Why And When Do We Need To Treat ADHD
Start With Your Primary Care Doctor
If you are concerned that you have ADHD or that your child has it, the first step is to talk to a professional. We recommend that you speak with someone who has experience assessing and treating ADHD and who can do a thorough assessment. These professionals include psychiatrists, psychologists, psychiatric nurses, and social workers.
The process of diagnosis is one of exclusion, because many other disorders such as anxiety, depression, or sleep disorder can have similar symptoms.
Psychological testing is not required to make the diagnosis. The AAP (American Academy of Pediatrics), APA (American Psychiatric Association) and AACAP (American Association of Child and Adolescent Psychiatry) guidelines recommend that the healthcare professionals ask the patient, the parents, the teachers or other adults involved in the interactions with the patient about changes in the behavior in at least two areas (for school age children it is at home and at school).
ADHD and Executive Function
By and large ADHD can be conceptualized as a disorder of “executive function.” Individuals with ADHD show a reduced ability to exert and maintain cognitive control of their behavior. Compared to their peers, individuals with ADHD have a lower ability to react to insignificant external or internal stimuli. The MRI studies of individuals with ADHD show thinning of the cortex in the areas associated with working memory and attention. (Molecular Neuropharmacology; Nestle, Hyman 321-323).
ADHD is diagnosed based on the DSM 5(Diagnostic and Statistical Manual of Mental Disorders, 5th edition) diagnosis criteria. Here are the criteria below in shortened form. Please note that they are presented just for your information and not to be used for self-diagnosis. Only trained health care providers can properly diagnose or treat ADHD.
DSM-5 Criteria for ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development in these areas:
1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months and they are inappropriate for developmental level:
o Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
o Often has trouble holding attention on tasks or play activities.
o Often does not seem to listen when spoken to directly.
o Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
o Often has trouble organizing tasks and activities.
o Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
o Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
o Is often easily distracted
o Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go” acting as if “driven by a motor”.
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more setting, (such as at home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
Types Of ADHD
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.
ADHD in Adults
ADHD often lasts into adulthood. About 65% of individuals diagnosed as children with ADHD will have persistent impairing symptoms by age 25. (Parikh MD, Baker, MD Adult ADHD: Pharmacology in the DSM -5 era, Current psychiatry, Oct 2016)
Changes In The DSM-5
The fifth edition of the DSM was released in May 2013 and replaces the previous version, the text revision of the fourth edition (DSM-IV-TR). There were some changes in the DSM-5 for the diagnosis of ADHD:
• Symptoms can now occur by age 12 rather than by age 6;
• Several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting;
• New descriptions were added to show what symptoms might look like at older ages; and
• For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children.
Obstacles In The Treatment OF ADHD
One of the obstacles I see in my practice to effectively treat ADHD is the fear of addiction to the medication. This is a myth. In fact, a multi-cohort national study sampling of about 40 000 individuals, recently published in the journal of the AACAP in June 2016 showed that starting the treatment for ADHD early and continuing it for more than 6 years was associated with a rate of substance use which was lower than in the general population. Also, individuals who started the treatment later, and taking the medication for less than 2 years had similar rates of substance use with the general population.
Relative immaturity is one of the challenges that ADHD brings with it. It has been shown that children and adolescents with ADHD tend to be less mature than their peers. (JACCAP 2016;55(10):886-895). The female gender is more protected against developing ADHD than the male gender (JAACAP 2016;55(6):504-512), and that also explains the higher prevalence in males than in females.
a. amphetamine preparations come in short acting and long acting formulations that can be combined according to the individual response. They act through increasing the release of norepinephrine and dopamine that are essential for the frontal brain circuits.
b. methyphenidate preparations also come in short and long acting formulations. Together with the amphetamines they are by far the most effective medications for ADHD. They have common side effects such as insomnia, decreased appetite, growth delay. Combining them would increase the likelihood of the side effects.
c. atomoxetine increases the availability of norepinephrine, is not as effective as a stimulant and can be used as an alternative for people who do not tolerate the amphetamines or methylphenidine.
d. alpha-adrenergic agonist, clonidine and guanfacine also have short and long acting formulations, and can be used by themselves or in combination with the stimulants;
e. bupropion, considered a third line of treatment for individuals who do not tolerate the amphetamines or methylphenidate or can be added to them to enhance the response.
Evidence from well-controlled studies failed to support neurofeedback as an effective treatment for ADHD (Cortese and collab JAACAP 2016;55(6):444-455).
3. Brain Training Games
Brain training games did not gather solid scientific evidence that it works for ADHD, however these programs are early in their development and it is believed that the future will bring new possibilities. At the present time they are being used for cognitive rehabilitation. (Psychiatric Times, June 2014: The Evidence and Application of Brain Training Games: Science or Sales, Larry Brooks).
Myths About The Treatment Of ADHD
(Strawn, MD/Current Psychiatry October 2016)
1. Contrary to the popular belief that treatment with stimulants would worsen anxiety, a meta-analysis of about 3000 patients showed that a stimulant treatment has a low relative risk for anxiety and many patients experience improvement in their anxiety while some of them could experience an increase in anxiety level.
2. A meta-analysis of 22 studies including 2400 patients showed a lack of association between stimulant treatment and a new onset or worsening of tics despite the ‘contraindication’ included in the package insert.
3. Polypharmacy(the simultaneous use of multiple drugs to treat a single ailment or condition) in ADHD is beneficial because it allows synergistic effects of different medications and does not represent a treatment ‘failure’.
Consequences Of Not Treating ADHD
Here is what the research says about the consequence of not treating ADHD.
1. School failure, peer rejection, and subsequent association with a delinquent peer group can increase the likelihood of substance use, especially in the presence of comorbid conduct disorder (Molecular Neuropharmacology, Nestle, Heyman pg 321-323)
2. ADHD in childhood and adolescence predicted homelessness in adulthood, maybe partly for the high degree of comorbidities with conduct, SUD, arrest, and school dropouts. (Garcia Murillo and colab/JAACAP 2016;55(11):931-936
3. The degree of severity of ADHD symptoms in adults is related to not addressing the symptoms during childhood. In other words, treating ADHD during childhood and adolescence minimizes the symptoms persistent into adulthood. (Roy and colab JCAAP 2016;55(11):937-944
4. Adult functioning is worse, when less ADHD symptoms persist from the adolescence period. (Hechtman, MD and collab/JAACAP 2016;55(11):945-952). It is important to identify ADHD symptoms early and intervene in a timely manner to promote better functional outcomes
5. Adults with ADHD have more traffic violations and accidents and a higher rate of incarcerations and convictions
6. A mortality rate almost 2 times higher with great differences in suicide and accidents (Parikh, Baker Current Psychiatry 2016, October)
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.
CDC website: https://www.cdc.gov/ncbddd/adhd/diagnosis.html