Attention Deficit Hyperactivity Disorder (ADHD)

DSM-IV TR Criteria

DSM-IV TR Diagnostic Criteria for Attention Deficit Hyperactivity Disorder (ADHD)

A. Either 1 or 2:

1. Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

b. Often has difficulty sustaining attention in tasks or play activities

c.often does not seem to listen when spoken to directly

d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

e. Often has difficulty organizing tasks and activities

f.Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework)

g. Often loses things necessary for tasks or activities (toys, school assignments, pencils, books, or tools)

h. Is often easily distracted by extraneous stimuli

i.Is often forgetful in daily activities

2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

a. Often fidgets with hands or feet or squirms in seat

b. Often leaves seat in classroom or in other situations in which remaining seated is expected

c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

d. Often has difficulty playing or engaging in leisure activities quietly

e. Is often "on the go" or often acts as if "driven by a motor"

f.Often talks excessively

Impulsivity

g. Often blurts out answers before questions have been completed

h. Often has difficulty awaiting turn

i.Often interrupts or intrudes on others (such as butting into conversations or games)

B. Some hyperactive, impulsive, or inattentive symptoms thatcaused impairment were present before age 7 years

C. Some impairment from the symptoms is present in two or moresettings (such as in school or work and at home)

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or another psychotic disorder and are not better accounted for by another mental disorder (such as a mood, anxiety, dissociative, or personality disorder)

ADHD Types Using DSM-IV TR criteria

ADHD, predominantly inattentive type

Meets inattention criteria (section Al) for the past 6 months

ADHD, predominantly hyperactive-impulsive type

Meets hyperactive-impulsive criteria (section A2) for the past 6 months

ADHD, combined type

Meets criteria for section Al and section A2 for the past 6 months

ADHD, not otherwise specified

Prominent symptoms of inattention or hyperactivity-impulsivity that do not meet the criteria for ADHD

In partial remission

Definition

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurobiological brain disorder that manifests as a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.

Statistics

  • Approximately 3% to 7% of school-aged children have ADHD
  • The prevalence rate for ADHDin adults is approximately 4%
  • The prevalence ratio of ADHD in boys to girls has reportedly ranged from 9:1 to 6:1, but other studies offer a more conservative figure of 3:1
  • Individuals with ADHD make up a significant portion(about 50%) of the child psychiatric population
  • About 13% of the adult population with ADHD is treated with medication
  • From 1984 to 2001, Ritalin prescriptions rose from 1.5 million tablets to 19.3 million
  • 500,000 children in the USA were diagnosed ADHD in 1985 and between 5 and 7 million were in 2004

Causes

The exact cause is not clear. However,there are two theories:

  • Chemical balances in the brain which affect temperament and behavior
  • Genetic conditions

Symptoms

Examples of symptoms of ADHD include:

  • Restlessness or fidgetiness
  • Difficulty concentrating or focusing on one thing
  • Starting multiple projects at the same time, but rarely finishing them
  • Procrastination on projects that take a lot of attention to detail
  • Problems remembering appointments or obligations
  • Trouble staying seated during meetings or other activities
  • Disorganization
  • Losingor misplacing things

Course of Illness

ADHD begins in childhood and can persist into adulthood as well. In about 10-60% of the cases, ADHD persists into adulthood.While some children outgrow ADHD, about 60% continue to have symptoms into adulthood. The disorder manifests differently in adults as hyperactivity tends to diminish.

Diagnosis

ADHD is usually diagnosed when a child is 6 to 12 years of age.

Adult diagnosis of ADHD is based on the DSM-IV TR. The physician will diagnose ADHD based on three components:

1) Symptoms
Adults with ADHD may tell their physician aboutvarious symptoms.

2) Impairment
An adult with ADHD may have difficulties at work, at home and in their personal relationships.

3) History
Adults with ADHD must have had their first symptoms prior to age 7 and these symptoms must have continued to cause impairment on a regular basis since then.

Treatment

1) Stimulants:

The effects of stimulants in treating ADHD are quite paradoxical because they make children calmer rather than more active with improved concentration and reduced restlessness. Stimulants have long been the mainstay of medication therapy for ADHD because they are safer and more effective than clonidine (Catapres) or the antidepressants, particularly tricyclics.

Stimulants Frequently Used to Treat ADHD:

Dextroamphetamine (Dexedrine) - Rapid absorption and onset (within 30 minutes but can last up to 5 hours)

Methylphenidate (Ritalin,Concerta, or Metadate CD) - Rapid absorption and onset (within 30 minutes but lasts 24 hours)

Pemoline (Cylert) - Effects felt in about 2 hours but can last up to 9 hours and requires 3-6 weeks to see full effect

Stimulant side effects:

  • Appetite loss, stomach aches
  • Nervousness
  • Insomnia (usually subside within a week or can be eliminated by lowering the dose)
  • Reduction of growth speed (found to be temporary and mild)
  • Cardiovascular effects such as palpitations, tachycardia and increased blood pressure
  • Liver malfunctioning

2) Other drugs are also used in treating ADHD when the patient does not improve on stimulants or cannot tolerate their side effects.

Propranolol (Inderal) or Nadolol (Corgard) (Beta-blockers)- reduces jitters.

Bupropion (Wellbutrin) (Anti-depressant)

3) Socialization training - improve interpersonal communication and problem-solving skills

4) Behavior management and modification - manage stress

5) Psychotherapy and/or counseling

6) Vocational assessments and counseling - improve time management and organizational skills

Accommodations

Deficits in Reading
Tape-recorded directives, messages, materials
Reading machines
Screen reading software for computer use
Colored mylar templates for reading and scanning

Color-coded manuals, outlines, maps
Scanners which allow the user to enter hard copies into the computer system

Deficits in Writing

Personal computers/laptop computers
Voice output software that highlights and reads (via a speech synthesizer) what has been keyed into the computer.
Voice input software which recognizes the user's voice and changes it to text on the computer screen
Word processing software
Spell checking software/electronic spell checkers
Software with highlighting capabilities
Grammar checking software
Word prediction software
Form producing software that computerizes order forms, claim forms, applications, credit histories, equation and formula fields

Deficits in Mathematics

Fractional, decimal, statistical, scientific calculators
Talking calculators
Computer Assisted Instruction (CAI) software for arithmetic/ mathematics
Computer Assisted Design (CAD) software for architecture/engineering
Large display screens for calculators, adding machines
Colored mylar templates, colored coding for maintaining ledger columns

Deficits in Organizational Skills, Memory, and Time Management

Day Planners
Electronic organizers/schedulers
Software organizers with/without highlighting capabilities
LCD Watches, data bank watches, timers, counters, alarms
Personal Information Managers (P.I.M.S.)
Use of electronic mail (E-mail) for memory deficits

Managing the Physical Environment

Room enclosures/cubicles to reduce auditory and visual distractions
A private office space
Use of "white noise" by using a sound soother/environmental sound machine
Use of colored files
Mapping of the workspace/office

Recommended Readings

  • Job Accommodations Network (JAN) -

The Job Accommodation Network (JAN) is a free consulting service that provides information about job accommodations, the Americans with Disabilities Act (ADA), and the employability of people with disabilities.

  • Mental Health Matters: -

Mental Health Matters, was founded to supply information and resources to mental health consumers, professionals, students and supporters. While the percentage of people facing a diagnosable Mental Disorder in any given year is substantial, the acceptance of these problems can be hard to come by. Essentially, Mental Health Issues are hidden illnesses. The main purpose is to provide a structured source of information about mental health issues. To this end, Mental Health Matters will offer detailed technical briefs on disorders, symptoms, treatment modes, and in time, a "comparison engine" that allows users to compare different aspects of disorders. With this information, we hope to educate consumers and guide them towards intelligent decisions in their pursuit of Mental Health.

  • Psychiatric Disabilities:Reasonable Accommodations -

This on-line resource provides information about reasonable accommodations for people with psychiatric disabilities, specifically in order to aid employers and educators. Reasonable accommodations are those adjustments within a work or school site that allow an otherwise qualified employee or student with a disability to perform the tasks required.

  • Research Article - Weiss, M & Murray, C. (2003). Assessment and management of attention-deficit hyperactivity disorder in adults.Canadian Medical Association Journal, 168 (6), 715-722.