Attention Deficit Hyperactivity Disorder (ADHD)

What is ADHD?

ADHD is short for Attention Deficit Hyperactivity disorder. It is covers a wide range of behavioral symptoms which may include hyperactivity, lack of attention or concentration and tendency towards impulsive behavior.

ADHD commonly also includes other problems like sleep disturbances, learning problems etc. However, contrary to the popular myth, having ADHD does not necessarily mean low or poor intelligence. (1)

How is ADHD diagnosed?

Diagnosis of ADHD is usually made in children. Since many of the symptoms of ADHD are present to a mild degree in many children, diagnosis using set criteria is important.

Most patients are diagnosed between ages three and seven. ADHD may also manifest in adulthood. Due to the lack of age-appropriate criteria and symptomatology, diagnosis in adults may be more difficult. (1)

Types of ADHD

There are classically three different types of ADHD. This classification is based on the strongest symptom showed by the child. (2)

  1. Predominantly Inattentive – This includes major symptoms like lack of attention, purposefulness to complete a given task, follow instructions and conversation and pay attention to smaller details. Distraction is common in these persons.
  2. Predominantly Hyperactive – Persons with this type of ADHD often fidget and talk more than necessary. They find it difficult to sit still for work, meals or school. In toddlers this may manifest as constant running, jumping and physical movements. This condition also manifests as impulsivity. The person may speak out of turn or grab things from others. This impulsivity also makes the individuals prone to accidents and injuries.
  3. Combination of both types – These persons show a mixture of symptoms of both types.

Other symptoms of ADHD

Children with ADHD are also prone to have other mental health related conditions and illnesses. Various learning disabilities are the most common, such as difficulty with spelling, reading, writing or math.

Some children may show Oppositional Defiant Disorder which is characterized by stubborn nature or rebelliousness.

Some children may also have conduct disorders that cause them to do wilful harm to persons or properties. These children run a risk of getting arrested for illegal activities.

Children with ADHD may also develop Anxiety disorders and Depression. Some may also be diagnosed with concomitant Bipolar Disorder, insomnia, bed-wetting, substance abuse or Tourette syndrome.

Tourette syndrome is characterized by repeated actions like tics, blinks, facial grimaces etc. These mental health problems need to be diagnosed and addressed while treating patients with ADHD. (3)

How many people does ADHD affect?

In The United Kingdom, ADHD affects approximately 3-9% of all school-going children and young people. (1)

According to the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 3-7% of school aged children in the United States have ADHD. However studies have shown higher percentages in communities. (4)

ADHD affects 2% of the adult population worldwide. ADHD is more common among males. (1)

Impact of ADHD

The impact of ADHD on the child is enormous. Children with ADHD have 3 times higher problems with their peers than those who do not have ADHD.

Parents of these children are 10 times more likely to report that the condition interferes with forming friendships in their children. A study shows that children with ADHD are more likely to suffer non-fatal injuries. In addition those with ADHD are also more likely to suffer major injuries, emergency department, hospital in or outpatient admissions.

When older these children are further at a higher risk of drink driving, automobile accidents and violations of traffic rules. (4)

Apart from this, ADHD also implies a heavy economic burden on the country. The cost includes not only those for ambulatory care visits but also other health care costs, costs of admissions, medications, therapy and cost of work loss for patient as well as family members and parents.

Those with ADHD have increased chances of having at least one day off for sickness per month compared to healthy workers. Studies estimate that ADHD is the reason for 143.8 million lost days of productivity annually. (4,3)

Are there any cures for ADHD?

At present there are no definitive cures for ADHD. Around two thirds of the children with ADHD continue to have symptoms of the conditions at the age of 25.

Symptoms may, however, be controlled and learning difficulties may be overcome using medication, behavioral, psychological and social therapy. (1)

Edited by April Cashin-Garbutt, BA Hons (Cantab)


ADHD Causes and Risk factors

ADHD (short for Attention Deficit Hyperactivity Disorder) encompasses a wide range of behavioural disorders characterized by lack of attention and concentration, hyperactivity and inability to control impulsivity.

Causes of ADHD

A parent of a recently diagnosed child may blame themselves or their parenting, but more often than not the cause of the condition is not related to parenting at all.

Parenting and environment, however, may, to a certain extent, be responsible for worsening the child’s behavioural problems.

Risk factors of ADHD

There are no definite causes that have been found to trigger ADHD in a child. However, the following factors may contribute to a raised risk of the condition:-

  1. Altered anatomy or function of the brain – Brain scans have shown that some areas of the brain especially those related to activity and attention spans are different among children and adults with ADHD. (1) Some studies reveal that the frontal lobe of the brain (lies in the forefront of the brain) is different among people with ADHD. This area is related to decision making. There may also be derangement of neurotransmitters like dopamine and noradrenaline in the brain. These neurotransmitters are chemical messengers of the brain. (2)

  2. Genetics – ADHD sometimes may be inherited. There are studies that have found several genes that are related to ADHD causation. (1)

  3. Being male – Boys and men are more at risk of developing ADHD than girls and women. This could be due to genetic factors or hormonal factors. Studies suggest that since ADHD is commonly associated with violent and hyperactivity symptoms, many girls who have predominant inattentive type of ADHD maybe missed out while diagnosing. These girls often grow up to manifest the condition as adolescents or young adults. (2)

  4. Maternal drug abuse, alcohol intake and smoking – Some studies have shown that pregnant women who smoke, take alcohol or use recreational drugs are at a higher risk of giving birth to children who go on to develop ADHD. The exact pathology behind this association is not well known. However, it is speculated that this type of abuse in utero, or within the womb, reduces the neuronal activity and alters the nerve messenger chemicals neurotransmitters. Pregnant women who are exposed to environmental toxins are also at risk of giving birth to babies who may develop ADHD. (1)

  5. Exposure to toxins – Toddlers and preschoolers who are exposed to environmental poisons and toxins are also at higher risk of behavioural problems. Notable among these is lead exposure from paint and pipes in old buildings that has been linked to short attention spans and violent behaviour in some children. (1)

  6. Traumatic brain injury – Brain injury has also been linked to ADHD in some studies. However the number of children who have suffered such brain injuries is too small to explain the rising prevalence of ADHD. (3)

  7. Additives – Some food additives such as preservatives and artificial colouring have been linked to aggravation and increased risk of ADHD. Detailed research in this area is warranted as there is no definitive evidence. (1)

  8. Sugar – Studies and common belief says excess sugar in a child’s diet often leads to behavioural problems. However, detailed studies have shown that there is no association between excess sugar in diet and raised risk of ADHD or even worsening of symptoms in children diagnosed with ADHD. (3)

  9. Food intolerance – Certain food intolerance like that to milk, wheat and nuts has also been linked to raised risk of ADHD. (2)

  10. Exposure to television – There have been concerns that excessive exposure to television at a young age may lead to an increased risk of ADHD. Although there are no studies that actually prove this association; there is evidence that exposure to excessive television may lead to inattentiveness and risk of ADHD later in life. (2)

  11. Other risk factors – These include being born prematurely before 37 weeks of gestation and being born with a low birth weight. Brain damage in utero, or in the first few years of life, or having impaired hearing is also linked to ADHD (2)

Edited by April Cashin-Garbutt, BA Hons (Cantab)


ADHD Symptoms

ADHD stands for Attention Deficit Hyperactivity Disorder. It is fast becoming one of the commonest childhood behavioural disorders. In many children it is diagnosed between ages three and seven and may continue up to adolescence or adulthood.

Main symptoms of ADHD

The prominent symptoms include lack of attention, concentration, difficulty in controlling impulsiveness and behaviour and over activity.

While symptomatology differs among children, diagnosis when based on these symptoms need to be categorized in several steps.

In addition, children and individuals with ADHD also commonly may develop concomitant mental ailments like anxiety disorders, depression, learning disabilities, sleep disorders etc.

Diagnosis of ADHD

Diagnosis is made on the basis of criteria set by the American Psychiatric Association’s Diagnostic and Statistical Manual-IV, Text Revision (DSM-IV-TR).

A standard diagnosis based on these criteria keeps diagnosis uniform. This is important since symptoms of ADHD may often be overlapping, which makes the condition difficult to diagnose. (1)

The symptomatology may be classified as per the disease classification –

  1. Predominantly hyperactive and impulsive:
    1. The major symptoms of hyperactivity include: –
      1. Fidgeting
      2. Talking continuously
      3. Constant running,playing or touching
      4. Difficulty sitting still through meals, school or story telling sessions
      5. Constantly moving
    2. The major symptoms of impulsivity include:-
      1. Impatience
      2. lack of emotional restraint and acting without regards to consequences<
      3. Speaking out of turn
      4. Difficulty waiting for turns
      5. Habit of interrupting conversations
  2. Predominantly inattentive:
    1. The major symptoms of inattention include:-
      1. Easily distracted, often forgetful. Switching from one activity to another
      2. Difficulty in focussing
      3. Easily bored with one task
      4. Difficulty in concentrating and learning something new
      5. Difficulty in completing tasks and losing implements (pencils, paper etc.) needed to complete tasks or activities
      6. Inability to pay attention to instructions
      7. Daydreaming, confused and slow movements
      8. Difficulty in processing information accurately and quickly
      9. Difficulty in following instructions
    Children with predominantly inattentive ADHD often sit quietly and have difficulty in interacting with peers. These children often get missed out while diagnosing ADHD as most parents and teachers fail to notice their behavioural problem. For diagnosis of ADHD the symptoms must be present for at least six months. (2)
  3. Combined type – These children display a mixture of symptoms of hyperactivity-impulsiveness and inattention. These children are more difficult to diagnose.

Variation in symptoms of ADHD

Symptoms vary among boys and girls. While ADHD commonly manifests as hyperactivity among boys; girls are more likely to be inattentive.

Inattention also varies between boys and girls. Girls who are inattentive often daydream and are confused when spoken to. However, boys who are inattentive may play or fiddle without purpose.

Boys with ADHD are more difficult to manage by parents, teachers and caregivers. Thus their behaviour is often more conspicuous than girls. (3)

Symptoms of comorbid conditions like anxiety disorders, depressions, sleep related problems, learning disabilities are also seen among children with ADHD. These need careful evaluation and management.

How severe do symptoms need to be to be classified as ADHD?

Some amount of high energetic behaviour, inattention and is common among normal preschoolers. Many preschoolers have a short attention span and this may be seen among older children and adolescents as well.

However, these children often show normal attention span for tasks they love like listening to or playing music, painting etc. The attention span may be low for homework or other tasks that they find uninteresting.

Over activity is also common among preschoolers. They may also be more active when they are tired, anxious or hungry. Sometimes the problems may surface only at home and not show up at school or public places.

Parents and caregivers should be suspicious of behaviour problems if they notice such inattention, impulsivity or over activity in their child that lasts over six months, occurs in more than one environment (home as well as school), disrupts play, daily activities and school work on a regular basis and hampers peer and adult relationships. (3)

Parents may consult their paediatrician if they suspect such symptoms in their child. They may then be referred to specialists who would use a panel of behavioural tests to diagnose the condition.

A detailed medical evaluation to exclude other causes of inattention or hyperactivity is important as is diagnosis of comorbid conditions. (3)

Edited by April Cashin-Garbutt, BA Hons (Cantab)

ADHD Diagnosis

All children are different and Attention Deficit Hyperactivity Disorder (ADHD) is often difficult to diagnose among children.

Many normal preschoolers may display many common symptoms of ADHD like over activity, high energy, fidgetiness, impulsivity, inattention or low attention spans and easy distractions.

Diagnosis of ADHD thus needs to follow set guidelines and standardized criteria. There are however, no single tests to diagnose the condition.

History of child’s behaviour

The clinician often needs to take a detailed history of the child’s behavior at various settings like home, school etc. to arrive at a conclusive diagnosis.

The diagnosis of ADHD is often made between ages 3 and 6 in a child. The clinician may need to talk to other care givers like babysitters, coaches etc. to study the child’s behavioural problems in detail. (1, 2)

Parents may help by writing down in detail the nature and extent of the problem in the form of a diary. They can note the major changes in the child’s immediate environment and life to be shown to the clinician.

They can also prepare a list of medications and vitamin supplements that the child is taking.

Common questions put to caregivers include duration of behavioral problems, if the problems are more with respect to peers and the number of settings like school, playground or home where the problems are manifested.

The doctor may also ask if anything worsens or improves the child’s behavior, and ask about caffeine intake of the child, sleep patterns of the child, current and earlier academic performance records, and preferred discipline method used at home.

He or she may ask the parent or caregiver to describe a typical day’s routine in the child’s life. (1, 2)

Ruling out other conditions

The paediatrician who is consulted first, as well as the mental health specialist who is called in for referral, will initially rule out other conditions that may lead to symptoms of hyperactivity, impulsiveness or inattention.

There may be undetected seizures. Commonly “absence seizures” result in blanking out that may be mistaken for inattention.

There may be undetected middle ear infections leading to hearing problems or undetected vision problems that may lead to inattention.

Medical problems that lead to altered thinking and behavior maybe mistaken for ADHD as can anxiety disorders, depression and other metal ailments.

Learning disabilities, psychological trauma due to sudden change like death, parental divorce or parental loss of job may also give rise to behavioral problems.

Once detailed analysis is made and the child fulfils all criteria the child is diagnosed with ADHD. (2, 3)

Official Diagnosis

According to the American Psychiatric Association’s Diagnostic and Statistical Manual-IV, Text Revision (DSM-IV-TR) criteria for ADHD, ADHD can be diagnosed based on number of symptoms of hyperactivity-impulsiveness and inattention. (4)

  1. Predominantly inattentive – Six or more symptoms of inattention present over six months at a point that is “inappropriate for developmental level”.
    1. Lack of close attention
    2. Lack of attention to tasks and play activities
    3. Does not listen when spoken to
    4. Does not follow instructions
    5. Cannot organize activities
    6. Lack of interest in activities that require mental effort
    7. Losing things needed for activities and tasks
    8. Easily distracted
    9. Forgetful
  2. Predominantly hyperactive-impulsive – Six or more symptoms of hyperactive-impulsivity present over six months at a point that is “disruptive inappropriate for developmental level”.
    1. Hyperactive –
      1. Fidgets or squirms
      2. Often gets up when asked to sit
      3. Excessive running, climbing and movements
      4. Trouble with play and leisurely activities
      5. Often “on the go” as if “driven by a motor”
      6. Excessive talking
    2. Impulsive -
      1. Blurting out comments and answers before question is finished
      2. Trouble waiting for one’s turn
      3. Habit of interrupting conversation

Other criteria:

  • Symptoms (some of them) present before age of 7 years
  • Symptoms present in more than one environment (e.g. school, playground and home).
  • Symptoms affecting social, work and school performance.
  • No other psychiatric or psychological ailments like Pervasive Developmental Disorder, Anxiety disorder, Dissociative disorder, Personality disorder or Schizophrenia can explain the symptoms.

Based on these symptoms over six months –

  • ADHD Combined type is diagnosed if there is presence of both criteria A and B
  • ADHD Predominantly Inattentive type if A is fulfilled but B is not.
  • ADHD Predominantly hyperactive impulsive type if criteria B is met but A is not.

Edited By April Cashin-Garbutt, BA Hons (Cantab)

ADHD Treatment

There is no cure for Attention Deficit Hyperactivity Disorder (ADHD). Therapy aims to reduce the symptoms to allow for normal learning and growth of the child.

Basic tenets of therapy include medication and counselling. Other parts of therapy include accommodating the child in regular classrooms and providing family and community support.

Types of ADHD Medication  –

(1, 2, 3, 4)

Medications used for ADHD are known as psychostimulants and nonstimulants like Atomoxetine. These come in oral forms like tablets, capsules, liquids and also in form of skin patches.

Stimulants include Methylphenidate (Brand names Ritalin, Concerta, Daytrana), Dextroamphetamine-amphetamine (Adderall) and Dextroamphetamine (Dexedrine, Dextrostat).

These stimulants improve the deranged balance of nerve messengers in the brain called neurotransmitters. They help to improve the major symptoms of hyperactivity-impulsivity and inattention.

Length of action of ADHD medication

ADHD medication may be short acting, where action lasts for around four hours, or long acting where action lasts between six and twelve hours.

Methylphenidate for example can be given as a patch that when applied over the hip much like a bandaid can deliver the medication into the body over nine hours.

Long acting preparations usually take time to begin their action but carry the advantage of less frequent dosing.

These stimulants however tend to lose their efficacy over time. In addition all children do not benefit at similar doses and the right dosing sometimes may take time.

Side effects of ADHD medication

Common side effects include weight loss and loss of appetite, sleep disturbances, irritability towards the end of action of the medication etc.

Some children may develop twitches or jerky movements as side effects and in some growth may be affected.

These side effects are not permanent and may be reversed after the drug is stopped.

There are some reports of sudden death in children and adolescents using psychostimulants. This risk is raised in those with underlying heart disease or heart defect.

Furthermore, Methylphenidate and Dexamphetamine cannot be taken by pregnant women, children or persons with glaucoma, hyperthyroidism (overactive thyroid) and severe depression.

Nonstimulant ADHD medication

Nonstimulant medication for ADHD includes Atomoxetine. It is chosen when stimulant drugs are ineffective or cause side effects.

This drug needs to be taken once or twice daily and also reduces anxiety.

Side effects include loss of appetite and weight, nausea and sleepiness. Rare side effects include liver problems, depression and suicidal thoughts.

Children who do not respond to these medications are prescribed other drugs. These include antidepressants and Clonidine (actually a high blood pressure medication).

All medications used in ADHD should be kept out of the child’s reach and administered only under adult supervision.

Behavioural therapy and counselling for ADHD  –

(1, 2, 3, 4)

Apart from medications, children with ADHD often benefit from counselling and behavioural therapy.

This may be imparted by a trained psychologist, psychiatrist, mental health care professional or social worker. These include –

  1. Behavioural therapy – In this the parents and caregivers are taught strategies to deal with difficult situations. These may include reward systems and timeouts.
  2. Parental, family and sibling training – Parents may be taught better parental skills to bring out the best behaviour in the child and also help cope with behavioural problems. Similarly the whole family may be taught how to support the child with ADHD in a positive manner. Major family and parental skill includes patience, lover and care for the child, keeping things in perspective, appreciation, organization, regularity of schedules and avoidance of major changes. The child should be well rested and difficult situations should be anticipated beforehand. Instructions given to the child need to be simply worded and easy to follow.
  3. Psychotherapy is beneficial for older children. Negative behaviours may be reduced by this method.
  4. Social skills training – Children with ADHD can be taught various social skills to help them adapt better to the community.
  5. Discovering a talent – This helps the child feel good about themselves and often improves self-esteem and symptoms of ADHD.

Behavioural therapy is team effort and needs to be coordinated.

Other therapies for ADHD

Other alternative calming therapies include yoga and meditation.

There is no solid evidence that certain foods if banished from diet or added (like vitamin supplements, herbal medications, essential fatty acids etc.) help in reducing symptoms of ADHD. However ADHD children need to be given a healthy balanced diet. It is advisable not to remove anything from the child’s diet without medical advice.

Regular exercise is also recommended in persons with ADHD. Over years the symptoms of ADHD lessen considerably but may never completely go away.

Edited by April Cashin-Garbutt, BA Hons (Cantab)