Attention Deficit Hyperactivity Disorder (ADHD)

Clinical Picture

Attention Deficit Hyperactivity Disorder famously known as ADHD is a neurodevelopment disorder that involves problems in majorly two areas i.e. inattention and hyperactivity and impulsivity which impaired the performance of children in school, work and social situations. This disorder typically appears before children enter into school and often lasts into adulthood. 

Earlier in DSM-II this disorder was named as hyperkinesis, a synonym for “hyperactivity,” whereas DSM-III labeled it attention-deficit disorder (ADD). In DSM- 5 Attention Deficit Hyperactivity Disorder has been categorized into two symptoms. The first includes symptoms related to inattention. Children appear not interested in listening or focused. They are easily distracted, make careless mistakes. Second includes hyperactivity and impulsivity. Hyperactivity involves squirming, fidgeting, and restless behavior.

They can’t sit still and are in constant motion; they are always in a rush. Impulsivity includes act before thinking, fail to wait their turn, burst out answers before questioning. Hyperactivity and attention deficit each have been viewed as the core symptom of Attention Deficit Hyperactivity Disorder but to diagnose either inattention or hyperactivity and impulsivity or sets of symptoms must be presented. Children with Attention Deficit Hyperactivity Disorder may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.

Diagnostic Criteria (DSM)

1. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (A) and/or (B):

A. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: 

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
2. Often has trouble holding attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
5. Often have trouble organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
7. Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted
9. Is often forgetful in daily activities.

B. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: 

1. Often fidgets with or taps hands or feet, or squirms in their seat.
2. Often leaves the seat in situations when remaining seated is expected.
3. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
4. Often unable to play or take part in leisure activities quietly.
5. Is often “on the go” acting as if “driven by a motor”.
6. Often talks excessively.
7. Often blurts out an answer before a question has been completed.
8. Often has trouble waiting their turn.
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)

C. Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

D. Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities).

E. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

F. The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Comorbidity 

In clinical settings comorbid disorders are frequently in individuals whose symptoms meet criteria of Attention Deficit Hyperactivity Disorder. In general population oppositional defiant disorder co-occurs with Attention Deficit Hyperactivity Disorder in approximately half of children. Specific learning disorder also co-occurs with Attention Deficit Hyperactivity Disorder. Anxiety disorder and major depressive disorder occur in a minority of individuals with ADHD (APA, 2013). The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders in adults (Katzman et.al, 2017). 

Prevalence 

Population surveys suggest that ADHD occurs in most cultures in about 5% of children and about 2.5% of adults (APA, 2013), whereas another study by Polanczyk, et.al 2007 has found about 5.2 % of the child population across all regions of the world has ADHD. ADHD affects an estimated 8 to 11% of school-aged children (Ghandour, Bitsko & Danielson, et.al 2018). A meta-analysis of 175 research studies worldwide on ADHD prevalence in children aged 18 and under found an overall pooled estimate of 7.2% (Thomas et al. 2015)

In a study performed by Chaulagain & Kumar et.al, 2019 found that the prevalence rate of ADHD was 10-11% in various clinical samples of children and adolescents. In the same paper they have mentioned that research conducted by Rimal, 2014 prevalence rate of ADHD in one of the hospitals based in Nepal was 10%, however they haven’t cleared out the number of patients in the hospital. 

In a study conducted by Rimal & Pokharel in 2016 at Nobel Medical College Teaching Hospital, Biratnagar between April 2014 – March 2015 found that ration of male to female is 4:1 (i.e 41, n= not mentioned), same study also found that mean age for Attention Deficit Hyperactivity Disorder was 7 years and 5 months. The above three studies show that the prevalence rate of ADHD in Nepal is very high. 

Etiology 

The exact cause of Attention deficit hyperactivity disorder (ADHD) is yet to be fully understood, many researchers are still giving their effort to find its exact cause. Although a combination of factors is thought to be responsible for causing ADHD. 

Like any other mental disorder, ADHD runs in the family. If parents had Attention Deficit Hyperactivity Disorder earlier in their childhood or adulthood, there are 1 in 4 chances that their offspring may have ADHD. Thus genetic factors are implicated in ADHD and can’t be ignored. Attention Deficit Hyperactivity Disorder has supported a strong genetic contribution with heritability ranging from 60-90% Sharp, McQuillin & Gurling 2009). Approximately one third of affected children have a first degree relative with a history of ADHD. Despite ADHD being inherited it’s thought to be more complex than that and is not only related to genetic factors. 

Brain imaging studies of children with ADHD from those children without Attention Deficit Hyperactivity Disorder have shown differences in frontal lobes, temporal gray matter, nucleus, and cerebellum (Emond, Joyal, Poissant & Encephale, 2009). Research has shown that some parts of the brain tend to be smaller and take longer to mature in children with ADHD.

Prenatal, perinatal and postnatal environmental factors during pregnancy have an imperative role in the pathogenesis of ADHD (Moavero,D’Agati,Curatolo, 2010). Prenatal exposures to alcohol, lead, maternal smoking, nicotine smoking, exposure to viral infection (for example encephalitis, influenza virus) (Millichap, 2007), or even brain damage in the womb increase the risk of developing ADHD. Peri-natal factors have also been implicated in ADHD. Infants that are born prematurely (before 37^th week) or with low in weight during birth, mother having difficult labor or complication pregnancy can cause ADHD in children. Postnatal factors like infancy deprived from malnutrition and dietary deficiency, omega 3 fatty acids (Millichap, 2007), and iodine deficiency (Juneja, Jain, Singh & Mallika, 2010 can prove to have ADHD. 

Treatment 

Nonpharmacologic therapies include psychosocial education, behavioral interventions, school interventions, cognitive training therapies, learning training, biofeedback or neurofeedback, parent behavior training (i.e., training parents to reduce unwanted behaviors, foster desired behaviors and interactions, and improve family relationships) are some of successful therapies for ADHD children. This kind of therapy is not only given to children but also to other people who are associated with them. 

Psychoeducation educate the children, parents, relatives and others people to learn and discuss about Attention Deficit Hyperactivity Disorder and its effects. This kind of education to the people helps them to self diagnosed if their children are having problem of ADHD and required professional help or not. When symptoms are not severe, psychoeducation also educated them who to cope and live with the ADHD.