Das et al Understanding ADHD: A practitioner's guide

Al-Rafidain J Med Sci. 2024;7(1):18-28.

DOI: https://doi.org/10.54133/ajms.v7i1.756

Review article

Understanding Attention Deficit Hyperactivity Disorder: Prevalence, Etiology, Diagnosis,

and Therapeutic Approaches
Jamuna Das1 , Jitendriya Biswal1* , Rakesh Mohanty1 , Manika Bose2 , Sansita Parida2
1
Department of Psychiatry, IMS & SUM Hospital (SOA Deemed to be University), Bhubaneswar, Odisha, India;
2
Department of Pharmacology, IMS & SUM Hospital (SOA Deemed to be University), Bhubaneswar, Odisha, India
Received: 20 March 2024; Revised: 7 May 2024; Accepted: 10 May 2024

Abstract

Background: Attention deficit hyperactivity disorder (ADHD) is classified using neoclassical systems such as the Diagnostic
Statistical Manual of Mental Disorders-5 and the International Classification of Disease-10. There is significant evidence
that pharmaceutical treatment, particularly stimulants, can reduce symptoms in the short term. Objective: To explore the
comprehensive landscape of childhood to adulthood ADHD within the literature, which involves delving into its prevalence,
etiology, risk factors, diagnosis, and treatment modalities. Methods: A literature search was conducted across articles
published in English between 2011 and 2023; the literature extensively explored the prevalence, etiology, risk factors and
diagnosis of the subject, with limited attention given to treatment between 2003 and 2023, utilizing electronic search engines
such as Google Scholar, PubMed, IndMED, and MedIND, Scopus, and Web of Science. The search terms included "ADHD,"
"Attention Deficit and Hyperactivity Disorder," "Hyperactivity," "Child Psychiatry," "Hyperkinetic Disorder," "Attention
Deficit Disorder," and "Worldwide.” Results: Out of the 400 papers evaluated, only 52 met the criteria encompassing
prevalence, etiology, diagnosis, and treatment. Conclusions: ADHD is a prevalent neurodevelopmental disorder impacting
individuals from childhood to adulthood, with varying prevalence rates globally. Methodological differences influence
prevalence estimates, highlighting the need for standardized study designs. Both genetic and environmental factors contribute
to its development. Management typically involves a combination of psychotherapy, lifestyle adjustments, and medication.
However, refined diagnostic criteria and tailored treatment guidelines for children and adults are necessary. Continuous
evaluation of interventions is crucial for optimizing care and enhancing the well-being of individuals with ADHD.

Keywords: ADHD, Diagnosis, Etiology, Prevalence, Stimulants and non-stimulant.

‫ االنتشار والمسببات والتشخيص واألساليب العالجية‬:‫فهم اضطراب نقص االنتباه وفرط النشاط‬

‫الخالصة‬

‫ والتصنيف‬5- ‫) باستخدام األنظمة الكالسيكية الجديدة مثل الدليل اإلحصائي التشخيصي لالضطرابات العقلية‬ADHD( ‫ يتم تصنيف اضطراب نقص االنتباه وفرط النشاط‬:‫الخلفية‬
‫ استكشاف المشهد الشامل الضطراب‬:‫ الهدف‬.‫ يمكن أن يقلل من األعراض على المدى القصير‬،‫ وخاصة المنشطات‬،‫ هناك أدلة مهمة على أن العالج الدوائي‬.10- ‫الدولي لألمراض‬
‫ تم‬:‫ الطريقة‬.‫ وطرق العالج‬،‫ والتشخيص‬،‫ وعوامل الخطر‬،‫ والمسببات‬،‫ والذي يتضمن الخوض في انتشاره‬،‫فرط الحركة ونقص االنتباه من الطفولة إلى مرحلة البلوغ في األدبيات‬
‫ استكشفت األدبيات على نطاق واسع انتشار الموضوع ومسبباته وعوامل الخطر‬. 2023 ‫ و‬2011 ‫إجراء بحث في األدبيات عبر المقاالت المنشورة باللغة اإلنجليزية بين عامي‬
MedIND ‫ و‬IndMED ‫ و‬PubMed ‫ و‬Google Scholar ‫ باستخدام محركات البحث اإللكترونية مثل‬،2023 ‫ و‬2003 ‫ مع إيالء اهتمام محدود للعالج بين عامي‬، ‫وتشخيصه‬
‫ تضمنت مصطلحات البحث "اضطراب فرط الحركة ونقص االنتباه" و "اضطراب نقص االنتباه وفرط النشاط" و "فرط النشاط" و "الطب‬Web of Science. ‫ و‬Scopus ‫و‬
‫ فقط المعايير التي تشمل‬52 ‫ استوفت‬،‫ ورقة تم تقييمها‬400 ‫ من بين‬:‫ النتائج‬."‫النفسي لألطفال" و "اضطراب فرط الحركة" و "اضطراب نقص االنتباه" و "في جميع أنحاء العالم‬
‫ مع‬، ‫ اضطراب فرط الحركة ونقص االنتباه هو اضطراب نمو عصبي سائد يؤثر على األفراد من الطفولة إلى مرحلة البلوغ‬: ‫ االستنتاجات‬.‫االنتشار والمسببات والتشخيص والعالج‬
‫ تساهم كل من العوامل الوراثية والبيئية‬.‫ مما يبرز الحاجة إلى تصاميم موحدة للدراسة‬،‫ تؤثر االختالفات المنهجية على تقديرات االنتشار‬.‫معدالت انتشار مت فاوتة على مستوى العالم‬
‫ من الضروري وجود معايير تشخيصية محسنة وإرشادات عالجية مخصصة‬،‫ ومع ذلك‬.‫ تتضمن اإلدارة عادة مزيجا من العالج النفسي وتعديالت نمط الحياة واألدوية‬.‫في تطورها‬
.‫ التقييم المستمر للتدخالت أمر بالغ األهمية لتحسين الرعاية وتعزيز رفاهية األفراد المصابين باضطراب فرط الحركة ونقص االنتباه‬.‫لألطفال والبالغين‬

* Corresponding author: Jitendriya Biswal, Department of Psychiatry, IMS & SUM Hospital (SOA Deemed to be University),
Bhubaneswar, Odisha, India; Email: drjbiswal@gmail.com

Article citation: Das J, Biswal J, Mohanty R, Bose M, Parida S. Understanding Attention Deficit Hyperactivity Disorder:
Prevalence, Etiology, Diagnosis, and Therapeutic Approaches. Al-Rafidain J Med Sci. 2024;7(1):18-28. doi:
https://doi.org/10.54133/ajms.v7i1.756

© 2024 The Author(s). Published by Al-Rafidain University College. This is an open access journal issued under the CC BY-NC-SA
4.0 license (https://creativecommons.org/licenses/by-nc-sa/4.0/).

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Das et al Understanding ADHD: A practitioner's guide

INTRODUCTION METHODS

Genetic differences in gene expression in several brain We utilized various online resources, including Web of
function areas, such as attention deficit hyperactivity Science, Embase, Scopus, Google Scholar, PubMed,
disorder (ADHD), are characterized by long-term IndMED, and MedIND, by searching for terms such as
inattention, hyperactivity, and impulsivity [1,2]. ADHD "hyperkinetic disorder," "attention deficit disorder,"
is a common yet complex neurological disorder. Early "ADHD," "attention deficit and hyperactivity disorder,"
diagnosis is common, and some people with ADHD may "hyperactivity," and "impulsivity." From 2011 to 2024,
never recover completely as adults. This condition we evaluated the prevalence, etiology, and diagnosis
manifests in three primary subtypes: predominantly literature, with limited attention given to treatment
inattentive (ADHD-I), hyperactive/impulsive (ADHD- between 2003 and 2023.
HI), or a combination of both (ADHD-C) [3,4].
Symptoms typically manifest early in life and often Inclusion and exclusion criteria
encompass inattentiveness, lack of focus, disorganization,
forgetfulness, and trouble completing tasks. To meet the We refined our search criteria to encompass both children
criteria for ADHD, these symptoms must emerge before and adults, focusing on longitudinal, observational, and
the age of 12, persist for at least six months, and cross-sectional studies related to ADHD. Our
significantly disrupt daily activities. Furthermore, they investigation covers a broad spectrum, including the
should be observable in multiple environments, such as general population, patients, educational institutions, and
home, school, or extracurricular activities. ADHD can colleges, and emphasizes the standardized prevalence,
lead to various challenges, including impaired social etiology, screening, therapy, and diagnostic criteria
interactions, heightened risk-taking behaviors, employed in ADHD research. We specifically opted for
occupational instability, and academic underachievement original research and meticulously assessed the literature.
[5]. Understanding ADHD in childhood and adolescence This comprehensive review was conducted exclusively in
requires a comprehensive approach that considers English. We excluded the thesis papers from the search.
multiple factors, such as genetics, neuropsychology,
cognition, and psychosocial dynamics. The Data extraction
developmental trajectory of ADHD encompasses not only
its early manifestations but also its persistent features, The inclusion and exclusion rules correctly guided the
which extend into adulthood [6]. Identifying risk and review of the studies. A flowchart was used to collect the
resilience factors is crucial for understanding how data after this comprehensive assessment of prevalence,
individuals with ADHD adapt and thrive. It's encouraging risk factors, diagnosis, and treatments. Subsequently, the
to see that strategies like coaching, tutoring, therapeutic extracted data was systematically categorized into distinct
support, and parental involvement can significantly themes, encompassing crucial aspects such as prevalence
enhance executive functions in ADHD children. These and five key risk factors. These themes included
interventions improve academic performance and pharmacological and non-pharmacological interventions,
cultivate crucial skills like planning, self-monitoring, and as well as exploring adherence, the care pathway, and
memory. Additionally, teaching children to utilize tools treatment seeking. Furthermore, the data analysis also
like lists, reminders, and day planners can empower them delved into the knowledge and attitude surrounding
to develop compensatory strategies, fostering ADHD, shedding light on important aspects of this
independence and self-management. They build complex condition.
compensatory skills through lists, reminders, and day
planners [7]. They are present at high levels, either alone Research Gap
or in combination, and they cause significant
psychological, social, educational, or vocational The review can identify existing research articles on
impairment. The severity of ADHD is determined by the ADHD, addressing the data gaps on ADHD prevalence,
extent of impairment, prevalence, individual variables, etiology, risk factors, screening, diagnosis, and treatment.
familial and societal context, and other factors [8].
RESULTS
Significance of the study
Out of 400 studies, 52 were eligible for prevalence, risk
While significant progress has been made in factors, diagnosis, and treatment in the review. Figure 1
understanding prevalence and treating ADHD, there displays the study flowchart. The primary findings from
remains a need for further research to deepen our the studies categorized by prevalence, as outlined in Table
understanding of its underlying mechanisms, refine 1, Table 2, etiology and Table 3, identify five key risk
diagnostic criteria and assessment tools, and develop factors.
more targeted and individualized treatment approaches.
Addressing these gaps will ultimately lead to improved Prevalence
outcomes from childhood to adulthood with ADHD. A
literature search was conducted across articles published In 2020, the global prevalence of ADHD was expected to
in English between 2011 and 2023; the literature be 7.2% in children [9], persistent adult ADHD was
extensively explored the subject's causes, prevalence, 2.58%, and symptomatic adult ADHD was at 6.76% [10].
etiology, and diagnosis, with limited articles published on Various epidemiological studies may have either inflated
ADHD patients given treatment between 2003 and 2023.

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Das et al Understanding ADHD: A practitioner's guide

or underestimated the prevalence of ADHD, attributed to 15,124 students aged six to fourteen, indicate a prevailing
the wide array of measurement methods and assessment ADHD prevalence of 8.0%. Within these studies, ADHD
tools employed by researchers. prevalence rates among boys were notably higher than
among girls, at 12%, 15.6%, and 17.2%, compared to
7.9% and 5.5%, respectively [17]. Researchers may have
overestimated or underestimated the prevalence of
ADHD with substance use disorder (SUD) among this
population in various epidemiological studies because
they used different measurement scales and instruments
to investigate the phenomenon globally, including alcohol
dependence, opioid dependence, and high-risk and low-
risk alcohol use, all of which impact the quality of life for
ADHD patients. Furthermore, the study's geographical
location significantly influenced the prevalence of ADHD
among children, adolescents, and adults, as well as the
association of ADHD with SUDs among adults.
According to the studies conducted in India, there is a
strong link between adult ADHD and substance use
disorders (SUDs) [18–25]. In 2018, the highest
prevalence rate was found in Karnataka state, Bengaluru,
with a rate of 62% [24] in 2022, while the prevalence rate
in Bhubaneswar, Odisha, was 58.8% [26] in Eastern
India. A similar method was used to estimate the global
prevalence of ADHD with SUDs in this group globally
[27,28]. This study assesses the research on treating adults
Figure 1: Flowchart outlining the search and selection strategy. and adolescents who have co-occurring drug use disorders
and ADHD. According to the data, stabilizing addiction
Additionally, geographical location emerged as a critical will only lead to moderate improvements in ADHD and
determinant influencing ADHD prevalence across no discernible improvement in SUD [29]. Controlled
different age groups—children, adolescents, and adults. trials have found no significant advantage in treating
The analysis encompassed globally reviewed research ADHD in people who also have SUD. More studies are
articles, investigating prevalence rates across multiple needed to determine the long-term efficacy of therapy.
nations such as the United States, China, Spain, India, and According to the narrative review, the global prevalence
various African countries [9,11–16]. According to the of ADHD and SUD is increasing as diagnostic criteria and
reviewed literature, the World Federation of ADHD awareness improve. Stimulant-assisted treatment can
International Consensus Statement (2008) provides potentially enhance long-term outcomes and avoid the
evidence-based conclusions on the disorder, which onset of SUD [30]. We have thoroughly examined and
primarily affects boys and girls and has a global categorized the prevalence of ADHD methodologies
prevalence of 5.9% of young people and 2.8% of adults, based on the included studies, incorporating systematic
reducing misconceptions and stigma [6]. Polanczyk and reviews, review articles, and original research papers into
colleagues conducted a meta-analysis in 2015 that the comprehensive summary presented in Table 1.
comprised 41 studies from 27 countries, revealing a 3.4%
prevalence of ADHD. This study emphasizes the Etiology and risk factors
necessity for a more thorough information analysis.
According to the systematic and meta-analysis reviews, Several kinds of literature, encompassing genotype and
they had a lower frequency of ADHD than those with environmental analyses alongside systematic analyses,
more primary studies. The estimates exhibited significant have prenatal and perinatal environmental elements that
diversity, with the diagnostic interview, sample elevate the risk of ADHD (Table 2). However, none of
representativeness, and sample framing playing essential these factors are exclusive to the disorder. Conditions
roles [13]. Another systematic review analyzed 175 such as maternal distress during pregnancy, premature
relevant research articles, estimating an overall ADHD birth, low birth weight, socioeconomic deprivation, and
prevalence of 7.2%. Different editions of the Diagnostic moderate exposure to lead and other environmental toxins
and Statistical Manual of Mental Disorders showed no are among the potential contributors necessitating deeper
significant variations. Notably, only a few studies utilized causal and mechanistic exploration [31]. Consequently,
random population samples for their analysis [9]. An many of these findings stem from observational studies,
analysis of 13 studies indicated that the global incidence which could potentially overlook unmeasured variables
of ADHD in children and adolescents is 8.0%, with boys like genetic predisposition [32–41]. This literature
having twice the rate as girls. ADHD-inattentive is the conducted with 79 children diagnosed with ADHD and
most prevalent subtype, followed by hyperactive and their parents revealed a noteworthy occurrence of ADHD
mixed kinds. The prevalence ranged from 3.4% to 14%, symptoms among the parents. Specifically, 41.3% of
with significant variations across studies [11]. Other mothers and 51.0% of fathers fulfilled the criteria for
comparable experiments yielded similar results and ADHD. Despite parents reporting relatively mild
outcomes [12]. Recent meta-analytic assessments of 27 symptoms, a significant portion experienced symptoms of
articles spanning from 2001 to 2016, encompassing moderate severity.

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Das et al Understanding ADHD: A practitioner's guide
Table 1: Summary in Prevalence of ADHD globally
Sample
No Author Type of Study Study Setting Age Group Assessment Prevalence
Characteristics
Systematic Europe Diagnostic criteria from
Thomas et al. 175 eligible studies Not mention
1 review and compared with DSM-III, DSM-III-R and 7.2%
(2015) [9] 179 ADHD affected age
meta-analysis North America DSM-IV
139.84 million and Persistent adult ADHD
Systematic
Song et al. 366.33 million Adult ADHD Not mention The diagnostic criteria from was 2.58%, and
2 review and
(2021) [10] affected adults in globally age and DSM-5 symptomatic adult ADHD
meta-analysis
2020 globally. was 6.76%
Children Measurement Tool to Assess
Ayano et al. Not mention
3 Meta-analysis 588 primary studies and adolescents Systematic Reviews 8.0 %
(2023) [11] age
globally (AMSTAR)
Systematic Children
Ayano et al. Not mention
4 review and 7452 articles and adolescents Cochran's Q- and the I 2-test 7.47%
(2020) [12] age
meta-analysis Africa
Systematic
Polanczyk (2015) 41studies conducted Children Not mention
5 review and DSM or ICD 3.4%
[13] in 27 countries and adolescents age
meta-analysis
15.9% among Black
Black, White,
Systematic children and adolescents,
Cénat et al. Latino and Not mention
6. review and 155 articles DSM-5 16.6% among Whites,
(2022) [14] Asian children age
meta-analysis 10.1% among Latinos and
and adolescents.
12.4% among Asians
Systematic Children Meta-
Vasileva et al. 18,282 children ,8
7 review and younger than 7 analysis, Not Not mentioned 4.3%
(2021) [15] countries
meta-analysis years mention age
CCMD (Chinese
Systematic 67 studies, 275,502 Children Meta-
Wang et al. Classification of Mental
8 review and children and and adolescents analysis, Not 6.26%
(2017) [16] Disorders), DSM(III, III-R,
meta-analysis adolescent in China mention age
IV, or ICD(9-10)
Meta-
Yadegari et al. Meta- 27 articles, 15124 Parents
9 analysis, Not DSM-IV 12%
(2018) [17] Analysis students and teachers
mention age
Cross- Adult Attention Deficit
Ganesh et al. 240 patients, 135 Patients Before 25
10 sectional Hyperactivity Disorder self- 56.25%
(2017) [18] cases years
study reporting scale
Cross-
Lohit et al. Patients 18 and 60 Adult ADHD Self Report
12 sectional 100 inpatients 19%
(2019) [20] years Scale, DSM-5
study
Cross- Adult Attention-Deficit
Gupta et al. Patients
13 sectional 132 inpatients <18 years Hyperactivity Disorder Self- 18.2%
(2020) [21]
study Report Scale
Adult ADHD self-report
Cross- scale, Symptom Checklist
Ganesan et al. 711 engineering
14 sectional Student, college 17-25 years (ASRS-v1.1) and impulsivity 40.9%
(2021) [22] students
study by the Barratt Impulsiveness
Scale (BIS-11)
Cross- The WHO ASRS was used to
Kumar et al. Patients Below 25
15 sectional 82 patients screen adult ADHD. 25.60%
(2021) [24] years
study
Cross-
Dhagudu et al. People <18 years of
16 sectional 200 Adult ADHD Rating Scale 18%
(2021) [23] age
study
Cross-
Samal et al. 18 and 65 Adult ADHD Self-Report
17 sectional 226 Patients 24.3%
(2022) [25] years Scale (v1.1) DSM-5
study
Adult
Rohner et al. 31 studies 12,524 Participant Meta-
18 Meta Analysis ADHD self-report scale 21.5%
(2023) [26] participant analysis
v1.1, DSM-5
van Emmerik- Meta- meta-
19 van Oortmerssen regression 59 articles Articles regression DSM-criteria 23.1%
et al. (2012) [27] analyses analyses
Cross-
International,
van de Glind et sectional
20 3558patients multi-center 18–65 years DSM-IV and DSM-5, ASRS 5.4%
al. (2014) [29] study in 10
patients
countries
Srichawla et al. A narrative less than 17 WHO Adult ADHD Self-
21 49 articles globally Adolescent 2%-7%
(2022) [30] review years Report Scale (ASRS)
Aberration: Diagnostic and Statistical Manual 3 edition(DSM-III), Diagnostic and Statistical Manual 3rd edition revision (DSM-III-R) and Diagnostic and
rd

Statistical Manual 4th edition (DSM-IV)

Surprisingly, the study did not find a significant potential triggers for the disorder. Despite extensive
correlation between parental ADHD diagnoses and those research, brain imaging studies of ADHD patients have
of their children.However, it raised concerns about how yielded inconsistent findings. Furthermore, changes in
parental ADHD might impact family dynamics, parenting dopaminergic receptor levels, particularly reduced levels
approaches, and the efficacy of parent-focused in the frontal lobes, have been linked to the disorder's
interventions and therapies. In this study, we emphasize onset [43,44]. ADHD is an inherited condition, which is
the importance of taking parental ADHD into account the primary cause and constitutes 70% of ADHD cases.
when comprehensively addressing ADHD [42]. In this Though environmental factors influence the development
article, sibling relationships can intensify the risk of of ADHD children, without being active, children can
ADHD, doubling it compared to those without siblings. inherit ADHD genes [45]. The prevalence of ADHD
Researchers have explored various factors like viral among mothers and fathers was 41.3% and 51.0%,
infections, maternal smoking during pregnancy, respectively, with mixed and hyperactive-impulsive
inadequate nutrition, and fetal alcohol exposure as subtypes.

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Das et al Understanding ADHD: A practitioner's guide

Table 2: Etiology of ADHD

ADHD tends to run in families, with individuals who have a parent or sibling with the condition being at a higher risk of having
Genetics
it themselves. Additionally, twins are more likely to be diagnosed with ADHD compared to non-twin siblings
Being born prematurely or with very low birth weight elevates the risk for ADHD. These conditions may increase the
probability of developing ADHD, although they aren't direct causes. Premature birth and low birth weight often correlate with
Birth factors
changes in brain development, especially in regions governing attention, impulse control, and executive functions—areas
closely linked with ADHD.
1. Drug or alcohol use
2. Use of certain drugs (corticosteroids and antidepressants)
Factors for the 3. Mental problems
expectant mother 4. High blood pressure
include 5. Hyperthyroidism
6. Smoking
7. Exposure to certain environmental toxins (lead).

Symptoms were classified as low, medium, or severe, and heterogeneity is critical to understanding the etiology and
there was no significant relationship between parental mechanisms of ADHD.
diagnosis and diagnosis [46]. These studies discovered
that pregnant women who smoke have a much higher risk Screening and diagnosis
of giving birth to babies with ADHD; similarly, pregnant
women who drink alcohol or use drugs increase their To establish diagnostic validity, most studies used a
child's risk of having the disorder. Older children born variety of standardized techniques for evaluation and
before their due date are more likely to develop ADHD diagnosis. The International Classification of Diseases
[47,48] A 2018 pediatrics study discovered that smoking (ICD) and the Diagnostic and Statistical Manual (DSM)
during pregnancy dramatically increases a child's risk of are tools for determining prevalence, etiology, and
having ADHD. The offspring of heavy smokers are more treatment. Assessments have included questionnaires
likely to develop ADHD. The study identified a graded by teachers, parents, physicians, and students. The
relationship but was unable to determine whether Diagnostic and Statistical Manual, Fourth Edition Text
smoking caused ADHD [49,50]. A 2019 study discovered Revision Criteria and DSM-5, the Conner's Parent Rating
that consuming four or more beers at once or frequent Scale (CPRS), the Conner's Teachers Rating Scale
low- to moderate-alcohol consumption was associated (CTRS), and the Vanderbilt Assessment Scale (VAS)
with a significant increase in the risk that a child would were the most commonly used measures, along with the
later develop ADHD [51]. Females are more likely to adult ADHD self-report scale (ASRS v1.1) and other
acquire ADHD, with middle childhood being the riskiest ASRS evaluations. Xu et al. (2018) conducted a
time of development. Researchers have linked obesity in nationwide study to assess the prevalence of ADHD
men to increased oppositional behaviors, poor sleep, among children and adolescents in the United States from
motor coordination issues, and methylphenidate abuse 1997 to 2016, using data representative of the nation [60].
[52]. Although ADHD is substantially heritable, They discovered that the prevalence of ADHD was 6.1%
environmental factors account for 10–40% of its variance. during the study period, with a notable increase to 10.2%
The prenatal environment may influence the development in 2015–2016. Moreover, they identified significant
of ADHD. Despite the lack of proven causation, previous ethnic disparities in ADHD diagnosis rates. Importantly,
epidemiological studies and data linkage research have the prevalence of ADHD increased significantly across all
shed light on this association. Developing a new standard demographic categories throughout the study period [65].
for ADHD research requires an examination of This systematic review of the literature suggests that
prospective data gathering as well as other genetic and screening for ADHD should begin at the age of six or
family characteristics [53]. Several studies have upon the child's initial diagnosis. Moreover, it emphasizes
consistently found genetic and environmental review the importance of ongoing screening and reassessment
articles that link ADHD to alcoholism as an adult, the following any alterations in antiepileptic medication
same literature on an emotional problem as a child, and (AED). The review also stresses how important it is for
DNA variants in the brain-derived neurotrophic increase medical professionals with advanced knowledge in
the risk of ADHD [45,54–58]. Despite the DSM-5 ADHD (Level U) to be involved in the diagnosis process
acknowledging the clinical variability within ADHD [66]. According to the research, school staff should use
through its three subtype presentations, the limitations of behavior rating scales, school histories, vision and hearing
the symptom checklist diagnosis method underscore a tests, and classroom observations to learn more about kids
broader issue. The polygenic nature of ADHD suggests a who are having trouble learning and behaving. It
diverse genetic landscape, complicating efforts to identify emphasizes the importance of multimodal treatments,
an etiology or universally applicable processes. such as pharmaceutical trials, psychological assessments,
Moreover, studies indicate that the relevant and academic endeavors. It also recommends keeping in
neurobiological factors for ADHD vary among touch with parents and schools during changes, such as
individuals and are multifaceted, contributing to the pharmaceutical and psychological trials [67]. Our
challenge of understanding its underlying mechanisms. literature review assessed the diagnostic accuracy of
Notably, even among those with abnormal brain various techniques across different types of samples and
structures, a minority of ADHD patients exhibit reporters, including population-based, clinical, and high-
deviations from the typical anatomical profile of the risk groups. The findings remained consistent across these
disorder [59–64]. Describing and refining phenotypic diverse populations. It is crucial to note that, due to

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Das et al Understanding ADHD: A practitioner's guide

limited scientific research in this area, our study lower dose. According to a meta-analysis of randomized
exclusively focused on papers originating from a specific controlled trials, d-MPH may be effective in treating
geographic region. The literature reviewed used the ICD- ADHD in early children and adolescents. The basic
10 and various versions of the DSM, including the DSM- psychometric properties of the Swanson Kotkin, Agler,
IV, DSM-IV TR, and DSM-5, as tools for screening and M-Flynn, and Pelham Scale (SKAMP), which measures
diagnosing ADHD patients [68]. functional impairment related to ADHD, are significantly
better in the laboratory. Parents and instructors reported
Treatment comparable results. According to the NNT of three, d-
MPH treatment will benefit one in every three ADHD
Therapies are part of a multimodal approach to treating patients [77].
ADHD. The Food and Drug Administration (FDA) has
approved ADHD treatment stimulants such as Dextroamphetamine and combined amphetamine salts
methylphenidate, dexmethylphenidate,
dextroamphetamine, mixed amphetamine salts, Stein et al. [73] did a study that showed that as doses went
dextromethamphetamine, and lisdexamphetamine [69], as up, the effects of extended-release dexmethylphenidate
well as non-drugs such as atomoxetine, alpha-2a (ER d-MPH) and extended-release mixed amphetamine
adrenergic receptor agonists such as clonidine and salts (ER MAS) on ADHD symptoms got much weaker.
guanfacine, modafinil, bupropion, and antidepressants Both stimulants relieved symptoms of ADHD and
[70]. hyperactivity/impulsivity, but they also caused reduced
appetite and tiredness. 43 percent selected only one
Stimulants medicine.

A systematic review, narrative review, and original Dextromethamphetamine with lisdexamfetamine

literature were used to evaluate the immediate-released
(IR) methylphenidate as a placebo; the study discovered The 2016 review paper found that lisdexamfetamine
extremely low-certainty evidence that it may reduce dimesylate, a long-lasting prodrug of d-amphetamine, can
ADHD symptoms. The data require a higher level of treat adults, adolescents, and children with ADHD when
confidence. However, IR methylphenidate showed only a used in conjunction with active amphetamine exposure
mild effect on ADHD symptoms. Furthermore, there is and efficacy duration. A lower Cmax, a longer latency to
very little conclusive evidence that IR methylphenidate Cmax, and reduced variability within and across people
may reduce the clinical perception of the severity of distinguish its pharmacokinetic profile. Following a dose,
ADHD symptoms [71,72]. The meta-analyses revealed LDX's therapeutic effects persist for at least 14 hours in
that the study found strong evidence in the childhood and adults and 13 hours in children [78]. After five
adolescent literature to support the hypothesis that randomized controlled studies and multiple open-label
methylphenidate helps treat adult ADHD. MPH effect investigations, Health Canada approved it for children
sizes were associated with higher dosages and physician aged six to twelve. It has similar side effects to other long-
outcome evaluations. Clinicians now have greater acting amphetamine formulations [79]. A laboratory
confidence in the effective use of the ADHD diagnosis in school did a literature analysis and discovered that pupils
adults, thanks to a one-day trial [73,74]. Further research with ADHD who took LDX had much fewer symptoms
has shown that the most often used ADHD medicine is than those who got a placebo. During the crossover
methylphenidate, which acts on dopamine and treatment, we observed effectiveness at post-dose periods
norepinephrine transporters, increasing norepinephrine of 1.5 hours and up to 13.0 hours. It indicates that LDX
levels in the prefrontal brain cortex [75]. All sustained- may help children with ADHD manage their symptoms
release formulations of methylphenidate have a once- during the day, especially during family time and after-
daily dose, although their pharmacodynamic effects school activities [80]. In a case study [81], a 33-year-old
differ. Current long-acting formulations include ADHD patient was treated with lisdexamfetamine (30
Concerta®, Focalin XR®, Metadate® CD, and Ritalin® mg), which was then increased to 40 mg. Serenity, quiet,
LA. Intermediate-acting medications like Ritalin® SR, focus, and reduced procrastination were essential benefits
Metadate® ER, and Methylin® ER may require twice- for the patient. He had fewer amphetamine cravings and
daily administration or immediate-release no desire to use illicit substances again.
pharmaceuticals in the middle of the day. When
considering a once-daily dose, practitioners must consider Non-Stimulants
symptoms and the duration of action. Peak concentration
time and total "coverage" vary significantly between In their 2023 study, Radonjic et al. conducted a meta-
products. Ritalin® LA and Focalin® XR use a spheroidal analysis and systematic review focusing on non-stimulant
oral drug absorption system (SODAS). It produces two therapies for ADHD, aiming to assess their acceptability,
concentration maxima that are identical to those observed tolerability, and efficacy. Their comprehensive analysis
in twice-daily immediate-release formulations [76]. incorporated one narrative synthesis along with 18
research papers. Findings indicated that atomoxetine,
Dexmethylphenidate guanfacine, and viloxazine ER exhibited significantly
higher effectiveness compared to the control group.
An effective isomer of MPH known as Notably, in treating ADHD among adults, all non-
dexmethylphenidate was commercially available to treat stimulants under investigation outperformed placebos.
ADHD; it has a 1% to 2% longer half-life and requires a However, it's noteworthy that the placebo was perceived

23
Das et al Understanding ADHD: A practitioner's guide

as more palatable and acceptable [82]. This research paper psychostimulants, providing a comprehensive approach
describes a study that employed a genetic model and that considers their expectations about medical attention
pharmacological screening to find five potential non- and treatment preferences [90]. We conducted a literature
stimulant therapies for ADHD [83]. The study identified search and categorized the treatment approaches into
three non-stimulant therapies that interrupted sleep and stimulant and non-stimulant categories based on
potentially reversed the hyperactive phenotype. Four systematic and meta-analysis, review articles, case
drugs, namely moxonidine, doxazosin, amlodipine, and studies, and original publications included in the study.
aceclofenac, have similar effects to atomoxetine. This study reveals disparities among the diagnostic
Moxonidine, which strongly binds to the imidazoline criteria outlined in the DSM-IV, DSM-5, and ICD-10 for
receptor, has been shown to improve cognitive function. ADHD. While all three systems feature similar symptom
The findings provide a novel tool for understanding the lists, they diverge in their approaches to diagnosis,
brain circuitry and causation of ADHD [84]. A literature prevalence etiology, risk factors and treatments. The
review explored the impact of stimulant and non- DSM-5 introduces two diagnostic dimensions,
stimulant medications on the autonomic nervous system accommodating cases where only a few symptoms are
(ANS) in individuals with ADHD. The analysis present. Hyperactivity and impulsivity are key features
encompassed eleven studies examining blood pressure considered across both adolescent and child dimensions.
and heart rate, one study on pupillometry, and five studies In contrast, the ICD-10 mandates fulfilling all criteria in
on electrodermal activity. The findings revealed that both multiple situational contexts for diagnosis. The DSM-5
stimulants and non-stimulants elevate blood pressure, emphasizes impairment across various situations as a
heart rate, and alertness in individuals with ADHD. diagnostic criterion. We employ a blend of these scales
However, to better anticipate or monitor these effects, alongside other assessment modalities. Nonetheless,
further extensive research is necessary to elucidate the honing in on a child's symptoms or treatment trajectory
interplay between arousal, medication, and behavior in may pose challenges amidst daily interactions. Despite
ADHD [85]. A research study conducted between 2005 these complexities, these scales serve as invaluable
and 2017, with a follow-up from 2011 to 2021, examined instruments in diagnosing and treating ADHD, offering a
the impact of stimulant medication use for attention- systematic approach to data collection and assessment
deficit/hyperactivity disorder (ADHD) during involving children, parents, educators, and mentors alike
adolescence on cocaine and methamphetamine use during [91]. Exploring ADHD comprehensively involves
young adulthood. The study focused on secondary examining its prevalence, causes, diagnosis, and
students and investigated the associations between treatments. This includes understanding how ADHD
ADHD medication history and prescription stimulant affects different groups, such as from childhood to
misuse (PSM), as well as cocaine and methamphetamine adulthood. It also entails uncovering the mix of genetic,
use. According to the findings, teenagers who did not environmental, and neurological factors that contribute to
have a history of ADHD medication use had the lowest ADHD's development. Identifying prevalence and risk
rates of past-year outcomes: 4.7% for PSM, 1.6% for factors associated with ADHD onset is crucial, as is using
cocaine, and 0.7% for methamphetamine. In contrast, reliable diagnostic criteria for accurate identification.
those with a history of combined stimulant and non- Finally, it is crucial to implement a variety of therapeutic
stimulant therapy showed the highest rates: 22.3% for interventions to effectively manage symptoms and
PSM, 10.4% for cocaine, and 7.8% for improve overall functioning.
methamphetamine. Interestingly, there were no
significant differences in rates between teenagers Future directions
undergoing monotherapy; the rates remained moderate
[86]. The findings suggest that youths taking ADHD Future research could look into risk factors, treatments,
medication should undergo regular monitoring for and potential applications for various health disorders.
stimulant effects, particularly those who have previously More research is needed to determine how to medicate
undergone both stimulant and non-stimulant therapy ADHD individuals based on age, gender, and geography.
[87,88]. A survey by ML Wolraich and colleagues has More research is required in order to better understand the
unveiled fresh insights into a specific condition's causes, sources of risk indicators and their long-term
symptoms, and treatment options. Managing symptoms repercussions for ADHD patients worldwide. The
and improving functioning through medication is definition of psychopathology is evolving from separate
beneficial, yet diagnosing and treating ADHD poses diseases to overlapping symptoms. Executive dysfunction
significant challenges. Raising awareness of ADHD and inattention are standard features of dysregulatory
among both medical practitioners and the public is crucial psychopathology, which includes ADHD. The review
to ensuring appropriate treatment. Furthermore, improves the use of neuropsychological testing for
advancing research is imperative for developing more ADHD diagnosis; however, its particular contributions
effective medications and a deeper understanding of the are unclear. People are increasingly asking psychologists
complexities of ADHD [89]. It is impossible to overstate and neurologists to explain the importance of their roles
the importance of psychosocial therapies in the treatment in healthcare. More studies are needed to evaluate the
of adults, children, and adolescents with ADHD. validity and unique utility of neuropsychological testing
Therapists can manage ADHD flexibly and in ADHD diagnostic and treatment trials, as well as its
knowledgeably if they have access to adequate and potential role in the creation and execution of treatment
reliable medications. Creating an overview of evidence- plans.
based interventions can provide patients with various
treatment options that can supplement or replace

24
Das et al Understanding ADHD: A practitioner's guide

Table 3: Summary of ADHD Risk Factors

No of
Study Study design Risk factor Main outcomes and measures
population
Haddad et al., 7921 Population- Early-life exposures. Factors affecting pregnancy and childbirth can be broadly categorized into
(2022) [87] mothers based cohort Maternal ADHD PRS, ASD PRS, and maternal lifestyle and behavior, maternal use of nutritional supplements and
study SCZ PRS were calculated using medications during pregnancy, maternal illnesses, and perinatal factors.
discovery effect size estimates from the
largest available genome-wide
association study and a significance
threshold.
Havdahl et al., 14 539 Cohort study PGS for ADHD, autism, and Self-reported measures pertaining to pregnancy that encompass lifestyle
(2022) [88] mothers schizophrenia, calculated (using behaviors, metabolic health, infectious and autoimmune diseases, other
discovery effect size estimates and physical health conditions, and medication usage.
threshold of P < .05) from the largest
available genome-wide association
studies
Neugebauer et 234 Cohort study Increasing prenatal PCDD/F and PCB Exposure to PCDD/F and PCB during the pre-and perinatal periods could
al., (2015) concentrations were significantly (p < subtly impact attention performance in healthy children, even at low
[89] 0.05) associated with a higher number of environmental levels. Conversely, behavior changes may be adversely
omission errors in the subtest Divided affected. Specifically, prenatal exposure to PCDD/F or PCB was found to
Attention. have a negative association with ADHD-related behavior, such as a decrease
of 10% (95% CI: 0.82–0.99) in the case of PCB exposure.
Abid et al., 1,257 Cross- PAH exposure was measured by urinary Outcomes were defined by parental report of (1) ever doctor-diagnosed
(2014) [90] sectional metabolite concentrations. ADHD, (2) ever doctor- or school representative-identified LD, and (3)
survey receipt of SE or early intervention services
Perera et al., 351 Prospective Prenatal Polycyclic aromatic These exposures might reduce the risk of ADHD problems, additional
(2018) [91] children cohort study hydrocarbons (PAH) exposure benefit to the developing fetus and young child would come from a
multifaceted approach to reduce PAH exposure and alleviate material
hardship.
Aberration: Autism spectrum disorder (ASD PRS), and schizophrenia (SCZ PRS), polygenic scores (PGS), polychlorinated biphenyls (PCBs),
polychlorinated dibenzo-p-dioxins and -furans (PCDD/Fs)

Future studies on the treatment of Funding source

dextromethamphetamine and lisdexamphetamine should
include a randomized controlled trial with a more The authors did not receive any source of fund.
extended follow-up period to establish long-term clinical Data sharing statement
benefits.
Supplementary data can be shared with the corresponding
Conclusion author upon reasonable request.

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