Symptoms of ADHD

Although ADHD generally is considered a childhood disorder, symptoms can persist into adolescence and adulthood. The prevalence of adulthood ADHD is estimated to be 4%, with 60% of adults having manifested symptoms of ADHD from childhood.8,9 Further, problems associated with ADHD (e.g., social, marital, academic, career, anxiety, depression, smoking, and substance-abuse problems) increase with the transition of patients into adulthood. 

The choice of ADHD medication should be made based on the patient s condition, the prescriber s familiarity with the medications, the ease of administration, and cost. Stimulants should be used first line in most ADHD patients, although there is no dear advantage of using one stimulant over another in managing symptoms of ADHD.16... 

Bupropion is a monocyclic antidepressant that inhibits the reuptake of norepinephrine and dopamine. Bupropion is effective for relieving symptoms of ADHD in children but is... 

The tricyclic antidepressants (TCAs), such as imipramine, can alleviate symptoms of ADHD. Like bupropion, TCAs likely will improve symptoms associated with comorbid anxiety and depression. The mechanism of action of TCAs is in blocking norepinephrine transporters, thus increasing norepinephrine concentrations in the synapse the increase in norepinephrine is believed to alleviate the symptoms of ADHD. TCAs have been demonstrated to be an effective non-stimulant option for ADHD but less effective than stimulants. However, their use in ADHD has declined owing to case reports of sudden death and anticholinergic side effects6,13 (Table 39-3). Further, TCAs may lower seizure threshold and increase the risk of car-diotoxicity, (e.g., arrythmias). Patients starting on TCAs should have a baseline and routine electrocardiograms. 

Attention Deficit-Hyperactivity Disorder (ADHD). Only recently has ADHD been added to the differential diagnosis of BPAD. ADHD was long considered a childhood illness that resolved before adulthood. Moreover, the onset of BPAD was long believed to occur exclusively during adulthood. Both of these statements are now known to be untrue. Many of the symptoms of ADHD persist into adulthood. Meanwhile, an increasing number of child psychiatrists and epidemiologists have noted that the onset of BPAD not infrequently occurs in children before they reach puberty. 

In addition to having a certain number of these symptoms, DSM-IV also requires that the illness be evident before age 7 and that it be seen in at least two settings (nsually school, work, or home). The age of onset is important. Many adults, for example, with major depressive disorder will have symptoms of ADHD, and perhaps even score high on standardized ADHD scales. One does not, however, develop ADHD at 20, 30, or 40 years of age. 

By definition, ADHD must appear before age 7. ADHD has been diagnosed in preschool children as early as age 3, but it is very difficult to diagnose the disorder reliably at this young age. Many preschoolers are called hyperactive by their parents, but they do not have the symptoms of ADHD when they begin school. Only children with the most severe cases of ADHD can be diagnosed accurately during the preschool years. 

Another set of tools that could be utilized are brief rating scales. DSM-IV mandates that ADHD symptoms must be present in at least two settings. For children and adolescents, school is invariably one of the two settings. To get a sense of the comparative problems in school versus those at home, psychiatrists often use rating scales that can be completed by both parents and one or more teachers. The Conners Teacher Rating Scale, Conners Parent Rating Scale, and the Child Behavior Checklist are the most commonly nsed scales to evalnate the symptoms of ADHD. 

Depression. Depressed children and adolescents are often irritable and argumentative. They may also be inattentive and easily distracted. A depressed child therefore potentially looks and behaves much like a child with ADHD. In such cases, one should not immediately make both diagnoses. First, treat the child for depression. If the symptoms of ADHD remain after the depression has resolved, then and only then does it make sense to diagnose and treat ADHD as well. 

Pemoline is less potent than the other available stimulants. It is started at 18.75 mg each morning and is increased in increments of 18.75 mg every week or two. The maximum dose is 112.5mg/day, though some patients do require higher doses. Because pemoline is less potent than other stimulants, it is more likely to be ineffective even at its higher doses. When pemoline does not relieve the symptoms of ADHD, patients should be changed to a different stimulant. 

Murphy, K. and Barkley, R. (1996) Prevalence of DSM-IV symptoms of ADHD in adult licensed drivers implications for clinical diagnosis. J Attention Disord 1 147-161. 

A recent 8-week placebo-controlled study of guanfacine in 34 children (ages 7-14 years) with a mild to moderate tic disorder and ADHD found guanfacine significantly superior to placebo in reducing the core symptoms of ADHD, as evidenced by a 36% decrease in scores on teacher rating scales, compared to an 8% decrease for the placebo group. This difference was ev-... 

The prevalent theory among both health professionals and the general public today is that the symptoms of ADHD have a biological cause. The most generally cited causes are birth defects, an infant trauma, and the brain s inability to produce enough of specific neurotransmitters, or brain chemical messengers. 

Ritalin is a mild stimulant. On the contrary, the studies found that Ritalin, although effective in treating the symptoms of ADHD, shows no clear long-term improvement on users and can have dangerous effects on health, including death. Because the effects of Ritalin on humans are virtually identical to those produced by cocaine, amphetamine, and methamphetamine (speed), the researchers noted that its abuse liability is high and can lead to marked tolerance and psychological dependence. 

Wc look at the diagnosis of psychological disorders in Chapter 13, but the ADHD controversy is certainly a thorny one. What seems clear is that although many of the symptoms of ADHD (inattention, fidgeting, restlessness) arc indeed common to virtually all children (and adults), Ibr some children these problems are far more severe and debilitating. 

It has already been noted that maternal tobacco and marijuana smoking are causative agents for ADHD symptomology. 1617 Tobacco and marijuana smoke are very complex chemical mixtures containing more than 4000 different chemicals. The ADHD causative agents in these are unknown. Xenobiotic chemicals contained in foods, however, are fewer in number, more easily identified, and have been tested as agents that induce the symptoms of ADHD. 

Despite knowledge of the effects of stimulants on neurotransmitter activity, how these drugs affect the primary symptoms of ADHD is unclear. To varying degrees the central nervous system (CNS) stimulants inhibit the reuptake of DA and NE, enhance release of DA and NE from the presynaptic neuron, or inhibit the enzyme monoamine oxidase (MAO). Because stimulants work through slightly different mechanisms, lack of response to one stimulant does not preclude response to another. ... 

Pharmacotherapy with stimulants increases dopaminergic and noradrenergic activity, which has the potential to aggravate or precipitate tics. One study examined the comparative effects of methylphenidate and dextroamphetamine on tics in children and found the majority experienced improvement in ADHD symptoms with acceptable effects on tics. Methylphenidate was better tolerated than dextroamphetamine. Another double-blind placebo-controlled trial compared methylphenidate or clonidine monotherapy to combination methylphenidate and clonidine in patients with ADHD and Tourette s disorder. Combination therapy demonstrated the greatest benefit in reducing symptoms of ADHD and tics (p <0.0001). Clonidine appeared most helpful for impulsivity and hyperactivity, while methylphenidate was most helpful for inattention. All treatments were well tolerated. 

Controlled trials of TCA therapy for comorbid ADHD and chronic tics or Tourette s disorder show significant improvement in inattentive and hyperactive/impulsive symptoms without worsening of tics. In one study, both tics and symptoms of ADHD improved. TCAs offer an alternative to clonidine or combined clonidine/ methylphenidate therapy that may be more effective for some patients. 

Arriving at the ADHD diagnosis is particularly problematic when you consider that not all children diagnosed with ADHD show the same behavior, and that some toxins produce some but not all of the behavior of the ADHD disorder. For example, fetal exposure to alcohol can produce fetal alcohol spectrum disorder, but some of the symptoms of that disorder are very similar to some of the symptoms of ADHD. 

In addition to toxins, the effects of postnatal childhood virus infections, meningitis, head injury, encephalitis, epilepsy, and prescription drugs have also been associated with ADHD.46 We veer close to a diagnostic situation in which anything that damages the brain, either before or after birth, can produce the symptoms of ADHD. 

Atomoxetine is used as a safe and well-tolerated nonstimulant treatment of ADHD in both adults and children and of depression. Among children and adolescents aged 8 to 18 years, atomoxetine was superior to placebo in reducing symptoms of ADHD and in improving social and family functioning symptoms. Oral atomoxetine is promoted as an alternative to conventional ADHD therapy with methylphenidate, dextroamphetamine, and pemoline. It also can be a replacement for bupropion or for TCAs. Onset of action is approximately 7 days. 

Difficulty in following verbal instruction is a symptom of ADHD this indicates the medication is not effective. 

Fetal or infant exposure to phthalates was shown to be associated with reproductive or developmental health outcomes in males (e.g., correlation with shortened anogenital distance (Swan, 2006) or prematnre breast development (Colon et al., 2000)). Positive associations between phthalate metabolites in urine and symptoms of ADHD (Kim et al., 2009) as well as phthalate exposure and asthma or allergy (Bomehag et al., 2004) among school-age children have been reported. 

Although stimulants are highly effective in controlling the symptoms of ADHD, some children do not respond to, or are intolerant of, stimulants. Thus, the need for non-stimulant medications has become increasingly apparent [56 ]. 

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