What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder described in international classifications as “a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with an individual’s functioning or development”.
It is a common disorder (the most common of all neurodevelopmental disorders). Until a few years ago it was estimated that its prevalence in Spain ranged between 4 and 6%. The truth is that in recent years epidemiological studies have found a higher prevalence, even reaching 10% in some series. Despite what it may seem, and as I will explain throughout the article, these data do not speak of an overdiagnosis of ADHD (in fact, it is estimated that in some areas of Spain we have not yet reached the diagnosis figures that correspond to our prevalence), but of an underdiagnosis in previous decades.
The diagnosis of ADHD is clinical, i.e., there are no complementary tests to confirm or rule it out. The fundamental tool to do so is a thorough clinical history, where we look for the degree of repercussion or dysfunction that these symptoms generate in the development and functioning of our patient, in the different areas in which he/she has to develop (usually school, family and social life). That is, you can be mobile or absent-minded and not have ADHD if these traits do not have a significant impact on your development as an individual; but if these symptoms generate problems in the functioning of daily life and normal development, then we will speak of a “disorder”.
At the neuropsychological level, in ADHD we usually find an immaturity or dysfunction in executive functions. Executive functions are actually those complex higher functions, housed in the prefrontal cortex, which allow us, in short, to plan, organize and execute our actions, from the organization of speech when speaking, to our physical or intellectual activity.
When they are affected we find problems of task organization, difficulties in sustained attention, high fatigue, difficulties to inhibit responses or to expect rewards in the medium term, need for very high stimuli to “trigger” attention or motivation towards an activity…
ADHD has a known neurobiological basis closely related to these executive functions. It is mainly characterized by a decrease in the release of neurotransmitters (mostly dopamine, to a lesser extent noradrenaline and serotonin) in brain circuits that are related precisely to the aforementioned prefrontal cortex and reward circuits.
Are there children more prone to ADHD?
ADHD has a powerful and well-known genetic basis on which environmental factors act (some of them known and many others yet to be known), favoring the development of the disorder.
In many patients we find direct relatives who had the same difficulties in childhood as our patient, although they were not diagnosed.
As I said before, in previous decades underdiagnosis was the norm, but this does not mean that the difficulties did not exist… In fact, when I describe to parents what the profile of a child with ADHD or ADD is like, almost everyone is able to remember someone in their class who perfectly fit that pattern (and in almost all cases we remember them suffering a lot, or at least more than the rest of the children of their age, because of the manifestations related to the disorder).
Therefore, children of parents who have had ADHD (diagnosed or not) will be more likely to develop the disorder.
On the other hand, there are environmental factors that are also related to the development of ADHD. For example, the relationship with extreme prematurity or low birth weight is known. It is also known that there is an increased risk with the consumption of toxic substances during gestation (in the case of alcohol, for example, as part of the so-called Fetal Alcohol Syndrome).
Finally, there are genetic syndromes that are frequently associated with ADHD, in addition to the clinical features of the syndrome itself (Fragile X or Neurofibromatosis type 1 as some examples).
What are the symptoms of ADHD?
As mentioned in previous sections, ADHD is characterized by excessive movement and/or inattention and/or impulsivity. Different subtypes are described depending on the predominant symptoms, resulting in profiles that I would describe as almost opposite.
Thus, on the one hand, we would have the combined subtype ADHD and the hyperactive/impulsive type, where we would find children with a clear excess of movement, difficulty to wait their turn or stay seated in a chair, impulsive responses or often reckless behaviors. They also tend to be “vigilant” (they come to the defense of what seems unfair to them, even if it is not their responsibility), somewhat childish for their age, and seek social interaction with peers, although sometimes they are so intense that they may have conflicts in this area.
They are children who attract attention very early, and are usually diagnosed at relatively early ages because this symptomatology is very disruptive in the classroom or at home. It is very easy for them to be labeled as “misbehaving children”, and although in reality the symptoms of ADHD do not speak of behavior, it is easier for problems to appear in this area because of the difficulty to control their impulses.
Although the diagnosis should not be made before the age of 6 years, the complaints have been evident throughout the infant stage, and are often described retrospectively as “high demand” and “very little sleep” babies.
On the other hand, we have ADHD of INATENTAL predominance, which is a completely different profile and unfortunately often goes unnoticed until later ages. It is the predominant profile in girls, but not exclusive to them. Girls with inattentive ADD (allow me to describe it in feminine as a generalization), can be especially quiet, generally with good behavior and with a good attitude towards work (at least in kindergarten and primary school). In class they do not bother, indeed, their behavior and work capacity is usually remarkable, but their academic performance does not correspond to such effort. They feel insecure, which makes them participate little, and they manage to reach the objectives in primary school, but with a lot of work and with the help of their parents. If they are not diagnosed in primary school, it is easy that, in secondary school, when increasing the degree of demand and the need for autonomy, their academic performance drops significantly, giving rise to problems of self-esteem and often anxiety towards exams.
Outside of academics, they can be slow and not very autonomous for daily activities, they can be messy or lose things frequently. It is especially difficult for them to follow sequential commands (often their parents have unknowingly developed strategies for this ADD, and understand that they can only give their daughter one command at a time, and, if possible, seeking and forcing eye contact). On a social level they may also be shy girls, with difficulties in making or securing friends, although this is not always the case.
In fact, as I pointed out in the introduction, executive dysfunction is the nexus of the two profiles, so the difficulty in organizing, planning, inhibiting or sustaining attention on the task will be largely what generates repercussions.
This difficulty predominates in their lives, and explains very well the symptoms that those of us who live around them observe, and the “incongruities” that a priori we can find (“he can spend hours concentrating on what he likes”).
What treatments are available?
The approach to ADHD should be comprehensive and multidisciplinary. Addressing academic difficulties through psychoeducational support and training in self-control strategies, time management and emotion management through psychotherapy, should always be present and help greatly to alleviate the impact of symptoms.
As is well known, we also have the possibility of adding pharmacological treatment.
Most of the drugs we use in ADHD are “stimulants”. This means that they work by increasing the release of “activating” neurotransmitters (mostly dopamine) in the synaptic space of the neurons of the prefrontal cortex, balancing the circuits involved in these areas. There is another group of drugs called “non-stimulants” with different mechanisms, but which ultimately also act on executive functions, self-control, attention and decision-making.
They are effective drugs with an adequate safety profile, and help all the other actions carried out from the psycho-pedagogical and psychological support to bear fruit.
Although the benefit/risk must be individualized and selected in each case, it must be taken into account that pharmacological treatment will facilitate the child’s performance of the tasks required of him/her, both academic and in daily life functioning, having a positive impact on his/her self-esteem and the feeling that he/she is capable of doing what he/she is asked to do.
For this reason, it should not be considered a last option when the situation is extreme or the academic failure evident, because in such cases, although care may improve, the “emotional backpack” or sense of inadequacy that will have been forged over the years is difficult to treat and overcome.
In any case, careful assessment by an expert professional of both the diagnosis and treatment options is critical in all cases.