• Sharen Lui

Attention Deficit Hyperactivity Disorder

Updated: Oct 17, 2021



Definition & Diagnosis

Attention-Deficit/Hyperactivity Disorder (ADHD) 314.0X (F90.X)

A persistent pattern of:

  • Inattention; and/or

  • hyperactive and impulsive behaviour

  • Lifelong condition

  • Symptoms usually present from early childhood

  • Significant impairment in educational, social and emotional function

There are three types of ADHD:

  1. ADHD-combined subtype, which includes both inattention symptoms and impulsive/hyperactive symptoms

  2. ADHD-predominantly inattentive subtype

  3. ADHD-predominantly hyperactive/impulsive subtype

There is no simple test to diagnose ADHD. Although there are diagnostic guidelines from the DSM-5 and ICD-10, it generally requires a significant knowledge of the condition, clinical experience, a review of the clients' current symptoms, and a careful consolidation of their developmental and educational history for professionals to confirm the diagnosis.


Neurobiology & Aetiology

Epigenetic theory

Human development is defined by the interplay of genetics (nature) and the environment (nurture). ADHD is a neurobiological difference with genetic and environmental contributions.

Neurobiology

Neuroimaging studies suggest ADHD symptoms relate to the structure and function of the prefrontal cortex, the basal ganglia and the cerebellum. Research has found that the fronto-striato-cerebellar brain circuitry underpins Executive Functioning (EF) deficits.

Genes

Like many other neurodevelopmental differences, twin studies showed a strong genetic component in ADHD.

Possible Environmental Risk Factors

Antenatal exposures to tobacco, alcohol and other substances, children born with birth complications and prematurity, maternal and prenatal stress, Acquired Brain Injury (ABI), and head trauma are all possible environmental risk factors of developing ADHD symptoms.

Psychosocial Factors

Increased risk of ADHD was found to be linked to psychosocial factors like adverse early childhood experiences, social, familial and cultural factors, family dysfunctioning and maternal influences .


Prevalence

ADHD is present amongst individuals (ADHDers) across all cultural and ethnic groups, social classes and educational levels. It is more common amongst males than females as research has found. It is the most common (and diagnosed) neurodevelopmental difference in childhood.

Prevelance of ADHD in children is around 6.8% in Australia.

Similarly, in the United States and Asian countries, the prevalence is around 5-12%.

  • ~6.8% of children in Australia (NHMRC)

  • ~9.4% of children in US (CDC, 2016)

  • ~5-12% of children in Asian countries (e.g., Taiwan, Hong Kong)


Comorbiditis & Challanges

Comorbidities with other problems are common in ADHD:

  • Oppositional Defiant Disorder/Conduct Disorder

  • Anxiety

  • Depression

  • Autism

  • Tics Disorder

  • Intellectual Disability

  • Learning Disorders

It poses challenges for individual's social, emotional, familial functioning and their long-term health, social and emotional outcomes. It often impacts on the quality of life for the ADHDer and their family. Anxiety and depression can arise from under-managed symptoms and negative thoughts about the self. Rejection Sensitive Dysphoria (RSD) has been recognized amongst some ADHDers, stemming from their consistent difficulties to meet their own or other's expectations.


Some symptoms of ADHD are not just specific to ADHD, but are common features of autism. Early diagnosis of ADHD, at times, leads to a late-identification of undiagnosed autism.


The social impact of an ADHD diagnosis is not limited to the individuals themselves, but can also lead to issues in families. Without the knowledge and understanding of ADHD, carers and educators are often challenged by its daily impact and consequences.


ADHD may exacerbate underlying familial issues and serve as a significant stress factor for families. More so, treatment planning for children with ADHD needs to take into account whether the parent or caregiver has symptoms of ADHD themselves, and whether they can provide support to their child and implement intervention successfully.


Pathological Demand Avoidance (PDA) is a profile identified in many autistic individuals and ADHDers. PDA was defined by British psychologist Elizabeth Newson as an anxiety-driven avoidance of the ordinary demands of life. This presentation can be seen in childhood, adolescence, and adulthood. It is often described by PDAers themselves as "a neurological tug of war between the brain, heart and body". With PDA, demands come in all types, including forms that are not thought as a demand (e.g., reward charts, expectations, timetables, choices). They trigger an automatic response of threat or anxiety, which leads PDAers to avoid and escape. Understanding and additional support are often needed.


Management & Strategies

ADHD is a condition that affects people across the lifespan.

Each individual with the condition experience it differently. It depends on their available resources, personal circumstances, family history, personality, individual strengths and weaknesses. Below is a summary of possible interventions:

  • Psychosocial interventions

  • Pharmacological management. Stimulants are mainly used to help to control impulses, behaviour and concentration

  • Positive Behavioural intervention. Minimizing stigma and providing positive outcome

  • Combined Intervention is preferred (Psychosocial & pharmacological) It is most beneficial when professionals work collaboratively to implement intervention and support

  • Psychoeducation to parents, caregivers, teachers, schools

  • School-based intervention. Peer support (e.g. buddy systems) can be helpful for children and adolescents experiencing learning, behaviour, organisation and concentration difficulties by enhancing their learning, social and behavioural outcomes.






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