ADHD is the common name for Attention deficit and hyperactivity disorder (ADHD), a group of syndromes that occur in childhood and are characterized by significant difficulty concentrating attention, short attention span, hyperactivity or impulsivity compared to children of the same age. ADHD is a relatively common disorder in children, with a reported prevalence of 3-5% and a male-to-female ratio of 4-9:1.
Disease etiology genetic factors
Current research suggests that the disorder is associated with genetic factors, with a heritability of 0.75-0.91. The mode of inheritance is unknown and may be polygenic. Molecular genetic studies suggest that the disorder is associated with polymorphisms in the dopamine receptor gene.
Neurophysiological factors
Children with this disorder have a high rate of EEG abnormalities, mainly increased slow-wave activity. EEG power spectrum analysis revealed an increase in slow wave power, a decrease in alpha wave power, and a decrease in mean frequency. This suggests a delayed maturation of the central nervous system or a lack of cortical arousal in children with this disorder.
Mild brain injury
Minor brain injury during maternal, perinatal, and postnatal periods from a variety of causes may be the cause of this disorder in some children, but no single brain injury is present in all children with this disorder, and not all children with this injury have this disorder, and many children do not have evidence of brain injury.
Neurobiochemical factors
Some studies suggest that the disorder may be associated with impaired metabolism and abnormal function of central neurotransmitters, including: decreased dopamine and epinephrine renewal rates, and low dopamine and noradrenaline function.
Neuroanatomical factors
Magnetic resonance studies have reported reduced volume of the corpus callosum and caudate nucleus in children with this disorder, and functional MRI studies have also reported reduced metabolism of the caudate nucleus, frontal region, and anterior cingulate gyrus in children with this disorder.
Psychosocial factors
Adverse social and family environments, such as economic poverty, parental breakdown, and inappropriate parenting styles, may increase the risk of developing the disorder in children.
Other factors
The disorder may be associated with zinc and iron deficiency and elevated blood lead. Coke, coffee, and food additives may increase the risk of the disorder in children.
Clinical manifestations of attention deficit
Children with this disorder have short attention spans and are easily distracted; they often fail to filter out extraneous stimuli and respond to a variety of stimuli. As a result, children with this disorder often have difficulty sustaining attention when listening to lectures, doing homework, or doing other things, and tend to fidget and wander; are often distracted by movement in their surroundings and look around or pick up conversations; have difficulty sustaining tasks, often doing one thing before another; have difficulty consistently following instructions and completing required tasks; often fail to pay attention to details when doing things, and often make mistakes due to carelessness Often avoids or is reluctant to engage in tasks that require longer periods of concentration, such as writing assignments, and is unable to complete these tasks on time. Often loses things, loses his/her belongings, or forgets things; often distracted when talking to him/her, seems to listen but not to listen, etc.
Hyperactivity
Overactivity is defined as a level of activity that is beyond what is appropriate for the child’s development compared to most children of the same age and gender. Most hyperactivity begins in early childhood, but some children begin in infancy. In infancy, children are extra active, crawling out of their cribs or carts, and when they start to walk, they often run instead of walk; after early childhood, children are active, unable to sit still, climbing high and low, rummaging through boxes, and have difficulty doing things quietly and playing quietly. After going to school, the child’s performance is more prominent due to discipline and other restrictions. The child has trouble sitting in class, twisting around in his seat, making small movements, often playing with pencils, erasers and even school bag straps, talking with classmates and even getting out of his seat; after class, the child provokes classmates, talks a lot, runs around and makes a lot of noise, and has difficulty playing quietly. After entering puberty, the child’s small movements decrease, but may feel subjectively restless.
Impulsive
Children with this disorder are impulsive and do not consider the consequences. As a result, the child often interrupts or interrupts conversations without regard to the occasion; often interrupts or interferes with the activities of others; often answers questions without permission before the teacher finishes; often climbs high and low without considering the danger; and recklessly causes injury to others or himself. The child is often emotionally unstable, easily overexcited, impatient, angry, or crying over trivial matters, and even defiant and aggressive behavior.
Cognitive impairment and learning difficulties
Some children with this disorder have spatial perception disorder and audio-visual conversion disorder. Although the child has normal or near-normal intelligence, he or she often has learning difficulties due to attention deficit, hyperactivity and cognitive impairment, and his or her academic performance often lags behind the level of intelligence.
Emotional Behavior Disorder
Some children with this disorder suffer from anxiety and depression due to frequent criticism by teachers and parents and rejection by peers. 20%-30% of children with this disorder have anxiety disorders, and the co-morbidity rate of this disorder and conduct disorder is as high as 30%-58%. Compared to their peers, adolescents with ADHD appear to be less emotionally mature. They also have more emotional and behavioral problems such as oppositional defiant disorder, impulsivity, temper tantrums, drug use, and delinquency. Studies have now shown that children with ADHD can easily lead to juvenile delinquency if not treated aggressively. In fact, emotional and behavioral disorders are often a significant cause of impairment in social functioning in children with ADHD.
Diagnosis and classification
The diagnosis should be made by integrating the findings of the history, physical and neurological examination, psychiatric examination, and ancillary tests. In this process, it is important to take a detailed and correct history, as children with milder conditions may not present with prominent symptoms during a brief psychiatric examination.
Diagnostic points
1. The onset of the disease is before the age of 7 years, and the symptoms last at least six months.
2. The main clinical manifestations are attention deficit, hyperactivity and impulsivity.
3. Adverse effects on social functions (academic or interpersonal relationships, etc.).
4.Exclude mental retardation, pervasive developmental disorder, mood disorder, etc.
Diagnostic criteria
Clinicians can choose the diagnostic criteria according to their needs. Currently, the DSM-IV diagnostic criteria for ADHD are mostly used: A-E are required to be met.
A Symptom criteria.
(1) Attention deficit symptoms: meeting at least 6 of the following attention deficit symptoms, lasting for at least 6 months, reaching maladaptive levels, and not commensurate with developmental level.
① Often inattentive to details and prone to errors due to carelessness during learning, work, or other activities.
② Often has difficulty maintaining attention during learning or play activities.
③ Often distracted and seemingly listening when spoken to.
④ often fails to complete homework, daily chores, or work as directed (not due to oppositional behavior or failure to understand)
⑤ often has difficulty completing structured tasks or other activities
⑥ dislikes and is unwilling to engage in things that require sustained energy (such as homework or chores) and often seeks to avoid them
(7) Often loses things necessary for learning and activities (e.g., toys, textbooks, pencils, books, or tools).
(8) Is easily distracted by external stimuli.
⑨ Often forgets things in daily activities.
(2) Hyperactivity/impulsivity symptoms: At least 6 of the following hyperactivity and impulsivity symptoms are present, persist for at least 6 months, reach maladaptive levels, and are not commensurate with developmental level.
① Frequently moving hands and feet or squirming around in their seats.
② Often leaves the seat without permission in the classroom or other settings where sitting is required.
③ often runs around or climbs up and down excessively in inappropriate situations (in adolescents or adults there may only be a subjective feeling of fidgeting)
④ is often unable to play quietly or participate in leisure activities
⑤ is often momentarily active, as if a machine is driving him.
(6) often talks a lot.
(7) Often rushes to answer questions before they are finished.
(8) Often fails to wait patiently in line for a turn in an activity.
⑨ often interrupts or interferes with others (e.g., interrupts while others are talking or interferes with other children’s play).
B Disease course criteria: certain symptoms that cause impairment appear before age 7.
C Certain symptoms causing impairment appear in at least two settings (e.g., school and home).
D Severity criteria: clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E Exclusion criteria: Symptoms are not present in the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and cannot be explained by other psychiatric disorders (e.g., mood disorders, anxiety disorders, dissociative disorders, or personality disorders).
Clinical Types
The DSM-IV classifies ADHD into three subtypes.
(1) Attention-disorder-dominant type: 6 or more of the 9 symptoms of attention disorder are met. The DSM-IV field test data and some studies have found that this type is more suitable for girls and adolescents.
(2) Hyperactivity/impulsivity-oriented type: 6 or more of the 9 symptoms of hyperactivity/impulsivity are met. It is commonly seen in preschool and early elementary school children, with hyperactivity as the main manifestation, usually without academic problems, and with more comorbid character disorders and oppositional defiant disorders. This type is less common in clinical practice.
(3) Mixed type: Both attention disorder symptoms and hyperactivity/impulsivity symptoms meet 6 or more criteria. This type has the most severe impairment in activity level, impulsivity, attention, academic and cognitive functioning and represents the most common concept of ADHD with high comorbid oppositional defiant disorder (ODD), conduct disorder (CD), anxiety and depression disorders, high impairment in social functioning and poor prognosis. This type is the most common in clinical practice.
Differential diagnosis
In addition, attention should be paid to differentiate ADHD from the following disorders in the diagnosis of ADHD.
1, mental retardation: children with this disorder can be accompanied by hyperactivity and attention deficit, and if they can attend school, their learning difficulties are quite prominent, so they are easily confused with attention deficit and hyperactivity disorder. But trace the medical history, can find that the children with this disorder since childhood growth and development than the normal children of the same age delay, social adaptation ability is low, academic level and intelligence level is more than equivalent, IQ test IQ below 70. above can help identify.
2. Childhood autism: Although children with this disorder often have hyperactivity and attention disorders, they also have the three core symptoms of childhood autism, namely: social interaction disorder, communication disorder, narrow interests and stereotypical repetitive behavior, so it is not difficult to distinguish them from attention deficit and hyperactivity disorder.
3. Character disorders: Character disorders and attention deficits have a high rate of co-morbidity with hyperactivity disorder. If the child does not have hyperactivity and attention disorder, only character disorder is diagnosed. If the child has hyperactivity and attention disorder at the same time, and meet the diagnostic criteria of attention deficit and hyperactivity disorder, then both diagnoses need to be made.
4, children’s mood disorders or mood disorders: children in anxiety, depression or manic state may appear too much activity, inattention, learning difficulties and other symptoms, attention deficit and hyperactivity disorder children because of frequent criticism by teachers and parents and peer rejection can also appear anxiety and depression, so the two need to distinguish. The main points of differentiation are as follows: (1) Attention deficit and hyperactivity disorders start before the age of 7, while the onset of mood disorders or mood disorders can be early or late; (2) Attention deficit and hyperactivity disorders have a chronic and persistent course, while the course of mood disorders varies, and mood disorders have an episodic course; (3) The first and main symptoms of attention deficit and hyperactivity disorders are attention deficit, hyperactivity, and impulsivity, while the symptoms of mood disorders or mood disorders have a chronic and persistent course. The first and main symptoms of mood disorder or mood disorder are emotional problems; ④ children with mood disorder or mood disorder will have their hyperactivity and attention disorders disappear after improving their mood through treatment. In contrast, after children with attention deficit and hyperactivity disorder take anxiolytics or antidepressants to improve their mood, hyperactivity, attention deficit and impulsivity may improve, but still persist.
5, children with schizophrenia: the onset of the disorder is later than attention deficit and hyperactivity disorder, the peak of the onset of preadolescence and adolescence, in early inattention, academic performance decline, often accompanied by other emotional, behavioral or personality changes, and with the development of the disease, will gradually appear perceptual disorders, thought disorders, emotional indifference and incoordination, strange behavior, lack of intention, etc. symptoms of schizophrenia, whereby it can be differentiated from attention deficit and hyperactivity disorder. [1][2][3]
Disease treatment
The etiology, manifestations and diagnosis of ADHD are so complex that treatment of course requires a comprehensive approach. Rational selection of the best treatment and is very necessary. The current treatment methods for ADHD are mainly pharmacotherapy, psycho-behavioral therapy, family therapy, and EEG biofeedback therapy, among which pharmacotherapy is preferred. Studies have concluded that pharmacological treatment is the best strategy, combined with psycho-behavioral therapy, family therapy or EEG biofeedback therapy.
Pharmacological treatment
Pharmacological treatment includes central stimulants, antidepressants, antihypertensives and norepinephrine reuptake inhibitors. From the perspective of TCM, children with deficient kidney yin, rising deficiency fire and irritability, therefore have a developmental period where yin is often deficient and yang is often surplus, which can trigger hyperactivity in children. Therefore, nourishing Yin and tonifying the kidneys to strengthen the brain is the only way to treat hyperactivity in children’s Chinese medicine drugs are also many, however, the lack of scientific methods to verify its efficacy.
(1) Central stimulant: It is the drug of choice. Mainly used for children over 6 years old, can reduce hyperactivity, impulsivity, improve attention. Commonly used: ① Methylphenidate (Methylphenidate),. The efficiency of this drug is 75-80%. ② Pemoline, which is no longer recommended because of the increased risk of acute liver failure.
A growing number of studies and reports over the last decade have shown that long-acting, extended-release or controlled-release methylphenidate is more durable and stable in its efficacy. There is a trend to replace traditional fast-acting methylphenidate.
(2) Selective norepinephrine reuptake inhibitor: tomoxetine. Tomoxetine is a selective norepinephrine reuptake inhibitor (SNRI). It is the first non-excitatory drug approved for the treatment of attention deficit hyperactivity disorder (ADHD), and has been used for 3-4 years abroad and nearly 2 years in China. Clinical practice shows that the efficacy of this drug for ADHD is comparable to that of methylphenidate, with insignificant side effects. At present, it is also one of the main treatment drugs.
Psychosocial interventional treatment
These include behavioral therapy, learning support, family therapy, and health care coordination. Most of the treatments need to be completed by professionals, taking family therapy as an example.
Family therapy: From a systemic viewpoint, the child as a member of the family system, the child has problems, reflecting problems in the family such as dysfunctional parent-child relationships and unscientific family education. Also, the presence of a child with ADHD in the family often leads to tension between adults. Therefore, when taking active measures to prevent and treat the problem, other family members should also receive counseling if necessary. Receiving counseling allows parents to learn to understand and sympathize with each other and to be able to learn from and comfort each other. The purpose of family therapy is to: (1) harmonize and improve the relationship between family members, especially the parent-child relationship; (2) give parents the necessary guidance to understand the disorder, view the symptoms of the affected child correctly, effectively avoid conflicts and contradictions with the child, get along and communicate with the child harmoniously, master the methods of behavior modification, and use appropriate methods to correct the behavior of the affected child.
Parent Training
Through training, parents are taught how to manage their child’s behavior. Parents are explained the reasons why children with ADHD develop oppositional behaviors, and are instructed how to focus on and praise their children and how to correct their children’s undesirable behaviors. It enables parents to better understand the needs of their children and to better provide appropriate feedback on their behavior. Parent training creates a long-term, ongoing, recovery-friendly environment in which children can reduce oppositional behaviors and gradually demonstrate their ability to behave well.
Social Skills Training
This includes social skills, cognitive skills, and somatic skills training. It helps children with ADHD learn practical social skills, treat others properly, resolve interpersonal relationships, learn from each other, accept rewards or criticism, and deal with frustration and anger. This approach has been shown to be effective in the long term for ADHD.
Disease Prevention
It is generally believed that the following measures can prevent ADHD to some extent.
1, to promote premarital examination, to avoid marriage of close relatives; when choosing a spouse, pay attention to whether the other party has epilepsy, schizophrenia and other mental disorders.
2, marriage at the right age, do not marry early, early pregnancy, and do not marry too late, late pregnancy, to avoid congenital deficiencies of the baby; planned eugenics.
3, in order to avoid birth injuries, reduce the chance of brain damage, should be natural normal birth, because the clinical findings of ADHD children with a higher proportion of caesarean section.
4, pregnant women should pay attention to temperament, keep a happy mood, mental peace, avoid cold and heat, disease prevention, careful use of drugs, prohibit smoking and alcohol, avoid poisoning, trauma and physical factors.
5, to create a warm and harmonious living environment, so that children spend their childhood in a relaxed and happy environment, to teach according to the material, do not blindly hope that the child will become a dragon.
6, pay attention to reasonable nutrition, so that children develop good eating habits, not partial food, not picky food; ensure sufficient sleep time.
7. Avoid children playing with lacquered toys containing lead as much as possible, especially not to hold such toys in the mouth.