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• Volume 90, Issue suppl 1
• The effect of ADHD on the life of an individual, their family, and community from preschool to adult life
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• Correspondence to: Dr V A Harpin Ryegate Children’s Centre, Sheffield Children’s NHS Trust, Tapton Crescent Road, Sheffield S10 5DD, UK; Val.Harpinsheffch-tr.trent.nhs.uk

Attention deficit/hyperactivity disorder (ADHD) may affect all aspects of a child’s life. Indeed, it impacts not only on the child, but also on parents and siblings, causing disturbances to family and marital functioning. The adverse effects of ADHD upon children and their families changes from the preschool years to primary school and adolescence, with varying aspects of the disorder being more prominent at different stages. ADHD may persist into adulthood causing disruptions to both professional and personal life. In addition, ADHD has been associated with increased healthcare costs for patients and their family members.

• CHQ, Child Health Questionnaire
• ODD, oppositional defiant disorder

http://dx.doi.org/10.1136/adc.2004.059006

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Attention deficit/hyperactivity disorder (ADHD) is a chronic, debilitating disorder which may impact upon many aspects of an individual’s life, including academic difficulties, 1 social skills problems, 2 and strained parent-child relationships. 3 Whereas it was previously thought that children eventually outgrow ADHD, recent studies suggest that 30–60% of affected individuals continue to show significant symptoms of the disorder into adulthood. 4 Children with the disorder are at greater risk for longer term negative outcomes, such as lower educational and employment attainment. 5 A vital consideration in the effective treatment of ADHD is how the disorder affects the daily lives of children, young people, and their families. Indeed, it is not sufficient to merely consider ADHD symptoms during school hours—a thorough examination of the disorder should take into account the functioning and wellbeing of the entire family.

As children with ADHD get older, the way the disorder impacts upon them and their families changes (fig 1 ⇓ ). The core difficulties in executive function seen in ADHD 7 result in a different picture in later life, depending upon the demands made on the individual by their environment. This varies with family and school resources, as well as with age, cognitive ability, and insight of the child or young person. An environment that is sensitive to the needs of an individual with ADHD and aware of the implications of the disorder is vital. Optimal medical and behavioural management is aimed at supporting the individual with ADHD and allowing them to achieve their full potential while minimising adverse effects on themselves and society as a whole.

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 Stages of ADHD. Adapted from Kewley G (1999). 6

The aim of this paper is to follow the natural history of this complex disorder through preschool years, school life, and adulthood and to consider its effect on the family, the community, and society as a whole. In addition, comorbidities and healthcare costs are examined.

THE PRESCHOOL CHILD

Poor concentration, high levels of activity, and impulsiveness are frequent characteristics of normal preschool children. Consequently, a high level of supervision is the norm. Even so, children with ADHD may still stand out. In this age group there is often unusually poor intensity of play and excessive motor restlessness. 8, 9 Associated difficulties, such as delayed development, oppositional behaviour, and poor social skills, may also be present. If ADHD is a possibility, it is vital to offer targeted parenting advice and support. Even at this early stage parental stress may be huge when a child does not respond to ordinary parental requests and behavioural advice. 9 Targeted work with preschool children and their carers has been shown to be effective in improving parent child interaction and reducing parental stress. 10, 11 A useful review of the available evidence and methods is provided by Barkley. 12

PRIMARY SCHOOL YEARS

The primary school child with ADHD frequently begins to be seen as being different as classmates start to develop the skills and maturity that enable them to learn successfully in school. Although a sensitive teacher may be able to adapt the classroom to allow an able child with ADHD to succeed, more frequently the child experiences academic failure, rejection by peers, and low self esteem (fig 2 ⇓ ). Comorbid problems, such as specific learning difficulties, may also start to impact on the child, further complicating diagnosis and management. Assessment by an educational psychologist may help to unravel learning strengths and difficulties, and advise on necessary support in the classroom.

 Emotional and family functioning in children with ADHD compared with controls. 13 *Higher scores indicative of greater functioning. CHQ, Child Health Questionnaire. 13

Frequently, difficulties at home or on outings with carers (for example, when shopping, out in the park, or visiting other family members) also become more apparent at this age. Parents may find that family members refuse to care for the child, and that other children do not invite them to parties or out to play. Many children with ADHD have very poor sleep patterns, and although they appear not to need much sleep, daytime behaviour is often worse when sleep is badly affected. As a result, parents have little time to themselves; whenever the child is awake they have to be watching them. Not surprisingly, family relationships may be severely strained, and in some cases break down, bringing additional social and financial difficulties. 14 This may cause children to feel sad or even show oppositional or aggressive behaviour.

Assessing the quality of life of the child suffering from ADHD is difficult. Behavioural assessments are usually carried out by parents, teachers, or healthcare professionals, and it can usually only be inferred how the child must feel. However, data from self evaluations indicate that children with ADHD view their most problematic behaviour as less within their control and more prevalent than children without ADHD. 15 Participation in a school based, nurse led support group was associated with an increase in self worth in pre-adolescents with ADHD. 16

Johnston and Mash reviewed the evidence of the effect of having a child with ADHD on family functioning. 14 They concluded that the presence of a child with ADHD results in increased likelihood of disturbances to family and marital functioning, disrupted parent-child relationships, reduced parenting efficacy, and increased levels of parent stress, particularly when ADHD is comorbid with conduct problems.

In a survey of the mothers and fathers of 66 children, parents of children with ADHD combined and inattentive subtypes expressed more role dissatisfaction than parents of control children. 17 Furthermore, ADHD in children was reported to predict depression in mothers. 18 Pelham et al reported that the deviant child behaviours that represent major chronic interpersonal stressors for parents of ADHD children are associated with increased parental alcohol consumption. 19

Limited attention has been given to sibling relationships in families with ADHD children. While it has been reported that siblings of children with ADHD are at increased risk for conduct and emotional disorders, 20 a more recent study presenting sibling accounts of ADHD identified disruption caused by symptoms and behavioural manifestations of ADHD as the most significant problem. 21 This disruption was experienced by siblings in three primary ways: victimisation, caretaking, and sorrow and loss. Siblings reported feeling victimised by aggressive acts from their ADHD brothers through overt acts of physical violence, verbal aggression, and manipulation and control. In addition, siblings reported that parents expected them to care for and protect their ADHD brothers because of the social and emotional immaturity associated with ADHD. Furthermore, as a result of the ADHD symptoms and consequent disruption, many siblings described feeling anxious, worried, and sad. 21

Broader social and family functioning has been assessed using the Child Health Questionnaire (CHQ), a parent rated health outcome scale that measures physical and psychosocial wellbeing. 22– , 24 The studies demonstrated that treatment of ADHD with atomoxetine, a new non-stimulant medication for ADHD, resulted in improved perception of quality of life, with improvements being apparent in social and family functioning, and self esteem. Further research assessing the ongoing quality of life for the child and their family following multimodal input is urgently needed.

ADHD IN YOUNG PEOPLE

Adolescence may bring about a reduction in the overactivity that is often so striking in younger children, but inattention, impulsiveness, and inner restlessness remain major difficulties. A distorted sense of self and a disruption of the normal development of self has been reported by adolescents with ADHD. 25 Furthermore, excessively aggressive and antisocial behaviour may develop, adding further problems (fig 3 ⇓ ). A study by Edwards et al 27 examined teenagers with ADHD and oppositional defiant disorder (ODD), which is defined by the presence of markedly defiant, disobedient, provocative behaviour and by the absence of more severe dissocial or aggressive acts that violate the law or the rights of others. These teenagers rated themselves as having more parent-teen conflict than did community controls. Increased parent-teen conflict was also reported when parents of teenagers with ADHD carried out the rating exercise. In addition, a survey of 11–15 year olds showed that those with hyperkinesis were twice as likely as the overall population to have “a severe lack of friendship”. 28

 Antisocial behaviour in adolescents with ADHD. 26 Data primarily represents outcomes in those with conduct disorder as teenagers.

Young people with ADHD are at increased risk of academic failure, dropping out of school or college, teenage pregnancy, and criminal behaviour (fig 4A ⇓ and B). Driving poses an additional risk. Individuals with ADHD are easily distracted from concentrating on driving when going slowly, but while driving fast may also be dangerous. It has been shown that, compared with age matched controls, drivers with ADHD are at increased risk of traffic violations, especially speeding, and are considered to be at fault in more traffic accidents, including fatal ones (fig 5 ⇓ ). 30 The risk of such events was increased further by the presence of concomitant ODD. 29 However, it has been suggested that treatment may have a positive effect on driving skills. 31

 Impact of ADHD in adolescence. Data from Barkley RA; 26 (A) Impact at school; (B) impact on health, social, and psychiatric wellbeing.

 Driving-related offences in young adults with ADHD and controls. NS, not significant. Data from Barkley RA et al . 29

As many as 60% of individuals with ADHD symptoms in childhood continue to have difficulties in adult life. 32, 33 Adults with ADHD are more likely to be dismissed from employment and have often tried a number of jobs before being able to find one at which they can succeed. 5 They may need to choose specific types of work and are frequently self employed. In the workplace, adults with ADHD experience more interpersonal difficulties with employers and colleagues. Further problems are caused by lateness, absenteeism, excessive errors, and an inability to accomplish expected workloads. At home, relationship difficulties and break-ups are more common. The risk of drug and substance abuse is significantly increased in adults with persisting ADHD symptoms who have not been receiving medication. 34 The genetic aspects of ADHD mean that adults with ADHD are more likely to have children with ADHD. This in turn causes further problems, especially as the success of parenting programmes for parents of children with ADHD is highly influenced by the presence of parental ADHD. 35 Thus, ADHD in parents and children can lead to a cycle of difficulties.

COMORBIDITIES

Comorbid disorders may impact on individuals with ADHD throughout their lives. It is estimated that at least 65% of children with ADHD have one or more comorbid conditions. 36 The reported incidence of some of the most frequent comorbidities is shown in figure 6 ⇓ , with neurodevelopmental problems, such as dyslexia and developmental coordination disorder, being particularly common. Many children with ADHD also suffer from tic disorders (not related to stimulant medication). In addition, around 60% of children with Tourette’s Syndrome fulfil criteria for ADHD, 38, 39 and autistic spectrum disorder is increasingly recognised with comorbid ADHD. 39 Initially, excessive hyperactivity may mask the features of autistic spectrum disorder until the child receives medication. Conduct disorder and ODD coexist with ADHD in at least 30%, and in some reports up to 90%, of cases. 36 These most frequently occurring comorbidities can, however, be considered more as complications of ADHD, with adversity in their psychological environment possibly determining whether children at risk make the transition to antisocial conduct. 40

 ADHD and comorbidity in Swedish school age children. 37 MR, mental retardation; RWD, reading/writing disorder; DC, developmental coordination; ODD, oppositional defiant disorder.

PROBLEMS ASSOCIATED WITH TREATMENT

Growth deficits in children receiving stimulant treatment for ADHD have long been the subject of scientific discussion. Conflicting results have been reported with some authors indicating that stimulants do indeed affect growth in children, 41– , 43 but that this only occurs during active treatment phase and does not compromise final height. 44 Other studies, however, have not found any evidence to suggest that stimulants influence growth. 45, 46 Taken together, the results suggest that clinicians should monitor the growth of hyperactive children receiving stimulants, and consider dose reduction in individual cases should evidence of growth suppression occur.

Another frequently quoted concern about treatment of ADHD with stimulant medications is that it could lead to drug addiction in later life. Young people with ADHD are by nature impulsive risk takers, and there is clear evidence that untreated ADHD—especially with concomitant conduct disorder—is associated with a three- to fourfold increase in the risk of substance misuse. 47, 48 In contrast, patients medicated with stimulants have a similar risk of substance misuse to controls. 49 These data therefore provide strong evidence in favour of careful treatment and support for young people with ADHD.

HEALTHCARE COSTS

Healthcare costs for individuals with ADHD in the UK have not been fully estimated, but evidence from the USA suggests that they are increased compared with age matched controls. A population based, historical cohort study followed 4880 individuals from 1987 to 1995 and compared the nine year median medical cost per person: ADHD medical costs were US$4306, whereas non-ADHD medical costs were US$1944 (p<0.01). 50 These findings are likely to reflect increased injury following accidents and a rise in use of substance abuse services and other outpatient facilities, although poor ability to comply with advice on medication (for example, asthma management) may also be implicated. A study of the injuries to children with ADHD established that children with ADHD were more likely to be injured as pedestrians or bicyclists than children not suffering from ADHD. They were more likely to sustain injuries to multiple body regions, head injuries, and to be severely injured. 51 ADHD has been found to represent a risk factor for substance abuse, 47, 52 and an investigation of prevalence of ADHD among substance abusers has established that ADHD was significantly overrepresented among inpatients with psychoactive substance use disorder. 53 Increased use of health services is also seen in the relatives of individuals with ADHD. A study has shown that direct and indirect medical costs were twice as high as those of family members of a control group. 54 The difference in these costs was primarily due to a higher incidence of mental health problems in the family members of ADHD patients, which reflects the increased stresses and demands of living with an adult or child with ADHD. Indeed, ADHD related family stress has been linked to increased risk of parental depression and alcohol related disorders. 55– , 57

It is vital to consider the role of treatment of ADHD in decreasing the individual’s risk of adverse outcomes. A number of studies on the effect of treatment of ADHD on the risk of substance abuse encouragingly demonstrate a fall in risk to that of the normal population. 58– , 60

Mannuzza’s review of the long term prognosis in ADHD concludes that childhood ADHD does not preclude high educational and vocational achievements (for example, Master’s degree or medical qualification). 61 However, ADHD is a disorder that may affect all aspects of a child’s life. Careful assessment is paramount, and if this demonstrates significant impairment as a result of ADHD, there is clear evidence that treatment of ADHD should be instituted. 62, 63 Current treatment focuses mainly on the short term relief of core symptoms, mainly during the school day. This means that important times of the day, such as early mornings before school and evening to bedtime, are frequently unaffected by current treatment regimes. This can negatively impact on child and family functioning and fail to optimise self esteem and long term mental health development.

In 2003, the American Academy of Pediatrics recommended that clinicians should work with children and their families to monitor the success (or failure) of treatment, using certain criteria to assess specific areas of difficulty and quality of life as a whole. 64 There has been a reluctance in the UK to treat ADHD with medication, fuelled by concerns about possible over-prescription in the USA. In addition, newspaper and media coverage of ADHD is often negative and stigmatising. The evidence of potentially severe difficulties for the child, the family, and, in some cases, for society as a whole, means that coordinated multi-agency effort to support the child and family is essential. Moreover, healthcare professionals have an important role in providing balanced and supportive information about ADHD and meeting the needs of affected individuals and their families.

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• v.3(2); 2015 Sep 30

Overview of Attention Deficit Hyperactivity Disorder in Young Children

1 Department of Early Childhood and Elementary Education, College of Education and Human Services, Murray State University, Murray, KY, USA

Chia Jung Yeh

2 Human Development and Family Science, College of Health and Human Performance, East Carolina University, Greenville, NC, USA

Nidhi Verma

3 Department of Psychology, Kurukshetra University, Kurukshetra, India

Ajay Kumar Das

4 Department of Adolescent, Career and Special Education, Murray State University, Murray, KY, USA

Contributions: AS, NV contributed equally as first authors.

Attention deficit hyperactivity disorder (ADHD) is a complex disorder, which can be seen as a disorder of life time, developing in preschool years and manifesting symptoms (full and/or partial) throughout the adulthood; therefore, it is not surprising that there are no simple solutions. The aim of this paper is to provide a short and concise review which can be used to inform affected children and adults; family members of affected children and adults, and other medical, paramedical, non-medical, and educational professionals about the disorder. This paper has also tried to look into the process of how ADHD develops; what are the associated problems; and how many other children and adults are affected by such problems all over the world basically to understand ADHD more precisely in order to develop a better medical and or non-medical multimodal intervention plan. If preschool teachers and clinicians are aware of what the research tells us about ADHD, the varying theories of its cause, and which areas need further research, the knowledge will assist them in supporting the families of children with ADHD. By including information in this review about the connection between biological behavior, it is hoped that preschool teachers and clinicians at all levels will feel more confident about explaining to parents of ADHD children, and older ADHD children themselves about the probable causes of ADHD.

Overview of attention deficit hyperactivity disorder in young children

Literally thousands of studies have been conducted on attention deficit hyperactivity disorder (ADHD) and it’s various predecessors in diagnostic nomenclatures prior to DSM-V (The Diagnostic and Statistical Manual of Mental Disorders-V). Despite this long research history, ADHD is not necessarily well understood among the lay public, given the many controversies and public misconceptions concerning the disorder. 1 , 2 Longitudinal evidence suggests that childhood ADHD persists into young adulthood in 60-70% of the cases when defined relative to same-age peers and in 58% of the cases when DSM-V criteria and parental reports are used. 3-6 These early studies of childhood hyperactivity excluded many children that would currently meet the DSM criteria for ADHD, particularly the inactive sub-type. 7 The scientific status of ADHD is one of the most controversial issues in child health. 8-10 This paper examines the overview of ADHD in children in relation to its genetics, taxonomy, neurobiology, comorbidity, diet, treatment, and concludes with a discussion.

Précis of attention deficit hyperactivity disorder

ADHD is recognized as a common childhood psychiatric disorder and has a strong genetic, neuro-biologic, and neurochemical basis. 11 , 12 It is characterized by symptoms of inattention and/or impulsivity and hyperactivity which can significantly impact many aspects of behavior as well as performance, both at school and at home. 13 ADHD is characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity according to DSM-V. 14-16 The World Health Organization (WHO) uses a different name hyperkinetic disorder (HD)-but lists similar operational criteria for the disorder. 17 Regardless of name used, ADHD is one of the most thoroughly researched disorders in medicine. 18 The DSM diagnostic criteria for ADHD were based on reviews of existing research and a field trial in which alternative diagnostic criteria were evaluated. 19

Classification of what constitutes ADHD has changed dramatically over the last 32 years, with each successive revision of the Diagnostic and Statistical Manual, the diagnostic criteria used to describe the disorder. Current classification for combined type ADHD requires a minimum of six out of nine symptoms of inattention of hyperactivity/impulsivity. 16 , 17 , 20 In addition there must be some impairment from symptoms in two or more settings ( e.g . home and school) and clear evidence of significant impairment in social, school or work functioning. The DSM also allows the classification of two sub-type disorders: i) predominantly inattentive where the child only meets criteria for inattention; and ii) predominantly hyperactive-impulsive where only the hyperactive-impulsive criteria are met.

Prevalence of attention deficit hyperactivity disorder

The relatively prevalence of the disorder is high, affecting approximately 4% of all children, although estimates vary widely from 3% to 11% or more. 21 , 22 The disorder usually begins in early childhood and is characterized by excessive activity, even when developmental level and limited behavioral control are taken into consideration. 23 , 24 reviewed the findings of six large epidemiological studies that identified cases of ADHD within these samples. The prevalences found in these studies ranged from a low of 2% to a high of 6.3%, with most falling within the range of 4.2% to 6.3%. Other studies have found similar prevalence rates in elementary school-age children (4-5.5%; in Breton et al ., 25 7.9% in Briggs-Gowan et al. , 26 5-6% in DuPaul, 27 and 2.5-4% in Pelham et al . 28 Lower rates result from using complete DSM criteria and parent reports (2-6% in Breton et al ., 25 and higher ones if just a cutoff on teacher ratings is used (up to 23% in DuPaul, 27 15.8% in Nolan et al ., 29 14.3% in Trites et al . 30 Sex and age differences in prevalence are routinely found in research. For instance, prevalence rates may be 4% in girls and 8% in boys in the preschool age group, 29 yet fall to 2-4% in girls and 6-9% in boys during the 6- to 12-year-old age period based on parent reports. 25 The prevalence decreases again to 0.9-2% in girls and 1-5.6% in boys by adolescence. 25 , 31-33 Overall ADHD affects 2% to 9% in school age children.

Etiological elucidation of attention deficit hyperactivity disorder

Underlying etiological explanations of ADHD can be simply divided into biological and environmental. In simple terms biological explanations include genetics, brain structure and their influence on neuropsychology, while predominant environmental explanations include problems during and after birth, exposure to environmental toxins, parenting and diet.

Heredity of attention deficit hyperactivity disorder

Heredity of ADHD has been an important issue. 34 For years, researchers have noted the higher prevalence of psychopathology in the parents and other relatives of children with ADHD. Between 10% and 35% of the immediate family members of children with ADHD are also likely to have the disorder, with the risk to siblings being approximately 32%. 35-37

Even more striking is the finding that if a parent has ADHD, the risk to the offspring is 57%. 12 Thus, ADHD clusters significantly among the biological relatives of children with the disorder, strongly implying a hereditary basis to this condition. 38 Subsequently, these elevated rates of disorders have been noted in African American samples with ADHD, 39 as well as in girls with ADHD compared to boys. 40

Genetic factor

The heredity basis for psychiatric disorders was already recognized at the turn of the nineteenth century by Enail Kraepelin. 41 There is now little doubt that ADHD is a condition in which genetic factors (genetic differences between children) make a substantial contribution to the risk of the disorder. 42 Genetic factors are accounted for 80% of the etiology of ADHD, while more recent studies have begun to examine which particular genes might be implicated in ADHD, 43 , 44 reported an association between ADHD and a null allele of the C4B complement locus in the MHC -gene region of chromosome 6, a locus also associated with reading disability. 45 Interest in a potential genetic mechanism underlying ADHD increased with reports of an association with a single dopamine transporter gene, 46 and with reports of variations within the D4 receptor gene. 47 Genetic studies have focused mainly on candidate genes involved in dopaminergic transmission. Several reasons exist for this particular focus, dopaminergic drugs (methylphenidate) are clinically efficacious in addressing the core problems associated with ADHD. A gene related to dopamine, the DRD4 (repeater gene), has been the most reliably found in samples of children with ADHD. 48 It is the seven-repeat form of this gene that has been found to be overrepresented in children with ADHD. 47 Such a finding is quite interesting, because this gene has previously been associated with the personality trait of high novelty-seeking behavior; because this variant of the gene affects pharmacological responsiveness; and because the gene’s impact on postsynaptic sensitivity is primarily found in frontal and prefrontal cortical regions believed to be associated with executive functions and attention. 49 The finding of an overrepresentation of the seven-repeat DRD4 gene has now been replicated in a number of other studies, not only of children with ADHD, but also of adolescents and adults with the disorder. 42 , 48

Monitoring the correspondence between the intended and actually executed action, a fundamental mechanism of behavioral regulation, is reflected by error-related negativity (ERN), an ERP component generated by the anterior cingulate cortex. Based on this process assumption, a study by LaHoste et al . 50 examined genetic influences on the ERN and other components related to action monitoring (correct negativity, CRN, and error positivity, P e ). A flanker task was administered to adolescent twins (age 12) including 99 monozygotic (MZ) and 175 dizygotic (DZ) pairs. Genetic analysis showed substantial heritability of all three ERP components (40-60%) and significant genetic correlations between them. This study provides the first evidence for heritable individual differences in the neural substrates of action monitoring and suggests that ERN, CRN, and P e can potentially serve as endophenotypes for genetic studies of personality traits and psychopathology associated with abnormal regulation of behavior. 50

Cognitive genetics

The sequencing of the human genome and the identification of a vast array of DNA polymorphisms has afforded cognitive scientists with the opportunity to interrogate the genetic basis of cognition with renewed vigor. Advances in the understanding of the neural substrates of sustained and spatial attention arising from the cognitive neurosciences can help guide putative linkages in cognitive genetics. 51 In line with catecholamine models of sustained attention, associations have been reported between sustained attention and allelic variation in the dopamine beta hydroxylase gene ( DBH ), the dopamine D2 and D4 receptor genes ( DRD2, DRD4 ) and the dopamine transporter gene ( DAT1 ). 51 Much evidence implicates the cholinergic system in spatial attention. Accordingly, individual differences in spatial attention have been associated with variation in an alpha-4 cholinergic receptor gene (CHRNA4). APOE-4 allele dosage has been shown to influence the speed of attentional reorienting in independent samples of nonaffected individuals. Preliminary evidence in both healthy children and children with ADHD suggests association with variants of the DAT1 gene and the control of spatial attention across the hemifields. 51

Fronto-striatal circuitry in attention deficit hyperactivity disorder

Imaging studies using positron emission tomography (PET), and magnetic resonance imaging (MRI) techniques have implicated the fronto-striatal circuitry in ADHD, an area rich in dopaminergic activity. However certain meta-analytic studies have questioned the robust association between dopaminergic genes and ADHD. 52 Other candidate genes have also been investigated including serotonin transporter genes. 53 Genetic investigations aim to examine whether different genes contribute to specific aspects of ADHD. For example, a meta-analysis by Bellgrove and Mattingley has shown that the dopamine transporter gene DAT1 is more closely associated with the ADHD combined sub-type than with the inattentive +sub-type. 54 Future molecular genetic studies aim to examine gene-environment interactions, the extent to which environmental factors moderate genetic risks for ADHD. As well as gene-gene interactions, the extent to which having a cocktail of different genetic influences might elevate risk for ADHD.

Brain structure

A wealth of literature has examined the anatomical structure of the brain in children with ADHD. Using brain scanning technology such as MRI these studies suggest that the brain circuits linking the prefrontal cortex, striatum and cerebellum are not functioning normally in children with ADHD. 55 Further evidence has examined the relationship between brain structure and behavioral measures of inhibition and attention. These results suggest that compromised brain morphology of selected regions is related to behavioral measures of inhibition and attention. 56 Another study suggests that abnormalities in circuits important for motor response selection contribute to deficits in response inhibition in children with ADHD. 57 This lends support to the growing awareness of ADHD-associated anomalies in medial frontal regions which are important for the control of voluntary actions. Studies using PET to assess cerebral glucose metabolism have found diminished metabolism in adults with ADHD, particularly in the frontal region. 58 , 59 Using a radioactive tracer that indicates dopamine activity, 60 found abnormal dopamine activity in the right midbrain region of children with ADHD, and discovered that severity of symptoms was correlated with the degree of this abnormality. Another study pointed that children with ADHD were found to have a smaller corpus callosum, particularly in the area of the genu and splenium and that region just anterior to the splenium. 61 Interestingly, the study by Zametkin et al. 62 also found smaller cerebellar volume in those with ADHD. This would be consistent with views that the cerebellum plays a major role in executive functioning and the motor presetting aspects of sensory perception that derive from planning and other executive actions. 63 MRI showed no differences between groups in the regions of the corpus callosum in either of the other studies. 62 , 64 Further investigations of anatomical structure may allow the development of pharmacological interventions for ADHD, 65 which are better targeted to specific sites of action in the brain.

Neurobiology of attention deficit hyperactivity disorder

Neurobiology of ADHD has been another valued topic of investigation. 66 Researchers describe at least 11 different neuroanatomical theories of ADHD. 67 These theories can be categorized into two domains. The bottom-up theories propose disturbances in subcortical regions, such as the thalamus, and hypothalamus and reticular activating systems are responsible for ADHD symptomology. The top-down theories attribute the dysfunction to frontal and prefrontal and sagittal cortices. Smaller frontal lobe or right prefrontal cortex was found for the ADHD groups in all studies that examined this measure. Five of six studies found a smaller anterior or posterior corpus callosum. Four of six found loss of the normal caudate asymmetry, and these four also found a smaller left or right globus pallidus. 68 Neuroimaging studies of children with ADHD have investigated and found evidence of abnormalities in the frontal cortex, basal ganglia, corpus callosum, and cerebellum. 69-72 The cerebellum is functionally linked with the pre-frontal cortex, and three anatomical measures, namely the right globus pallidus volume, caudate asymmetry, and left cerebellum volume, correlate highly with ADHD in children. 68 Preliminary evidence has not found differences in the thalamus in children with ADHD. 62 , 73

Role of the basal ganglia

The role of the basal ganglia in ADHD has been given serious importance in neuropsychological research. The basal ganglia are a collection of large subcortical structures that can be divided into two sets of core structures: i) the striatum consisting of the caudate, putamen, and ventral striatum and ii) the pallidum or globus pallidus consisting of the external segment, internal segment, and ventral pallidum. The striatum receives input from the entire cerebral cortex, thalamus, substantia nigra, and amygdala and sends projections to the pallidum and substantia nigra. The pallidum sends input to the thalamic nuclei and additional subcortical nuclei, where information will be sent back to the frontal or pre-frontal cortex. 74 The organization of the striatum is important in the execution of motor planning, sequencing, and coordination, as well as feedback and learning after motor execution, 75 suggest that the striatum serves as a crossroads , combining sensory-motor information with emotional processing from the amygdala and dopamine mediated reinforcement. The primary neurotransmitter involved in modulation of the basal ganglia is dopamine, and disruption of this system has been found in ADHD. Initial studies found higher levels of the dopamine metabolite, and homovanillic acid in cerebral spinal fluid were positively correlated with the amount of hyperactivity in boys. 62 A recent genetic study found that alleles of the gene encoding dopamine beta hydroxylase, an enzyme that breaks down dopamine, may be related to the expression of ADHD. 76 Further support for dopamine dysfunction in ADHD comes from a functional MRI study that found children with ADHD had reduced activity in the frontal-striatal regions and impaired performance on response inhibition tasks. 77 Additionally, methylphenidate, which acts on the dopamine transporter (DAT), increased both frontal-striatal activity and performance on response inhibition tasks. A study using single PET-CT found that adults with ADHD had increased levels of striatal DAT compared to normal controls, which may lead to decreased availability of striatal dopamine in ADHD. 78

Research on the role of the basal ganglia in ADHD has primarily focused on the caudate. 79 The caudate has been implicated in a complex loop , receiving information from the association cortices and indirectly sending it via the thalamus to the prefrontal cortex. 80 Studies have found neuroanatomical differences in the caudate of children with ADHD with mixed results. 56 , 62 ,69, 81-83 Found that boys with ADHD had a smaller right caudate; recently, this finding was not replicated in ADHD girls. 69 In boys with ADHD, smaller right caudate volumes were found to significantly correlate with poor accuracy on sensory selection tasks, and left and right caudate volumes were negatively correlated with mean reaction times. 81 Conflicting results found ADHD adolescents had larger right caudate than normal adolescents, and the right caudate volume was associated with poorer performance on attention tasks and higher ratings of hyperactivity and impulsivity. 83 Another study found that children with ADHD had smaller left caudate volumes. 73 , 82 More recently, Manor et al . 56 reported that boys with ADHD were found to have a decreased volume of the left head of the caudate. These children were also more likely to show a reversed caudate asymmetry when compared to healthy controls, with the left being smaller than right. Moreover, a significant relationship between the reduction in left caudate volume and performance on behavioral inhibition tasks was found. In addition, children displaying reversed caudate asymmetry (L<R) were more likely to perform poorly on tasks of behavioral inhibition and attention regardless of group membership. 56 , 81 It has been also previously found that reversed caudate asymmetry was related to deficits in response execution tasks in ADHD. This evidence suggests that asymmetry of the caudate regardless of volume has important implications in attention and behavioral control. Finally, functional imaging studies have found decreases in blood flow to the caudate in ADHD. 62 , 84

Role of the putamen

The role of the putamen has also been studied as an etiological factor for the ADHD. 85 The putamen is hypothesized to be part of the motor loop because it receives information from the sensory-motor cortex and then sends it indirectly back to the premotor regions of the frontal cortex. Based on the putamen’s anatomical connections and function, a role for the putamen in ADHD is possible although currently unclear because of equivocal evidence. 80 There are relatively few studies investigating the neuroanatomical role of the putamen in ADHD. 69 Another study have not found volumetric differences in the putamen between children with ADHD and healthy controls. 62 In addition, they found that the volume of the putamen did not correlate with performance on response inhibition tasks. However, two studies suggest that the putamen may actually be important in the expression of ADHD symptomology. Researchers found that the ADHD diagnosis was significantly associated with the titer of two ant streptococcal antibodies. 86

In addition, they found that higher antibodies titers were associated with larger volumes in the left putamen and right globus pallidus in children with ADHD. 86 Although this study found structural evidence for the role of the putamen in ADHD, the second study demonstrates functional differences in the putamen of children with ADHD. Recent advances in functional MRI technology have provided new methods to investigate blood flow to various regions of the brain. Functional MRI relaxometry allows researchers to investigate the resting or steady state conditions and medication-related changes and were able to indirectly assess blood volume to the striatum (caudate and putamen). 75 They found that blood flow to both sides of the putamen was decreased in ADHD children compared to normal children. In addition, they found that blood flow to the left was more decreased than blood flow to the right side. They found no differences in blood flow to the thalamus and caudate, although there was a non-significant trend in the right caudate. Methylphenidate administration significantly altered the blood flow to the right and left putamen, and changes were correlated to the child’s unmedicated state.

There were no significant differences in blood flow to the caudate off or on medication. Filipek et al . 75 found strong associations between measures of activity and inattention with T2-RT measures in the putamen. They propose that ADHD symptoms are closely related to functional abnormalities in the putamen, which is closely involved in the control of motor behavior. These hypotheses lay the foundation for our study of the neuroanatomy of the putamen in children with ADHD. Investigators in their study using magnetic resonance imaging scans of boys in residential treatment with symptoms of ADHDand psychopathic traits found no differences in the total, left and right putamen volumes across the ADHD or control group. A significant reversal of asymmetry across groups was found; children with ADHD more frequently had a smaller left putamen than right. In contrast, the control group more frequently has a smaller right than left putamen.

Several studies have examined cerebral blood flow using single-photon emission computed tomography (SPECT) in children with ADHD and normal children. 68 , 72 They have consistently shown decreased blood flow to the prefrontal regions (most recently in the right frontal area), and to pathways connecting these regions with the limbic system via the striatum and specifically its anterior region known as the caudate, and with the cerebellum. 87 , 88

Neuropsychology of attention deficit hyperactivity disorder

Studies examining the neuropsychology of ADHD provide an opportunity to understand the relationship between underlying biological processes and symptoms of ADHD. For many years it was accepted that symptoms of ADHD were the result of cognitive dysregulation. 89 The behavior of a child with ADHD resulted from insufficient forethought, planning and control. 90 Evidence to support this view point came from many studies using neuropsychological tests which demonstrated that children with ADHD performed less well on these tests than did matched controls to match familiar figures, children with ADHD demonstrated more impulsive responding and higher error rates than did matched controls. 91 , 92

Cognitive dysregulation

A summary of ADHD as a disorder of cognitive dysregulation suggested that the relationship between biology and behavior in children with ADHD was mediated by inhibitory dysfunction. 93 In contrast to the dominant view, researchers offered an alternative view of ADHD, not as a disorder of cognitive dysregulation, but as a motivational style. This viewed ADHD as a functional response by the child, aimed at avoiding delay. This alternative viewpoint of ADHD was based on other studies, 92 which showed that most of the neuropsychological evidence to support ADHD as a result of cognitive dysregulation was confounded by delay. To demonstrate this, researchers got children with ADHD and match control children to participate in the matching familiar figures test, and found the same results as previous studies. 92 Children with ADHD made more impulsive responses and more errors. However, researchers pointed out that all these studies involved trial constraints where as soon as one trial ended the next began and were confounded with delay. 92 In order words, children with ADHD made more impulsive responses because it allowed them to complete the task quicker and therefore escape delay. When researchers re-ran their study under time constraint (for a fixed period of time where early or impulsive responses had no influence on delay), children with ADHD performed no differently from controls. 92 Results of these studies lead to the development of the delay aversion hypothesis, 94 which characterized the influence of delay on behavior dependent upon whether the child has control over their environment or not. When the child is in control of their environment they can choose to minimize delay by acting impulsively, e.g. by skipping the queue at the end of the slide! When the child is not in control of their environment, or at least where they are expected to behave in certain ways or face sanctions, the child would choose to distract themselves from the passing of time. For example, in a classroom context during literacy lessons the child could achieve this either by daydreaming (inattention) or by fidgeting (hyperactivity). A summary of ADHD as a motivational style suggests that the relationship between biology and behavior in ADHD is mediated by delay aversion.

Traditionally these two different accounts of ADHD have both sought to independently explain the disorder. However, a study by Sonuga-Barke et al . 95 compared the measurement of both of these hypotheses in a head-to-head study. Results of this study showed that measures used to test each hypothesis were uncorrelated, demonstrating that they measured different constructs. Both sets of measures were correlated with ADHD, and when combined were highly diagnostic, correctly distinguishing 87.5 of cases from non-cases. These results suggested that both accounts appeared to help to explain ADHD, but that neither explanation was the single theory of ADHD which both theoretical camps had been searching for. Based on these findings, researchers proposed his dual pathway model of ADHD. 93 This model proposed two possible routes between biology and ADHD behavior. The first one is through cognitive dysregulation and another via motivational style. Clinically the dual pathway model suggests that there may be merit in targeting different sub-types with specific treatments, as well as allowing the development of novel interventions, perhaps aimed at desensitizing delay. Some have suggested ways in which the greater understanding about the influence of delay aversion on the development of ADHD could be used to develop alternative interventions. 93 , 96 These suggestions include the use of delay fading, a technique to systematically reorganize the child’s delay experience, as a means of increasing tolerance for delay, and reducing ADHD symptoms.

Some studies have not found a greater incidence of prenatal (pregnancy or birth complications) in children with ADHD compared to normal children whereas others have found a slightly higher prevalence of unusually short or long labor, fetal distress, low forceps delivery, and toxemia or eclampsia in children with ADHD. 97 Nevertheless, though children with ADHD may not experience greater pregnancy complications, prematurity, or lower birth-weight as a group, children born prematurely or who have markedly lower birth-weights are at high risk for later hyperactivity or ADHD.

Researchers found that smoking and maternal stress during the pregnancy is associated with onset of ADHD during early childhood. Similarly observed that parental smoking during pregnancy predicts non-responsiveness to intervention targeting ADHD symptoms in elementary school children. Hartsough et al . observed that behavioral symptoms of ADHD were predicted by a lower ponderal index (kg/m 3 ), 98 a smaller head circumference, and a smaller head-circumference-to-length ratio. Length of gestation, mother’s age, tobacco and alcohol during pregnancy and pre-pregnancy, body mass index or parity, the monthly gross income of family, child’s BMI at the age of five or six years or gender didn’t have any significant effect on the behavioral symptoms of ADHD at the age of five or six.

Exposure to environmental toxins

Exposure to environmental toxins specifically lead has also been reviewed as a causal factor for ADHD. An amazing variety of toxins extent in the modern environment have deleterious effects on the central nervous system that range from severe organic destruction to subtle brain dysfunction. 99 , 100 Toxic metals are ubiquitous in the modern environment, as are organohalide pesticides, herbicides, and fumigants, and a wide range of aromatic and aliphatic solvents. 101 All these categories of environmental pollutants have been linked to abnormalities in behavior, perception, cognition, and motor ability that can be subtle during early childhood but disabling over the long term. 102 Children exposed acutely or chronically to lead, arsenic, aluminum, mercury, or cadmium are often left with permanent neurological sequelae that include attentional deficits, emotional lability, and behavioral reactivity. 101 Elevated body lead burden has been shown to have a small but consistent and statistically significant relationship to the symptoms of ADHD. 103 , 104 However, even at relatively high levels of lead, fewer than 38% of children in one study were rated as having the behavior of hyperactivity on a teacher rating scale, 104 implying that most lead-poisoned children do not develop symptoms of ADHD. And most children with ADHD likewise, do not have significantly elevated lead burdens. 105

Environmental influences

Environmental influences on ADHD have also been reviewed extensively. Attention deficit hyperactivity disorder is best viewed as a gene × environment interaction. 106 Children who have a genetic predisposition will express the disorder when put in the correct environment, typically one characterized by chaotic parenting. 107 The best evidence for environmental influences on ADHD come from intervention studies which have demonstrated improvements in ADHD symptoms, when parents have been taught alternative parenting skills. 108 , 109 Results of these studies do not necessarily imply that parents of children with ADHD are bad parents. In fact, influence of parenting on ADHD is best viewed from an interactionist viewpoint. The relationship between ADHD and parenting may result from both negative aspects of the child influencing the parents’ behavior, and negative aspects of the parents influencing the child’s behavior. Studies examining mother-child interaction have found that children with ADHD are less often on task, less compliant, less responsive and more active than controls; researchers investigated both mother-son and father-son interactions and found that parents of boys with ADHD were more demanding, aversive and power assertive; 110-112 while the findings of Buhrmester et al. 113 have demonstrated that mothers of children with ADHD have been found to be more negative, controlling, intrusive and disapproving, and less rewarding and responsive than mothers of children without ADHD.

Research finds that ADHD affects the interactions of children with their parents, and hence the manner in which parents may respond to these children. 114 Those with ADHD are more talkative, negative and defiant; less compliant and cooperative; more demanding of assistance from others; and less able to play and work independently of their mothers. 115-118 Their mothers are less responsive to the questions of their children, more negative and directive, and less rewarding of their children’s behavior. 107 , 116 Mothers of children with ADHD have been shown to give both more commands and more rewards to sons with ADHD than to daughters with the disorder, 119 , 120 but also to be more emotional and acrimonious in their interactions with sons. 112 Children and teens with ADHD seem to be nearly as problematic for their fathers as their mothers. 112 , 118 , 121 Contrary to what may be seen in normal mother-child interactions, the conflicts between children and teens with ADHD (especially boys) and their mothers may actually increase when fathers join the interactions. 112 , 121 So while parents of children with ADHD may engage in less than optimal parenting, it is easy to see how such responses might have evolved.

In addition, genetic studies highlight the familial basis of ADHD. 122 , 123 Children with ADHD are more likely to have a parent with ADHD. ADHD symptoms in parents usually interfere with consistent and appropriate parenting. Researchers found that ADHD in parents prevented effective parental monitoring and consistent use of constructive parenting techniques. 124 Other researchers found that parental ADHD symptoms were associated with lax discipline, 125 while Harvey et al. 126 found that high ADHD symptoms in mothers were a barrier to successful psychosocial intervention for pre-school children with ADHD.

Most widely researched and commonly prescribed treatments for ADHD are the psychostimulants, including methylphenidate, amphetamine, and pemoline. 2 , 127 Several studies have demonstrated the short-term efficacy of stimulant compared to placebo conditions in improving both core ADHD symptoms and important ancillary features of the disorder. 128 Controlled studies of stimulants have shown their effect on reducing interrupting in class, reducing task-irrelevant activity in school, improving performance on spelling and arithmetic tasks, improving sustained attention during play, and improving parent-child interaction.

Meaningful effects have been documented across a wide array of outcome domains, cognitive attentional performance, school behavior, and learning, parent-child interactions, interaction with peers, and with a wide variety of assessment approaches, direct observations of behavior in natural and laboratory settings, and objective laboratory performance. 129

Diet is another environmental influence, often cited by parents as having an adverse influence on the ADHD symptoms of their child. 130 Specifically, food additives, refined sugars and fatty acid deficiencies have all been associated with ADHD symptoms. 131

However, the majority of this literature comes from older studies, with a variety of methodological problems, and small sample sizes. 131 In fact, a large recent randomized control trial examined the influence of food colorings and benzoate preservatives on pre-school hyperactivity. Results demonstrated a general adverse effect of food coloring and benzoate preservatives on hyperactive behavior of preschool children, based on parental reports, but not on simple clinic assessment. Children with high levels of hyperactivity were no more vulnerable to this effect than children with low levels of hyperactivity. 132 While improving children’s diet might impact on their general health and improve their overall behavior, the clinical importance of dietary change as a means of remediating ADHD remains doubtful. 133

Co-morbidity

ADHD appears to be associated with a wide variety of other psychiatry problems, which are often co-morbid with it. ADHD co-occurs with other childhood disorders far more often than it appears alone. 134 Notable associations exist with Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), tic disorder, mood disorder, autism spectrum disorder, specific learning disorder such as dyslexia, 135 , 136 depression and anxiety. About 50-60% of children with ADHD meet criteria for ODD, even in the pre-school period. 137 Busch and colleagues (2002) reported that ADHD children in primary care settings were significantly more likely than non-ADHD clinic controls to demonstrate mood disorders (57%) such as depression, multiple anxiety disorders (31%), and substance use disorders (11.5%). However, in the recent British Child Mental Health Survey, 138 anxiety was not associated with ADHD when adjustment was made for the presence of a third disorder. It is widely accepted that ADHD is a co-morbid disorder. Copeland et al. 135 point out that co-morbidity can mean a common underlying etiology which leads to two or more different disorders, or that one disorder leads to another, or even that two unrelated disorders co-occur. The term co-morbid also implies that their entities are morbid conditions, i.e. diseases. High rates of comorbidity with either other neurodevelopmental disorders ( e.g ., mental retardation, and learning disabilities) or psychiatric disorders ( e.g ., anxiety) make delineation of the phenotype difficult. 139

Some studies found that 47% children with ADHD have co-morbid ODD, 140-142 27% have anxiety disorder and 7% have mood disorder. 38% of children with ADHD were found to have CD and 13% have depression. In fact, the vast majority of co-morbidities with ADHD represent functional impairments and symptoms, which are not rooted in specific diseases. 135 Studies of clinic-referred children with ADHD find that between 54% and 67% will meet criteria for a diagnosis of ODD by 7 years of age or later. ODD is a frequent precursor to CD, a more severe and often (though not always) later occurring stage of ODD. 143. The co-occurrence of CD with ADHD may be 20-50% in children and 44-50% in adolescence with ADHD. 144 By adulthood, up to 26% may continue to have CD, while 12–21% will qualify for a diagnosis of antisocial personality disorder (ASPD).

In addition to associations with other psychiatric disorders children with ADHD are also more likely than their non-ADHD counterparts to experience a substantial array of developmental, social and health risks. It therefore seems important to discuss associated problems along with co-morbidity.

Motor coordination

Children with ADHD often demonstrate poor motor co-ordination or motor performance and balance. 145-147 Substantial evidences have been observed for problems in motor development and motor execution children with ADHD. 148 Clinical and epidemiological studies report that 30% to 50% of children with ADHD suffer from motor coordination problems. 146 These percentage are dependent of the type of motor assessment, referral sources and the cut-off points used. 149-151 As noted by Needleman et al ., 105 children with ADHD display greater difficulties with the development of motor coordination, planning and execution of complex, lengthy tasks, and novel chains of goal directed responses.

Academic functioning

Children with ADHD have an impaired academic functioning and are usually at an educational disadvantage upon school entry. 152 , 153 ADHD children are more likely than their non-ADHD peers to demonstrate difficulties with basic mathematics and pre-reading skills during their first year at school. 147 , 154 , 155 Executive academic functions were found to be core deficits specific to ADHD. Girls with ADHD were found to be less impaired than boys with ADHD. 156 Even pre-school children with ADHD demonstrate educational disadvantage, DuPaul et al . 157 demonstrated that their sample of pre-school ADHD children demonstrated deficits in pre-academic skills even prior to formal school entry. The pre-school ADHD children in their sample scored on average one standard deviation lower on the Battelle Developmental Index, 158 than did their non-ADHD control group. Researchers emphasized the importance of look away behavior (inattention) as a major reason for poor academic achievement. 159

Clinic-referred children with ADHD often present with lower scores on intelligence tests than control groups, specifically verbal intelligence with differences ranging from 7 to 10 standard score points. 160 Studies with community samples of ADHD children have also demonstrated negative associations between ADHD and intelligence. 161 , 162

Children with ADHD demonstrate serious difficulties with psychosocial functioning. Social adjustment is often given little attention on assessment protocols, given its designation as an associated feature of ADHD. 15 However, the high levels of disruptive behavior demonstrated by ADHD children increases the likelihood of negative reactions from parent, teachers and also peers. 163 In addition, negative social interactions with peers ultimately lead to peer’s rejection, 164 because these social difficulties are often resistant to psychosocial and pharmacological treatment, 165 they are expected to continue into adolescence, and even adulthood when criteria for the disorder may no longer be met. 166 The patterns of disruptive, intrusive, excessive, negative, and emotional social interactions that have been found between children with ADHD and their parents, have also been found to occur in the children’s interactions with teachers and peers. 157 , 167 , 168 It should come as no surprise, then, that those with ADHD receive more correction, punishment, censure, and criticism than other children from their teachers, as well as more school suspensions and expulsions, particularly if they have ODD/CD. 168 , 169 In their social relationships, children with ADHD are less liked by other children, have fewer friends, and are overwhelmingly rejected as a consequence, 170 particularly if they have comorbid conduct problems. 107 , 125 , 171 , 172 Another research study demonstrated that the co-occurrence of conduct disorder and anxiety disorder with ADHD in childhood predicted a more severe course for ADHD in adolescence. 173

Unintentional physical injury

Children with ADHD appear to be at a greater risk for unintentional physical injury and accidental poisoning. 157 , 174 In one of the first studies of the issue, Stewart and colleagues found that four times as many hyperactive children as control children (43% vs . 11%) were described by parents as accidentprone. Later studies have also identified such risks; up to 57% of children with hyperactivity or ADHD are said to be accident-prone by parents, relative to 11% or fewer of control children. 175 , 176 Most studies find that children with ADHD experience more injuries of various sorts than control children. In one study, 16% of the hyperactive sample had at least four or more serious accidental injuries (broken bones, lacerations, head injuries, severe bruises, lost teeth, etc.), compared to just 5% of control children. 2 , 177 found that 68% of children with DSM-IV-TR ADD, compared to 39% of control children, had experienced physical trauma sufficient to warrant sutures, hospitalization, or extensive/painful procedures. Several other studies likewise found a greater frequency of accidental injuries than among control children. Researchers found that children with ADHD were at a greater risk for suffering fractures, 178 most likely as a result of hyperactive and impulsive behavior. Children with AD/HD are also more likely than their non-ADHD counterparts to be injured as pedestrians, to inflict injuries to themselves, to sustain injuries to multiple body regions and to experience head injury. 179 Knowledge about safety does not appear to be lower in these children; implying interventions aimed at increasing knowledge about safety may have little impact. 180

Sleep disturbances

Studies report an association between ADHD and sleep disturbances found that sleep problems occurred twice as often in ADHD as in control children. 181-184 The problems are mainly more behavioral and include settling difficulties, a longer time to fall asleep, and instability of sleep duration, tiredness at awakening or frequent night waking. The direction of effect, between ADHD and sleep problems is unclear. It is possible that sleep difficulties increase ADHD symptoms during the daytime, as the research on normal children implies. 105 Yet some research finds that the sleep problems of children with ADHD are not associated with the severity of their symptoms; this suggests that the disorder, not the impaired sleeping, is what contributes to impaired daytime alertness, inattention, and behavioral problems. 184 , 185

While knowledge about the associations between ADHD and other related variables is useful in terms of diagnostic profiles, less is known about the impact of related variables on the long-term outcome for the disorder. Even less is known about the specificity of these associated problems to ADHD. In the preschool years a wealth of evidence now exists comparing the symptoms of pre-school ADHD symptoms to its school-aged counterpart. Children with a pre-school variant of ADHD present with the same symptom structure, 186 , 187 similar associated impairment and developmental risk, 187 and similar patterns of neuropsychology. 188 Despite the similarities between pre-school ADHD and school-aged ADHD, little is known about what constitutes impairment during the pre-school years although school readiness should be what clinicians focus on. And even less is known about the relationship between early hyperactivity and later expression of the ADHD disorder. 189

While originally conceived of as a disorder of childhood and adolescence, evidence suggests scientific merit and clinical value in examining ADHD in adulthood, 40 , 189 as well as the pre-school period. 189 ADHD symptoms have been shown to persist into later life with up to 40% of childhood cases continuing to meet full criteria in the adult years. 190 , 191 Adult ADHD appears to share many characteristics of the childhood disorder. Similar to their childhood counterparts, adults with ADHD display impairment in the interpersonal, vocational and cognitive domains. 192-194 The adult and childhood disorders also appear to share a common neuropathology, 195 , 196 and demonstrate a similar response to treatment. 197

Conclusions

We have discussed two different possible causes of ADHD in neurological research. The top down theory says that ADHD begins with frontal and pre-frontal lobe dysfunction. The other theory says that the sub-cortical regions, the thalamus and the hypothalamus are responsible for ADHD. Neuro-imaging doesn’t show abnormality in the thalamus, but does show changes in the frontal and prefrontal area. Researchers agree that genetic factors are a strong contribution to the occurrence of ADHD.

DSM-IV has an aura of scientific legitimacy, many authors have written about its shortcomings in terms of reliability and validity. 198 , 199 The primary function and goal of the DSM, 200 is to lend credibility to the claim that certain (mis) behaviors are mental disorders and that such disorders are medical diseases. Although the DSM-IV is often used when discussing mental illnesses, be it in a research setting or a clinical practice setting. Researchers apply points out that such extensive use does not in itself guarantee either its validity or reliability. 201 The DSM-IV is purely descriptive and presents no new scientific insights about the causes of the many mental disorders it lists. Despite a wide level of acceptance, ADHD is not an uncontested condition. 202 For example, another researcher has argued that ….the working dogma that ADHD is a disease or neurobehavioral condition does not at this time hold up . 203 , 204 A more recent perspective presented by Lollar has also stated that there are no valid neurological markers for the diagnosis of ADHD. 205 Additionally, Shaw et al . 206 observe that there is currently no verifiable objective evidence to support the claims of ADHD advocates. Given the lack of validity as a medical condition, it is important to ask why the label of ADHD is applied, and under what conditions?

Another researcher found no association between DAT1 and ADHD. 207 Another gene for which there have been many studies is the dopamine receptor D4, DRD4, on chromosome 11. Another researchers found no evidence of an association between ADHD and DRD4. 208 Environmental effects could also include child-specific experiences of salient environmental influences such as maternal lifestyle or parenting. 209 Childhood ADHD symptoms do remit across time for some, 4 , 210 but not all children. 209

Some of the controversial treatments have involved dietary management, herbs and antioxidants. The removal of artificial food colorings and preservatives from the diet is an indispensable and practicable clinical intervention in ADHD, but rarely is sufficient to eliminate symptomatology. 102 Up to 88 percent of ADHD children react to these substances in sublingual challenge testing, but in blinded studies no child reacted to these alone. Allergies to the foods themselves must also be identified and eliminated. 211 Sugar intake makes a marked contribution to hyperactive, aggressive, and destructive behavior. 212 , 213-222 Overall body of evidence currently does not support dietary use as sole therapy for ADHD. There is a group of children with ADHD who do not respond well to treatment. More resources should be made available to help them, through clinical research and clinical-based treatment. 214

The actual degree to which genetic heritability may predispose to childhood onset of ADHD is still an open question. 102 Population studies indicate attentional problems, conduct problems, and emotional problems tend to cluster within families. 215 , 223 , 224 Genetics and environment are notoriously difficult to separate within the family unit, and researchers suggested the genetic predisposition to ADHD might fuel a negative family atmosphere that exacerbates latent ADHD in the child, 102 , 225 , 226

It is unknown whether the association of motor coordination problems with ADHD is comparable across ages. The limitation in daily life caused by poor motor performance varies with age. 146 Four to six years old children mainly have problems with dressing, use of scissors, drawing, trying shoelaces, and riding a bike. Children seven to ten years old encounter difficulties in writing, dressing, swimming, constructional play, ball skills and outdoor play, while eleven to nineteen year olds have problems of clumsiness in writing, drawing, ball skills, poor table manners and tool use. 218

Research on long term effects and safety of ADHD medications has been especially lacking. 36 , 219 According to researchers of a study of psychotropic drugs used with preschoolers, earlier ages of initiation and longer duration of treatment means that the possibility of adverse effects on the developing brain cannot be ruled out . Another research study of longer term ADHD treatments suggested the side effects such as depression, worrying, and irritability from ADHD medications. 227 , 228 In some of these children, drug therapy is insufficient because of persistent symptoms of coexisting conditions. 228 , 229 Future studies will be needed to define the subgroups clearly. There is much to learn about it.

Articles and Key Findings About ADHD

Key findings, featured articles, scientific articles.

National Prevalence of ADHD and Treatment: New statistics for children and adolescents, 2016 As of 2016, 6.1 million children aged 2-17 years living in the U.S. had been diagnosed with ADHD, which is similar to previous estimates. (Published: February 14, 2018)

What Types of Treatment Do Children with ADHD Receive? Learn about the national rates of ADHD medication, behavior therapy, and other types of treatment in children with ADHD aged 4 to 17 years in 2014. (Published: November 10, 2017)

National profile of ADHD diagnosis and treatment in young children Learn about the rates of diagnosis, medication, and behavior treatment in children aged 2 to 5 years in 2011-2012 (Published: July 18, 2017)

Treatment of Disruptive Behavior Problems – What Works? Learn about current evidence on the most effective treatments for behavior problems in children (Published: May 1, 2017)

ADHD Across the Lifetime ADHD symptoms often start in childhood and continue into adulthood, but they may look different in adults. (Published October 16, 2023)

Where Children Live Might Impact ADHD Learn what CDC is doing to understand differences in ADHD diagnosis and treatment. (Published October 18, 2022)

Not Just ADHD? Learn more about how to help children who have ADHD and other disorders (Published September 28, 2021)

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Behavior Therapy First for Young Children with ADHD Learn about using parent behavior therapy first to help young children with ADHD. (Published: February 3, 2020)

Protecting the Health of Children with ADHD Learn about health risks associated with ADHD and about healthy habits that can help protect children from long-term health risks. (Published: October 8, 2019)

Is it ADHD? Learn about the symptoms of ADHD and what to do if you’re concerned that your child might have this disorder. (Published: August 28, 2019)

Vital Signs: ADHD in Young Children Use recommended treatment first. (Published: May 3, 2016)

* These CDC scientific articles are listed in order of date published

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A National Profile of Attention-Deficit Hyperactivity Disorder Diagnosis and Treatment Among US Children Aged 2 to 5 Years Journal of Developmental and Behavioral Pediatrics. 2017, 38(7), 455–464. Melissa L. Danielson, Susanna S. Visser, Mary Margaret M. Gleason, Georgina Peacock, Angelika H. Claussen, Stephen Blumberg. Read key findings

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Demographic Differences Among a National Sample of US Youth With Behavioral Disorders Clinical Pediatrics, 2016; 55(14), 1358-1362. Susanna N. Visser, Emily L. Deubler, Rebecca H. Bitsko, Joseph R. Holbrook, and Melissa L. Danielson, Read extract

Persistence of Parent-Reported ADHD Symptoms From Childhood Through Adolescence in a Community Sample. Journal of Attention Disorders . 2016 Jan;20(1):11-20 Joseph R. Holbrook, Steven P. Cuffe , Bo Cai, Susanna N. Visser, Melinda S. Forthofer, Matteo Bottai, Andrew Ortaglia, Robert E. McKeown Read key findings |  Read summary

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Treatment of Attention-Deficit/Hyperactivity Disorder among Children with Special Health Care Needs Journal of Pediatrics, 2015; 166:1423-30. Susanna N. Visser, Rebecca H. Bitsko, Melissa L. Danielson, Reem M. Gandhour, Stephen J. Blumberg, Laura Schieve, Joseph R. Holbrook, Mark L. Wolraich,  Stephen P. Cuffe. Read key findings |  Read article

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Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated ADHD Disorder: United States, 2003—2011. Journal of the American Academy of Child and Adolescent Psychiatry;  2014,53(1):34–46.e2. Susanna N. Visser, Melissa L. Danielson, Rebecca H. Bitsko, Joseph R. Holbrook, Michael D. Kogan, Reem M. Ghandour, Ruth Perou, Stephen J. Blumberg Read key findings |  Read article |  Listen to a podcast by the journal discussing the study

Convergent validity of parent-reported attention-deficit/hyperactivity disorder diagnosis: A cross-study comparison. JAMA Pediatrics 2013; 167(7):674-675. Susanna N. Visser, Melissa L. Danielson, Rebecca H. Bitsko, Ruth Perou, Stephen J. Blumberg Read key findings |  Read article

The prevalence of ADHD: Its diagnosis and treatment in four school districts across two states Journal of Attention Disorders. October 2014; 18 (7), 563-575. Mark L. Wolraich, Robert E. McKeown, Susanna N. Visser, David Bard, Steven Cuffe, Barbara Neas Lorie L. Geryk, Melissa Doffing, Matteo Bottai, Ann J. Abramowitz, Laoma Beck, Joseph R. Holbrook, Melissa Danielson Read article

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• ORIGINAL PAPER
• Published: 20 January 2022

“Being ADHD”: a Qualitative Study

• Rosalind Redshaw   ORCID: orcid.org/0000-0002-4965-4000 1 &
• Lynne McCormack 1  

Advances in Neurodevelopmental Disorders volume  6 ,  pages 20–28 ( 2022 ) Cite this article

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Attention deficit hyperactivity disorder (ADHD) is well recognised as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development; however, little is known about the subjective experience of “being ADHD”. This phenomenological idiographic study explored how nine individuals with ADHD make sense of their life experiences, ability to function, and ideas about self in the context of ADHD.

Semi-structured interviews were used to collect data from nine participants aged 29 to 54. Audio recordings of interviews were then transcribed and analysed according to the protocols of interpretative phenomenological analysis (IPA).

Three themes emerged (1) otherness; (2) pixies, monkeys, and living in the moment; and (3) Challenging “broken”. Themes encompass the experience of being different to others, mechanics of daily functioning, and advantages of being ADHD.

A tendency to live in the moment was consistent across the nine participants in this study and aligns with quantitative research showing differences in the processing of temporal information in ADHD. The effects of this tendency on day-to-day functioning are linked to typical symptoms of ADHD, as well as perceived advantages. Participants attributed an uncommon degree of energy, optimism, adventurousness and curiosity, and novel problem-solving ability to their ADHD, adding to existing literature that suggests there are advantages to this unique mental architecture. Identifying positive aspects to ADHD offers clinicians and educators a pathway for mitigating the negative effects on self that flow from the challenges of ADHD.

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We are extremely grateful to the participants who took part in this research for their time and efforts.

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RR: designed and executed the study, independently and jointly analysed the data, and wrote the paper. LM: trained RR in IPA, independently and jointly analysed the data, and collaborated with the design and writing of the study and editing of the final manuscript.

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Redshaw, R., McCormack, L. “Being ADHD”: a Qualitative Study. Adv Neurodev Disord 6 , 20–28 (2022). https://doi.org/10.1007/s41252-021-00227-5

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• CAREER COLUMN
• 13 May 2020

The ADHD paper that triggered a backlash, and what it taught me

• Anita Thapar 0

Anita Thapar is professor of child and adolescent psychiatry at Cardiff University, UK.

You can also search for this author in PubMed   Google Scholar

In September 2010, I and two colleagues held a press conference on a paper we were about to have published in The Lancet . The paper was a genome-wide analysis that showed a higher burden of rare chromosomal deletions or duplications in people with attention-deficit hyperactivity disorder (ADHD) than in those unaffected by the condition (N. M. Williams et al. Lancet 376 , 1401–1408; 2010).

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doi: https://doi.org/10.1038/d41586-020-01433-2

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ADHD Research Roundup: New Studies, Findings & Insights

Adhd research continues to reveal new insights about attention deficit — its relationship to trauma, race, emotional dysregulation, rejection sensitive dysphoria, and treatments ranging from medication to video games. we’ve curated the most significant news of the past year., adhd research continues to reveal new truths.

ADHD research has produced groundbreaking and impactful discoveries in the past year. Our understanding of the relationship between health care and race has deepened. Alternative treatments, like video games and neurofeedback, are showing encouraging promise while ADHD stimulant medication continues to demonstrate benefits for patients of all ages. The connections between comorbid conditions, gender, and ADHD are better understood than ever before. And we are encouraged by the ongoing work coming from the world’s leading research teams.

Read below to catch up on the most significant news and research from 2020, and stay updated on new findings as they are published by subscribing to ADDitude’s free monthly research digest .

General ADHD Research

Study: Long-Term Health Outcomes of Childhood ADHD are Chronic, Severe November 24, 2020 Childhood ADHD should be considered a chronic health problem that increases the likelihood of adverse long-term health outcomes, according to a population-based birth cohort study of children with ADHD and psychiatric disorders. Further research on the impact of treatment is needed.

Study: Living with ADHD Causes Significant Socioeconomic Burden October 21, 2020 Living with ADHD poses a significant economic burden, according to a new study of the Australian population that found the annual social and economic cost of ADHD was $12.76 billion, with per person costs of $15,664 over a lifetime.

Study: Unmedicated ADHD Increases the Risk of Contracting COVID-19 July 23, 2020 The COVID-19 infection rate is nearly 50% higher among individuals with unmedicated ADHD compared to individuals without ADHD , according to a study of 14,022 patients in Israel. The study found that ADHD treatment with stimulant medication significantly reduces the risk of virus exposure among individuals with ADHD symptoms like hyperactivity and impulsivity.

[ Does My Child Have ADHD? Take This Test to Find Out ]

Study: Poverty Increases Risk for ADHD and Learning Disabilities March 23, 2020 Children from families living below the poverty level, and those whose parents did not pursue education beyond high school, are more likely to be diagnosed with ADHD or learning disabilities, according to a new U.S. data brief that introduces more questions than it answers.

ADHD and Children

Study: Diagnosed and Subthreshold ADHD Equally Impair Educational Outcomes in Children December 21, 2020 Children with diagnosed and subthreshold ADHD both experienced impaired academic and non-academic performance compared to controls used in an Australian study examining the two community cohorts.

Study: Children with ADHD More Likely to Bully — and to Be Bullied November 23, 2020 Children with ADHD are more likely than their neurotypical peers to be the bully, the victim of bullying, or both, according to a new study.

Study: ADHD Symptoms in Girls Diminish with Extracurricular Sports Activity October 16, 2020 Consistent participation in organized sports reliably predicted improved behavior and attentiveness in girls with ADHD, according to a recent study of elementary school students active — and not active — in extracurricular activities. No such association was found for boys with ADHD.

[ Do I Have ADHD? Take This Test to Find Out ]

Study: ADHD in Toddlers May Be Predicted by Infant Attentional Behaviors August 12, 2020 Infants who exhibit behaviors such as “visually examining, acting on, or exploring nonsocial stimuli including objects, body parts, or sensory features” may be more likely to demonstrate symptoms of ADHD as a toddler, according to a new study that also found a correlation between this Nonsocial Sensory Attention and later symptoms of executive dysfunction.

Study Shows Gender Disparities in ADHD Symptoms of Hyperactivity and Poor Response Inhibition June 26, 2020 Girls with ADHD are less physically hyperactive than are boys with the condition, and experience fewer problems with inhibition and cognitive flexibility, according to a new meta-analysis that says more accurate screening tools are needed to recognize the subtler manifestations of ADHD in girls.

Study: Raising a Child with ADHD Negatively Impacts Caregivers’ Mental Wellbeing July 27, 2020 Caring for a child with ADHD negatively impacts caregivers’ quality of sleep, relationships, and satisfaction with free time, among other indicators of mental wellbeing, according to a recent study from the United Kingdom. The significant deficit in sleep and leisure satisfaction led researchers to conclude that caregivers may benefit from greater support — for example, coordinated health and social care — that focuses on these areas.

Study: ADHD, Diet, Exercise, Screen Time All Directly or Indirectly Impact Sleep July 27, 2020 A child with ADHD is more likely to experience sleep problems, in part because ADHD symptoms influence diet and physical activity — two factors that directly impact sleep. This finding comes from a new study that also shows how screen time impacts exercise, which in turn impacts sleep. Understanding these interwoven lifestyle factors may help caregivers and practitioners better treat children with ADHD.

ADHD and Adolescents

Teens with ADHD Should Be Regularly Screened for Substance Use Disorder: International Consensus Reached July 17, 2020 Adolescents with ADHD should be regularly screened for comorbid substance use disorder, and vice versa. This was one of 36 statements and recommendations regarding SUD and ADD recently published in the European Research Addiction Journal.

Study: Girls with ADHD Face Increased Risk for Teen Pregnancy February 12, 2020 Teenagers with ADHD face an increased risk for early pregnancy, according to a new study in Taiwan. However, long-term use of ADHD medications does reduce the risk for teen pregnancies. Researchers suggested that ADHD treatment reduces the risk of any pregnancy and early pregnancy both directly by reducing impulsivity and risky sexual behaviors and indirectly by lowering risk and severity of the associated comorbidities, such as disruptive behavior and substance use disorders.

Study: Teens with ADHD Face Increased Risk for Nicotine Addiction January 27, 2020 Young people with ADHD find nicotine use more pleasurable and reinforcing after just their first smoking or vaping experience, and this may lead to higher rates of dependence, according to findings from a new study published in the Journal of Neuropsychopharmacology .

Study: Adolescent Health Risks Associated with ADHD Go Unmonitored by Doctors February 27, 2020 The health risks facing adolescents with ADHD — teen pregnancy, unsafe driving, medication diversion, and more — are well documented. Yet, according to new research, primary care doctors still largely fail to address and monitor these urgent topics during their patients’ transition to young adulthood.

Study: Emotional Dysregulation Associated with Weak, Risky Romantic Relationships Among Teens with ADHD May 20, 2020 Severe emotional dysregulation increases the chances that an adolescent with ADHD will engage in shallow, short-lived romantic relationships and participate in unprotected sex, according to a new study that suggests negative patterns developed in adolescence may continue to harm the romantic relationships and health of adults with ADHD .

ADHD and Adults

Study: Discontinuing Stimulant Medication Negatively Impacts Pregnant Women with ADHD December 17, 2020 Women with ADHD experience negative impacts on mood and family functioning when they discontinue stimulant medication use during pregnancy, according to a new observational cohort study that suggests medical professionals should consider overall functioning and mental health when offering treatment guidance to expectant mothers.

New Study: Adult ADHD Diagnosis Criteria Should Include Emotional Symptoms April 21, 2020 The ADHD diagnosis criteria in the DSM-5 does not currently include emotional symptoms, despite research indicating their importance. Now, a new replication analysis has found that ADHD in adults presents in two subtypes: attentional and emotional. Researchers suggest that this system offers a more clinically relevant approach to diagnosing ADHD in adults than does the DSM-5 .

Study: Stimulant ADHD Medication Relatively Safe and Effective for Older Adults June 30, 2020 Older adults with ADHD largely experience symptom improvement when taking a low dose of stimulant medication, which is well tolerated and does not cause clinically significant cardiovascular changes. This is the finding of a recent study examining the effects of stimulant medication among adults aged 55 to 79 with ADHD, some of whom had a pre-existing cardiovascular risk profile.

ADHD, Race, and Culture

Study Explores Medication Decision Making for African American Children with ADHD June 23, 2020 In a synthesis of 14 existing studies, researchers have concluded that African American children with ADHD are significantly less likely than their White counterparts to treat their symptoms with medication for three main reasons: caregiver perspectives on ADHD and ADHD-like behaviors; beliefs regarding the risks and benefits associated with stimulant medications; and the belief that ADHD represents a form of social control.

Culturally Adapted Treatment Improves Understanding of ADHD In Latinx Families August 31, 2020 Latinx parents are more likely to recognize and understand ADHD after engaging in culturally adapted treatment (CAT) that includes parent management training sessions adapted to be more culturally appropriate and acceptable, plus home visits to practice skills. This recent review of ADHD knowledge among Latinx parents found that CAT outperformed evidence-based treatment (EBT) in terms of parent-reported knowledge of ADHD.

Treating ADHD

Study: New Parent Behavior Therapy Yields Longer ADHD Symptom Control in Children October 6, 2020 ADHD symptom relapse was significantly reduced in children of parents who participated in a new schema-enhanced parent behavior therapy, compared to those whose parents participated in standard PBT.

Research: Physical Exercise Is the Most Effective Natural Treatment for ADHD — and Severely Underutilized January 22, 2020 A new meta-analysis shows that physical exercise is the most effective natural treatment for controlling ADHD symptoms such as inhibition, attention, and working memory . At the same time, a comprehensive study reveals that children with ADHD are significantly less likely to engage in daily physical activity than are their neurotypical peers.

A Video Game Prescription for ADHD? FDA Approves First-Ever Game-Based Therapy for Attention June 18, 2020 Akili Interactive’s EndeavorRx is the first game-based digital therapeutic device approved by the FDA for the treatment of attention function in children with ADHD. The history-making FDA OK followed a limited-time release of the device during the coronavirus pandemic, and several years of testing the device in randomized controlled trials.

Study: Neurofeedback Effectively Treats ADHD April 9, 2020 Neurofeedback is an effective treatment for ADHD , according to a new quantitative review that used benchmark studies to measure efficacy and effectiveness against stimulant medication and behavior therapy. These findings relate to standard neurofeedback protocols, not “unconventional” ones, for which significant evidence was not found.

Study: Mindfulness-Enhanced Behavioral Parent Training More Beneficial for ADHD Families June 29, 2020 Behavioral parent training (BPT) enhanced with mindfulness meditation techniques provides additional benefits to parents of children with ADHD, such as improved discipline practices and parental behavioral regulation. This is the finding of a new randomized control trial conducted by researchers who compared mindfulness-enhanced to standard BPT.

Mapping the ADHD Brain: MRI Scans May Unlock Better Treatment and Even Symptom Prevention March 9, 2020 Brain MRI is a new and experimental tool in the world of ADHD research. Though brain scans cannot yet reliably diagnose ADHD, some scientists are using them to identify environmental and prenatal factors that affect symptoms, and to better understand how stimulant medications trigger symptom control vs. side effects.

New Clinical Guidelines: Holistic Treatment Is Best for Children with ADHD and Comorbidities February 3, 2020 The Society for Developmental and Behavioral Pediatrics (SDBP) says that children and teens with ADHD plus comorbidities should receive psychosocial treatment, such as classroom-based management tools, in addition to ADHD medication.

Study: Mindfulness Exercises Effectively Reduce Symptoms in Boys with ADHD and ODD May 19, 2020 Boys with both ADHD and ODD were less hyperactive and more attentive after attending a multi-week mindfulness training program, according to a new study that finds promise in this treatment as a viable complement or alternative to medication.

ADHD and Comorbid Conditions

Study: Risk for Diabetes 50% Higher for Adults with ADHD October 23, 2020 A diagnosis of ADHD increased the likelihood of diabetes by as much as 50% for adults with ADHD, according to a recent study from the National Health Interview Survey that found the strong correlation independent of BMI.

Study: ADHD Symptoms Associated with More Severe Gambling Disorder and Emotional Dysregulation January 28, 2020 Roughly one-fifth of individuals diagnosed with gambling disorder in the study also tested positive for ADHD symptoms. This population is more likely to experience severe or acute symptoms of gambling disorder, which is tied to higher emotional dysregulation, according to a new study of 98 Spanish men.

ADHD Research: Next Steps

• Read: New Insights Into Rejection Sensitive Dysphoria
• Download: The All-Time Best Books on ADHD
• Learn: What Is ADHD? Definition, Myths & Truths

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TOP TEN RESEARCH PRIORITIES FOR ATTENTION DEFICIT/HYPERACTIVITY DISORDER TREATMENT

Affiliations.

• 1 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU)[email protected].
• 2 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU)Faculty of Odontology,Malmö University.
• 3 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU).
• 4 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU)Faculty of Odontology,Malmö University,Department of Dental Medicine,Karolinska Institutet.
• PMID: 27516379
• DOI: 10.1017/S0266462316000179

Objectives: The aim of this project was to identify the ten most important research questions for attention deficit/hyperactivity disorder (ADHD) treatment as identified by people with ADHD together with personnel involved in the treatment of ADHD in school, health, and correction services.

Methods: A working group consisting of consumers and personnel was established. The method for prioritization was primarily based on James Lind Alliance's guidebook, consisting of an interim priority setting exercise and a workshop.

Results: The top ten list includes the risk of drug dependency later in life when treated with methylphenidate as a child, teacher support, multimodal therapy, comparisons between atomoxetine and methylphenidate, methylphenidate treatment in substance abusers, parental support programmes, supported conversation, computer-aided working memory training, psychoeducative treatment, and melatonin.

Conclusions: We have shown that consumers and personnel can reach consensus on research priorities for treatments for ADHD. We encourage researchers and funders to consider the list for future studies.

Keywords: Attention deficit disorder with hyperactivity; Mental disorders; Patient participation.

• Attention Deficit Disorder with Hyperactivity / drug therapy*
• Central Nervous System Stimulants / therapeutic use
• Patient Participation
• Randomized Controlled Trials as Topic
• Central Nervous System Stimulants

• Open access
• Published: 16 November 2023

Clinical implications of ADHD, ASD, and their co-occurrence in early adulthood—the prospective ABIS-study

• Andrea Lebeña 1 ,
• Åshild Faresjö 2 ,
• Tomas Faresjö 2 &
• Johnny Ludvigsson 1 , 3  

BMC Psychiatry volume  23 , Article number:  851 ( 2023 ) Cite this article

267 Accesses

5 Altmetric

Metrics details

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are childhood-onset disorders associated with functional and psychosocial impairments that may persist into adulthood, leading to serious personal and societal costs.

This study aimed to examine the socio-economic difficulties, physical and mental comorbidities, and psycho-social vulnerabilities associated with ADHD, ASD, and their co-occurrence among young adults.

16 365 families with children born 1997–1999, were involved in the prospective population-based ABIS study (All Babies in Southeast Sweden). A total of 6 233 ABIS young adults answered the questionnaire at the 17–19-year follow-up and were included in this case–control study. Diagnoses of ADHD and ASD from birth up to 17 years of age were obtained from the Swedish National Diagnosis Register. N =182 individuals received a single diagnosis of ADHD, n =78 of ASD, and n =51 received both diagnoses and were considered the co-occurrence group. Multiple multinomial logistic regression analyses were performed.

In the univariate analyses all three conditions were significantly associated with concentration difficulties, worse health quality, lower socio-economic status, lower faith in the future, less control over life, and lower social support. In the adjusted analyses, individuals with ADHD were almost three-times more likely to have less money compared with their friends (aOR 2.86; p  < .001), experienced worse sleep quality (aOR 1.50; p  = .043) and concentration difficulties (aOR 1.96; p  < .001). ASD group were two-fold more likely to experience concentration difficulties (aOR 2.35; p  = .002) and tended not to have faith in the future (aOR .63; p  = .055), however, showed lesser risk-taking bahaviours (aOR .40; p  < .001). Finally, the co-occurrence was significantly associated with unemployment (aOR 2.64; p  = .007) and tended to have a higher risk of autoimmune disorders (aOR 2.41; p  = .051), however, showed a 51% lower risk of stomach pain (aOR .49; p  = .030).

Conclusions

All these conditions significantly deteriorated several areas of life. ADHD/ASD co-occurrence is a heavy burden for health associated with several psychosocial vulnerabilities, that shared a similar morbidity pattern with ADHD although showed less risk cognitive and behavioral profile, similar to the ASD group. Long-term follow-up and support for individuals with these conditions over the life course are crucial.

Peer Review reports

Introduction

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are common childhood-onset neurodevelopmental disorders [ 1 , 2 ] generally persisting into adulthood [ 3 , 4 , 5 ]. The challenges for these persons are twofold: they face age-related effects experienced by the general population, such as new social challenges and biological and emotional transition to adulthood, alongside disorder-specific effects [ 6 ].

The phenotypes of neurodevelopmental disorders (NDDs) are heterogeneous, and their complexity is compounded by high comorbidity rates with several conditions (i.e., gastrointestinal disturbances, congenital anomalies, and immunological disorders) [ 7 ]. In previous studies, ADHD and ASD have been associated with coexisting psychiatric and neurological conditions, such as oppositional and conduct disorders, tic disorders, epilepsy, depression, anxiety, and substance use disorders [ 8 , 9 ]. Moreover, both disorders have been found to be associated with psychosocial functional impairments and a range of adverse outcomes in patients and their families [ 4 , 5 , 10 , 11 ]. Children and adults with ADHD or ASD often experience emotional and social difficulties, which also negatively impact their quality of life [ 3 , 4 , 5 ].

It has also been shown that psychological, physical, and sexual forms of abuse and household dysfunction such as substance abuse, mental illness, and violence were associated with risk behaviours like binge drinking and smoking, poor health in general, and a higher risk of obesity, myocardial infarction, and stroke [ 12 ]. Risk-taking behaviours and unhealthy habits are mostly established during adolescence and are often carried into adulthood, having long-term effects on lifestyle and health [ 13 ]. Finally, several studies have suggested that ASD and ADHD may be even associated with an increased risk of mortality due to both natural and non-natural causes [ 14 , 15 , 16 ].

Despite the growing body of research pointing at the impact of ADHD and ASD on health and quality of life, little is known regarding their co-occurrence, which could be associated with greater impairment than a single condition and could be less responsive to standard treatments for either disorder. The current study aimed to examine the socio-economic difficulties, physical and mental comorbidities, and psycho-social vulnerabilities associated with ADHD, ASD, and especially their co-occurrence in early adulthood.

Study population

This study includes data from the ABIS-Study (All Babies in Southeast Sweden), a longitudinal, population-based cohort study based on data collected from 16 365 families with children born between October 1997 and October 1999 in Southeast Sweden. ABIS-Study aims to investigate how environmental and genetic factors influence the development of immune-mediated diseases, which include ADHD and ASD, where immune mechanisms may play a role [ 17 ]. The children included in the ABIS-Study have been followed from birth onwards, and questionnaires data, biological samples, and register data of diseases (based on medical records) have been collected at birth and age of 1, 3, 5, 8, 10–12, 17–19, and 23–25 years. A total of 6 233 young adults who were included in the ABIS-Study at birth and answered the questionnaire at 17–19 years follow-up, were included in this prospective case–control sub study (Fig.  1 ).

Study population flow-chart

Definition of case and control groups based on the cumulative incidence rates for ADHD, ASD, and their co-occurrence from birth until 17 years of age. ADHD indicates attention-deficit/hyperactivity disorder, while ASD indicates autism spectrum disorder

Diagnosis of ADHD, ASD, and their co-occurrence

The diagnoses of ADHD, ASD, and their co-occurrence were obtained from birth until 17 years of age for the 17–19 years follow-up participants ( n  = 6 233), by cross-linking with the Swedish National Patient Register (NPR), containing all hospital inpatients (since 1973) and outpatients (since 2001) International Classification of Diseases (ICD-8 to ICD-10) based on doctor-set diagnoses [ 18 ]. According to ICD-10, F90 (F90.0, F90.1, F90.8, and F90.9) and F84 (F84.0, F84.1, F84.2, F84.3, F84.4, F84.5, F84.8, and F84.9) were the diagnostic codes used for ADHD and ASD, respectively. Those participants who got a unique diagnosis of ADHD ( n  = 182), those who received a unique ASD diagnosis ( n  = 78), and those who got both diagnoses (ADHD and ASD co-occurrence) ( n  = 51), according to the NPR, are the three-case groups. The rest of the study population constitutes the control group ( N  = 5 860) (Fig.  1 ).

The parents were given oral and written information before giving informed consent to participate in the study. The ABIS study was approved by the research ethics committees at Linköping University (Dnr 96–287, Dnr 99–321, and Dnr 03–092) and Lund University (LU 83–97) in Sweden, and connection of the ABIS registers to National registers was approved by the Research Ethics Committee in Linköping (Dnr 2013/253–32). All methods were carried out following relevant guidelines and regulations.

The items from the web survey answered at 17–19 years of age (see Additional file 1 ), were categorized into four major areas:

Socio-economic indicators

Included if they have enough money to do the same thing as their friends, and questions regarding occupation (studying, working or unemployed).

Health-related factors

Comprised questions regarding health quality (ranged from 1 very poor to 5 excellent), exercise until get sweaty (dichotomic), weekdays and weekends screen time exposure (categorized in less or more than 4hs per day, according to The American Academy of Pediatrics—AAP) [ 19 ], sleep quality (ranged from 1 very poor to 5 excellent), headache, stomach, and joint pain (ranged from 1 never to 5 almost every day), if they have been or being severely ill (dichotomic), if they have allergies, and BMI (underweight < 18.36, normal 18.37–26.35, overweight 26.36–30.11, or obese > 30.12). Doctor-set diagnoses of autoimmune diseases: celiac disease, psoriasis, immune thrombocytopenic purpura, hypothyroidism, thyrotoxicosis (hyperthyroidism), autoimmune thyroiditis, type 1 diabetes mellitus, arteritis, Crohn’s disease, ulcerative colitis, vitiligo, juvenile arthritis, Kawasaki syndrome, and Sjögren syndrome, were obtained by cross-linking with the Swedish National Patient Register (NPR).

Psychosocial vulnerability

Involved questions about faith in the future, control over life, perceived stress during the last month (ranged from 1 not at all to 10 very much), and being bullied (ranged from 1 never to 5 always). If they feel down or depressed, worried or anxious, and concentration difficulties (ranged from 1 never to 5 almost every day) were also added. Questions regarding job or academic feelings/performance , and social support (from friends, family, or school) were included as well. It also involved if the participants had been exposed to serious life events in the last two years, including death or severe illness in the family (death of parent, sibling, or grandparents, and severe illness within the family), unstable family situation (many conflicts between adults, divorced or separated parents, sole custody with regular or no/sporadic contact with the non-custodial parent, new adults in the family, new children in the family, contact with a supportive family), contact with social authorities for support, if they were sexually or physically abused (by an adult or peer), and robbery victim. An index of stressful life events was developed based on the cumulative frequency of the described stressful events (none, one or two, more than three).

Risk-taking behaviours and perceptions of risks

The questionnaire included 5 dichotomic items regarding tobacco smoking, e-cigarette use, hashish/marijuana smoking, snuff use, and alcohol consumption. An index with a max. score of 5 points was made and a higher score corresponded to many unhealthier/risk-taking behaviours. The questionnaire also included other 5 items that assessed particpants´perceptions of the above-mentioned risk-taking behaviours (eg. “imagine someone that smokes 2–3 times/day: how harmful do you think this is for health?”). All items ranged from 1 (not harmful at all) to 5 (extremely harmful), the index had a max. score of 25. Scores from 5 to 15 were considered slightly/moderately harmful, while scores between 16 and 25 were considered extremely/quite harmful.

Statistical analyses

All statistical analyses were performed in SPSS software version 28.0 (IBM SPSS Inc., Chicago, IL, USA). Dichotomous variables were presented as frequencies and percentages, and differences between groups were assessed using the Chi-squared test. A p -value ≤ 0.05 was considered statistically significant, and multiple comparisons between the three case-groups were adjusted using Bonferroni correction (Tables 1 , 2 , 3 and  4 ). A comparison was made between those who participated in the 17–19 year follow-up and those who did not to evaluate the risk of skewness in participation over time. Identification of statistically independent discriminators used a backward elimination algorithm in which all univariately statistically significant discriminators (Unadjusted model – Table 5 ) were entered into a single full model in the multiple multinomial logistic regression analyses (Adjusted model – Table 5 ). Effect sizes were reported as odds ratios (OR) within 95% confidence intervals (95% CI) and 2-tailed p -values.

All case-groups showed lower participation in the 17–19 years follow-up compared to the controls. Females constitute 36.5% of NDDs cases, 48.4% of ADHD, 37.2% of ASD, and 37.3% of the co-occurrence group, were women. All three conditions reported having less money than friends, while ASD and the co-occurrence groups were more likely to be unemployed (Table 1 ).

Health-related outcomes

All three case-groups reported worse health quality compared with the control group. The ADHD group reported having somatic complaints (stomach and joint pain) more regularly, lower physical activity, and worse sleep quality than the control group did. ASD group reported having severe illness in the last two years, lower physical activity, and were more likely to be overweight/obese. The ASD group also reported longer screen exposure (> 4 h/day) than the control group. The co-occurrence group was more likely to have a severe illness and autoimmune diseases, tended to be underweight or overweight/obese, and reported worse sleep quality than the control group did. The co-occurrence group also reported longer screen exposure (> 4 h/day) during weekends but was not significant (Table 2 ).

All three case-groups reported having contacted social authorities for support, regular concentration difficulties, lower faith in the future, and a lack of social support, compared with the control group. The ADHD and the co-occurrence groups were more likely to experienced 3 or more serious life events in the last two years, however, those events were more violence-related (physical abuse by an adult or peer and robberies) in the ADHD group, while death/illness in the family and unstable family situation where predominantly associated with the co-occurrence group. Both groups also indicated worse job or academic feelings/performance, frequent anxious and depressed feelings, and being bullied (did not rich the significance in the ADHD group). The ADHD group also reported greater perceived stress, and less control over life than the control group did. The ASD group, like the ADHD group, reported less control over life (Table 3 ).

Tobacco, e-cigarettes, hashish/marijuana smoking, and snuff use, were more frequently reported among the ADHD group. ASD group reported instead e-cigarettes and hashish/marijuana smoking, but also alcohol consumption to a lesser extent than the control group did. The co-occurrence group was also less likely to alcohol consumption compared with the control group. Regarding perceptions of risks, tobacco and e-cigarettes smoking every day, and hashish/marijuana smoking and snuff use every week, were considered less harmful among the ADHD group compared to the control group (Table 4 ).

Case-group comparisons

The ADHD group showed lower participation in the 17–19 year follow-up than ASD and reported lower unemployment rates than the co-occurrence group. The co-occurrence group, compared to the ADHD were more likely to be either underweight or overweight/obese and to report severe illness, while ADHD reported having stomach pain more frequently than ASD and the co-occurrence group. The ASD group reported longer screen exposure (during weekends) than the ADHD group, and better sleep quality than the ADHD and the co-occurrence group. In terms of vulnerability, the co-occurrence group reported having contact with social authorities to a greater extent than the ADHD group and being bullied more often compared to the ASD group. The ADHD group perceived higher stress levels than the ASD group did. What concerns about risk-taking behaviours, the ADHD group was more likely to smoke e-cigarettes and consume alcohol than ASD and the co-occurrence group, but also used snuff to a  greater extent than the ASD group. Oppositely, the ASD group reported tobacco and hashish/marijuana smoking to a lesser extent than the ADHD and the co-occurrence group. Regarding perceptions of risk-taking behaviours, the co-occurrence group considered smoking hashish/marijuana every week as more harmful than the ADHD group, and alcohol consumption every week than the ASD group (case-groups comparisons column, Tables 1 , 2 , 3 and  4 ).

Statistically independent effects

Less money than friends, concentration difficulties, and bad sleep quality remain significant for ADHD in the multiple multinomial logistic regression analyses, while perceptions of risks showed a tendential effect (Table 5 ). Regarding the ASD group, concentration difficulties, and fewer risk-taking behaviours were the ones that remained significant in the multiple multinomial logistic regression analyses, together with a lower faith in the future, lower perceived stress levels, and less money than friends, all of them showed a tendential effect. Finally, being unemployed, and having less stomach pain were the ones statistically associated with the co-occurrence group, while having an autoimmune disease was tendential.

This is the first-ever prospective study evaluating the impact of ADHD, ASD, and their co-occurrence on socio-economic, health, psychosocial vulnerabilities, risk-taking behaviours, and perceptions of risks in early adulthood. The observed associations suggested that socio-economic status, health quality, faith in the future, control over life, and social support are significantly compromised in individuals with any of these conditions. Our aim was especially to study the impact of the co-occurrence of both disorders, since it was shown that between 30 and 50% of individuals with ASD manifest ADHD symptoms, and two-thirds of individuals with ADHD show features of ASD [ 20 ].

The co-occurrence condition shared several morbidities with the ADHD group, thus both often experienced depressed and anxious feelings and worse sleep quality. Previous studies have found that as many as 80% of adults with ADHD have at least one coexisting psychiatric disorder [ 21 , 22 ], including depression and anxiety, bipolar disorder, and substance use disorder (SUD) [ 23 , 24 ]. Despite some studies also reporting higher lifetime rates of psychiatric comorbidities (major depressive disorder, anxiety, social phobia, and obsessive–compulsive disorder) in persons with autism [ 25 , 26 , 27 ], in this study the ASD group did not report depression or anxious feelings, neither higher perceived stress. Considering the association observed in this study between the co-occurrence and ADHD and serious life events, we could hypothesize that these individuals experienced, alongside the disorder-specific challenges, a more hostile environment (violence-related in the ADHD and more psychosocial in the co-occurrence), which can make them more prone to develop comorbid psychiatric symptomatology. In this line, it was also observed in this study that the co-occurrence group reported being bullied more often. Previous studies found that ADHD adults were more likely to have been divorced and less satisfied with their personal, social, and professional lives [ 28 ], while adults with autism often have satisfying social relationships [ 29 ]. Despite that, a lack of social support was reported as a common experience among all three conditions and could be attributed to social communication difficulties [ 30 ]. Interestingly the co-occurrence, but not each condition separately, was associated with a high risk of having an autoimmune disorder, which may suggest that both disorders could share the same autoimmune etiological mechanism. In previous studies celiac disease, ulcerative colitis, psoriasis, and T1D were linked to ADHD [ 31 , 32 ], similarly, a study on adults on the spectrum reported a high prevalence of immune conditions (70.2%) in their sample [ 33 ].

In this study, individuals with ASD or those with the co-occurrence condition, were more likely to be unemployed, on this line, studies consistently reported unemployment rates around 30–40% in adults with autism [ 34 , 35 ]. In accordance also with ASD, unlike the ADHD group, the co-occurrence was associated with lesser risk-taking behaviours and perceptions of risks. ADHD is accompanied by less activation of the frontoparietal networks associated with deficient inhibition, and impairments in executive functioning and decision-making [ 36 ], which may explain why this group perceived tobacco, e-cigarette, hashish/marijuana smoking, snuff use, and alcohol consumption as less harmful and therefore was more prone to these risk-taking behaviours. This same mechanism could also explain the association of ADHD with externalizing disorders such as conduct disorder and oppositional defiant disorder [ 37 ]. However, it could also be that drug use, through its pharmacological effects, make these persons less concerned with the consequences of their actions or more willing to become involved in risky behaviours or bad lifestyle to support a drug dependency or addiction [ 38 ]. Intriguingly, although there is a reported association between ADHD and overweight, we did not find a significant association, which may depend on the pharmacological treatment for ADHD, which is known to reduce appetite [ 39 ]. The co-occurrence however, showed a high risk of being underweight or overweight (similar to the ASD group). In the same direction as our results, some studies have reported higher rates of common chronic health conditions related to obesity, such as hypertension, dyslipidemia, diabetes, and in general poorer health outcomes in adults with autism [ 40 ]. Another study found self-rating general health as worse in a higher proportion of adults with autism [ 41 ]. In this study, despite all case-groups showing low health quality, the co-occurrence and ASD groups reported severe illness in the last two years in greater proportion than the control group did.

According to the results observed in this study, the individuals with ADHD seem to be exposed to different challenges than those with ASD. The ADHD group was characterized by more frequent somatic complaints (especially stomach and joint pain). In this line, a study found that adults with ADHD visited physicians 10 times more often and had rates of emergency room visits and hospitalization three times greater than controls [ 42 ]. This group also had worse job or academic feelings/performance, and lower physical activity. The ASD group also showed lower physical activity and longer screen exposure during weekends (> 4h/day). Establishing social relationships often comes with unique challenges for young-adults with ASD. One study found that subjects with autism who use social networking sites were found more likely to have close friends [ 43 ], which could explain the longer screen exposure of this group during weekends. A better understanding of the relative impact of these conditions in several areas of life could provide clues for enhanced specific-treatment options.

Strengths and limitations

Our study has important strengths as our results are based on a large prospective birth cohort from the general population with a follow-up for more than 20 years and the strength of merging doctor-set diagnoses of ADHD, ASD, and autoimmune disorders via the National Diagnosis Register. However, our study also has some limitations. Besides diagnosis and household income, all other data are based on self-reported questionnaires, and therefore they could potentially be subject to recall bias, even though it is unlikely that this can explain our results. The attrition analyses showed that the families of young adults that responded to the 17–19 year questionnaire, have higher household income, higher parental education level, both parents were born in Sweden, and live together. If anything, this makes our observed associations even more obvious, suggesting that socio-economic status, health quality, faith in the future, control over life and social support are significantly compromised in individuals with any of these conditions. In addition, more young females than males participated, but we saw the same trends in both sexes. Future studies should gather information from sources beyond self-reports of individuals with ADHD and ASD, especially if they have psychiatric comorbidities. It might also be warranted to consider pharmacological treatment in subjects with ADHD in relation to different comorbidities.

ADHD, ASD, and their co-occurrence significantly deteriorated socio-economic status, health quality, faith in the future, control over life, and social support. The co-occurrence of both disorders is a heavy burden for health, it is associated with several psychosocial vulnerabilities, and shares a similar morbidity pattern with ADHD while a less risk-taking behaviours and perceptions, according to the ASD group. Subjects with ADHD are exposed to different challenges than those with ASD. Understanding the impact of ADHD, ASD, and their co-occurrence allows improving the chance of prevention and development of early treatments with the potential to change the specific trajectory of morbidity later in life.

Availability of data and materials

Deidentified participant data can be shared on reasonable request and ethical approval for a specified purpose, after approval by Johnny Ludvigsson ([email protected]) through a signed data access agreement.

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Acknowledgements

We are grateful to all the participating families who take part in ABIS ongoing cohort study and all the staff at Obstetric Department and Well-Baby Clinics. Sincere thanks to Prof. Fredrikson (Department of Biomedical and Clinical Sciences, Linköping University) for the supervision of the statistical analysis.

Open access funding provided by Linköping University. ABIS-study has received funding from the County Council of Östergötland, Swedish Research Council (K2005-72X-11242-11A and K2008-69X-20826–01-4), Swedish Child Diabetes Foundation (Barndiabetesfonden), Juvenile Diabetes Research Foundation, Wallenberg Foundation (K 98-99D-12813-01A), Medical Research Council of Southeast Sweden (FORSS), Swedish Council for Working Life and Social Research (FAS2004–1775), Östgöta Brandstodsbolag, and Joanna Cocozza Foundation.

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JL. created and still leads the ABIS study. JL. collected all data, supported this study, including funding acquisition. ÅF. and TF. led the design of the study. AL. and JL. wrote the initial and final drafts of the manuscript. AL. and ÅF. performed the statistical analyses. All authors contributed to the interpretation of findings, critical revisions, and redrafting of the manuscript. The first and last authors (the manuscript’s guarantors) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported and that no important aspects of the study have been omitted. All authors have confirmed the final version of the manuscript.

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Lebeña, A., Faresjö, Å., Faresjö, T. et al. Clinical implications of ADHD, ASD, and their co-occurrence in early adulthood—the prospective ABIS-study. BMC Psychiatry 23 , 851 (2023). https://doi.org/10.1186/s12888-023-05298-3

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CVD indicates cardiovascular disease; RR, risk ratio.

CVD indicates cardiovascular disease; HR, hazard ratio; IRR, incidence rate ratio; OR, odds ratio.

eTable 1. Search Strategy and Results From Each Electronic Database

eTable 2. Items of the GRACE Checklist

eTable 3. Studies Excluded From the Systematic Review After Full-Text Screen, With Reasons

eTable 4. Absolute Risk and Risk Difference in CVD Outcomes Among the ADHD Medication Use Group vs the Reference Group

eTable 5. Quality Assessment by GRACE Checklist

eFigure 1. Results of Leave-One-Out Sensitivity Analysis

eFigure 2. Results From Egger Test

eFigure 3. Publication Bias of Included Studies

eFigure 4. Associations of Stimulant and Nonstimulant ADHD Medication Use With CVD

eFigure 5. Associations Between ADHD Medication Use and Specific CVD Outcomes

eFigure 6. Associations Between Stimulant ADHD Medication Use and Specific CVD Outcomes

eFigure 7. Associations Between ADHD Medication Use and CVD, by Sex Group

eFigure 8. Associations Between ADHD Medication Use and CVD, by History of CVD

eReferences.

• Paying Attention to ADHD Medications and Cardiovascular Risk JAMA Network Open Invited Commentary November 23, 2022 Roy C. Ziegelstein, MD

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Zhang L , Yao H , Li L, et al. Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity Disorder : A Systematic Review and Meta-analysis . JAMA Netw Open. 2022;5(11):e2243597. doi:10.1001/jamanetworkopen.2022.43597

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Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity Disorder : A Systematic Review and Meta-analysis

• 1 Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
• 2 School of Medical Sciences, Örebro University, Örebro, Sweden
• 3 Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
• 4 Heart and Vascular Division, Karolinska University Hospital, Stockholm, Sweden
• 5 Department of Psychological and Brain Sciences, Indiana University, Bloomington
• 6 Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton and NHS Trust, Southampton, United Kingdom
• 7 Hassenfeld Children’s Hospital at NYU Langone, New York University Child Study Center, New York
• 8 Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
• Invited Commentary Paying Attention to ADHD Medications and Cardiovascular Risk Roy C. Ziegelstein, MD JAMA Network Open

Question   Are attention-deficit/hyperactivity disorder (ADHD) medications associated with the risk of cardiovascular disease (CVD)?

Findings   This systematic review and meta-analysis based on 19 observational studies with more than 3.9 million participants suggested that there was no statistically significant association between ADHD medications and the risk of cardiovascular events among children and adolescents, young and middle-aged adults, or older adults.

Meaning   Despite no statistically significant association between ADHD medications and CVD, more evidence is needed for the potential risk of cardiac arrest and tachyarrhythmias, the cardiovascular risk in female patients and in those with preexisting CVD, and long-term risk.

Importance   Use of attention-deficit/hyperactivity disorder (ADHD) medications has increased substantially over the past decades, but there are concerns regarding their cardiovascular safety.

Objective   To provide an updated synthesis of evidence on whether ADHD medications are associated with the risk of a broad range of cardiovascular diseases (CVDs).

Data Sources   PubMed, Embase, PsycINFO, and Web of Science up to May 1, 2022.

Study Selection   Observational studies investigating the association between ADHD medications (including stimulants and nonstimulants) and risk of CVD.

Data Extraction and Synthesis   Independent reviewers extracted data and assessed study quality using the Good Research for Comparative Effectiveness (GRACE) checklist. Data were pooled using random-effects models. This study is reported according to the Meta-analyses of Observational Studies in Epidemiology guideline.

Main Outcomes and Measures   The outcome was any type of cardiovascular event, including hypertension, ischemic heart disease, cerebrovascular disease, heart failure, venous thromboembolism, tachyarrhythmias, and cardiac arrest.

Results   Nineteen studies (with 3 931 532 participants including children, adolescents, and adults; 60.9% male), of which 14 were cohort studies, from 6 countries or regions were included in the meta-analysis. Median follow-up time ranged from 0.25 to 9.5 years (median, 1.5 years). Pooled adjusted relative risk (RR) did not show a statistically significant association between ADHD medication use and any CVD among children and adolescents (RR, 1.18; 95% CI, 0.91-1.53), young or middle-aged adults (RR, 1.04; 95% CI, 0.43-2.48), or older adults (RR, 1.59; 95% CI, 0.62-4.05). No significant associations for stimulants (RR, 1.24; 95% CI, 0.84-1.83) or nonstimulants (RR, 1.22; 95% CI, 0.25-5.97) were observed. For specific cardiovascular outcomes, no statistically significant association was found in relation to cardiac arrest or arrhythmias (RR, 1.60; 95% CI, 0.94-2.72), cerebrovascular diseases (RR, 0.91; 95% CI, 0.72-1.15), or myocardial infarction (RR, 1.06; 95% CI, 0.68-1.65). There was no associations with any CVD in female patients (RR, 1.88; 95% CI, 0.43-8.24) and in those with preexisting CVD (RR, 1.31; 95% CI, 0.80-2.16). Heterogeneity between studies was high and significant except for the analysis on cerebrovascular diseases.

Conclusions and Relevance   This meta-analysis suggests no statistically significant association between ADHD medications and the risk of CVD across age groups, although a modest risk increase could not be ruled out, especially for the risk of cardiac arrest or tachyarrhythmias. Further investigation is warranted for the cardiovascular risk in female patients and patients with preexisting CVD as well as long-term risks associated with ADHD medication use.

Attention-deficit/hyperactivity disorder (ADHD), one of the most common neurodevelopmental disorders, is characterized by developmentally inappropriate inattention and/or hyperactivity-impulsivity symptoms starting in childhood. 1 The symptoms often persist into adulthood, 2 , 3 and even into older age for a substantial number of patients. 4 ADHD medications, including both stimulants and nonstimulants, are recommended for pharmacological treatment of ADHD, and the prevalence of ADHD medication use among both children and adults has increased substantially in many countries. 5

While evidence from randomized clinical trials (RCTs) suggests ADHD medications are efficacious in reducing core ADHD symptoms, 6 there are concerns about their cardiovascular safety. 7 As ADHD medications are sympathomimetic agents that exert dopaminergic and noradrenergic effects, increasing heart rate and blood pressure is biologically plausible. 8 A previous Cochrane review of RCTs found that the stimulant methylphenidate was associated with increased pulse or heart rate. 7 However, as these RCTs could only evaluate short-term effects, it remains uncertain whether these changes led to a clinically significant risk of cardiovascular disease (CVD) over time. Longitudinal observation studies evaluating serious cardiovascular outcomes associated with ADHD medication use have emerged during the last decade, but with mixed findings. 9 - 12 A review paper incorporating five large population-based studies in the US reported no association between stimulants and serious cardiovascular events in children. 13 A meta-analysis of only 3 studies 14 found no increased risk of arrhythmic and ischemic cardiac events but a decreased risk of stroke. A more recent meta-analysis of 10 studies 15 showed a positive association between ADHD medications and risk of sudden death or arrhythmia but not for stroke, myocardial infarction, or all-cause mortality. However, it had several methodology limitations (eg, not preregistered, narrow outcome definition, and missing several important studies). Moreover, several new original studies have been published after these meta-analyses. 16 - 20 Thus, an updated synthesis is needed to address those limitations as well as to include a broader range of cardiovascular events (eg, hypertension, heart failure, and transient ischemic attack that have not been included in previous meta-analyses) and conduct sub-analyses by type of cardiovascular events and ADHD medications. In addition, observational studies that evaluate the benefits or risks of medical treatments are prone to bias (eg, immortal time bias, prevalent user bias, confounding by indication) if not conducted appropriately. It is therefore critical to make a rigorous quality assessment of the available studies and discuss common problems that future studies need to address. Understanding whether, and to what extent, ADHD medications are associated with CVD is highly relevant from both clinical and public health perspectives, as an increasing number of individuals are receiving ADHD medications globally. Findings of any significant association would prompt research on underlying causal mechanisms (eg, dopaminergic dysfunction and alterations in cytochrome P450 2D6 metabolism). 8 , 21

The current study aims to provide a comprehensive and updated systematic review and meta-analysis to assess the associations between ADHD medications and risks of a broad range of cardiovascular events. In addition, we aim to examine whether there is any difference in the associations by types of ADHD medication, types of cardiovascular events, sex, age, and preexisting CVD conditions.

This study was conducted and reported according to the Meta-analyses of Observational Studies in Epidemiology ( MOOSE ) checklist. 22 Our protocol is registered in the International Prospective Register of Systematic Reviews ( CRD42021283702 ). 23

A systematic search for observational studies was conducted in MEDLINE via PubMed, Embase, PsycINFO, and Web of Science, up to May 1, 2022. We used various combinations of the following keywords: cardiovascular disease , coronary heart disease , heart disease , sudden death , ischemic heart disease , hypertension , cerebrovascular disease , stroke , transient ischemic attack , attention-deficit hyperactivity disorder , central nervous system stimulants , and observational study . No restrictions to language were applied. The search strategy was designed with the assistance of a university librarian at Karolinska Institute (eTable 1 in the Supplement ). In addition, we performed manual searches through the reference lists of relevant original publications and reviews to identify further pertinent studies.

We included all types of observational studies investigating associations between ADHD medication use and the risk of any CVD. We excluded reports, review articles, animal research, RCTs, and conference abstracts; studies without a comparator group; and studies with abuse or misuse of ADHD medication as the exposure. Titles, abstracts, and full text of included studies were screened independently by 2 investigators (L.Z. and H.Y.). Discrepancies were resolved through discussion with a senior investigator (L.L.).

The following information was extracted from each study for the qualitative and quantitative synthesis: first author, year of publication, sample size, data source, study country, age and sex distribution, study design, year of original data collection, follow-up time, type of ADHD medication, measure of medication use, definition of CVD, relative risk, and covariate adjustment. Two investigators conducted the data extraction separately (L.Z. and H.Y.), and any disagreements were resolved through discussion with a senior investigator (L.L.).

Good Research for Comparative Effectiveness (GRACE) checklist version 2 was used for quality assessment. 24 Unlike the commonly used Newcastle-Ottawa Scale, 25 the GRACE checklist is tailored for evaluating the quality of observational studies that examine the outcomes of medical treatment. It evaluates the quality of observational research based on the use of concurrent comparators, equivalent measurement of outcomes in different groups, collection of data on confounders and effect modifiers, risk of immortal time bias, and reporting of sensitivity analysis. 24 Eleven items in the GRACE Checklist are grouped into 2 groups reflecting the quality of data and methods (eTable 2 in the Supplement ). The quality assessment was completed by two investigators independently (L.Z. and H.Y.), and any discrepancies were solved by discussing with a senior investigator (L.L.).

The characteristics of all included studies were described. Hazard ratios (HRs) from Cox regression, incidence rate ratios (IRRs) from Poisson regression, and odds ratios (ORs) from logistic regression were combined as approximations to relative risks (RRs), because under rare event assumption, different effect measures would yield mathematically similar estimates. 26 , 27 We used random-effects models to account for heterogeneity between studies. The significance of heterogeneity across studies was examined using Cochran Q test, while the percentage of variation attributed to true heterogeneity was estimated using the inconsistency index ( I 2 ). 28 The restricted maximum likelihood method was used to estimate between-study variability, with the Hartung-Knapp-Sidik-Jonkman confidence interval for the summary estimates. 29 , 30

We meta-analyzed adjusted RRs across all studies and by age groups (children and adolescents, young and middle-aged adults, and older adults). To evaluate each study’s influence on the pooled estimates, the leave-one-out analysis was conducted. Publication bias was first assessed through visual inspection of the funnel plot and then tested quantitatively with Egger test. Subgroup analyses were conducted to investigate the associations of (1) stimulant and nonstimulant medications with any CVD, (2) ADHD medications with specific CVD (ie, cardiac arrest or tachyarrhythmias, cerebrovascular disease, myocardial infarction), (3) stimulant ADHD medications with specific CVD, (4) ADHD medications with any CVD in individuals with and without a history of CVD, and (5) ADHD medications with any CVD by sex. All analyses were performed with Stata version 16.0 (StataCorp). Statistical significance was set at P  < .05, and all tests were 2-tailed.

The process of study selection is shown in Figure 1 . Detailed information on excluded articles with reasons is shown in eTable 3 in the Supplement . Overall, we included 19 studies published during 2007 to 2021, and their main characteristics are presented in Table 1 . 9 - 12 , 16 - 20 , 31 - 40 A total of 3 931 532 participants from 6 countries or regions (United States, South Korea, Canada, Denmark, Spain, and Hong Kong) were included. The study samples included children, adolescents, and adults, and 60.9% of participants were male. Average follow-up time ranged from 0.25 to 9.5 (median, 1.5) years. Most studies (14) were cohort studies, 9 - 12 , 18 , 20 , 32 - 37 , 39 , 40 followed by 3 nested case-control studies, 16 , 19 , 31 and 2 self-controlled case series. 17 , 38 The most common data source was insurance claims databases (15 studies). 9 , 10 , 12 , 16 , 17 , 20 , 31 - 33 , 35 - 39 More than half of the studies (10) used incident users, 17 , 20 , 31 - 33 , 35 - 39 while others included prevalent users. 9 - 12 , 16 , 18 , 19 , 34 , 40 Most studies used International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision to define CVD, except 1 study 34 that used self-reported CVD and another 40 without sufficient information on outcome measurement. Absolute risks of CVD in the included studies are shown in eTable 4 in the Supplement . All studies adjusted for measured covariates as an attempt to control for confounding, but the included covariates varied substantially across studies. The 2 self-controlled case series studies 17 , 38 further accounted for unmeasured confounders that are time invariant. The GRACE quality scores ranged from 5 to 11 (median, 9). Immortal time bias and lack of meaningful sensitivity analyses were the most common limitations in studies with lower scores (eTable 5 in the Supplement ).

We found that ADHD medication use was not statistically significantly associated with the risk of any CVD among children and adolescents (RR, 1.18; 95% CI, 0.91-1.53), young and middle-aged adults (RR, 1.04; 95% CI, 0.43-2.48), older adults (RR, 1.59; 95% CI, 0.62-4.05) ( Figure 2 ), or overall (RR, 1.22; 95% CI, 0.88-1.68 ( Figure 3 ). Analysis by effect measures also did not show significant estimates for HR (1.09; 95% CI, 0.84-1.42), OR (1.17; 95% CI, 0.51-2.66), or IRR (1.42; 95% CI, 0.43-4.68 ( Figure 3 ). Heterogeneity between studies was high and significant (Cochran Q  = 292.7; P  < .001; I 2  = 93.2%). When restricting to specific effect measurements, heterogeneity was not significant for the analysis with HR as effect measures, yet it was still significant in other subgroups ( Figure 3 ). As shown in the leave-one-out sensitivity analysis (eFigure 1 in the Supplement ), the estimate was not driven by a single study. There was no evidence of publication bias, and a small study effect for the primary outcomes (eFigures 2 and 3 in the Supplement ).

In subgroup analyses, we found no statistically significant associations of stimulant (RR, 1.24; 95% CI, 0.84-1.83) and nonstimulant medications (RR, 1.22; 95% CI, 0.25-5.97) with any CVD ( Table 2 ; eFigure 4 in the Supplement ). When examining specific CVD outcomes ( Table 2 ; eFigure 5 in the Supplement ), no statistically significant associations were suggested for cardiac arrest or arrhythmias (RR, 1.60; 95% CI, 0.94-2.72), cerebrovascular diseases (RR, 0.91; 95% CI, 0.72-1.15), or myocardial infarction (RR, 1.06; 95% CI, 0.68-1.65). When examining stimulant medications, we found a similar pattern of results (eFigure 6 in the Supplement ).

There was no association between ADHD medication use and any CVD for female (RR, 1.88; 95% CI, 0.43-8.24) and male (RR, 1.08; 95% CI, 0.32-3.67) patients. ( Table 2 ; eFigure 7 in the Supplement ). We found no statistically significant associations in either individuals without a history of CVD (RR, 0.99; 95% CI, 0.73-1.33) or individuals with a history of CVD (RR, 1.31; 95% CI, 0.80-2.16) ( Table 2 ). In particular, the only 2 studies 11 , 40 with long-term follow-up both showed elevated risk (RR, 2.01; 95% CI, 1.98-2.06 and RR, 3.07; 95% CI, 1.09-8.64) in those with a history of CVD (eFigure 8 in the Supplement ).

To our knowledge, this is the most comprehensive systematic review and meta-analysis of longitudinal observational studies on the association between ADHD medication use and the risk of CVD. By pooling results of 19 studies, we found no statistically significant association between ADHD medication use and CVD among children and adolescents, young and middle-aged adults, or older adults, although the pooled RR did not exclude a modest risk increase, especially for the risk of cardiac arrest or tachyarrhythmias. We did not detect any difference in the cardiovascular risk between stimulant and nonstimulant ADHD medication use. There was no association between ADHD medication and any CVD among female patients and those with preexisting CVD, although further study may be needed in these populations.

This updated meta-analysis enabled us to include 13 more studies than the previous meta-analyses. 14 , 15 Unlike the previous meta-analyses, we did not include all-cause mortality in our primary outcome (but sudden cardiac death), as previous studies have shown that most of the mortality in patients with ADHD was due to unnatural causes (eg, accidents and suicide). 41 , 42 We examined a broad range of cardiovascular outcomes including important cardiovascular outcomes (eg, hypertension and heart failure) in addition to those examined in previous meta-analyses (cardiac arrest, tachyarrhythmias, myocardial infarction, and stroke). We found no statistically significant association between ADHD medication use and CVD among children and adolescents, young and middle-aged adults, or older adults, although the confidence interval could not exclude an increased risk. It should be noted that as the absolute risk is relatively low, even a significant RR of 22% risk increase in general would possibly be offset by the benefits of medications, eg, alleviating ADHD symptoms and reducing risky behavior. 6 , 43 The trade-off between benefits and risks could be different in high-risk patients. Regarding specific cardiovascular outcomes, results from previous meta-analyses for specific cardiovascular outcomes (ie, cardiac arrest or tachyarrhythmias and stroke) are inconsistent. 14 , 15 We found that ADHD medication use seemed to be associated with an increased risk of cardiac arrest or tachyarrhythmias, but not with cerebrovascular disease and myocardial infarction.

We also reported several findings that were not explored in previous meta-analyses. In terms of types of ADHD medication, we found both stimulant and nonstimulant ADHD medications were not statistically significantly associated with any CVD, with similar pooled RRs. These would suggest similar null effects on CVD or similar degree of confounding in studies of both stimulants and nonstimulants. We were unable to compare stimulants vs nonstimulants for the risk of specific CVD due to the limited number of studies that examined nonstimulants. Of note, 1 previous open-label extension of an RCT study 44 compared the cardiovascular risks of a stimulant ADHD medication (dexmethylphenidate) vs a nonstimulant ADHD medication guanfacine. The study found that dexmethylphenidate was associated with increased systolic blood pressure, while guanfacine was associated with decreased heart rate, but both returned to baseline value during the 1-year open-label extension phase. It suggests that there might be differences in cardiovascular risks between stimulants and nonstimulants, but these differences may attenuate over time, thus not leading to a significant difference in clinically relevant outcomes. Nevertheless, head-to-head comparison studies based on observational data are warranted to compare stimulant vs nonstimulant ADHD medications regarding the risk of specific CVD.

We found that the risk of cardiovascular events associated with ADHD medications seemed to be higher among those with preexisting CVD compared with no prior CVD, although the findings did not reach the threshold for statistical significance. This coincides with raising concerns that individuals with congenital or acquired CVD are predisposed to additional risk. 45 Despite the lack of data supporting CVD history as a contraindication for ADHD medications, the FDA labeling includes a warning on the use of ADHD medications among individuals with structural cardiac abnormalities or other serious heart problems. Current treatment guidelines generally recommend carefully assessing patients with ADHD (eg, personal and family history of CVD, physical examination, electrocardiogram) and identifying individuals at risk before initiating ADHD medications. 45 Careful monitoring should also be performed after initiation. 46 , 47 Further studies focusing on the potential modifying risk of preexisting CVD, ideally separating risks for congenital or acquired CVD, are warranted. Clinical guidelines on prescribing ADHD medications among high-risk individuals should be updated once further evidence is available. We also found the point estimates for risk of CVD seemed to be higher among female compared with male patients, although only 3 studies have examined the sex-specific association along with high heterogeneity between studies. Previous research has shown that females with ADHD have somewhat different patterns of comorbidities 48 , 49 and response to stimulants 50 than males, and additional research is needed to examine this potential sex difference.

The analysis of observational data provides an emerging opportunity to generate evidence to inform clinical decisions, but there are important issues to consider to avoid biases. 51 One key issue is that treatment is not randomly assigned, which could result in confounded estimates. The included studies mainly reflected practice in clinical settings rather than controlled settings, so the prescription of ADHD medications is influenced by the clinician’s perception of CVD risk. Most studies adjusted for a range of measured confounders, but the included confounders varied across studies. Many studies adjusted for demographic characteristics, and several adjusted for baseline comorbid conditions (eg, psychosis, obesity, and diabetes) and comedications (eg, antiepileptics, antidepressants, and asthma medications), yet few studies accounted for time-varying confounding factors. Moreover, several studies used general population control (rather than individuals with ADHD) as the comparison group, but only 1 study 9 adjusted for ADHD status. Not accounting for ADHD status would lead to bias, as recent research found that ADHD itself is a risk factor for CVD independent from comorbid psychiatric and somatic conditions. 52

In addition, other fundamental flaws, such as selection bias and immortal time bias, need to be considered carefully when interpreting results from observational studies. 51 Nine of the 19 included studies 9 - 12 , 16 , 18 , 19 , 34 , 40 used prevalent users instead of incident users, and 7 studies 16 , 18 , 19 , 34 - 37 were at risk of immortal time bias. Misclassification and exclusion of the so-called immortality period would necessarily bias the results toward favoring the treatment. 53 Unlike lack of randomization, these flaws can be easily prevented by study design, eg, explicitly emulating a pragmatic target trial. 54 Moreover, most of the included studies (17 of 19) had an average follow-up time of up to 2 years. Only 2 studies had sufficient follow-up time to examine the long-term cardiovascular risk associated with ADHD medication, but these studies were only moderate in their quality (GRACE score, 6 and 8 of 11). Thus, further studies with rigorous methods are needed to evaluate the long-term risk of CVD associated with ADHD medication use.

Overall, our meta-analysis provides reassuring data on the putative cardiovascular risk with ADHD medications, but the possible associations with cardiac arrest or tachyarrhythmias, among female patients, and among those with preexisting CVD warrants further investigation. Importantly, our findings are presented at the population level; in clinical practice, specific individuals with ADHD might be particularly prone to negative cardiovascular outcomes; therefore, clinicians should discuss with their patients and families the possible cardiovascular risk of ADHD medication in light of the latest evidence, and they should rigorously follow clinical guidelines that suggest monitoring of blood pressure and heart rate at baseline and each medication review.

There are several limitations to consider when interpreting the results. First, heterogeneity was high and significant for most analyses. Although this heterogeneity does not invalidate our results, it indicates that the pooled RR cannot appropriately summarize results from all individual studies and should therefore be interpreted with caution. 55 When restricting to specific cardiovascular outcomes, heterogeneity was not significant for the analysis on CVDs, yet it was still significant in the subgroup analyses by sex and preexisting CVD. Second, due to a lack of data, we were unable to compare the associations with specific ADHD medications. Third, as few studies have information on dosage and duration of medication use, investigation of the dose-response association was not possible. Fourth, although the GRACE checklist is validated for evaluating the quality of observational studies of medical treatment, a total score approach for risk of bias assessment needed to be validated. Additionally, most of the included studies were conducted in the United States and Europe, which means the results may not generalize to other settings.

The results of this meta-analysis suggested no statistically significant association between ADHD medication use and the risk of any cardiovascular events across age groups, although a modest risk increase could not be excluded, especially for the risk of cardiac arrest or tachyarrhythmias. Our study also warrants future studies with rigorous study designs to investigate the risk of cardiovascular events among female patients and among those with preexisting CVD, as well as the long-term risk of ADHD medication use.

Accepted for Publication: October 3, 2022.

Published: November 23, 2022. doi:10.1001/jamanetworkopen.2022.43597

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Zhang L et al. JAMA Network Open .

Corresponding Author: Le Zhang, MPH ( [email protected] ), and Zheng Chang, PhD ( [email protected] ), Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 65, Stockholm, Sweden.

Author Contributions: Ms Zhang and Dr Chang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Mss Zhang, Yao, and Dr Li contributed equally.

Concept and design: Zhang, Yao, Larsson, Chang.

Acquisition, analysis, or interpretation of data: Zhang, Yao, Li, Du Rietz, Andell, Garcia-Argibay, D’Onofrio, Cortese, Chang.

Drafting of the manuscript: Zhang, Yao.

Critical revision of the manuscript for important intellectual content: Zhang, Li, Du Rietz, Andell, Garcia-Argibay, D’Onofrio, Cortese, Larsson, Chang.

Statistical analysis: Zhang, Li, Andell, Garcia-Argibay.

Obtained funding: D’Onofrio, Chang.

Administrative, technical, or material support: Zhang, Li, Du Rietz, D’Onofrio, Chang.

Supervision: Andell, Cortese, Larsson, Chang.

Conflict of Interest Disclosures: Dr Du Rietz reported receiving grants from the Swedish Society for Medical Research, the Fredrik & Ingrid Thurings Stiftelse, the Strategic Research Area in Epidemiology and Biostatistics, and Fonden for Psykisk Halsa and receiving personal fees from Shire AB, a Takeda Pharmaceutical Company, outside the submitted work. Dr Cortese reported receiving personal fees from the Association for Child and Adolescent Mental Health, the British Association of Psychopharmacology, and the Canadian ADHD Alliance resource outside the submitted work. Dr Larsson reported receiving grants from Shire/Takeda; receiving personal fees from Shire/Takeda, Medici, and Evolan; and receiving travel funding from Shire/Takeda and Eolvan outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grants from the Swedish Research Council for Health, Working Life, and Welfare (2019-01172) and European Union’s Horizon 2020 research and innovation program under grant agreement 965381. Dr Du Rietz received financial support from the Swedish Society for Medical Research, the Fredrik & Ingrid Thurings Stiftelse, and the Strategic Research Area in Epidemiology and Biostatistics.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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ADHD Research Paper

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Get 10% off with fall23 discount code, i. introduction.

II. Historical Context

III. Description and Diagnosis

A. The Core Symptoms

B. associated cognitive impairments, iv. theoretical framework.

V. Potential Etiologies

VI. Epidemiology of ADHD

Vii. developmental course and adult outcome, viii. diagnostic criteria, ix. conclusion.

X. Bibliography

It is not unusual for young children to be energetic and active, or to become bored quickly and move from one activity to another as they explore their environment. A young child’s desire for immediate gratification is to be expected, rather than the restraint or self-control that would be demanded of someone older. However, some children persistently display levels of activity that are far in excess of their age group. Some are unable to sustain their attention to activities, their interest in tasks assigned to them by others, or their persistence in achieving long-term goals as well as their peers.

When a child’s impulse control, sustained attention, and general self-regulation lag far behind expectations for their developmental level, they are likely to be diagnosed as having ADHD. Children with ADHD have a greater probability of experiencing a number of problems in their social, academic, and emotional development and daily adaptive functioning.

Attention Deficit/Hyperactivity Disorder (ADHD) has captured public commentary and scientific interest for more than 100 years. While the diagnostic labels for disorders of inattention, hyperactivity, and impulsiveness have changed numerous times, the actual nature of the disorder has changed little, if at all, from descriptions provided at the turn of the century. During the past century, and especially during the last 30 years, thousands of published scientific papers have focused on ADHD, making it one of the most wellstudied childhood psychiatric disorders.

II. Historical Context of ADHD

Serious clinical interest in children who have severe problems with inattention, hyperactivity, and poor impulse control is first found in three published lectures by the English physician, George Still, presented to the Royal Academy of Physicians in 1902. Still reported on a group of 20 children in his clinical practice whom he defined as having a deficit in “volitional inhibition” or a “defect in moral control” over their own behavior. Still’s observations described many of the associated features of ADHD that would be supported by research almost a century later, such as an overrepresentation of boys compared to girls, the greater incidence of alcoholism, criminal conduct, and depression among the biological relatives, and a familial predisposition to the disorder.

Initial interest in children with these characteristics arose in North America around the time of the great encephalitis epidemics of 1917 and 1918. Children surviving these brain infections were noted to have many behavioral problems similar to those comprising contemporary ADHD. These cases, as well as others known to have arisen from birth trauma, head injury, toxin exposure, and infections, gave rise to the concept of a “brain-injured child syndrome,” often associated with mental retardation. This term was eventually applied to children without a history of brain damage or evidence of retardation but who manifested behavioral problems such as hyperactivity or poor impulse control. This concept would later evolve into that of “minimal brain damage,” and eventually “minimal brain dysfunction” (MBD), as challenges were raised to the label given the lack of evidence of brain injury in many of these cases.

During the 1950s researchers became increasingly interested in hyperactivity. “Hyperkinetic impulse disorder” was attributed to cortical overstimulation resuiting from ineffective filtering of stimuli entering the brain. These studies gave rise to the notion of the “hyperactive child syndrome” typified by daily motor movement that was far in excess of that seen in normal children of the same age.

By the 1970s research findings emphasized the importance of problems with sustained attention and impulse control in addition to hyperactivity in understanding the nature of the disorder. In 1983 Virginia Douglas proposed that the disorder was comprised of major deficits in four areas: (1) the investment, organization, and maintenance of attention and effort; (2) the ability to inhibit impulsive behavior; (3) the ability to modulate arousal levels to meet situational demands; and (4) an unusually strong inclination to seek immediate reinforcement. Douglas’ work, along with numerous subsequent studies of attention, impulsiveness, and other cognitive factors, eventually led to renaming the disorder “Attention Deficit Disorder” (ADD) in 1980.

Just as significant as the renaming of the condition at that time was the distinction made between two types of ADD: those with hyperactivity and those without it. Little research existed at the time on the latter subtype. However, later research suggested that ADD without hyperactivity might be a separate and distinct disorder of a different component of attention (selective or focused) than was the type of inattention seen in those with ADD with hyperactivity (persistence and distractibility). Thus, rather than being related subtypes of a single disorder with a shared, common impairment in attention, future research may show these subtypes to constitute separate disorders of attention altogether.

Within a few years of the creation of the label ADD, concern was raised by Barkley in 1990 and Weiss and Hechtman in 1993 that problems with hyperactivity and impulse control were features critically important to differentiating the disorder from other conditions and to predicting later developmental risks. In 1987 the disorder was renamed Attention Deficit Hyperactivity Disorder. Diagnostic symptoms were identified from a single list of items incorporating all three constructs: hyperactivity, impulsivity, and inattention. The subtype of ADD without Hyperactivity was now renamed Undifferentiated ADD and relegated to minor diagnostic status until further research could clarify its nature and relationship to ADHD.

Around this same time (mid-1980s to 1990s) reports began to appear that challenged the notion that ADHD was primarily a disturbance in attention. Over the previous decade, researchers studying information-processing capacities in children with ADHD were having difficulty demonstrating that the problems these children had with attending to tasks were actually attentional in nature (i.e., related to the processing of incoming information). Problems in response inhibition and preparedness of the motor control system appeared to be more reliably demonstrated. Researchers, moreover, were finding that the problems with hyperactivity and impulsivity were not separate constructs but formed a single dimension of behavior. All of this led to the creation of two separate lists of symptoms for ADHD when the latest diagnostic manual for psychiatry, The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (also known as the DSM-IV) was published by the American Psychiatric Association in 1994. In the DSM-IV, one symptom list now existed for inattention and another for hyperactive-impulsive behavior. The inattention list once again permitted the diagnosis of a subtype of ADHD that consisted principally of problems with attention (ADHD Predominantly Inattentive Type). But two other subtypes were also identified (Predominantly Hyperactive-Impulsive and Combined Types). As of this writing, debate continues over the core deficit(s) involved in ADHD, with increasing emphasis being given to a central problem specifically with behavioral inhibition and more generally with self-regulation or executive functioning.

III. ADHD Description and Diagnosis

Problems with attention consist of the child’s inability to sustain attention or respond to tasks or play activities as long as others of the same age or to follow through on rules and instructions as well as others. The child appears more disorganized, distracted, and forgetful than others of the same age. Parents and teachers frequently complain that these children do not seem to listen as well as they should for their age, cannot concentrate, are easily distracted, fail to finish assignments, daydream, and change activities more often than others.

Research corroborates that, when compared to normal children, ADHD children are often more “off-task,” less likely to complete as much work as others, look away more from the activities they are requested to do (including television), persist less in correctly performing boring activities, and are slower and less likely to return to an activity once interrupted. Yet objective research does not find children with ADHD to be generally more distracted by most forms of extraneous events occurring during their task performance, although distractors within the task may prove more disruptive to them than to normal children. Research instead documents that ADHD children are more active than other children, are less mature in controlling motor movements, and have considerable difficulties with stopping an ongoing behavior. They frequently talk more than others and interrupt others’ conversations. They are less able to resist immediate temptations and delay gratification and respond too quickly and too often when they are required to wait and watch for events to happen.

Recent research shows that the problems with behavioral or motor inhibition arise first, at age 3 to 4 years, with those related to inattention emerging somewhat later in the developmental course of ADHD, at age 5 to 7 years. Whereas the symptoms of disinhibition seem to decline with age, those of inattention remain relatively stable during the elementary grades. Yet even the inattentiveness may decline by adolescence in some cases.

A number of factors have been noted to influence the ability of children with ADHD to sustain their attention to task performance, to control their impulses to act, to regulate their activity level, and to produce work consistently. They include: time of day or fatigue; increasing task complexity where organizational strategies are required; extent of restraint demanded for the context; level of stimulation within the setting; the schedule of immediate consequences associated with the task; and the absence of adult supervision during task performance.

It has been shown that children with ADHD are most problematic in their behavior when persistence in work-related tasks is required (i.e., chores, homework, etc.) or where behavioral restraint is necessary, especially in settings involving reduced parental monitoring (i.e., in church, in restaurants, when a parent is on the phone, etc.). Such children are least likely to pose behavioral management problems during free play, when little self-control is required. Fluctuations in the severity of ADHD symptoms have also been documented across a variety of school contexts. In this case, classroom activities involving self-organization and task-directed persistence are the most problematic, with significantly fewer problems posed by contexts involving fewer performance demands (i.e., at lunch, in hallways, at recess, etc.), and even fewer problems posed during highly entertaining special events (i.e., field trips, assemblies, etc.).

Although ADHD is defined by the presence of the two major symptom dimensions of inattention and disinhibition (hyperactivity-impulsivity), research indicates that these children often demonstrate deficiencies in many other abilities. These include: motor coordination and sequencing; working memory and mental computation; planning and anticipation or preparedness for action; verbal fluency and confrontational communication; effort allocation; applying organization strategies; the internalization of self-directed speech; adhering to restrictive instructions; the self-regulation of emotions; and self-motivation. Several studies have also demonstrated what both Still (1902) and Douglas (1983) noted anecdotally years ago–ADHD may be associated with less mature or diminished moral reasoning and the moral control of behavior.

The commonality among most or all of these seemingly disparate abilities is that all fall within the neuropsychological domain described as executive functions. The neurologist Joaquim Fuster wrote in 1989 that these executive abilities are probably mediated by the frontal cortex of the brain, and particularly the prefrontal lobes. Barkley has recently defined executive functions as being those neuropsychological processes that permit or assist with human self-regulation. Self-regulation is then defined as any self-directed form of behavior (both overt and covert) that serves to modify the probability of a subsequent behavior by the individual so as to alter the probability of a later consequence. Such behavior may even involve forgoing immediate rewards for the sake of maximizing delayed outcomes or even exposing oneself to immediate aversive circumstances for this same purpose. Self-regulatory behavior, therefore, includes thinking within this realm of private or covert self-directed behavior. By appreciating the role of the frontal lobes and the prefrontal cortex in these executive abilities, it is easy to see why researchers have repeatedly speculated that ADHD probably arises out of some disturbance or dysfunction of this brain region.

Many different hypotheses on the nature of ADHD have been proposed over the past century, such as Still’s (1902) notion of defective volitional inhibition and moral regulation of behavior, and Douglas’ (1983) theory of deficient attention, inhibition, arousal, and preference for immediate reward. Few of these have produced models of the disorder that were widely adopted by both scientists and clinicians or that served to drive further programmatic research initiatives. Some of these theories have suggested that ADHD is a deficit in sensitivity to reinforcement, a more general motivational disorder, or a deficit in rule-governed behavior (i.e., the control of behavior by language). Most recently, several theorists working in this area have proposed that ADHD represents a deficit behavioral inhibition; an assertion for which there is substantial evidence, at least for those subtypes that involve hyperactive-impulsive symptoms.

Consistent with these proposals, Barkley outlined a model of ADHD in 1994 that was based upon an earlier theory by Jacob Bronowski first set forth in 1966 on the evolution of the unique properties of human language and their relationship to response inhibition. Bronowski’s model was subsequently combined with that of Juaquim Fuster published in 1989, which specified that the overarching role of the prefrontal cortex is the cross-temporal organization of behavior. Barkley’s hybrid theoretical model of ADHD places behavioral inhibition at a central point and supportive point in relation to four other executive functions dependent upon it for their own effective execution. These functions are working memory, the self-regulation of emotion/motivation, the internalization of speech, and reconstitution (analysis and synthesis of behavioral structures in the service of goal-directed behavioral creativity). The four functions are believed to permit and subserve human self-regulation, bringing behavior progressively under the control of internally represented information, often about the future, and transferring it at least partially away from the control of behavior by more immediate consequences and external events. The executive control of behavior afforded by these functions is proposed to result in a greater capacity for predicting and controlling one’s self and one’s environment so as to maximize future consequences over immediate ones for the individual. And, more generally, the interaction of these executive functions permits far more organized and effective adaptive functioning.

Several assumptions are important in understanding this model as it is applied to ADHD. First, the capacity for behavioral inhibition begins to emerge first in the child’s development, prior to or corresponding with the emergence of the four executive functions. Second, inhibition does not directly cause the activation of these executive functions but sets the occasion for their occurrence and is necessary for their effective performance. Third, these functions probably emerge at different times in the child’s development and may have relatively independent developmental trajectories, although interactive. Fourth, the sweeping cognitive impairments that ADHD creates across these executive functions are secondary to the primary deficit in behavioral inhibition, implying that if inhibition were to be improved, these executive functions would likewise improve.

The deficit in behavioral inhibition is thought to arise principally from genetic and neurodevelopmental origins, rather than from purely social ones, although its expression is certainly influenced by a variety of social factors. The secondary deficits in the executive functions and self-regulation created by the primary deficit in inhibition feedback to contribute to further deficits in behavioral inhibition because self-regulation is required for self-restraint.

Behavioral inhibition is viewed in the model as comprising three related processes: (1) the capacity to inhibit “prepotent” responses prior to their initiation; (2) the capacity to cease ongoing response patterns once initiated such that both (1) and (2) create delays in responding to events; and (3) the protection of this delay and the self-directed (often private or cognitive) actions occurring within it from interference by competing events and their prepotent responses (interference control). Prepotent responses are defined as those for which immediate reinforcement (both positive and negative) is available for their performance or for which there is a strong history of reinforcement in this context. Through the postponement of the prepotent, automatic responses and the creation of this protected period of delay, the occasion is set for the four executive functions to act effectively in modifying the individual’s eventual initial responding to events or modifying their ongoing responses to those events (creating a sensitivity to feedback or errors). The executive system described here may exist so as to achieve a net maximization of both temporally distant and immediate consequences rather than immediate consequences alone. The chain of goal-directed, future-oriented behaviors set in motion by these acts of self-regulation is then also protected from interference during its performance by this same process of inhibition (interference control). Even if disrupted, the individual retains the capacity or intention (via working memory) to return to the goal-directed actions until the outcome is successfully achieved or judged to be no longer necessary.

Space permits here only a brief description of each of the four executive components of this new model of ADHD. The first of these involves working memory, or the capacity for prolonging and manipulating mental representations of events and using such information to control motor behavior. This particular type of memory can be thought of as remembering so as to do and serves to sustain otherwise fleeting information that will be useful in controlling subsequent responding, such as is seen in privately rehearsing a telephone number in mind so as to later dial it accurately. One component of working memory may be related to self-speech (verbal working memory), while a second component is related to perceptual imagery (visual-spatial) and probably involves self-directed sensing, as in visual imagery or covert audition. This retention of information related to past events (retrospection) gives rise to the conjecturing of future events (prospection), which sets in motion a preparedness to act in anticipation of the arrival of these future events (anticipatory set). Out of this continuous referencing or sensing of past and future probably arises the psychological sense of time. These activities taking place in working memory appear to be dependent upon behavioral inhibition. Such working memory processes have been shown to exist in rudimentary form even in young infants permitting them to successfully perform delayed response tasks to a limited degree. As the capacity for inhibition increases developmentally, it probably contributes to the further efficiency and effectiveness of working memory.

According to this model of ADHD, behavioral inhibition also sets the stage for the development of the second executive component of this model, that being the self-regulation of emotion in children. The inhibition of the initial prepotent response includes the inhibition of the initial emotional reaction that it may have elicited. It is not that the child does not experience emotion; rather, the behavioral reaction to or expression of that emotion is delayed along with any motor behavior associated with it. The delay in responding this creates allows the child time to engage in self-directed behaviors that will modify both the eventual response to the event as well as the emotional reaction that may accompany it. Because emotions are themselves forms of both motivational and arousal states, the model argues that deficits in the self-regulation of emotion should be associated with deficits in self-motivation and the self-control of arousal, particularly in the service of goal-directed behavior.

The internalization of self-directed speech, as originally described by Vygotsky, forms the third executive component of this model of ADHD. During the early preschool years, speech, once developed, is initially employed for communication with others. As behavioral inhibition progresses, language becomes turned on the self. It now is not just a means of influencing the behavior of others but provides a means of reflection as well as a means for controlling one’s own behavior (instruction).

The fourth component of this model involves the capacity to rapidly take apart and recombine units of behavior, including language. The delay in responding that behavioral inhibition permits allows time for information related to the event to be mentally prolonged and then dissassembled so as to extract more information about the event that will aid in preparing a response to it. In a related fashion, previously learned response patterns can also be broken down into smaller units of behavior. This internal decomposition of information and its associated response patterns permits the complementary process to occur, that being synthesis, or the invention of novel combinations of behavioral structures, including words and ideas, in the service of goal-directed action. This gives a highly creative or generative character as well as a hierarchically organized nature to human goal-directed behavior.

Finally, the internally represented information and motivation generated by these four executive functions is used to control a separate unit within the model, that being motor behavior itself. Such information serves to program, execute, and sustain behavior directed toward goals and the future, giving human behavior an intentional or purposive quality. Task-irrelevant movement is now more effectively suppressed, goal-directed behavior better sustained, and this pattern of behavior more efficiently reengaged should disruption of the behavioral pattern occur because of the control afforded by the internal information being generated from the four executive functions.

The impairment in behavioral inhibition occurring in ADHD is hypothesized to disrupt the efficient execution of these executive functions, thereby limiting the capacity of these individuals for self-regulation. The result is an impairment in the cross-temporal organization of behavior, in the prediction and control of one’s own behavior and environment, and inevitably in the maximization of long-term consequences for the individual.

How does this model account for the problems with attention believed to exist in ADHD? According to this model, it is critical to distinguish between two forms of sustained attention that are traditionally confused in the research literature on ADHD. The first is called contingency-shaped attention. This refers to continued responding in a situation or to a task as a function of the immediate available contingencies of reinforcement provided by the task or its context. Responding that is maintained under these conditions then is directly dependent on the immediate environmental contingencies. Many factors affect this form of sustained attention or responding: the novelty of the task, the intrinsic interest the activity may hold for the individual, the immediate reinforcement it provides for responding in the task, the state of fatigue of the individual, and the presence or absence of an adult supervisor (or other stimuli which signal other consequences for performance that are outside the task itself). The model predicts that this type of sustained attention relatively unaffected by ADHD as it is behavior under the control of external events.

As children mature, however, a second form of sustained attention emerges described in the model as goal-directed persistence. This form of sustained responding arises as a direct consequence of the development of self-regulation or the control of behavior by internally represented information. Such persistence derives from the development of a progressively greater capacity by the child to hold events, goals, and plans in mind (working memory), to adhere to rules governing behavior and to formulate and follow such rules, to self-induce a motivational state supportive of the plans and goals formulated by the individual so as to maintain goal-directed behavior, and even to create novel behaviors in the service of the goal’s attainment. The capacity to initiate and sustain chains of goal-directed behavior in spite of the absence of immediate environmental contingencies for their performance is predicted to be the form of sustained attention disrupted by ADHD.

Apart from this heuristically valuable distinction in forms of sustained attention, this theoretical model of ADHD makes numerous predictions about the cognitive and behavioral deficits likely to be found in those with the disorder (i.e., impaired working memory and sense of time, delayed internalization of speech, etc.), many of which have received little or no attention in research on ADHD. It also provides a framework by which to better organize and understand the numerous cognitive deficits identified in previous studies of children with ADHD than does the current view of ADHD as being chiefly an attention deficit.

V. Potential Etiologies of ADHD

The precise causes of ADHD are unknown at the present time. Numerous causes have been proposed, but evidence for many has been weak or lacking entirely. However, a number of factors have been shown to be associated with a significantly increased risk for ADHD in children.

The vast majority of the potentially causative factors associated with ADHD that are supported by empirical research seem to be biological in nature; that is, they are factors known to be related to or to have a direct effect on brain development and/or functioning. The precise causal pathways by which these factors lead to ADHD, however, are simply not known at this time.

Even so, far less evidence is available to support any purely psychosocial etiology of ADHD. In the vast majority of cases where such psychosocial risks have been found to be significantly associated with ADHD or hyperactivity, more careful analysis has shown these to be either the result of ADHD in the child or, far more often, to be related to aggression or conduct disorder rather than to ADHD. For instance, the child management methods used by parents, parenting stress, marital conflict, or parental psychopathology have now been shown to be far more strongly associated with aggressive and antisocial behavior than with ADHD. The strong hereditary influence in ADHD may also contribute to an apparent link between ADHD and poor child management by a parent — a link that may be attributable to the parent’s own ADHD. The environment in which the child is raised and schooled probably plays a larger role in determining the outcomes of children with the disorder and a much lesser role in primary causation.

Throughout the century, investigators have repeatedly noted the similarities between symptoms of ADHD and those produced by lesions or injuries to the frontal lobes of the brain, particularly the prefrontal cortex. Both children and adults suffering injuries to the certain regions of prefrontal cortex demonstrate deficits in sustained attention, inhibition, working memory, the regulation of emotion and motivation, and the capacity to organize behavior across time.

Numerous other lines of evidence have been suggestive of a neurological origin to the disorder. Several studies have examined cerebral blood flow in ADHD and normal children. They have consistently shown decreased blood flow to the prefrontal regions of the brain and the striatum with which these regions are richly interconnected, particularly in its anterior portion. More recently, studies using positron emission tomography (PET) to assess cerebral glucose metabolism have found diminished metabolism in adults and adolescent females with ADHD although not in adolescent males with ADHD. However, significant correlations have been noted between diminished metabolic activity in the left anterior frontal region of the brain and severity of ADHD symptoms in adolescent males with ADHD. This demonstration of an association between the metabolic activity of certain brain regions and symptoms of ADHD is critical in demonstrating a connection between the findings pertaining to brain activation and the behavior comprising ADHD.

More detailed analysis of brain structures using high resolution magnetic resonance imaging (MRI) devices has also suggested differences in some brain regions in those with ADHD. Initial studies that focused on reading-disabled children and used ADHD children as a contrast group examined the region of the left and right temporal lobes (the planum temporale). These regions are thought to be involved with auditory detection and analysis and, therefore, with certain subtypes of reading disabilities. For some time, researchers studying reading disorders have focused on these brain regions because of their connection to the rapid analysis of speech sounds. Children with ADHD and children with reading disabilities were found to have smaller right hemisphere plana temporale than the control group, while only the reading disabled children had a smaller left plana temporale. In another study, the corpus callosum was examined in subjects with ADHD. This structure assists with the interhemispheric transfer of information. Those with ADHD were found to have a smaller callosum, particularly in the area of the genu and splenium and that region just anterior to the splenium. An attempt to replicate this finding, however, failed to show any differences between ADHD and control children in the size or shape of the entire corpus callosum with the exception of the posterior portion of the splenium, which was significantly smaller in subjects with ADHD. Two additional studies examining the corpus callosum, however, documented smaller anterior (rostral) regions in children with ADHD; findings more consistent with prior studies of brain anatomy and functioning in children with ADHD. Most recently, two studies using larger samples of ADHD and normal children and MRI technology have both documented a smaller right prefrontal cortex and smaller right striatum and right basal ganglia (of which the striatum is a part) in ADHD children. Thus, despite some inconsistencies in findings across some of the earlier studies of brain morphology and functioning in ADHD, more recent studies are increasingly identifying the prefrontal regions of the brain and certain regions of the basal ganglia, such as the striatum, as probably being involved in the disorder.

None of these studies found evidence of frank brain damage in any of these structures in those with ADHD. This is consistent with past reviews of the literature conducted by Michael Rutter in 1983 suggesting that brain damage was related to less than 5% of those with hyperactivity. It is also consistent with more recent studies of twins suggesting that nonshared environmental factors, such as pre-, peri-, and postnatal neurological insults, among other factors, account for approximately 15 to 20% of the differences among individuals in the behavioral pattern associated with ADHD (inattention and hyperactive-impulsive behavior). Where differences in brain structures are found, they are probably the result of abnormalities that arise in brain development (embryology) within these particular regions, the causes of which are not known but may have to do with particular genes responsible for the construction of these brain regions.

No evidence exists to show that ADHD is the result of abnormal chromosomal structures (as in Down’s Syndrome), their fragility (as in Fragile X) or transmutation, or of extra chromosomal material (as in XXY syndrome). Children with such chromosomal abnormalities may show greater problems with attention, but such abnormalities are very uncommon in children with ADHD.

By far, the preponderance of research evidence suggests that ADHD is a trait that is highly hereditary in nature, making heredity one of the most well substantiated among the potential etiologies for ADHD. Multiple lines of research support such a conclusion. For years, researchers have noted the higher prevalence of psychopathology in the parents and other relatives of children with ADHD. In particular, higher rates of ADHD, conduct problems, substance abuse, and depression have been repeatedly observed in these studies. Research such as that by Joseph Biederman and colleagues at the Harvard Medical School (Massachusetts General Hospital) shows that between 10 and 35% of the immediate family members of children with ADHD are also likely to have the disorder, with the risk to siblings of the ADHD children being approximately 32%. More recent studies even suggest that if either parent has ADHD, the risk to offspring for the disorder may be as high as 50%.

Another line of evidence for genetic involvement in ADHD has emerged from studies of adopted children, which have found higher rates of hyperactivity in the biological parents of hyperactive children than in adoptive parents of hyperactive children. Biologically related and unrelated pairs of international adoptees also identified a strong genetic component to the behavioral dimension underlying ADHD.

Studies of twins conducted in the United States, Australia, and the United Kingdom provide a third avenue of evidence for a genetic contribution to ADHD. In general, these studies suggest that if one twin is diagnosed with ADHD, the concordance for the disorder in the second twin may be as high as 81 to 92% in monozygotic twins but only 29 to 35% in dizygotic twins.

Quantitative genetic analyses of a large sample of families studied in Boston by Joseph Biederman and his colleagues suggest that a single gene may account for the expression of the disorder. The focus of research recently has been on the dopamine type 2 gene, given findings of its increased association with alcoholism, Tourette’s Syndrome, and ADHD. However, difficulties have arisen in the replication of this finding. More recent studies have implicated the dopamine transporter gene as being involved in ADHD as might the D4D repeator gene, which has shown an association with novelty-seeking and risk-taking personality traits. Clearly, research into the genetic mechanisms involved in the transmission of ADHD across generations will prove an exciting and fruitful area of research endeavor over the next decade as the human genome is mapped and better understood and as more sophisticated genetic technologies arising from this project come to be applied to the study of the genetics of ADHD.

Pre-, peri-, and postnatal complications, and malnutrition, diseases, trauma, and other neurologically compromising events may occur during the development of the nervous system before and after birth. Among these various biologically compromising events, several have been repeatedly linked to risks for inattention and hyperactive behavior. Elevated body lead burden has been shown to have a small but consistent and statistically significant relationship to the symptoms comprising ADHD. However, even at relatively high levels of lead, less than 38% of these children are rated as hyperactive on teacher rating scales, implying that most lead-poisoned children do not develop symptoms of ADHD. Other types of environmental toxins found to have some relationship to inattention and hyperactivity are prenatal exposure to alcohol and tobacco smoke.

The prevalence of ADHD, as reviewed by Peter Szatmari in 1992, using large epidemiological studies ranges from a low of 2 % to a high of 6.3 %, with most falling within the range of 4.2 to 6.3 %. Most studies have found similar prevalence rates in elementary school-aged children. Differences in prevalence rates are due in part to different methods of selecting these populations, to the criteria used to define a case of ADHD, and to the age range of the samples. For instance, prevalence rates may be 2 to 3% in females but 6 to 9% in males during the 6 to 12-year-old age period, but fall to 1 to 2% in females and 3 to 4.5 % in males by adolescence.

While the declining prevalence of ADHD with age may reflect real recovery from the disorder, it may also involve, at least in part, an artifact of methodology. This artifact results from the use of items in the diagnostic symptom lists across the life span that are were developed upon and chiefly applicable to young children. These items may reflect the underlying constructs of ADHD very well at younger ages but may be increasingly less appropriate for older age groups. This could create a situation where individuals remain impaired by ADHD characteristics as they mature, but outgrow the diagnostic symptom list for the disorder, resulting in an illusory decline in prevalence over development. Until more age-appropriate symptoms are studied for adolescent and adult populations, this issue remains unresolved.

Gender appears to play a significant role in determining prevalence of ADHD within a population. On average, males are between 2 and 6 times more likely than females to be diagnosed with ADHD in epidemiological samples of children, with the average being roughly 3:1. Within clinic-referred samples, the sex ratio can rise to 6:1 to 9:1, suggesting that males with ADHD are far more likely to be referred to clinics than females, especially if they have an associated oppositional or conduct disorder. It is unclear at this time why males should be more likely to have ADHD than females. This could result partly from an artifact of the relationship between male gender and more aggressive and oppositional behavior; such behavior is known to increase the probability of referral to mental health centers. Because such behavior is often associated with ADHD, clinic-referred males are also more likely to have ADHD. The greater preponderance of males might also, in part, be an artifact of applying a set of diagnostic criteria developed primarily on males to females. Using a predominantly male population to set diagnostic criteria as was done for the DSM-IV (see below) could create a higher threshold for diagnosis for females relative to other females than for males relative to other males. Such a circumstance argues for the eventual examination of whether separate diagnostic criteria (symptom thresholds) ought to be considered for each gender.

ADHD occurs across all socioeconomic levels. Where differences in prevalence rates are found across levels of social class, they may be artifacts of the source used to define the disorder or of the association of ADHD with other disorders known to be related to social class, such as aggression and conduct disorder. No one, however, has made the argument that the nature or qualitative aspects of ADHD differ across social classes.

Hyperactivity or ADHD is present in all countries studied so far, such as New Zealand, Japan, Italy, Germany, India, and Australia. While it may not receive the same diagnostic label in each country, the behavior pattern comprising the disorder appears to be present internationally. ADHD arises also in all ethnic groups studied so far.

Major follow-up studies of clinically referred hyperactive children have been ongoing during the last 25 years at five sites: Montreal, New York City, Iowa City, Los Angeles, and Milwaukee. Follow-up studies of children identified as hyperactive during epidemiological screenings of general populations have also been conducted in the United States, Australia, New Zealand, and England.

The onset of ADHD symptoms has been found to be generally in the preschool years, typically by age 3 or 4, and usually by entry into formal schooling. First to arise in many cases is the pattern of hyperactive-impulsive behavior and, in some cases, oppositional and aggressive conduct. Preschool-aged children with significant degrees of inattentive and hyperactive behavior who are difficult to manage for their parents or teachers and whose pattern of such behavior is persistent for at least a year or more are highly likely to have ADHD and to retain their symptoms into the elementary school years.

By the time ADHD children move into the age range of 6 to 12 years, the problems with hyperactive-impulsive behavior are increasingly associated with difficulties with the form of sustained attention referred to above as goal-directed persistence and distractibility (poor interference control). These symptoms of inattention appear to arise by the age of 5 to 7 years and may emerge out of the increasing difficulties ADHD children are having with self-regulation. The inattentiveness evident in children having ADD without Hyperactivity (Predominantly Inattentive Type of ADHD) may be of a qualitatively different form (focused or selective attention) and may not emerge or be impairing of the child’s school performance until even later, such as mid-to-late childhood.

When ADHD is present in clinic-referred children, the likelihood is that 50 to 80% will continue to have their disorder into adolescence. Although severity levels of symptoms are declining over development, this does not mean hyperactive children are necessarily outgrowing their disorder relative to normal children; like mental retardation, the disorder of ADHD is defined by a developmentally relative deficiency, rather than an absolute one, that persists in many children over time.

The persistence of ADHD symptoms across childhood as well as into early adolescence appears to be associated with the initial degree of hyperactive/impulsive behavior in childhood, the co-existence of conduct problems or oppositional/hostile behavior, poor family relations and conflict in parent-child interactions, as well as maternal depression. These predictors have also been associated with the development and persistence of oppositional and conduct disorder into adolescence.

The Montreal follow-up study of Weiss and Hechtman reported in 1993 that at least half of their subjects were still impaired by some symptoms of the disorder in adulthood. The New York City longitudinal study by Salvatore Mannuzza and Rachel Klein suggested that 18 to 30% of hyperactive children continue to have significant symptoms of ADHD into adulthood. Most recently, the Milwaukee follow-up study by Barkley and Fischer suggests that the source of information about the symptoms may be a significant factor in establishing the persistence of the disorder into adulthood. Less than 25 % of ADHD children reported having significant symptom levels of the disorder in adulthood when asked about themselves as young adults while their parents indicated that more than 60% of these subjects continued to have clinically significant degrees of the disorder as young adults. Until more studies report adult outcomes for ADHD children using clinical diagnostic criteria appropriate for adults and collecting information not only from the adult but from a parent or an immediate family member who knows them well, the true persistence of the disorder into adulthood will remain a matter of some controversy. At the very least, current research suggests it may be 30 to 50%, although the percentage may be higher among clinic-referred children followed to adulthood.

The most recent diagnostic criteria for ADHD are defined in the DSM-IV (1994). They stipulate that individuals have had their symptoms of ADHD for at least 6 months, that these symptoms exist to a degree that is developmentally deviant, and that they have developed by 7 years of age. From the Inattention item list, six of nine items must be endorsed as developmentally inappropriate. Likewise, from the Hyperactive-Impulsive item list, six of nine items must be endorsed as deviant. Depending upon whether criteria are met for either or both symptom lists will determine the type of ADHD that is to be diagnosed: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, or Combined Type.

These diagnostic criteria are empirically derived and are the most rigorous ever available in the history of clinical diagnosis for this disorder. They were developed by a committee of some of the leading experts in the field, a literature review of research on ADHD, an informal survey of rating scales assessing the behavioral dimensions related to ADHD by the committee, and from statistical analyses of the results of a field trial of the items using a large sample of children from 10 different sites in North America.

Controversy continues over whether ADHD-Predominantly Inattentive Type represents a true subtype of ADHD. It is unclear if these children share a common attentional disturbance with the Combined Type and are distinguished simply by the relative absence of significant hyperactivity-impulsivity or whether they have a qualitatively different impairment in attention from that seen in the Combined Type. Several recent reviews of the literature have suggested that this is not in fact a true subtype but actually a separate, distinct disorder having a different attentional disturbance than the one present in ADHD-Combined Type. However, evidence for this subtype’s existence was at least strong enough to place it within the DSM-IV while awaiting more research on its course and treatment responsiveness to help clarify its status. The very limited research available to date suggests that Predominantly Inattentive ADHD children have more problems in the focused or selective component of attention, appear sluggish in their speed of information processing, and may have memory retrieval problems; in contrast, those with ADHD-Combined Type have more problems with persistence and distractibility as well as with poor inhibition.

The research criteria from the International Classification of Diseases (ICD-10) for Hyperkinetic Disorders closely resemble the DSM-IV in stressing two lists of symptoms related to inattention and overactivity and in requiring that pervasiveness across settings be demonstrated. The specific item contents, manner of presenting these symptoms lists within the home and school setting, requirement for office observation of the symptoms, and the earlier age of onset (age 6 years) clearly differs from the DSM-IV, as does the specification of a lower bound of IQ below which the diagnosis should not be given.

Social critics have charged that professionals have been too quick to label energetic and exuberant children as having this mental disorder and that educators also may be using these labels simply as an excuse for poor educational environments. This would imply that children who are hyperactive or are diagnosed with ADHD are actually normal but are being labelled as mentally disordered because of parent and teacher intolerance. If this were actually true, then we should find no differences of any cognitive, behavioral, or social significance between ADHD children and normal children. We should also find ADHD is not associated with any significant later risks in development for maladjustment within any domains of adaptive functioning, social, or school performance. Furthermore, research on potential etiologies for the disorder should also come up empty-handed. This is hardly the case. It should become clear from the totality of information on ADHD presented here and elsewhere in reviews such as those by Barkley in 1990 and Hinshaw in 1994 that those with ADHD have significant deficits in behavioral inhibition and associated executive functions that are critical for effective self-regulation, that these deficits are significantly associated with various biological factors, and particularly genetic and neurodevelopmental ones, and that ADHD symptoms and other associated disorders pose substantial risks for these individuals over the life span.

Future research needs to address the nature of the attentional problems in ADHD given that current research seriously questions whether these problems are actually within the realm of attention at all. Most studies of ADHD point to impairment within the motor, output, or motivational systems of the brain being most closely affiliated with ADHD rather than deficiencies in the sensory processing systems where attention has been traditionally thought to reside. Even the problem with sustained attention may represent a deficiency in a more complex form of goal-directed persistence that arises out of poor self-regulation rather than representing a disturbance in the more primitive form of sustained responding that is contingency shaped. Our understanding of the very nature of the disorder of ADHD is at stake in how research comes to resolve these issues.

Key to understanding ADHD is the notion that it is actually a disorder of behavioral performance and not one of skill; of how and when one’s intelligence comes to be applied in everyday effective adaptive functioning and not in that knowledge itself; of doing what one knows how to do rather than of knowing what to do. The concepts of time, timing, and timeliness are likely to prove increasingly crucial in deepening our understanding of ADHD. In particular, psychological time, how it is sensed, and how it is used in the crosstemporal organizing of complex, goal-directed behavior and in self-regulation may come to be a critical element in models of ADHD. Undoubtedly, research on brain function and structure is likely to further our understanding of the unique role of the prefrontal cortex and the midbrain structures with which it is closely associated in ADHD. But advances in theoretical models must also occur in order to better understand the nature and organization of the executive functions subserved by these brain regions and even the relationship of genetics, which builds these brain regions in embryological development, to ADHD and the deficits it produces in behavioral performance. And the current body of twin studies further suggests that while such genetic influences are important, there exists a lesser but still important role for unique (nonshared) environmental influences on the differences among individuals in symptoms of ADHD and its underlying behavioral traits. Some of these influences are no doubt social in nature while others are likely to be nongenetic pre-, peri-, and postnatal factors affecting brain development. Such studies, not only on the basic psychological nature of ADHD but also on its basic neuroanatomic and neurogenetic origins and the influence of unique social factors upon them, forebode further significant and exciting advances to come in the understanding and treatment of this fascinating developmental disorder.

Bibliography:

• American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
• Barkley, R. A. (1997a). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94.
• Barkley, R. A. (1977b). ADHD and the nature of self-controI. New York: Guilford.
• Barkley, R. A. (1994). Impaired delayed responding: A unified theory of attention deficit hyperactivity disorder. In D. K. Routh (Ed.), Disruptive behavior disorders: Essays in honor of Herbert Quay (pp. 11-57). New York: Plenum.
• Barkley, R. A. (1990). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford.
• Biederman, J., Faraone, S. V., Keenan, K., & Tsuang, M. T. (1991 ). Evidence of a familial association between attention deficit disorder and major affective disorders. Archives of General Psychiatry, 48, 633-642.
• Bronowski, J. (1977). Human and animal languages. A sense of the future (pp. 104-131 ). Cambridge, MA: MIT Press.
• Denckla, M. B. (1994). Measurement of executive function. In G. R. Lyon (Ed.), Frames of reference for the assessment of learning disabilities: New view on measurement issues (pp. 117-142). Baltimore, MD: Paul H. Brookes.
• Douglas, V. I. (1983). Attention and cognitive problems. In M. Rutter (Ed.), Developmental neuropsychiatry (pp. 280-329). New York: Guilford.
• Fuster, J. M. (1989). The prefrontal cortex. New York: Raven.
• Hinshaw, S. P. (1994). Attention deficits and hyperactivity in children. Thousand Oaks, CA: Sage.
• Rutter, M. (1983). Introduction: Concepts of brain dysfunction syndromes. In M. Rutter, (Ed.), Developmental neuropsychiatry (pp. 1-14). New York: Guilford.
• Szatmari, P. (1992). The epidemiology of ADHD. In G. Weiss (Ed.), Child and adolescent psychiatric clinics of North America (Vol. 1, pp. 361-372). Philadelphia: W. B. Saunders.
• Weiss, G. & Hechtman, L. (1993). Hyperactive children grown up. New York: Guilford.

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AI may aid in diagnosing adolescents with ADHD

Using artificial intelligence (AI) to analyze specialized brain MRI scans of adolescents with and without attention-deficit/hyperactivity disorder (ADHD), researchers found significant differences in nine brain white matter tracts in individuals with ADHD. Results of the study will be presented today at the annual meeting of the Radiological Society of North America (RSNA).

ADHD is a common disorder often diagnosed in childhood and continuing into adulthood, according to the Centers for Disease Control and Prevention. In the U.S., an estimated 5.7 million children and adolescents between the ages of 6 and 17 have been diagnosed with ADHD.

"ADHD often manifests at an early age and can have a massive impact on someone's quality of life and ability to function in society," said study co-author Justin Huynh, M.S., a research specialist in the Department of Neuroradiology at the University of California, San Francisco, and medical student at the Carle Illinois College of Medicine at Urbana-Champaign. "It is also becoming increasingly prevalent in society among today's youth, with the influx of smartphones and other distracting devices readily accessible."

Children with ADHD may have trouble paying attention, controlling impulsive behaviors or regulating activity. Early diagnosis and intervention are key to managing the condition.

"ADHD is extremely difficult to diagnose and relies on subjective self-reported surveys," Huynh said. "There is definitely an unmet need for more objective metrics for diagnosis. That's the gap we are trying to fill."

Huynh said this is the first study to apply deep learning, a type of AI, to identify markers of ADHD in the multi-institutional Adolescent Brain Cognitive Development (ABCD) Study, which includes brain imaging, clinical surveys and other data on over 11,000 adolescents from 21 research sites in the U.S. The brain imaging data included a specialized type of MRI called diffusion-weighted imaging (DWI).

"Prior research studies using AI to detect ADHD have not been successful due to a small sample size and the complexity of the disorder," Huynh said.

The research team selected a group of 1,704 individuals from the ABCD dataset, including adolescents with and without ADHD. Using DWI scans, the researchers extracted fractional anisotropy (FA) measurements along 30 major white matter tracts in the brain. FA is a measure of how water molecules move along the fibers of white matter tracts.

The FA values from 1,371 individuals were used as input for training a deep-learning AI model, which was then tested on 333 patients, including 193 diagnosed with ADHD and 140 without. ADHD diagnoses were determined by the Brief Problem Monitor assessment, a rating tool used for monitoring a child's functioning and their responses to interventions.

With the help of AI, the researchers discovered that in patients with ADHD, FA values were significantly elevated in nine white matter tracts.

"These differences in MRI signatures in individuals with ADHD have never been seen before at this level of detail," Huynh said. "In general, the abnormalities seen in the nine white matter tracts coincide with the symptoms of ADHD."

The researchers intend to continue obtaining data from the rest of the individuals in the ABCD dataset, comparing the performance of additional AI models.

"Many people feel that they have ADHD, but it is undiagnosed due to the subjective nature of the available diagnostic tests," Huynh said. "This method provides a promising step towards finding imaging biomarkers that can be used to diagnose ADHD in a quantitative, objective diagnostic framework," Huynh said.

Co-authors are Pierre F. Nedelec, M.S., M.T.M., Samuel Lashof-Regas, Michael Romano, M.D., Ph.D., Leo P. Sugrue, M.D., Ph.D., and Andreas M. Rauschecker, M.D., Ph.D.

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ADHD, Research Paper Example

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What Is ADHD?

George’s son had always been a bit hyper. He was frantically playing with his toys, breaking them and nothing could hold his attention for a while. He was also unaware of the dangers around him…like just throwing himself in the middle of a crowded road. It was exhausting for the parents, and they shunned of the activities of their boy thinking that it was natural for the boys to have this nature. However when he grew inattentive and disruptive even at the school, the teacher suggested an evaluation of Attention Deficit Hyperactivity Disorder (ADHD).

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th edition, 1994), defines ADHD “as the ‘core’ signs of inattention, hyperactivity and impulsiveness,” while International Classification of Diseases describes it as ‘hyperkinetic disorder’ in the 10th revision of the (WHO, Geneva, 1992).

The Background on the Disability ADHD

For decades, the symptoms of inconsistent behavior, chronic restlessness and impulsive actions were characterized by childhood behavioral patterns of ADHD. There was little research on ADHD and how it was different from hyper active yet normal behavior of children. There was no clear definition or demarcation between the thin lines of “hyperactive” or “abnormal” behavior. Thus the disease went undiagnosed. Gradually the disease gained momentum and received different connotations.

In 1902, the first case relating to the disorder was documented which related to impulsive behavior. Dr. Still diagnosed this behavior in Britain and named it “Defect of Moral Control” and considered that the patient had a peculiar disorder beyond medical control. The next evidence of such symptoms were attributed the name “Post-Encephalitic Behavior Disorder.” The next case was registered in 1937, under the supervision of Dr. Charles Bradley. He introduced the use of stimulants to treat hyperactive children, and in 1956 Ritalin was formulated as the medicine to treat hyperactivity.  Thus the major symptom which detected abnormal behavior was hyperactivity. However, at the end of the decade, the disorder got the name of “Hyperkinetic Disorder of Childhood.” In 1970, the number of cases grew and the doctors recognized that there were certain other symptoms like ‘paying attention or listening to teachers’. Thus the focus changed from exclusive hyperactivity to inattentive behavior, restlessness and impulsive activity and gave a major change in the paradigm of the disease and its diagnoses.

Thus now after the symptoms of inattentive nature, impulsiveness were added in the list of characteristic symptoms of ADHD, and in 1980 the disease got its current name Attention Deficit Disorder and the American Psychiatric Association (APA) documented ADD and ADHD as two different diagnoses. In 1987, ADD transformed into ADHD and was noted as a medical diagnosis rather than a psychological disorder by the APA. New research further highlights ADHD symptoms which neuropsychologists term as impairment of executive functions. These are essentially ‘brain’s cognitive management functions’, the parts or the circuits which control and prioritize, mitigate and synchronize other cognizant functions.

Methods of Diagnosis

ADHD has been divided in three subgroups:

• The combined Type: The patients are inattentive, hyperactive and impulsive
• The Inattentive Type: The patients are basically inattentive but does not show signs of hyperactivity or impulsiveness
• The Hyperactive/Impulsive Type: The patients suffer from hyperactivity/ impulsivity rather than being inattentive.

There are no diagnostic laboratory tests for the disease. It is based fully on evaluation of symptoms. Medical tests are needed to be done to know whether the disease actually persists and also to identify the category of the disease for treatment. The most prevalent diagnostic tool is Clinical interview. ADHD affects all age groups but is diagnosed in childhood. The symptoms are studied and diagnosed in the Clinical interview and includes: family history, academic and family environment, emotional and social influences and level of development. Various psychological tests are also performed like: For Children – The Conner’s’ Parent and Teacher Rating Scale; for teenagers – The Brown Attention Deficit Disorder Scale  (BADDS).

Symptoms: In children at the age of 5 years the soft signs of ADHD appear like: difficulty in coordination, the involuntary movement of the eyes (nystagmus), and impaired visual –motor problems (also known as hand-eye coordination).

Possible treatments: Since the disease was based on evaluation, doctors differed in their treatment approaches until Dr. Gephart in a joint initiative by National Initiative for Children’s Healthcare Quality and the Robert Wood Johnson Foundation made a set of formulations and guidelines for the pediatrics to diagnose and treat ADHD. It is mostly treated in a combination therapy of medication as well as behavioral changes. The parent works in tandem with the advice of the doctor to help the child control his own behavior. The medications used are mostly Stimulants, Non Stimulants and Antidepressants. While in Behavior therapy, attempts are made to change and stabilize the behavioral patterns of the child by adjusting the environment of his school, home and his social circle.

Classroom Teaching of ADHD Learning

A quote from Henry Adams, “A teacher affects eternity; he can never tell where his influence stops.” Teachers play one of the major roles in the life of an ADHD child. In one of the Bollywood films, which even competed for the Oscar nominations, “Tare Zameen Par”, there is a great revelation of the teacher student relationship. It characterizes the teacher as a guiding force in the life of the child and how his fun teachings strategies and easy interpretations made the child win over the disease. With my personal experience, I feel it is difficult at the foremost to manage a ADHD child but is lot easier with time and developed relationship.

Yes, once you meet the child who answers you while looking at the ceiling, and replies to your question: what is the color of your hair? Huh, this is my pencil. So do not be perturbed by their activity. The criteria required for studying in the class like: attention, concentration and following instructions are difficult for the ADHD children to adapt, not because they do not want to do so but are their brains would not let them do so.

What are the classroom challenges faced by the teachers?

• They are inattentive and absent minded. Many of them find the characters are flowing or running and they cannot categorize A-Z of the alphabetical order. So the alphabets A and E are almost same to them. Thus have tremendous learning difficulties and the teachers need to divert more attention to them.
• They are negligent in writing down their homework, they are not able to take notes and since alphabets have no meaning to them, reading their work is a real problem.
• They fail to comply with stand alone projects
• Does not concentrate and may even jeopardize class activities

What makes the situation worse? When teachers are stressed to handle the activities of the extraneous child, they often opt for punishments and scolding, resulting in further aggravation of the problem. Thus “the primary purpose of a school is to guide the child’s discovery of herself and her world and to identify and mature the child’s talents. Just as each seed contains the future tree, each child is born with infinite potential.” The teachers should assume the role of gardeners instead of being potters in molding the future of these children.

The successful integration of the techniques of psychological teaching, accommodation, instructions and intervention help the ADHD children to learn better and develop the core method of controlling his emotional self.

• The Psychological Teaching Method
• Focus on the strengths of the ADHD child
• Boost his/her self confidence
• Tame his hyperactive spirits
• Discover the child’s hidden talents
• Help the child to find his right vocation in the discourse:
• Observe the tendencies of the child
• Have fun while learning:
• Teacher should be affectionate and patient:
• Accommodation
• Seating: The ADHD students should be seated away from the windows and doors so that they are not distracted.
• Always try to put the child close to your desk, in front of your desk so that you can observe closely his activities.
• Seating should be row wise not in round tables so that there is a constant teacher student eye contact.
• Information Delivery
• The instructions should be broken in parts and one at a time.
• Work on difficult assignments in the morning
• Diagrams, visual display, colors, music, pictures are the best tools for teaching.
• Give them an outline of the home work so that they learn to organize and synchronize.
• Create special worksheets for them with fewer items so that they don’t feel confused.
• Give them occasional quiz, puzzles to solve
• Reduce the number of time tests which creates pressure on their brains
• Give the ADHD students more fill in the blanks
• Help them track their work by using bookmark or pointers
• Always give credit to their work
• Teaching Pattern
• Use Short Segments: Break the lessons in parts and sub parts, this will help the student from being attentive and increase his concentration on the subject. Keep in consideration that the lessons should be allocated a few minutes, and make them more colourful with music, colour, rhythm and involving partial playing activities.
• Give them short, easy and achievable goals: Give them homework or projects which are easy and short. This would give them the inertia to complete their work and once the work is achieved it would boost their self confidence.
• Repetition: Repeat the sentences, words and assignment details. Help them absorb the content or the project in their minds and let four different students repeat it and then let the class talk about it in unison and then put it on board.
• Make the learning a fun: Let the ADHD students enjoy as they learn. Don’t make the studies be a burden to them and help them learn the work in fun. This will greatly help them to cope with the excess stress of education. Divide the chapters in a game display board..like in Mathematics, draw the trains that is coming at different speeds and calculate their distance.
• Signal the start of a lesson: Always start a lesson with a aural cue so that he becomes immediately attentive.
• Set unobtrusive clues: The teacher should set up unobtrusive clues with the ADHD child, like a pat on the shoulder or placing a sticker on the table of the child to remind him of the assigned task.
• Let the child play with a Koosh ball or some soft toys that will not make any noise in the class.
• Let the student take multiple breaks.
• Do not allocate difficult tasks to him
• Do not embarrass him before the class or in public.
• Teach them in the method of stories

Thomas Edison, Pablo Picasso, Albert Einstein and Winston Churchill all suffered from ADHD at some point of time in their lives. However, proper guidance, love and proper channelization of their talents made them what they are. Thus teachers are the building block in their traumatised lives and a bridge between the hypothetical and reality.

Martha Bridge Denckla,, In Attention Memory and Executive Function ,

Thomas E. Brown, Attention Deficit Disorder: The Unfocused Mind in Children and Adults .

Londrie, Keith, (2006)”History of ADHD.”  History of ADHD

Movie: Taare Zammen Par, (2007) last Retrieved On November 13, 2009 from http://wplay.wordpress.com/2007/12/28/aamir-khans-taare-zameen-par/

Biederman J (1998). “Attention-deficit/hyperactivity disorder: a life-span perspective”. The Journal of Clinical Psychiatry

Ramsay, J. Russell. (2007) Cognitive Behavioral Therapy for Adult ADHD.

Nair J, Ehimare U, Beitman BD, Nair SS, Lavin A (2006). “Clinical review: evidence-based diagnosis and treatment of ADHD in children”.

Van Cleave J, Leslie LK (August 2008). “Approaching ADHD as a chronic condition: implications for long-term adherence”. Journal of psychosocial nursing and mental health services.

National Association of School Psychologists (NASP) http://www.nasponline.org

American Academy of Pediatrics (AAP) http://www.aap.org

National Attention Deficit Disorder Association (ADDA) http://www.add.org

hildren and Adults With Attention Deficit / Hyperactivity Disorder (CHADD) http://www.chadd.org

Adult ADHD: Evaluation and Treatment in Family Medicine by HR Searight, Ph.D., JM Burke, Pharm.D. and F Rottnek, M.D. ( American Family Physician   November 1, 2000, http://www.aafp.org/afp/20001101/2077.html)

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What to know about an 'ADHD watch'

Posted: November 29, 2023 | Last updated: November 29, 2023

Dr. Shazia Savul treats adults whose lives are significantly affected by symptoms of attention deficit hyperactivity disorder.

These patients, whom Savul sees as the lead psychiatrist of clinical services for adult ADHD at University of Pennsylvania's Perelman School of Medicine, frequently experience challenges with focus and time management that consistently impact their work, school, relationships, and mental health . This can include losing track of time, falling behind on tasks, and becoming so focused on a specific activity that other obligations fall to the wayside.

Savul has a list of evidence-based treatments that she recommends to patients with ADHD. Prescribing a technological device like a smartwatch is not among them.

This may surprise some consumers with ADHD, who may have seen products like smartwatches advertised to help improve their time management skills. Even retailers like Amazon and Walmart have category pages devoted to ADHD watches, despite the fact that experts like Savul don't rely on or prescribe them for treating patients.

"There's no specific device or gadget or watch or any instrument that we specifically recommend for ADHD to improve executive skills — not yet," Savul says, noting that research on such devices is very limited.  

That doesn't mean ruling out tech devices altogether as an intervention for ADHD. Indeed, there are testimonials on TikTok and elsewhere online describing the potential benefits of using a watch or timer for managing symptoms. Savul says that if a tool or gadget helps with organization or forgetfulness, a patient should "by all means" use it.

But before you splurge on an expensive watch billed as the solution to your ADHD-related time management problems, here's what you should know:

Why do some people with ADHD struggle with focus and time management?

ADHD is a neurodevelopmental condition that is believed to affect the part of the brain responsible for executive functioning. Typically, people develop a related set of skills to execute tasks and goals, like sorting through competing demands and making deliberate choices about what to prioritize.

But for people with ADHD, the brain's executive functioning can be impaired, perhaps because that area of the brain is less active or has difficulty suppressing various incoming stimuli and signals. In turn, Savul says this can affect time perception, orientation, and management. Time blindness , a popular term to describe the phenomenon of losing an awareness of time, can happen to anyone, but it is often pronounced in people with ADHD.

While not everyone with ADHD struggles with time equally, those who do often find it hard to subjectively gauge time as it passes, meaning minutes can evaporate into hours with diminished awareness of what's happening.

In children, this frequently shows up as distractibility, being unable to stick with a task, and taking much longer to do routine tasks than their peers, even if they have an established routine, says Dr. William Benson, a psychologist in the ADHD and Behavior Disorders Center at the Child Mind Institute. Typically, ADHD emerges in elementary-school age children as classwork expectations grow.

Still, the condition isn't always identified in childhood. Savul often treats patients who are being diagnosed for the first time as adults. Sometimes, these patients had a degree of structure and support that effectively reduced their symptoms. But when they reached adulthood and their environment changed, their symptoms became unmanageable. In other cases, patients may have been treated for depression or anxiety, but also had ADHD that went undetected.

Both Savul and Benson told Mashable that children and adults should seek professional help when symptoms interfere with daily functioning.

"These things can happen in almost every person some of the time, but if it's consistent, it's a pattern, it's repetitive, it's getting in the way of doing things, moving forward, then that's when it's important to have it evaluated," says Savul.

What is an "ADHD watch"?

While some watch products are described as being designed for ADHD, there is little high-quality research on whether smartwatches reduce symptoms for people with the condition.

Instead, features like timers, vibrations, and alarms are marketed as ways to help the user keep track of time and stay on task.

In one six-week pilot study conducted during the early stage of the COVID pandemic , 10 children with ADHD between the ages of 10 and 15 received an Apple Watch and iPhone in order to evaluate whether timed reminders helped their organizational skills. The reminders popped up on participants' watches five minutes before they needed to attend virtual class.

The results, which were published in PLOS ONE in October 2021, found that some parents noticed improved self-awareness and self-motivation for their children. One participant's parent, however, said the watch distracted their child because they'd never worn a device on their wrist and experienced "tactile sensitivity."

Additionally, the children generally wore their watches during the first three weeks of the study, after which use decreased by half.

The study authors noted that far more research is needed to better understand how a smartwatch can support children with ADHD.

When a watch or time-assistive device can be helpful for ADHD

Stimulant medication , which promotes focus, is typically the first choice for treatment, given how effective it is, says Savul. Still, some patients don't see improvements in their time management or organizational skills.

That's when cognitive behavioral therapy specifically designed for ADHD can be useful, specifically for adults. That type of psychotherapy can address " cognitive distortions ," or unhelpful thought patterns, that surface in ADHD, often in tandem with depression or anxiety. A patient may have a negative view of themselves based on years of coping with ADHD, a dynamic that can interfere with their problem-solving skills.

In Savul's clinic, patients can also receive ADHD coaching, which offers training in organizational skills and time management. The goal is to help patients become more productive and have more control over accomplishing their daily tasks.

But instead of fancy gadgets, Savul says patients may work with digital and paper planners, scheduling tools, and other time-assistive devices, like a basic timer.

For kids with ADHD, Benson says that it's important to help them understand how much time is passing in simple ways. A 15-minute block, for example, is half the length of their favorite cartoon. An hourglass or visual timer can also be helpful, as are posted schedules and calendars with a detailed breakdown of their day.

While learning to track time is key, kids also need to develop the ability to accurately estimate how long a certain task will take. They might think a homework assignment will require just 10 minutes but forget the time that elapses when they're booting up a computer or sorting through different class projects.

Benson says that a watch might be helpful if it provides visual or physical reminders (like a vibration), but insight is just as important. In other words, it's key to understand how and when a specific tool, like a watch, is effective.

If, for example, a child feels the buzz of a reminder but is so overwhelmed by a messy workstation that they can't transition to the next task, the watch may not yield positive benefits. There's also the risk that a watch's novelty will wear off; it's not so useful when the alarms just get snoozed or when kids stop wearing the watch altogether.

Savul says that each patient's treatment needs to reflect what works best for them. One patient may find success with a digital task organizer, while another thrives when using sticky notes.

They key is finding strategies that become routine, says Savul: "It's important to recognize, 'What is it that I can do which I can maintain consistently?'"

Be skeptical of products for ADHD that could be snake oil

Savul cautions people against spending a lot of money on unproven strategies or products for ADHD. She says that, in fact, many strategies for time management aren't costly, like using a planner. She also reiterates that there's no specific items that she recommends to patients with ADHD at this point.

Though treatment for ADHD can be expensive, even with insurance coverage, Benson says that products making unsupported claims can also be pricey.

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In general, he notes that there's no evidence for expensive interventions that use high-tech equipment. He also urges families to be wary of blood testing or scans that purport to determine what "type" of ADHD a child has in order to customize their treatment.

"That's not accepted by the scientific community," he says.

Similarly, certain products that use games and activities to train working memory as a way to treat ADHD don't seem to be effective, says Benson. Some products may even say they are "cleared" by the Food and Drug Administration, but that doesn't mean they're effective, and it's not the same as receiving approval from the federal agency, he adds.

If you see an ad or product that looks interesting, even if it's in a publication that you otherwise trust, Benson recommends looking at its claims and how they're backed.

"Be a skeptical consumer," he says.

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ADHD Research Papers Examples

Type of paper: Research Paper

Topic: Children , Family , ADHD , Disorders , Behavior , Condition , Attention , Students

Words: 1650

Published: 2020/12/08

ADHD refers to Attention Deficit Hyperactivity Disorder. It is a chronic mental condition involving problems of difficulty in paying attention, hyper activity and impulsiveness. It is ranked as the most common neurobehavioral disorder in childhood. This disorder, however, may continue during adolescence and even into adulthood. The disorder consists of three sub types, Predominantly Hyperactive Impulsive, Predominantly inattentive, and the Combined Hyperactive – Impulsive and Inattentive. The predominantly hyperactive – impulsive is characterized by more symptoms of hyper-activity and impulsiveness and less of symptoms of inactiveness. The Predominantly Inattentive kind consists of more symptoms of inattentiveness and fewer symptoms of hyper-activity. In this category, the affected children have difficulties getting along with other children and being pro-active. The combined hyper active- Impulsive and inattentive type is a combination of the three symptoms of hyperactivity, impulsivity and inattention. Most children who suffer from ADHD have the combined type. The cause of this disorder is not clear. Scientific studies have nonetheless suggested possible causes of the condition. Studies imply that ADHD conditions run in families and therefore, genes play a key role in contributing to the condition. Children that carry a particular type of gene have a thinner brain tissue in the parts of the brain that are tasked with attention. When the children grow older, the brain tissue has been shown to grow to normal size. More research needs to be carried out to specify the type of genes combinations that cause the disorder. It has also been suggested that children of cigarette smoking or alcoholic mothers during the pregnancies have a higher risk of contracting the disorder. Brain injuries in children have also been linked to cause some ADHD related behaviors. Other studies indicate that exposure to fluoridated water and lead may increase risks to the disorder. Concrete scientific findings are yet to be presented as to the causes of this disorder. The symptoms associated with the disorder are as follows. In the hyperactivity category, people with the disorder always fidget and squirm in their seats. They also are in constant motion and can barely sit still during family events or dinner. Affected children keep running around and mostly have problems doing tasks in a quiet manner. They also tend talk nonstop. In the impulsivity grouping, victims of this disorder are known to be rather impatient. They have no restraint to speak and often are insensitive in their comments. They easily are nagging about always being first to receive things as they cannot wait for their turn. They constantly interrupt conversations and are often a nuisance to their parents in presence of visitors. Children that suffer more symptoms of inactivity have behaviors such as, being easily distracted. These have a problem in focusing on one thing. They become bored with an activity within very few minutes and do not pay attention to what they are doing. They struggle to follow instructions and so are really affected in their studies as they rarely complete assignments. Moreover, they do not seem to listen when someone is speaking to them. These symptoms and behaviors in the child may be a major cause of frustration and bad attitude towards the child by parents, teachers and other people around him or her. This may be avoided if these people are aware of the condition that the child is suffering from and they adopt deliberate measures to assist the affected child or person. Children suffering from this disorder are prone to challenges in their academics. It leads to poor grades, detention and even expulsion from school. In some children, it causes low self-esteem and often leads to drug and substance abuse. It is therefore critical that ADHD is diagnosed as early as possible so as the affected party is assisted through medication and therapy. The condition is not curative and the various types of medication prescribed come to reduce the symptoms. Stimulant pills are for instance known to cause calmness in children. However, the medication prescribed for children or adults may not work for all people suffering from ADHD. There are various ways to assist people living with ADHD to manage the disorder and still make successful lives. These include medication, use of psychotherapy and Education and training. Therapy involves use of practical interventions that help in the behavioral change of the affected child. Parents may work together with teachers and therapists to help in the reduction of symptoms of ADHD in children and adolescents. This can be done by using a system of rewards and consequences to correct the child’s behavior. Giving positive and negative feedback immediately a child does a particular act may discourage the bad behavior and encourage the correct one. Parents may help also by offering practical help such as helping children to complete assignments by sitting with them over the homework sessions. The use of rewards for completed tasks and other good behavior is a motivation for positive change. Due to the child’s condition, they may always feel like failures. Parents may assist to mitigate this by praising the child’s abilities and strengths. This calms them down and reduces some bad behavior. Clear rules and schedules assist children with ADHD to be organized and to pay attention to detail. Consistent and clear schedules may be helpful. Parents need to be deliberate in guiding these children to follow the schedules effectively. For organization purposes, the children may benefit by having their everyday items organized for them. Parent administered interventions have been shown to be effective in moderating and reducing ADHD symptoms and conduct problems. However, the parents carrying out the interventions may need to go through stress management techniques in order to respond calmly to the child’s behavior and for effectiveness in the process. Therapists may also be of major help in teaching children practical social skills such as sharing, how to give others an opportunity and how to wait for their turn. Adults suffering from the condition may be helped by way of professional counseling and therapy. Practical assistance may be in form of assisting them to divide large tasks in smaller ones to increase their effectiveness. Education and training them about the disorder is also essential in to helping them understand themselves better. These people need patience and encouragement around them to eventually assist them to lead successful lives. ADH affects 9.0% of American children of ages 13 to 18 years and about 4.1% of American adults age 18 years and older in a year. The boy child is at a higher risk than the girl child for reasons not yet settled by scientific study. With this kind of statistics, therefore, it is the responsibility of every member of society to assist this population to lead a worthy life despite their condition. In classrooms, children suffering from ADHD should be handled slightly different from those that are normal. Studies show that students suffering from ADHD have difficulties in processing information. Their analyzing speed is slow as compared to normal children and adolescents. The school program could be made a bit more flexible in order to assist such students. For instance, allowing these students to have a bit more time in tests and examinations would help them to excel. The problem with this is the argument that it would put them at an advantage against their peers. However, it is important to acknowledge that these students require special attention as compared to their colleagues. Teachers may carry out special class sessions with these students to ensure materials previously taught is understood. This attention is vital in improving the condition of these students. The other major way of helping those living with ADHD is acceptance. ADHD is a disorder that can be managed. Parents with children suffering from this disorder find themselves rejecting these children due to their behavior. Gaining education about the condition as a family may lead to an acceptance of the one with the condition. Punishment for these children should be differently. It is important to discipline children living with ADHD. However, discipline measures for these kinds of children and teens should be in form of awards for good behavior and slight unpleasant activities to discipline them for wrong actions. Severe punishment may lead to worse behavior and loss of self-esteem for children with ADHD. In classrooms, a firm rebuke is sufficient to disapprove certain behavior. Behavioral control measures such as having rules written down and placed near such children is another way to help combat ADHD behavior. Punishment should be done in a loving and understanding way for these children. The condition is here to stay until a cause and a permanent cure is discovered. In the meantime, people living with this condition have to be helped to live and make achievements.

Works Cited

Brown, Thomas Edwards, Donald Michael Quinlan and Philip Christian Reichel. "Extended Time Improves Reading Comprehension Test Scores." Open Journal of Psychiatry (2011): 79-87. Coates, Janne, John A Taylor and Kapil Sayal. "Parenting Interventions for ADHD:A Systematic Literature REview And Meta-Analysis." Journal of Attention Disoders (2014): 1-13. Corkum, Penny, Mellisa Mc Gonell and Russell Schachar. "Factors Affecting Academic Achievement In Children With ADHD." Journal of Applied Research On Learning (2010). Feldman, Heidi M and Irene M Loe. "Academic And Educational Outcomes Of Children With ADHD." Journal of Pediatric Psychology 32.6 (2006): 643-654. Malin, Ashley J and Christine Till. "Exposure to Flouridated water And Attention Deficit Hyperactivity Disoder Prevalence Among Children And Adolscents In The United States : An Ecological Assocuiation." Enviromental Health 14.17 (2015): 26-37. Thapar, Anita, et al. "What Causes Attention Deficit Hyperactivity Disorder?" Archives of Disease In Childhood 97.3 (2011): 260-265. The American Academy of Pediatrics. "ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents." Pediatrics 128.5 (2011): 1007-1022.

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Research Paper

Attention deficit/hyperactivity disorders (adhd) research paper.

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Attention deficit/hyperactivity disorder (ADHD) is a psychiatric disorder affecting 3 to 5% of children. Recent data suggest that the incidence of ADHD may be even higher (5–7%). ADHD is a chronic disorder, with approximately 75 to 80% of affected individuals showing evidence of significant impairment during adolescence and adulthood. Estimates suggest that 1.5 to 2.0% of adults and 2 to 6% of adolescents have ADHD. Research indicates that children with persistent ADHD have more severe symptoms, significant impairment in functioning, stressful family environments, and more adverse risk factors. There are a number of factors that interact with ADHD and further compromise adjustment over the life span.

• Core Characteristics of Attention Deficit/Hyperactivity Disorder
• Associated Problems
• ADHD with Other Disorders
• Gender and Cultural Issues
• Etiology of ADHD
• Developmental Context for ADHD
• Evidence-Based Interventions for ADHD
• Medication Monitoring and Adherence
• Risk and Resiliency Factors that Affect ADHD

1. Core Characteristics Of Attention Deficit/ Hyperactivity Disorder

Core symptoms of inattention, impulsivity, and hyperactivity comprise the major characteristics of attention deficit/hyperactivity disorder (ADHD), with new conceptualizations emphasizing poor self-control and behavioral disinhibition. Behavioral disinhibition is synonymous with poor self-regulation or the inability to control one’s activity level, attention, and emotions. In 1997, Barkley posited that disinhibition interferes with executive control functions, including working memory, internalization of speech to guide one’s behavior, motor control for goal-directed behavior, the ability to analyze and synthesize responses, and self-regulation of emotions, motivation, and arousal.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) outlined three subtypes of ADHD: attention deficit disorder/predominantly inattentive type (ADD/PI), attention deficit disorder/predominantly hyperactive-impulsive type (ADD/PHI), and attention deficit disorder/combined type (ADD/C). Inattention is multifaceted and refers to difficulties with distractibility, alertness, and arousal as well as with selective, sustained, and persistent attention to tasks. Individuals with ADD/PI appear to have cognitive disabilities (e.g., spacey, ‘‘daydreamy,’’ sluggish, easily confused) that arise from slow information processing and poor focused/selective attention. There is some debate in the literature as to whether ADD/PI is a separate disorder distinct from ADD/PHI or ADD/C. Further research is warranted on this issue, particularly as it relates to gender differences. For example, some studies report that girls have higher rates of inattention than of impulsivity and hyperactivity.

Impulsivity encompasses the inability to inhibit behavior, delay responding, and delay gratification to reach long-term goals and perform tasks. Hyperactivity is one of the more obvious core features of the disorder and refers to excessive activity (both verbal and physical). Individuals with ADD/PHI display primary problems with hyperactivity and impulsivity, whereas those with ADD/C show deficits in all core symptoms, including impulsivity, inattention, and hyperactivity.

2. Associated Problems

The core symptoms of ADHD lead to impairment in all aspects of life activities, including school attainment, family adjustment, social relations, occupational functioning, and self-sufficiency. Sleep disorders, health problems (e.g., allergies), and accidental injuries (e.g., bone fractures, poisoning) also appear to be higher in children with ADHD than in controls. More accidental injuries may occur in youth with high levels of aggression than in those with hyperactivity alone. Long-term complications associated with ADHD include risk of substance abuse problems; problems in marriage, family cohesiveness, and chronic family conflict; employment difficulties such as frequent job changes, stress on the job, and underemployment; increased health risks such as early cigarette smoking, early sexual activity, increased driving accidents and eating disorders, and sleep disorders in children and adolescents; and risk of comorbid psychiatric disorders.

3. ADHD With Other Disorders

ADHD places individuals at risk for other psychiatric disorders. Oppositional defiant disorder (ODD, 54–67%) and conduct disorders (20–56%) are among the most frequent comorbid disorders in children due to impulsivity and an inability to follow rules. Conduct disorders are also common in teens (44–50%). The presence of ADHD with conduct problems increases the risk of later difficulties, including drug use and abuse, driving accidents, and additional psychiatric problems. Social problems are common in individuals with ADHD, where intrusive, inappropriate, awkward, and/or ineffective behaviors lead to rejection or strained relations with others. Mood disorders are also high (20–36%), with 27 to 30% having anxiety and 15 to 70% having major depression or dysthmia. Stimulant medication might not be as effective in individuals with ADHD plus anxiety, and side effects might be higher than in nonanxious ADHD groups. Learning disabilities are also frequent, with as many as 20 to 50% of children exhibiting significant learning problems due to difficulties with attention, work completion, and disruptive problems in the classroom.

In 1997, Jensen and colleagues cautioned that clinic based longitudinal studies may increase the appearance of comorbidity because persons with more severe and comorbid conditions may be more likely to participate in ongoing studies. Rates of psychiatric comorbidity differ somewhat in community-based studies of children with ADHD. For example, the Multimodal Treatment Assessment (MTA) study of youth with ADHD reported comorbidity rates as follows: In the sample of children, 31.8% had ADHD alone, 33.5% had anxiety, 14.3% had conduct disorders, 39.9% had ODD, 3.8% had an affective disorder, and 10.9% had tic disorders.

Adults with ADHD have comorbidity rates of 16 to 31% for major depression, 24 to 35% for ODD, 17 to 25% for conduct disorders, 4 to 14% for obsessive– compulsive disorders, 35% for alcohol dependence or abuse, 24% for substance abuse (i.e., cannabis or other drugs), 43% for generalized anxiety disorder, and 52% for overanxious disorder. Rates of conduct disorders or antisocial personality disorder are also high in adults with ADHD (22%).

The mechanisms of comorbidity are not well understood, but it appears that ADHD places an individual at risk for other psychiatric disorders and the presence of comorbid disorders interacts with and alters the developmental trajectory and treatment responsivity of ADHD. In 2003, Pliska and colleagues provided an assessment and treatment approach for children with ADHD and comorbid disorders. It is recommended for addressing more complex cases of ADHD.

4. Gender And Cultural Issues

National reports have highlighted the disparity of diagnosis and treatment for mental illness for girls and nonWhite children. Despite similarities in the incidence rates of hyperactivity in Black children, service delivery is lower in Black children than in Whites with similar problems. Referral and treatment rates are lower for girls (three times less likely to receive treatment compared with boys) and for Black children (three times less likely to be referred compared with White children).

There is some evidence that gender differences may be a function of the referral source, that is, clinic referred children versus non-clinic-referred children. In a review of 18 studies on girls with ADHD in 1997, Gaub and Carlson found that nonreferred samples of girls with ADHD, as compared with boys with ADHD, had more intellectual impairments but were less aggressive, were less inattentive, and had lower levels of hyperactivity. However, when compared with clinic referred samples, girls and boys with ADHD had more similarities than differences on core ADHD symptoms.

Other studies of clinic-referred girls indicate that girls with ADD/C are indistinguishable from boys with ADHD on measures of comorbid disorder, behavioral ratings of core symptoms, psychological functioning, and family history of psychopathology. However, when differences did occur, girls had lower reading scores and higher parent-rated measures of inattention. Furthermore, referred girls were a more extreme sample than were boys, with the former having higher rates of familial ADHD. Girls also showed a more positive response to stimulant medication than did boys. In 1999, Biederman and colleagues found similar results in girls referred to pediatricians and psychiatrists. Girls referred for ADHD were more likely to show conduct problems, mood and anxiety disorders, a lower intelligence quotient (IQ), and more impairment on social, family, and school functioning than were nonreferred girls. Conduct problems were lower in girls than in boys with ADHD, and this may account for lower referral rates. However, high rates of mood and anxiety disorders suggest the need for comprehensive treatment. It was of particular note that girls in this study also had high rates of substance abuse disorders, including alcohol, drug, and cigarette use, and were at an increased risk for panic and obsessive– compulsive disorders.

In sum, clinic-referred girls with ADHD present with more symptoms than do girls without ADHD and are indistinguishable from clinic-referred boys with ADHD. It is important to note that girls who are referred for ADHD may represent a more severely impaired group than do community-based samples of girls. Further evidence suggests that girls who are in need of treatment for ADHD may be overlooked because they tend to be less disruptive than boys. Additional longitudinal research investigating gender differences would be helpful to resolve these critical issues.

5. Etiology of ADHD

Research indicates that problems in behavioral inhibition or self-control are a result of dysfunction in frontal– striatal networks, whereas other brain regions (e.g., basal ganglia that includes the caudate nucleus and cerebellum) are also implicated. The evidence of genetic transmission of ADHD, primarily involving the dopamine systems that innervate frontal–striatal regions, is strong. Studies estimate that 70 to 95% of deficits in behavioral inhibition and inattention are transmitted genetically. Research investigating the manner in which the environment interacts with subtle brain anomalies and genetic mutations is ongoing. Traumatic events, the presence of comorbid disorders, and other psychosocial stressors (i.e., poverty, family dysfunction) complicate ADHD but are not considered to be causal.

Although neurological and genetic substrates appear to be compromised, multiple interacting factors are likely involved in the expression of ADHD. It is likely that compromised neural systems influence adaptive functioning and that family, school/work, and community environments affect how ADHD is manifested and may contribute to the development of various coexisting disorders. There may be other factors, including exposure to environmental toxins (e.g., elevated lead exposure), prenatal smoking, and alcohol use, that increase the risk for ADHD. However, these risk factors are not present in all children with ADHD. Some environmental explanations are inaccurate and non-scientifically based, including high sugar ingestion, allergies or sensitivities to foods, family discord, parental alcoholism, poor or ineffective parenting, and poor motivation. Furthermore, inaccurate beliefs about the nature of ADHD often lead to ineffective treatment approaches.

6. Developmental Context For ADHD

Although ADHD has been considered to be a disorder of childhood, there is compelling evidence that a majority of children do not outgrow ADHD. This section highlights the major challenges of ADHD throughout the life span.

6.1. ADHD During Early Childhood

Symptoms of ADHD typically first appear during early childhood. Infants are often described as temperamental, difficult to care for due to excessive crying and irritability, difficultly in calming, overly sensitive to stimulation, and overly active. These complications often interfere with normal parent–child bonding and often lead to negative parental interactions (e.g., fewer interactions, less affection, higher parental stress). These patterns affect child compliance and lead to frustrating and challenging interactions. In preschool, hyperactivity levels are pronounced and lead to difficulty in adjusting to expectations to sit, listen, and get along with other children. Impulsivity interferes with play and often leads to rejection. Referral rates are high during this stage of development as children come into contact with other adults and face greater demands for self-control. Interventions at the stage frequently focus on increasing parenting skills, building positive parent–child relationships, increasing parent support, and implementing other preventive measures (e.g., reinforcing prosocial behaviors, training preschool teachers, using behavioral management principles).

6.2. ADHD During Middle Childhood

Most research on ADHD has been conducted on children between 6 and 12 years of age. Deficits in self-control continue to be problematic and are highlighted by disruptive, noncompliant, and off-task behaviors at home and at school. Poor attention to schoolwork, poor work completion, low motivation, low persistence to challenging tasks, and poor organizational skills negatively affect academic and school adjustment. Difficulties with social situations, negative peer and adult interactions, poor anger control, and low self-esteem create secondary problems that can be chronic. Parent–child relationships are often strained due to noncompliance, failure to complete household chores, and the need for constant monitoring of everyday activities (e.g., bathing, eating, getting dressed, going to bed). These difficulties can increase family stress and interfere with sibling relationships. Other comorbid disorders, including oppositional deviance, conduct problems, depression, and anxiety, may also emerge during this stage. Severe oppositional deviance is problematic and often presages antisocial behavior during later adolescence and adulthood. Treatments during this stage typically are multimodal, including parent training, behavior classroom management, academic interventions, self-management training (e.g., self-instruction, anger control), and medication.

6.3. ADHD During Adolescence

Longitudinal studies reveal significant difficulties for approximately 70 to 80% of teens who had ADHD as young children. Although cognitive deficits and learning disabilities are common in children with ADHD, they are less well documented in adolescents and adults. Longitudinal studies show that youth with ADHD have significant academic difficulties, including high suspension rates (46%), high dropout rates (10%), and placements in special education for learning disabilities (32.5%), emotional disturbance (35.8%), and speech language disorders (16.3%). Negative academic outcomes were present even after intensive treatments, including medication, individual therapy, family therapy, and special education placement. In general, children with hyperactivity are less well educated, have higher rates of grade retention, and have lower grades compared with controls at 5and 10-year follow-ups. Adolescents with ADHD also show higher rates of automobile accidents and speeding tickets than do teens without ADHD. Both cigarette use and marijuana use are higher according to parental reports, whereas teens with ADHD report higher rates of cigarette use but not of alcohol use, or of marijuana, cocaine, heroin, and other illegal substances use, compared with non-ADHD teens. Antisocial behaviors, including theft, breaking and entering, disorderly conduct, carrying a weapon, assault with a weapon, assault with fists, setting fires, and running away from home, were reported in the Milwaukee Longitudinal Study.

In general, treatment options for teens are less well researched than are those for children. Treatment for adolescents with ADHD typically focuses on increasing problem solving and communication between parents and teens, psychopharmacotherapy, and classroom accommodations for academic difficulties. More systematic study is needed to investigate the strength of these various interventions. It has been suggested that children with ADHD might not receive needed treatment.

6.4. ADHD During Adulthood

In 1996, Barkley and colleagues found that adults with ADHD had similar levels of educational achievement and occupational adjustment but differed from controls on symptoms of ADHD and oppositional problems in college and at work. They also had shorter duration of employment, more psychological distress and maladjustment, and more antisocial acts and arrests for disorderly conduct and thefts compared with controls. Even though conduct problems and risk for comorbid antisocial personality disorder appear in approximately 25% of individuals with ADHD, the majority of adults with hyperactivity do not engage in criminal behaviors.

According to driving instructors and self and parent-reports of driving skills, young adults with ADHD were more distractible and impulsive while driving. High rates of driving-related difficulties, including license suspensions or revocations, serious accidents (i.e., involving a wrecked car), and hit-and-run accidents, were also reported. In 1998, Barkley indicated that young adults with ADHD had sexual intercourse at an earlier age, more sexual partners, and higher rates of pregnancy. Contraceptive use was lower, sexually transmitted diseases were higher, and testing for HIV/ AIDS was higher in the ADHD group than in controls. Treatments for adults with ADHD are not well documented but often include multiple approaches, including family and couples therapy, occupational and career counseling, occupational accommodations, medication, and treatment for comorbid disorders (e.g., alcohol or drug treatment, depression, bipolar disorders). Others have emphasized the need for counseling to change the negative mind-set that results from years of failure and coaching for everyday responsibilities. Although empirical studies are needed to determine the efficacy of various treatment options, studies do show the efficacy of stimulant medication in the treatment of ADHD in adults.

7. Evidence-Based Interventions For ADHD

The American Academy of Child and Adolescent Psychiatry (AACAP) has developed practice guidelines for the diagnosis and treatment of ADHD. The American Academy of Pediatrics (AAP) recommends that stimulant medication should not be used as the only treatment for ADHD and should be administered only after a careful evaluation. Practice guidelines recommend a comprehensive multimethod approach for the diagnosis of ADHD in children and youth.

7.1. Multimodal Treatment Regimens

The MTA study, funded by the National Institute for Mental Health, reported that children with ADHD received suboptimal care in the community. Even though two-thirds of the sample received stimulant medication, care in the community was less effective than were carefully managed medication, behavioral treatment, and combined treatments. Only 25% of children receiving care in the community were normalized after a 14-month trial, whereas 68% of the combined group, 56% of the carefully managed medication group, and 34% of the behavioral treatment group showed normalization. When community care is provided, it is not carefully monitored, nor is it as effective as multimodal intensive treatment. The MTA study showed that children with ADHD had the best response to multimodal treatment that included 35 sessions of parent training, a full-time summer treatment program for children to learn social and sports skills and to practice academic skills, weekly teacher consultation, a paraprofessional aide in the classroom, contingency management in the classroom, and medication. This extensive treatment was highly effective in reducing the major symptoms of ADHD and was superior to treatment generally found in the community. It is difficult to discern whether the quality and level of treatment described in the MTA study can be easily implemented in the community.

7.2. Other Evidence-Based Interventions

Other empirically supported treatments for children with ADHD include behavioral therapy and contingency management techniques; a summer treatment program with a systematic reward/response cost program, sports skills training, a 1-hour daily academic special education class, training in effective social skills, daily report cards, and parent training; parent training combined with contingency management and didactic counseling to increase parent knowledge of ADHD; a community-based family therapy program; the good behavior game, response cost, using the ‘‘attention trainer’’; modification of classroom assignments and task demands; and the Irvine Paraprofessional Program. Self-management, direct contingency management, and intensive behavioral and social skills training have also been shown to be effective.

8. Medication Monitoring And Adherence

Research on the short-term efficacy of stimulant medication is well documented for 75 to 80% of children with ADHD; however, medication monitoring and adherence is problematic. For example, in 2001, Vitiello stated, ‘‘For optimal pharmacological treatment of children with ADHD, medication adjustments are needed for long-term treatment even when the initial dose is chosen in a careful, comprehensive, and unbiased manner.’’ In the MTA study, more than 70% of children assigned to the medical management group were on different doses after a 13-month trial. Although the majority of children receiving community care in the MTA study were treated with stimulant medication, as a whole, children in the medical management group received more careful medication monitoring from physicians and showed greater improvement of symptoms than did children in the care in the community group.

In 2001, Thiruchelvam and colleagues investigated medication adherence in children 6 to 12 years of age. The most salient factors affecting compliance were the absence of ODD, the severity of ADHD symptoms, and the age of the children. Children with ODD were 11 times more likely to refuse medication. Youth with more symptoms were more responsive to the medication and were more compliant when taking medication as well. Positive stimulant response may encourage parents and children to stick to the medication regimen at higher rates than in cases where medication is not very helpful. Older children were also more likely to refuse medication. Because there is a decrease in hyperactivity symptoms with age, older children may perceive less benefit from medication and choose not to adhere. Social stigma may also play a role in adherence at this stage. Physicians are advised to develop adherence plans for youth on medication.

In sum, research indicates that multiple therapies are needed to adequately address the problems associated with ADHD. Stimulant medication with behavioral and psychosocial interventions, including classroom behavior management and parent management training, improve ADHD symptoms and associated problems in children with ADHD. Initial research indicates that stimulant medication is effective for adults and that other cognitive–behavioral interventions (e.g., self-management) show promise. Currently, treatment within a single modality (medication vs behavioral) appears to have very little long-term impact. Effective treatments are less well documented for adolescents and adults with ADHD. Although studies have shown that stimulant medication is effective, less is known about the effects of multimodal treatment in older groups.

9. Risk And Resiliency Factors That Affect ADHD

Although ADHD presents challenges throughout the life span, some factors complicate the disorder, whereas others appear to be protective. Risk factors that alter the course of ADHD include child characteristics (e.g., severity of ADHD symptoms, intelligence levels, comorbidity), family discord or environmental distress, and early treatment for ADHD and the presence of coexisting disorders. In an effort to optimize outcome, comorbid disorders should be targeted for treatment along with the ADHD symptoms. Oppositional defiant behavior problems are among the most debilitating difficulties over time because they often lead to conduct disorders and antisocial personality disorders during adolescence and adulthood. There is evidence that effective parenting skills can interrupt this progression in many children. Other family factors that increase the complexity of ADHD include parental psychopathology such as maternal depression and paternal antisocial personality disorder. These parental difficulties often interfere with effective parenting and produce added stress to vulnerable families whose members are already challenged by disruptive noncompliant child behaviors. There is strong evidence that raising a child with ADHD is stressful, so additional parental problems make this challenge even more overwhelming. Furthermore, as noted by Goldstein in 2002, ‘‘Living in a household, above the poverty level, with parents who are free of serious psychiatric problems, consistent in their parenting style, and available to their children appear to be among the most powerful variables at predicting good outcome.’’ Parents are also advised to seek individual and family therapy for their own problems in an effort to strengthen interpersonal effectiveness and family cohesiveness.

The extent to which treatment alters the developmental course of ADHD is not well understood. Some studies of children who received extensive treatment showed that these youth still had poor outcomes during adolescence. However, the MTA study showed short-term improvement (over a 14-month period) in children receiving comprehensive multimodal treatment in highly controlled and monitored programs. Furthermore, growing evidence suggests that medication may buffer some of the negative effects of ADHD. Although there are reasons to be cautious about the use of stimulant medication in young children, recent studies suggest that early treatment may alter the neurodevelopmental pathways of ADHD in positive ways. Stimulant treatment also appears to improve outcomes for adults. In 1999, Wilens and colleagues also found that 70% of adults receiving a year of cognitive therapy and stimulant medication showed a reduction of ADHD symptoms and were less anxious and depressed.

Current studies of ADHD are focusing on the long-term effects of multimodal treatment for children and are investigating what works best for adolescents and adults with ADHD. Current research is promising, but researchers are still exploring how the outcome and course of ADHD can be altered with effective treatments. The impact of environmental events on the development of attention and self-regulation is of particular interest.

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