Introduction

            Attention-deficit hyperactivity disorder (ADHD) is composed of symptoms in three areas:

1. Short attention span
2. Impulsivity
3. Hyperactivity

The behavioral disturbances must have been present for at least six months and must first have appeared before the age of 7.

Extent of Disease

• Incidence of ADHD in the United States is about 3 to 5 percent of prepubertal elementary school children.
• In Great Britain the incidence is more in boys than in girls, with the ratio being from 4 to 1.
• It is most common in firstborn boys.
• The parents of children with ADHD show an increased incidence of hyperkinesias, sociopath, alcoholism, and conversion disorder.
• Onset is usually by the age of 3, the diagnosis is generally not made until the child is in elementary school and the formal learning situation requires structured behavior patterns, including developmentally appropriate attention span and concentration.

Causes:

• Some children with the disorder may have minimal and subtle brain damage from adverse circulatory, toxic, metabolic, or other effects by stress and physical insults to the brain during early infancy, caused by infection, inflammation, and trauma.
• A cerebral blood flow study showed less blood flow in frontal lobe of brain.
• A positron emission tomography scan study of adults having a history of childhood attention deficit disorder with hyperactivity showed depressed metabolic rates in many areas of the brain, particularly in the premotor and somatosenosory cortex.

Genetic Causes

• A genetic basis of ADHD has been suggested by data that show a greater concordance rate in Monozygotic twins than in dizygotic twins.
• Siblings of hyperactive children are also at a greater risk for hyperactivity than are half siblings.
• Alcoholism, antisocial personality disorder and Briquette's syndrome are more common in parents of adopted away ADHD children, than in parents of other children.

Hypersensesitivity

             Hypersensitivity and idiosyncratic responses to food additives have been suggested as causes of the disorder, but these claims have not been scientifically validated.

Maturational Lag:

            Some children have a maturational delay in developmental sequence and may show a clinical picture of ADHD that is temporary and disappears as maturational lags catch up to normal milestones at around puberty.

Psychological Factors

• Children in institutions (Hostels, Orphanages, Remand Homes, etc) are frequently overactive and have poor attention spans.
• These symptoms result from prolonged emotional prolonged emotional deprivation and disappears when derivational factors are removed, such as through placement in foster home or adoption.
• Stressful psychic events, a disruption of family equilibrium and other anxiety-inducing factors contribute to the initiation or perpetuation of ADHD.

Predisposing Factors

These are child’s temperament, genetic familial factors and demands of society to adhere to a routinized way of behaving and performing.

Clinical Features

• The disorder may have its onset in infancy.
• Infants with ADHD are unduly sensitive to stimuli and are easily upset by noise, light, temperature and other environmental changes.It is more common, though, for infants with ADHD to be active in the crib, sleep little and cry a great deal.
• At times, the reverse occurs and the children are placid and limp, sleep much of the time and appear to develop slowly in the first months.

• ADHD children are far less likely than normal children to reduce their locomotors activity when their environment is structured by social limits.

• They are often accident prone.

• These children are often explosively irritable. This irritability may be set off by relatively minor stimuli, which may puzzle and dismay them.
• • They are frequently emotionally labile, easily set of to laughter or to tears and their mood and performance are apt to be variable and unpredictable.
• • Concomitant emotional difficulties are frequent. The fact that other children grow out of this kind of behavior and that ADHD children do not grow out of it at the same time and rate, the variability of their performance and the general nuisance and inexplicability of their behavior all may lead to adults’ dissatisfaction and pressure. The resulting negative self-concept and reactive hostility are worsened by the children’s frequent recognition that they are not right inside.

Short attention span, distractibility, lack of perseveration, failure to finish things, inattention, poor concentration.

Action before thought, abrupt shifts in activity, lack of organization, jumping up in class.

Impulsiveness and an inability to delay gratification are characteristic.

In school ADHD children may rapidly attack a test but answer only the first two questions.

They may be unable to wait to be called on in school and may respond for everyone else and at home they cannot be put off for even a minute.

School difficulties, both learning and behavioral, are common, sometimes coming from concomitant developmental language disorders or academic skills disorders or from the children’s distractibility and fluctuating attention, which hamper their acquisition, retention and display of knowledge.

The adverse reactions of school personnel to the behavior characteristic of ADHD and the lowering of self-regard because of felt inadequacies may combine with the adverse comments of peers to make school a place of unhappy defeat.

This in turn, may lead to acting out antisocial behavior and self defeating, self punitive behaviors.

Course:

• It is highly variable. Symptoms may persist into adolescence & adult life or they may remit at puberty.

Remission:

• It is highly variable. Symptoms may persist into adolescence & adult life or they may remit at puberty.
• The over activity is usually the first symptom to remit and distractibility the last. Remission is not likely before the age of 12. It is usually between the ages of 12 and 20.
• Remission may be accompanied by a productive adolescence and adult life, satisfying interpersonal relationships and few significant sequels.
• The majority of patients with ADHD, however, undergo partial remission.

• Adult ADHD
  
• In about 20 percent of cases, the symptoms of ADHD persist into adulthood.
• Those with the disorder may show diminished hyperactivity but remain somewhat impulsive and accident prone.
• Educational attainment is lower than that of persons without ADHD.
• Many children with ADHD become delinquent in adolescence or develop antisocial personality disorder in adulthood or both. This progression has been reported in about 25 percent of all children with ADHD.

Treatment:

The pharmacological agents for ADHD are as follows.

Dextroamphetamine, Methylphenidate and Pemoline.

These drugs are controversial because they may suppress growth slightly. However, drug holidays over school vacation periods apparently result in rebounds in growth.

There is also a debate about the potential for abuse and habit formation with these drugs. When used judiciously and within the recommended dosage range, the stimulants have benefits that outweigh their risks for abuse.

Imipramine has been tried with some success in ADHD. It is particularly helpful for ADHD plus depression or anxiety.

Desipramine has benefited some ADHD children who failed to improve when given stimulants. It can also be used to treat ADHD with associated tics. They ar used with great care in children because of their potential cardiotoxic effects.

Individual psychotherapy, behavior modification, parent counseling and treatment of any coexisting specific developmental disorder are necessary.

When given medication, ADHD children should be given the opportunity to explore the meaning of the medication for them, helping dispel misconceptions. These children need to understand that they need not always be perfect.

When ADHD children are not only allowed but also helped to structure their environment, their anxiety diminishes. Thus, their parents and teachers should set up a predictable structure of reward and punishment, using a behavior therapy model and applying it to the physical, temporal and interpersonal environment. An almost universal requirement is to help the parents recognize that permissiveness is not helpful to their child. Children with ADHD do not benefit from being exempted from the requirements, expectations and planning applicable to other children.

Evaluation of Therapeutic Progress

             Monitoring starts with the initiation of medication. Because school performance is most markedly affected, special attention and effort should be given to establishing and maintaining a close collaborative working relationship with the children’s school.

In addition, medication can improve self-esteem when the ADHD children are no longer constantly reprimanded for behavior.