ADHD/ADD: Symptoms, Aetiology and Treatment Options

Symptoms

In 2012, CDC data showed that 11% of school children in the US had been diagnosed with ADD/ADHD. It remains unclear why these figures are rising. Perhaps any or all of theses things are contributing: constant changes in diagnostic criteria that are expanding the symptomology, a greater acceptance of neurological disorders has prompted more people to step forward and accept a diagnosis, a shift in society that is actually increasing the rate of ADD/ADHD or even just misdiagnosis. One of the major changes in the DSM-V diagnosis is the recognition of adults with ADD/ADHD. Previously, ADD/ADHD has merely focused on the symptoms observed in childhood onset. In fact, the majority of children that develop the disorder go on to experience a variety of difficulties into adulthood. Being able to recognise ADHD as a long-term condition will hopefully improve the level of care for adults with a childhood diagnosis.

ADD

The symptoms of diagnosis can be broken down into two major categories: inattention and hyperactivity with impulsivity. Classic examples of these behaviours include: difficulty to failure to pay attention to details, difficulty organising tasks, fidgeting, excessive talking and inability to remain still or seated for a prolonged period. In order to be diagnosed with ADD/ADHD according to DSM-V guidelines, a child must present with six symptoms in either or both the inattention criteria and hyperactivity and impulsivity categories. Accordingly, the disorder can present in three ways: combined, predominately inattentive and predominately hyperactive-impulsive presentative. Adults (over the age of 17) must be present with a minimum of five symptoms. For both children and adults, these symptoms must be present for 6 months prior to diagnosis and should interfere with normal, daily life. Finally, these symptoms should be present in two or more settings, before the age of 12 and not singularly in conjunction with any other mental disorder.

Inattention Symptom – Taken directly from the DSM-V

  • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
  • Often has trouble holding attention on tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
  • Often has trouble organising tasks and activities.
  • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
  • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
  • Is often easily distracted
  • Is often forgetful in daily activities.

Hyperactivity and Impulsivity Symptoms 

  • 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)

I was very fortunate to receive permission to use a first hand report of how ADHD/ADD feels. Below are his experiences in his own words. Please check out the Reddit post where he discusses his experiences with ADHD/ADD. It is linked in the reference section under the author Jonathan Michael. His personal experience really helped my understanding of what these symptoms feel like, not just what they are.

“ADD is almost like having a regulator switch turned off in my head…I feel like my mind is racing at 90 miles per hour, constantly thirsting to take in information and sense perception all around me.”

“It’s not that I can’t “pay attention”, it’s that I’m paying attention to almost everything around me and can’t consciously order which is “most important” to pay attention to fast enough, or sometimes at all.”

“ADD isn’t about “becoming bored”, it’s about losing the natural instinct to be able to prioritize what should be focused on instead of what shouldn’t be…For us, we literally lose chunks of time because we were so wrapped up in something else.”

Psychiatrist Edward M. Hallowell, M.D. describes ADHD/ADD as such, and Jonathan Michael mentioned in his post that he found it a very accurate metaphor for the disorder. 

“In ADD, time collapses. Time becomes a black hole. To the person with ADD it feels as if everything is happening all at once. This creates a sense of inner turmoil or even panic. The individual loses perspective and the ability to prioritize. He or she is always on the go, trying to keep the world from caving in on top.”

Aetiology and Treatment Options 

Genetics

Researchers suggest a strong correlation between genetics and ADD/ADHD. A meta-analysis of 20 international twin studies revealed a heritability estimate of 0.76 for ADHD, making it the most heritable psychiatric disorder (2). However, despite a high concordance rate between monozygotic twins (72-83%) and fraternal twins (21-45%), pinpointing what genes are different has proven difficult. One of the main reasons it has been so hard to map the genetic component to the disorder is because many genes seem to be implicated. This makes sense because ADD/ADHD is so complex that it is far more likely the phenotypes found result from the additive characteristics of many different genes. Not only that but the variation in symptoms suggests the possibility that ADD/ADHD involves endophenotypes. In other words, ADHD has hereditary characteristics associated with it but that are not a direct symptom of  it or dependent upon it.

ADD Brain

Natalie M. Zahr, Ph.D., and Edith V. Sullivan, Ph.D. “Translational Studies of Alcoholism Bridging the Gap” Alcohol Research & Health, Volume 31, Number 3, p.215- (2008)[1]

The Brain 

As with genetic factors, the brain regions involved in ADHD/ADD are not completely clear either. One region that appears to be most involved is the prefrontal cortex. The prefrontal cortex’s main role is executive function – planning, self-control and attention. Catecholimanergic (dopamine and noradrenaline) neurotransmitter pathways in the prefrontal cortex have been implicated. Symptoms of ADD/ADHD reflect problems in executive function. Drug therapies prescribed to individuals target these catecholaminergic pathways by inhibiting the re-uptake of dopamine and noradrenaline to increase the levels of these neurotransmitters in the synaptic cleft. Common drug treatments that act as a reuptake of inhibitor of dopamine an/or noradrenialine have methylphenidate, dexamfetamine or atomoxetine as an active ingredient. These active ingredients are stimulants which may seem counterintuitive when treating a hyperactivity disorder. However, as dopamine and noradrenaline in the prefrontal cortex increase self-control, attention, planning, etc. stimulating the release of these neurotransmitters is suitable. Unfortunately as with all drugs, those used in treatment of ADD/ADHD have side effects that sometimes outweigh the benefits of the treatment for some. Common side effects of Ritalin f.eg. includes depression, irritability, anxiety, aggression, reduced sex drive, heart palpitations and more. Other options include behavioural therapy which works on central executive tasks such as goal setting, impulse control, planning and organisation.

Common ADHD/ADD drugs:

  • Concerta XL (methylphenidate)
  • Dexamfetamine
  • Elvanse (lisdexamfetamine)
  • Equasym XL (methylphenidate)
  • Medikinet (methylphenidate)
  • Ritalin (methylphenidate)
  • Strattera (atomoxetine)

Diet and Environment

Researchers suggest that damage or trauma to a foetus’ brain or trauma in early childhood can in some cases lead to the development of ADHD/ADD later in life. A  foetus exposed to drugs, alcohol, cigarettes and/or high levels of stress due to their mother’s habits or environment whilst in the womb are more likely to develop ADHD. From birth into childhood, brain diseases or infection, trauma during birth, head injury or exposure to secondhand smoke are also seen as risk factors. Some parents argue that diet or supplements reduce the symptoms of or prevent ADHD; however, little evidence supports this belief. A few studies have found that children with ADHD have lower levels of fatty acids, but it remains unclear whether this actually plays any role in the pathogenesis of the disorder. A poor family environment, a difficult upbringing or many life upheavals in early life are found more often in children with ADHD, but as of yet there is no way of knowing whether a difficult family environment acts as a stressor or if related genes in ADHD put the family at risk for more familial conflicts and unlawful behaviour. Importantly, as with any disorder or even personality a poor familial or social environment aggravates any imperfect aspects of our character. As I emphasise with any post on mental health, the key is to recognise the true severity of the disorder and to respect those who fight through it on a daily basis.

For those seeking help for ADD/ADHD:

  • Contact your local GP
  • Speak to a family member or friend
  • http://www.nhs.co.uk/ (UK)
  • http://www.youngminds.org.uk/ (UK)
  • http://www.mentalhealth.org.uk/ (UK)
  • http://www.help4adhd.org/ (US)
  • http://www.addhelpline.org/ (Global)
  • http://www.cdc.gov/ (US)

References

American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.

Attention Deficit Hyperactivity Disorder. (2012, January 1). Retrieved November 10, 2014, from http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml#pub5

Faraone SV, Perlis RH, Doyle AE, et al.: Molecular genetics of attention deficit hyperactivity disorder. Biol Psychiatry 2005, 57:1313–1323.

Hallowell, E.M (2012). What’s it Like to Have ADHD?. [ONLINE] Available at: http://www.huffingtonpost.com/edward-m-hallowell-md/what-adhd-feels-like_b_1627463.html. [Last Accessed 10 November 2014].

Khan, S. A., & Faraone, S. V. (2006). The genetics of ADHD: a literature review of 2005. Current Psychiatry Reports, 8(5), 393-397.

Michael, J. (2014). My husband was diagnosed with ADD because he can’t focus on reading or similar tasks. I can read a book all day but simply *cannot* focus on a movie or a TV show. My mind will not stay focused. How come he has ADD and I don’t?. [ONLINE] Available at: http://np.reddit.com/r/NoStupidQuestions/comments/2b6bt9/my_husband_was_diagnosed_with_add_because_he_cant/cj2e6a6. [Last Accessed 20 July 2014].

Millichap, J. Gordon, and Michelle M. Yee. “The diet factor in attention-deficit/hyperactivity disorder.” Pediatrics 129.2 (2012): 330-337.

Rutherford, D. (2014, January 24). What causes ADHD? Retrieved November 10, 2014, from http://www.netdoctor.co.uk/adhd/whatcausesadhd.htm

Symptoms and Diagnosis. (2014, September 29). Retrieved November 10, 2014, from http://www.cdc.gov/ncbddd/adhd/diagnosis.html