Attention-Deficit/Hyperactivity Disorder

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting 11

percent of school-age children. Symptoms continue into adulthood in more than three-quarters of
cases. ADHD is characterized by developmentally inappropriate levels of inattention, impulsivity
and hyperactivity.
Symptoms
Typically, ADHD symptoms arise in early childhood. According to the DSM-5, several symptoms
are required to be present before the age of 12. Many parents report excessive motor activity during
the toddler years, but ADHD symptoms can be hard to distinguish from the impulsivity,
inattentiveness and active behavior that is typical for kids under the age of four. In making the
diagnosis, children should have six or more symptoms of the disorder present; adolescents 17 and
older and adults should have at least five of the symptoms present. The DSM-5 lists three
presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The
symptoms for each are adapted and summarized below.
ADHD predominantly inattentive presentation
 Fails to give close attention to details or makes careless mistakes
 Has difficulty sustaining attention
 Does not appear to listen
 Struggles to follow through with instructions
 Has difficulty with organization
 Avoids or dislikes tasks requiring sustained mental effort
 Loses things
 Is easily distracted
 Is forgetful in daily activities
ADHD predominantly hyperactive-impulsive presentation
 Fidgets with hands or feet or squirms in chair
 Has difficulty remaining seated
 Runs about or climbs excessively in children; extreme restlessness in adults
 Difficulty engaging in activities quietly
 Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor
 Talks excessively
 Blurts out answers before questions have been completed
ADHD combined presentation
 The individual meets the criteria for both inattention and hyperactive-impulsive ADHD
presentations.
These symptoms can change over time, so children may fit different presentations as they get older.
Etiology of ADHD
Research has demonstrated that ADHD has a very strong neurobiological basis. Although precise
causes have not yet been identified, there is little question that heredity makes the largest
contribution to the expression of the disorder in the population.
In instances where heredity does not seem to be a factor, difficulties during pregnancy, prenatal
exposure to alcohol and tobacco, premature delivery, significantly low birth weight, excessively
high body lead levels, and postnatal injury to the prefrontal regions of the brain have all been found
to contribute to the risk for ADHD to varying degrees.
Research does not support the popularly held views that ADHD arises from excessive sugar intake,
excessive television viewing, poor child management by parents, or social and environmental
factors such as poverty or family chaos. Of course, many things, including these, might aggravate
symptoms, especially in certain individuals. But the evidence for such individual aggravating
circumstances is not strong enough to conclude that they are primary causes of ADHD. A related
problem that has some accumulating evidence is sensitivity to food or additives such as colorings
and preservatives. Several controlled double-blind studies suggest that these might be important
for a minority of children with ADHD, and a couple of controlled studies suggest a small effect
on all children whether or not they have ADHD. Further research on this connection is warranted.
Neurochemistry
Structural and functional imaging research on the neurochemistry of ADHD implicates the
catecholamine-rich frontal-subcortical systems in the pathophysiology of ADHD. The
effectiveness of stimulant medication, along with animal models of hyperactivity, also point to
catecholamine disruption as at least one source of ADHD brain dysfunction.
A 10-year study by National Institute of Mental Health found that brains of children and
adolescents with ADHD are 3-4% smaller than those of children who don’t have the disorder and
that medication treatment is not the cause.
Basic neuroimaging research is being conducted to further delineate the pathophysiology of
ADHD, determine diagnostic utility of neuroimaging, and elucidate the physiological effects of
treatment. However, the research is not definitive enough for practical application of
neuroimaging.
Executive Function
Many of the symptoms classified as ADHD symptoms of inattention are actually symptoms of
executive function impairments. Executive function refers to a wide range of central control
processes in the brain that activate, integrate, and manage other brain functions.
Best put, Thomas E. Brown, Ph.D., of Yale University compares executive function to the
conductor of an orchestra. The conductor organizes, activates, focuses, integrates, and directs the
musicians as they play, enabling the orchestra to produce complex music. Similarly, the brain’s
executive functions organize, activate, focus, integrate and direct, allowing the brain to perform
both routine and creative work.
The components of executive functioning that impact school or work:
 working memory and recall (holding facts in mind while manipulating information;
accessing facts stored in long-term memory)
 activation, arousal and effort (getting started; paying attention; completing work)
 emotion control (tolerating frustration; thinking before acting or speaking)
 internalizing language (using self-talk to control one’s behavior and direct future actions)
 complex problem solving (taking an issue apart, analyzing the pieces, reconstituting and
organizing them into new ideas)
Prevalence of ADHD
Population-based surveys have reported that the prevalence ADHD is about 5% among children
and 2.5% among adults in most cultures as cited in the DSM-5

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ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting 11

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