Introduction

Ever seen a child who just couldn't be calm or attentive and you think... "what's wrong with you?!" Well, you should take a breather and understand that though, some kids may just be outright annoying, some have ADHD.
The behavioural activities of children vary
across different situations and contexts.
Many parents and teachers describe their wards as "overactive".

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This overactivity can range from a normal high spirits to a severe and persistent disorder - Attention Deficit Hyperactive Disorder (ADHD).
ADHD is defined as a persistent pattern of
inattention and/or hyperactivity that is
developmentally inappropriate.

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Epidemiology

An estimated 8.4% of children and 2.5% of adults have ADHD.

Prevalence rates:
1- 2% (ICD -10)
5% (DSM IV)
There is a decreasing prevalence of ADHD over the years. This has been attributed to better awareness of the disorder and prompt response.

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Males are more commonly affected with a male to female ratio of 3:1.
Boys tend to present with hyperactivity and other externalizing symptoms whereas girls tend to have inactivity.
Increased media attention may account for the increase in diagnostic rates and use of stimulants for treatment in recent years as epidemiological studies have not shown an increase in prevalence.

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Aetiology

The causes of ADHD are multifactorial.

Genetics: twins, family and adoption studies have shown the importance of genetic factors.

Risk estimates- twins 50x, siblings 2-3x.
Genes involved in the dopaminergic transmitter system have been implicated.

Neurological: neurological “soft” signs suggesting impairments or delay.
Functional imaging studies show frontal
metabolism.
Neurotransmitters: frontal disregulation in the noradrenergic and dopaminergic systems.

Psychosocial factors: increase rates associated with stress, poor social conditions and institutions.

Others: food additives, lead, zinc and alcohol exposure. (no firm evidence base)

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Research does not support the popularly held views that ADHD is caused by eating too much sugar, watching too much television, parenting, or social and environmental factors such as poverty or family chaos. Of course, many things, including these, might make symptoms worse, especially in certain people. But the evidence is not strong enough to conclude that they are the main causes of ADHD.

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Clinical features

Hyperactivity symptoms include: fidgeting,
constantly on the move, getting up and running about, climbing on desks, etc.

Talking excessively; unable to play quietly.
Impulsivity symptoms: blurting out answers, unable to withhold responses, jumping queues, continually interrupting.
Inattention symptoms include:
cannot sustain attention; easily distracted;
poor task completion; can't organize, and makes mistakes with tasks
that require attention; doesn't listen, is forgetful, and loses things.

Other associated symptoms includes:
Aggression, low self esteem and depressive mood.
Most symptoms start when the child begins to walk but sometimes overactivity starts early in infancy.

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Adults with ADHD may experience poor self-worth, sensitivity towards criticism, and increased self-criticism possibly stemming from higher levels of criticism throughout life.
80% of children having a comorbid disorder, most common are specific learning disorders (60%), Conduct disorders and Oppositional Defiant disorders (40%).
Others include substance abuse, depression, bipolar disorder.

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Types

Predominantly inattentive presentation.

It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.

Predominantly hyperactive/impulsive presentation.

The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.

Combined presentation.

Symptoms of the above two types are equally present in the person.

The type may change from one to the other as the symptoms may change over time.

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Diagnosis

A diagnosis is based on the presence of persistent symptoms that have occurred over a period of time and are noticeable over the past six months. While ADHD can be diagnosed at any age, this disorder begins in childhood. When considering the diagnosis, the symptoms must be present before the individual is 12 years old and must have caused difficulties in more than one setting. For instance, the symptoms can not only occur at home.

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Diagnostic criteria;
World Health Organization; ICD-10:
Symptoms of hyperactivity/impulsivity AND
impaired attention that is maladaptive and
inconsistent with developmental age.
Occurs in at least 2 settings. Starts before 6yrs of age.
Duration: at least 6 months.

Aerican Psychiatric Association; DSM IV:
Persistent symptoms of EITHER inattention OR
hyperactivity with impulsiveness ocurring in at least ONE setting, with impairment in the other. Starts before 7yrs.

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Treatment

In most cases, ADHD is best treated with a combination of behavior therapy and medication.

Psychological

Psychosocial interventions in form of:
Support to parents and teachers.
Family, group and behavioural therapy.
Special education may be warranted.
Behavior therapy, particularly training for parents, is recommended as the first line of treatment before medication is tried.

Better diet and eating habits should be developed. Healthy eating has been shown to play a role. Improve fruits and vegetables. Lean protein is preferred as protein source.
Child should be encouraged to participate in physical activities suitable for age and screen time should be supervised and limited. Adequate amount of sleep is necessary and should be observed.

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Pharmacological

For severe cases.
Medications: Stimulants; Methylphenidate.
2nd line agent: Atomoxetine.
Overactivity usually disappears by adolescence especially when mild.
Most cases do not meet diagnostic criteria in adulthood but some may have some functional impairment.
Prognosis is worse with increasing severity and co-morbidity.

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Conclusion

ADHD is a childhood condition that rarely advances into adulthood due to poor management. It is usually detected early and managed properly, resulting in a reduction in its prevalence.

References

P. Cowen et al, Shorter oxford handbook of
psychiatry, 6th ed.
D. Semple et al, Oxford handbook of psychiatry. 1st ed.
Beaton, et al., 2022
Danielson, 2018;
Simon, et al., 2009
https://www.cdc.gov/ncbddd/adhd/facts
https://www.psychiatry.org/patients-families/adhd/what-is-adhd