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AnitaPuustjärvi

ADHD

Essentials

  • ADHD (attention deficit/hyperactivity disorder) is a common neuropsychiatric syndrome with onset in childhood that often continues to adulthood.
    • The primary symptoms include problems with the regulation of attention and activity, and impulsiveness. Difficulty in activity regulation most typically appears as hyperactivity but may also appear as hypoactivity, i.e. inability to act, and as sluggishness.
    • In addition, nearly all patients have problems with executive functions, often with regulation of emotions and behaviour.
    • Concomitant developmental and psychiatric disturbances are common and must be taken into account when planning the treatment and rehabilitation.
  • To diagnose ADHD, extensive assessment of the symptoms and the patient's life situation is needed. ADHD is possible even if other illnesses affecting the patient's functional ability can be identified.
  • Untreated ADHD increases accident proneness and is associated with poorer performance in studies and in working life. It also increases the risk of substance use disorder, social exclusion and criminal conduct, particularly when occurring concomitantly with a conduct disorder.
  • The treatment of ADHD consists of arrangements supporting functional ability and symptom control at home, in day care, at school, in the study place and in working life, of various forms of psychosocial treatment and medication, as necessary. Tenacious treatment of the symptoms improves the quality of life and reduces the known risks.

Prevalence

  • An estimated 5 to 7% of school-aged children and 3 to 4% of adults have ADHD.
  • The symptoms of ADHD often (in 60-80% of cases) continue from childhood to adulthood, but visible symptoms are often alleviated with age.
    • In some individuals, ADHD symptoms may be mild in childhood due to e.g. an environment that supports functional capacity, and ADHD is recognized only in adulthood when the symptoms interfere with functional capacity more.
  • ADHD is diagnosed 3 to 6 times as often in boys as in girls but the difference between men and women affected is smaller.

Aetiology

  • Genetic predisposition explains about 60-80% of occurrence of ADHD.
  • Environmental factors may affect the occurrence of ADHD by regulating the activity of risk genes, by causing changes in the brain function and the course of normal development, and by affecting the symptoms' severity and the level of harm they cause.
    • Risk factors during pregnancy include being exposed to maternal smoking, alcohol consumption or substance use, and fetal asphyxia. Severe maternal stress and use of pharmaceuticals during pregnancy may also be significant.
    • Risk factors associated with the family, such as interactive problems and conflicts, increase oppositional defiant and behavioural symptoms, in particular, and impair functional ability but do not alone cause ADHD.
    • Excessive exposure to fast-tempo tv programmes before the age of 3 years would appear to increase concentration problems at school age. Excessive playing of computer games may also increase restlessness and concentration problems especially, if it diminishes the time spent for sleeping and exercising.
  • The essential findings related to brain activity are associated with abnormal dopamine- and noradrenaline-mediated nerve activity in brain regions regulating attention, impulse control and activity and in connections between such regions.
    • The regulation of alertness is often abnormal, and this may be associated with sleep problems (the patient not being able to calm down sufficiently).

Symptoms and clinical picture

  • Occasional symptoms of inattention, hyperactivity or impulsiveness are quite common but in patients with ADHD such symptoms are frequent, present for a long time, and clearly affect their functional ability.
  • Three types of ADHD can be distinguished.
    • Attention deficit disorder (ADD) involving predominantly concentration problems without associated impulsiveness or hyperactivity
    • Overactivity and impulsiveness without significant concentration problems
    • A mixed type of disorder with problems in all the main symptom areas
  • All types should be diagnosed under the ICD code F90.0. The predominant symptoms can be further defined verbally, as necessary, if the patient record system being used allows this.
  • The manifestations of the symptoms are different at different ages.
    • In children below school age, hyperactivity often appears as physical restlessness, climbing and running all over. In school-aged children, it may appear as difficulty sitting still in class, and in adults as avoiding events where they would need to remain still and as internal restlessness.
    • In children below school age, the difficulty of regulating attention may appear as a short attention span when playing, in school-aged children as distractibility, being absorbed in thought, making careless mistakes and forgetting their belongings. In adults inattentiveness may manifest, for example, as difficulty in maintaining concentration and as a tendency to get involved in secondary tasks instead of those of primary importance.
    • In children below school age, impulsiveness often appears as unpredictable scurrying and in school-aged children as inability to wait for their turn in games, when playing or in discussions. In adults, impulsiveness may lead to sudden changes of place of study or workplace and difficulties in relationships. Quick and strong emotional reactions are also typical.
  • The degree of disturbance caused by the symptoms depends on environmental factors. For example, symptoms are more likely to appear in a large group than in a one-to-one situation.
    • Motivation affects concentration, in particular. There may also be excessive concentration at times, meaning that patients immerse themselves in matters of interest to such an extent that they lose their sense of time and situation.
    • Factors affecting physical wellbeing (lack of physical activity or sleep, hunger), strong emotions (excitement, anger) and stressful situations (disproportionate demands, conflicts at home, bullying) increase symptoms.
    • Symptoms may not occur at all in a peaceful environment, within interesting activity, when movement that supports alertness control is possible.

Diagnosis

Diagnostic criteria

  • ADHD is a symptomatic diagnosis; there are no specific diagnostic examinations.
  • An extensive assessment of the overall situation is necessary to make the diagnosis and for differential diagnosis.
    • Extensive history (developmental abnormalities, past and current symptoms, any other diseases/disorders, history of examinations and treatments, current stress factors, family situation, family history)
      • The duration of symptoms and their occurrence in various situations (preferably ask the day care centre / school / other place directly)
      • Review of factors affecting the patient's symptoms and functional ability
    • Clinical physical and neurological examination
    • Examinations required for differential diagnosis
      • Laboratory tests are utilized, as necessary, to exclude other conditions that impair the ability to concentrate or possibly cause restlessness (anaemia, thyroid function disorders, coeliac disease, etc.)
      • Brain imaging and EEG are usually unnecessary.
      • A psychological or neuropsychological examination is not necessary for diagnosis but it may be useful for differential diagnosis and for treatment and rehabilitation.
      • In children, assessment by a speech or occupational therapist may be necessary to obtain an overall picture of the situation.
  • For diagnosis, the patient must have 6 symptoms of impaired attention and 6 symptoms of hyperactivity-impulsiveness of the total of 18 symptom criteria.
    • In patients of 17 years or older, 5 symptoms of impaired attention and/or hyperactivity-impulsiveness are sufficient (according to the DSM-5 criteria).
  • Symptoms usually appear already in childhood. Nevertheless, they may not have been identified until school age and, according to the DSM-5 criteria, it is sufficient for symptoms to have occurred before the age of 12 years.
    • Care must be taken in making the diagnosis before school age, and reliable diagnosis may not be possible before the age of 5 years.
    • When diagnosing adults, it must be ensured (from documents, for instance) that symptoms have occurred since, the latest, primary school age (about 7 to 12 years of age). It is not necessary, however, to verify that all diagnostic criteria were met in childhood years.
  • Symptoms must occur in several types of situations and with different people but not necessarily in every situation, such as at a doctor's office or in connection with a psychological examination.
    • Symptoms may be different in different situations, and the severity of symptoms may vary.
    • Observations related to different functional abilities in different situations may help to find means for alleviating the symptoms.
    • Being successful at school or in working life does not exclude the possibility of having ADHD.
  • Having another psychiatric diagnosis does not exclude the diagnosis of ADHD if the patient has clearly separate but simultaneous disorders. There may be some overlapping symptoms.

Questionnaires

Differential diagnosis

  • Hyperactivity in a child below school age may, for instance, be due to an autism spectrum disorder, a language disorder, motor or sensory disorders or more extensive developmental delay.
  • In school-aged children, it is additionally important to include learning difficulties, anxiety disorders, oppositional defiant and conduct disorder or depression, for instance, in the differential diagnosis.
  • In adolescents and adults, it is important to include affective syndromes (depression, bipolar disorder), substance use disorders, psychotic disorders (such as the prodromal stage in schizophrenia), anxiety disorders and emotionally unstable or antisocial personality in the differential diagnosis.
    • An abstinence period of, at minimum, 1-3 months after the cessation of withdrawal symptoms should take place before diagnosing ADHD in a person with substance use disorder.
  • Possible physical causes include epilepsy (absence seizures), other neurological disorders (such as neurofibromatosis) and sequel of brain injury.
  • Restlessness and inattention may also be due to sleep disorders (sleep apnoea, restless legs, long-term sleep deprivation).
  • Traumatic experiences or current stress (being bullied, changes in family situation, losses, abuse, attachment disorders) may also cause similar symptoms. Nevertheless, it should be remembered that symptoms of ADHD as such predispose to stress, negative experiences affecting the self-image, and maltreatment.

Other simultaneous disorders

  • As many as 75-80% of patients have some simultaneous psychiatric disorder or substance use disorder.
  • Various types of learning difficulties, developmental language or motor disorders or executive or sensory regulation problems may occur simultaneously with ADHD.
  • Sleep disorders Sleep Disorders in Children and Adolescents are more common than in other people. Falling asleep is often delayed and the quality of sleep impaired.
  • In 50-90% of patients, ADHD symptoms are associated with depression Childhood Depression, oppositional defiant and/or conduct disorders Conduct Disorders in Children and Adolescents or problems associated with self-image, self-esteem or social interactive skills, often secondary to receiving inadequate support.
  • Anxiety disorders, such as obsessive-compulsive disorder Obsessive-Compulsive Disorder (OCD) in Children Obsessive-Compulsive Disorder (OCD), are also more common.
  • ADHD may occur as a part of a more severe neuropsychiatric entity, possibly with symptoms of the autism spectrum Autism Spectrum Disorders and/or tics Tic Disorders in Childhood. It is possible to have several neuropsychiatric disorders at the same time.
  • ADHD is a risk factor for developing a substance use disorder and for smoking. Pharmacological treatment of ADHD will not increase the risk.

Treatment and rehabilitation Dextroamphetamine for Attention Deficit Hyperactivity Disorder in Children with Intellectual Disabilities, Meditation Therapies for ADHD, Drug Treatment for ADHD in Children with Comorbid Tic Disorders, Polyunsaturated Fatty Acids (Pufa) for ADHD in Children and Adolescents, Family Therapy for Attention-Deficit Disorder, Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents

  • Good treatment of ADHD involves sufficient provision of information and counselling (psychoeducation), psychosocial treatment, and pharmacological treatment, as necessary.
    • To control ADHD symptoms, it is important to take sufficient care of general wellbeing (sleep, physical exercise, diet, positive interaction).
    • Combination of various forms of treatment and, in particular, methods for making daily life run smoothly is often needed.
    • When planning treatment, other simultaneous disorders, problems affecting the overall situation and coping of the parents and the whole family must be considered.
  • In children below school age, the first-choice treatment is psychosocial treatment started in primary care.
    • Pharmacological treatment is rarely used and it should be started in specialized care.
  • In school-aged and older patients pharmacological treatment can be started simultaneously with other treatment or if other forms of support have not helped sufficiently.

Non-pharmacological treatment

  • Non-pharmacological, or psychosocial, treatments may involve various methods of supporting functional ability (guidance, environmental modification), support measures and practising of skills alone or in a group. It is often most sensible to provide such treatment largely as a part of the patient's daily life, but various forms of individual or group therapies may be included, as necessary.
    • The need for occupational therapy, neuropsychological rehabilitation and speech therapy must be assessed individually.
    • Some children with ADHD may need support for the development of social skills Social Skills Training for ADHD in Children.
  • Psychotherapy is not a primary form of treatment of ADHD, but it may be beneficial due to the severity or nature of problems.
  • An attempt should be made to alleviate ADHD symptoms and increase experiences of success by guiding the patient's behaviour and eliminating disturbing environmental factors. This can, for instance, be done by employing anticipation, advance planning of things, immediate feedback, structuring, and splitting tasks into smaller parts. Beneficial are also reward systems as well as concrete aids (e.g. pictograms, visual clock, daily routine).
    • ADHD coaching is solution- and resource-focused rehabilitation implemented in daily life at home and in other working environments, such as the school. It usually involves behavioural guidance, methods of coping in everyday life, and practising of various skills. The methods can also be used without an actual coaching relationship, as part of other psychosocial support forms, guided by e.g. a healthcare actor.
  • Parent training Parent Training Interventions for ADHD will help parents to recognise their child's behaviour and factors affecting it and to guide the child's behaviour in the desired direction.
    • Parent training can be provided individually for each family or in groups. Find out about local possibilities.
    • Written material can be used to support the training.
    • ADHD symptoms may affect the child-parent relationship and lead to a vicious circle of negative interaction that should be broken. ADHD in a child also increases the risk of conflicts and relationship problems between the parents.
  • Various kinds of support arrangements in day care and at school improve the functional capacity of children with ADHD. These may be started as soon as the problems have been observed, based on a pedagogical assessment, even in the absence of a diagnosis.
    • Close cooperation between school and home (and the place of treatment) is necessary both in planning and in implementing support measures.
    • The most common measures include structuring, dividing tasks into smaller entities, anticipation, immediate feedback and reward systems. Allowing non-disturbing movement to maintain alertness often facilitates work in class (e.g. sitting on a gym ball, playing with blue tack). Sufficient guidance during breaks and other free activities will reduce conflicts.
    • Some children need special arrangements, such as more time for answering questions in exams, support by an assistant, differentiated tuition in various situations or subjects or small group tuition.
    • Based on a medical certificate, ADHD can be taken into consideration in taking and/or assessing the matriculation examination.
    • Expertise is also needed for the guidance of studies and for vocational guidance.
  • Adjustment training courses for people of various ages and peer support activities are readily available.
  • Some families will benefit from the types of support offered by social services, such as people or families providing support.
  • If a parent has clearly disturbing ADHD or other problems affecting their functional ability, they also need appropriate treatment and rehabilitation.

Pharmacotherapy

  • Correctly implemented pharmacological treatment of ADHD is effective and safe.
  • The action of ADHD medication is based on the activation of dopamine- and noradrenaline-mediated neural pathways, reducing the amount of symptoms during medication.
  • Psychostimulants (methylphenidate, lisdexamphetamine, dexamphetamine), atomoxetine or guanfacine can be used.
    • The action of psychostimulants is mainly dopamine-mediated, with rapid onset about 30-60 minutes after taking the medication.
    • The action of atomoxetine is mainly noradrenaline-mediated, with gradual onset within 1-6 weeks from starting to take the medication.
    • Guanfacine is an alpha-2A-adrenergic receptor agonist but its action is noradrenaline-mediated, with onset in 1-3 weeks.
    • Routine medication breaks ("drug holidays") are not required even in psychostimulant medication, especially if, during such a break, symptoms considerably impair functional capacity.
  • Medication is usually started with methylphenidate Treatments for Attention-Deficit/Hyperactivity Disorder; there are products with different durations of action and drug release profiles available.
    • The product should be chosen based on the duration of action and the maximum desired effect.
    • Pharmacotherapy should be started at low doses which are increased depending on the response and any adverse effects so as to achieve sufficient efficacy without significant adverse effects. Notice that the effect of intermediate-acting drugs does not continue until the evening, and consequently it may be difficult for, for example, the parents to assess the effect of the medication, and an assessment by the teacher is needed.
    • Frequent monitoring and adjustment of dosage, perhaps as often as once a week, are needed in the beginning of pharmacological treatment. Once a suitable dosage has been found, the monitoring may take place at longer intervals. Later, after a possible medication break, the medication may be continued directly with an earlier dosage that is known to be effective.
    • If the first methylphenidate product does not produce the desired response, it may be appropriate to try another one with a different profile, and subsequently change to either lisdexamfetamine or dextroamphetamineAmphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents, atomoxetine or guanfacine.
      • Not all medicines are indicated for the treatment of adult ADHD.
    • Once a suitable product and dose have been found, follow-up visits should take place every 3 to 12 months to assess the patient's overall mental and physical state, treatment response, need for medication and sufficiency of dosage. Routine breaks in medication are not absolutely necessary but they are useful for assessment.
    • During medication, children's growth rate (weight and height assessed on growth curves) and all patients' pulse rate and blood pressure, as well as any adverse effects, should be monitored regularly.
      • If there is loss of appetite or changes in pharmacotherapy, monitoring can be more frequent.
      • Once the growth has ended in adolescents, it is sufficient, as considered appropriate, to monitor weight; i.e. if the adolescent perceives that his/her appetite is good and the patient does not seem to lose weight, there is no special need for regular follow-up measurements.
      • The blood pressure and heart rate should be measured before starting medication and during the pharmacotherapy. If no significant change is observed, it is sufficient to measure these whenever the dosage or drug is changed, or if the adolescent has symptoms, such as heart palpitations. In a stable situation, a control appointment once or twice a year is sufficient.
  • The most common adverse effects of stimulants and atomoxetine are reduced appetite, headaches, various kinds of mild abdominal discomfort, behavioural symptoms (irritability, aggressiveness) and sleeping problems Methylphenidate for Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents - Assessment of Adverse Events in Nonrandomised Studies. Slightly increased pulse rates and elevated blood pressure are common. These are normally insignificant in the treatment of cardiovascularly healthy persons. Sufficient monitoring of blood pressure is important particularly in the beginning of pharmacological treatment and in association with any increase in dosage. Fatigue, hypotension, bradycardia, vertigo, a fainting tendency and weight increase may occur as adverse effects of guanfacine. In addition, guanfacine may lengthen the QT interval.
    • If mild adverse effects occur, try adjusting the dosage or the time of drug administration or changing the product. If necessary, the drug is discontinued, e.g. if the QT time becomes prolonged.
    • If difficult or severe adverse effects occur, or if mild adverse effects are not reduced by adjusting the dosage, the drug is discontinued.
  • In some children and adolescents, the need for pharmacological treatment will decrease with time but some will need such treatment even as adults. It is also possible to start the pharmacological treatment for the first time only in adulthood.
  • Other forms of treatment are usually combined to parmacotherapy
    • Multifaceted treatment considering any other disorders affecting the symptoms or the treatment is recommended also for adults.
  • There is a risk of misuse associated with pharmacological treatment of ADHD that is often associated with intoxicant abuse and an antisocial tendency. Pharmacotherapy for ADHD does not cause dependence or increase the risk of substance use disorder.
    • Pharmacological treatment of any person with substance use disorder and diagnosed ADHD must be followed up extremely strictly, and in most cases it is justified to use other than stimulant-based medication.
    • In alcohol abusers with ADHD, atomoxetine may be useful in reducing ADHD symptoms but it will not affect alcohol consumption.

Other forms of treatment

  • Polyunsaturated fatty acids are ineffective in the treatment of ADHD in children and adolescents, and their use is not recommended.
  • Mindfulness methods may be useful in controlling ADHD symptoms.
  • Regular aerobic physical exercise may reduce essential symptoms of ADHD in children and adolescents.

Chain of treatment and criteria for referral

  • Preliminary examination for suspected ADHD and starting support measures belong to the remit of primary health care in all age groups.
  • In school-aged children also a drug treatment trial may be carried out within primary health care.
  • In most towns, a treatment chain has been defined or other agreement made concerning the division of tasks and cooperation between primary health care and specialized care. If not, a referral should be written to specialized care as follows:
    • to a child psychiatrist or an adolescent psychiatrist if the child's symptoms include significant or worsening mental symptoms or significant problems in child-parent interaction;
    • to an adolescent psychiatrist if the adolescent's symptoms include significant or worsening mental symptoms, severe behavioural problems or a substance-related disorder;
    • to a child neurologist if the child or adolescent is suspected of having a neurological disorder (e.g. neurofibromatosis, epilepsy) or intellectual disability.
  • Differential diagnostic examinations of patients with comorbidities or severe symptoms, any further examinations needed, starting of more aggressive pharmacological treatment, planning of the treatment and rehabilitation of such patients and making of agreements on further treatment and follow-up fall under the responsibility of specialized care.

    References

    • Bello NT. Clinical utility of guanfacine extended release in the treatment of ADHD in children and adolescents. Patient Prefer Adherence 2015;9():877-85. [PubMed]
    • Goode AP, Coeytaux RR, Maslow GR ym. Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review. Pediatrics 2018;141(6):. [PubMed]