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多动症
多动症，即注意力缺陷多动障碍（ADHD），是一种常见的神经发育障碍，以注意力不集中、多动和冲动行为为主要特征，并伴有执行功能、情绪调节和动机方面的缺陷。ADHD 在儿童期发病，且在儿童和青少年精神疾病中最为常见，患病率超过 5% 。全球范围内，ADHD 的患病率估计存在显著差异，但一项荟萃分析显示，全球总患病率为 5.29% 。最新的系统评价和荟萃分析显示，通过登记研究的 ADHD 总体患病率为 1.6%，调查研究为 5.0%，单阶段临床研究为 4.2%，两阶段临床研究为 4.8% 。ADHD 在男孩中比女孩更常见 。尽管其患病率在近年持续上升，引发了关于过度诊断的担忧，但也有观点认为这反映了对未被充分诊断人群的更高识别度，尤其是在代表性不足的少数民族和女性中 。
诊断标准与临床表现
ADHD 的诊断是严格的临床诊断，主要基于行为症状，即注意力不集中、冲动和多动 。诊断标准依据《精神疾病诊断与统计手册》第五版 (DSM-5) 和《国际疾病分类》第十版/第十一版 (ICD-10/11) 等 nosological 系统，依赖于观察和信息报告的行为标准 。尽管在 ADHD 研究方面取得了显著进展，但目前仍缺乏有效的神经生物学标志物或其他客观标准来明确诊断分类 。
DSM-5 对 ADHD 的修订标准包括：症状出现的最高年龄、症状需存在于多个环境中，以及对 17 岁及以上患者所需的症状数量要求 。需要注意的是，许多患者的症状会持续到青春期，甚至成年 。大约一半的患儿在成年后仍会出现症状，对他们的社交互动、学习和就业表现产生严重影响 。
病因学
ADHD 是一种高度遗传和多因素的疾病，多种基因和非遗传因素共同作用 。遗传因素在 ADHD 的发病机制中起着基础性作用 。双生子、收养和分子遗传学研究表明 ADHD 具有高度遗传性 。研究还指出，遗传因素可能通过决定个体对环境暴露（特别是产前阶段的暴露）的反应来影响个体的状况 。
除了遗传因素，产前和围产期因素也被认为是风险因素 。例如，极端早期逆境、产前和产后接触铅以及低出生体重/早产都被一致认为是风险因素 。然而，确切的病因仍不清楚 。
关于 ADHD 的病理生理学，动物和人类研究的证据表明，额叶-皮质下-小脑儿茶酚胺回路的失调与 ADHD 相关 。分子影像学研究提示多巴胺转运蛋白异常可能导致神经递质传递受损 。
共病与情绪失调
ADHD 患者常伴有其他共病，如学习、认知、语言、运动和心理健康障碍 。患有发育障碍的儿童也更容易出现共病 ADHD 。青少年和成人 ADHD 患者中，情绪症状普遍且持续存在，并与发病率升高相关 。一些研究认为情绪失调是 ADHD 的核心特征，而另一些则认为其非特异性，不应作为诊断标准 。情绪冲动（EI）和情绪自我调节不足（DESR）可能是 ADHD 的特异性症状，可以作为诊断标准，但如何界定这些概念以使其对该疾病具有特异性仍无共识 。在 ADHD 中，情绪失调可能源于对情绪刺激的定向、识别和/或分配注意力方面的缺陷，这些缺陷涉及纹状体-杏仁核-内侧前额叶皮层网络的功能障碍 。
常见的共病障碍包括抑郁症、破坏性行为障碍或药物滥用，这些需要在治疗计划中优先解决 。例如，在 ADHD 患者中，自闭症谱系障碍 (ASD) 的共存也带来了诊断和治疗的挑战。通常，患有 ADHD 和 ASD 的儿童比单纯患有 ASD 的儿童晚两年才能被诊断出 ASD 。这两种疾病之间存在共享的功能性大脑改变，并且 ADHD 的既定治疗方法对这种共病也有效 。
治疗方法
ADHD 的治疗通常采用多模式方法，包括药物治疗、行为干预和心理社会支持 。大多数指南建议采取分阶段治疗方法，首先是非药物干预，然后是对严重患者进行药物治疗 。治疗的目标是成功改善症状 。
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药物治疗
- 兴奋剂：兴奋剂是治疗 ADHD 最有效且历史最悠久的药物，已应用 70 多年 。这些药物通过影响额叶-皮质下-小脑儿茶酚胺回路来改善症状 。最常见的兴奋剂包括哌醋甲酯和苯丙胺的速释和缓释制剂 。虽然它们通常具有相似的副作用，但个体患者可能对特定类别（哌醋甲酯或苯丙胺）或制剂有更好的反应或耐受性 。随机对照试验显示兴奋剂药物和托莫西汀具有短期益处 。
- 非兴奋剂药物：过去十年中，新的非兴奋剂药物和长效制剂的安全性与有效性也得到了证实 。
- 其他药物：三环类抗抑郁药和非典型抗抑郁药可作为二线药物用于成人和儿童 。
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非药物干预
- 认知行为疗法 (CBT)：CBT 被认为是治疗成人 ADHD 的有效方法，特别是在与药物治疗结合时 。CBT 旨在通过教授患者控制核心症状的技术，改变强化疾病有害影响的思维和行为 。它还旨在帮助患者应对焦虑和抑郁等情绪，并提高自尊 。
- CBT 与非特异性对照条件：与支持性心理疗法相比，CBT 在改善临床医生报告的 ADHD 症状方面更有效 。与等待名单相比，CBT 在临床医生报告和自我报告的 ADHD 症状方面均显示出更大的益处 。此外，CBT 还能改善自我报告的抑郁和焦虑症状，并对自我报告的愤怒情绪和自尊有积极影响 。
- CBT 加药物治疗与单独药物治疗：CBT 加药物治疗在改善临床医生报告的核心症状、自我报告的核心症状、自我报告的注意力不集中、临床总体印象评分、自我报告的抑郁和焦虑方面均优于单独药物治疗 。
- CBT 与其他特定干预措施：CBT 在临床医生报告和自我报告的 ADHD 症状严重程度方面均显示出显著差异 。
- 证据质量与局限性：尽管有低质量证据表明 CBT 在短期内对治疗成人 ADHD 有益，且在减轻核心症状方面具有一致性，但长期随访数据不足、测量结果的异质性以及地理位置限制（主要在北半球和澳大利亚）限制了结果的普遍性 。研究中未报告严重不良事件，但少数患者报告了痛苦和焦虑等轻微不良事件 。
- 行为干预：行为干预可以帮助减轻 ADHD 症状并解决儿童的共病情况 。对于幼儿，行为策略是主要的管理方法；对于中年儿童，则倾向于药物和行为策略相结合；对于青少年，则以药物干预为主 。
- 运动：有目的的体育活动可以改善认知功能。具有认知需求的体育活动与不具有认知需求的体育活动相比，对 ADHD 儿童的执行功能和行为症状的改善效果更好且更持久 。将身体和认知任务相结合的认知康复对 ADHD 儿童受损的执行功能和行为症状具有有益且持久的影响 。
- 数字化心理健康干预 (DMHIs)：针对儿童和青少年的游戏化 DMHIs 对 ADHD 和抑郁症表现出适度的显著效果 。对于 ADHD，通过电脑提供的 DMHIs 以及男性参与者较多的随机对照试验产生了更大的治疗效果 。这些创新解决方案对于满足儿科心理健康护理的需求至关重要，为儿科医生和其他医疗专业人员提供了新的、可及的有效选择 。
- 认知行为疗法 (CBT)：CBT 被认为是治疗成人 ADHD 的有效方法，特别是在与药物治疗结合时 。CBT 旨在通过教授患者控制核心症状的技术，改变强化疾病有害影响的思维和行为 。它还旨在帮助患者应对焦虑和抑郁等情绪，并提高自尊 。
未来方向
由于可用治疗方案日益增多，临床医生在选择或优先安排治疗时面临挑战 。需要更多研究来确定成人 ADHD 的最佳心理社会治疗方案 。此外，对于 ADHD 的病因学研究，仍需探究其与神经发育问题的重叠性，以及如何将研究发现转化为公共卫生政策和家庭教育，避免将遗传/生物学解释与环境解释对立起来 。精准诊断工具和更有效的干预措施仍是未来研究和临床实践的重点 。
References
1Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults.PubMed
Pablo Luis Lopez, Fernando Manuel Torrente, Agustín Ciapponi, et al.
BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity, along with deficits in executive function, emotional regulation and motivation. The persistence of ADHD in adulthood is a serious clinical problem.ADHD significantly affects social interactions, study and employment performance.Previous studies suggest that cognitive-behavioural therapy (CBT) could be effective in treating adults with ADHD, especially when combined with pharmacological treatment. CBT aims to change the thoughts and behaviours that reinforce harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self-esteem. OBJECTIVES: To assess the effects of cognitive-behavioural-based therapy for ADHD in adults. SEARCH METHODS: In June 2017, we searched CENTRAL, MEDLINE, Embase, seven other databases and three trials registries. We also checked reference lists, handsearched congress abstracts, and contacted experts and researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating any form of CBT for adults with ADHD, either as a monotherapy or in conjunction with another treatment, versus one of the following: unspecific control conditions (comprising supportive psychotherapies, no treatment or waiting list) or other specific interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures suggested by Cochrane. MAIN RESULTS: We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.Primary outcomes: ADHD symptomsCBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment)- CBT versus supportive psychotherapies: CBT was more effective than supportive therapy for improving clinician-reported ADHD symptoms (1 study, 81 participants; low-quality evidence) but not for self-reported ADHD symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence; small effect size).- CBT versus waiting list: CBT led to a larger benefit in clinician-reported ADHD symptoms (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants; very low-quality evidence; large effect size). We also found significant differences in favour of CBT for self-reported ADHD symptoms (SMD -0.84, 95% CI -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence; large effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: CBT with pharmacotherapy was more effective than pharmacotherapy alone for clinician-reported core symptoms (SMD -0.80, 95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence; large effect size), self-reported core symptoms (MD -7.42 points, 95% CI -11.63 points to -3.22 points; 2 studies, 66 participants low-quality evidence) and self-reported inattention (1 study, 35 participants).CBT versus other interventions that included therapeutic ingredients specifically targeted to ADHD: we found a significant difference in favour of CBT for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence; moderate effect size) and for self-reported ADHD symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low-quality evidence; small effect size).Secondary outcomesCBT versus unspecific control conditions: we found differences in favour of CBT compared with waiting-list control for self-reported depression (SMD -0.36, 95% CI -0.60 to -0.11; 5 studies, 258 participants; small effect size) and for self-reported anxiety (SMD -0.45, 95% CI -0.71 to -0.19; 4 studies, 239 participants; small effect size). We also observed differences in favour of CBT for self-reported state anger (1 study, 43 participants) and self-reported self-esteem (1 study 43 participants) compared to waiting list. We found no differences between CBT and supportive therapy (1 study, 81 participants) for self-rated depression, clinician-rated anxiety or self-rated self-esteem. Additionally, there were no differences between CBT and the waiting list for self-reported trait anger (1 study, 43 participants) or self-reported quality of life (SMD 0.21, 95% CI -0.29 to 0.71; 2 studies, 64 participants; small effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: we found differences in favour of CBT plus pharmacotherapy for the Clinical Global Impression score (MD -0.75 points, 95% CI -1.21 points to -0.30 points; 2 studies, 65 participants), self-reported depression (MD -6.09 points, 95% CI -9.55 points to -2.63 points; 2 studies, 66 participants) and self-reported anxiety (SMD -0.58, 95% CI -1.08 to -0.08; 2 studies, 66 participants; moderate effect size). We also observed differences favouring CBT plus pharmacotherapy (1 study, 31 participants) for clinician-reported depression and clinician-reported anxiety.CBT versus other specific interventions: we found no differences for any of the secondary outcomes, such as self-reported depression and anxiety, and findings on self-reported quality of life varied across different studies. AUTHORS' CONCLUSIONS: There is low-quality evidence that cognitive-behavioural-based treatments may be beneficial for treating adults with ADHD in the short term. Reductions in core symptoms of ADHD were fairly consistent across the different comparisons: in CBT plus pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list. There is low-quality evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression and anxiety. However, the paucity of long-term follow-up data, the heterogeneous nature of the measured outcomes, and the limited geographical location (northern hemisphere and Australia) limit the generalisability of the results. None of the included studies reported severe adverse events, but five participants receiving different modalities of CBT described some type of adverse event, such as distress and anxiety.
2ADHD in Children and Adults: Diagnosis and Prognosis.PubMed
Douglas Teixeira Leffa, Arthur Caye, Luis Augusto Rohde
Attention-Deficit Hyperactivity Disorder (ADHD) is a prevalent neuropsychiatric disorder associated with significant impairment and distress throughout the lifespan. Recent investigations have shed light on different aspects regarding the trajectory of ADHD, including reports on risk factors in childhood, that are associated with remission or persistence in adulthood. Despite significant advances in our understanding of the pathophysiology of the disorder, the diagnosis of ADHD remains strictly clinical and is based on behavioral symptoms of inattention, impulsivity, and hyperactivity. In this chapter we review the diagnostic process of ADHD, discuss the clinical presentation of the disorder across the lifespan, and examine patterns of comorbidity and longitudinal predictor of outcomes.
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: Current Concepts and Treatments in Children and Adolescents.PubMed
Renate Drechsler, Silvia Brem, Daniel Brandeis, et al.
Attention deficit hyperactivity disorder (ADHD) is among the most frequent disorders within child and adolescent psychiatry, with a prevalence of over 5%. Nosological systems, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, editions 10 and 11 (ICD-10/11) continue to define ADHD according to behavioral criteria, based on observation and on informant reports. Despite an overwhelming body of research on ADHD over the last 10 to 20 years, valid neurobiological markers or other objective criteria that may lead to unequivocal diagnostic classification are still lacking. On the contrary, the concept of ADHD seems to have become broader and more heterogeneous. Thus, the diagnosis and treatment of ADHD are still challenging for clinicians, necessitating increased reliance on their expertise and experience. The first part of this review presents an overview of the current definitions of the disorder (DSM-5, ICD-10/11). Furthermore, it discusses more controversial aspects of the construct of ADHD, including the dimensional versus categorical approach, alternative ADHD constructs, and aspects pertaining to epidemiology and prevalence. The second part focuses on comorbidities, on the difficulty of distinguishing between "primary" and "secondary" ADHD for purposes of differential diagnosis, and on clinical diagnostic procedures. In the third and most prominent part, an overview of current neurobiological concepts of ADHD is given, including neuropsychological and neurophysiological researches and summaries of current neuroimaging and genetic studies. Finally, treatment options are reviewed, including a discussion of multimodal, pharmacological, and nonpharmacological interventions and their evidence base.
5Treatment strategies for ADHD: an evidence-based guide to select optimal treatment.PubMed
Arthur Caye, James M Swanson, David Coghill, et al.
Attention-deficit/hyperactivity disorder (ADHD) is a common and impairing disorder affecting children, adolescents, and adults. Several treatment strategies are available that can successfully ameliorate symptoms, ranging from pharmacological to dietary interventions. Due to the increasing range of available options, an informed selection or prioritization of treatments is becoming harder for clinicians. This review aims to provide an evidence-based appraisal of the literature on ADHD treatment, supplemented by expert opinion on plausibility. We outline proposed mechanisms of action of established pharmacologic and non-pharmacologic treatments, and we review targets of novel treatments. The most relevant evidence supporting efficacy and safety of each treatment strategy is discussed. We review the individualized features of the patient that should guide the selection of treatments in a shared decision-making continuum. We provide guidance for optimizing initiation of treatment and follow-up of patients in clinical settings.
6Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder - implications for clinical recognition and intervention.PubMed
Stephen V Faraone, Anthony L Rostain, Joseph Blader, et al.
BACKGROUND: Because emotional symptoms are common in attention-deficit/hyperactivity disorder (ADHD) patients and associate with much morbidity, some consider it to be a core feature rather than an associated trait. Others argue that emotional symptoms are too nonspecific for use as diagnostic criteria. This debate has been difficult to resolve due, in part, to the many terms used to describe emotional symptoms in ADHD and to concerns about overlap with mood disorders. METHODS: We sought to clarify the nature of emotional symptoms in ADHD by reviewing conceptual and measurement issues and by examining the evidence base regarding specificity of such symptoms for ADHD. We reviewed the various terms used to define emotional symptoms in ADHD, clarify how these symptoms are demarcated from mood disorders, and assess the possibility that symptoms of emotional impulsivity and deficient emotional self-regulation should be considered as core symptoms. We addressed psychiatric comorbidities, the effects of ADHD treatments on associated emotional dysregulation, and the utility of current rating scales to assess emotional symptoms associated with ADHD. RESULTS: Emotional symptoms are common and persistent in youth and adults with ADHD. Although emotional symptoms are common in other psychiatric disorders, emotional impulsivity (EI), and deficient emotional self-regulation (DESR) may be sufficiently specific for ADHD to function as diagnostic criteria. CONCLUSIONS: Emotional symptoms in ADHD cause clinically significant impairments. Although there is a solid theoretical rationale for considering EI and DESR to be core symptoms of ADHD, there is no consensus about how to define these constructs sin a manner that would be specific to the disorder. An instrument to measure EI and DESR which demarcates them from irritability and other emotional symptoms could improve the accuracy of diagnostic criteria for ADHD.
7Attention-Deficit/Hyperactivity Disorder.PubMed
Meghna Rajaprakash, Mary L Leppert
Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent neurobehavioral disorder in childhood. The major components of this disorder are developmentally inappropriate levels of inattention and hyperactivity/impulsivity, which result in functional impairment in 1 or more areas of academic, social, and emotional function. In addition to the propensity for children to have some compromise of academic and emotional function, children with ADHD also have a higher frequency of co-occurring learning, cognitive, language, motor, and mental health disorders. Similarly, children with developmental disorders have a higher risk of co-occurring ADHD. The diagnosis of ADHD can be ascertained by a review of the risks for the condition, consideration of masquerading conditions, a careful history and physical examination, and the recognition of co-occurring disorders. The signs and symptoms of co-occurring disorders and the management of ADHD differ across early childhood, middle childhood, and adolescence. Management is largely limited to behavioral and pharmacologic interventions, and it favors behavioral strategies in early childhood, pharmacologic and behavioral strategies in middle childhood, and pharmacologic interventions in adolescence. This article offers an approach to the evaluation, presentation, and management of ADHD with a focus on guiding primary care pediatricians.
8Attention-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.
9ADHD Diagnostic Trends: Increased Recognition or Overdiagnosis?PubMed
Elie Abdelnour, Madeline O Jansen, Jessica A Gold
The prevalence of Attention Deficit Hyperactivity Disorder (ADHD) has seen a consistent rise in recent years. These numbers spark a debate over the reason for the observed trends, with some concerned about over diagnosis and over prescription of stimulant medications, and others raising the issue of diagnostic disparities, particularly in underrepresented populations. In this paper we look at both sides, starting with the history of ADHD and its diagnostic criteria changes, from early concepts of alterations in attention and hyperactivity in the 19th and 20th century, to its introduction in the Diagnostical and Statistical Manual of Mental Disorders (DSM), and its evolution into how it is defined today. The general broadening of ADHD diagnostically over time plays a role in the increased prevalence over the years, but it is not the only reason. Increased awareness of physicians and the public is also believed to play a big role, particularly in underrepresented minorities and women. However, there continues to be disparities in detection of ADHD in these groups. There are significant consequences to a patient's social, interpersonal, and professional life when ADHD is left unrecognized and untreated. Thoughtful evaluation, accurate diagnosis, and adequate treatment can make a big difference.
10ADHD 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%.
11Efficacy of Gamified Digital Mental Health Interventions for Pediatric Mental Health Conditions: A Systematic Review and Meta-Analysis.PubMed
Barry R Bryant, Morgan R Sisk, Joseph F McGuire
IMPORTANCE: Anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) affect up to 20% of children and adolescents. Despite demonstrated efficacy, evidence-based treatments for these conditions are often inaccessible; innovative solutions are essential to meet the demand for pediatric mental health care. OBJECTIVE: To examine the efficacy and moderators of gamified DMHIs for anxiety, depression, and ADHD in randomized clinical trials (RCTs) for children and adolescents. DATA SOURCES: A systematic search of PubMed, PsycInfo, and Web of Science was conducted for RCTs published before March 20, 2024. STUDY SELECTION: RCTs that evaluated the efficacy of gamified DMHIs for treating pediatric ADHD, depression, or anxiety were included. Studies were excluded if they did not use a gamified DMHI, provide sufficient data for effect sizes, or were unavailable in English. DATA EXTRACTION AND SYNTHESIS: Efficacy data were extracted from rating scales for ADHD, depression, and anxiety. Extracted moderator variables included participant characteristics (eg, age and sex), intervention characteristics (eg, delivery modality and time limit), and trial design characteristics (eg, outcome measure and risk of bias). MAIN OUTCOMES AND MEASURES: The primary outcome was change in ADHD, depression, or anxiety severity in the treatment group compared to the control group. Hedges g quantified treatment effects. RESULTS: The search strategy identified 27 RCTs that included 2911 participants across ADHD, depression, and anxiety disorders. There were modest significant effects of gamified DMHIs on ADHD (g, 0.28; 95% CI, 0.09 to 0.48) and depression (g, 0.28; 95% CI, 0.08 to 0.47) but small, nonsignificant effects for anxiety disorders (g, 0.07; 95% CI, -0.02 to 0.17). Moderator analyses revealed that DMHIs for ADHD delivered on a computer and those RCTs that had a greater preponderance of male participants produced larger treatment effects. DMHIs for depressive disorders that used preset time limits for gamified DMHIs also exhibited larger treatment effects. CONCLUSIONS AND RELEVANCE: The findings suggest a benefit of gamified DMHIs for youth with ADHD or depressive disorder. Pediatricians and other health care professionals have new information about novel, accessible, and efficacious options for pediatric mental health care.
12[Autism spectrum disorder and attention-deficit/hyperactivity disorder: challenge in diagnosis and treatment].PubMed
Myriam Velarde, Aland Cárdenas
The coexistence of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) definitely poses new challenges, such as making an early diagnosis, considering that the former is usually diagnosed 2 years later in children with ADHD comorbid with autism compared to those with ASD alone; this is a problem at a personal, family and social level, since they must receive timely intervention. This coexistence raises questions about the efficacy of treatment in ADHD in people with autism, genetic, anatomical and functional concordances, among others; these are the challenges that are currently posed. In this review, we present some responses to the challenges posed by such coexistence, and we highlight some pending issues to be solved, being these of great importance for their better understanding and management. In all patients with ADHD or ASD, a coexistence between them should be sought. There are shared functional brain alterations in both disorders identified by functional brain magnetic resonance imaging; the treatment established for ADHD is also effective in this comorbidity.
13Prenatal risk factors and genetic causes of ADHD in children.PubMed
Naghmeh Kian, Noosha Samieefar, Nima Rezaei
BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is a common disease among children; it affected 5-7% of the population in 2015. ADHD is a multifactorial disease, and its etiology is still not clearly understood. DATA SOURCES: This narrative review has been done by searching the PubMed and Embase databases using attention deficit/hyperactivity disorder, ADHD, risk factors; genetics; pediatrics; psychiatrics as keywords. RESULTS: ADHD is considered to be a hereditary disorder in which genes play the fundamental role in the pathogenesis; however, findings from genetic-environmental studies support the hypothesis that genetic factors can exert effects on an individual's condition by determining his/her responses to environmental exposures, especially those during the prenatal stage. CONCLUSION: ADHD is considered as a hereditary disorder in which genes and prenatal risk factors play fundamental roles in the pathogenesis.
14Prevalence of attention-deficit hyperactivity disorder (ADHD): systematic review and meta-analysis.PubMed
Sara Popit, Klara Serod, Igor Locatelli, et al.
BACKGROUND: The estimates of attention-deficit hyperactivity disorder (ADHD) prevalence across various studies are significantly variable, contributing to uncertainty in ADHD prevalence estimation. Previous systematic reviews and meta-analyses have attributed this variability primarily to the methodological characteristics of the studies, including the diagnostic criteria, source of information, and impairment requirement for the diagnosis. METHODS: Review identified studies reporting ADHD prevalence in representative samples of children and adults in Europe and worldwide. Studies that were conducted in the general population were included. We focused on studies that report ADHD prevalence based on clinical diagnosis (clinical diagnostic criteria based on the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases criteria, other diagnostic tools, such as various scales or interviews based on clinical diagnostic criteria). PubMed/Medline was searched to identify relevant articles published until 2024/2/01. The study was registered in PROSPERO (CRD42020200220) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines for systematic review and meta-analysis. RESULTS: In total, 117 studies were subjected to full evaluation. In the meta-analysis, 103 studies representing 159 independent datapoints were included. The overall prevalence of ADHD in register studies was 1.6%, 95% CI [0.9; 3.0], in survey studies 5.0%, 95% CI [2.9; 8.6], in one-stage clinical studies 4.2%, 95% CI [2.9; 6.0], and in two-stage clinical studies 4.8%, 95% CI [4.0; 5.8]. CONCLUSIONS: Exact comparisons among studies with different diagnostic criteria and types of sampling can impact prevalence estimates. When comparing data from methodologically different studies, these factors need to be considered.
15Stimulants.PubMed
Ann C Childress
Stimulants have been available for the treatment of attention-deficit/hyperactivity disorder (ADHD) for more than 70 years and are the most effective medications available. During the past 2 decades, several new immediate-release (IR) and extended-release methylphenidate (MPH) and amphetamine (AMPH) formulations have become available. These products differ by dose form (capsules, tablets, oral suspensions, oral disintegrating tablets, and patch), by onset and duration of effect, and by bioavailability. The side effect profile is generally similar for all compounds. Although the products are similar, individual patients may have a better response or tolerability to a particular class (MPH or AMPH) or formulation.
16The effect of physical activity with and without cognitive demand on the improvement of executive functions and behavioral symptoms in children with ADHD.PubMed
Vahid Nejati, Zahra Derakhshan
: Purposeful physical activities improve cognitive functions. Two possible mechanisms are available for this intervention including the impact of the physical component of exercise and goal-directedness as a cognitive component. In the present study, we aimed to compare the effect of physical activity with and without cognitive demand on executive functions and behavioral symptoms in children with ADHD.: Thirty children with ADHD were randomly assigned to two equal groups of physical activity training with and without cognitive demand. Exercise for cognitive improvement and rehabilitation (EXCIR) or running, as an aerobic exercise, were used for intervention in two groups. Executive functions and ADHD symptoms were measured in three sessions including baseline, post-intervention, and follow-up assessments, using 1-back, Wisconsin Card Sorting, and Go/No-Go tests and Conner's Teacher and Parent Rating scales. Repeated measures ANOVAs were used for analysis.: The results showed physical activity with cognitive demand, compared to the physical activity without cognitive demand, has a better and longer impact on the improvement of executive functions and ADHD symptoms.: Cognitive rehabilitation with combined physical and cognitive tasks has a beneficial and lasting impact on impaired executive functions and behavioral symptoms in children with ADHD.
17Emotion dysregulation in attention deficit hyperactivity disorder.PubMed
Philip Shaw, Argyris Stringaris, Joel Nigg, et al.
Although it has long been recognized that many individuals with attention deficit hyperactivity disorder (ADHD) also have difficulties with emotion regulation, no consensus has been reached on how to conceptualize this clinically challenging domain. The authors examine the current literature using both quantitative and qualitative methods. Three key findings emerge. First, emotion dysregulation is prevalent in ADHD throughout the lifespan and is a major contributor to impairment. Second, emotion dysregulation in ADHD may arise from deficits in orienting toward, recognizing, and/or allocating attention to emotional stimuli; these deficits implicate dysfunction within a striato-amygdalo-medial prefrontal cortical network. Third, while current treatments for ADHD often also ameliorate emotion dysregulation, a focus on this combination of symptoms reframes clinical questions and could stimulate novel therapeutic approaches. The authors then consider three models to explain the overlap between emotion dysregulation and ADHD: emotion dysregulation and ADHD are correlated but distinct dimensions; emotion dysregulation is a core diagnostic feature of ADHD; and the combination constitutes a nosological entity distinct from both ADHD and emotion dysregulation alone. The differing predictions from each model can guide research on the much-neglected population of patients with ADHD and emotion dysregulation.
18What have we learnt about the causes of ADHD?PubMed
Anita Thapar, Miriam Cooper, Olga Eyre, et al.
BACKGROUND: Attention deficit hyperactivity disorder (ADHD) and its possible causes still attract controversy. Genes, pre and perinatal risks, psychosocial factors and environmental toxins have all been considered as potential risk factors. METHOD: This review (focussing on literature published since 1997, selected from a search of PubMed) critically considers putative risk factors with a focus on genetics and selected environmental risks, examines their relationships with ADHD and discusses the likelihood that these risks are causal as well as some of the main implications. RESULTS: No single risk factor explains ADHD. Both inherited and noninherited factors contribute and their effects are interdependent. ADHD is familial and heritable. Research into the inherited and molecular genetic contributions to ADHD suggest an important overlap with other neurodevelopmental problems, notably, autism spectrum disorders. Having a biological relative with ADHD, large, rare copy number variants, some small effect size candidate gene variants, extreme early adversity, pre and postnatal exposure to lead and low birth weight/prematurity have been most consistently found as risk factors, but none are yet known to be definitely causal. There is a large literature documenting associations between ADHD and a wide variety of putative environmental risks that can, at present, only be regarded as correlates. Findings from research designs that go beyond simply testing for association are beginning to contest the robustness of some environmental exposures previously thought to be ADHD risk factors. CONCLUSIONS: The genetic risks implicated in ADHD generally tend to have small effect sizes or be rare and often increase risk of many other types of psychopathology. Thus, they cannot be used for prediction, genetic testing or diagnostic purposes beyond what is predicted by a family history. There is a need to consider the possibility of parents and siblings being similarly affected and how this might impact on engagement with families, influence interventions and require integration with adult services. Genetic contributions to disorder do not necessarily mean that medications are the treatment of choice. We also consider how findings might influence the conceptualisation of ADHD, public health policy implications and why it is unhelpful and incorrect to dichotomise genetic/biological and environmental explanations. It is essential that practitioners can interpret genetic and aetiological research findings and impart informed explanations to families.
19The worldwide prevalence of ADHD: a systematic review and metaregression analysis.PubMed
Guilherme Polanczyk, Maurício Silva de Lima, Bernardo Lessa Horta, et al.
OBJECTIVE: The worldwide prevalence estimates of attention deficit hyperactivity disorder (ADHD)/hyperkinetic disorder (HD) are highly heterogeneous. Presently, the reasons for this discrepancy remain poorly understood. The purpose of this study was to determine the possible causes of the varied worldwide estimates of the disorder and to compute its worldwide-pooled prevalence. METHOD: The authors searched MEDLINE and PsycINFO databases from January 1978 to December 2005 and reviewed textbooks and reference lists of the studies selected. Authors of relevant articles from North America, South America, Europe, Africa, Asia, Oceania, and the Middle East and ADHD/HD experts were contacted. Surveys were included if they reported point prevalence of ADHD/HD for subjects 18 years of age or younger from the general population or schools according to DSM or ICD criteria. RESULTS: The literature search generated 9,105 records, and 303 full-text articles were reviewed. One hundred and two studies comprising 171,756 subjects from all world regions were included. The ADHD/HD worldwide-pooled prevalence was 5.29%. This estimate was associated with significant variability. In the multivariate metaregression model, diagnostic criteria, source of information, requirement of impairment for diagnosis, and geographic origin of the studies were significantly associated with ADHD/HD prevalence rates. Geographic location was associated with significant variability only between estimates from North America and both Africa and the Middle East. No significant differences were found between Europe and North America. CONCLUSIONS: Our findings suggest that geographic location plays a limited role in the reasons for the large variability of ADHD/HD prevalence estimates worldwide. Instead, this variability seems to be explained primarily by the methodological characteristics of studies.
20Attention-deficit/hyperactivity disorder.PubMed
J B Schweitzer, T K Cummins, C A Kant
ADHD continues to be one of the most common psychiatric disorders in children and is recognized increasingly as a common psychiatric disorder in adults. Diagnosis of the disorder requires careful consideration of other psychiatric and medical disorders that may mimic symptoms of ADHD. Comorbid disorders are common in patients with ADHD and require careful attention. A recommended diagnostic evaluation for children and adults includes the completion of a psychiatric interview, rating scales from multiple informants, and often individually tailored psychologic testing. Pharmacologic treatment options include the first-line stimulant agents for adults and children and TCAs and atypical antidepressants as second-line agents. Behavioral interventions may help reduce ADHD symptoms and address comorbid conditions in children. Future research is needed to identify the optimal psychosocial treatment for adults with ADHD.