Attention Deficit Hyperactivity Disorder (ADHD)

It is a neurodevelopmental disorder in which deficits occur during the developmental phase of life. It is usually first diagnosed in childhood and often lasts into adulthood. It is common for children to have trouble focusing but the children with ADHD do not grow out of these symptoms.

Clinical Features of Attention Deficit Hyperactivity Disorder

• It occurs mainly in boys than girls
• The parents will come with complaints that their children fidget with or tap their hands or feet.
• Most of the kids have complaints from school that they leave their seats in class and roam around.
• The children do not remain seated as expected in places like restaurants and movie theaters.
• The patient talks excessively.
• The patient will have inattention features like:
  • The patient will not be able to pay close attention to details.
  • Making careless mistakes.
  • Difficulty in sustaining attention in tasks.
  • Fails to finish the work given in school or outside the school.
  • The patient will get easily distracted.
  • The patient will show features of impulsivity and they have difficulty waiting for their turn.
  • Interrupts others very frequently.
  • The patient will have learning difficulties and often aggressive behavior.

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Diagnostic Features of Attention Deficit Hyperactivity Disorder

• According to the Diagnostic and Statistical Manual of Mental Disorders 5^th edition, there are some factors to be considered:
  • The onset of symptoms is before 12 years of age.
  • These symptoms should be present in two or more settings example home, school, or more.
  • These symptoms present for more than six months of time.

Subtypes of ADHD

• Combined Presentation- In this disorder, the patient has symptoms of both inattention and hyperactivity.
• Predominantly Inattentive Presentation- In this, the patient will have inattentive symptoms only
• Predominantly Hyperactive Presentation- In this disorder, the patient will have the symptoms of hyperactivity and impulsivity mainly

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Etiology of Attention Deficit Hyperactivity Disorder

• Genetically there is a 75% chance of its inheritance from parents.
• It is been studied that it occurs due to dysfunction in dopamine and norepinephrine.
• The prefrontal cortex of the brain is considered to play a role in attention and regulation of impulse control.

Adult ADHD

• The onset of symptoms is in childhood. These symptoms persist in adulthood and alter the routine lifestyle of the patient
• It is diagnosed by retrospective childhood ADHD diagnosis by parent interview or as reported by the patient.
• The characteristic features of ADHD in adults are:
  • Inattention
  • Hyperactivity
  • Mood dysregulation
  • Irritability
  • Impulsivity

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Treatment of Attention Deficit Hyperactivity Disorder

• ADHD is considered a serious medical condition therefore it requires treatment.
• It is very important to educate the parents and family members regarding the treatment because the child is not in control of their behaviors.
• There are two kinds of interventions involved, these are pharmacotherapy and psychosocial interventions.
• Pharmacotherapy- It is the first line of treatment. It consists of two categories of drugs, these are CNS stimulants and nonstimulants.
• CNS stimulants
  • It is the first choice of agent used for the treatment of ADHD.
  • It can cause insomnia and should not be given at night.
  • It should be given in the morning or in the afternoon. The drugs are:

1. Methylphenidate- It is a drug of choice. It is a dopamine agonist and it stimulates the central nervous system of the children. The side effects are:
   • Headache
   • Nausea
   • Insomnia
   • It can exacerbate the ticks
   • It can cause growth suppression.
2. Amphetamine
   • It is used when methylphenidate does not show any positive results.
   • It is also a dopamine agonist.
3. Modafinil
   • It is an alpha-1 agonist and it helps in adult ADHD.
   • It is not FDA-approved because during clinical trials patients develop Stevens-Johnson skin rash.

• Non-stimulants
  • These are used in patients where stimulants have very little or poor response, if the side effects are very high, or if there is any contraindication. The drugs are Atomoxetine and Bupropion.

1. Atomoxetine is a norepinephrine reuptake inhibitor.
   • It reduces tics and hence is preferred for patients with comorbid tic disorder when stimulants increase the ticks.
2. Bupropion is a nor-epinephrine dopamine reuptake inhibitor.
   • It is an antidepressant that is used in the treatment of ADHD.
   • The risk of seizure is higher at higher doses. 
   • Psychosocial interventions
     • It is very important to psycho-educate the parents and family members.
     • It includes cognitive behavioral therapy.
     • Behavior therapy should be provided.
     • The children should be given regular social skills training.
     • Group therapy can also be considered.

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