ADHD Symptoms and Treatments - DSM-5

Trapping Pen and Wobbly Legs - ADHD

• Learning Goals: Understand ADHD symptoms, causes, treatments, and related disorders.

ADHD (Attention-Deficit/Hyperactivity Disorder) - DSM-5

• Symptoms: Persistent pattern of inattention and/or hyperactivity-impulsivity, more frequent than expected for the child's developmental stage. Manifests in various ways, including:
  • Lack of attention in different settings (academic, occupational, social)
  • Careless mistakes in schoolwork/tasks
  • Difficulty maintaining attention
  • Appearing distracted and failing to follow instructions
  • Shifting between tasks without completing them
  • Dislike for sustained effort/attention tasks
  • Easily distracted
  • Excessive fidgeting/not remaining seated
  • Excessive running/climbing in inappropriate situations
  • Excessive talking
  • Impatience/interrupting others
  • Desire for immediate over delayed reward
  • Accidents/dangerous activities
• Prevalence: Up to 5% of school- and pre-school-age children and 2.5% of adults are diagnosed worldwide. Slightly more common in boys, possibly due to referral bias.
• Diagnosis:
  • Inattention: At least six symptoms for at least 6 months
    • Not paying close attention to details
    • Difficulty maintaining attention
    • Difficulty listening carefully
    • Disregarding instructions
    • Difficulty organizing tasks
    • Avoiding tasks requiring mental effort
    • Losing things needed for tasks
    • Getting easily distracted
    • Being forgetful in daily activities
  • Hyperactivity/Impulsivity: At least six symptoms for at least 6 months
    • Fidgeting, squirming
    • Leaving seat frequently
    • Running/climbing when inappropriate
    • Inability to play quietly
    • Excessive talking
    • Interrupting or intruding on others
  • Symptoms present before age 12
  • Symptoms present in at least two settings
  • Symptoms significantly impair functioning
  • Symptoms not attributable to another disorder
• Subtypes: Primarily inattentive, primarily hyperactive/impulsive, combined presentation

Comorbidities

• Oppositional defiant (conduct) disorder (ODD/CD): Approximately 50% of those with combined ADHD also have ODD/CD. ODD/CD is characterized by violating social norms and the rights of others. This comorbidity signals a more severe prognosis.
• Conduct disorder: Earlier onset of conduct disorder is associated with ADHD.
• Antisocial personality disorder: Childhood ADHD does not singularly predict adult antisocial personality disorder. However, children who develop conduct disorder with ADHD may increase chances for antisocial behaviors.
• Anxiety and depression: Comorbid in a minority of children with ADHD.
• Other potential issues: Substance use disorders, marital problems, job changes, and traffic accidents.

Treatment

• Pharmacological: Stimulants (methylphenidate, amphetamines) are highly effective for a large portion of children with ADHD, showing a decrease in demanding, disruptive, and noncompliant behaviors. Side effects include reduced appetite, insomnia, and gastrointestinal upset. Atomoxetine, guanfacine, clonidine are also used.
• Behavioral Therapies: Reinforce positive, attentive behaviors and extinguish impulsive ones. Techniques often involve parents and teachers. Combining medication and behavioral therapy can produce results exceeding those with either alone initially, but efficacy differences over longer periods are less distinct.

Other factors in ADHD

• Cultural and Gender Considerations:
  • Cultural contexts may affect how ADHD symptoms are identified or reported
  • Evidence suggests that diagnosis may be more common in boys due to differing behavioral expectations and tendencies, but that there are now recognized parallels and rates in girls and boys.
• Causes: Biologically based, with average heritability estimated as high as 76%. Multiple genetic genes have been linked to ADHD, although individual effects are small, with environment and interaction being significant factors.Prenatal smoking and maternal alcohol use are among the environmental risk factors.
• Neurological factors: Smaller brains, and differences in grey matter volumes in the frontal cortex, basal ganglia, and cerebellum have been discovered in children with ADHD when compared to neurotypical peers.
• Cognitive Tests: Tests such as CPT (Continuous Performance Test), Stroop Task, Trail Making test, and COWAT (Controlled Word Association Test) evaluate inattention and executive functions in ADHD. Other tests, such as Conner's Parents Rating Scale (CPRS) measure ADHD symptoms.

Additional Points

• Impact of Treatment: Children with ADHD who receive treatment show better outcomes across most areas.
• Treatment Selection: Factors like age, symptom severity, and comorbid conditions are considered. For example, behavioural therapies are often suggested for younger children or those with less severe conditions.
• Continued Care: Ongoing monitoring and follow-up with appropriate symptom scales are crucial to effective and long-lasting treatment success.
• Educational Support: Effective intervention can improve educational outcomes.
• Cognitive Training: Improving specific neuropsychological functions (e.g. attention, memory) was shown to have some impact on symptoms. Computerized training and neurofeedback show potential, but further research is necessary for definite conclusions.
• Dietary modifications: Certain approaches, such as removing artificial food colors, to lessen symptoms can have a positive or minimal effect.

Further Study:

• Treatment strategies for optimal ADHD diagnosis
• Differences and comparisons in ADHD based on different pathway models
• Long-term impacts of ADHD
• Treatment efficiency and efficacy of different modalities for ADHD