Attention Deficit Hyperactivity Disorder (ADHD)

How common is ADHD?

  1. 10% of children with ADHD have other learning disabilities
  2. ADHD is one of the most common childhood disorders and can continue through adolescence and into adulthood.
  3. The average age of onset is 7 years old. ADHD affects about 4.1% American adults age 18 years and older in a given year.
  4. The disorder affects 9.0% of American children age 13 to 18 years. Boys are four times at risk than girls. Studies show that the number of children being diagnosed with ADHD is increasing, but it is unclear why.

What are the different types of the ADHD?

  • Predominantly hyperactive-impulsive
    • Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
    • Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
  • Predominantly inattentive
    • The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
    • Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.
  • Combined hyperactive-impulsive and inattentive
    • Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
    • Most children have the combined type of ADHD.

What causes ADHD?

Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.

Genes. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder. Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments.

Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.

Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children. In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD.

Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury.

Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities than those who received the sugar substitute. Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results.

In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical of their behavior, compared to mothers who thought their children received aspartame.

Food additives. Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity. Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity.

What are some of the common symptoms of ADHD?

Inattention and Distractibility symptoms symptoms:

  1. Poor attention
  2. Poor concentration
  3. Easily distractable
  4. Unable to get the works and assignments done without supervision
  5. Difficulty get organizing tasks
  6. Difficulty with completing the tasks in a timely manner
  7. Dreaming most of the day
  8. Often loses necessary stuff such as keys, phone, or other personal stuff

Impulsivity symptoms:

  1. Involved in risk taking behaviors
  2. Unable to wait for his/her turn
  3. Constantly interrupting others
  4. Highly emotional

Hyperactivity/Overactivity components:

  1. Talkative and speeches with high tone and pressure
  2. Highly active

What are some common associated features of ADHD?

  1. Academic failure
  2. Social problems, involved in fights or drugs, …
  3. School failure
  4. Poor planning, organization and task performance
  5. Delayed speech and language problems
  6. Poor motor coordination
  7. Enuresis

What other medical conditions could resemble ADHD?

  1. Conduct disorder
    1. Set fire
    2. Cruel to animals
    3. Lie often
    4. Fighting repeatedly
    5. Stealing
    6. boys > girls
    7. hereditary
  2. Oppositional defiant disorder
    1. hostile and defiant behavior against parents, teacher, …
    2. behaves normally around peers
    3. is not cruel to animals
    4. do not lie
    5. is not criminal
  3. Mood disorder
    1. Depression
    2. Anxiety disorders
  4. Bipolar disorders
  5. OCD
  6. Autism spectrum disorders
  7. Substance abuse
  8. Learning disorders
  9. Hearing impairment
  10. Head trauma
  11. Seizure disorders
  12. Lead posining
  13. Child abuse or neglect
  14. Personality disorders

Currently available medications for treatment of ADHD

Amphetamine based stimulants:

  1. Adderall XR:
    1. Capsuls: 5 10, 15, 20, 25, 30 mg
    2. Increase at 5-10 mg weekly intervals
    3. max daily dose: 20-30  mg for adults
  2. Dexedrine
    1. Tablets: 5 mg
    2. Capsules: 10 mg, 15 mg
    3. Increase 2.5-5 mg weekly
    4. Max dose: 40 mg
  3. Vyvanse capsules:
    1. 10, 20, 30, 40 , 50, 60 mg
    2. Increase by clinical discretion weekly
    3. Max dose: 60 mg

 

Methylphenidate bases stimulants:

  1. Biphentin
    1. Capsules: 10, 15, 20, 30, 40, 50, 60, 80 mg
    2. Increase 10 mg weekly
    3. Max daily dose: 80 mg for adults
  2. Concerta:
    1. Tablets ER: 18, 27, 36, 54 mg
    2. Increase 18 mg weekly
    3. Maximum dose: 72 mg for adults
  3. Methylphenidate short acting:
    1. Tablets 5 mg
    2. Increase 5-10 mg weekly
    3. Max dose: 60 mg all ages
  4. Ritalin
    1. Tablets: 10 mg, 20 mg
    2. Increase 5-10 mg weekly
    3. Max dose: 60 mg all ages

 

SNRIs:

  1. Strattera (Atomoxetine)
    1. Capsules: 10, 18, 25, 40, 60, 80, 100 mg
    2. Start: 40 mg daily for 7-14 days at least and then increase 20 mg weekly
    3. Max dose: 80 mg daily

 

Selective A-agnoists:

  1. Intuniv XR (Guanfacine XR)
    1. Tablets: 1, 2, 3, 4 mg
    2. Start at 1 mg daily for 7 days then increase 1 mg weekly
    3. max dose: 4 mg daily

How is ADHD diagnosed?

Diagnosis of ADHD starts with ruling out all other potential medical conditions that could mimic the symptoms of ADHD such as generalized anxiety disorders, depression, stimulant abuse, learning difficulties, child abuse, hyperthyroidism, ….etc. This would require doing some laboratory work ups.

Individuals who are actively using drugs or alcohol need to be detoxed, drug and alcohol free and stabilized, prior to an in-depth assessment for ADHD is performed.

Standardized questionnaires are developed to collect the symptoms of ADHD. If the person is a child, often interviewing and collecting information from parents, care providers and teachers is helpful.

How is ADHD treated?

Non-Pharmacologic

  1. Goal setting for assignments and projects
  2. Educational Interventions for children with ADHD
  3. Educate the family and the school
  4. Counseling for parents and adolescent patients
  5. Family understanding (Coping)

Medication

-If history of stimulant dependence:

  1. First line:
    1. Bupropion (Wellbutrin)

-If no history of stimulant dependence:

  1. First line:
    1. Long acting stimulants such as (Concerta, Aptensio)
  2. Second line (if no history of stimulant abuse):
    1. lisdexamfetamine dimesylate (Vyvanse® )
    2. Methylphenidate LA (Ritalin LA)
    3. Amphetamine-Dextroamphetamine (Adderall XR)
    4. Methylphenidate (Concerta)
    5. Tomoxetine (Strattera) is a Non-stimulant agent (SNRI)
  3. Third line (if no history of stimulant abuse):
    1. SSRI if:
      1. Comorbid Major Depression
      2. Hyper-focused on activity (e.g. computer games)
      3. Obsessive-Compulsive type behavior
      4. Agents
        1. Bupropion (Wellbutrin)
        2. Venlafaxine (Effexor)
    2. TCAs for:
      1. Insomnia
      2. Enuresis
      3. Agents
        1. Imipramine
          1. Start 10 mg PO qhs (Up to 150 mg/day divided bid)
        2. Desipramine (Risk of sudden CV death)
          1. Start 10 mg PO qhs (Up to 150 mg/day divided bid)

Who should not take ADHD medications?

Stimulants should not be prescribed to individuals:

  1. Are allergic to this medications
  2. Present with mania or acute psychosis
  3. Who are taking MAO inhibitors and for 14 days after discontinuation of MAOi
  4. with Glaucoma
  5. diagnosed with untreated hyperthroid
  6. who has high blood pressure or severe heart diseases

 

Atomoxetine (Strattera) should be avoided in patients with:

  1. Allergic to this medications
  2. Who are taking MAO inhibitors and for 14 days after discontinuation of MAOi
  3. Has been diagnosed with Glaucoma
  4. have untreated hyperthroid
  5. Have high blood pressure or severe heart diseases

References

  • American Pediatric Association. ADHD: clinical practice guideline for the diagnosis, evaluation, and
    treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011
    Nov;128(5):1007-22.
  • DuPaul GJ, Gormley MJ, Laracy SD. Comorbidity of LD and ADHD: implications of DSM-5 for assessment and treatment. J Learn Disabil. 2013 Jan-Feb;46(1):43-51. doi: 10.1177/0022219412464351.
  • Murphy, K., Psychosocial treatments for ADHD in teens and adults: a practice-friendly review. J Clin
    Psychol, 2005. 61(5): p. 607-19.
  • Cumyn L, French L, Hechtman L. Comorbidity in adults with attention-deficit hyperactivity disorder. Can J Psychiatry. 2009 Oct;54(10):673-83.
  • Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community. J Clin Psychiatry 2006; 67: 524-540.
  • Cussen A, Sciberras E, Ukoumunne OC, et al. Relationship between symptoms of attention-deficit/hyperactivity disorder and family functioning: a community-based study. Eur J Pediatr 2012; 171: 271-280.
  • Caci H, Doepfner M, Asherson P, et al. Daily life impairments associated with self-reported childhood/adolescent attention-deficit/hyperactivity disorder and experiences of diagnosis and treatment: results from the European Lifetime Impairment Survey. Eur Psychiatry 2014; 29: 316-323.
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