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.
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.
- 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.
- difficulty standing still
- difficulty waiting in a queue
- acting before thinking
- excessive talking
- interrupting during discussions
- interference with others
- 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
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 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.
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.
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:
- 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).
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.
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).
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.
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.