What is Attention Deficit Hyperactivity Disorder?

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by a suite of symptoms which collectively result in trouble paying attention, difficulty controlling behaviour and excessive activity1-3.

Although ADHD is often thought of as a childhood disorder, adults also suffer from the condition. Symptoms, however, may be different during adulthood due to the increased growth of the brain, different societal pressures and the implementation of coping mechanisms over a person’s lifetime.

ADHD in children can result in poor school performance and social impairment, while in adults it can cause job and relationship related difficulties1. Despite this, many features of ADHD are associated with positive traits. This means that while someone with ADHD may struggle to function in particular environments, they can excel in others.  Persons with ADHD can, therefore, lead a somewhat normal life and exhibit good attention spans if their symptoms are effectively treated, especially for tasks they feel interested in.

For more information and support, you can contact the ADHD Association of South Africa (ADHASA).

What are the symptoms of ADHD?

The symptoms of ADHD are complex and must occur in combination and be persistent to reach a diagnosis. Many of the symptoms overlap with other disorders or are particularly difficult to define as ‘unusual’ as, for example, whether someone is abnormally overactive will depend on the setting, other aspects of their personality and societal pressures. If you notice any of the symptoms in yourself, your children or those around you, it is therefore important to seek professional advice.

Major symptoms of ADHD include inattention, hyperactivity or restlessness, disruptive behaviour and impulsivity1-3. Girls with ADHD are more likely to have intellectual issues4. Problems with keeping motivated and goal-oriented tasks can be experienced as ADHD predisposes sufferers to focus on short-term rather than long-term rewards5. Emotional issues such as anger, anxiety and depression are also more common in ADHD sufferers6. ADHD is often associated with drifting off during conversations, as well as language issues, both verbal and non-verbal, causing social cues to be missed7.

These symptoms often result in poor academic and job-related performance, as well as problems in relationships and social interaction. As children age, symptoms often change, both due to the development of coping mechanisms and the changing brain. For example, hyperactivity may transform into inner restlessness and constant mental activity8.

Depending on the exact symptoms, ADHD can be divided into three subtypes: ADHD inattentive type, ADHD hyperactive-impulsive type and ADHD combined type3

ADHD inattentive type is characterised by difficulty in staying focused and completing tasks, and is best described by the following symptoms:

  • Easily distracted, misses details, forgets or loses things, frequently switches from one activity to another and struggles to follow instructions
  • Difficulty focusing attention on, organizing and completing, or becoming easily bored with tasks
  • Struggling to learn new things and difficulty processing information as quickly and accurately as others
  • Seems to not be listening when spoken to, daydreams or becomes easily confused

ADHD hyperactive-impulsive type is characterized by restlessness, hyperactivity and childish or destructive behaviours, including:

  • Fidgeting, having trouble sitting still and doing quiet tasks or activities
  • Talking nonstop, interrupting conversations or others’ activities, blurting out inappropriate comments and showing emotions without restraint
  • Constantly moving around, touching or playing with anything and everything in sight, acting without regard for consequences
  • Being very impatient

ADHD combined type exists as a combination of symptoms of the other two types.

What causes ADHD?

The underlying causes of ADHD are, in the majority of cases, unknown. This is because ADHD is a complex disorder, caused by interactions between genetic and environmental factors1,9. ADHD is therefore not exactly the same for each person in terms of the presence and severity of symptoms and their causes.

ADHD is often inherited in families, suggesting underlying genetic causes in two-thirds of cases10,11. A number of contributing genes have also been discovered, which largely play a role in neurotransmission12,13. Environmental factors may also result in the syndrome or exacerbate the underlying genetic causes. The major environmental factors which can lead directly to ADHD are alcohol intake and exposure to tobacco smoke during pregnancy1,2,14,15, extremely premature birth or low birth weight and exposure to certain toxic substances such as lead and polychlorinated biphenyls16. Traumatic brain injury and infection of the brain by certain viruses and bacteria during early childhood may also result in ADHD17.

Underlying genetic and environmental causes lead to abnormalities in neurotransmitter systems – the chemicals and signalling systems in your brain which facilitate communication, pleasure-seeking, motivation, activity and decision-making. These are primarily the dopamine and norepinephrine systems18,19. Due to imbalances in these pathways, people with ADHD struggle with controlling their behaviours in the same way as others, and medications primarily attempt to correct these imbalances.

Is the prevalence of ADHD increasing and how common is it?

According to the diagnostic criteria used in South Africa, ADHD affects between 5 and 7% of children and 2-5% of adults8. More boys are diagnosed with ADHD, most likely due to them exhibiting more disruptive symptoms than girls4. This effect seems to decline in adulthood, possibly due to girl’s symptoms becoming more obvious as intellectual demands increase with age20.

Although diagnosis has been increasing since the 1970’s, it is not believed that this shows an increase in the frequency of the disorder, but rather reflects better diagnosis strategies, awareness and acceptance, as well changing societal pressures toward busier and focussed lifestyles21.

Can environmental factors make ADHD worse?

Some environmental factors, although not supported as leading to ADHD, may worsen symptoms or make it harder for sufferers to focus on tasks at hand2,22.

Stress is a large contributor, making concentrating, sleeping and staying focused more difficult. Many ADHD like symptoms can also cause stress, resulting in a cycle which only makes ADHD worse. Effective stress management is therefore essential to living with ADHD.

Overstimulation can also worsen symptoms and usually occurs when a person is in a loud and busy environment, such as in crowds. In these circumstances, it becomes difficult for the brain to decide which stimuli are meaningful and which are not, resulting in worsening of ADHD symptoms, especially in terms of the ability to focus.

Other contributing factors to worsening of ADHD symptoms include sleep deprivation and the presence of distractions such as TV, cell phones and loud music.

Is ADHD associated with any other psychological conditions?

The symptoms and causes of ADHD overlap with a number of other psychological conditions. Due to this, ADHD can be associated with other disorders. These include:

  • Sleep disorders such as insomnia and restless leg syndrome23,24
  • Learning disabilities, including speech, language and academic skills disorders25
  • Anxiety disorders26
  • Mood disorders, including bipolar and depression1,6
  • Obsessive-compulsive disorder27
  • Substance use disorders, both as an attempt to cope with symptoms and difficulty in balancing risk versus rewards28
  • Tourette syndrome29
  • Some other non-psychological issues such as obesity, asthma and migraine30

How is ADHD diagnosed?

Diagnosis of ADHD should be carried out by a qualified professional. Diagnosis can be difficult due to the complexity of the condition, ranges of severity of each separate symptom and difficulty in quantifying ‘normal’ versus ‘abnormal’ ranges of each.

In order for a diagnosis to be made, symptoms must3,31:

  • Appear between the ages of 6 and 12 and be present for more than 6 months
  • Not be appropriate for children of that age
  • Occur and cause problems in at least more than one setting (e.g. work, school, home)

Specifically, diagnosis takes place via a number of routes which assess behavioural and mental development. In children, this is based on feedback from teachers and parents, self-rating scales and other tests designed to assess goal orientation, concentration and activity levels32. Associated conditions are also taken into account. The procedure for adults is mostly the same, although it is necessary to question persons, such as parents or guardians, who knew the individual between the ages of six and 12 to confirm that symptoms were present at this stage33.

Can I or my child live a normal life and still be successful with ADHD?

ADHD can be a lifelong condition, with between 30 and 50% of children diagnosed presenting symptoms into adulthood21,34.

Adolescents with ADHD are most likely to experience trouble due to increased social pressures, changing demands at school, and a rapidly developing brain35. Despite this most people learn how to deal with the condition and develop coping skills, allowing them to lead a more normal life36.

Treatment strategies are essential to developing healthy coping mechanisms as well as reducing symptoms. Unhealthy coping strategies such as avoidance of work or relationships and procrastination are more likely to result in deviant behaviour, substance use and poor social functioning and self-esteem37. With proper treatment, however, those with ADHD can improve over time and develop healthy coping mechanisms, behaviour, good self-esteem and productive social relationships. This is especially true if they pursue a career which they express interest in.

How is ADHD treated?

ADHD treatment revolves around both behavioural and medicinal interventions. Depending on the severity, symptoms and age, approaches can vary, and may be either in isolation or a combination of the two. There is, however, no known cure for ADHD38.

Behavioural therapy

Behavioural therapies are best for candidates with mild symptoms or who are not eligible for drug treatment (such as pre-school aged children), and those with behavioural and emotional issues39. Behavioural therapies can also improve self-esteem, compliance to treatment, lessen the likelihood of substance abuse and other deviant behaviours as well as generally improve functioning at school, work, home and in social situations through teaching sufferers to better recognise and control their own behaviour. These therapies become more effective with age, possibly due to an increased awareness of one’s self and increasing the ability to consciously adopt these strategies20.

Exercise, especially aerobic, has been shown to have significant benefit for ADHD40. This includes significantly improved behavioural control, memory and self-esteem. Mood-related disorders are also benefitted. This is thought to be because exercise causes an increase in neurotransmitters in the brain. Together with this, exercise appears to improve the effectivity of stimulant medications.

Medication

In most cases, stimulant medications such as methylphenidate (Ritalin/Concerta) and amphetamines are prescribed41. These generally affect the dopamine and norepinephrine pathways within the brain, increasing the availability of these signalling molecules42. Non-stimulant medications, such as atomoxetine (an anti-depressant) may also be administered41, but do not appear to affect academic performance and concentration to the same extent43.

Methylphenidate appears to better symptoms in the majority of people44, and stimulants may reduce abnormalities in brain structure and function, at least while the medication is being administered45.

Are there side effects to ADHD treatments?

While stimulant medications offer a number of benefits, there are some document side-effects to their use20,46. These should be discussed with your doctor.

Are there any other solutions to ADHD?

While the side-effects of medication might cause parents and sufferers to seek alternative treatments, they should not ignore the advice of their healthcare provider. Behavioural therapies and medication can offer significant benefit, but in cases where additional support is required, some herbal supplements can help reduce the severity of symptoms.

A few natural compounds have been shown to have improved symptoms which are associated with ADHD while causing few side-effects. Of these, two of the most promising is Rhodiola Rosea (Roseroot) and inositol. Both of these ingredients are well backed by science and are known to have positive effects on a range of factors associated with the mental function.

Rhodiola Rosea has been used for thousands of years in northern European countries to improve mood and combat stress. Recent research has uncovered its ability, in addition to these uses, to enhance mental function, memory and attention span, in part through increasing neurotransmitters such as dopamine in the brain47. This is reflected in its wide use and recognition as an assistive therapy in Russia, Scandinavia, the UK and Sweden.

Inositol is a naturally occurring B vitamin which is present in the body and a number of food sources, especially fruit, beans and nuts. The molecule plays a role in a number of pathways in the brain, especially during the biosynthesis of norepinephrine. Low levels of inositol have been associated with some psychological conditions characterised by low mood, motivation and anxiety48,49, and supplementation of inositol has been shown to alleviate these symtoms49,50.

NeuroVance, a unique blend of the above scientifically endorsed plant-based ingredients, has been developed by The Medical Nutritional Institute to safely and effectively improve mental functioning. The individual ingredients (Rhodiola Rosea, inositol, magnesium and zinc) target multiple biological pathways recognised to reduce stress, improve concentration and focus and promote calmness in both children and adults. As an assistive therapy, NeuroVance can, therefore, help to lessen symptoms of ADHD and assist you or your child in reaching your full potential.

What about diet?

Diet in itself is not likely to cause ADHD, but poor eating habits can worsen symptoms and impair proper brain development.

Refined carbohydrates, simple sugars and some food colourants and additives are known to negatively affect mental function and worsen hyperactivity. Furthermore, ADHD sufferers are more likely to crave and binge eat these foods due to their ability to increase reward signalling in the brain, leading to other health and eating-related disorders, such as obesity. A healthy, well-balanced diet is also essential to proper development of the brain, and lack of many nutrients can cause impairments in brain development.

If you feel a particular food-stuff is negatively affecting your or your child’s ADHD, remove this from the diet and see if symptoms are improved. This should, however, not be done to an extreme – it can be difficult to pick out the true causative factors and removing too many foods from anyone’s diet can result in negative health consequences.

It is most important to ensure that you or your child are eating a healthy, well-balanced diet based on plant-based sources of nutrients and which avoids junk foods and processed carbohydrates.

For more advice on healthy eating in general and with regards to ADHD, email our dietician at dietician@mnilifestyle.co.za .

How can I manage my or my child’s ADHD?

First of all, it is essential to seek professional advice and treatment. There are, however, a few strategies which you can begin to include in your daily life.

  • Organise your or your child’s day, set a routine and create structure. When major changes occur, like a holiday or a visit from a relative, make sure you are aware and prepared for them.
  • Remove distracting stimuli from the environment, especially during times when the focus is required. Ensure that you or your child know that activities such as TV watching are only allowed after work is complete.
  • Do regular aerobic exercise.
  • Set a good example, put rules, structure and discipline strategies in place in both day to day life and before activities. Make sure you or your child understand these and do not deviate from what you have set in place. Consistency is key to maintaining productive behaviour.
  • Talk with teachers and other guardians to ensure they employ these strategies and to understand how your child acts in situations when you are not present.
  • Focus on positive reinforcement, praise and rewards more than punishment. People with ADHD are more likely to perform if they feel that an experience will be pleasurable than to avoid something because of possible negative consequences.
  • Involve your child in the above processes, especially as they age. This will help them develop the ability to implement their own coping strategies, improve their self-esteem and make compliance more likely as they will feel they are actively trying to better themselves.

Taking NeuroVance alongside the above behavioural interventions can also safely and effectively assist you or your child in improving mental function, concentration and motivation, allowing you to live a more productive life and helping you to excel in the activities you see as important.

 

Sources:

  1. Attention Deficit Hyperactivity Disorder. National Institute of Mental Health. Acessed 04 August 2017; https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
  2. Attention-Deficit / Hyperactivity Disorder (ADHD).  Centers for Disease Control and Prevention. Accessed 04 August 2017; https://www.cdc.gov/ncbddd/adhd/facts.html
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®).  (American Psychiatric Pub, 2013).
  4. Gershon, J. & Gershon, J. A meta-analytic review of gender differences in ADHD. Journal of attention disorders 5, 143-154 (2002).
  5. Modesto-Lowe, V., Chaplin, M., Soovajian, V. & Meyer, A. Are motivation deficits underestimated in patients with ADHD? A review of the literature. Postgraduate medicine 125, 47-52 (2013).
  6. Shaw, P., Stringaris, A., Nigg, J. & Leibenluft, E. Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry 171, 276-293 (2014).
  7. Coleman, W. Social competence and friendship formation in adolescents with attention-deficit/hyperactivity disorder. Adolescent medicine: state of the art reviews 19, 278-299, x (2008).
  8. Kooij, S. J. et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC psychiatry 10, 67 (2010).
  9. Thapar, A., Cooper, M., Eyre, O. & Langley, K. Practitioner review: what have we learnt about the causes of ADHD? Journal of Child Psychology and Psychiatry 54, 3-16 (2013).
  10. Neale, B. M. et al. Meta-analysis of genome-wide association studies of attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry 49, 884-897 (2010).
  11. Franke, B. et al. The genetics of attention deficit/hyperactivity disorder in adults, a review. Molecular psychiatry 17, 960 (2012).
  12. Gizer, I. R., Ficks, C. & Waldman, I. D. Candidate gene studies of ADHD: a meta-analytic review. Human genetics 126, 51-90 (2009).
  13. Kebir, O., Tabbane, K., Sengupta, S. & Joober, R. Candidate genes and neuropsychological phenotypes in children with ADHD: review of association studies. Journal of psychiatry & neuroscience: JPN 34, 88 (2009).
  14. Burger, P. et al. How does maternal alcohol consumption during pregnancy affect the development of attention deficit/hyperactivity syndrome in the child. Fortschritte der Neurologie-Psychiatrie 79, 500-506 (2011).
  15. Abbott, L. C. & Winzer-Serhan, U. H. Smoking during pregnancy: lessons learned from epidemiological studies and experimental studies using animal models. Critical reviews in toxicology 42, 279-303 (2012).
  16. Eubig, P. A., Aguiar, A. & Schantz, S. L. Lead and PCBs as risk factors for attention deficit/hyperactivity disorder. Environmental health perspectives 118, 1654 (2010).
  17. Eme, R. ADHD: an integration with pediatric traumatic brain injury. Expert review of neurotherapeutics 12, 475-483 (2012).
  18. Schultz, W. Neuronal reward and decision signals: from theories to data. Physiological Reviews 95, 853-951 (2015).
  19. Jamkhande, P. G. & Khawaja, A. Role of norepinephrine reuptake inhibitors in attention deficit hyperactivity disorder: A mechanism-based short review. International Journal of Nutrition, Pharmacology, Neurological Diseases 6, 146 (2016).
  20. Brahmbhatt, K. et al. Diagnosis and treatment of attention deficit hyperactivity disorder during adolescence in the primary care setting: A concise review. Journal of Adolescent Health 59, 135-143 (2016).
  21. Thomas, R., Sanders, S., Doust, J., Beller, E. & Glasziou, P. Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics 135, e994-e1001 (2015).
  22. Identifying Your ADHD Triggers. Healthline. Acessed 04 August 2017; http://www.healthline.com/health/adhd/adhd-trigger-symptoms
  23. Corkum, P., Davidson, F. & MacPherson, M. A framework for the assessment and treatment of sleep problems in children with attention-deficit/hyperactivity disorder. Pediatric Clinics of North America 58, 667-683 (2011).
  24. Tsai, M.-H. & Huang, Y.-S. Attention-deficit/hyperactivity disorder and sleep disorders in children. Medical Clinics of North America 94, 615-632 (2010).
  25. DuPaul, G. J., Gormley, M. J. & Laracy, S. D. Comorbidity of LD and ADHD: Implications of DSM-5 for assessment and treatment. Journal of Learning Disabilities 46, 43-51 (2013).
  26. Bériault, M. et al. Comorbidity of ADHD and anxiety disorders in school-age children: impact on sleep and response to a cognitive-behavioral treatment. Journal of attention disorders, 1087054715605914 (2015).
  27. Abramovitch, A., Dar, R., Mittelman, A. & Wilhelm, S. Comorbidity between attention deficit/hyperactivity disorder and obsessive-compulsive disorder across the lifespan: a systematic and critical review. Harvard review of psychiatry 23, 245 (2015).
  28. Ortal, S. et al. The Role of Different Aspects of Impulsivity as Independent Risk Factors for Substance Use Disorders in Patients with ADHD: A Review. Current drug abuse reviews 8, 119-133 (2014).
  29. El Malhany, N., Gulisano, M., Rizzo, R. & Curatolo, P. Tourette syndrome and comorbid ADHD: causes and consequences. European journal of pediatrics 174, 279-288 (2015).
  30. Instanes, J. T., Klungsøyr, K., Halmøy, A., Fasmer, O. B. & Haavik, J. Adult ADHD and comorbid somatic disease: a systematic literature review. Journal of attention disorders, 1087054716669589 (2016).
  31. Steinau, S. Diagnostic criteria in attention deficit hyperactivity disorder–changes in DSM 5. Frontiers in psychiatry 4 (2013).
  32. Subcommittee on attention-deficit/hyperactivity disorder, steering committee on quality improvement and management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, peds. 2011-2654 (2011).
  33. De Crescenzo, F., Cortese, S., Adamo, N. & Janiri, L. Pharmacological and non-pharmacological treatment of adults with ADHD: a meta-review. Evidence-based mental health 20, 4-11 (2017).
  34. Ginsberg, Y., Quintero, J., Anand, E., Casillas, M. & Upadhyaya, H. P. Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. The primary care companion for CNS disorders 16 (2014).
  35. Molina, B. S. et al. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child & Adolescent Psychiatry 48, 484-500 (2009).
  36. Gentile, J. P., Atiq, R. & Gillig, P. M. Adult ADHD: diagnosis, differential diagnosis, and medication management. Psychiatry (Edgmont) 3, 25 (2006).
  37. Harpin, V., Mazzone, L., Raynaud, J.-P., Kahle, J. & Hodgkins, P. Long-term outcomes of ADHD: a systematic review of self-esteem and social function. Journal of attention disorders 20, 295-305 (2016).
  38. Shaw, M. et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC medicine 10, 99 (2012).
  39. Fabiano, G. A. et al. A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. Clinical psychology review 29, 129-140 (2009).
  40. Den Heijer, A. E. et al. Sweat it out? The effects of physical exercise on cognition and behavior in children and adults with ADHD: a systematic literature review. Journal of Neural Transmission 124, 3-26 (2017).
  41. Markowitz, J. S. & Yu, G. in Applied Clinical Pharmacokinetics and Pharmacodynamics of Psychopharmacological Agents     303-327 (Springer, 2016).
  42. Rubia, K. et al. Effects of stimulants on brain function in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Biological Psychiatry 76, 616-628 (2014).
  43. Prasad, V. et al. How effective are drug treatments for children with ADHD at improving on-task behaviour and academic achievement in the school classroom? A systematic review and meta-analysis. European child & adolescent psychiatry 22, 203-216 (2013).
  44. Parker, J., Wales, G., Chalhoub, N. & Harpin, V. The long-term outcomes of interventions for the management of attention-deficit hyperactivity disorder in children and adolescents: a systematic review of randomized controlled trials. Psychology research and behavior management 6, 87 (2013).
  45. Spencer, T. J. et al. Effect of psychostimulants on brain structure and function in ADHD: a qualitative literature review of MRI-based neuroimaging studies. The Journal of clinical psychiatry 74, 902 (2013).
  46. Watson, S. M. R., Richels, C., Michalek, A. P. & Raymer, A. Psychosocial treatments for ADHD: A systematic appraisal of the evidence. Journal of attention disorders 19, 3-10 (2015).
  47. Hung, S. K., Perry, R. & Ernst, E. The effectiveness and efficacy of Rhodiola rosea L.: a systematic review of randomized clinical trials. Phytomedicine 18, 235-244 (2011).
  48. Kim, H., McGrath, B. M. & Silverstone, P. H. A review of the possible relevance of inositol and the phosphatidylinositol second messenger system (PI‐cycle) to psychiatric disorders—focus on magnetic resonance spectroscopy (MRS) studies. Human Psychopharmacology: Clinical and Experimental 20, 309-326 (2005).
  49. Mukai, T., Kishi, T., Matsuda, Y. & Iwata, N. A meta‐analysis of inositol for depression and anxiety disorders. Human Psychopharmacology: Clinical and Experimental 29, 55-63 (2014).
  50. Akhondzadeh, S., Gerbarg, P. L. & Brown, R. P. Nutrients for prevention and treatment of mental health disorders. Psychiatric Clinics of North America 36, 25-36 (2013).