Attention Deficit and Hyperactivity Disorder, commonly abbreviated as ADHD, is characterized by abnormally high levels of hyperactive and impulsive behaviors. In the last few years, there has been a significant increase in the diagnosis of ADHD, which is especially true for North America. Xu et al. (2018) found that between 1997 and 2016, the prevalence of the disorder among children and adolescents aged 4-17 had risen from 6.4 to 10.2%. A meta-analysis by Polanczyk et al. (2014) pointed out high heterogeneity of findings and concluded a 5.27% prevalence of ADHD around the world. Because an ample body of evidence indicates that the disorder becomes more common than ever, it is compelling to investigate its nature. This paper seeks to shed light on the existing etiological theories and review literature on therapeutic approaches toward ADHD.
Diagnosing ADHD is a challenging task for doctors and parents alike. In the United States, health professionals rely on DSM-5 (American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition) criteria when making the diagnosis. As of now, DSM-5 states that ADHD manifests itself through constant patterns of inattention and hyperactivity-impulsivity that create significant difficulties for functioning or development. ADHD may be diagnosed if a child has six or more symptoms of inattention (e.g. easily distracted, forgetful, not listening) and hyperactivity and impulsivity (e.g. excessive talking, running when inappropriate) (American Psychiatric Association & American Psychiatric Association, 2013). DSM-5 is different from other editions because it does not have ADD without hyperactivity as a separate diagnosis (Epstein & Loren, 2015). Besides, DSM-5 only requires the presence of five symptoms in each category for making a diagnosis in adolescents and adults (Epstein & Loren, 2015).
Surely, raising awareness of ADHD and refining the diagnostic framework improved the quality of life for many children and adults. Yet, there is evidence that sometimes ADHD diagnosis is used in the pursuit of personal interest. For example, Schwarz (2016) noticed that since the introduction of the No Child is Left Behind Act, the ADHD prevalence in the United States has increased by 22%. One explanation may be that the act allowed schools to exclude the test results of students with ADHD. Therefore, overdiagnosis helped to improve statistics and receive more government support,
Today, there is an extensive body of research suggesting that ADHD may be passed genetically and traced back to specific changes in brain functioning. Hayman and Fernandez (2018) write that the brain affected by ADHD has less global and white matter volume as compared to the normal brain. Additionally, certain brain regions show ADHD-specific morphological changes: for instance, one such affected area is frontostriatal structures, which include the lateral prefrontal cortex, dorsal anterior cingulate cortex, and dorsal striatum. It has been found that children and adolescents suffering from ADHD have smaller basal ganglia, which causes issues with carrying out cognitive tasks, controlling movements, and managing reactions (Hayman & Fernandez, 2018). Apart from that, there has been some success in locating ADHD genes. The disorder is believed to run in families, which shows its hereditary nature.
While the etiology of the disorder itself can be tied to biological factors, an increase in its prevalence may be a consequence of increasing environmental degradation. Air pollution has become worse in recent years, and the World Health Organization estimates that nine out of ten people may be breathing air with above-normal levels of environmental pollutants (Lelieveld et al., 2020). Myhre et al. (2018) suggest that there might be a relationship between prenatal exposure to particulate matter in urban air and the decreased size of the corpus callosum in babies. This structure plays a significant role in the development of ADHD and autism spectrum disorder. Therefore, environmental factors cannot be ruled out when understanding the increase in ADHD prevalence.
Environmental factors go beyond the physical circumstances in which a child is born and brought up and include the intangibles, such as familial factors and relations. Having analyzed a large sample of South African ADHD patients and their families, Van Dyk et al. (2015) were able to recognize some patterns. It seemed that birth complications, the absence of maternal figure, adverse early childhood experiences, and early breastfeeding cessation correlated with ADHD risk. Rowland et al. (2018) contributed to the growing body of evidence on familial factors by investigating the socio-economic situation of families where children are diagnosed with ADHD. It is now a well-established fact that psychopathology prevalence is higher among the poor (Rowland et al., 2018). It seems that ADHD is not an exception: the disorder occurs more frequently in low-income households.
European researchers Storebø et al. (2016) approach the issue from the perspective of Bowlby’s attachment theory. The theory suggested all children strive to form attachments to their parental figures for the sake of survival. Based on the quality of these primary relationships, attachments may fall into one of the four categories: secure, insecure dismissing, insecure preoccupied, and disorganized (Storebø et al., 2016). Storebø et al. (2016) found that unregulated emotions and insecure attachment played a role in ADHD development. Summing the evidence up, it is safe to assume that ADHD requires a biopsychosocial approach because there appears to be an interplay of multiple diverse factors.
Treatment, Interventions, and Therapy
ADHD is often associated with the decreased quality of life of the affected person as well as their family. For this reason, modern medicine has been on the search for comprehensive treatment. Today, there exist pharmacological approaches toward treating ADHD that relieve symptoms and help patients manage their academic, professional, and social lives better. The American Academy of Pediatrics has given green light to several drugs for treating ADHD in children even under six years. At the moment, the most common medications are stimulants that are further categorized into immediate-release (short-acting) medications and extended-release (intermediate-acting and long-acting) medications. Some examples of the first group include Adderall, Dexedine, and Focalin, while the second group includes Adderall XR and Focalin XR. Generally speaking, stimulants increase dopamine levels in the brain (Castells et al., 2020). Dopamine is a hormone that is associated with attention, motivation, and movements – the domains in which people with ADHD typically experience shortcomings.
In recent years, ADHD medication has undergone many improvements, and yet, there are certain reservations regarding their use. First and foremost, ADHD pharmacological therapy comes with a host of side effects. Some children experience troubles falling asleep, which typically means that either the dosage does not work or the medication does not wear off soon enough before bed (Craig et al., 2015). Some stimulants are known to suppress appetite, in which case it may also have something to do with scheduling (Craig et al., 2015). Other side effects include growth delay during the first year (mainly for boys), nausea, and headaches (Craig et al., 2015).
Secondly, like any pharmacological treatment, managing ADHD with medications requires commitment and adherence. Brinkman et al. (2018) found that many factors were at play when it came to the continuity of treatment. In the short term, continuing treatment relies mainly on parents’ satisfaction with information and medication titration. It is important that parents belief that ADHD symptoms are manageable and that they observe actual progress that motivates them to continue. In the long term, children’s acceptance of treatment and willingness to undergo it start to play a more central role (Brinkman et al., 2018). Besides, parents have to find a compromise between their perceived need of medication and concerns about its side effects (Brinkman et al., 2018).
Medication is not a sufficient response to a disorder as complex as ADHD, which is why it is best combined with psychosocial interventions. Cognitive behavioral therapy (CBT) is commonly used for teaching children, adolescents, and their families to deal with ADHD symptoms. Sprich et al. (2015) demonstrate evidence-based effectiveness of CBT ADHD interventions that seek to change how individuals think and act. In relation to ADHD in particular, CBT addresses domains such as organization, distractibility, and cognitive restructuring (Sprich et al., 2015). While CBT has been proven effective for a range of mental disorders, it does have considerable limitations. First and foremost, CBT is often criticized for focusing on the “now” and treating symptoms rather than exposing the roots of a problem (Dobson & Dobson, 2018). Further, CBT requires commitment, which includes doing homework, and not all patients are willing to do that.
Another way to stage a psychosocial intervention is in a family setting. One of the reasons why family-based therapy may be beneficial is because family determinants play a serious role in ADHD development, as discussed in the previous section. For example, Lo et al. (2016) look at families as systems whose elements are always in the state of change and interactions. Lo et al. (2016) propose family-based mindfulness training intervention whose goal is to make persons more aware and focus on their feelings and emotions. Mindfulness is known to improve attention, cognitive development, and overall functioning (Lo et al., 2016). It is suggested that mindfulness can overcome the barriers of cognitive-behavioral and pharmacological therapy, and the family setting can lead to the emergence of a sustainable family system.
Family therapy is only effective when every single person is equally involved and determined to work toward a positive result. Family engagement is both the strength of and the necessary prerequisite for family therapy to yield the desired effects. Heath et al. (2015) argue that parents with children with ADHD are almost permanently under stress because they have to deal with their children’s disturbing and disrupting symptoms. They are seen as “agents of change” and are assigned the key role in managing childhood ADHD (Heath et al., 2015). Heath et al. (2015) found that parents’ self-esteem and self-efficacy predicted positive outcomes. Therefore, family therapy should focus not only on children but also parents as their well-being too often suffers and needs attention.
ADHD is a complex disorder that is often misunderstood and stigmatized. Therefore, to approach it in both humane and effective ways, healthcare practitioners need to collaborate with parents. Smith et al. (2016) emphasize the importance of early interventions that rely on non-pharmacological treatments, such as parenting programmes (PPs). While early interventions are highly recommended, the follow-through and adherence rates are inadequately low (Smith et al., 2016). Having analyzed a UK sample of families where children have been diagnosed with ADHD, Smith et al. (2016) were able to identify key barriers to starting early treatment that roughly fall into three categories: parent factors, programme factors, and service factors.
When it comes to parental variables, Smith et al. (2016) found that many parents felt shame and embarrassment and had low confidence in their management skills. Situation factors concerning the family setup also created barriers: for instance, single or low-income parents had little resources to deal with ADHD (Smith et al., 2016). As for programme factors, the initial contact with the family mattered a lot. Further, parents often felt that their own needs were not attended to. They wanted programmes to be better tailored and customized to meet their expectations (Smith et al., 2016). Lastly, service factors also determined the success of early intervention. Participants of the study mentioned that there was low awareness of ADHD management programmes. Besides, they wished for better interagency collaboration in which several parties (parents, GPs, school staff, and others) would work on the issue.
ADHD patients are not a homogenous group of people; in fact, they vary not only in demographic characteristics but also in lifestyle choices. All these factors should be taken into account when putting together a treatment plan for an ADHD patient. Mowlem et al. (2018) report that ADHD is more commonly diagnosed in males than females. However, male-to-female ratios are higher in clinical studies than in population-based studies, which makes one think that diagnosing criteria might be biased (Mowlem et al., 2018). Mowlem et al. (2018) found that ADHD may manifest itself different in males and females. In particular, males are more prone to externalising symptoms, which makes the disorder easier to diagnose.
Further, healthcare practitioners should keep in mind that ADHD and substance use disorders (ADHD) often co-occur. As noted by Carpentier and Levin (2018), ADHD and SUD is a “complex constellation” that may lead to further psychosocial issues and psychopathology. Carpentier and Levin (2018) argue that comorbidities require an integrated approach in which all disorders should be paid adequate attention. Luckily, modern psychostimulant formulations are evolving to accommodate complicated cases as well as increase chances of adherence.
Based on the scientific evidence, one may conclude that ADHD may develop due to a set of factors. While the disorder does have a genetic component, environmental and psychological factors shape the outcome as well. For this reason, it is best not to confine ADHD therapy and management to only one method. It seems that the best route to take is to choose a biopsychosocial approach that incorporates medication, psychotherapy, and family-based interventions. When it comes to medication, health practitioners and parents should be aware of two aspects: the diversity of available options and possible side effects. It is not uncommon that parents have to experiment with medication until they find the right kind and release for their child. Further, to increase adherence among patients, health practitioners should be extremely clear about the treatment plan (Ahmed et al., 2017). They should work not only with parents’ knowledge but also with their motivation because some might have limiting beliefs and little faith in medication or themselves.
ADHD medication is best combined with cognitive-behavioral therapy and/ or family-based interventions. When approaching the subject of intervention, health practitioners need to make the most out of the first interaction. Further, they should keep in mind that while it is the child that needs help, parents are also frequently severely stressed and even burned out (Leitch et al., 2019). Therefore, it is better when intervention programmes are flexible and take into consideration family situational and psychological factors. Further, ADHD specialists should be wary of gender differences in how the disorder manifests itself and also look for comorbidities in the anamnesis.
Children affected by ADHD are notoriously difficult to handle: they can barely focus their attention on a single task or sit still for prolonged periods of time. At the moment, science has not confined the etiology of the disorder to only one factor. It might as well be that genetic, environmental, and relational factors all play a role in its development. Among the existing approaches toward managing ADHD are pharmacological, psychotherapeutic, and family-based. They all have their strengths and limitations, which is why it is recommended to incorporate elements of all three. When it comes to ADHD, parents should not only be engaged but also cared for because managing childhood ADHD is quite a challenging task. Therefore, treatment approaches should look at demographic variables, family situation factors, the psychological state of parents, and available service quality.
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