ADHD - Attention Deficit Hyperactivity Disorder

Content

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by a set of behavioral symptoms that include inattention, hyperactivity and impulsivity (Video).

The signs of the presence of ADHD usually manifest themselves at an early age and become evident upon entering primary school. Generally, the assessment (diagnosis) takes place between 7 and 10 years of age.

In most cases, there is an improvement in the disorders (symptoms) with advancing age, however, about one third of the adults affected at a young age continue to show symptoms.

People with ADHD may also have other health problems such as sleep disturbances and anxiety disorders.

Many children go through phases where they are particularly restless and distracted. This is completely normal and should not be confused with ADHD. However, if you suspect that your behavior differs from that of your peers, you should report the problem to the pediatrician, the child's teachers or the educational needs area coordinator. special (read the Bufala).

It is advisable to contact the family doctor even if an adult suspects that he has ADHD even if he was not diagnosed as a child.

The exact cause of ADHD is not known but some familiarity has been found.

Research has identified some possible differences in the brains of people with ADHD versus those who do not suffer from this disorder but their significance is not yet fully understood.

Other factors that could play a role in the onset of ADHD are:

  • premature birth (before 37th week of pregnancy)
  • low birth weight
  • smoking, alcohol, or drug abuse during pregnancy

ADHD is more common among males than females. It can be managed with appropriate educational intervention aimed at parents and children with the disorder by integrating it, if necessary, with drug therapy (multimodal treatment). The latter is often the first treatment offered to adults with ADHD, although psychological therapies such as cognitive-behavioral therapy (CBT) can be useful.

Caring for a person with ADHD can be very challenging, but it is important to remember that these children cannot do anything to control their behavior.

Some problems that can arise in daily life concern:

  • take the baby to bed in the evening
  • prepare to get to school in time
  • listen and follow instructions
  • organize a job
  • participate in social occasions
  • shopping

Adults with ADHD can also have the same difficulties, some even have problems with drugs, crime or work.

Symptoms

Symptoms of attention deficit hyperactivity disorder (ADHD) can be grouped into two categories of behavioral problems:

  • inattention
  • hyperactivity and impulsivity

Most people with ADHD have both inattention and hyperactivity / impulsivity (Video). However, in some cases, only attention deficit disorder (ADD) is present, which can also go unnoticed since the symptoms are less evident.

Disorders (symptoms) in children and adolescents

ADHD disorders are well defined, already evident before the age of 6 and manifest themselves at home, at school and in the social life of the child.

The main signs of inattention are:

  • reduced attention and easy distraction
  • forgetfulness and aptitude to lose objects
  • inability to perform boring tasks or that take a long time
  • inability to listen or follow the instructions
  • constantly changing activities
  • difficulty in organizing tasks

The main signs of hyperactivity and impulsivity are:

  • not being able to stay still, especially in a quiet and peaceful environment
  • fidget all the time
  • talk too much
  • not respecting your turn
  • act impulsively
  • interrupt other people's conversations
  • altered sense of danger

These symptoms can cause significant problems in a child's life: poor academic performance, poor social relations with peers and adults, disciplinary problems.

In some children ADHD is associated with:

  • anxiety disorder, the child is frightened and nervous most of the time, may have a fast heartbeat, sweating and dizziness
  • oppositional defiant disorder (DOP), negative and disruptive behavior in particular towards the authority of parents and teachers
  • conduct disorder with antisocial behavior, theft, aggression, vandalism and injury to people or animals
  • depression
  • sleep disturbance, with difficulty falling asleep and irregular sleep
  • autism spectrum disorders (ASD), with difficulties in social interaction, communication and behavior
  • epilepsy, a neurological disease that causes violent convulsive movements of the muscles and loss of consciousness
  • Tourette's syndrome, nervous system disease characterized by a combination of involuntary noises and movements called tics
  • learning disabilities including dyslexia e dyscalculia

Disorders (symptoms) in adults

ADHD is a neurodevelopmental disorder and the specific disorders (symptoms) it causes, as well as associated diseases or conditions (comorbidities) such as depression or dyslexia, can persist into adulthood.

ADHD can also manifest itself directly in adults. The disorders (symptoms) are the same as in children and adolescents but manifest themselves in different ways: hyperactivity tends to decrease, while inattention worsens with the increase in the commitments of adult life . The ailments are much more subtle than those found in children and include:

  • carelessness and lack of attention for details
  • start up of new businesses before finishing those already started
  • poor organizational capacity
  • inability to concentrate or to set priorities
  • forgetfulness
  • restlessness and nervousness
  • difficulty keeping silent, speak out of turn
  • stammer out the answers often interrupting others
  • unstable mood, irritability, short temper
  • inability to handle stress
  • extreme impatience
  • lack of perception of risk (e.g. driving dangerously)

Even in adults, ADHD can be associated with other disorders, in particular with depression. Other diseases associated with ADHD are:

  • personality disorders, with thoughts, experiences and behaviors that differ considerably from the culture to which the individual belongs
  • bipolar disorder, with mood swings from one extreme to the other
  • obsessive-compulsive disorder (OCD), with obsessive thoughts and repetitive behaviors (compulsions)

Behavioral problems associated with ADHD can cause difficulties in relationships with others, drug use, crime. Some adults with ADHD have difficulty finding and keeping jobs.

Causes

Attention Deficit Hyperactivity Disorder (ADHD) is a so-called disorder multifactorial in which both genetic and environmental elements come into play, only partially identified.

Genetic factors

ADHD tends to occur in the same "branch" of the family and, in most cases, genes inherited from parents are thought to play a significant role in its development.

Scientific studies show that both parents and siblings of a child with ADHD are four to five times more likely to have the disease than other people.

However, the way ADHD is transmitted may be more complex and unrelated to a single genetic defect.

Functions and structure of the brain

Research has identified a number of possible differences in the brains of people with ADHD versus those without the disorder, although the exact meaning of those differences is unclear.

For example, CT (computed tomography) studies of the brain have shown that some areas of the brain may be smaller in people with ADHD, while other areas may be larger.

Brain images obtained with CT and / or nuclear magnetic resonance imaging (MRI) also show that the brains of children with ADHD can take an average of two to three years longer to mature than children without the disorder.

Other studies have suggested that people with ADHD may have an imbalance in the level of brain neurotransmitters (dopamine, noradrenaline) or that these chemicals may not function properly.

Other possible causes

It is possible that various other causes play a role in the development of ADHD, including:

  • premature birth (before 37th week of pregnancy)
  • low birth weight
  • brain damage in the womb or in the first years of life
  • smoking, alcohol, drugs taken during pregnancy
  • exposure to high levels of lead at a young age

However, scientific evidence for many of these factors is insufficient and more studies are needed to establish whether they actually contribute to the development of ADHD.

Diagnosis

If a parent thinks their child may have attention deficit hyperactivity disorder (ADHD), they should talk to their family doctor or pediatrician (read the hoax).

It may also be helpful to check if the teachers have noticed anything strange in the child's behavior.

The family doctor or pediatrician can ascertain (diagnose) ADHD but, to confirm its presence, a specialist evaluation is required (Video).

Steps to take

If the pediatrician suspects that a child may have ADHD, he or she may suggest a "watchful waiting" period of about 10 weeks to see if the complaints (symptoms) improve, stay the same, or worsen. They may also recommend initiating training. with the aim of learning the right ways to help the child (parent training).

If the behavior does not improve and severely impairs daily life, the pediatrician will request an evaluation by a specialist.

If it is an adult who shows the signs of ADHD, the family doctor will first evaluate the disorders present and then send to a specialist if the disorders (symptoms) caused by ADHD:

  • they began in childhood and they still persist
  • they cannot be explained by a mental health problem
  • have a significant impact on daily life: for example, problems of inefficiency at work or in interpersonal relationships

The evaluation

The reference specialists are:

  • child neurospychiatrist, or adult psychiatrist
  • clinical psychologist

There is no simple test to determine if a person has ADHD, but the specialist can make an accurate diagnosis after a detailed assessment that includes:

  • physical examination, to exclude that the cause of the disorders may be other diseases (differential diagnosis)
  • interviews with the child or adult affected by the disorder
  • interviews or reports from significant other people: parents and teachers

Diagnosis in children and adolescents

The diagnosis of ADHD in children is based on the application of a set of strict criteria. In order for ADHD to be diagnosed, there must be 6 or more symptoms of inattention or 6 or more symptoms of hyperactivity and impulsivity. In addition, it is necessary that the disorders (symptoms):

  • have been present continuously for at least 6 months
  • appeared before the age of 7
  • have occurred in at least two different contexts, for example at home and at school, to rule out the possibility that the behavior is just a reaction to certain teachers or parental control
  • are such as to make life much more difficult at a social, educational or work level

Diagnosis in adults

The "ascertainment (diagnosis) of ADHD in adults is more difficult because there is disagreement on the validity of the" list of disorders (symptoms) used to ascertain it in children and adolescents.

In an adult, ADHD can be ascertained (diagnosed) if he has 5 or more symptoms of inattention or 5 or more symptoms of hyperactivity and impulsivity.

The diagnosis of ADHD in adults cannot be confirmed unless the disorders (symptoms) have been present since childhood.

If you have not been diagnosed with ADHD at a young age or do not remember having ADHD-related disorders as a child, the specialist may ask to view school records or speak to parents, teachers and anyone else who can provide information on the period. of childhood.

In order for an adult to be diagnosed with ADHD, the symptoms (symptoms) manifested should have a moderate impact on different areas of life, such as:

  • poor work or school performance
  • dangerous driving
  • difficulty making and maintaining friendships
  • difficulties in the relationship with your partner

Therapy

Attention Deficit Hyperactivity Disorder (ADHD) can be treated with psychotherapy or with a combination of drugs and psychotherapy (multimodal treatment). The treatment (therapy) acts on the manifestations of ADHD but does not remove the causes (Video).

Multimodal care can only be prescribed by a child neuropsychiatrist working in a reference center for ADHD accredited by the region according to the criteria provided by the Istituto Superiore di Sanità. In the case of an adult, however, the prescription is up to the psychiatrist. In any case, the administration of the drug is part of a six-monthly therapeutic plan.The control (monitoring) of the effects of the treatment over time can be entrusted to the family doctor or pediatrician.

Pharmacological therapy

The drugs authorized in Italy for the treatment of ADHD in children and adults are:

  • methylphenidate
  • atomoxetine

These drugs do not cure ADHD, but they can improve the ability to concentrate, decrease impulsivity, promote relaxation and the acquisition of new skills. Their use begins with a test dose for methylphenidate and with gradually increasing doses for atomoxetine. Regular medical checks are provided to verify the effectiveness of the treatment and the appearance of any unwanted effects (side effects).

The specialist will decide the duration of the therapy, which, in many cases, will continue until it produces positive results.

Methylphenidate

Methylphenidate is the most widely used drug for treating ADHD. It belongs to a group of drugs called central nervous system stimulants which act by increasing the activity of the brain, in particular of the areas that control attention and behavior, modulating the release of dopamine, a substance found in nerve cells (neurons).

Methylphenidate is currently considered the reference pharmacological treatment for children over the age of 6, adolescents and adults with ADHD.

The drug can be taken both in the form of immediate-release tablets (two to three times a day) and in modified-release tablets (once a day).

The most common undesirable effects (side effects) associated with the use of methylphenidate are:

  • decreased appetite, with weight loss
  • transient delay in growth which disappears when drug therapy is discontinued
  • difficulty falling asleep
  • headache
  • stomach ache
  • mood swings

Atomoxetine

Atomoxetine is a selective norepinephrine reuptake inhibitor. In other words, it causes an increase in the concentration of this substance in the brain. Norepinephrine transmits messages between brain cells and, therefore, increasing it can aid concentration and impulse control.

Atomoxetine can be used by adolescents and children over the age of six and by adults. It is available in capsule form of various strengths, to be taken once daily depending on the doctor's prescription.

The most common undesirable effects (side effects) of atomoxetine are:

  • nausea and vomit
  • stomach ache
  • difficulty falling asleep
  • headache
  • irritability

Non-pharmacological therapies

Treatment not based on the use of drugs can be useful for treating ADHD in children, adolescents and adults.

Psychotherapy is also effective in the treatment of any associated problems such as, for example, conduct or anxiety disorders.
Some of the non-drug therapies include:

  • psycho-educational intervention, encourages the child to discuss ADHD and its disorders (symptoms).This can help them make sense of the disease, cope better with the disorder, and live with it
  • behavioral therapy, provides support to parents and teachers of children with ADHD. Therapy usually involves behavior management using a reward system to stimulate the child to try to control her disorder. For example, to encourage the child to sit at the table to eat, he is given a small reward when he behaves well, while a privilege is taken away from him when he behaves badly. Teachers will need to learn to plan and structure activities to praise and encourage children for even small progress
  • educational intervention aimed at parents, specific and personalized educational interventions allow parents to learn ways of talking to the child, playing and working with him to improve attention and behavior. Parent training can also be offered before the child is formally diagnosed with ADHD. These interventions are usually organized in groups and can last several weeks. They aim to teach parents and caregivers different ways of managing behavior while increasing the parent's confidence in their ability to help their child and improve the relationship with him
  • training for the acquisition of social skills, involves the child's involvement, making him participate in role-playing games, with the aim of teaching him how to behave in social situations and learn how her behavior affects others
  • cognitive-behavioral therapy (CBT), it can help manage problems by changing the way you think and behave. A CBT therapist will try to change how the child feels in a given situation and this could lead to changes in her behavior.CBT can be done as an individual or group therapy
  • other possible treatments, may be useful for some people, however, there is no evidence that they work and should not be attempted without close medical supervision

Diet

People with ADHD should eat a healthy and balanced diet.

Some may notice a certain link between certain types of food and worsening of ailments. For example, sugar, dyes, additives and caffeine are often blamed for aggravating hyperactivity. Others believe they have gluten or dairy intolerances which add to their ailments (symptoms). In this case, it may be. It is useful to keep a diary of what you eat and drink and the behaviors that appear.In any case, it is advisable to always discuss it with your family doctor who, if he deems it necessary, can advise you to contact a health professional specialized in nutrition.

It is inadvisable to change your child's diet without a doctor's advice.

Supplements

Some studies have suggested that omega-6 and omega-3 fatty acid supplements may be helpful in people with ADHD, although the evidence to support this hypothesis is very limited.

It is always necessary to speak to your GP before using any supplements because some can react unpredictably with medications or make them less effective.

Furthermore, some supplements should not be taken for a long time because they can reach dangerous concentrations in the body.

Ethical aspects

Often attention deficit hyperactivity disorder (ADHD) is cited as an example of the so-called medicalization, understood as the appropriation by the medical profession of a previously non-medical problem, with a process of commodification of the disease (disease mongering) aimed at increasing the sale of drugs or therapeutic procedures.

In fact, the main disorders (symptoms) of ADHD all fall within the normal range of children's behaviors and, as with other mental disorders, the diagnosis is based on the clinical evaluation of the specialist.

The data on the spread of ADHD in the world, which show great differences between the different countries with percentages ranging between 2.2% and 17.8%, seem to support the hypothesis that subjective factors, including socio-cultural ones, a heavy weight in influencing the diagnosis of the disorder.

According to some, the lack of a clear dividing line that allows to distinguish the behavior of a normal child from one affected by ADHD, poses the risk of over-diagnosis of the disorder with a consequent over-treatment that raises obvious ethical problems.

However, there are also those in the scientific community who argue that the condition is under-diagnosed and under-treated with negative consequences for the person suffering from it, including the possible correction hyperactive behavior with isolation or physical punishment.

Linked to the issue of diagnostic excess or defect, is the search for the main causes of ADHD in order to choose the most suitable treatment (pharmacological or psycho-behavioral).

There is some agreement in arguing that ADHD is a complex condition in which biological and environmental factors interact in various ways and, therefore, the solution cannot be simply pharmacological.

It should also be emphasized that the medicines prescribed to control ADHD disorders (symptoms), including methylphenidate and amphetamine products, such as adderall, are today among the most common drugs used for so-called strengthening (enhancement) cognitive, that is, to improve cognitive or behavioral functioning even in the absence of a real need.

According to some, the use of ADHD drugs also for the purpose of cognitive enhancement indicates how the attempt to establish universal criteria to distinguish situations of normality and abnormality is, in fact, useless since the cognitive enhancement a legitimate and desirable human goal, without prejudice to the safe and responsible use of drugs.

The American Academy of Neurology has embraced this view by justifying its members prescribing such drugs to healthy patients at their request.

In any case, the disorders caused by ADHD (inattention, hyperactivity and impulsivity) can represent a serious threat to the harmonious development of the person in the age of development (developmental age) and to the organization of daily activities and, therefore, it is necessary to intervene to control its intensity.

Living with

Caring for a child with attention deficit hyperactivity disorder (ADHD) can be very challenging. The impulsive, fearless and chaotic behaviors typical of ADHD can make normal daily activities tiring and stressful.

Ways to deal with the problem

It is important to remember that a child with ADHD cannot do anything to control her behavior as having difficulty suppressing impulses does not stop to evaluate a situation or its consequences, before taking action.

Useful tips for managing a child with ADHD

  • plan the day, the child must know what to expect. Routines can make a difference to how a child with ADHD copes with daily life. For example, if he is to prepare for school, it is helpful to break this activity down into structured steps so that he knows exactly what he needs to do.
  • set clear limits, make sure everyone knows what the expected behavior is and reward it with immediate praise or rewards when it occurs. If, on the other hand, the rules are exceeded, there must be consequences (for example, taking away a privilege) that must be pursued consistently
  • to be positive, express specific praise. Instead of a generic, “Thanks for doing this,” you prefer “You did the dishes very well. Thank you". This will make it clearer to the child that you are happy, and why
  • give instructions, provide the child with short, specific instructions. Instead of asking, "Can you tidy up your bedroom?" "Please put your toys in the box and the books back on the shelf" is preferable. It will become clearer to the child what he needs to do, and when things are done right, he can be praised
  • incentives, set up the incentive system using a dot or star chart, so that with good behavior you can earn privileges. For example, behaving well while shopping will earn the child extra time to spend on the computer or playstation. Allow the child to help decide what privileges she will be able to obtain by behaving appropriately. These charts need to be edited regularly or they could get boring. The goals should be:
    • immediate (daily)
    • intermediate (weekly)
    • long-term (quarterly)
    Try to focus on only one or two behaviors at a time
  • intervene early, pay attention to warning signs. If the child appears frustrated, over-stimulated and in the process of losing self-control, it is necessary to intervene by distracting him, if possible, away from the critical situation, and trying to calm him down.
  • social situations, create short and pleasant social occasions. Invite friends to play, but for a short time, so that the child does not lose control of himself. Avoid doing this when you are tired or hungry, such as after a day at school
  • exercise, make sure your baby gets plenty of physical activity during the day as it helps improve sleep quality
  • Power supply, control what the child eats.If you become hyperactive after consuming certain foods containing additives or caffeine, it is advisable to make a note of them and discuss them with your pediatrician.
  • sleeping times, make sure the baby goes to bed and wakes up at the same time every time. Avoid engaging in overly stimulating activities, such as playing computer games, watching TV, exercising right before bed
  • night, ADHD can worsen the quality of sleep and this can worsen the disorders (symptoms). Many children get up several times after being put to bed. It is advisable to make sleep a pleasant routine so that the child understands that the bed is not a battlefield
  • help at school, children with ADHD often have behavior problems in school that negatively impact their academic progress. Any extra support the child may need should be discussed with teachers

What NOT to do when you have a student with ADHD:

  • tell him to stay calm
  • talk to him slowly
  • make it read or write slowly and with precision
  • leave him alone in organizing homework and the activities of the day
  • organize its activities in its place
  • making sudden changes during the school day
  • stop it frequently while writing or reading or doing an assignment
  • ignore the presence of distracting factors in the environment (ornaments, objects, people, noises ...)
  • remove any stimulus of interest from the school context
  • give explanations, reminders, long or repeated reproaches
  • deny or procrastinate rests, intervals, motor or play activities
  • force him to be still or careful
  • tell him he's listless, unable, unintelligent
  • thinking that inattention and hyperactivity are two different problems

Useful tips for adults with ADHD:

  • if it is hard to always be organized, it is useful to make lists, keep a journal, use reminders, and set aside some time to plan activities
  • use daily physical exercise as a relief valve
  • find ways to relax, such as listening to music or practicing relaxation techniques
  • if you are employed, talk about your disorder with your "boss" so that he can identify conditions that allow him to perform his work in the best possible way
  • talk to your doctor about your fitness to drive, and evaluate together with him whether to communicate any problems to the Civil Motorization
  • contact a local support group, or national, to get to know other people who live in a similar situation and can be a source of support, information and advice

Bibliography

NHS Choices. Attention deficit hyperactivity disorder (ADHD) (English)

Conrad P. The medicalization of society: On the transformation of human conditions into treatable disorders. Johns Hopkins UP: Baltimore, 2007

Polanczyk GV, GWillcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis International. Journal of Epidemiology. 2014; 43: 434–42

Parens E. On good and bad forms of medicalization. [Synthesis] Bioethics. 2013; 27:28–35

Presidency of the Council of Ministers, National Bioethics Committee. Neuroscience and pharmacological cognitive enhancement: bioethical profiles

Singh I, Filipe AM, Bard I, Bergey M, Baker L. Globalization and cognitive enhancement: emerging social and ethical challenges for ADHD clinicians. [Synthesis] Current Psychiatry Reports. 2013; 15: 385-6

Skounti M, Philalithis A, Galanakis E. Variations in prevalence of attention deficit hyperactivity disorder worldwide. [Synthesis] European Journal of Pediatrics. 2007; 166 : 117–23

In-depth link

Higher Institute of Health (ISS). ADHD

World Health Organization (WHO). Child and adolescent mental disorders (English)

Italian Association of Attention and Hyperactivity Disorders (AIDAI)

Italian Association of ADHD Families (AIFA) Odv

Italian Society of Childhood and Adolescent Neuropsychiatry (SINPIA)

National Institute of Mental Health. Attention Deficit / Hyperactivity Disorder (English)

Centers for Disease Control and Prevention (CDC). Attention-Deficit / Hyperactivity Disorder (ADHD) (English)

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