ADHD (attention deficit hyperactivity disorder)

ADHD (attention deficit hyperactivity disorder)
International Classification (ICD) F90.0

Basics

Especially in elementary school, people like to throw around the term ADHD when it comes to children who require a high level of attention. The children are accused of constantly disrupting lessons, not being able to sit still and being too much of a burden. And they are quickly diagnosed with ADHD, even though they are far from qualified to do so.

Yet this disorder has not played a role in our society for all that long. It was only with the introduction of compulsory education that the possibility of the disorder taking root in our minds was created. Because before that, children were not forced to follow lessons quietly and with concentration for longer periods of time.

Spread of ADHD

Today, ADHD is one of the most commonly diagnosed psychiatric disorders in children and adolescents. Even though the disorder begins before the age of six, it often reaches its peak severity after children start school.

Overall, about three percent of school children are affected by ADHD today. At first glance, boys seem to be affected much more frequently than girls. However, new studies and findings suggest that many girls are also affected. However, since these show a somewhat different symptomatic picture, they are rarely diagnosed correctly.

Clichés around ADHD

Today, there is a whole collection of clichés and prejudices surrounding ADHD. However, many of these can be completely debunked if you take a closer look at the disorder.

ADHD is not a disease of modern civilization and has nothing to do with wrong education, wrong nutrition or the use of computer games. And you must always be aware that not every fidget suffers from ADHD.

The positive sides of ADHD

However, just because a child has ADHD does not exclusively mean that they need special care and support. Having a child with ADHD doesn't just mean that it takes a lot of attention and effort. In contrast, the children also have all strengths and positive sides. For example, those affected often also show a high level of creativity and the gift of a strong imagination. A high ability to improvise can also often be observed. Last but not least, a strong sense of justice can also be seen in many ADHD children.

Definition

ADHD is an abbreviation for attention deficit hyperactivity disorder. This is a mental disorder associated with the symptom complex of inattention, overreactivity and impulsivity.

However, ADHD is not a firmly defined and precisely describable disorder. Often there are mixed forms and combinations with other disorders. Tics, moodiness, anxiety and aggression can also occur. In children, a behavioural disorder is also frequently present. Adults with ADHD show a tendency to dissocial behaviour and tend to abuse addictive substances.

In principle, three types of ADHD can be distinguished

  • predominantlyinattentive type: deficits of attention come to the fore, whereas hyperactive and impulsive behaviour can hardly be observed.
  • predominantlyhyperactive-impulsive type: hyperactive and impulsive behaviour comes to the fore, while deficits in attention are not observed.
  • Mixed type: This is a wide field in which both attention deficits, hyperactivity and impulsivity are seen.

In most cases, the symptomatology begins before the age of six. Even if it is a congenital disorder, there are also children in whom the diagnosis can only be made after they have started school, because they only become conspicuous in everyday school life. With younger children it is often difficult to distinguish behaviour in the sense of ADHD symptoms from age-appropriate development.

Causes

As the diversity of the clinical picture already suggests, the causes of ADHD are also very difficult to grasp. In general, it can be said that mainly biological and constitutional factors are relevant for the development, while psychosocial factors can be held responsible for the maintenance of the disorder.

Stress and ADHD

One trigger for ADHD can be living under constant stress. At some point, the permanent overload can no longer be compensated and the described disorder forms.

However, it must also be said that ADHD itself also causes a permanent stress load. The disorder prevents the correct filtering of information in the brain. Thus, all information from the environment is consciously taken in without the unimportant data being unconsciously sorted out first. For the brain, this means that it has to process a vast amount of data. This leads to forgetfulness, aggressiveness and restlessness. Some children, especially girls, do not react to this flood of data with hyperactivity, but are unusually calm and dreamy.

Genetic influencing factors

Another suspected cause is a change in genetic makeup. Thus, it is believed that a genetic disorder results in the absence of dopamine and norepinephrine in the brain, which play a major role in attention, drive and motivation. They are needed in the connections of nerve cells to transfer information from one cell to the next. When there is a deficiency of these neurotransmitters, little information can be passed on, and deficiencies occur in the areas described.

This theory is supported by the fact that ADHD often occurs in clusters in affected families. Nevertheless, no evidence has yet been found to prove that it is a genetic disorder.

Brain damage and ADHD

There is also likely a link between early childhood brain damage and ADHD. While perhaps a brief lack of oxygen during birth may be discrete enough that no negative effects can be detected for the time being. Nevertheless, damage may have occurred that will cause ADHD to develop sooner or later.

Nutrition as a trigger

Nutrition has been a much-discussed aspect of almost every medical condition in recent years. And also with ADHD one suspects a connection between the admission of colorings and preservatives with the food and the outbreak of ADHD.

Even though these substances have not been proven to be toxic, there is some data to suggest that diet does play a role. However, more precise facts in this regard have not yet been proven. So it still remains a speculation to be confirmed.

Maternal behaviour during pregnancy

As with many other childhood diseases and disorders, pregnancy is also a potential trigger of ADHD. For example, the use of nicotine, alcohol, and drugs could perhaps lead to promoting the disorder.

Environments that perpetuate ADHD

A child's living environment obviously plays no role in the development of ADHD. But this is still not to be neglected because it determines whether the symptoms persist or subside.

In the normal course of the disease, there is often a spontaneous improvement of the symptoms. This may not occur if the child's environment is not adapted to his or her needs. For example, cramped living conditions, lack of emotional attention, a hectic daily routine with a lot of noise, the lack of transparent structures, lack of exercise and time pressure can have a negative influence.

Nevertheless, it must be said that a bad upbringing or negative experiences during childhood can be ruled out as the cause of ADHD.

The cause is often an unsolved mystery

In most cases, the exact cause cannot be determined. Even if there are various indications of the cause, it is still unclear which factors are really decisive.

Symptoms

ADHD is defined by four cardinal symptoms: Hypermotor skills, attention deficit disorder with increased distractibility, impulsivity, and disturbances in psychosocial adjustment. However, the symptoms also depend on the age of the child concerned. Thus, the child's current stage of development must always be considered when looking for symptoms of ADHD.

In general, ADHD is a disorder that presents itself very differently at different stages of life. Below is a brief look at the symptomatology of ADHD at different stages of life.

ADHS in infancy

Infants with ADHD are characterised by frequent and prolonged crying phases and motor restlessness. In addition, parents often face massive eating and sleeping problems of the affected children. Some already reject physical contact in the first months of life and are disproportionately often bad-tempered.

ADHD in toddlers (including kindergarten age)

In toddlers, hyperactive gross motor skills are most noticeable. The children run, climb and romp all day, but hardly manage to sit still. If they have to remain seated, they are constantly ready to jump up again and move around. This activity, however, rarely has a certain goal; children are mainly concerned with satisfying their urge to move. In the process, risks and dangers are often misjudged, which is why it is not uncommon for accidents to occur.

Toddlers with ADHD are often very erratic in their play and constantly change their actions. When playing with others, it is noticeable that they show little stamina.

Marked defiance and other negative behaviors make social behavior very difficult, which is why the children also have trouble building consistent friendships.

Some young children with ADHD also exhibit performance deficits in hearing, vision, fine or gross motor skills. Sometimes there are also peculiarities in language development, which can be either particularly rapid or delayed.

ADHS in school children

In school children, the urge to move is usually reduced, but they are also constantly restless and fidgety. In addition, it is noticeable that rules are very difficult to accept and adhere to. This applies not only to rules within the family, but also to principles in playgroups and class communities. The children are disruptive in class, show little perseverance and are easily distracted.

Both at school and in everyday life, frustrations easily occur, which are also increasingly perceived by the child himself, often leading to tantrums and aggressive behavior.

The child's overall behaviour can be seen as chaotic. This affects not only the organization of tasks, but also their own room. The children are also often conspicuous by an almost unstoppable urge to talk, inappropriate facial expressions, gestures and body language and clumsiness, which then often leads to accidents.

In school, they often present with dyslexia, dyscalculia, or other learning performance problems. In addition, ADHD children are often unable to maintain social bonds over the long term, which quickly turns them into outsiders with diminished self-esteem.

ADHD in adolescence

As development progresses, motor hyperactivity is reduced more and more. The focus is now on symptoms such as impulsivity, stubbornness, unstable moods, low frustration tolerance and dissocial tendencies.

The adolescents avoid any tasks that would require prolonged concentration and effort. In stressful situations, the symptoms are usually noticeably intensified.

Overall, the adolescents can be described as inattentive and having a no-nonsense mentality. In addition, the adolescents often have a greatly reduced self-esteem and struggle with anxiety and depression. As outsiders, they more often socialize with marginalized social groups and show a tendency toward delinquency, alcohol, and drugs.

ADHD in adults

ADHD is not very rare in adults either, even though the symptoms disappear with time in many of those affected. Affected adults are conspicuous for their scatterbrainedness and forgetfulness. They have trouble planning tasks from the beginning and also completing them. The professional situation and social ties usually prove to be unstable. The sufferers often suffer from anxiety, depression and irascibility. In addition, they also tend to delinquency, alcohol and drugs.

Disorders resulting from ADHD

In addition to the defining symptoms, learning disorders, behavioral problems, self-esteem disorders, emotional lability, and psychosomatic symptoms often occur with or as a result of ADHD. In the case of the learning disorder, it is particularly noticeable that the children are easily distracted, use an ineffective learning style and cannot abstract.

Strong differences in the individual manifestation

When describing the symptoms as a whole, it must be mentioned once again that they can vary greatly in severity. Some children show all the typical symptoms in a pronounced form, others only show signs of a few characteristics.

The positive sides of ADHD

With all these negative symptoms, however, it must not be forgotten that people with ADHD also show a number of positive characteristics. These include, for example, a wealth of ideas and artistic creativity. Even if they sometimes lack perseverance, many ADHD patients are very enthusiastic and above all helpful. They also have a strong sense of justice.

Diagnosis

The observation of the clinical symptom picture plays a major role in establishing the diagnosis. In order to be able to make the diagnosis of ADHD, several criteria must be fulfilled, which are shown below.

Criteria for ADHD

Even though the variety of possible symptoms in ADHD is very large, there are symptom lists of which a certain minimum number of symptoms must be present in order to make the diagnosis of ADHD.

For example, at least six of the following inattention symptoms must be consistently present over an extended period of time:

  • frequent careless mistakes or lack of attention to detail
  • inability to concentrate over a longer period of time
  • failure to listen when spoken to directly
  • incomplete execution of instructions or tasks
  • lack of organisation of tasks and activities
  • refusal to perform tasks requiring sustained concentration
  • losing objects needed for certain tasks
  • easy distraction by non-essential stimuli
  • high forgetfulness of everyday activities

In addition, at least six of the following symptoms of hyperactivity and impulsivity must be true in order for an ADHD diagnosis to be made:

  • restless sitting and fidgeting
  • frequently leaving the seat, even when sitting is expected
  • frequent running around and climbing, even when inappropriate
  • restlessness
  • high volume when playing
  • behaving as if driven by a motor
  • almost uncontrollable urge to talk
  • answers before the question is finished
  • Difficulty in keeping to order
  • Disturbing and interrupting other conversations and games

To be diagnosed with ADHD, there must also be a clear impairment in the social, educational, or occupational areas.

Exclusion of other possible causes

In addition, all other possible causes of hyperactive disorder must also be ruled out. These include, for example, a reduction in intelligence, epilepsy, psychoses and affective disorders. In addition, organic causes, such as hyperthyroidism, must be ruled out.

Diagnosis only by a specialist

Overall, it can be said that in typical cases the diagnosis is relatively easy to make. Nevertheless, this must always be done by a competent specialist in paediatrics or child and adolescent psychiatry. Because only in this way can a confirmed diagnosis be reached, which then leads to appropriate treatment.

In addition, the correct diagnosis is of course more difficult if the case is not quite typical. And many ADHD children and ADHD adults do not show the typical symptoms, but present with alternative manifestations of ADHD.

Frequent misdiagnosis in adults

Especially in adulthood, a misdiagnosis can occur. This is because depression and other disorders often come to the fore here, the cause of which usually lies in social problems. These in turn are often hidden due to the hyperactivity that ADHD brings with it.

Does my child suffer from ADHD?

If one suspects that one's own child might suffer from ADHD, first of all the behaviour must be observed and described in detail. In doing so, it should be determined exactly which abnormalities occur at which times.

Open discussions with other contact persons of the child can also be helpful. These include, above all, the caregivers in kindergarten, school and after-school care or grandparents and other babysitters who regularly spend time with the child. After gathering the facts, it is important to consult a pediatrician or adolescent doctor.

Even before the diagnosis has been made, one can seek contact to self-help groups or ADHD forums in order to be able to exchange information with other affected persons.

At the specialist or child psychologist

When you visit a specialist in paediatrics or a child or adolescent psychologist, you should be prepared to answer a few questions. If you think about them beforehand, you can give more concrete answers. Preparing for the appointment can therefore make the diagnosis a lot easier.

The specialist will ask exactly about the situation in the family and possible diseases, behavioral problems and other peculiarities. In addition, questions about addictive behavior and psychiatric illnesses are also important and purposeful. In addition, questions will be asked about special features during pregnancy, at birth and in the development to date. Any previous illnesses and other complaints should also be disclosed.

After a detailed anamnesis, not only the parents but also other caregivers must be interviewed. The social skills and performance behavior of the child are assessed in particular.

After that, a detailed clinical examination is done to rule out possible other causes for the abnormalities. During the examination and the medical history, the specialist will pay close attention to the child's behavioral abnormalities.

In some cases, the specialist can obtain further information about the behaviour by means of a video camera. This also has the advantage that the parents can be shown directly what abnormalities the child has. This also shows conspicuous facial expressions, gestures and body language that would probably be overlooked as a parent.

Furthermore, ADHD-specific questionnaires can be filled out. Depending on the method, this is completed by parents, caregivers or in collaboration with the child. Typical questionnaires include the CBCL (Child Behaviour Checklist), which covers all possible childhood mental health conditions. More specific is the Conners Scale, which was developed primarily for the diagnosis of ADHD.

Therapy

The therapy of ADHD is very complex and comprehensive. Above all, it is important that an individually suitable therapy is found for each patient, even if this is very costly.

The aim is to enable those affected to lead a largely normal life. In the case of children, great importance is attached to enabling them to develop normally in order to avoid secondary diseases.

In order to be able to guarantee the individual therapy, a whole network of helpers is needed. Not only doctors and psychologists have to be supportive, but also parents, siblings, teachers and other caregivers have to be integrated into the therapy.

Drug therapy

Drug therapy involves the use of psychostimulants and other medications that should alleviate the symptoms of ADHD. Stimulants are currently the most effective drugs for improving attention and social behavior.

However, as well as the medications work, they are also difficult to manage. Since they are subject to narcotics laws, the treatment is somewhat costly and some parents are wary of it because of this.

In order to minimise the risks, close monitoring should be carried out during drug therapy so that any side effects can be detected at an early stage. These include appetite and sleep disturbances, impaired growth and increases in pulse or blood pressure. In most cases, these side effects can be eliminated by adjusting the dose used.

As an alternative to stimulants, neuroleptics, antidepressants, anticonvulsants, or MAO inhibitors may be used. However, these are not the drugs of choice and should only be used deliberately. Tranquilizers and barbiturates should not be used in ADHD children.

Overall, drug therapy can usually be avoided as long as children are not yet of school age. During school, however, it is nearly impossible for many ADHD children to meet the performance requirements unless they are helped to do so with medication.

Working with parents

Especially with young children, but also with adolescents, a lot of work has to be done with the parents. They must be very well informed, guided and also relieved. This is the only way to enable them to lead a regulated and fulfilling life with the ADHD child. If there are also other siblings, they should also be included in the therapy, since ADHD always affects the entire family.

With young children, parents are often the only way that the child's behavior can be positively influenced. This is because they are not yet able to cope with cognitive behavioural therapy due to their lack of development.

Behavioural therapy for ADHD

Cognitive behavioural therapy should always be considered for ADHD children from school age. This should also include attention and strategy training. In addition, training in social skills can also be useful and effective. Any therapeutic support for the children should always have a structuring character.

Consequences of the lack of treatment

Some parents refuse drug therapy because they have heard that ADHD can grow over time. And it is also true that in some children, the symptoms will lessen over time, even if no treatment is given.

But in many cases, the disorder persists in some form. If children are not treated and supported to the best of their ability, they can suffer serious consequences.

For example, success in school is almost impossible without appropriate therapy. As a result, vocational training that matches the child's actual cognitive abilities cannot be done either. Because even if attention is impaired and concentration is difficult, it does not mean that the children also suffer from a reduction in intelligence.

In addition to professional life, the effects on private life should not be underestimated. For example, the ability to relate to others can be drastically reduced, which is why social relationships can hardly be established and maintained.

In addition, there is an increased risk of becoming delinquent. And even if the adolescent ADHD patients do not get on a slippery slope, the accident risk of ADHD children is considerably increased. The constant urge to move causes them to misjudge danger, which can sometimes lead to serious injuries.

In adulthood, ADHD often leads to secondary diseases. For example, the risk for mental illnesses, such as anxiety disorders and depression, is increased overall if one suffered from ADHD as a child. Fibromyalgia syndrome, heart attacks and addiction disorders also occur more frequently.

Forecast

Especially in young adulthood, there is often a spontaneous attenuation of symptoms. In 30 to 50% of cases, however, the symptoms remain. Often, however, they change as development progresses. For example, the excessive motor skills are pushed further and further into the background, while scatterbrainedness, forgetfulness or a lack of organisation are more noticeable.

If a pronounced ADHD is not treated, it often leads to further disorders such as substance abuse, affective disorders and personality disorders. These entail a very unfavorable course.

Tips

Meeting the special demands of a child with ADHD is often not easy. Parents are usually always under pressure, expecting only the worst, because they know that the child will not run out of energy so quickly.

Above all, it also takes some time for the family to learn how to deal with the disorder. There is no universal magic formula for dealing with a child who has ADHD. On the contrary, each family must experiment on their own and try out which strategies work and which do not. Nevertheless, there are some general tips and tricks that can make everyday life easier.

Structure in the daily chaos

ADHD kids have a big problem creating and maintaining structure themselves. That's why showing the child how to structure and plan activities can be very helpful. For example, large tasks can be broken down into small sub-steps. Clear time and task schedules for the whole family and transparent and simple rules can also make everyday life much easier.

The time structure should also include sufficient recovery times and fixed eating and drinking times. Even if children are hyperactive, they need sufficient sleep and also rest periods. In addition, a balanced diet should be part of the daily routine and sufficient fluids should be consumed. In this way, the child is given the opportunity to perceive and assess the world around him and the respective situations with full attention.

Changes and surprises are a big problem for many ADHD children, which is why these should be avoided or at least carefully announced and discussed.

Rewards

As with any other child, a reward or two works wonders. Unlike punishments and reprimands, which often trigger a counterattack from the child, praise and rewards encourage good and pleasant behavior.

For a child with ADHD, it can be helpful to develop a fixed reward system. In this system, the child can earn perks, for example. Again, it is important to make sure that the basic features of the system are clearly explained and transparent.

Encouragement

Not only parents of ADHD children, but the children themselves are often frustrated because they also realize that they are different. Moreover, they often do not have the motivation to finish a task. Because of this, they need a lot of praise and encouragement to finish something.

So, clearly revealing the goal over and over again while the child is working on a task can also be very helpful. Reminding them of previous successes can also be very helpful, as these are often forgotten all too quickly.

Encouragement should also take place in the social realm. For example, constantly reminding children how important friends are and the benefits they bring can help in building friendships.

Quick and clear interactions

In order for ADHD children to be able to relate praise or reprimand to the causative situation, it is important to respond immediately when an extremely positive or negative behavior stands out. If you wait too long, the child will no longer know what the praising or admonishing words stand for.

When interacting with the child, one should always try to accept the child's idiosyncrasies and not try to change the child to what one would like him or her to be. Rather than trying to combat the negative aspects of the condition, it is often helpful to focus on the positive aspects of the child.

When dealing with undesirable behavior, it can also be helpful to always keep in mind that it is not the child's bad character that is causing problems, but the ADHD disorder, the symptoms of which often make life more difficult. So it's not the child, it's simply a symptom of an underlying neurobiological disorder.

Allow free space

In order to protect the child, there is often a tendency to curtail the child's freedom. However, a child with ADHD also needs his or her own free spaces in which, for example, social contacts with peers can be practiced. For example, outside of school, the child can work with clubs for sports or music. Of course, the child's wishes, interests and strengths must be taken into account in order to achieve a positive effect.

Sports, perhaps even martial arts, can also be helpful. Here not only letting off steam is made possible, but above all concentration and social interaction are strengthened. In addition, the children also learn to deal responsibly with their own physical strength. Of course, any other sport is also a wonderful way for a child with ADHD to learn important behaviors and skills.

Encouraging talents

When the child is encouraged with his or her strengths and talents, it has a twofold positive effect. On the one hand, it shows the parents and the environment that the child also has a lot of positive qualities, has things that he is good at. On the other hand, it also shows the child that he or she is good, which will help build self-confidence. Small and big feelings of success are extremely valuable for building self-confidence!

Always stay cool

No matter how stressful the situation may be, losing your own cool will only make it worse. So for parents, the key is to always try to stay cool yourself. To make this possible, one should also consciously take time out and fill it with recreation, leisure activities and socializing. The ADHD of the child will determine the everyday life anyway already very much, therefore one should create consciously areas, in which the illness plays no role.

In addition, one should always keep oneself informed. This especially takes away the doubts whether one could do anything better. Because if you know exactly about the symptoms, you also know that the child's behaviour is not your fault. For many, the exchange with other families has also been very helpful. This is possible through self-help groups and forums on the Internet.

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