ADHD symptoms, diagnosis, and combined treatment approaches in children

ADHD causes significant psychosocial dysfunction and severely affects academic performance of the child. The condition requires continuous monitoring and treatment, as the symptoms tend to persist well into adulthood. As several research studies indicate, a combined treatment model involving medications and behavioral therapy is the most effective method for improving symptoms and effective management of the disorder. The new developments in brain research and in particular studies of the functional MRI images have shed new light into our understanding of the pathology of ADHD. The development in genetic science has also furthered our understanding of the genetic susceptibility of ADHD.

Attention Deficit Hyperactivity Disorder

Introduction

Attention deficit Hyperactivity disorder is a common neurobehavioral disorder identified among 3 to 7% of children. Though, primarily a childhood condition, the disorder may persist into adulthood. [CDC] Statistics show that in around 60 to 80% of the children, symptoms of the disorder continue to persist in their adolescence. [Vincent Lanelli] Statistics also indicate that the disorder is more prevalent among boys than with girls with an approximately prevalence ratio of 3:1 (boys / girls). Three forms of the disease are identified among children namely the 'Predominantly inattentive type', 'Hyperactive type' and 'Combinational type'. Children with the hyperactive condition are fidgety and impulsive, exhibiting restless behavior. The predominantly inattentive type on the other hand, have difficulties in focusing on any task or absorbing things and have difficulties in carrying out even routine tasks. The combinational type, as the name suggests is a mixture of the symptoms of both the above types. Often other types of mental disorders also exist with ADHD. These concurrent conditions not only interfere with the diagnosis of ADHD, but also present additional problems for the patient. [CDC] Let us have a brief outlook into the symptoms, different treatment methods and also review some of the recent research studies on ADHD.

ADHD Symptoms and Diagnosis

The 'Diagnostic and Statistical Manual for Mental Disorders' (DSM iv TR) in 2000 symptomatically classified the three different types of ADHD. According to the DSM classification, the symptoms of inattentive type include, 1) lack of attention and carelessness, 2) difficulties in grasping and following given instructions as evident from the failure to finish schoolwork's or other tasks. 3) Lack of involvement in tasks that demand attention, 4) Having difficulties in organizing oneself and of highly forgetful disposition. Some of the symptoms for hyperactive type include 1) Exhibiting fidgety behavior, 2) Being restless and inability to sit in a place for a long time, 3) garrulous and lack of composure, 4) lack of patience as witnessed by the inability to wait for the chance resulting in frequent interruption of others, etc. As per the DSM, if these symptoms are manifest in the child for a period not less than six months, then the child may be clinically classified as falling into one of the three types of ADHD. (Based on the respective symptoms.) [CDC] Diagnosis of the disorder is made after a careful examination by the physician. After assessing other possible reasons such as family stress, (due to divorce, change of place, or any important event in life) the physician also examines for disorders of ear, eye and for emotional conditions such as depression, anxiety etc. The final diagnosis is arrived at after the physician completes an assessment of these comprehensive tests.

Treatment Methods

Treatment of ADHD involves both pharmacological interventions and behavioral therapy. If comorbid conditions are found to exist, the physician would include medications to manage these conditions as well. The two main types of drugs used in the treatment of ADHD are stimulants and non-stimulants. Rarely, tricyclic antidepressants such as Imipramine or Desipramine are also prescribed but an FDA report which relates the incidence of suicides among teenager to the use of anti-depressants has made them undesirable in the treatment of ADHD. Among the stimulants, there are different types namely short acting, intermediate acting and long acting, based on the duration of their effectiveness. Ritalin and Focalin are examples of two short acting stimulants having activity limited to 3 to 5 hours while other stimulants such as Concerta, Rilatin LA and Metadate CD have a more prolonged effect. (From 8 to 12 hours). [Vincent Lanelli] These stimulants though found to be very effective have some minor side effects such as insomnia, irritability, stomachache etc. [Douglas Tynan]. Based on the response of the child, the physician may change the stimulants and their dosage.

Though stimulants have been reported to have some side effects several studies have shown that stimulant medication is the best in terms of symptomatic management of the condition. A recent German research observed the sleeping patterns of ADHD patients and effectiveness of stimulant medications. For this study the researchers enrolled 34 non-medicated ADHD subjects and 34 healthy control subjects. Of the 34 ADHD subjects 10 were given a daily dosage of methylphenidate (a stimulant). All the candidates of the study were subjected to Polysomnographic recording for two consecutive nights. Results showed that all ADHD subjects showed increased nocturnal activity, poor REM sleep compared to the control subjects while the intervention with methylphenidate resulted in increased percentage of REM sleep and as a consequence improved the restorative value of sleep in the 10 subjects who were medicated. This study clearly shows that stimulants could improve the quality of sleep and lessen the nocturnal activity in ADHD patients. [Sobanski et.al]

Evidence from past studies also shows encouraging results for Stimulant therapy. A review of 413 randomized controlled trials using methylphenidate, which involved a total of 19,000 children, showed that the effect size (which is a statistical measure of the difference in means between the control group and the study group) for stimulant medication was 0.8 in terms of symptoms management and.4 to.5 in terms of improved academic performance. Another large randomized study compared the effectiveness of stimulant medication, behavioral therapy, both stimulant medication and behavioral therapy and community care. This study included 579 children between the age groups of 7 and 9.9 years. Results observed after 14 months of therapy showed that children in the medication and combined group (medication and behavioral therapy) fared much better than the other two groups in terms of ADHD symptoms. [Lisa Johnson, 2005]

Genetic and Brain Studies

There is a plethora of research on ADHD and new findings continue to expand our knowledge of the condition. Recently research based on family studies and studying twins has indicated a possible association between 8 different genes and the susceptibility to ADHD. Though researchers are yet to have any conclusive genetic profiling for ADHD some genes such as the dopamine receptor genes (DRD4 and DRD5), dopamine transporter gene (DAT), dopamine beta hydoxylase gene and the serotonin receptor and transporter genes have been showed to be associated with ADHD. [Stephen V Farrone]

Research has also focused on brain studies of ADHD subjects with the hope of a better understanding of the neurobehavioral disorders. Functional MRI images have revealed new information on the differences in the brain activation patterns among ADHD subjects and healthy people without the condition. The focus, which had thus far been restricted to the frontal lobe, has now been extended and researchers are actively studying other regions of the brain. One recent study showed that ADHD subjects not only exhibited underactivation in the prefrontal cortex but also in the parietal and the temporal cortex regions. Another study reported a distinct absence of activation of the anterior cingulate cortex region among ADHD subjects.

A recent Stanford university study has also concluded that ADHD patients showed lesser activation in the posterior parietal attention system when compared with control subjects. Using an odd ball task the researchers tested 12 healthy boys and 14 boys with ADHD. The test involved pressing two different buttons in response to two different images (circle and a triangle) showed on the screen. The results showed that control subjects fared much better than the ADHD subjects. Though there was no great difference in reaction time, functional MRI images showed that ADHD subjects exhibited very low activation of the bilateral association cortex, the right precuneus region and the thalamus regions of the brain when compared to the normal subjects. The researchers concluded that "[I]t is important to reconsider the notion of ADHD as primarily a disorder of the frontal-striatal function and consider the role of the parietal attention system in the behavioral phenotype of ADHD" [Aron Levin]

Conclusion

The significant psychosocial dysfunction accompanying ADHD has serious implications for children as their educational performance is considerably affected. Hence proper diagnosis and appropriate medical intervention is crucial. It is also important for parents to be sufficiently trained to handle children with ADHD. Most children show considerable improvement with the use of appropriate dosage of stimulants. Though pharmacological intervention is the mainstay treatment modality for the disorder behavioral therapy is also found to produce significant improvements in symptoms. In many cases symptoms continue well into adulthood and hence continuous monitoring and appropriate intervention is necessary. Psychological therapy has proved to be very effective in adults with residual symptoms. In general, a combination of drug therapy and behavioral therapy is optimal for the treatment of the disorder.