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多动症
多动症（全称注意缺陷多动障碍，简称ADHD）是一种从小就开始的神经发育问题，主要表现为注意力难以集中、做事冲动和多动。它不是小孩“故意调皮”或“懒”，而是一种会影响一生的大脑运作差异。
为了让你彻底弄明白多动症是怎么回事，我们从它是什么、有哪些表现、为什么会得这个病、怎么诊断以及怎么对付它这几个方面来细细讲。
一、多动症到底是什么？
简单来说，多动症患者的大脑在管理注意力、控制冲动和活动量这方面，跟普通人有点不一样。这会导致他们在家里、学校里或工作中遇到很多困难。
过去，很多人以为多动症是小孩子的专属，觉得长大了自然就好了。但现在的研究明确告诉我们，这其实是个持久的问题。虽然随着年龄增长，那种“上蹿下跳”的多动症状可能会减轻，但“注意力不集中”和“冲动”的问题往往会一直持续到成年。大概有30%到70%的多动症孩子，长大后依然会有症状。在全球范围内，大约5%的孩子和2.5%的大人受此影响。
二、多动症有哪些表现？
多动症的表现可以分成三大类，而且在不同年龄阶段表现还不一样：
- 注意力不集中：容易走神，丢三落四，很难把一件需要费脑子的事情从头做到尾。
- 多动：坐不住，总想动来动去，在小孩子身上特别明显。
- 冲动：做事不经过大脑，比如别人话还没说完就抢着回答，或者很难排队等待。
多动症还分几种不同的“款式”（亚型）：
- 注意缺陷为主型：主要问题是走神、发呆，不怎么多动。这种在成年男性和男孩中更多见。
- 多动/冲动为主型：主要问题是坐不住和鲁莽，走神的情况不严重。这种在成年女性和女孩中更多见，而且她们的生活质量往往受影响更大，更容易焦虑。
- 联合型：既有严重的注意力问题，又有多动冲动的问题，这是最常见的一种，大概占了70%。
值得一提的是，多动症的表现非常“狡猾”，它会随着时间、场合甚至孩子当天的状态而变化，有时候看着挺好，有时候又特别糟糕，这让很多家长误以为孩子是“故意的”。
三、为什么会得多动症？（原因与风险）
多动症不是由单一原因引起的，而是基因和环境共同起作用的结果。
- 遗传是主力：多动症有很强的家族遗传性。如果家里有人得多动症，孩子得病的几率也会增加。研究发现，多动症和孤独症（自闭症）在遗传上都有相似的地方，这两种病经常一起出现——有20%到50%的多动症孩子同时有孤独症的特征，而30%到80%的孤独症孩子也符合多动症的标准。
- 孕期和出生时的风险：妈妈怀孕期间如果遇到一些问题，或者生产时孩子遇到并发症，可能会增加孩子得多动症的风险。
- 家庭环境的影响：虽然糟糕的家庭教育不会“直接导致”多动症，但家庭环境确实会影响症状的轻重。比如，父母对孩子态度粗暴、经常责骂，或者孩子遭受了虐待、父母离异、甚至坐牢，这些都会增加孩子得多动症或让症状变严重的风险。相反，父母如果对孩子温暖、敏感，多动症的风险就会降低。
- 大脑里的秘密：通过给大脑拍照片（核磁共振等），科学家发现多动症患者的大脑确实有点不一样。他们大脑的成熟速度比普通人要慢。特别是大脑前部（前额叶——负责做计划、管住自己不冲动的地方）和深层（基底节——负责控制动作的地方）之间的连线工作不够协调。
四、多动症常常带着“难兄难弟”（共患病）
多动症很少单独来，它经常带着其他问题一起出现，这在医学上叫“共患病”。
- 在美国最新的数据中，大约77.9%的多动症孩子至少还同时有另外一种心理或行为问题。
- 常见搭配：对立违抗障碍（就是专门跟人对着干、脾气暴躁）、品行障碍（偷东西、打架等严重违规行为）、抑郁、焦虑、抽动症（不受控制地眨眼、清嗓子等）。
- 大人的烦恼：如果小时候多动症没治好，长大后又叠加了品行障碍，那么成年后出现反社会行为、酗酒和滥用药物的风险就会非常高。长期追踪研究也发现，多动症人群在成年后面临更多的心理健康问题、社交困难，甚至过早死亡的风险也会增加。
五、怎么诊断多动症？
诊断多动症不能只凭感觉。现在用的诊断手册（DSM-5）规定，症状必须在12岁之前就出现了，而且必须是在两个以上的场合（比如既在学校捣乱，在家里也坐不住）都有表现，才能下诊断。对于17岁及以上的人，诊断需要的症状条数可以稍微放宽一点。
医生诊断主要靠详细的聊天（临床访谈），了解病史和生活情况，再配合一些量表来打分。值得注意的是，多动症很容易被误诊，如果不做全面仔细的检查，很容易把别的问题当成多动症，或者把多动症当成别的问题。
六、怎么对付多动症？（治疗与干预）
虽然多动症目前没法彻底“除根”，但有很多科学的方法可以大大减轻症状，让生活步入正轨。治疗一般讲究“多管齐下”，也就是药物和非药物方法一起上。
-
非药物方法（基础优先）：
- 教育和行为干预：这是最重要的基石。比如在学校里，老师可以给孩子制定特别的行为规则，把大任务拆成小任务，或者教孩子怎么管住自己。
- 心理治疗：比如认知行为疗法（CBT，简单说就是帮孩子识别和改变脑子里那些让他冲动的坏想法）。虽然单靠CBT治多动症效果不够猛，但如果配合药物一起用，或者在孩子减药的时候用，效果就很好。
- 家庭支持：教父母怎么跟多动症孩子沟通、怎么管教，这不仅能改善孩子的行为，还能让家里少点战火。
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药物治疗（效果最直接）：
- 当非药物方法不够，或者症状比较严重时，医生会建议吃药。
- 兴奋剂类药物：这是治多动症最有效的一类药，比如哌甲酯（俗称“专注达”等）。你可能会问：“多动症本来就闹腾，怎么还吃兴奋剂？”其实，这类药是让大脑里负责“踩刹车”和“集中注意力”的物质（如多巴胺）增多，从而帮孩子安静下来、专注起来。大量研究证明这类药效果很好，副作用一般也不大，最需要注意的副作用是可能会引发抽动（tics）。
- 非兴奋剂：如果兴奋剂效果不好或者副作用受不了，还有其他药可以选，比如托莫西汀（一种抗抑郁药改的），或者某些降压药等。
一项非常有名的14个月大型研究（MTA研究）发现：对于多动症的核心症状（走神、多动），规范的药物治疗效果最好，单纯的行为治疗比吃药差点；但如果把吃药和行为治疗结合起来，虽然对核心症状不比单纯吃药好多少，但在改善对立情绪、亲子关系和阅读能力方面，联合治疗有独特的优势。
七、现状与挑战：很多人没有得到应有的帮助
多动症是一个越来越受关注的公共卫生问题。在美国，2022年的数据显示，大约每9个孩子里就有1个（11.4%）曾被诊断过多动症，比2016年增加了约100万人。这说明多动症很常见，但也可能存在过度诊断的风险，需要专业医生仔细甄别。
更让人揪心的是，在目前确诊的多动症孩子中，大约有58.1%属于中度或重度，但竟然有近三分之一（30.1%）的孩子没有接受任何针对多动症的治疗。
对成年人来说，情况更不乐观。长期以来，人们对成年期多动症缺乏认识，很多大人只觉得自己“笨”、“懒”、“一事无成”，却不知道脑子里其实是多动症在作祟。成年期多动症不仅影响工作表现，还容易导致交通事故、人际关系破裂等。因此，不管是大人还是小孩，只要怀疑自己有多动症的倾向，都应该去寻求专业精神科或心理科医生的帮助，早发现、早干预，生活完全可以大变样。
References
1Adult ADHD: A new disease?PubMed
Gil Zalsman, Tal Shilton
OBJECTIVES: Until recently, it was believed that attention deficit and hyperactivity disorder (ADHD) are outgrown by the end of adolescence and the beginning of adulthood. The purpose of this review is to describe the characteristics of the disease in adults, depict comorbidities that accompany it, and expand the scope over methods of diagnosis and treatment of these ages. METHODS: A search was conducted in the PubMed/MEDLINE database for relevant key words 'ADHD', 'attention deficit', 'hyperactivity' and 'adult'. Secondary search parameters were 'comorbid', 'prevalence', 'epidemiology', 'therapy' and 'drug therapy'. Search was limited to 'English' and 'Humans'. RESULTS: Over the years, the persistent nature of the disorder has been clarified, elucidating prevalence rate, gender differences and subtype shifts among adult ADHD population. Nevertheless, even today, there is only limited awareness of the existence of the disorder across one's lifespan, its consequences and the appropriate treatment. CONCLUSIONS: Our results emphasise the growing awareness of adult psychosocial impairments due to ADHD symptoms and comorbidities, as well as the need for further collaboration among practitioners and mental health-care professionals to better identify the condition and allow for effective treatment.
2Attention-deficit/hyperactivity disorder.PubMed
B A Shaywitz, J M Fletcher, S E Shaywitz
In this chapter we have reviewed the diagnosis and management of attention deficit disorder, focusing particularly on the role of stimulant therapy in ADHD. Hisorical review suggests that ADHD has roots that extend back almost a century. The definition of ADHD is based on inclusion and exclusion criteria that are established by history and reflect behavioral concerns. Attention-deficit/hyperactivity disorder is a chronic disorder affecting the child's home, school, and community life. The primary symptoms of the disorder manifest a developmental pattern: activity diminishes while attentional deficits persist. Major sources of concern are the secondary and often more resistant problems of learning difficulties, behavioral problems, lack of peer acceptance, and low self-esteem. An often frustrating and perplexing characteristic of the disorder is its marked variability-over time, across situations, and within the same child and similar situations. Educational management represents an important priority and often forms the cornerstone of all other therapies, nonpharmacologic or pharmacologic. Cognitive-behavioral therapies represent the most widely used alternative to pharmacotherapy. Although the effects of CBT alone are disappointing, recent studies suggest that such therapies may provide a useful adjunct to pharmacotherapy and may be helpful when children are tapered off medication. Psychotherapy, or a combination of psychotherapy and medication (termed multimodality therapy), may also be useful. Pharmacotherapy for ADHD originated almost 60 years ago, and at this time the ameliorative effects of medications in ADHD are well established. The general skepticism of experienced clinicians, coupled with a climate where parents are reluctant to medicare children, serves to limit their use except where indicated. Although the effects of stimulants on attention and activity seem well established, effects on cognition, conduct, and social behavior are more controversial. Within recent years, a great deal has been learned about the pharmacokinetics of stimulants in children with ADHD, providing a rational basis for administration. It is also clear that side effects are minimal, the most serious being the possibility of the emergence of tics. Whereas stimulants are clearly the most effective agents, other agents, including antidepressants, may also be effective. Recent advances may now provide an opportunity to better understand the neural and molecular basis for ADHD. Recent advances in imaging technology, particularly fMRI, offer an opportunity to examine the neural basis of ADHD, and advances in genetics may provide clues to its etiology.
3Attention deficit hyperactivity disorder.PubMed
Anita Thapar, Miriam Cooper
Attention deficit hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental disorder with a prevalence of 1·4-3·0%. It is more common in boys than girls. Comorbidity with childhood-onset neurodevelopmental disorders and psychiatric disorders is substantial. ADHD is highly heritable and multifactorial; multiple genes and non-inherited factors contribute to the disorder. Prenatal and perinatal factors have been implicated as risks, but definite causes remain unknown. Most guidelines recommend a stepwise approach to treatment, beginning with non-drug interventions and then moving to pharmacological treatment in those most severely affected. Randomised controlled trials show short-term benefits of stimulant medication and atomoxetine. Meta-analyses of blinded trials of non-drug treatments have not yet proven the efficacy of such interventions. Longitudinal studies of ADHD show heightened risk of multiple mental health and social difficulties as well as premature mortality in adult life.
4ADHD in adults: clinical subtypes and associated characteristics.PubMed
Virginio Salvi, Giovanni Migliarese, Viviana Venturi, et al.
INTRODUCTION: Attention Deficit Hyperactivity Disorder (ADHD) is an early onset clinical condition characterized by attention difficulties, hyperactivity and impulsivity which can persist across the lifespan, significantly influencing the evolutionary course and facilitating the rise of psychiatric comorbidities. The presence of different ADHD subtypes in adults is a heterogeneity factor to be recognized in order to orient prognosis and treatment, as indicated by studies that described differences in the characterization of different subtypes in relation to both severity and comorbidities. MATERIALS AND METHODS: In the present study we evaluated the socio-demographic and clinical characteristics of a sample of adults with ADHD and the characteristics associated with the different disorder subtypes. We described 60 patients aged between 18 and 65 years (mean age 34.1) with primary diagnosis of ADHD consecutively admitted to the Regional Centre for diagnosis and treatment of ADHD in adults in Milan. RESULTS: We observed high severity of symptoms and low quality of life, in particular in the "life outlook" dimension. The subtypes distribution was the following: 18.3% inattentive subtype, 8.3% hyperactive/impulsive subtype and 70% combined subtype. The hyperactive/impulsive subtype showed a significantly higher frequency in females, while the inattentive subtype was more frequent in males. Patients with the hyperactive/impulsive subtype showed worse quality of life and more frequent anxiety disorders. CONCLUSIONS: Considering the different clinical profiles among various subtypes, these data add relevance to subtypes classification of adult ADHD.
5ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment.PubMed
Melissa L Danielson, Angelika H Claussen, Rebecca H Bitsko, et al.
OBJECTIVE: To provide updated national prevalence estimates of diagnosed attention-deficit/hyperactivity disorder (ADHD), ADHD severity, co-occurring disorders, and receipt of ADHD medication and behavioral treatment among U.S. children and adolescents by demographic and clinical subgroups using data from the 2022 National Survey of Children's Health (NSCH). METHOD: This study used 2022 NSCH data to estimate the prevalence of ever diagnosed and current ADHD among U.S. children aged 3-17 years. Among children with current ADHD, ADHD severity, presence of current co-occurring disorders, and receipt of medication and behavioral treatment were estimated. Weighted estimates were calculated overall and for demographic and clinical subgroups ( = 45,169). RESULTS: Approximately 1 in 9 U.S. children have ever received an ADHD diagnosis (11.4%, 7.1 million children) and 10.5% (6.5 million) had current ADHD. Among children with current ADHD, 58.1% had moderate or severe ADHD, 77.9% had at least one co-occurring disorder, approximately half of children with current ADHD (53.6%) received ADHD medication, and 44.4% had received behavioral treatment for ADHD in the past year; nearly one third (30.1%) did not receive any ADHD-specific treatment. CONCLUSIONS: Pediatric ADHD remains an ongoing and expanding public health concern, as approximately 1 million more children had ever received an ADHD diagnosis in 2022 than in 2016. Estimates from the 2022 NSCH provide information on pediatric ADHD during the last full year of the COVID-19 pandemic and can be used by policymakers, government agencies, health care systems, public health practitioners, and other partners to plan for needs of children with ADHD.
6Role of attention deficit hyperactivity disorder in learning disabilities.PubMed
G S Golden
ADHD refers to a combination of symptoms in the general areas of inattention, impulsivity, and hyperactivity. This condition becomes evident in the preschool years and affects males predominantly. The behavior is seen as being disruptive and unacceptable by parents and teachers, and the child is socially handicapped as a result. Treatment relies on behavioral techniques and medication, predominantly psychostimulants. ADHD is strongly associated with learning disabilities; the treatment of the learning disorder should be based on educational intervention, not drug therapy. Symptoms of ADHD may continue into adulthood, and recommendations for treatment of adults are being made with increasing frequency. The prognosis is best for children who do not have symptoms of a conduct disorder and who lose the symptoms of ADHD before adolescence. A superimposed conduct disorder and maintenance of the symptoms of ADHD put the patient at high risk for antisocial behavior and substance abuse in adolescence and adulthood.
7Attention-deficit/hyperactivity disorder.PubMed
Stephen V Faraone, Philip Asherson, Tobias Banaschewski, et al.
Attention-deficit/hyperactivity disorder (ADHD) is a persistent neurodevelopmental disorder that affects 5% of children and adolescents and 2.5% of adults worldwide. Throughout an individual's lifetime, ADHD can increase the risk of other psychiatric disorders, educational and occupational failure, accidents, criminality, social disability and addictions. No single risk factor is necessary or sufficient to cause ADHD. In most cases ADHD arises from several genetic and environmental risk factors that each have a small individual effect and act together to increase susceptibility. The multifactorial causation of ADHD is consistent with the heterogeneity of the disorder, which is shown by its extensive psychiatric co-morbidity, its multiple domains of neurocognitive impairment and the wide range of structural and functional brain anomalies associated with it. The diagnosis of ADHD is reliable and valid when evaluated with standard criteria for psychiatric disorders. Rating scales and clinical interviews facilitate diagnosis and aid screening. The expression of symptoms varies as a function of patient developmental stage and social and academic contexts. Although there are no curative treatments for ADHD, evidenced-based treatments can markedly reduce its symptoms and associated impairments. For example, medications are efficacious and normally well tolerated, and various non-pharmacological approaches are also valuable. Ongoing clinical and neurobiological research holds the promise of advancing diagnostic and therapeutic approaches to ADHD. For an illustrated summary of this Primer, visit: http://go.nature.com/J6jiwl.
8[DMS-5 - attention-deficit/hyperactivity disorder].PubMed
Tobias Banaschewski, Manfred Döpfner
Modifications to the DSM-5 criteria for the diagnosis of attention-deficit/hyperactivity disorders are described and discussed. The main modifications concern the onset of the disorder, the reduction on the number of criteria fulfilled for a diagnosis in patients aged 17 years or older, and the elimination of autism spectrum disorders as an exclusion criterion for this diagnosis. These changes are mainly welcomed. However, the demanded increase in the age for the latest onset of the disorder may prove to be problematic.
9ADHD and behavioral disorders: Assessment, management, and an update from DSM-5.PubMed
Joseph Austerman
Behavioral disorders in pediatric patients--primarily attention deficit hyperactivity disorder (ADHD)--pose a clinical challenge for health care providers to accurately assess, diagnose, and treat. In 2013, updated diagnostic criteria for behavioral disorders were published, including ADHD and a new diagnostic entity: disruptive mood dysregulation disorder. Revised criteria for ADHD includes oldest age for occurrence of symptoms, need for symptoms to be present in more than one setting, and requirement for number of symptoms in those aged 17 and older. Assessment of ADHD relies primarily on the clinical interview, including the medical and social history, along with the aid of objective measures. The clinical course of ADHD is chronic with symptom onset occurring well before adolescence. Most patients have symptoms that continue into adolescence, and some into adulthood. Many patients with ADHD have comorbid disorders such as depression, disruptive behavior disorders, or substance abuse, which need to be addressed first in the treatment plan. Treatment of ADHD relies on a combination of psychopharmacologic, academic, and behavioral interventions, which produce response rates up to 80%.
10Is attention deficit hyperactivity disorder familial?PubMed
S V Faraone, J Biederman
Using two sources of data, we review methodologic issues pertinent to family studies of attention deficit hyperactivity disorder to evaluate whether such studies define attention deficit hyperactivity disorder as a familial disorder. We systematically evaluate the relevant literature and provide a detailed overview of the Massachusetts General Hospital family-genetic studies of attention deficit disorder as defined in DSM-III and attention deficit hyperactivity disorder as defined in DSM-III-R. The available literature, and our double-blind, controlled studies indicate that attention deficit disorder and attention deficit hyperactivity disorder are familial. Moreover, the pattern of transmission of comorbid disorders suggests that attention deficit hyperactivity disorder is, from a familial perspective, distinct from anxiety disorders and learning disabilities. In contrast, attention deficit hyperactivity disorder with conduct disorder appears to be a familial subtype, and major depression appears to be a variable expression of the familial predisposition to attention deficit hyperactivity disorder. Although the available literature provides strong evidence for the familial transmission of attention deficit hyperactivity disorder, the mode of transmission requires further clarification. In addition, attention deficit hyperactivity disorder appears to be genetically heterogeneous, indicating that more work is needed to delineate genetically homogeneous subtypes and to describe the range of expression of their underlying genotypes. Family-genetic studies will continue to clarify the etiology and nosology of attention deficit hyperactivity disorder.
11Attention-deficit/hyperactivity disorder and comorbidity.PubMed
T Spencer, J Biederman, T Wilens
Studies of children with ADHD consistently document high rates of comorbid psychiatric conditions, including conduct disorders, depression and other mood disorders, anxiety disorders, and tic disorders. In diagnosing children with ADHD, one must be careful not to dismiss other symptomatology as secondary. Poor social skills, problems with parents, low academic functioning, and other correlates of ADHD can be construed as causal factors. Although these should not be ignored, neither should the possibility that a child suffers from another psychiatric disorder that might respond to appropriate pharmacotherapy. A variety of behavior rating scales are available to the practitioner as the first steps in this process.
12All in the Family? A Systematic Review and Meta-analysis of Parenting and Family Environment as Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD) in Children.PubMed
Angelika H Claussen, Joseph R Holbrook, Helena J Hutchins, et al.
Parenting and family environment have significant impact on child development, including development of executive function, attention, and self-regulation, and may affect the risk of developmental disorders including attention-deficit/hyperactivity disorder (ADHD). This paper examines the relationship of parenting and family environment factors with ADHD. A systematic review of the literature was conducted in 2014 and identified 52 longitudinal studies. A follow-up search in 2021 identified 7 additional articles, for a total of 59 studies that examined the association of parenting factors with ADHD outcomes: ADHD overall (diagnosis or symptoms), ADHD diagnosis specifically, or presence of the specific ADHD symptoms of inattention and hyperactivity/impulsivity. For parenting factors that were present in three or more studies, pooled effect sizes were calculated separately for dichotomous or continuous ADHD outcomes, accounting for each study's conditional variance. Factors with sufficient information for analysis were parenting interaction quality (sensitivity/warmth, intrusiveness/reactivity, and negativity/harsh discipline), maltreatment (general maltreatment and physical abuse), parental relationship status (divorce, single parenting), parental incarceration, and child media exposure. All factors showed a significant direct association with ADHD outcomes, except sensitivity/warmth which had an inverse association. Parenting factors predicted diagnosis and overall symptoms as well as inattentive and hyperactive symptoms when measured, but multiple factors showed significant heterogeneity across studies. These findings support the possibility that parenting and family environment influences ADHD symptoms and may affect a child's likelihood of being diagnosed with ADHD. Prevention strategies that support parents, such as decreasing parenting challenges and increasing access to parent training in behavior management, may improve children's long-term developmental health.
13Attention-deficit/hyperactivity disorder: a neurodevelopmental approach.PubMed
K Ludwikowski, M DeValk
TOPIC: Attention-deficit/hyperactivity disorder is frequently overdiagnosed when a complete evaluation by a knowledgeable clinician is not undertaken. Because of the recent negative media campaign regarding psychostimulant medication, it becomes more imperative that a thorough and accurate evaluation be completed before starting children and adolescents on psychostimulant medications. PURPOSE: To describe the neurodevelopmental perspective in the assessment and treatment of ADHD. SOURCES: Published literature and clinical experience. CONCLUSION: It is useful in practice to conceptualize the developmental path of children with ADHD not as disordered but as delayed, and to build on each child's strengths. The neurodevelopmental approach provides the child psychiatric nurse a child-focused framework for assessment and development of individualized interventions.
14School-based interventions for elementary school students with ADHD.PubMed
George J DuPaul, Matthew J Gormley, Seth D Laracy
Children with attention-deficit/hyperactivity disorder (ADHD) experience significant difficulties with behavior, social functioning, and academic performance in elementary school classrooms. Although psychotropic medication may enhance classroom behavior, pharmacologic treatment is rarely sufficient in addressing the many challenges encountered by individuals with ADHD in school settings. This article describes 3 evidence-based strategies including behavioral, academic, and self-regulation interventions. Future directions for research on school-based interventions are discussed.
15Is ADHD a disinhibitory disorder?PubMed
J T Nigg
Attention deficit hyperactivity disorder (ADHD) is widely theorized to stem from dysfunctional inhibitory processes. However, the definition of inhibition is imprecisely distinguished across theories. To clarify the evidence for this conception, the author relies on a heuristic distinction between inhibition that is under executive control and inhibition that is under motivational control (anxiety or fear). It is argued that ADHD is unlikely to be due to a motivational inhibitory control deficit, although suggestions are made for additional studies that could overturn that conclusion. Evidence for a deficit in an executive motor inhibition process for the ADHD combined type is more compelling but is not equally strong for all forms of executive inhibitory control. Remaining issues include specificity to ADHD, whether inhibitory problems are primary or secondary in causing ADHD, role of comorbid anxiety and conduct disorder, and functional deficits in the inattentive ADHD subtype.
16Attention-deficit hyperactivity disorder in adults.PubMed
L Bellak, R B Black
It has been estimated that 30% to 70% of children who are diagnosed as having attention-deficit hyperactivity disorder (ADHD) will continue to show symptoms of the condition as adults. Since the prevalence of ADHD among school children may be 3% or more, its prevalence among adults may be 1% or 2%. The third revised edition of the Diagnostic and Statistical Manual (1987) of the American Psychiatric Association lists three essential features for the diagnosis of ADHD: "developmentally inappropriate inattention, impulsiveness, and hyperactivity." Other conditions associated with ADHD in adults include learning disabilities (or their sequelae), general anxiety disorder, drug and alcohol abuse, and dysthymic and cyclothymic disorders. Strong correlations have been found between ADHD and oppositional defiant and conduct disorders in children and an increased risk for antisocial disorders in adults. A combination of genetic, biologic, and environmental factors appears to be implicated in the etiology of ADHD. The management of adult ADHD requires a multimodal approach. The patient needs to be informed of the cause of his or her impulsive and often self-destructive behavior. Many patients will have learning difficulties that require evaluation and remediation by specialists in learning disabilities. Psychotherapy can help the patients resolve disturbances in perceptions of self and others and family therapy can address difficulties in the adult's relationships with family members. Pharmacotherapy of adult ADHD includes the use of central nervous system stimulants, such as methylphenidate, dextroamphetamine, and pemoline, of the tricyclic antidepressants imipramine and desimipramine, and of other antihypertensive, analgesic, and antimanic drugs.
17Attention-deficit hyperactivity disorder.PubMed
Joseph Biederman, Stephen V Faraone
Attention-deficit hyperactivity disorder (ADHD) is a disorder of inattention, impulsivity, and hyperactivity that affects 8-12% of children worldwide. Although the rate of ADHD falls with age, at least half of children with the disorder will have impairing symptoms in adulthood. Twin, adoption, and molecular genetic studies show ADHD to be highly heritable, and other findings have recorded obstetric complications and psychosocial adversity as predisposing risk factors. Converging evidence from animal and human studies implicates the dysregulation of frontal-subcortical-cerebellar catecholaminergic circuits in the pathophysiology of ADHD, and molecular imaging studies suggest that abnormalities of the dopamine transporter lead to impaired neurotransmission. Studies during the past decade have shown the safety and effectiveness of new non-stimulant drugs and long-acting formulations of methylphenidate and amfetamine. Other investigations have also clarified the appropriate role of targeted psychosocial treatments in the context of ongoing pharmacotherapy.
18Shared heritability of attention-deficit/hyperactivity disorder and autism spectrum disorder.PubMed
Nanda N J Rommelse, Barbara Franke, Hilde M Geurts, et al.
Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are both highly heritable neurodevelopmental disorders. Evidence indicates both disorders co-occur with a high frequency, in 20-50% of children with ADHD meeting criteria for ASD and in 30-80% of ASD children meeting criteria for ADHD. This review will provide an overview on all available studies [family based, twin, candidate gene, linkage, and genome wide association (GWA) studies] shedding light on the role of shared genetic underpinnings of ADHD and ASD. It is concluded that family and twin studies do provide support for the hypothesis that ADHD and ASD originate from partly similar familial/genetic factors. Only a few candidate gene studies, linkage studies and GWA studies have specifically addressed this co-occurrence, pinpointing to some promising pleiotropic genes, loci and single nucleotide polymorphisms (SNPs), but the research field is in urgent need for better designed and powered studies to tackle this complex issue. We propose that future studies examining shared familial etiological factors for ADHD and ASD use a family-based design in which the same phenotypic (ADHD and ASD), candidate endophenotypic, and environmental measurements are obtained from all family members. Multivariate multi-level models are probably best suited for the statistical analysis.
19A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD.PubMed
BACKGROUND: Previous studies have demonstrated the short-term efficacy of pharmacotherapy and behavior therapy for attention-deficit/hyperactivity disorder (ADHD), but no longer-term (i.e., >4 months) investigations have compared these 2 treatments or their combination. METHODS: A group of 579 children with ADHD Combined Type, aged 7 to 9.9 years, were assigned to 14 months of medication management (titration followed by monthly visits); intensive behavioral treatment (parent, school, and child components, with therapist involvement gradually reduced over time); the two combined; or standard community care (treatments by community providers). Outcomes were assessed in multiple domains before and during treatment and at treatment end point (with the combined treatment and medication management groups continuing medication at all assessment points). Data were analyzed through intent-to-treat random-effects regression procedures. RESULTS: All 4 groups showed sizable reductions in symptoms over time, with significant differences among them in degrees of change. For most ADHD symptoms, children in the combined treatment and medication management groups showed significantly greater improvement than those given intensive behavioral treatment and community care. Combined and medication management treatments did not differ significantly on any direct comparisons, but in several instances (oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement) combined treatment proved superior to intensive behavioral treatment and/or community care while medication management did not. Study medication strategies were superior to community care treatments, despite the fact that two thirds of community-treated subjects received medication during the study period. CONCLUSIONS: For ADHD symptoms, our carefully crafted medication management was superior to behavioral treatment and to routine community care that included medication. Our combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms, but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes.
20Brain abnormalities in attention-deficit hyperactivity disorder: a review.PubMed
Katya Rubia, Analucía A Alegría, Helen Brinson
AIM: To review the magnetic resonance imaging findings in child and adult attention-deficit hyperactivity disorder (ADHD). DEVELOPMENT: Studies have shown that ADHD is characterised by multiple functional and structural neural network abnormalities including most prominently fronto-striatal, but also fronto-parieto-temporal, fronto-cerebellar and even fronto-limbic networks. Evidence from longitudinal structural imaging studies has shown that ADHD is characterised by a delay in structural brain maturation. This is reinforced by indirect evidence from cross-sectional imaging studies for more immature brain function as well as structural and functional connectivity patterns, which, however, needs corroboration by longitudinal studies. Dysfunction of the ventrolateral prefrontal cortex seems to be more pronounced in ADHD relative to other pediatric disorders and there is some evidence for differential abnormalities in the basal ganglia. A meta-analysis of stimulant effects on brain function shows that the most consistent mechanism of action of acute psychostimulant medication is the increased activation of the inferior prefrontal cortex and the basal ganglia. First attempts to use neuroimaging data to make individual diagnostic classifications of ADHD children based on pattern recognition techniques are promising but need replication across centres and scanners. CONCLUSIONS: The last two decades of neuroimaging have shaped out biomarkers of ADHD. Future studies will need to focus on using this information for clinical translation such as using neuroimaging for individual diagnostic and prognostic classification or by using neuroimaging as a neurotherapy to reverse those brain function abnormalities that have been established over the last two decades of neuroimaging.