ADHD – Causes, Symptoms, Treatment

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adhd causesAttention deficit hyperkinetic syndrome (ADHD) is a behavioral disorder that manifests in the child’s attention deficit and difficulties in performing a task. ADHD is common, it begins in childhood but can persist into adulthood. If not detected and treated properly it can significantly disrupt social, professional or school life.


Exact pathogenesis of the disorder is unknown, but recent research has revealed that it is most likely a genetic TDHA (researchers are concerned with identifying genes that predispose to the development TDHA).
Brain imaging studies have provided evidence of the existence of changes in the brain, which supports the theory that ADHD is a neurobiological disorder. The following abnormalities supporting the hypothesis neurobiological disorder have been described:
- Alterations in brain structure – evidence neuroanatomic
- Malfunction of the neurotransmitters involved in controlling attention and activity (dopamine and norepinephrine) – neurochemical evidence
- Differences in the activation of brain regions responsible for inhibition mechanisms (frontal lobes), leading to difficulties in inhibiting emotional reactions, cognitive and behavioral – neuropsychological evidence.

There are etiological hypotheses which claim that exposure in the womb to alcohol, tobacco, drugs and other neurotoxic substances (lead) increases the risk of developing TDHA.
The nutritional theory, according to which increased consumption of sugar or food additives (colorings and preservatives) may be responsible for the appearance of hyperactivity, was not supported by experimental data. A study by the NIH (National Institutes of Health) showed that a restricted diet without sugar consumption does not improve symptoms to more than 5% of children with TDHA. Other studies show that there is no correlation between sugar consumption and TDHA.

Risk Factors

Research has shown that ADHD is transmitted genetically from parents to children. For the propensity to lead to the appearance ADHD, genetic factors must be correlated with environmental factors (psychosocial), so called biopsychosocial context. Parent-child interaction is considered to be a contributing factor. A stressful family environment (family events and particular aspects of its functionality) contribute to the symptoms of ADHD.


Core symptoms of ADHD are:
- Inattention, characterized by poor concentration on performing a task, easy distractibility by external stimuli
- Impulsiveness can lead to involvement in risky activities without children taking into account the consequences
- Hyperactivity / agitation and inappropriate behavior.

In preschool, the three symptoms, inattention, hyperactivity and impulsivity are part of normal child behavior. It is therefore difficult to distinguish ADHD from age-specific normal behavior. Symptoms become apparent or increased with the beginning of school, because the social and academic environment require those skills in children with ADHD which are not their strengths.
Children and adolescents with ADHD have difficulty due to academic disorder symptoms. During this period (6-12 years) expectations of the adults (parents and teachers) are becoming larger in terms of independence, autonomy and social functioning. In school cognitive and socio-emotional skills of children are assessed.

TDHA can be suggested by:
- Grades and low scores on aptitude tests
- Poor organization and planning skills of the act of learning
- Social issues
- Negative self-image and impression that is rejected by peers.

Symptoms in adolescence

During adolescence, between 13-18 years, the disorder is relatively stable. However, if there are no therapeutic interventions, problems may persist or even worsen. Teens with ADHD will have poor school results which will be most evident when changing school or when going tot secondary school or college.

Symptoms in adulthood

In adulthood, symptoms alleviate, but some may persist causing difficulty concentrating, planning and completing an activity. Many adults can get away undiagnosed and untreated and may present problems of social maladjustment (difficulty keeping a job) or affective disorders (depression). However, adaptation of adults with ADHD is better than the hyperkinetic children. Most adults with ADHD will have problems in both family and workplace, will often present a low self-esteem and frustration. Divorce rate, the smoking, alcoholism or drug abuse is higher in people with ADHD. It was found that the number of high school graduates and / or college is lower among those who suffer from ADHD compared with others of the same age. Some adults find out that they suffer from ADHD only after their child was diagnosed with the disease.

Effect on family

The family of a hyperkinetic child is often troubled; raising a child with ADHD can be a challenge for the parents. Parents will watch carefully their child’s behavior and will learn to respond appropriately to desirable behaviors. If other malfunctions occur in family life (such as divorce, family violence, alcohol and drugs), they will interfere with the behavior management of children with ADHD.
Comorbidity with other mental disorders
There is ample evidence that shows that ADHD is often associated with one or more mental disorders such as dyslexia, challenging oppositional disorder, conduct disorder, mood disorders (depression) and anxiety disorders. The treatment will help control symptoms while allowing growth and normal development.

Seeking medical advice

Parents will ask for health advice in the following situations:
- When noticing symptoms of ADHD in a child younger than 7 years
- When the ADHD symptoms cause difficulty in school, home and relationships. These problems are noticed by parents and teachers with the entry into first grade primary
- When a child shows signs of mental disorders like depression and anxiety that lasts for weeks or symptoms worsen later on
- When a child presents school failure and behavior problems.

Watchful expectative

During the first 5 years of life

Watchful expectative is the best attitude to this age group (under 5 years) as the limit of normal behavior and symptoms of ADHD is very difficult to establish. If parents have observed undesirable behaviors and if after a period of six months they have tried to modify the child’s behavioral problems and have not managed to improve or resolve them, especially if they lead to expulsion from the nursery or kindergarten child, they will have to address a behavioral specialist for evaluation and treatment.

School period and adolescence

Watchful waiting is not appropriate at this age. If the child’s relationship problems are found both inside the family and at school, where he will present poor academic performance, it is advisable to seek advice from a specialist. Problems caused by inattention may not be significant and may be detected only in situations when school change is required (moving to another school, the transition from primary to the secondary school or college admission) or environment (moving to another city).


Watchful waiting may not be the best therapeutic approach to ADHD in adulthood. Adults with hyperactivity will try to remember when they started ADHD symptoms, to analyze in the context of major changes occurred and to assess whether disorder symptoms have affected decisions in crisis situations in life. Once the problems were identified, they will be managed and resolved, but if the symptoms cause discomfort, adults with ADHD will require expert advice. Also, experts in the field will make the diagnosis of therapy and may prescribe treatments for other mental problems like depression and anxiety, which are often associated with ADHD.

Recommended medical specialists

Health professionals who can diagnose or apply treatment for ADHD are:
- GP
- Pediatrician
- Child or adult psychiatrist
- Child or adult neurologist

Specialists who are not authorized to prescribe medication but may provide psychotherapy and counseling services are:
- Psychologist who can frequently diagnose ADHD
- Behavioral therapist
- Social worker
- Specialist counseling
- Family therapist.

It will appeal only to competent persons to assess symptoms and to establish the correct diagnosis of ADHD. Also, the diagnosis cannot be made hastily, but only after careful examination of the child and a detailed interview with the parents. Accurate diagnosis and determining treatment require close observation over several visits to the specialist.


American Association of Psychiatry established a set of criteria based on which a diagnosis of ADHD can be made. Under these criteria, in the DSM-IV manual several subtypes were described:
- the combined type ADHD
- ADHD where symptoms of inattention are dominant
- the predominantly hyperactive / impulsive ADHD.

He also described the type specified when symptoms of inattention, hyperactivity and impulsivity are present but cannot be put in any of the three types described above.

Medical professionals use defined criteria for a diagnosis of ADHD:
- Child’s history: father will make a brief description of the socio-emotional, educational and behavioral
- Physical examination
- Completion by parents and teachers of standardized scales and questionnaires for ADHD.

Based on a mental status assessment (assessment of vocabulary and speaking skills, clinical estimation of intelligence, fine motor coordination or coarse, evaluation form, content and logic thinking) your doctor will determine if behavioral problems are caused by ADHD or psychiatric disorders related to it.

In addition, educational assessment will determine the deficiencies in the development of written language and reading, and math problems. Testing learning disorders is an important component as it is the basis for the composition of an interventional individualized program tailored deficiencies and needs of the child.

Further investigations will provide evidence to support the diagnosis of medical problems that interfere with the development and acquisitions of a school child and can explain symptoms such as:
- Deficiencies of hearing (auditory acuity assessment)
- Vision impairment (visual acuity assessment).

Other laboratory tests useful for diagnosis:
- Determination of lead, if history suggests pica or environmental exposure
- Counts: it can identify anemia that can cause apathy and decrease in concentration
- Determination of thyroid hormone that affects thyroid dysfunction highlights the capacity of attention and concentration, but they are most common in adulthood.
- EEG (electroencephalogram) is needed to diagnose seizures that can cause alterations in the neural functionality, translated into changes in the behavior plan.

One of the concerns parents have is the overdiagnosis. Scientists and researchers in the field believe the number of cases of ADHD is not due to the overdiagnosis but to the improvement of the evaluation and diagnosis methods (the emergence of standardized scales).
Behavioral assessment of adults with ADHD can be done with WURS Scale (Wender Utah Rating Scale) which consists of 25 questions (items) about childhood problems commonly found in this condition. This scale assesses the presence and severity of symptoms in childhood.

Early diagnosis

It is not recommended to screen the entire population of children in order to make early diagnosis of ADHD. But parents who are worried about their child’s difficult behavior, their poor academic performance and affective development can address behavior specialist; before they visit the specialist, they will have to review the age at which symptoms started to show, the context in which behavior problems were triggered, their duration and the impact on school performance and social integration.

adhd behavior in class

Differentiated diagnosis

Differential diagnosis in children should exclude these comorbid conditions:
- Conduct disorder
- Disruption of opposition (oppositional challenging)
- Affective disorders (depression, bipolar disorder)
- Anxiety disorders
- Disease tics (Tourette’s disorder)
- Substance abuse
- Learning disorders
- Pervasive developmental disorders
- Mental retardation or intellect to the limit.

Initial treatment

An effective treatment requires proper diagnosis and an accurate assessment of the abilities and problems of children.
American Association of Pediatrics, based on longitudinal clinical trial, conducted on a group of hyperactive school-age children, recommends combination drug therapy with behavioral intervention. Children receiving stimulating medication showed a significant improvement in symptoms (inattention, impulsivity and hyperactivity were significantly improved).

Drug treatment includes:

- Central nervous system stimulants from the amphetamine family (Dextroamphetamin, Methylphenidate) improve symptoms in about 70% of children with ADHD.
Cerebral stimulant effect may seem paradoxal, they reduce hyperactivity and impulsiveness increasing concentration. Some parents worry that stimulant medications are addictive. One of the important findings of recent studies with rigorous scientific methodology is that, in patients with ADHD, psichostimulants in therapeutic doses, does not create a habit or addiction and not exposed to an increased risk of addiction to the drug (or later during treatment, in adulthood). However, parents should carefully monitor the administration of the treatment, as it has been reported a misuse of psichostimulants among adolescents (siblings or peers) and adults in the family of the patient.

The most common side effects of incentives are loss of appetite, nervousness, tics or Tourette’s disorder occurrence, insomnia.
- Non-stimulant medication – Atomoxetine is a non-stimulant drug (norepinephrine reuptake inhibitor) administered in the absence of effective incentives brain or of side effects to them. Atomoxetine is not a controlled substance (the-counter).
American Psychiatric Association also recommends for treating ADHD behavioral therapy, which is a specific set of interventions through which parents and teachers learn behavioral techniques, such as the reinforcements that modify the child’s undesirable behavior. Children develop problem – solving skills, communication skills and self-affirmation abilities.
Psychological counseling for children with ADHD and adults in his family is very useful in identifying symptoms due to hyperactivity and behavior problems and in finding their solution strategies. It is also effective in solving frustration and overcoming stressful situations.

Behavioral interventions may be useful in the management of anxiety and challenging oppositional disorder, common in some children with ADHD.
Often, those who identify and signal ADHD symptoms are teachers, because the stringent requirements of the school environment highlight the difficulties children have to sit quietly in their seats, to pay attention in class, to meet educational requirements and comply with class rules. Some children with ADHD will be lead to special education, the specialized psychologists will prepare tailored projects (PTP). PTP is made after the evaluation of complex educational and after it is adjusted to the child’s special needs and deficiencies.

Changes in education involve adjustment of the class (children with ADHD should be placed in the first row), work tools and tasks, adaptation of curricula and teaching modality.
Together with the specialist realistic educational and vocational goals will be set.
In the case of a preschool child behavior therapy is preferred in an attempt to keep control of behavior and avoid medication at an early age. But if behavioral therapy is not effective in controlling symptoms they will have to go to psychostimulants medication, even if for this age there is controversy among specialists regarding medication, because of the small number of clinical studies. There is clinical study in progress, which evaluates therapeutic efficacy of methylphenidate in preschool children.

Maintenance treatment

The most effective way of intervention in ADHD is multidisciplinary approach: medical, psychological and educational, in which are involved parents, teachers, psychologist and doctors specialised in child and teenager psychiatry. Teenagers benefit from treatment with stimulant medication and non-stimulating brain. Parents will have to be careful that the misuse of stimulant medications by adolescents does not lead to psychological and physical addiction to amphetamines or other drugs.
A study that followed over 4 years in children and adolescents with ADHD showed that the incidence of alcoholism and drug abuse is lower in those taking psycho stimulant medications. Special attention should be paid to hyperkinetic adolescents. Parent involvement in the application of behavioral strategies of intervention is extremely important in order to get good results. The teenagers’ inability to cope with school tasks and their difficulty in paying and maintaining attention are symptoms that deserve a special approach.
Rewards systems of interest to teens will be used, parents will work with children in acceptable targets and will negotiate with them to achieve appropriate reward goal.

Treatment of ADHD in adults

For the treatment of ADHD in adulthood combined drug therapy and psychotherapy can be relied on. Psychological counseling includes:
- Learning about ADHD, attending support groups or individual counseling and skills development. In skill development sessions they are taught a good time management, organizational techniques while the sessions also include academic and vocational counseling.

Studies have shown that 58% of adults with ADHD have improved ability to concentrate and have not presented hyperactivity and impulsivity following treatment with psychostimulants. If cerebral stimulants are not effective or if bothersome side effects occur, the psychiatrist can prescribe Atomoxetine. Some antidepressants like Bupropion or tricyclic antidepressants (imipramins, nortriptylins, desipramins) may be effective in treating ADHD in adults.

To be kept in mind!
FDA (U.S. Food and Drug Administration) issued several warnings regarding atomoxetine. Parents and adults who take care of children and adolescents with ADHD will be vigilant for warning signs of suicide risk, without being, however, required to stop medication.
They have to fight with myths and misconceptions about the disease; ADHD is a medical problem that cannot be controlled in the absence of drug treatment.
Parents should give children as much information about ADHD and to explain the importance of respecting the therapeutic strategy. Effective treatment will consist in a greater involvement of the child in the management of his symptoms (eg to take his medication on time). Nutritional therapy (restriction of sugar, fish oil etc) is a therapeutic method recommended because these diets have no clinical support at their core.


There are no ways to prevent ADHD. You should avoid smoking, alcohol or drugs during pregnancy, not only as a prophylactic measure to ADHD but also to other health problems of the future child. Some useful tips for moms to reduce the risk of learning problems and attention of their children:

- A careful medical supervise of pregnant women and promotion of healthy behaviors during pregnancy
- A school for the parents, through which they achieve good parenting skills
- Maximize the learning skills and training attention, adequate stimulation in preschool (fathers should read stories and play puzzle with the child). Development of attention can be enhanced by these activities in a greater measure than watching television. In addition, parenting techniques right from birth and continuing throughout childhood are essential to optimal development.

Home treatment

ADHD treatment practices are focused on symptom management. Therapeutic process in children is different from that of adults, but all at ages the focus is on a better understanding of the disease, the establishment of daily routines and the achievement of full support from others.
Involving children in the therapeutic process increases the efficiency of the therapeutic intervention. Also, the parent will understand that helping himself will be helpful to the child.

Tips for parents
- The parent’s task is very hard and caring for his own mental and physical state should be as important because the role of the parent in applying therapeutic strategy is of major importance
- Parents must be as well informed as possible about ADHD, from reliable sources; the more competent the parent is, the more effective his intervention on the child will be
- Parents will learn child behavior management. Children with ADHD experience difficulty learning a behavior by observing another person and must learn to interact with others by being explained the behavioral sequence and the negative impact of problematic behaviors.
- Parents will help the child to help build a positive self-image by developing social group membership and trust his learning abilities
- Parents will be involved in improving children’s academic performance
- Parents will help children to perform tasks at home. Hyperkinetic children cannot follow the instructions in performing a task and attention will be easily distracted by external stimuli. With patience, perseverance and creativity from the parent’s part, it can be extremely useful in gaining skills necessary to accomplish a task.

Medical treatment

Medication used to treat ADHD:
- Psihostimulants (Methylphenidate, Dextroamfetamine, the association between Dextroamfetamine and amphetamine) are effective in treating ADHD in both children and adults, 70% of cases to obtain a rapid and significant improvement of ADHD symptoms
- Atomoxetine, non-stimulant drug used successfully to treat children, adolescents and adults with ADHD

If non-stimulating psichostimulants and medication had no effect, the following are used:
- Antidepressants (Bupropion)
- Antihypertensives (Clonidine, Guanfacine) that can reduce aggression and impulsivity in some cases of ADHD.

Comorbid diseases and anxiety disorders will also be treated with drugs. Parents will closely monitor the effects of medication and will address the psychiatrist whenever adverse reactions occur, especially if atomoxetine and antidepressants are used, suicidal signs will be closely followed.

To be kept in mind!
FDA allows administration of psychostimulant medication after the age of 3. However there are few studies in children younger than 5 years and some experts recommend not taking medication before entering school, because young children have increased risk of developing secondary reactions. If symptoms are severe and seriously affect the behavior and quality of life of the child, the establishment of drug treatment at a younger age is permitted.

Other treatments

Drug therapy is reserved for cases with severe symptoms in ADHD. Other interventional methods are indicated in the following situations:

- Moderate symptoms
- When symptoms are unresponsive to drug therapy
- For installation of medication side effects
- Occurrence of other psychiatric problems such as anxiety.
Medication combined with other therapeutic methods is often used successfully.

Behavioral interventions in ADHD

Behavioral interventions are implemented by parents, teachers or other adults who are responsible for the child. They are prepared to perform behavior management through training and learning. Training programs are focused on creating a structured environment of a daily routine, a set of rules of conduct and a careful and rigorous monitoring of the progress made. Using behavioral techniques, such as the reward system, aim at strengthening desirable behaviors, compliance and reducing inappropriate behavior.
The effectiveness of these methods is much higher than cognitive-behavioral therapy techniques, which require emotional and behavioral self. Children with ADHD do not have the necessary skills or modifying dysfunctional cognitive pattern of negative emotions, and therefore require consistent and constant support of parents and teachers.

Behavioral intervention strategies include:
- Behavior modification techniques: time-out (exclude) and a system of rewards (positive and negative strengthening) are extremely effective for learning appropriate behavior in class or at home. The optimal number of training sessions offering advice to parents was identified as an average of 6-12 weekly sessions, lasting 1-2 hours per session
- Social skills and emotional development; through this method the child learns to be less aggressive and impulsive, he ca learn how to control anger and how to act as a socially desirable human being.
- Counseling and psychotherapy for all active members of the family, family therapy: this therapeutic procedure improves the prognosis of children with ADHD.
In adults, behavioral interventions focus on counseling and learning organizational skills for the development of children with ADHD and to promote “healthy” social relations (which are the modifications needed for optimal functioning and social behavior).

Alternative therapies and complementary therapies

Alternative and complementary therapies are practiced by therapists who work in a parallel system to that of conventional medicine. Further studies are needed before recommending alternative and complementary therapies as a method of first treatment choice for ADHD. It is recommended that complementary therapies should be applied with conventional treatment methods, not to replace the medical treatment of ADHD.

For example, acupuncture can reduce stress and muscle tension improving wellbeing and increasing the quality of life for children.
If parents believe that these methods, alternative or complementary, can be useful in the treatment of child hyperactivity, an expert’s advice is required first, and he will recommend them only that experimental method proved to be effective in controlling ADHD symptoms and which does not cause physical or emotional side effects.

To be kept in mind

Drug treatment has proven very effective for reducing ADHD symptoms, although the therapeutic response varies from patient to patient. The techniques used for behavior modification, training sessions, education and advise the parents are sufficient to control symptoms of mild ADHD. Typically, behavioral interventions are used with drug therapy in moderate and severe forms.
Parents which are rightly reluctant to administer their child medication on an indefinite time, must understand that drug therapy is safe and highly effective, improving the quality of life for both children and family members.



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