Overview: ADHD in Children

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Just because a child cannot sit still, it does not mean he or she suffers from ADHD. In fact, children are expected to have bundles of energy and perhaps a little rebellious. However, concern is raised when a child’s behavior disrupts his daily life. A typical scenario at home would be continuously bouncing around the house, crashing into things, and never completing his or her chores. Meanwhile at school, a child with ADHD would blurt out things in class and constantly fidgeting or out of his or her chair. It would also involve forgetting books at home and difficulty following rules. The symptoms are a mix of inattentive, such as acting carelessly, hyperactive, constantly in motion, and impulsive, acting without thinking.

ADHD can only be identified by characteristic behaviors, as there are no distinct physical symptoms that can be seen in a brain scan. Every child with ADHD may have different behaviors that characterizes him or her. Thus, ADHD is a term that describes several different patterns of behavior that likely have different causes.


Definition

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by an age-inappropriate levels of hyperactivity, impulsivity, and/or inattention.

ADHD is considered a neurodevelopmental disorder because

  • it has an early onset and persistent course
  • it is associated with lasting alterations in neural development
  • it is often accompanied by subtle delays and problems in language, motor, and social development that overlap with other neurodevelopmental disorders

More recently, in addition to inattention and hyperactivity–impulsivity, the problems of poor self-regulation, difficulty in inhibiting behavior, and reward and motivational deficits have been emphasized as central impairments of the disorder. Multi-pathway models propose different pathways to ADHD with different neural substrates, meaning that different children with ADHD may have different reasons for their behavior.

Although there is growing agreement about the nature of ADHD, views continue to evolve as a result of new findings and discoveries. Despite the label for this disorder, the main difficulties in ADHD are far more complex than simply a deficit in attention.

Diagnosis

As per the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), a child is diagnosed with ADHD if

  • he/she experiences a continuous pattern of impulsivity–hyperactivity and/or inattention which disrupts the child’s behavior or development
  • symptoms are displayed before the age of 12 in two or more settings
  • the diagnosis of other disorders is ruled out

A minimum of 6 out of 9 major signs of inattention and/or impulsivity–hyperactivity must also be displayed by the child for at least of 6 months, to an extent that is not appropriate for the child’s developmental stage.

Hyperactivity-impulsivity Symptoms

  • difficulty standing still
  • restiveness
  • difficulty waiting in a queue
  • fidgeting
  • impatience
  • acting before thinking
  • excessive talking
  • interrupting during discussions
  • interference with others

Inattention Symptoms

  • a short attention span
  • inability to complete work or follow through on instructions
  • lack of organization
  • low attention to details
  • evasion of duties that involve mental effort for a long duration
  • poor memory
  • distractibility

Causes

While numerous factors are associated with the manifestation of ADHD, current literature clearly suggests that neurobiological and genetic factors assume a significant role.

Familial Studies

Familial studies have consistently demonstrated that ADHD has a notable hereditary risk. A twin report in Sweden demonstrated that ADHD heritability is high throughout the lifecycle, with an approximation of 88% heritability (Larsson, Chang, Donofrio, and Lichtenstein, 2013).

Moreover, the biggest longitudinal examination to date on familial aggregation demonstrated that relatives of ADHD-affected individuals were at a greater risk of ADHD than those of unaffected individuals and the familial aggregation augmented with the increase in genetic relatedness (Chen et al., 2017).

Despite the fact that findings suggest that ADHD is acquired, the exact mechanisms are not yet known.

Specific-Gene Studies

As suggested by molecular genetic analysis, particular genes may add to the expression of ADHD. The exact gene responsible has not yet been detected. Nevertheless, there has been an increased interest in genes that play a role in dopamine regulation since brain structures involved in ADHD, which are abundant in dopamine innervation, have been linked with dopamine dysregulation.

Gray Matter Volume

There are notably lower gray matter volume in ADHD adolescent patients, compared with their corresponding controls, in many brain areas (Bonath, Tegelbeckers, Wilke, Flechtner, and Krauel, 2016). Evidently, the decrease in gray matter measures inside the ACC is associated with attention deficits in ADHD patients.

Also, a considerable reduction of the right horizontal prefrontal cortex was found in ADHD-affected adolescents and children (Fernández-Jaén et al., 2015). Subsequently, this indicates that a specific subgroup of adolescents and children with ADHD are more likely to have brain anatomy reductions related to dopaminergic function.

Environmental Factors

The strong evidence for genetics and their link to ADHD does not rule out the environmental factors, as both biological and environmental risk factors contribute to the expression of ADHD. Several variables that influence the development of the nervous system are associated with ADHD symptoms, such as:

  • malnutrition
  • low birth weight
  • maternal smoking or alcohol use during pregnancy
  • pregnancy and/or birth complications
  • early neurological insult or trauma

A case-control study showed a strong correlation between prenatal tobacco exposure and ADHD in children (Wang, Hu, Chen, Xue, and Du, 2019). Also, increased risk of ADHD was linked to antidepressants exposure during second and third trimester of pregnancy, despite considering maternal ADHD and other maternal mental disorders (Boukhris, Sheehy, and Bérard, 2017).

Treatment

In spite of the various treatment methods for ADHD in children, which range from neurofeedback and cognitive training to dietary treatment and physical activity, medication and behavioral therapy are most commonly used and have the strongest evidence.

Psychostimulants

Lisdexamfetamine (LDX), a prodrug of the psychostimulant d-amphetamine, was found to effectively improve emotional lability and executive function, as well as attenuate major ADHD symptoms in children of ages 6 to 12 (Childress et al., 2012). Also, LDX was identified as an efficacious treatment option by a study on relative tolerability and effectiveness of medications for ADHD in children (Roskell, Setyawan, Zimovetz, & Hodgkins, 2014).

However, although medications can be effective in reducing ADHD symptoms, as indicated by the study mentioned earlier, some children experienced adverse symptoms such as sleep problems, decreased weight, and loss of appetite (Coghill et al., 2017).

Cognitive-Behavioral Therapy

Findings suggest that cognitive behavioral therapy (CBT) combined with medication may enhance key functions for children with anxiety and ADHD, such as the severity of symptoms and improved parental mental health and parenting (Sciberras et al., 2015). Improvement of parental stress is crucial because it shows that the treatment was not limited in its focus on the child’s behavior, rather, it addressed an issue that may cause problems for child-parent relationship.

Also, combined treatment seems to be promising in reducing, externalizing and internalizing symptoms, improving parent-child relationships, and decreasing core ADHD symptoms in adolescents (Antshel et al., 2014). However, there are no clear studies on CBT on children with ADHD without medication.  

Combined Treatment

Simultaneous use of behavioral therapy and stimulants may potentially improve attention development and decrease impulsive responding. It could reduce the dose and period of pharmacological treatments, and therefore, address the downfalls of pharmacotherapy by improving the tolerability of medication treatments. Although combined treatments for children with ADHD is encouraged, more studies on the effects of CBT treatment on children are necessary.

It is recommended that the treatment starts with a low dosage of behavioral treatment and proceed by either developing the behavioral treatment further or combining medication if and when needed, as it has been proven to produce better results and serves as a far less costly treatment method for ADHD than starting treatment with medication (Pelham et al., 2016).

Combined treatment has been found to be the most effective in treating ADHD in children. However, the decision on whether to use a combination of treatments should be based on the symptoms displayed, the children and their family’s needs as well as the healthcare services availability.

11 Comments Add yours

  1. Great post, very informative. It’s a travesty that any happy, energetic young child can be slapped with a medical label and drugged into a daze.

    Like

    1. carlaakil says:

      Thank you! Unfortunately, that is very common. I think we need more awareness.

      Liked by 1 person

  2. Harryson says:

    A nice blog…quite informative…keep up

    Like

    1. carlaakil says:

      Thank you 🙂

      Liked by 1 person

      1. Harryson says:

        you welcome

        Like

  3. Ben Harley says:

    Impressive, informative post. Good job!

    Like

  4. robertcday says:

    That is such a comprehensive look at ADHD – well done. Strikes me, as you comment, that most kids (and a good number of adults) are like this at some time or another, I certainly was. I remember when they used to put it down to eating too many smarties (the e-numbers were to blame). I still think that a high-sugar diet has impacts on behaviour that haven’t been fully explored yet.
    Like I say – well done!
    Kindness – Robert.

    Liked by 1 person

  5. G-Bear says:

    Very good post. Informative and helpful for a lot of people especially parents xx

    Liked by 1 person

  6. This makes me think of a conversation I had with my wife about fixed minset and growth mindset, and how it got my mind spinning in directions as to how our responses to a childs behaviour will tell them the difference from what we wanted or didn’t want them to do:

    And all of this off course supported by simply spending time and be kind and loving to them to create a safe environment for them to be able to learn anything at all in the first place. Expanding this safety “zone” by gradually showing them how we do things, then showing appreciation for when they repeat what we do that is good for them selves and others. How we may need to correct unwanted behaviour by being firm or stern, which could be perceived as punishment from the childs point of view at first. Punishment because it creates uncertainty about their behaviour and weather it is right to do what they did, which is what we wanted in the first place, because the behaviour wasn’t good for them or others (if that is the case). And then as they feel uncertain and hurt inside, they might come to us for comfort and to feel safe. At least if they feel safe with us in the first place.

    How we respond to that which they do will then tell them weather or not what they did was good or ok, and weather it is a solution to ignore, appreciate or correct what they do next. as so, they will respond again, and eventually the way we behave shapes weather they feel safe or not in situations that occure, safe around us or other people and the rest of the world. Because what happens on the outside of the world slowly intergrates and inprints their mindset and who they become.

    For some reason it makes me think about fight or flight. How we run away when we feel uncertain and afraid and when we hurt. We run towars that which is safe, and for some people in some situations, safety is in their past, or in other people. Some feel safe when they are alone, doing their own thing, and some barely feel safe at all anywhere, and as nothing makes them feel secure, they keep running from oone thing to the other, not trusting them selves to be able to do anything right. Not finishing anything, just running in insecurity

    wow, i just made a post on your post xD
    Here is a song too:

    Like

  7. and repeating patterns, is a way of creating harmony and security withing our selves… so if it works, we keep at it. If we avoid feeling punished and hurt by running, we keep at it

    Like

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