Attention Deficit Hyperactivity Disorder

Children and youngsters with ADHD present with one or more of the following signs and symptoms:

• Lack of attention to details
• Average or below average memory, have trouble remembering most things 
• Easily distracted
• Careless behavior, frequently lose possessions, mix up things, etc.
• Not good at following instructions 
• Unable or not good at completing step by step projects 
• Unable to stay focused
• Unable to stay still, continuously fidget and move
• Constantly 'up to something'
• Talk excessively and energetically 
• May act without thinking 
• Impatience 
• Mood swings

Workup includes a detailed history from the child, his/her parents and sometimes even questioning from teachers and friends of the affected child, along with a physical examination. Laboratory tests are conducted to rule out any hidden abnormality or disorder which may be the cause behind the child's symptoms. Other examinations may include:

• Checking for otitis media and other ear disorders to rule out hearing problems. If the child is unable to hear properly, that will result in failure to follow orders and understanding instructions.
• Eye examination: If the child is unable to see or read clearly, he may have trouble coping up with studies. 
• Checking for any learning disabilities like dyslexia .
• Testing for any other disease or abnormality that may result in impaired thinking and task execution.
• CT scan of the brain may be conducted.

No single diagnostic test is available to confirm ADHD. The diagnosis is based on exclusion as well as on appropriate identification and judging of symptoms and signs.

Where drug treatment is considered appropriate, methylphenidate, atomoxetine and dexamfetamine are recommended [8]. National Institute of Mental Health (NIMH)-funded research has shown that medication works best when treatment is regularly monitored by the prescribing doctor and the dose is adjusted based on the child's needs [9].

Cognitive behavioral therapy (CBT), behavior modification and intensive contingency treatment have been used. The latter two treatments are more effective than CBT in improving behavior and academic performance [10]. Psychotherapy may prove to be useful and support group sessions may also help in making the child understand his condition better and not feel alone in this.

A recent meta-analysis of follow-up studies of children found that [7]:

• About 15% continued to have ADHD.
• 65% had persistence of some symptoms and continuing functional impairment. 

There is no clear cure of ADHD yet, so prognosis varies from person to person. Sometimes, the child may grow out of this condition but this rarely happens.

 Complications

ADHD does not cause other disorders, but children suffering from this condition are more likely to have:

• Bipolar disorder
• Anxiety disorder
• Depression
• Tourette syndrome
• Borderline personality disorder
• Obsessive-compulsive disorder

The exact etiology of ADHD is unknown. Many factors have been implicated in the development of this disease, one of which is genetics. Recent studies of twins link genes with ADHD [3]. Many studies have shown that ADHD runs in families. Other factors include environmental triggers such as exposure to damaging radiation, toxins or undue stress. Maternal usage of alcohol, drugs or tobacco may also affect the child's developing brain. Lastly, idiopathic underdevelopment of the brain can cause ADHD to occur.

Incidence

ADHD is estimated to affect about 6-7% of people aged 18 and under when diagnosed via DSM-5 criteria [2].

Sex

Studies show that it is almost 3 times more common in boys than in girls.

Race

ADHD has no known predilection to any race and occurs worldwide with no known statistical difference.

Brain imaging studies have revealed that, in youth with ADHD, the brain matures at a normal pattern but is delayed, on average, by about 3 years [4]. This delay is most apparent in brain areas involved in generating thoughts and plans. More recent studies have found that the outermost layer of the brain, the cortex, shows delayed maturation overall [5].

Current models involve the mesocorticolimbic dopamine pathway and the locus ceruleus-nonadrenergic system [6]. So, the damage is clearly due to underdevelopment of the brain, be it just the prefrontal cortex, the posterior parietal cortex or the dopamine pathways. Due to this delayed or impaired development of the brain, the child appears to be slow, mentally impaired and 'abnormal'.

There is no exact preventive measure known but the following factors may contribute in the prevention of this condition:

• Maternal health care
• Proper diet
• Protection from exposure to any environmental toxin
• Providing a safe and secure social and home environment to the child

Attention deficit hyperactivity disorder (ADHD) is a chronic condition that includes a combination of problems, such as difficulty sustaining attention, hyperactivity and impulsive behaviour. ADHD is described as the most common neurobehavioural disorder of childhood [1], due to improper or delayed brain development. It occurs in children and may persist in adults as well.  

According to the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) of the American Psychiatric Association there are three different types of ADHD, depending on the presentation of the affected individual:

• Predominantly inattentive presentation
• Predominantly hyperactive-impulsive presentation
• Combined presentation

Attention deficit hyperactivity disorder (ADHD) is a common disorder affecting children and often goes undiagnosed when parents simply label the child as 'simpleminded or dull' when in reality the child is suffering from ADHD. A child with ADHD needs to be given special care and support with which he/she may lead a normal health life. Contact should be made with a specialist if your child shows symptoms including:

• Lack of attention to details
• Memory problems, trouble remembering most things 
• Easily distracted
• Careless behavior, frequently lose possessions, mix up things, etc.
• Not good at following instructions 
• Difficulty focusing attention
• Problems organizing and completing a task  
• Unable to stay focused
• Unable to stay or sit still, continuously fidget and move
• Constantly 'up to something'
• Talk excessively and energetically 
• May act without thinking 
• Impatience 
• Mood swings

1. American Academy of Paediatrics, author Clinical Practise Guideline:Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Peadiatrics 2000;105:1158-1170
2. Willcutt EG. The prevalence of DSM-IV ADHD: a meta-analytic review. Neurotherapeutics 2012 9(3):430-9. 
3. The ADHD Molecular Genetics Network. Reports from the third international meeting of the ADHD molecular genetics network. American Journal of Medical Genetics 2002; 272-277
4. Shaw P, Eckstrand K, Sharp W, Blumenthal J, Lerch JP, et al. Attention Deficit/Hyperactivity Disorder is characterised by a delay in cortical maturation. Proc Natl acad Sci USA 2007 Dec 4;104(49):19649-54. 
5. Shaw P, Malek M, Watson B, Sharp W, Evans A, Greenstein D. Development of cortical surface area and gyrification in attention deficit/hyperactivity disorder. Biol Psychiatry. 2012 Aug 1;72(3):191-7. 
6. Malenka RC, Nestler EJ, Hyman SE. 2009. Chapters 10 and 13. In Sydor A, Brown RY. Molecular Neuropharmacology: A Foundation for Clinical Neuroscience. 2nd ed. New York: McGraw Hill Medical, pp 266, 318-323 
7. Faroane SV, Biederman J, Mick E;The age-dependent decline of ADHD:a Psychol Med.2006 Feb:36(2):159-65
8. Attention-deficit Hyperactivity Disorder-ADHD. 'Methylphenidate, atomoxetine and dexamfetamine'; NICE 2006
9. The MTA Cooperative Group. A 14-month randomised clinical trial of treatment strategies for attention deficit-hyperactivity disorder. Arch Gen. Psychiatry. 1999 Dec;56(12):1073-86. PMID 10591283
10. Management of attention deficit and hyperkinetic disorders in children and young people; Scottish Intercollegiate Guidelines Network- SIGN (Oct 2009)

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