rottnek, 2000). Individual psychotherapy can help the adult patient with ADHD to deal with relationship problems, low self-esteem, failure, frequent job changes and to improve social skills (Searight, Burke, Rottnek, 2000). Marital counseling can help the patient to deal with communication problems, resolve conflicts, problem-solving, and emotional outbursts. Marital counseling can also help to educate the patient’s spouse about ADHD (Searight, Burke, Rottnek, 2000.)

Alternative approaches for ADHD

There has been a renewed interest from parents and health care providers for the use of complementary and alternative medicine (CAM) for ADHD. The reason for this is that the use of stimulants has been associated with adverse effects and the prospect of long-term use is daunting to many parents. The other reasons for turning to CAM include: dissatisfaction with conventional treatment for ADHD, uniqueness of CAM philosophies, and personal health beliefs (Sawni, 2008.)

Various alternative methods have been tried, and they include biofeedback, faith healing, homeopathy, dietary modifications, and supplements (Weyandt, 2007). In biofeedback, electrodes are used to attach the scalp or other body parts of the patient to a machine, which measures brain wave changes or changes in muscular tension (Weyandt, 2007). The patient tries to increase or decrease their brain activity, and feedback is provided via a computer or television screen (Weyandt, 2007). After many sessions, the patient is able to alter their brain waves. However, current evidence is not sufficient to support the use of biofeedback for ADHD (Weyandt, 2007.)

Caffeine is a central nervous stimulant and some studies have shown improved teacher and parent ratings of the ADHD child’s behavior after the use of caffeine. However, other studies have noted side effects like arrhythmias, agitation, irritability, bowel problems, and sleep disturbances, etc, which might restrict its use (Weyandt, 2007.)

Diet modification-proponents of the dietary approach for ADHD recommend the exclusion of foods that are high in sugar and refined carbohydrates (Weyandt, 2007). The best known of these ‘elimination diets’ is the Feingold diet (Lougy, DeRuvo, Rosenthal, 2007). The Feingold diet is based on the fact that some children with ADHD have an allergic-type reaction to certain dietary constituents. These dietary constituents include food preservatives, food additives, salicylate compounds, and food dyes. Other diets include the oligoantigenic diet, which restricts additives, dyes, and preservatives, and also limits the diet to two portions of meat, two vegetables, two fruits, two carbohydrates, etc (Wolraich, 2003.)

Supplements-A few studies have shown a decrease in aggressive behavior in ADHD patients after one to six months of supplementation with magnesium. Other studies have noted benefits with zinc and other minerals. However, based on just a few studies, the use of supplements cannot be recommended for ADHD (Weyandt, 2007). Both omega-3 and omega-6 long-chain polyunsaturated fatty acids (PUFA) have been postulated to improve human brain development and function (Frölich & Döpfner, 2008). Thus, supplementation of diet with essential fatty (as fish oil) may be beneficial in ADHD (Lougy, DeRuvo, Rosenthal, 2007).

The two primary EFAs under consideration for ADHD are linoleic and linolenic acids. Antioxidants include melatonin, gingko biloba, and pycnogenol. Herbal compounds, which supposedly have a beneficial effect on ADHD include charmomile, kava hops, lemon balm, valerian root, and passionflower. However, the efficacy of these and their potential side effects are unknown, and not much research has been done to know their efficacy in ADHD (Wolraich, 2003.)

Massage and yoga-few studies have noted beneficial effects with massage therapy and yoga but the paucity of such studies makes it infeasible to support their use in ADHD (Wolraich, 2003.)

Others-in adult ADHD, the use of light therapy for cognitive improvement has been noted in a few studies. However, their use cannot be recommended due to insufficient research (Terman M, 2007). Other alternative methods, which have been tried include: mirror feedback, channel-specific perceptual training, and vestibular stimulation, laser acupuncture, and meditation (Arnold, 2001.)

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