Attention Deficit Hyperactivity Disorder (ADHD)

Definition and common characteristics of attention deficit hyperactivity disorder

The defining characteristics of attention deficit hyperactivity disorder (ADHD) are persistent problems with attention and, or, problems with hyperactivity which is usually combined with impulsivity.

ADHD is a neurodevelopmental disorder beginning in childhood and generally persisting throughout the lifespan although, over the years, it may vary in severity and in which symptoms are most prominent.

The inattention can be seen in poor attention to detail, making careless mistakes, or increased forgetfulness as manifested in constantly losing things. These problems are particularly prevalent when the person with ADHD must carry out a boring routine task; it is then that he or she finds it exceedingly difficult to remain focussed.

Common examples are reading instructions, doing income tax. In contrast, they may get over involved in exciting activities such as playing computer games and spend too much time doing them and hence neglect more productive and necessary tasks.

The hyperactivity can be expressed in children by intense running around or climbing, sometimes into dangerous situations e.g. busy streets. In both children and adults, the hyperactivity can be expressed by fidgeting, drumming of fingers, or repetitive tapping of feet.

Impulsivity can manifest itself by lacking patience to wait for crossing lights to change or interrupting others by finishing their statements before they have a chance to.

For the diagnosis of ADHD to apply, these attentional and, or, hyperactivity-impulsivity problems must have existed in early childhood e.g. before the age of seven.

Although initially regarded as a childhood condition, much evidence points to ADHD as being a neurodevelopmental disorder that persists into adulthood although the symptoms may be somewhat modified with age.

Another diagnostic criteria is that these characteristic symptoms must manifest themselves in at least two settings e.g. home and school or work, and must impact negatively on functioning in social, academic or occupational areas.

Persons with ADHD may find it difficult to keep up their grades at school and academic problems are common. However, it is to be noted that some children with ADHD still manage to do very well at school perhaps compensating by using their high intelligence or by spending more time studying.

Specific diagnostic criteria for ADHD are provided in the Diagnostic and Statistical Manual , 4th Edition (1994, DSM-IV) of the American Psychiatric Society.

Associated features

Associated features are characteristics which although not necessarily present in ADHD are, to varying extents, co-existent with it. Research has determined the four most common associated features (Kessler et al, 2006) and these are listed below, ranked according to their frequency:

  • An anxiety disorder of some kind with a prevalence of 47.1%. Social phobia and specific phobia were particularly high.
  • A mood disorder of some kind. Prevalence 38.3%. Bipolar disorder was most prevalent here.
  • Intermittent explosive disorder. Prevalence 19.6%
  • A substance use disorder of some kind. Increased risk of developing an addiction e.g. either substance abuse e.g. alcohol dependence or abuse or a behavioural addiction e.g. cyber addiction including online pornography. Prevalence 15.2%

Other associated features, based on clinical experience and abundant research (Anthshel, Faraone & Kunwar, 2008; Friedrichs, Igl, Larsson, & Larsson, 2012; Kessler et al, 2006; Murphy, Barley & Bush 2002) are listed below:

  • Obsessive-compulsive disorder
  • Learning disability (dyslexia)
  • Oppositional defiant disorder
  • Borderline personality disorder (BPD). This is an extreme form of codependency (complex PTDS). Evidence for the association of BPD with ADHD comes from recent research by Dijk et al (2012, 2011). Using a relatively small sample size, Dijk et al in 2012 p. 41) found that about one third of cases of BPD also have coexisting ADHD while about 15% of cases of ADHD have BPD. This suggests that clients with BPD should be routinely assessed for ADHD and if found, this ADHD component should also be treated perhaps with the appropriate medication for ADHD.

Difficulties in everyday functioning

There often are difficulties in close interpersonal, including intimate, relationships perhaps because persons with ADHD may not pay attention to the usual things their intimate others expect them to remember e.g. to take out the garbage or birthdays.

Also they may be impulsive and lack the patience and tolerance that such relationships demand. For these reasons, affectional sexual relations may be problematical. This may be why a significant number of persons with ADHD turn to cybersex where the action is fast-paced and exciting.

There can be career difficulties due to ADHD symptoms such as restlessness, forgetfulness, impulsivity etc interfering with their work performance. For example, some people may find desk bound jobs insufferable.

However the solution may be find particular positions where there is more freedom of movement e.g. sales. Some with ADHD who need a lot of stimulation seek out exciting employment e.g. becoming a trader in the financial markets where the action is fast-paced and stimulating.

Lifetime prevalence

A recent large epidemiological survey conducted in the United States, found a lifetime prevalence for ADHD of 8.1% making it the third most common impulse control disorder outranked by conduct disorder at 9.5% and oppositional-defiant disorder at 8.5% (Kessler et a, 2005).

It also ranks as the seventh most prevalent disorder in the ten most prevalent psychiatric disorders (Kessler et al, 2005). A study using the same sample but using somewhat different criteria for ADHD and different method of analysis, found a current (not lifetime) prevalence of 4.4% (Kessler et al, 2006).

Aetiology

There is evidence that genetics plays an important role in the causation of ADHD (Faraone et al, 2005). Hence many children of adults with ADHD also have the condition. For this reason, it is only after their child has been newly diagnosed for ADHD that many adults for the first time learn of the existence of this condition, identify with its symptoms, and come for ADHD assessment themselves.

Treatment

A number of very useful treatment approaches exist for both childhood and adult ADHD:

  • Pharmacotherapy. Stimulant medications have long been used in the treatment of children with ADHD. In recent years, with the recognition that this condition persists into adult the same types of medication have been applied usefully to adults. Newer medications with different properties have also assisted the psychiatrist in adjusting the medication to suit individual variations in drug sensitivity.
  • Individual psychotherapy. Cognitive behavioral therapy, although more difficult for children, has been used effectively.
  • Support Groups. Both professionally led support groups and groups led by interested persons, usually the parents of a child with ADHD, are probably the chief source of assistance either directly or indirectly for people with ADHD.
  • Psychoeducation. Psychoeducation can take place either through large national organizations for ADHD, either child or adult, or through smaller community support groups including online groups. There are also of course face to face support groups for ADHD. There are also many extremely helpful books on ADHD including “Driven to Distraction” by Ned Hallowell.. Such increased understanding can greatly help individuals with ADHD manage their lives better.

References

Anthshel, K., Faraone, S. V., & Kunwar A. (2008). ADHD in Adults: How to Recognize—and Treat. Article available from Psychiatric Times at http://www.psychiatrictimes.com/print/article/10162/1349954

Faraone SV, Perlis RH, Doyle AE, et al. (2005). Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry. 57:1313-1323.

Fossati , A. Novella , L. Donati , D. Donini , M. Maffei , C. (2002). History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study. Compr Psychiatry 2002, 43(5):369-377.

Kessler , R. C. Adler , L. Barkley , R. Biederman , J. Conners , C. K. Demler , O. Faraone , S. V. Greenhill , L. L. Howes , M. J. Secnik , K. Spencer , T. Üstün , T. B. Walters , E. E. Zaslavsky , A. M. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006; 163: 716-23.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., Walters, E. E., (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol. 62(6), 593-602.

van Dijk, F. E., Lappenschaar, M., Kan, C. C., Verkesc, R. J., & Buitelaar J.J. (2012). Symptomatic overlap between attention-deficit/hyperactivity disorder and borderline personality disorder in women: the role of temperament and character traits. Comprehensive Psychiatry 53, 39–47.


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