Attention deficit hyperactivity disorder (ADHD)

ADD; ADHD; Childhood hyperkinesis

Last reviewed: February 22, 2010.
ADHD is a problem with inattentiveness, over-ativity, impulsivity, or a ombination. For these problems to be
dia!nosed as ADHD, they must be out o" the normal ran!e "or a hild#s a!e and development.
Causes, incidence, and risk factors
$ma!in! studies su!!est that the brains o" hildren with ADHD are di""erent "rom those o" other hildren. %hese
hildren handle neurotransmitters &inludin! dopamine, serotonin, and adrenaline' di""erently "rom their peers.
ADHD may run in "amilies, but it is not lear e(atly what auses it. )hatever the ause may be, it seems to be set
in motion early in li"e as the brain is developin!.
Depression, la* o" sleep, learnin! disabilities, ti disorders, and behavior problems may be on"used with, or appear
with, ADHD. +very hild suspeted o" havin! ADHD should have a are"ul evaluation to determine what is
ontributin! to the behaviors that are ausin! onern.
ADHD is the most ommonly dia!nosed behavioral disorder o" hildhood. $t a""ets about , - -. o" shool a!ed
hildren. ADHD is dia!nosed muh more o"ten in boys than in !irls.
/ost hildren with ADHD also have at least one other developmental or behavioral problem. %hey may also have
another psyhiatri problem, suh as depression or bipolar disorder.
Symptoms
%he symptoms o" ADHD are divided into inattentiveness, and hyperativity and impulsivity.
0ome hildren with ADHD primarily have the inattentive type, some the hyperative-impulsive type, and some the
ombined type. %hose with the inattentive type are less disruptive and are more li*ely to miss bein! dia!nosed with
ADHD.
$nattention symptoms:
1. Fails to !ive lose attention to details or ma*es areless mista*es in shoolwor*
2. Has di""iulty sustainin! attention in tas*s or play
,. Does not seem to listen when spo*en to diretly
1. Does not "ollow throu!h on instrutions and "ails to "inish shoolwor*, hores, or duties in the
wor*plae
-. Has di""iulty or!ani2in! tas*s and ativities
3. Avoids or disli*es tas*s that re4uire sustained mental e""ort &suh as shoolwor*'
5. 6"ten loses toys, assi!nments, penils, boo*s, or tools needed "or tas*s or ativities
7. $s easily distrated
8. $s o"ten "or!et"ul in daily ativities
Hyperativity symptoms:
1. Fid!ets with hands or "eet or s4uirms in seat
2. Leaves seat when remainin! seated is e(peted
,. 9uns about or limbs in inappropriate situations
1. Has di""iulty playin! 4uietly
-. $s o"ten :on the !o,: ats as i" :driven by a motor,: tal*s e(essively
$mpulsivity symptoms:
1. ;lurts out answers be"ore 4uestions have been ompleted
2. Has di""iulty awaitin! turn
,. $nterrupts or intrudes on others &butts into onversations or !ames'
Signs and tests
%oo o"ten, di""iult hildren are inorretly labeled with ADHD. 6n the other hand, many hildren who do have
ADHD remain undia!nosed. $n either ase, related learnin! disabilities or mood problems are o"ten missed. %he
Amerian Aademy o" <ediatris &AA<' has issued !uidelines to brin! more larity to this issue.
%he dia!nosis is based on very spei"i symptoms, whih must be present in more than one settin!.
=hildren should have at least 3 attention symptoms or 3 hyperativity>impulsivity symptoms, with some
symptoms present be"ore a!e 5.
%he symptoms must be present "or at least 3 months, seen in two or more settin!s, and not aused by
another problem.
%he symptoms must be severe enou!h to ause si!ni"iant di""iulties in many settin!s, inludin! home,
shool, and in relationships with peers.
$n older hildren, ADHD is in partial remission when they still have symptoms but no lon!er meet the "ull de"inition
o" the disorder.
%he hild should have an evaluation by a dotor i" ADHD is suspeted. +valuation may inlude:
<arent and teaher 4uestionnaires &"or e(ample, =onnors, ;ur*s'
<syholo!ial evaluation o" the hild A?D "amily, inludin! $@ testin! and psyholo!ial testin!
=omplete developmental, mental, nutritional, physial, and psyhosoial e(amination
Treatment
%he Amerian Aademy o" <ediatris has !uidelines "or treatin! ADHD:
0et spei"i, appropriate tar!et !oals to !uide therapy.
0tart mediation and behavior therapy.
)hen treatment has not met the tar!et !oals, re-evaluate the ori!inal dia!nosis, the possible presene o"
other onditions, and how well the treatment plan has been implemented.
Follow-up re!ularly with the dotor to he* on !oals, results, and any side e""ets o" mediations.
Durin! these he*-ups, in"ormation should be !athered "rom parents, teahers, and the hild.
/+D$=A%$6?0
=hildren who reeive both behavioral treatment and mediation o"ten do the best. %here are now several di""erent
lasses o" ADHD mediations that may be used alone or in ombination. <syhostimulants &also *nown as
stimulants' are the most ommonly used ADHD dr!us. Althou!h these dru!s are alled stimulants, they atually
have a almin! e""et on people with ADHD.
%hese dru!s inlude:
Amphetamine-de(troamphetamine &Adderall'
De(methylphenidate &Foalin'
De(troamphetamine &De(edrine, De(trostat'
Lisde(am"etamine &Ayvanse'
/ethylphenidate &9italin, =onerta, /etadate, Daytrana'
%he Food and Dru! Administration &FDA' has approved the nonstimulant dru! atomo(etine &0trattera' "or use in
ADHD. $t may be as e""etive as stimulants, and may be less li*ely to be misused.
0ome ADHD mediines have been lin*ed to rare sudden death in hildren with heart problems. %al* to your dotor
about whih dru! is best "or your hild.
;+HAA$69 %H+9A<B
;oth be"ore and a"ter a hild is dia!nosed, there is stress on the "amily. Families an e(periene blame, an!er, and
"rustration. %al* therapy "or both the hild and "amily an help everyone overome these "eelin!s and move "orward.
<arents should use a system o" rewards and onse4uenes to help !uide their hild#s behavior. $t is important to learn
to handle disruptive behaviors. 0upport !roups an help you onnet with others who have similar problems.
6ther tips to help your hild with ADHD inlude:
=ommuniate re!ularly with the hild#s teaher.
Ceep a onsistent daily shedule, inludin! re!ular times "or homewor*, meals, and outdoor ativities.
/a*e han!es to the shedule in advane and not at the last moment.
Limit distrations in the hild#s environment.
/a*e sure the hild !ets a healthy, varied diet, with plenty o" "iber and basi nutrients.
/a*e sure the hild !ets enou!h sleep.
<raise and reward !ood behavior.
<rovide lear and onsistent rules "or the hild.
ADHD an be a "rustratin! problem. Alternative remedies have beome popular, inludin! herbs, supplements, and
hiroprati manipulation. However, there is little or no solid evidene "or many remedies mar*eted to parents.
!pectations (prognosis)
ADHD is a lon!-term, hroni ondition. $" it is not treated appropriately, ADHD may lead to:
Dru! and alohol abuse
Failure in shool
<roblems *eepin! a Dob
%rouble with the law
About hal" o" hildren with ADHD will ontinue to have troublesome symptoms o" inattention or impulsivity as
adults. However, adults are o"ten more apable o" ontrollin! behavior and mas*in! di""iulties.
Calling your health care provider
=all your dotor i" you or your hild#s shool personnel suspet ADHD. Bou should also tell your dotor about any:
Di""iulties at home, shool, and in relationships with peers
/ediation side e""ets
0i!ns o" depression
"revention
Althou!h there is no proven way to prevent ADHD, early identi"iation and treatment an prevent many o" the
problems assoiated with ADHD.
#eferences
1. <lis2*a 0E AA=A< )or* Froup on @uality $ssues. <ratie parameter "or the assessment and treatment
o" hildren and adolesents with attention-de"iit>hyperativity disorder. J Am Acad Child Adolesc
Psychiatry. 2005 GulE13&5':781-821. H<ub/edI
2. ?ational $nstitute o" /ental Health &?$/H'. Attention de"iit hyperativity disorder &ADHD'. Aessed
Ganuary 11, 2010.
,. <rine G;, 0pener %G, )ilens %+, ;iederman G. <harmaotherapy o" attention-de"iit>hyperativity
disorder aross the li"e span. $n: 0tern %A, 9osenbaum GF, Fava /, ;iederman G, 9auh 0L,
eds.Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. <hiladelphia, <a: /osby
+lsevierE 2007:hap 18.
9eview Date: 2>22>2010.
9eviewed by: David ;. /errill, /D, Assistant =linial <ro"essor o" <syhiatry, Department o" <syhiatry,
=olumbia Jniversity /edial =enter, ?ew Bor*, ?B. Also reviewed by David Kieve, /D, /HA, /edial
Diretor, A.D.A./., $n.
?$H
)$C$<+D$A
Attention de"iit hyperativity disorder
From )i*ipedia, the "ree enylopedia
Attention$deficit%hyperactivity disorder
Classification and external resources
A hild not payin! attention in lass.
&CD$'( F 80.
&CD$) ,11.00, ,11.01
*+&+ 11,13-
DiseasesD, 31-7
+edline"lus 001--1
e+edicine med>,10, ped>155
+eSH D001278
Attention deficit hyperactivity disorder &ADHD or AD%HD or ADD' is a neurobehavioral
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developmental
disorder.
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$t is primarily harateri2ed by :the o-e(istene o" attentional problems and hyperativity, with eah
behavior ourrin! in"re4uently alone: and symptoms startin! be"ore seven years o" a!e.
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ADHD is the most ommonly studied and dia!nosed psyhiatri disorder in hildren, a""etin! about , to - perent
o" hildren !lobally
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and dia!nosed in about 2 to 13 perent o" shool a!ed hildren.
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$t is
a hroni disorder
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with ,0 to -0 perent o" those individuals dia!nosed in hildhood ontinuin! to have symptoms
into adulthood.
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Adolesents and adults with ADHD tend to develop opin! mehanisms to ompensate "or some
or all o" their impairments.
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$t is estimated that 1.5 perent o" Amerian adults live with ADHD.
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ADHD is dia!nosed two to "our times more "re4uently in boys than in !irls,
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thou!h studies su!!est this
disrepany may be partially due to subDetive bias o" re"errin! teahers.
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ADHD mana!ement usually involves
some ombination o" mediations, behavior modi"iations, li"estyle han!es, and ounselin!. $ts symptoms an be
di""iult to di""erentiate "rom other disorders, inreasin! the li*elihood that the dia!nosis o" ADHD will be missed.
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Additionally, most liniians have not reeived "ormal trainin! in the assessment and treatment o" ADHD,
partiularly in adult patients.
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ADHD and its dia!nosis and treatment have been onsidered ontroversial sine the 1850s.
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%he ontroversies have
involved liniians, teahers, poliyma*ers, parents and the media. %opis inlude the atuality o" the disorder, its
auses, and the use o" stimulant mediations in its treatment.
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/ost healthare providers aept that ADHD is
a !enuine disorder with debate in the sienti"i ommunity enterin! mainly around how it is dia!nosed and treated.
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%he Amerian /edial Assoiationonluded in 1887 that the dia!nosti riteria "or ADHD are based on
e(tensive researh and, i" applied appropriately, lead to the dia!nosis with hi!h reliability.
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Contents
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1 =lassi"iation
2 0i!ns and symptoms
o 2.1 =omorbid disorders
, =ause
o ,.1 Fenetis
o ,.2 +volutionary theories
o ,., +nvironmental
o ,.1 0oial
1 <athophysiolo!y
- Dia!nosis
o -.1 D0/-$A
o -.2 $=D-10
o -., 6ther !uidelines
o -.1 Di""erential
3 /ana!ement
o 3.1 <syhosoial
o 3.2 /ediation
5 <ro!nosis
7 +pidemiolo!y
8 History
10 0oiety and ulture
o 10.1 Le!al status o" mediations
o 10.2 =ontroversies
11 $n adult
12 9e"erenes
o 12.1 ;iblio!raphy
1, Further readin!
11 +(ternal lin*s
Classification
ADHD may be seen as one or more ontinuous traits "ound normally throu!hout the !eneral population.
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$t is
a developmental disorder in whih ertain traits suh as impulse ontrol la! in development. Jsin! ma!neti
resonane ima!in! o" the pre"rontal orte(, this developmental la! has been estimated to ran!e "rom , to - years.
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A dia!nosis o" ADHD does not, however, imply a neurolo!ial disease.
H21IHclarification neededI
ADHD is lassi"ied as
a disruptive behavior disorder alon! with oppositional de"iant disorder, ondut disorderand antisoial disorder.
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ADHD has three subtypes:
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<redominantly hyperative-impulsive
/ost symptoms &si( or more' are in the hyperativity-impulsivity ate!ories.
Fewer than si( symptoms o" inattention are present, althou!h inattention may still be present to
some de!ree.
<redominantly inattentive
%he maDority o" symptoms &si( or more' are in the inattention ate!ory and "ewer than si(
symptoms o" hyperativity-impulsivity are present, althou!h hyperativity-impulsivity may still be present
to some de!ree.
=hildren with this subtype are less li*ely to at out or have di""iulties !ettin! alon! with other
hildren. %hey may sit 4uietly, but they are not payin! attention to what they are doin!. %here"ore, the hild
may be overloo*ed, and parents and teahers may not notie symptoms o" ADHD.
=ombined hyperative-impulsive and inattentive
0i( or more symptoms o" inattention and si( or more symptoms o" hyperativity-impulsivity are
present.
/ost hildren with ADHD have the ombined type.
Signs and symptoms
$nattention, hyperativity, and impulsivity are the *ey behaviors o" ADHD. %he symptoms o" ADHD are espeially
di""iult to de"ine beause it is hard to draw the line at where normal levels o" inattention, hyperativity, and
impulsivity end and linially si!ni"iant levels re4uirin! intervention be!in.
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%o be dia!nosed with ADHD,
symptoms must be observed in two di""erent settin!s "or si( months or more and to a de!ree that is !reater than
other hildren o" the same a!e.
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%he symptom ate!ories o" ADHD in hildren yield three potential lassi"iations o" ADHDLpredominantly
inattentive type, predominantly hyperative-impulsive type, or ombined type i" riteria "or both subtypes are met:
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<redominantly inattentive type symptoms may inlude:
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;e easily distrated, miss details, "or!et thin!s, and "re4uently swith "rom one ativity to another
Have di""iulty maintainin! "ous on one tas*
;eome bored with a tas* a"ter only a "ew minutes, unless doin! somethin! enDoyable
Have di""iulty "ousin! attention on or!ani2in! and ompletin! a tas* or learnin! somethin! new or
trouble ompletin! or turnin! in homewor* assi!nments, o"ten losin! thin!s &e.!., penils, toys, assi!nments'
needed to omplete tas*s or ativities
?ot seem to listen when spo*en to
Daydream, beome easily on"used, and move slowly
Have di""iulty proessin! in"ormation as 4ui*ly and aurately as others
0tru!!le to "ollow instrutions.
<redominantly hyperative-impulsive type symptoms may inlude:
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Fid!et and s4uirm in their seats
%al* nonstop
Dash around, touhin! or playin! with anythin! and everythin! in si!ht
Have trouble sittin! still durin! dinner, shool, and story time
;e onstantly in motion
Have di""iulty doin! 4uiet tas*s or ativities.
and also these mani"estations primarily o" impulsivity:
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;e very impatient
;lurt out inappropriate omments, show their emotions without restraint, and at without re!ard "or
onse4uenes
Have di""iulty waitin! "or thin!s they want or waitin! their turns in !ames
/ost people e(hibit some o" these behaviors, but not to the de!ree where suh behaviors si!ni"iantly inter"ere with
a person#s wor*, relationships, or studies. %he ore impairments are onsistent even in di""erent ultural onte(ts.
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0ymptoms may persist into adulthood "or up to hal" o" hildren dia!nosed with ADHD. +stimatin! this is di""iult as
there are no o""iial dia!nosti riteria "or ADHD in adults.
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ADHD in adults remains a linial dia!nosis. %he
si!ns and symptoms may di""er "rom those durin! hildhood and adolesene due to the adaptive proesses and
avoidane mehanisms learned durin! the proess o" soialisation.
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A 2008 study "ound that hildren with ADHD move around a lot beause it helps them stay alert enou!h to omplete
hallen!in! tas*s.
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Comor-id disorders
ADHD may aompany other disorders suh as an(iety or depression. 0uh ombinations an !reatly ompliate
dia!nosis and treatment. Aademi studies and researh in private pratie su!!est that depression in ADHD appears
to be inreasin!ly prevalent in hildren as they !et older, with a hi!her rate o" inrease in !irls than in boys, and to
vary in prevalene with the subtype o" ADHD. )here a mood disorder ompliates ADHD it would be prudent to
treat the mood disorder "irst, but parents o" hildren who have ADHD o"ten wish to have the ADHD treated "irst,
beause the response to treatment is 4ui*er.
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$nattention and :hyperative: behavior are not the only problems in hildren with ADHD. ADHD e(ists alone in
only about 1>, o" the hildren dia!nosed with it. /any o-e(istin! onditions re4uire other ourses o" treatment and
should be dia!nosed separately instead o" bein! !rouped in the ADHD dia!nosis. 0ome o" the assoiated onditions
are:
6ppositional de"iant disorder &,-.' and ondut disorder &23.' whih both are harateri2ed by antisoial
behaviors suh as stubbornness, a!!ression, "re4uent temper tantrums, deeit"ulness, lyin!, or stealin!,
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inevitably lin*in! these omorbid disorders withantisoial personality disorder &A0<D'E about hal" o" those
with hyperativity and 6DD or =D develop A0<D in adulthood.
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;orderline personality disorder, whih was aordin! to a study on 120 "emale psyhiatri patients
dia!nosed and treated "or ;<D assoiated with ADHD in 50 perent o" those ases.
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<rimary disorder o" vi!ilane, whih is harateri2ed by poor attention and onentration, as well as
di""iulties stayin! awa*e. %hese hildren tend to "id!et, yawn and streth and appear to be hyperative in order
to remain alert and ative.
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/ood disorders. ;oys dia!nosed with the ombined subtype have been shown li*ely to su""er "rom a mood
disorder.
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;ipolar disorder. As many as 2- perent o" hildren with ADHD have bipolar disorder. =hildren with this
ombination may demonstrate more a!!ression and behavioral problems than those with ADHD alone.
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An(iety disorder, whih has been "ound to be ommon in !irls dia!nosed with the inattentive subtype o"
ADHD.
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6bsessive-ompulsive disorder. 6=D is believed to share a !eneti omponent with ADHD and shares
many o" its harateristis.
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Cause
%he spei"i auses o" ADHD are not *nown.
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%here are, however, a number o" "ators that may ontribute to, or
e(aerbate ADHD. %hey inlude !enetis, diet and the soial and physial environments.
.enetics
<+% san: ADHD brains dopamine transporters
%win studies indiate that the disorder is hi!hly heritable and that !enetis are a "ator in about 5- perent o" all
ases.
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Hyperativity also seems to be primarily a !eneti onditionE however, other auses do have an e""et.
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9esearhers believe that a lar!e maDority o" ADHD ases arise "rom a ombination o" various !enes, many o" whih
a""et dopamine transporters. =andidate !enes inlude M2A adrener!i reeptor, dopamine transporter, dopamine
reeptors D2>D,,
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dopamine beta-hydro(ylase monoamine o(idase A, ateholamine-methyl trans"erase, serotonin
transporter promoter &0L=3A1', -H%2A reeptor, -H%1; reeptor,
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the 10-repeat allele o" the DA%1 !ene,
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the 5-
repeat allele o" the D9D1 !ene,
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and the dopamine beta hydro(ylase !ene &D;H %a4$'.
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A ommon variant o" a
!ene alled L<H?, is estimated to be responsible "or about 8. o" the inidene o" ADHD, and ADHD ases where
this !ene is present are partiularly responsive to stimulant mediation.
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%he broad seletion o" tar!ets indiates that ADHD does not "ollow the traditional model o" :a simple !eneti
disease: and should there"ore be viewed as a omple( interation amon! !eneti and environmental "ators. +ven
thou!h all these !enes mi!ht play a role, to date no sin!le !ene has been shown to ma*e a maDor ontribution to
ADHD.
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volutionary theories
See also: Hunter vs. farmer theory
%he hunter vs. "armer theory is a hypothesis proposed by author %hom Hartmann about the ori!ins o" ADHD. %he
theory proposes that hyperativity may be an adaptive behavior in pre-modern humans
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and that those with ADHD
retain some o" the older :hunter: harateristis assoiated with early pre-a!riultural human soiety. Aordin! to
this theory, individuals with ADHD may be more adept at searhin! and see*in! and less adept at stayin! put and
mana!in! omple( tas*s over time.
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Further evidene showin! hyperativity may be evolutionarily bene"iial was
put "orth in 2003 in a study whih "ound it may arry spei"i bene"its "or ertain "orms o" anient soiety. $n these
soieties, those with ADHD are hypothesi2ed to have been more pro"iient in tas*s involvin! ris* or ompetition
&i.e. huntin!, matin! rituals, et.'.
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A !eneti variant assoiated with ADHD &D9D1 17bp A?%9 59 allele', has
been "ound to be at hi!her "re4ueny in more nomadi populations and those with more o" a history o" mi!ration.
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=onsistent with this, another !roup o" researhers observed that the health status o" nomadi Ariaal men was
hi!her i" they had the ADHD assoiated !eneti variant &59 alleles'. However in reently sedentary &non-
nomadi' Ariaal those with 59 alleles seemed to have sli!htly worse health.
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nvironmental
%win studies to date have su!!ested that appro(imately 8 to 20 perent o" the variane in hyperative-impulsive-
inattentive behavior or ADHD symptoms an be attributed to nonshared environmental &non!eneti' "ators.
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+nvironmental "ators impliated inlude alohol and tobao smo*e e(posure durin! pre!nany and
environmental e(posure to lead in very early li"e.
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%he relation o" smo*in! to ADHD ould be due to niotine
ausin! hypo(ia &la* o" o(y!en' to the "etus in utero.
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$t ould also be that women with ADHD are more li*ely to
smo*e
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and there"ore, due to the stron! !eneti omponent o" ADHD, are more li*ely to have hildren with
ADHD.
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=ompliations durin! pre!nany and birthLinludin! premature birthLmi!ht also play a role.
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ADHD
patients have been observed to have hi!her than avera!e rates o" head inDuriesE
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however, urrent evidene does
not indiate that head inDuries are the ause o" ADHD in the patients observed.
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$n"etions durin! pre!nany, at
birth, and in early hildhood are lin*ed to an inreased ris* o" developin! ADHD. %hese inlude various viruses
&measles, variella, rubella, enterovirus 51' and streptooal baterial in"etion.
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A 2005 study lin*ed the or!anophosphate insetiide hlorpyri"os, whih is used on some "ruits and ve!etables, with
delays in learnin! rates, redued physial oordination, and behavioral problems in hildren, espeially ADHD.
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A 2010 study "ound that pestiide e(posure is stron!ly assoiated with an inreased ris* o" ADHD in hildren.
9esearhers analy2ed the levels o" or!anophosphate residues in the urine o" more than 1,100 hildren a!ed 7 to 1-
years old, and "ound that those with the hi!hest levels o" dial*yl phosphates, whih are the brea*down produts o"
or!anophosphate pestiides, also had the hi!hest inidene o" ADHD. 6verall, they "ound a ,- perent inrease in
the odds o" developin! ADHD with every 10-"old inrease in urinary onentration o" the pestiide residues. %he
e""et was seen even at the low end o" e(posure: hildren who had any detetable, above-avera!e level o" pestiide
metabolite in their urine were twie as li*ely as those with undetetable levels to reord symptoms o" ADHD.
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Diet
Main article: Diet and attention deficit hyperactivity disorder
A study
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published in %he Lanet in 2005 "ound a lin* between hildrenNs in!estion o" many ommonly used
arti"iial "ood olors, the preservative sodium ben2oate and hyperativity. $n response to these "indin!s, the ;ritish
!overnment too* prompt ation. Aordin! to theFood 0tandards A!eny, the "ood re!ulatory a!eny in the JC,
"ood manu"aturers are bein! enoura!ed to voluntarily phase out the use o" most arti"iial "ood olors by the end o"
2008.
Hcitation neededI
Followin! the F0ANs ations, the +uropean =ommission ruled that any "ood produts ontainin! the
O0outhampton 0i(P &%he ontentious olourin!s are: sunset yellow F=F &+110', 4uinoline yellow &+101',
armoisine &+122', allura red &+128', tartra2ine &+102' and poneau 19 &+121'' must display warnin! labels on
their pa*a!in! by 2010.
Hcitation neededI
$n the J0, little has been done
Hclarification neededI
to urb "ood manu"aturerNs use o"
spei"i "ood olors, despite the new evidene presented by the 0outhampton study. However, the e(istin! J0 Food
Dru! and =osmeti At
H38I
had already re4uired that arti"iial "ood olors be approved "or use, that they must be
!iven FDQ= numbers by the FDA, and the use o" these olors must be indiated on the pa*a!e.
H50I
%his is why "ood
pa*a!in! in the J0A may state somethin! li*e: :=ontains FDQ= 9ed R10.:
Social
%he )orld Health 6r!ani2ation states that the dia!nosis o" ADHD an represent "amily dys"untion or inade4uaies
in the eduational system rather than individual psyhopatholo!y.
H51I
6ther researhers believe that relationships with
are!ivers have a pro"ound e""et on attentional and sel"-re!ulatory abilities. A study o" "oster hildren "ound that a
hi!h number o" them had symptoms losely resemblin! ADHD.
H52I
9esearhers have "ound behavior typial o"
ADHD in hildren who have su""ered violene and emotional abuse.
H21IH5,I
Furthermore,=omple( <ost %raumati
0tress Disorder an result in attention problems that an loo* li*e ADHD.
H51I
ADHD is also onsidered to be related
to sensory inte!ration dys"untion.
H5-I
A 2010 artile by =?? su!!ests that there is an inreased ris* "or internationally adopted hildren to develop mental
health disorders, suh as ADHD and 6DD.
H53I
%he ris* may be related to the len!th o" time the hildren spent in an
orphana!e, espeially i" they were ne!leted or abused. /any o" these "amilies who adopted the a""eted hildren
"eel overwhelmed and "rustrated, sine mana!in! their hildren may entail more responsibilities than ori!inally
antiipated. %he adoption a!enies may be aware o" the hild#s behavioral history, but deide to withhold the
in"ormation prior to the adoption. %his in turn has resulted in some parents suin! adoption a!enies, the abuse o"
hildren, and even the relin4uishment o" the hild.
/eurodiversity
Main article: eurodiversity
<roponents o" the neurodiversity theory assert that atypial &neurodiver!ent' neurolo!ial development is a normal
human di""erene that is to be tolerated and respeted Dust li*e any other human di""erene. 0oial ritis ar!ue that
while biolo!ial "ators may play a lar!e role in di""iulties with sittin! still in lass and>or onentratin! on
shoolwor* in some hildren, these hildren ould have "ailed to inte!rate others# soial e(petations o" their
behavior "or a variety o" other reasons.
H55I
As !eneti researh into ADHD proeeds, it may beome possible to
inte!rate this in"ormation with the neurobiolo!y in order to distin!uish disability "rom varieties o" normal or even
e(eptional "untionin! in people alon! the same spetrum o" attention di""erenes.
H57I
Social construct theory of ADHD
Main article: Social construct theory of ADHD
0oial onstrution theory states that it is soieties that determine where the line between normal and abnormal
behavior is drawn. %hus soiety members inludin! physiians, parents, teahers, and others are the ones who
determine whih dia!nosti riteria are applied and thus determine the number o" people a""eted.
H58I
%his is
e(empli"ied in the "at that the D0/ $A arrives at levels o" ADHD three to "our times hi!her than those obtained
with use o" the $=D 10.
H1,I
%homas 02as2, an e(treme proponent o" this theory, has !one so "ar as to state that ADHD
was :invented and not disovered.:
H70IH71I
0o1 arousal theory
Main article: !o" arousal theory
Aordin! to the low arousal theory, people with ADHD need e(essive ativity as sel"-stimulation beause o" their
state o" abnormally lowarousal.
H72IH7,I
%he theory states that those with ADHD annot sel"-moderate, and their
attention an only be !ained by means o" environmental stimuli,
H72I
whih in turn results in disruption o" attentional
apaity and an inrease in hyperative behaviour.
H71I
)ithout enou!h stimulation omin! "rom the environment, an ADHD hild will reate it him or hersel" by wal*in!
around, "id!etin!, tal*in!, et. %his theory also e(plains why stimulant mediations have hi!h suess rates and an
indue a almin! e""et at therapeuti dosa!es amon! hildren with ADHD. $t establishes a stron! lin* with
sienti"i data that ADHD is onneted to abnormalities with the neurohemial dopamine and a power"ul lin* with
low-stimulation <+% san results in ADHD subDets.
H72I
"athophysiology
Dia!ram o" the human brain
%he pathophysiolo!y o" ADHD is unlear and there are a number o" ompetin! theories.
H7-I
9esearh on hildren
with ADHD has shown a !eneral redution o" brain volume, but with a proportionally !reater redution in the
volume o" the le"t-sided pre"rontal orte(. %hese "indin!s su!!est that the ore ADHD "eatures o" inattention,
hyperativity, and impulsivity may re"let"rontal lobe dys"untion, but other brain re!ions partiularly
the erebellum have also been impliated.
H73I
?euroima!in! studies in ADHD have not always !iven onsistent
results and as o" 2007 are only used "or researh not dia!nosti purposes.
H75I
A 200- review o" published studies
involvin! neuroima!in!, neuropsyholo!ial !enetis, and neurohemistry "ound onver!in! lines o" evidene to
su!!est that "our onneted "rontostriatal re!ions play a role in the pathophysiolo!y o" ADHD: %he lateral pre"rontal
orte(, dorsal anterior in!ulate orte(, audate, and putamen.
H77I
$n one study a delay in development o" ertain brain strutures by an avera!e o" three years ourred in ADHD
elementary shool a!ed patients. %he delay was most prominent in the"rontal orte( and temporal lobe, whih are
believed to be responsible "or the ability to ontrol and "ous thin*in!. $n ontrast, the motor orte(in the ADHD
patients was seen to mature "aster than normal, su!!estin! that both slower development o" behavioral ontrol and
advaned motor development mi!ht be re4uired "or the "id!etiness that harateri2es ADHD.
H78I
$t should be noted
that stimulant mediation itsel" may a""et !rowth "ators o" the entral nervous system.
H80I
%he same laboratory had previously "ound involvement o" the :5-repeat: variant o" the dopamine D1 reeptor !ene,
whih aounts "or about ,0 perent o" the !eneti ris* "or ADHD, in unusual thinness o" the orte( o" the ri!ht side
o" the brainE however, in ontrast to other variants o" the !ene "ound in ADHD patients, the re!ion normali2ed in
thi*ness durin! the teen years in these hildren, oinidin! with linial improvement.
H81I
Additionally, 0<+=% sans "ound people with ADHD to have redued blood irulation &indiatin! low neural
ativity',
H82I
and a si!ni"iantly hi!her onentration o" dopamine transporters in the striatum whih is in har!e o"
plannin! ahead.
H8,IH81I
A study by the J.0. Department o" +ner!yNs ;roo*haven ?ational Laboratory in ollaboration
with /ount 0inai 0hool o" /ediine in ?ew Bor* su!!est that it is not the dopamine transporter levels that indiate
ADHD, but the brain#s ability to produe neurotransmitters li*e dopamine itsel". %he study was done by inDetin! 20
ADHD subDets and 2- ontrol subDets with a radiotraer that attahes itsel" to dopamine transporters. %he study
"ound that it was not the transporter levels that indiated ADHD, but the dopamine itsel". ADHD subDets showed
lower levels o" dopamine &hypodopaminer!ia' aross the board. %hey speulated that sine ADHD subDets had
lower levels o" dopamine to be!in with, the number o" transporters in the brain was not the tellin! "ator. $n support
o" this notion, plasma homovanilli aid, an inde( o" dopamine levels, was "ound to be inversely related not only to
hildhood ADHD symptoms in adult psyhiatri patients, but to :hildhood learnin! problems: in healthy subDets
as well.
H8-I
6ne interpretation o" dopamine pathway traers is that the biohemial :reward: mehanism wor*s "or
those with ADHD only when the tas* per"ormed is inherently motivatin!E low levels o" dopamine raise the threshold
at whih someone an maintain "ous on a tas* whih is otherwise borin!.
H83I
?euroima!in! studies also "ound
that neurotransmitters level &e.!. dopamine and serotonin' in the synapti le"t !oes down durin! depression.
H85IH87I
A 1880 <+% san study by Alan G. Kamet*in et al. "ound that !lobal erebral !luose metabolism was 7 perent
lower in mediation-naive adults who had been hyperative sine hildhood.
H88I
Further studies "ound that hroni
stimulant treatment had little e""et on !lobal !luose metabolism,
H100I
a 188, study in !irls "ailed to "ind a dereased
!lobal !luose metabolism, but "ound si!ni"iant di""erenes in !luose metabolism in 3 spei"i re!ions o" the
brains o" ADHD !irls as ompared to ontrol subDets. %he study also "ound that di""erenes in one spei"i re!ion o"
the "rontal lobe were statistially orrelated with symptom severity.
H101I
A "urther study in 1885 also "ailed to "ind
!lobal di""erenes in !luose metabolism, but similarly "ound di""erenes in !luose normali2ation in spei"i
re!ions o" the brain. %he 1885 study also noted that their "indin!s were somewhat di""erent than those in the 188,
study, and onluded that se(ual maturation may have played a role in this disrepany.
H102I
%he si!ni"iane o" the
researh by Kamet*in has not been determined and neither his !roup nor any other has been able to repliate the
1880 results.
H10,IH101IH10-I
=ritis, suh as Gonathan Leo and David =ohen, who reDet the harateri2ation o" ADHD as a disorder, ontend that
the ontrols "or stimulant mediation usa!e were inade4uate in some lobar volumetri studies whih ma*es it
impossible to determine whether ADHD itsel" orpsyhotropi mediation used to treat ADHD is responsible "or the
dereased thi*ness observed
H103I
in ertain brain re!ions. )hile the main study in 4uestion used a!e-mathed
ontrols, it did not provide in"ormation on hei!ht and wei!ht o" the subDets. %hese variables it has been ar!ued
ould aount "or the re!ional brain si2e di""erenes rather than ADHD itsel".
H105IH107I
%hey believe many
neuroima!in! studies are oversimpli"ied in both popular and sienti"i disourse and !iven undue wei!ht despite
de"iienies in e(perimental methodolo!y.
H105I
Diagnosis
ADHD is dia!nosed via a psyhiatri assessmentE to rule out other potential auses or omorbidities, physial
e(amination, radiolo!ial ima!in!, and laboratory tests may be used.
H108I
$n ?orth Ameria, the D0/-$A riteria are o"ten the basis "or a dia!nosis, while +uropean ountries usually use
the $=D-10. $" the D0/-$A riteria are used, rather than the $=D-10, a dia!nosis o" ADHD is ,S1 times more li*ely.
H1,I
Fators other than those within the D0/ or $=D however have been "ound to a""et the dia!nosis in linial
pratie. A hild#s soial and shool environment as well as aademi pressures at shool are li*ely to be o"
in"luene.
H110I
/any o" the symptoms o" ADHD our "rom time to time in everyoneE in patients with ADHD, the "re4ueny o"
these symptoms is !reater and patients# lives are si!ni"iantly impaired. $mpairment must our in multiple settin!s
to be lassi"ied as ADHD.
H27I
As with many other psyhiatri and medial disorders, the "ormal dia!nosis is made by
a 4uali"ied pro"essional in the "ield based on a set number o" riteria. $n the J0A these riteria are laid down by the
Amerian <syhiatri Assoiation in their Dia!nosti and 0tatistial /anual o" /ental Disorders &D0/-$A', 1th
edition. ;ased on the D0/-$A riteria listed below, three types o" ADHD are lassi"ied:
1. ADHD, =ombined %ype: i" both riteria 1A and 1; are met "or the past 3 months
2. ADHD <redominantly $nattentive %ype: i" riterion 1A is met but riterion 1; is not met "or the past si(
months
,. ADHD, <redominantly Hyperative-$mpulsive %ype: i" riterion 1; is met but riterion 1A is not met "or
the past si( months.
H111I
%he previously used term ADD e(pired with the most reent revision o" the D0/. =onse4uently, ADHD is the
urrent nomenlature used to desribe the disorder as one distint disorder whih an mani"est itsel" as bein! a
primary de"iit resultin! in hyperativity>impulsivity &ADHD, predominately hyperative-impulsive type' or
inattention &ADHD predominately inattentive type' or both &ADHD ombined type'.
DS+$&2
$A. 0i( or more o" the "ollowin! si!ns o" inattention have been present "or at least 3 months to a point that is
disruptive and inappropriate "or developmental level:
#nattention:
1. 6"ten does not !ive lose attention to details or ma*es areless mista*es in shoolwor*, wor*, or
other ativities.
2. 6"ten has trouble *eepin! attention on tas*s or play ativities.
,. 6"ten does not seem to listen when spo*en to diretly.
1. 6"ten does not "ollow instrutions and "ails to "inish shoolwor*, hores, or duties in the
wor*plae &not due to oppositional behavior or "ailure to understand instrutions'.
-. 6"ten has trouble or!ani2in! ativities.
3. 6"ten avoids, disli*es, or doesn#t want to do thin!s that ta*e a lot o" mental e""ort "or a lon! period
o" time &suh as shoolwor* or homewor*'.
5. 6"ten loses thin!s needed "or tas*s and ativities &suh as toys, shool assi!nments, penils,
boo*s, or tools'.
7. $s o"ten easily distrated.
8. 6"ten "or!et"ul in daily ativities.
$;. 0i( or more o" the "ollowin! si!ns o" hyperativity-impulsivity have been present "or at least 3 months to
an e(tent that is disruptive and inappropriate "or developmental level:
Hyperactivity:
1. 6"ten "id!ets with hands or "eet or s4uirms in seat.
2. 6"ten !ets up "rom seat when remainin! in seat is e(peted.
,. 6"ten runs about or limbs when and where it is not appropriate &adolesents or adults may "eel
very restless'.
1. 6"ten has trouble playin! or enDoyin! leisure ativities 4uietly.
-. $s o"ten :on the !o: or o"ten ats as i" :driven by a motor:.
3. 6"ten tal*s e(essively.
#mpulsiveness:
1. 6"ten blurts out answers be"ore 4uestions have been "inished.
2. 6"ten has trouble waitin! one#s turn.
,. 6"ten interrupts or intrudes on others &e(ample: butts into onversations or !ames'.
$$. 0ome si!ns that ause impairment were present be"ore a!e 5 years.
$$$. 0ome impairment "rom the si!ns is present in two or more settin!s &suh as at shool>wor* and
at home'.
$A. %here must be lear evidene o" si!ni"iant impairment in soial, shool, or wor* "untionin!.
A. %he si!ns do not happen only durin! the ourse o" a <ervasive Developmental
Disorder, 0hi2ophrenia, or other <syhoti Disorder. %he si!ns are not better aounted "or by
another mental disorder &suh as /ood Disorder, An(iety Disorder, Dissoiative $dentity
Disorder, or a<ersonality Disorder'.
H112I
&CD$'(
$n the tenth edition o" the #nternational Statistical Classification of Diseases and $elated Health
Pro%lems &$=D-10' the si!ns o" ADHD are !iven the name :Hyper*ineti disorders:. )hen
a ondut disorder &as de"ined by $=D-10
H11,I
' is present, the ondition is re"erred to as
:Hyper*ineti ondut disorder:. 6therwise the disorder is lassi"ied as :Disturbane o" Ativity
and Attention:, :6ther Hyper*ineti Disorders: or :Hyper*ineti Disorders, Jnspei"ied:. %he
latter is sometimes re"erred to as, :Hyper*ineti 0yndrome:.
H11,I
*ther guidelines
%he Amerian Aademy o" <ediatris =linial <ratie Fuideline "or hildren with ADHD
emphasi2es that a reliable dia!nosis is dependent upon the "ul"illment o" three riteria:
H111I
%he use o" e(pliit riteria "or the dia!nosis usin! the D0/-$A-%9.
%he importane o" obtainin! in"ormation about the hildNs si!ns in more than one settin!.
%he searh "or oe(istin! onditions that may ma*e the dia!nosis more di""iult or ompliate
treatment plannin!.
All three riteria are determined usin! the patient#s history !iven by the parents, teahers and>or
the patient.
Adults o"ten ontinue to be impaired by ADHD. Adults with ADHD are dia!nosed under the same
riteria, inludin! the stipulation that their si!ns must have been present prior to the a!e o" seven.
H11-I
Adults "ae some o" their !reatest hallen!es in the areas o" sel"-ontrol and sel"-motivation, as
well as e(eutive "untionin!, usually havin! more si!ns o" inattention and "ewer o" hyperativity
or impulsiveness than hildren do.
H113I
%he Amerian Aademy o" =hild Adolesent <syhiatry &AA=A<' onsiders it neessary that the
"ollowin! be present be"ore attahin! the label o" ADHD to a hild:
%he behaviors must appear be"ore a!e 5.
%hey must ontinue "or at least si( months.
%he symptoms must also reate a real handiap in at least two o" the "ollowin! areas o" the
hildNs li"e:
in the lassroom,
on the play!round,
at home,
in the ommunity, or
in soial settin!s.
H115I
$" a hild seems too ative on the play!round but not elsewhere, the problem mi!ht not be ADHD.
$t mi!ht also not be ADHD i" the behaviors our in the lassroom but nowhere else. A hild who
shows some symptoms would not be dia!nosed with ADHD i" his or her shoolwor* or
"riendships are not impaired by the behaviors.
H115I
Differential
%o ma*e the dia!nosis o" ADHD, a number o" other possible medial and psyholo!ial
onditions must be e(luded.
+edical conditions
/edial onditions that must be e(luded inlude: hypothyroidism, anemia, lead
poisonin!, hroni illness, hearin! or vision impairment,substane abuse, mediation side e""ets,
sleep impairment and hild abuse,
H117I
and lutterin! &tahyphemia' amon! others.
Sleep conditions
As with other psyholo!ial and neurolo!ial issues, the relationship between ADHD and sleep is
omple(. $n addition to linial observations, there is substantial empirial evidene "rom a
neuroanatomi standpoint to su!!est that there is onsiderable overlap in the entral nervous
system enters that re!ulate sleep and those that re!ulate attention>arousal.
H118I
<rimary sleep
disorders play a role in the linial presentation o" symptoms o" inattention and behavioral
dysre!ulation. %here are multilevel and bidiretional relationships amon! sleep, neurobehavioral
"untionin! and the linial syndrome o" ADHD.
H120I
;ehavioral mani"estations o" sleepiness in hildren ran!e "rom the lassi ones &yawnin!, rubbin!
eyes', to e(ternali2in! behaviors &impulsivity, hyperativity, a!!ressiveness', to mood lability and
inattentiveness.
H118IH121IH122I
/any sleep disorders are important auses o" symptoms whih may
overlap with the ardinal symptoms o" ADHDE hildren with ADHD should be re!ularly and
systematially assessed "or sleep problems.
H118IH12,I
From a linial standpoint, mehanisms that aount "or the phenomenon o" e(essive daytime
sleepiness inlude:
=hroni sleep deprivation, that is insu""iient sleep "or physiolo!i sleep needs,
Fra!mented or disrupted sleep, aused by, "or e(ample, obstrutive sleep apnea &60A'
or periodi limb movement disorder &<L/D',
<rimary linial disorders o" e(essive daytime sleepiness, suh as narolepsy and
=iradian rhythm disorders, suh as delayed sleep phase syndrome &D0<0'. A study in the
?etherlands ompared two !roups o" unmediated 3-12-year-olds, all o" them with
:ri!orously dia!nosed ADHD:. 75 o" them had problems !ettin! to sleep, ,, had no sleep
problems. %he lar!er !roup had a si!ni"iantly later dim li!ht melatonin onset &DL/6' than
did the hildren with no sleep problems.
H121I
+anagement
Main article: Attention&deficit hyperactivity disorder mana'ement
/ethods o" treatment o"ten involve some ombination o" behavior modi"iation, li"e-style
han!es, ounselin!, and mediation. A 200- study "ound that medial mana!ement and
behavioral treatment is the most e""etive ADHD mana!ement strate!y, "ollowed by mediation
alone, and then behavioral treatment.
H12-I
)hile mediation has been shown to improve behavior
when ta*en over the short term, they have not been shown to alter lon! term outomes.
H123I
/ediations have at least some e""et in about 70. o" people.
H125I
"sychosocial
%he evidene is stron! "or the e""etiveness o" behavioral treatments in ADHD.
H127I
$t is
reommended "irst line in those who have mild symptoms and in preshool a!ed hildren.
H128I
<syholo!ial therapies used inlude psyhoeduational input, behavior therapy, o!nitive
behavioral therapy &=;%', interpersonal psyhotherapy &$<%', "amily therapy, shool-based
interventions, soial s*ills trainin! and parent mana!ement trainin!.
H21I
<arent trainin! and eduation have been "ound to have short term bene"its.
H1,0I
Family therapy has
shown to be o" little use in the treatment o" ADHD,
H1,1I
thou!h it may be worth notin! that parents
o" hildren with ADHD are more li*ely to divore than parents o" hildren without ADHD,
partiularly when their hildren are youn!er than ei!ht years old.
H1,2I
0everal ADHD spei"i
support !roups e(ist as in"ormational soures and to help "amilies ope with hallen!es assoiated
with dealin! with ADHD.
+edication
/ethylphenidate &9italin' 10 m! tablets
0timulant mediation are the medial treatment o" hoie.
H1,,I
%here are a number o" non-stimulant
mediations, suh as atomo(etine, that may be used as alternatives.
H1,,I
%here are no !ood studies
o" omparative e""etiveness between various mediations, and there is a la* o" evidene on their
e""ets on aademi per"ormane and soial behaviors.
H1,1I
)hile stimulants and atomo(etine are
!enerally sa"e, there are side e""ets and ontraindiations to their use.
H1,,I
/ediations are not
reommended "or preshool hildren, as their lon!-term e""ets in suh youn! people are
un*nown.
H21IH1,-I
%here is very little data on the lon!-term adverse e""ets or bene"its o" stimulants
"or ADHD.
H1,3I
Fuidelines on when to use mediations vary internationally, with the JC#s ?ational
$nstitute o" =linial +(ellene, "or e(ample, only reommendin! use in severe ases, while most
Jnited 0tates !uidelines reommend mediations in nearly all ases.
H1,5I
"rognosis
=hildren dia!nosed with ADHD have si!ni"iant di""iulties in adolesene, re!ardless o"
treatment.
H1,7I
$n the Jnited 0tates, ,5 perent o" those with ADHD do not !et a hi!h shool
diploma even thou!h many o" them will reeive speial eduation servies.
H1,8I
A 188- brie"in!
itin! a 1881 boo* review says the ombined outomes o" the e(pulsion and dropout rates indiate
that almost hal" o" all ADHD students never "inish hi!h shool.
H110I
Also in the J0, less than -
perent o" individuals with ADHD !et a olle!e de!ree
H111I
ompared to 27 perent o" the !eneral
population.
H112I
%hose with ADHD as hildren are at inreased ris* o" a number o" adverse li"e
outomes one they beome teena!ers. %hese inlude a !reater ris* o" auto rashes, inDury and
hi!her medial e(penses, earlier se(ual ativity, and teen pre!nany.
H11,I
9ussell ;ar*ley states that
adult ADHD impairments a""et :eduation, oupation, soial relationships, se(ual ativities,
datin! and marria!e, parentin! and o""sprin! psyholo!ial morbidity, rime and dru! abuse,
health and related li"estyles, "inanial mana!ement, or drivin!. ADHD an be "ound to produe
diverse and serious impairments:.
H111I
%he proportion o" hildren meetin! the dia!nosti riteria "or
ADHD drops by about -0 perent over three years a"ter the dia!nosis. %his ours re!ardless o"
the treatments used and also ours in untreated hildren with ADHD.
H117IH11-IH113I
ADHD persists
into adulthood in about ,0 to -0 perent o" ases.
H7I
%hose a""eted are li*ely to develop opin!
mehanisms as they mature, thus ompensatin! "or their previous ADHD.
H10I
pidemiology
<erent o" Jnited 0tates youth 1-15 ever dia!nosed with ADHD as o" 2005
<erent o" Jnited 0tates youth 1-15 ever dia!nosed with ADHD as o" 200,
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ADHD#s !lobal prevalene is estimated at , to - perent in people under the a!e o" 18. %here is,
however, both !eo!raphial and loal variability amon! studies. Feo!raphially, hildren in ?orth
Ameria appear to have a hi!her rate o" ADHD than hildren in A"ria and the /iddle +ast,
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well published studies have "ound rates o" ADHD as low as 2 perent and as hi!h as 11 perent
amon! shool a!ed hildren.
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%he rates o" dia!nosis and treatment o" ADHD are also muh
hi!her on the +ast =oast o" the J0A than on the )est =oast.
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%he "re4ueny o" the dia!nosis
di""ers between male hildren &10.' and "emale hildren &1.' in the Jnited 0tates.
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%his
di""erene between !enders may re"let either a di""erene in suseptibility or that "emales with
ADHD are less li*ely to be dia!nosed than males.
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9ates o" ADHD dia!nosis and treatment have inreased in both the JC and the J0A sine the
1850s. $n the JC an estimated 0.- per 1,000 hildren had ADHD in the 1850s, while , per 1,000
reeived ADHD mediations in the late 1880s. $n the J0A in the 1850s 12 per 1,000 hildren had
the dia!nosis, while in the late 1880s ,1 per 1,000 had the dia!nosis and the numbers ontinue to
inrease.
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$n the JC in 200, a prevalene o" ,.3 perent is reported in male hildren and less than 1 perent
is reported in "emale hildren.
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History
Main article: History of attention&deficit hyperactivity disorder
Hyperativity has lon! been part o" the human ondition. 0ir Ale(ander =rihton desribes
:mental restlessness: in his boo* An #n(uiry #nto the ature and )ri'in of Mental
Deran'ement written in 1587.
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%he terminolo!y used to desribe the symptoms o" ADHD
has !one throu!h many han!es over history inludin!: :minimal brain dama!e:, :minimal brain
dys"untion: &or disorder',
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:learnin!>behavioral disabilities: and :hyperativity:. $n the D0/-
$$ &1837' it was the :Hyper*ineti 9eation o" =hildhood:. $n the D0/-$$$ :ADD &Attention-
De"iit Disorder' with or without hyperativity: was introdued. $n 1875 this was han!ed to
ADHD in the D0/-$$$-9 and subse4uent editions.
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%he use o" stimulants to treat ADHD was
"irst desribed in 18,5.
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Society and culture
See also: !ist of people dia'nosed "ith attention&deficit hyperactivity disorder
%he media have reported on many issues related to ADHD. $n 2001 <;0#s Frontline aired a one-
hour pro!ram about the e""ets o" the dia!nosis and treatment o" ADHD in minors, entitled
:/ediatin! Cids.:
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%he pro!ram inluded a seletion o" interviews with representatives o"
various points o" view. $n one se!ment, entitled ;a*lash, retired neurolo!ist Fred
;au!hman and <eter ;re!!in whom <;0 desribed as :outspo*en ritis who insist HADHD isI a
"raud perpetrated by the psyhiatri and pharmaeutial industries on "amilies an(ious to
understand their hildren#s behavior:
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were interviewed on the le!itimay o" the
disorder. 9ussell ;ar*ley and Tavier =astellanos, then head o" ADHD researh at the ?ational
$nstitute o" /ental Health &?$/H', de"ended the viability o" the disorder. $n the interview with
=astellanos, he stated that little is sienti"ially understood.
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Lawrene Diller was interviewed
on the business o" ADHD alon! with a representative "rom 0hire <l.
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A number o" notable individuals have !iven ontroversial opinions on ADHD. 0ientolo!ist %om
=ruise#s interview with /att Lauer was widely wathed by the publi. $n this interview he spo*e
about postpartum depression and also re"erred to 9italin and Adderall as bein! :street dru!s:
rather than as ADHD mediation.
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$n +n!land ;aroness 0usan Freen"ield, a leadin!
neurosientist, spo*e out publily about the need "or a wide-ran!in! in4uiry in the House o" Lords
into the dramati inrease in the dia!nosis o" ADHD in the JC and possible auses
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"ollowin! a
2005 ;;= <anorama pro!ramme whih hi!hli!hted J0 researh &%he /ultimodal %reatment
0tudy o" =hildren with ADHD by the Jniversity o" ;u""alo showin! treatment results o" 300'
su!!estin! dru!s are no better than other "orms o" therapy "or ADHD in the lon! term.
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?eil ;ush &brother o" "ormer <resident Feor!e ). ;ush' is redited in the ast o" a 200- ADHD
doumentary alled *he Dru''in' of )ur Children
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direted by Fary ?ull. $n the "ilm#s
trailer
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;ush says: :Gust beause it is easy to dru! a *id and !et them to be ompliant doesn#t
ma*e it ri!ht to do it:.
As o" 2008, ei!ht perent o" all /aDor Lea!ue ;aseball players have been dia!nosed with ADHD,
ma*in! the disorder epidemi amon! this population. %he inrease oinided with the Lea!ue#s
2003 ban on stimulants &4.v. /aDor Lea!ue ;aseball dru! poliy'.
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0egal status of medications
0timulants le!al status was reently reviewed by several international or!ani2ations:
$nternationally, methylphenidate is a 0hedule $$ dru! under the =onvention on <syhotropi
0ubstanes.
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$n the Jnited 0tates, methylphenidate is lassi"ied as a 0hedule $$ ontrolled substane, the
desi!nation used "or substanes that have a reo!ni2ed medial value but present a hi!h
li*elihood "or abuse beause o" their additive potential.
$n the Jnited Cin!dom, methylphenidate is a ontrolled #=lass ;# substane, and possession
without presription is ille!al, with a sentene up to 11 years and>or an unlimited "ine.
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$n ?ew Kealand, it is a #lass ;2 ontrolled substane#. unlaw"ul possession is punishable by 3
month prison sentene and distribution o" it is punishable by a 11 year sentene.
Controversies
Main article: Attention&deficit hyperactivity disorder controversies
ADHD and its dia!nosis and treatment have been onsidered ontroversial sine the 1850s.
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%he ontroversies have involved liniians, teahers, poliyma*ers, parents and the media.
6pinions re!ardin! ADHD ran!e "rom not believin! it e(ists at all
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to believin! there are !eneti
and physiolo!ial bases "or the ondition as well as disa!reement about the use o" stimulant
mediations in treatment.
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0ome soiolo!ists onsider ADHD to be a :lassi e(ample o"
the mediali2ation o" deviant behavior, de"inin! a previously nonmedial problem as a medial
one:.
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/ost healthare providers in J.0. aept that ADHD is a !enuine disorder with debate in
enterin! mainly around how it is dia!nosed and treated.
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However,%he ;ritish
<syholo!ial 0oiety said in a 1885 report that physiians and psyhiatrists should not "ollow the
Amerian e(ample o" applyin! medial labels to suh a wide variety o" attention-related disorders:
:%he idea that hildren who donNt attend or who donNt sit still in shool have a mental disorder is
not entertained by most ;ritish liniians.:
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$n 2008, the ;ritish <syholo!ial 0oiety, in
ollaboration with the 9oyal =olle!e o" <syhiatrists, released a set o" !uidelines "or the dia!nosis
and treatment o" ADHD.
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$n its !uideline, it state that available evidene indiate that ADHD is
a valid dia!nosis. However, it states that the dia!nosis la* any biolo!ial basis and that
:HIontroversial issues surround han!in! thresholds applied to the de"inition o" illness as new
*nowled!e and treatments are developed and the e(tent to whih it is a*nowled!ed that linial
thresholds are soially and ulturally in"luened and determine how an individual#s level o"
"untionin! within the :normal ultural environment: is assessed. $t "urther states that :the
aeptable thresholds "or impairment are partly driven by the ontemporary soietal view o" what
is an aeptable level o" deviation "rom the norm.:
6thers have inluded that it may stem "rom a misunderstandin! o" the dia!nosti riteria and how
they are utili2ed by liniians,
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teahers, poliyma*ers, parents and the media.
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Debates
enter around *ey ontroversial issuesE whether ADHD is a disability or merely a neurolo!ial
desription, the ause o" the disorder, the han!in! o" the dia!nosti riteria, the rapid inrease in
dia!nosis o" ADHD, and the use o" stimulants to treat the disorder.
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Lon! term possible side
e""ets o" stimulants and their use"ulness are lar!ely un*nown beause o" a la* o" lon! term
studies.
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0ome researh raises 4uestions about the lon! term e""etiveness and side e""ets o"
mediations used to treat ADHD.
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$n 1887, the J0 ?ational $nstitutes o" Health &?$H' released a onsensus statement on the
dia!nosis and treatment o" ADHD. %he statement, while reo!ni2in! that stimulant treatment is
ontroversial, supports the validity o" the ADHD dia!nosis and the e""iay o" stimulant treatment.
$t "ound ontroversy only in the la* o" su""iient data on lon!-term use o" mediations, and in the
need "or more researh in many areas.
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)ith a :wide variation in dia!nosis aross states, raes, and ethniities:
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some investi!ators
suspet that "ators other than neurolo!ial onditions play a role when the dia!nosis o" ADHD is
made.
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%wo studies published in 2010 su!!est that the dia!nosis is more li*ely to be made in
the youn!er hildren within a !radeE the authors propose that suh a misdia!nosis o" ADHD within
a !rade may be due to di""erent states o" maturity and may lead to potentially inappropriate
treatment.
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&n adult
Main article: Adult attention&deficit disorder
9esearhers "ound that 30 perent o" the hildren dia!nosed with ADHD ontinue havin!
symptoms well into adulthood.
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/any adults, however, remain untreated.
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Jntreated
adults with ADHD o"ten have haoti li"estyles, may appear to be disor!ani2ed and may rely on
non-presribed dru!s and alohol to !et by.
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%hey o"ten have suh assoiated
psyhiatri omorbidities as depression, an(iety disorder,bipolar disorder, substane abuse, or
a learnin! disability.
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A dia!nosis o" ADHD may o""er adults insi!ht into their behaviors and
allow patients to beome more aware and see* help with opin! and treatment strate!ies.
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%here
is ontroversy amon!st some e(perts on whether ADHD persists into adulthood. 9eo!ni2ed as
ourrin! in adults in 1857, it is urrently not addressed separately "rom ADHD in hildhood.
6bstales that liniians "ae when assessin! adults who may have ADHD inlude
developmentally inappropriate dia!nosti riteria, a!e-related han!es, omorbidities and the
possibility that hi!h intelli!ene or situational "ators an mas* ADHD.