Attention Deficit Hyperactivity Disorder (ADHD or AD/HD or ADD) is a

neurobehavioral developmental disorder. It is primarily characterized by "the co-existence of

attentional problems and hyperactivity, with each behavior occurring infrequently alone" and
symptoms starting before seven years of age.
ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting
about 3 to 5 percent of children globally and diagnosed in about 2 to 16 percent of school
aged children. It is a chronic disorder with 30 to 50 percent of those individuals diagnosed in
childhood continuing to have symptoms into adulthood. Adolescents and adults with ADHD
tend to develop, coping mechanisms to compensate for some or all of their impairments. It is
estimated that 4.7 percent of American adults are estimated to live with ADHD.
ADHD is diagnosed two to four times as frequently in boys as in girls, though studies suggest
this discrepancy may be partially due to subjective bias of referring teachers. ADHD
management usually involves some combination of medications, behavior modifications,
lifestyle changes, and counseling. Its symptoms can be difficult to differentiate from other
disorders, increasing the likelihood that the diagnosis of ADHD will be missed. Additionally,
most clinicians have not received formal training in the assessment and treatment of ADHD,
particularly in adult patients.

Classification
Predominantly hyperactive-impulsive
 Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
 Fewer than six symptoms of inattention are present, although inattention may still
be present to some degree.
Predominantly inattentive
 The majority of symptoms (six or more) are in the inattention category and fewer
than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-
impulsivity may still be present to some degree.
 Children with this subtype are less likely to act out or have difficulties getting
along with other children. They may sit quietly, but they are not paying attention to what
they are doing. Therefore, the child may be overlooked, and parents and teachers may not
notice symptoms of ADHD.
Combined hyperactive-impulsive and inattentive
 Six or more symptoms of inattention and six or more symptoms of hyperactivity-
impulsivity are present.
 Most children with ADHD have the combined type.

Signs and symptoms

Predominantly inattentive type symptoms may include:
 Be easily distracted, miss details, forget things, and frequently switch from one activity
to another
 Have difficulty maintaining focus on one task
 Become bored with a task after only a few minutes, unless doing something enjoyable
 Have difficulty focusing attention on organizing and completing a task or learning
something new or trouble completing or turning in homework assignments, often losing
things (e.g., pencils, toys, assignments) needed to complete tasks or activities
 Not seem to listen when spoken to
 Daydream, become easily confused, and move slowly
  Have difficulty processing information as quickly and accurately as others
 Struggle to follow instructions.
Predominantly hyperactive-impulsive type symptoms may include:
 Fidget and squirm in their seats
 Talk nonstop
 Dash around, touching or playing with anything and everything in sight
 Have trouble sitting still during dinner, school, and story time
 Be constantly in motion
 Have difficulty doing quiet tasks or activities.
and also these manifestations primarily of impulsivity:
 Be very impatient
 Blurt out inappropriate comments, show their emotions without restraint, and act without
regard for consequences
 Have difficulty waiting for things they want or waiting their turns in games

Comorbid Disorders
Many co-existing conditions require other courses of treatment and should be diagnosed
separately instead of being grouped in the ADHD diagnosis. Some of the associated
conditions are:
 Oppositional defiant disorder (35%) and conduct disorder (26%) which both are
characterized by antisocial behaviors such as stubbornness, aggression, frequent temper
tantrums, deceitfulness, lying, or stealing, inevitably linking these comorbid disorders
with antisocial personality disorder (ASPD); about half of those with hyperactivity and ODD
or CD develop ASPD in adulthood.
 Borderline personality disorder, which was according to a study on 120 female
psychiatric patients diagnosed and treated for BPD associated with ADHD in 70 percent of
those cases.
 Primary disorder of vigilance, which is characterized by poor attention and
concentration, as well as difficulties staying awake. These children tend to fidget, yawn and
stretch and appear to be hyperactive in order to remain alert and active.
 Mood disorders. Boys diagnosed with the combined subtype have been shown likely to
suffer from a mood disorder.
 Bipolar disorder. As many as 25 percent of children with ADHD have bipolar disorder.
Children with this combination may demonstrate more aggression and behavioral problems
than those with ADHD alone.
 Anxiety disorder, which has been found to be common in girls diagnosed with the
inattentive subtype of ADHD.
 Obsessive-compulsive disorder. OCD is believed to share a genetic component with
ADHD and shares many of its characteristics.

Cause
The specific causes of ADHD are not known. There are, however, a number of factors that
may contribute to, or exacerbate ADHD. They include genetics, diet and the social and
physical environments.
Genetics

PET scan: ADHD brains dopamine transporters

Twin studies indicate that the disorder is highly heritable and that genetics are a factor in
about 75 percent of all cases. Hyperactivity also seems to be primarily a genetic condition;
however, other causes do have an effect.
Researchers believe that a large majority of ADHD cases arise from a combination of various
genes, many of which affect dopamine transporters. The broad selection of targets indicates
that ADHD does not follow the traditional model of "a simple genetic disease" and should
therefore be viewed as a complex interaction among genetic and environmental factors. Even
though all these genes might play a role, to date no single gene has been shown to make a
major contribution to ADHD.

Evolutionary theories
The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the
origins of ADHD. The theory proposes that hyperactivity may be an adaptive behavior in pre-
modern humans and that those with ADHD retain some of the older "hunter" characteristics
associated with early pre-agricultural human society. According to this theory, individuals with
ADHD may be more adept at searching and seeking and less adept at staying put and
managing complex tasks over time. Further evidence showing hyperactivity may be
evolutionarily beneficial was put forth in 2006 in a study which found it may carry specific
benefits for certain forms of ancient society.

Environmental
Environmental factors implicated include alcohol and tobacco smoke exposure during
pregnancy and environmental exposure to lead in very early life. The relation of smoking to
ADHD could be due to nicotine causing hypoxia (lack of oxygen) to the fetus in utero. It could
also be that women with ADHD are more likely to smoke and therefore, due to the strong
genetic component of ADHD, are more likely to have children with ADHD. Complications
during pregnancy and birth—including premature birth—might also play a role. ADHD patients
have been observed to have higher than average rates of head injuries; however, current
evidence does not indicate that head injuries are the cause of ADHD in the patients observed.
Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of
developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71)
and streptococcal bacterial infection.
A 2007 study linked the organophosphate insecticide chlorpyrifos, which is used on some
fruits and vegetables, with delays in learning rates, reduced physical coordination, and
behavioral problems in children, especially ADHD.

Diet
A study published in The Lancet in 2007 found a link between children’s ingestion of many
commonly used artificial food colors, the preservative sodium benzoate and hyperactivity.

Social
The World Health Organization states that the diagnosis of ADHD can represent family
dysfunction or inadequacies in the educational system rather than individual
psychopathology. Other researchers believe that relationships with caregivers have a
profound effect on attentional and self-regulatory abilities. A study of foster children found that
a high number of them had symptoms closely resembling ADHD. Researchers have found
behavior typical of ADHD in children who have suffered violence and emotional abuse. A 2010
article by CNN suggests that there is an increased risk for internationally adopted children to
develop mental health disorders, such as ADHD and Oppositional defiant disorder (ODD).

Neurodiversity
Proponents of the neurodiversity theory assert that atypical (neurodivergent) neurological
development is a normal human difference that is to be tolerated and respected just like any
other human difference. Social critics argue that while biological factors may play a large role
in difficulties with sitting still in class and/or concentrating on schoolwork in some children,
these children could have failed to integrate others' social expectations of their behavior for a
variety of other reasons.

Social Construct Theory of ADHD

Social construction theory states that it is societies that determine where the line between
normal and abnormal behavior is drawn. Thus society members including physicians, parents,
teachers, and others are the ones who determine which diagnostic criteria are applied and
thus determine the number of people affected.

Low Arousal Theory

According to the low arousal theory, people with ADHD need excessive activity as self-
stimulation because of their state of abnormally low arousal. The theory states that those with
ADHD cannot self-moderate, and their attention can only be gained by means of
environmental stimuli, which in turn results in disruption of attentional capacity and an
increase in hyperactive behavior.
Without enough stimulation coming from the environment, an ADHD child will create it him or
herself by walking around, fidgeting, talking, etc.
Pathophysiology

Diagram of the human brain

Diagnosis
ADHD is diagnosed via a psychiatric assessment; to rule out other potential causes or
comorbidities, physical examination, radiological imaging, and laboratory tests may be used.
Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria listed
below, three types of ADHD are classified:
1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
2. ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not
met for the past six months
3. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but
criterion 1A is not met for the past six months.
DSM-IV
IA. Six or more of the following signs of inattention have been present for at least 6 months to
a point that is disruptive and inappropriate for developmental level:
 Inattention:
1. Often does not give close attention to details or makes careless mistakes in
schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties
in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often have trouble organizing activities.
6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort
for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (such as toys, school
assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Often forgetful in daily activities.
IB. Six or more of the following signs of hyperactivity-impulsivity have been present for at least
6 months to an extent that is disruptive and inappropriate for developmental level:
 Hyperactivity:
1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Often runs about or climbs when and where it is not appropriate (adolescents or
adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.
 Impulsiveness:
1. Often blurts out answers before questions have been finished.
2. Often has trouble waiting one's turn.
3. Often interrupts or intrudes on others (example: butts into conversations or
games).
IIB. Some signs that cause impairment were present before age 7 years.
IIIB. Some impairment from the signs is present in two or more settings (such as at
school/work and at home).
IVB. There must be clear evidence of significant impairment in social, school, or work
functioning.
VB. The signs do not happen only during the course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another
mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or
a Personality Disorder).

ICD-10 (International Statistical Classification of Diseases and Related Health Problems

10th Revision)
Other Guidelines
The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD
emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria:
 The use of explicit criteria for the diagnosis using the DSM-IV-TR.
 The importance of obtaining information about the child’s signs in more than one
setting.
 The search for coexisting conditions that may make the diagnosis more difficult or
complicate treatment planning.
All three criteria are determined using the patient's history given by the parents, teachers
and/or the patient.
The American Academy of Child Adolescent Psychiatry (AACAP) considers it necessary that
the following be present before attaching the label of ADHD to a child:
 The behaviors must appear before age 7.
 They must continue for at least six months.
 The symptoms must also create a real handicap in at least two of the following areas of
the child’s life:
 in the classroom,
 on the playground,
 at home,
 in the community, or
 in social settings.
If a child seems too active on the playground but not elsewhere, the problem might not be
ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A
child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork
or friendships are not impaired by the behaviors.

Differential
To make the diagnosis of ADHD, a number of other possible medical and psychological
conditions must be excluded.

Medical conditions
Medical conditions that must be excluded include: hypothyroidism, anemia, lead poisoning,
chronic illness, hearing or vision impairment, substance abuse, medication side effects,
sleep impairment and child abuse, and cluttering (tachyphemia) among others.

Sleep conditions
As with other psychological and neurological issues, the relationship between ADHD and
sleep is complex. In addition to clinical observations, there is substantial empirical
evidence from a neuroanatomic standpoint to suggest that there is considerable overlap in
the central nervous system centers that regulate sleep and those that regulate
attention/arousal. Primary sleep disorders play a role in the clinical presentation of
 symptoms of inattention and behavioral deregulation. There are multilevel and bidirectional
relationships among sleep, neurobehavioral functioning and the clinical syndrome of
ADHD.
Behavioral manifestations of sleepiness in children range from the classic ones (yawning,
rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to
mood lability and inattentiveness. Many sleep disorders are important causes of symptoms
which may overlap with the cardinal symptoms of ADHD; children with ADHD should be
regularly and systematically assessed for sleep problems.
From a clinical standpoint, mechanisms that account for the phenomenon of excessive
daytime sleepiness include:
 Chronic sleep deprivation, that is insufficient sleep for physiologic sleep needs,
 Fragmented or disrupted sleep, caused by, for example, obstructive sleep apnea (OSA)
or periodic limb movement disorder (PLMD),
 Primary clinical disorders of excessive daytime sleepiness, such as narcolepsy and
 Circadian rhythm disorders, such as delayed sleep phase syndrome (DSPS).

Management
Methods of treatment often involve some combination of behavior modification, life-style
changes, counseling, and medication.

Psychosocial
The evidence is strong for the effectiveness of behavioral treatments in ADHD. Psychological
therapies used to treat ADHD include psychoeducational input, behavior therapy, cognitive
behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based
interventions, social skills training and parent management training.
Parent training and education have been found to have short term benefits. Family therapy
has shown to be of little use in the treatment of ADHD, though it may be worth noting that
parents of children with ADHD are more likely to divorce than parents of children without
ADHD, particularly when their children are younger than eight years old. Several ADHD
specific support groups exist as informational sources and to help families cope with
challenges associated with dealing with ADHD.
Medication

Methylphenidate (Ritalin 10 mg tablets) (AU)

Stimulant medications are the medical treatment of choice. There are a number of non-
stimulant medications (such as atomoxetine) which may be used as alternatives. There are no
good studies of comparative effectiveness between various medications and there is a lack of
evidence on their effects on academic performance and social behaviors. While stimulants
and atomoxetine are generally safe there are side effects and contraindications to there use.
Medications are not recommended for preschool children as their long term effects in such
young people are unknown. There is very little data on the long-term adverse effects or
benefits of stimulants for ADHD.
Prognosis
Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment. Those
with ADHD as children are at increased risk of a number of adverse life outcomes once they become
teenagers. These include a greater risk of auto crashes, injury and higher medical expenses, earlier sexual
activity, and teen pregnancy. Russell Barkley states that adult ADHD impairments affect "education,
occupation, social relationships, sexual activities, dating and marriage, parenting and offspring
psychological morbidity, crime and drug abuse, health and related lifestyles, financial management, or
driving. ADHD can be found to produce diverse and serious impairments".

Epidemiology

Percent of United States youth 4-17 ever diagnosed with ADHD as of 2007

Percent of United States youth 4-17 years of age ever diagnosed with ADHD as of 2003.
ADHD's global prevalence is estimated at 3 to 5 percent in people under the age of 19. There is, however,
both geographical and local variability among studies.

History
Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental
restlessness" in his book An Inquiry into the Nature and Origin of Mental Derangement written in 1798. The
terminology used to describe the symptoms of ADHD has gone through many changes over history
including: "minimal brain damage", "minimal brain dysfunction" (or disorder), "learning/behavioral
disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood". In the
DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced. In 1987 this was
changed to ADHD in the DSM-III-R and subsequent editions. The use of stimulants to treat ADHD was first
described in 1937.

Legal status of medications

Stimulants legal status was recently reviewed by several international organizations:
 Internationally, methylphenidate is a Schedule II drug under the Convention on Psychotropic
Substances.
 In the United States, methylphenidate is classified as a Schedule II controlled substance, the
designation used for substances that have a recognized medical value but present a high likelihood for
abuse because of their addictive potential.
 In the United Kingdom, methylphenidate is a controlled 'Class B' substance, and possession without
prescription is illegal, with a sentence up to 14 years and/or an unlimited fine.
 In New Zealand, it is a 'class B2 controlled substance'. Unlawful possession is punishable by 6
month prison sentence and distribution of it is punishable by a 14 year sentence.