Understanding Attention Deficit Hyperactivity Disorder (ADHD)

This is a fact-first primer on Attention Deficit Hyperactivity Disorder. It aims to inform, and sensitise caregivers, peers and all readers about what this condition looks like, means medically, and the developmental differences it comes with. TSC will keep adding sections to this post to aid a complete and compassionate understanding of people born with this condition.

Attention Deficit Hyperactivity Disorder, or ADHD, is a lifelong neurodevelopmental disorder that affects parts of the brain that help with planning, staying focused, and executing tasks. The condition makes it difficult to keep still, think before acting (impaired judgement) and/or manage emotions, besides impacting other skills.

It is one of the most common cognitive disorders affecting children.

Globally, an estimated 8.4% of children and 2.5% of adults [3] have ADHD. In India, a study puts this number at 11.32% for primary school children; prevalence was found to be higher among males (66.7%) as compared to females (33.3%) [6].

Newer studies indicate its occurrence is just as high among girls and boys, and the difference in prevalence could be a case of low detection rate since the presentation can be very different making it more difficult to diagnose in girls.

ADHD may or may not co-occur with intellectual disability. In fact, most persons with the disorder have normal to above-normal intelligence. But, children with ADHD are 20 times more likely to exhibit symptoms of Autism Spectrum Disorder [4].

The symptoms start in the developing years, but ADHD is difficult to diagnose in children younger than 4 years because they change very rapidly.

People, more specifically children, with this disorder can often be tagged “boisterous”, “procrastinators”, “easily bored”, or “unfocused”, and the condition can go undetected till it becomes disruptive.

A diagnosis is usually made when a child starts school and the behaviour becomes unsettling for others. If left untreated, this condition can severely hamper adaptive functioning at home, school and in the community.

ADHD is also one of the most difficult conditions to diagnose because there is no single test for it.

Causes And Risk Factors

Barring genetics, scientists are yet to identify specific causes of ADHD. There is evidence that ADHD runs in families. Three out of four children with the disorder have a close relative who also has it, and the chances of that relative being a parent is as high as 1 in 4.

An increasing body of research is linking ADHD with brain function as well. Researchers are observing a biological difference in the brains of people with ADHD. Low level of activity in parts of the brain that control attention and activity level may be associated with ADHD. 

“Connections between the prefrontal cortex (the thinking brain) and the striatum (which deals with reward behaviors) may be disrupted in people with ADHD. Neurotransmitters play a role, too—and in many people with ADHD, the dopamine and norepinephrine systems don’t activate as robustly in certain settings compared to people without ADHD” [1] affecting focus and motivation.

Research also indicates that the brains of persons with ADHD just take longer to develop centres that govern areas of deficiency. This means that as persons with ADHD grow older some of their symptoms become less pronounced, but the condition in itself never goes away.

Other risk factors for ADHD are:

• Head injury
• Premature birth, or low birth weight
• Prenatal exposure to alcohol or nicotine from smoking
• Exposure to toxins, like lead, from the environment 

There is no evidence to support popularly held views that eating too much sugar, watching too much TV, environmental factors like stress, poverty could cause ADHD. However, all these factors can aggravate the symptoms associated with ADHD in some people.

Types And Symptoms

ADHD, also called ADD or attention deficit disorder, does not look the same in all kids and adults. It is marked by three key symptoms which may or may not co-occur — inattention or not being able to keep focus; hyperactivity or excessive activity not fitting to the environment or stimuli; impulsivity or acting hastily without thought.

These broad symptoms also form the basis for classification, according to DSM-5 which mandates that a child must exhibit at least 6-7 of the listed symptoms in two or more settings — home, school, community — for a diagnosis.

While these symptoms are seen in most children, the giveaway for those with ADHD is that their behaviour can create distress or problems.

The three basic types of ADHD are defined on the basis of the symptoms. 

• Predominantly Inattentive

Formerly called ADD and categorised as a condition separate from ADHD. Children with this type of ADHD have difficulty paying attention, and are easily distracted. This type of ADHD is also more difficult to catch as such kids may not be disruptive in class, and get misunderstood as shy, spacey or daydreamy. Their problems are nor behavioural, but do pose them a lot of difficulty.

Symptoms

• Doesn’t pay close attention to details or makes careless mistakes.
• Has problems staying focused on tasks or activities, such as lectures, long conversations or reading.
• Does not seem to be listening when spoken to (i.e., seems to be elsewhere).
• Does not follow through on instructions and doesn’t complete schoolwork, chores or job duties (may start tasks but quickly loses focus).
• Has problems organizing tasks and work; is unable to manage time well; has messy, disorganized work; misses deadlines.
• Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms.
• Often loses things needed for tasks or daily life, such as school papers, books, keys, wallet, cell phone, eyeglasses, watch.
• Is easily distracted.
• Forgets daily tasks, such as doing chores and running errands. Older teens and adults may forget to return phone calls, pay bills or keep appointments.

• Hyperactive-Impulsive

Children with inattentive ADHD have symptoms of hyperactivity, they feel the need to move constantly, and struggle with impulse control. This type is seen most often in very young children, and is easier to spot.

Symptoms

• Fidgets with or taps hands or feet, or squirms in seat.
• Not able to stay seated (in classroom, workplace).
• Runs about or climbs where it is inappropriate.
• Unable to play or do leisure activities quietly.
• Always “on the go,” as if driven by a motor.
• Talks too much.
• Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations).
• Has difficulty waiting his or her turn, such as while waiting in line.
• Interrupts or intrudes on others (for instance, cuts into conversations, games or activities, or starts using other people’s things without permission). Older teens and adults may take over what others are doing.

• Combined.

Children with this type of ADHD show significant problems with hyperactivity, impulse control and inattention. As they grow older, the symptoms of hyperactivity and impulsivity get better, but they may need help with inattention and emotion-management to function well at work and in the community at large.

A diagnosis is based on the symptoms that have occurred over the past six months.

Co-occurring Conditions

ADHD may coexist with one or more disorders, and certain disorders tend to occur more commonly than others, like Autism Spectrum Disorder. Some studies suggest that co-occurrence of at least one other condition with ADHD is as high as ~66%.

Failure to assess the presence of other co-existing conditions is known to become one of the biggest challenges in getting a holistic ADHD treatment. 

Some of the commonly co-occurring conditions are:

• Autism Spectrum Disorder (ASD)
• Oppositional Defiant Disorder (ODD)
• Mood disorders
• Anxiety and depression
• Tics and Tourette Syndrome
• Learning difficulty
• Sleep disorder
• Substance abuse
• Increased risk to health and injury

These conditions, and their symptoms— fidgetiness, speaking out of turn, blurting out information, difficulty sitting still, lack of focus, irritability, need for constant reminders etc — can either overshadow ADHD or get masked by it. This makes diagnosis of the primary and secondary conditions difficult. Left untreated, they make life extremely difficult for persons with ADHD/their families. This also renders treatments less effective in building desired adaptive strengths.

Co-occurrence with ID

ADHD is not an intellectual disability (ID). Most children with ADHD have average to above-average intelligence which usually does not reflect in academic performance. While some symptoms do echo mild cognitive impairment, there is not enough evidence to draw conclusions.

Little is known of the clinical presentation of ADHD in children with intellectual disability. Those with lower cognitive ability are often excluded from studies on attention deficit hyperactivity disorder despite evidence that the condition is more common in children with IDs, and that the risk increases with increasing severity of intellectual disability. [2]

Studies have shown that co-occurrence of ID and ADHD may be underdiagnosed owing to issues such as “diagnostic overshadowing”, the tendency of clinicians to overlook additional psychiatric diagnoses after a diagnosis of ID, or “masking” in which the clinical characteristics of a mental disorder are masked by a cognitive, language, and/or speech deficit [2].

That said, the chances of ADHD co-occurring alongside ID is much higher than ID co-occurring with ADHD.

Diagnosis

Not everyone who is easily distracted has ADHD, and not everyone with ADHD responds to the same treatment. For example, two-third of the population with ADHD also has other disorders including anxiety and autism. So, getting relief involves a complete diagnosis and adopting a clutch of different strategies. That’s why it is so important to educate oneself fully, not self-diagnose and seek out a qualified practitioner.

The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5), has developed a standard set of symptoms and criteria for diagnosis. An accurate diagnosis requires detailed interviews about the child’s behaviour at home, in school, the playground etc from caregivers, siblings, teachers.

Criteria

• Six (or more) symptoms of inattentive or hyperactive-impulsive ADHD have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. 
• Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
• The symptoms are not solely a manifestation of another disorder/condition, oppositional behaviour, defiance, hostility, or a failure to understand tasks or instructions.

Unlike what was believed earlier, ADHD often lasts into adulthood and although certain symptoms may fade, overall difficulties demand treatment. Failing this, individuals are likely to face functional difficulty in all major work-life areas.

Rising awareness about behavioural issues caused by untreated ADHD has also led to many individuals who were “missed out” as children to seek a diagnosis in adulthood. To diagnose ADHD in adults, only 5 symptoms are needed instead of the 6 needed for younger children. But, the symptoms may present themselves differently like so [5]:

1. Lack of focus
2. Hyperfocus
3. Disorganisation
4. Sloppy time management
5. Forgetfulness
6. Impulsivity
7. Emotional distress
8. Negative self-image
9. Lack of motivation
10. Restlessness and anxiety
11. Fatigue
12. Physical health challenges
13. Relationship management
14. Substance abuse

Treatment And Management

ADHD is best addressed with a combination of medication and behaviour therapy, and neither should be feared or ignored.

Behaviour therapy, especially in preschool children, is recommended as the first line of treatment before medication is tried.

While medication improves quality of life by helping ease the symptoms, its prescription and efficacy depend on accurate diagnoses of other possible co-conditions. That said, medications work well and are safe when used as per instructions. 

Depending on the symptoms and age, an effective treatment plan may include both, in addition to close monitoring, timely follow-ups, and making changes along the way. 

If you feel you or someone you know may be on the spectrum, approach a clinician or reach out to The Sarvodya Collective to understand yourself better and how you relate to the world. 

References

[1] https://www.mindbodygreen.com/articles/adhd-in-women

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4078221/

[3] www.psychiatry.org

[4] https://www.additudemag.com/

[5] https://www.healthline.com/health/adhd/adult-adhd

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890923/