Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a medical condition that affects an individual's behaviour. Symptoms include hyperactivity, impulsivity, and inattention that occur in more than one setting (such as at school and at home). Symptoms of ADHD tend to be noticed when children are school-aged. Most cases are diagnosed before age 12 but some cases are diagnosed later on.

In many cases symptoms of ADHD improve with age, but many adults with significant ADHD symptoms in childhood continue to experience problems.

Origins

The exact cause of ADHD is unknown. However, genes related to dopaminergic activity (a neurotransmitter) are associated with ADHD. It is estimated that the degree to which ADHD is caused by genes is between 60-90%. Parents with ADHD have a greater than 50% chance of having a child with ADHD.

Other factors that potentially have a role in the development of ADHD include:

  • premature birth (before the 37th week of pregnancy)
  • having a low birthweight
  • smoking during pregnancy
  • drug or alcohol abuse during pregnancy

It is very common for ADHD to co-exist with other conditions, such as anxiety and sleep disorders.

ADHD is also common in people with learning disabilities.

ADHD Myths

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Presentations

Patients with ADHD are identified and classified into generalized types based on patterns of behaviours.

Inattentive Type

  • Fails to pay attention to details
  • Has difficulty sustaining attention
  • Does not seem to listen when spoken to
  • Fails to follow-through on instructions
  • Poor organization
  • Avoids tasks that require sustained attention
  • Frequently loses things
  • Becomes distracted easily
  • Forgetful

Hyperactive-Impulsive Type

  • Has difficulty sitting still
  • Talks excessively
  • Blurts out answers
  • Has trouble waiting for their turn
  • Often interrupts others
  • Unable to do leisure activities quietly

Combined Type

  • Symptoms of both types present in multiple settings
  • Symptoms of both types present before age 12

Presenting Features in Adulthood

In addition to the behaviours above, adults with uncontrolled ADHD often have encountered some significant dysfunction in important areas of their lives.

  • Erratic work history
  • Anger control problems
  • Marital problems
  • Parenting problems
  • Money management problems
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Mimics

There are several factors that can (alone or in combination) produce symptoms that overlap with, mimic, and worsen ADHD. Proper assessment and management of ADHD requires fully understanding and assessing these factors and their impact on a patient's symptoms. In some cases, especially those where the condition arose anew, there are reversible factors that are responsible instead of ADHD.

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Low Energy

Poor Mood

Disorganization

Unhealthy Lifestyle

Drug Side-Effects

ADHD-like Condition
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Developmental Impact

Untreated ADHD can result in challenges and dysfunction in many areas of life. The effects vary by age and can have severe and life-long consequences.

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Pre-school

School-aged

Adolescence

College-aged

Adulthood
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Comorbidities

ADHD is frequently present in patients with other conditions that can affect behaviour. In fact, 50-90% of children (and 85% of adults with ADHD) have at least one other comorbid disorder. It is important to identify if they are present so that the most effacacious approach can be employed for each patient. Often the comorbidities are more impairing than ADHD and should be treated first.

Prevalence

Condition Prevalence of comorbidities in patients with ADHD by age group
Child (6-12) Adolescent (13-17) Adult (≥18)
Anxiety 11-30% 11-30% >30%
Depression ≤10% 11-30% >30%
Learning Disabilities >30% >30% >30%
Autism Spectrum Disorder 11-30% 11-30% 11-30%
Oppositional Defiant Disorder >30% 11-30% ≤10%
Conduct Disorder (Children) or Antisocial Personality Disorder (Adults) 11-30% 11-30% 11-30%
Borderline Personality Disorder Unknown Unknown >30%
Obsessive Compulsive Disorder ≤10% ≤10% 11-30%

ADHD and Anxiety

Patients with ADHD and anxiety experience many of the same symptoms. However, a skilled physician can differentiate them (and identify cases where both are present) in part due to distinguishing patterns, which include:

Anxiety ADHD
Inattention only when anxious Inattention independent of emotional state
Fidgety only when anxious Fidgety, independent of emotional state
Physical symptoms (palpitations, nausea, difficulty breathing, tremulousness) No subjective physical symptoms
Social inhibition Social disinhibition
Insomnia due to worries Insomnia due to inability to "turn thoughts off"
Persistent worries focused on unrealistic situations or thoughts Transient and realistic worries

ADHD and Depression

The clinical picture of depression can also be confused with ADHD. Some key differentiating factors are:

Depression ADHD
Feeling tired or "slowed down" Difficulty concentrating regardless of energy level
Thoughts of death or suicide Not commonly associated with thoughts of death or suicide
Episodic symptoms Continuous symptoms
Impaired decision making due to being disengaged, perseverative, pessimistic Impaired decision making due to being inefficient, insufficiently reflective, inconsistent, and impulsive

ADHD and Autism

ADHD is present in 30-80% of individuals with Autism Spectrum Disorder (ASD). There is significant symptom overlap as detailed below. Treating ADHD when present in patients with ASD can improve overall functioning.

Autism ADHD
Can be diagnosed as early as 2-3 years old Usually diagnosed at 6-7 years old or later
Language skills delayed. Echolalia present. Language skills not delayed. No echolalia.
Avoids eye contact Less eye contact as eyes frequently shift focus
Less social in play More social in play
Not interested in others. "Parallel play" predominant. Ostracized for impulsive behaviour. Drawn to impulsive peers.
Rhythmic, stereotyped movements Hyperactive, "always on the go"
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Assessment

Diagnosing ADHD is a substantial process and since potentially overlapping pathologies need to be assessed, a physician with specific training in ADHD and related mental health conditions must be involved. The process requires taking a complete medical history as well as a history of personal development including academics. This is usually done over multiple appointments. Supporting documentation is collected and reviewed, which typically includes school report cards as well as reports from psychologists or behaviour interventionists.

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Non-Pharmacologic Treatment

Optimizing the Environment

There are some very important changes to the home and workplace that patients with ADHD can implement to make life easier and improve their symptoms. Common aspects of these changes are to create spaces that are calm, positive, and predictable. Patients with ADHD often feel that this helps them feel more organized and their behaviour in these spaces can be structured and modelled in patterns that produce success.


Landing and takeoff zones
Deposit your bag, keys, wallet, sunglasses, hat, ID badge, and any other critical belongings you may need on a typical day, in the same single location when you arrive at home. This makes staying organized easier and makes it less likely that you will forget something when it is time to head out again.

Reduce distractions
It is very important to be conscious of the sources of distraction in your environment. In each room in your home and workplace assess what tasks you accomplish there and also what distractions may exist so that you could can eliminate them to improve the productivity of the space.

Keep important items handy
It is very advantageous to keep important items handy. For example, putting important documents on the refrigerator in the kitchen and always keeping medications in the same place.

Ensure physical safety
Studies have shown that children and adults with ADHD are more likely to have accidents and injuries. It is essential to make sure that all home and work environments are scrutinized from a physical safety perspective with adjustments made as necessary.

Behavioural Interventions

Just as with the physical environment, building structure and predictability into behaviours is essential to functioning well with ADHD. Framing future plans within a positive outlook facilitates positive outcomes. Some examples are:

  • Implement structure and routines
  • Set clear, attainable goals that are tied to incentives
  • Use immediate small rewards
  • Praise specifically and frequently
  • Help prioritize instead of procrastinate
  • Use timers to help with tasks
  • Plan frequent movement breaks for prolonged tasks
  • Schedule family fun time
Optimizing behaviours can produce a positive-feedback loop that leads to success and further improved behaviour.
Self-esteem
Self-control
Harmony in family and relationships
Success

Cognitive Behavioural Therapy

CBT for patients with ADHD involves engaging in discussions about current thought patterns and their consequential behaviours. Effortfully changing thought patterns and implementing positive behaviour modifications though CBT alone can improve ADHD symptoms.

CBT involves encouraging patients to challenge their existing thought patterns such as acceptance of limiting self-beliefs. Patients should learn to recognize that "feelings are not facts" and that "you should not believe everything you think."

Most importantly, patients should learn to understand and actually believe that they have the ability to take control. If you change your behaviour, you will change how you feel.

CBT for ADHD should focus on:

  • Realistic goal-setting with action plans (S.M.A.R.T. goals)
  • Motivation enhancement
  • Attention management
  • Emotional regulation
  • Skills training
  • Time management
  • Adulting skills
  • Organization
  • Homework

Psychoeducational Reframing of ADHD Strengths

In some situations when patients with ADHD are frustrated with their symptoms it may be beneficial to reframe certain behavioural patterns as strengths.

Click on a trait below to see how it could be reframed

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Pharmacologic Treatment

The best outcomes for ADHD patients occur when non-pharmacologic approaches (including CBT with a trained physician or counsellor) are combined with medication.

First line: Long-acting Psychostimulants

Lower levels of dopamine and norepinephrine have been found to be related to symptoms of ADHD. Dopamine is associated with reward, pleasure, attention and mood. Norepinephrine is associated with energy, motivation, and mood.

Long-acting psychostimulants, such as amphetamine, methylphenidate, and their derivates are the best initial treatments for ADHD. They increase levels of dopamine and norepinephrine by blocking their reuptake. These medications offer:

  • Very high efficacy
  • Tolerability
  • Convenience (and increased compliance of once-daily dosing)

Alternative treatments

There are circumstances where alternatives to long-acting psychostimulants are appropriate treatments. There are many individualised factors to consider and these cases should always be assessed by an experienced physician.

For example, in adults with both ADHD and depression, the antidepressants bupropion and desipramine may reduce ADHD symptoms, but with significantly lower effects than the psychostimulants.

Potential Contraindications

Potential contraindications to treatment with psychostimulants include:
  • Pregnancy or lactation
  • Significant cardiovascular conditions
    • Structural heart defects
    • Arrhythmias
    • Advanced atherosclerosis
    • Family history of sudden early death
  • Untreated hypertension
  • Unstable substance use disorder
  • Unstable/Untreated psychosis or mania
  • Glaucoma
  • Seizure or tic disorder

Safety

It is critical that an experienced physician appropriately assesses each patient before prescribing any medication. This is especially true for psychostimulants. All assessments start with a history and physical exam. Some may require additional testing such as bloodwork and an ECG. High-risk patients may even require consultation with a cardiologist.

Side-Effects

Psychostimulant side-effects may include:

  • Dry mouth
  • Appetite reduction
  • GI upset
  • Insomnia
  • BP & HR elevation
  • Dysphoria/Irritability
  • Headaches
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Getting Help

If you or a family member are affected by symptoms of ADHD, book an appointment with Dr. Kwinter for a comprehneive assessment. You can book online or call 1-345-623-1000.

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Follow-up

Early in the course of treatment, patients with ADHD must follow-up frequently to monitor treatment response and to assess for side-effects of any prescribed medications. Once symptoms are optimized and function is acceptable, follow-up can be spaced out over time.

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