What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and/or impulsivity. It is a disorder of childhood, as symptoms typically begin before the age of 13. ADHD is usually diagnosed during childhood, and while some seem to grow out of the symptoms, it continues to affect many into adulthood.
It is estimated that anywhere from 2 to 18% of children and adolescents have ADHD, and that is present in nearly 4.5% of adults in the United States. ADHD is diagnosed more often in boys than girls and historically it has been thought that there is a 2-10 fold risk of males having ADHD. However, newer research points to the fact that males may be diagnosed more often, especially during childhood, because of differences in symptoms experienced, expression of the symptoms, and the severity of the symptoms. Women also tend to be diagnosed much later than men. Undiagnosed and untreated ADHD can cause problems with careers and relationships for any person.
What causes ADHD?
ADHD is a predominantly genetic disease. If you have a parent, sibling, or child diagnosed with ADHD, you have a greater chance of also being diagnosed with ADHD. Several genes have been implicated in the disease process, affecting different parts of brain development and impairing functioning through disturbances in levels of vital chemicals in the brain. The interactions of these genes with each other and with environmental factors can potentially increase the chance of developing ADHD or increasing the degree of deficit from ADHD. These factors can include exposure to toxins (alcohol use during pregnancy), head trauma, exposure to infections, and adverse early environmental stressors like malnutrition.
Symptoms of ADHD
The symptoms of ADHD manifest as:
- Inattention- Having trouble focusing on tasks or conversation, organizing and completing tasks in a timely matter, being easily distracted.
- Hyperactivity- You may feel you are always on the go and unable to stay still for long periods of time. Children often get into trouble for climbing and running at inappropriate times. In adults, the hyperactivity may manifest as mental or emotional hyperactivity rather than physical, with a feeling of racing thoughts and restlessness.
- Impulsivity- Interrupting people, inability to wait your turn, saying or doing things without thinking that you later regret, and problems with self-regulation.
These symptoms are the basis of the classifications of ADHD: predominantly inattentive type, predominantly hyperactive/impulsive type, and combined presentation.
However, diagnosing ADHD can be much more complex, especially if it is uncontrolled and negatively impacts different aspects of your life.
- Procrastinating and avoiding tasks that require focus or organization due to problems with inattention.
- Feeling like you take longer to complete the same tasks than others do.
- Problems with memory, such as forgetting where you kept something or forgetting to keep appointments.
- Academic difficulty or problems at work.
- Difficulty in socializing.
- Anxiety or depression stemming from problems at work and in relationships due to ADHD.
- Problems with emotional regulation.
- Feeling left behind or that you have not progressed to the same level as people of similar intelligence.
Symptoms and the resultant complications may vary from person to person. The symptoms in one person may also vary by situation, such as one-on-one or in group settings.
In addition, many people with ADHD suffer from other mental health conditions, often with overlapping symptoms, which can make diagnosis difficult.
Co-occurring conditions usually diagnosed in childhood include learning disorders, conduct and oppositional defiant disorder, Tourette’s syndrome, and mood disorders (anxiety, depression, and bipolar disorder). In adults, mood disorders, substance use disorders, and intermittent explosive disorder may be diagnosed.
When to See A Doctor
If you think your child has symptoms of ADHD, it is important to collaborate with their teacher to get an understanding of the symptoms are the same in school as at home. Using this information, your psychiatrist will be able to make the diagnosis of ADHD. Treating ADHD early will prevent further complications and distress for your child.
If you have ADHD or symptoms of ADHD that are interfering with your life despite self-help efforts to manage them, contact your doctor for an evaluation and to create a plan of treatment.
ADHD is a chronic condition that is best managed when treatment is started early. The course of treatment is determined by several factors:
- Severity of symptoms.
- Co-existing psychiatric or medical conditions.
- Tolerance of specific medications.
Behavioral therapy is the first treatment tried in very young children, unless symptoms are very severe. As patients get older, pharmacological treatment is most effective, but may be augmented with therapy and behavioral interventions.
While medications cannot cure ADHD, they are extremely effective in helping manage symptoms. There are several classes of medications approved for ADHD that you may be prescribed:
Stimulants work by balancing the chemicals, dopamine and norepinephrine, in the brain. These chemicals are involved in higher functions of the brain, such as focus, alertness, impulsivity, and executive function. The two main types of stimulants are amphetamines (Brands: Adderall, Dexedrine, Vyvanse) and methylphenidate (Brands: Concerta, Focalin, Quillivant, Ritalin). The response to treatment with stimulants is quick, with effects being noticed from 20 minutes to a few hours. Stimulants also have been found to have the greatest efficacy of the medications used to treat ADHD. However, careful monitoring is required due to potential risks and side effects:
- Decreased appetite.
- Weight loss.
- Trouble sleeping.
- Potential for abuse.
- Less commonly, you may experience increased heart rate or blood pressure, headaches, stomach pain, development or worsening of tics, and some people complain of a change in personality such as being more moody, withdrawn, irritable, or anxious.
- Rare but serious side effects include death in those with serious cardiac problems and psychiatric effects, including the development of suicidal behavior, aggression, and hallucinations. Those also diagnosed with bipolar disorder may see worsening of their symptoms.
2. Nonstimulant medications
There are a few non-stimulant medications that are used in those who cannot take stimulants for any reason.
Selective norepinephrine reuptake inhibitors (SNRIs)
SNRIs prevent the metabolism of norepinephrine, allowing more of the chemical to stay active in the brain. There are two SNRIs approved to treat ADHD.
Atomoxetine (Brand: Strattera)
Atomoxetine is used to treat adults, adolescents, and children over the age of 6 who are unable to tolerate or have contraindications to stimulant medications. It may take you anywhere from one to four weeks to notice any effects, and the medication must be taken daily to maintain appropriate levels in the body.
Potential side effects include:
- Common side effects: decreased appetite, weight loss, stomachaches, vomiting, nausea, dizziness, fatigue, and irritability.
- Severe and rare side effects: sudden cardiac death, priapism, tics, liver injury, and psychiatric effects such as suicidal thinking, psychotic or manic symptoms with no prior history, or aggressive behavior.
Viloxazine (Brand: Qelbree)
Viloxazine is a SNRI that was recently approved for treatment for children aged 6-17 years. It offers the advantage of being able to be administered by opening the capsule and sprinkled on food for children who have difficulty swallowing capsules.
Known side effects include increased heart rate and blood pressure, excessive sleepiness and fatigue, decreased appetite, nausea, vomiting, and irritability. An increased risk of suicidal thoughts and behaviors has also been found.
Alpha-2-adrenergic agonists are used to treat children who have not responded to, been able to tolerate, or have contraindications for the use of SNRIs. Alpha-2-adrenergic agonists are most effective in decreasing symptoms of hyperactivity and aggression. Originally used to treat high blood pressure, they work by indirectly increasing dopamine by binding to the alpha-2 receptors and decreasing levels of norepinephrine. The effects can take up to two weeks to be noticed, and the medications must be tapered slowly during the start and on discontinuation to prevent serious side effects. Alpha-2-adrenergic agonists may be prescribed for some children along with stimulants in case they don’t work as expected.
Extended-release clonidine (Brands: Kapvay, Catapres)
Clonidine is an alpha-2-adrenergic agonist used to treat ADHD in children alone or along with stimulants. While it is not as effective as other drugs, it is useful in those experiencing symptoms of hyperactivity, aggression, or restlessness. Clonidine has also demonstrated success in those who are also diagnosed with Tourette’s syndrome as it decreases tics. Through its calming effects, it can also help with some side effects of stimulants, such as difficulty in sleeping, and is usually prescribed to be taken at bedtime.
Side effects may include sleepiness, depression, headaches, decreased heart rate or blood pressure, allergic reaction, and rash. If clonidine is stopped abruptly, it may cause a sudden and potentially dangerous increase in blood pressure.
Extended-release guanfacine (Brands: Intuniv, Tenex)
Extended release guanfacine is an alpha-2a-adrenergic agonist. It functions similarly to clonidine and may be prescribed to those who cannot tolerate it. Guanfacine is also used to treat those with both ADHD and Tourette’s syndrome.
Side effects may include headaches, stomachaches, and sleepiness. Stopping Guanfacine without decreasing the dose slowly may also cause a sudden and dangerous increase in blood pressure.
Tricyclic antidepressants and bupropion are used to treat ADHD for those who have cannot tolerate or have contraindications to stimulant medications and SNRIs.
Imipramine, desipramine, and nortriptyline are tricyclic antidepressants that increase the amount of norepinephrine and serotonin in the brain by keeping them active in the synapses, the spaces between communicating neurons.
While tricyclics have some evidence in decreasing the symptoms of ADHD, they are associated with serious side effects such as cardiovascular events such as heart attacks and abnormal heart rhythms, and an increased risk of seizures. Other side effects include mild increases in heart rate and blood pressure, unwanted changes in appetite or weight, constipation, dry mouth, and inability to hold urine.
Bupropion is classified as an atypical antidepressant that prevents the breakdown of dopamine by keeping it in the synapse. It has been found to be moderately effective in treating ADHD and is more stimulating than tricyclic antidepressants. It is also may be prescribed in people with ADHD who are having trouble losing weight or those who want to stop smoking. A serious side effect is that it increases the risk of seizures, and it is important to inform your doctor if you or anyone in your family has a history of seizures. Other side effects include trouble sleeping, decreased appetite, and irritability.
Dr. Maria Arizaga, MD
MARIA ARIZAGA, MD
Dr. Maria Arizaga is a Psychiatry Specialist from Albuquerque, New Mexico. She graduated with honors from University of New Mexico School of Medicine in 2004. Having more than 17 years of diverse experiences, especially in psychiatry.