ADHD TREATMENT, CLASSIFICATION, AND PATHOGENESIS IN DUBAI

gregorkowalnew

Dr Gregor Kowal
Specialist in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

ADHD is a developmental disorder. It is characterized primarily by “the co-existence of attentional problems and hyperactivity, with each behaviour occurring infrequently alone” and symptoms starting before seven years of age. It is one of the most common childhood disorders and can continue through adolescence and adulthood. Those with ADHD in Dubai display the same problems with inattentiveness, over-activity, impulsivity, or a combination.

Signs and symptoms

Symptoms include difficulty staying focused and paying attention, difficulty controlling behaviour, hyperactivity (over-activity) and impulsivity. The symptoms are especially difficult to define because it is hard to draw the line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin.

Based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V)

ADHD Criteria

Below an excerpt from the ADHD Institute’s website:

Overview of the DSM-5TM medical classification system for ADHD
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:1
For children, six or more of the symptoms (Table) have persisted for at least 6 months to a degree that is inconsistent with developmental level, and that negatively impacts directly on social and academic/occupational activities. Please note: the symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or failure to understand tasks or instructions1
For older adolescents and adults (age 17 and older), five or more symptoms are required (Table)1
Several inattentive or hyperactive-impulsive symptoms present prior to age 12 years1
Several inattentive or hyperactive-impulsive symptoms present in two or more settings (e.g. at home, school or work; with friends or relatives; in other activities)1
Clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning1
Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).1
DSM-5TM diagnostic criteria for ADHD: symptoms of inattention, hyperactivity and impulsivity.

Symptoms of inattention Symptoms of hyperactivity and impulsivity
Often fails to give close attention to detail or makes mistakes Often fidgets with or taps hands and feet, or squirms in seat
Often has difficulty sustaining attention in tasks or activities Often leaves seat in situations when remaining seated is expected
Often does not seem to listen when spoken to directly Often runs and climbs in situations where it is inappropriate (in adolescents or adults, may be limited to feeling restless)
Often does not follow through on instructions and fails to finish schoolwork or workplace duties Often unable to play or engage in leisure activities quietly
Often has difficulty organising tasks and activities Is often ‘on the go’, acting as if ‘driven by a motor’
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort Often talks excessively
Often loses things necessary for tasks or activities Often blurts out answers before a question has been completed
Is easily distracted by extraneous stimuli Often has difficulty waiting their turn
Is often forgetful in daily activities Often interrupts or intrudes on others

Three presentations of ADHD are defined in DSM-5™ based on the predominant symptom pattern for the past 6 months:1

  • Combined presentation – all three core features are present and ADHD is diagnosed when ≥6 symptoms of hyperactivity/impulsivity and ≥6 symptoms of inattention have been observed for ≥6 months
  • Predominantly inattentive presentation – diagnosed if ≥6 symptoms of inattention (but <6 symptoms of hyperactivity/impulsivity) have persisted for ≥6 months
  • Predominantly hyperactive/impulsive presentation – diagnosed if ≥6 symptoms of hyperactivity/impulsivity (but <6 symptoms of inattention) have been present for ≥6 months.

Furthermore, the DSM-5TM also states that it must be specified whether the individual with ADHD is in ‘partial remission’ (when partial ADHD criteria have been met for the past 6 months with full criteria met previously, and the symptoms still result in impairment in social, academic or occupational functioning)1 and the current severity of the disease.1

The current severity of ADHD should also be specified:1

  • Mild – few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning
  • Moderate – symptoms or functional impairment between ‘mild’ and ‘severe’ are present
  • Severe – many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present; or the symptoms result in marked impairment in social or occupational functioning.

The DSM-5TM notes that although motor symptoms of hyperactivity become less obvious in adolescence and adulthood, difficulties persist with restlessness, inattention, poor planning and impulsivity. The DSM-5TM also acknowledges that a substantial proportion of children remain relatively impaired into adulthood.1
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2004.
 

Cause/ Causes:

Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. ADHD probably results from a combination of factors like genetics, environmental factors, and the social and physical environment.

Genetics

Inherited from our parents, genes are the “blueprints” for who we are. Results from several international studies of twins show that ADHD often runs in families. Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.

brain

PET scan: ADHD brains

Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases. Hyperactivity also seems to be primarily a genetic condition; however, other causes do have an effect. Researchers believe that a large majority of ADHD cases arise from a combination of various genes.The broad selection of targets indicates that ADHD does not follow the traditional model of “a simple genetic disease” and should therefore be viewed as a complex interaction among genetic and environmental factors. Even though all these genes might play a role, to date no single gene has been shown to make a major contribution to ADHD.

Environmental factors.

Twin studies have suggested that approximately 9 to 20 percent of the variance in hyperactive-impulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared environmental (nongenetic) factors. Complications and infections during pregnancy and in early childhood, premature births are linked to an increased risk of developing ADHD.

Evolutionary theories            

The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of ADHD. The theory suggests that hyperactivity may be an adaptive behavior in pre-modern humans and that those with ADHD retain some of the older “hunter” characteristics associated with early pre-agricultural human society. According to this theory, individuals with ADHD may be more adept at searching and seeking and less adept at staying put and managing complex tasks over time.

Further evidence showing hyperactivity may be evolutionarily beneficial was put forth in 2006 in a study which found it may carry specific benefits for certain forms of ancient societies. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk or competition (i.e. hunting, mating rituals, etc.).

A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele), has been found to be at higher frequency in more nomadic populations and those with more of a history of migration. Consistent with this, another group of researchers observed that the health status of nomadic Ariaal men was higher if they had the ADHD associated genetic variant (7R alleles). However in recently sedentary (non-nomadic) Ariaal those with 7R alleles seemed to have slightly worse health.

Social

Some researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. Behavior typical of ADHD has been found in children who have suffered violence and emotional abuse. Furthermore, Complex Post Traumatic Stress Disorder can result in attention problems that can look like ADHD.

Pathophysiology

The pathophysiology of ADHD is unclear and there are a number of competing theories. Research on children with ADHD has shown a proportionally greater reduction in the volume of the left-sided prefrontal cortex. A 2005 review of published studies involving neuroimaging, neuropsychological genetics, and neurochemistry found converging lines of evidence to suggest that four connected frontostriatal regions (the lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, and putamen) play a role in the pathophysiology of ADHD.

 

Diagnosis of ADHD in Dubai

As is generally the case, the symptoms of those with ADHD in Dubai usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. To be diagnosed with ADHD in Dubai, or elsewhere, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age. Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD.

ADHD should be diagnosed via a psychiatric assessment; to rule out other potential causes or comorbidities, physical examination, radiological imaging, and laboratory tests may be used.

Parents may first notice that their child loses interest in things sooner than other children, or seems constantly “out of control.” Often, teachers notice the symptoms first, when a child has trouble following rules, or frequently “spaces out” in the classroom or on the playground. No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behaviour and environment.

A specialist will also check school and medical records for clues, to see if the child`s home or school settings appear unusually stressful or disrupted, and gather information from the child`s parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted.

ADHD Treatment

ADHD treatment in Dubai is a partnership between the physician/psychologist, parents or caregivers, and the child. The entire process of ADHD treatment usually involves combination of medications, psychotherapy, behavior modifications and lifestyle changes. A 2005 study found that medical management and behavioral treatment is the most effective ADHD management strategy, followed by medication alone, and then behavioral treatment

Medications

The most common type of medication used for ADHD treatment is called a “stimulant.” Although it may seem unusual to treat ADHD with a medication considered a stimulant, this ADHD treatment actually has a calming effect on children. Many types of stimulant medications are available. One nonstimulant drug is also approved for the ADHD treatment and is less likely to be misused.

Psychotherapy

Different types of psychotherapy are used for ADHD treatment in Dubai. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. It also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. Clear rules, chore lists, and other structured routines can help a child control his or her behavior. Talk therapy for both the child and family can help everyone understand and gain control of the stressful feelings related to ADHD.

ADHD in adults

ADHD in adults remains a clinical diagnosis. The signs and symptoms may differ from those during childhood and adolescence due to the adaptive processes and avoidance mechanisms learned during the process of socialization. Many adults with ADHD in Dubai are not aware they have this mental health disorder. These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. They may seem restless and may try to do several things at once, most of them unsuccessfully.

ADHD in adults remains a clinical diagnosis. The signs and symptoms may differ from those during childhood and adolescence due to the adaptive processes and avoidance mechanisms learned during the process of socialization. Many adults who have the disorder don`t know it. These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. They may seem restless and may try to do several things at once, most of them unsuccessfully.

ADHD Treatment in adults

ADHD medications, including extended-release forms, often are prescribed and available for adults with ADHD in Dubai, but not all of these medications are approved for adults. However, those not approved for adults still may be prescribed by a doctor on an “off-label” basis.

Psychotherapy, including cognitive behavioral therapy, also can help change one`s poor self-image by examining the experiences that produced it. The therapist encourages the adult with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.

Facts:

– It is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 percent of children globally and diagnosed in about 2 to 16 percent of school aged children.

– It is a chronic disorder with 30 to 50 percent of those individuals diagnosed in childhood continuing to have symptoms into adulthood. Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.

– Medications have at least some effect in about 80% of the patients.

– ADHD exists alone in only about 1/3 of the children diagnosed with it. 2/3 appears in combination with other psychiatric diagnosis.

– ADHD is diagnosed two to four times more frequently in boys than in girls.

 

References

1 DSM-IV-TR workgroup. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.

2 Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry, 2005; 57:1313-1323.

3 Khan SA, Faraone SV. The genetics of attention-deficit/hyperactivity disorder: A literature review of 2005. Current Psychiatry Reports, 2006 Oct; 8:393-397.

4 Shaw P, Gornick M, Lerch J, Addington A, Seal J, Greenstein D, Sharp W, Evans A, Giedd JN, Castellanos FX, Rapoport JL. Polymorphisms of the D4 receptor, clinical outcome and cortical structure in attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 2007 Aug; 64(8):921-931.

5 Linnet KM, Dalsgaard S, Obel C, Wisborg K, Henriksen TB, Rodriguez A, Kotimaa A, Moilanen I, Thomsen PH, Olsen J, Jarvelin MR. Maternal lifestyle factors in pregnancy risk of attention-deficit/hyperactivity disorder and associated behaviors: review of the current evidence. American Journal of Psychiatry, 2003 Jun; 160(6):1028-1040.

6 Mick E, Biederman J, Faraone SV, Sayer J, Kleinman S. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry, 2002 Apr; 41(4):378-385.

7 Braun J, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to environmental toxicants and attention-deficit/hyperactivity disorder in U.S. children.Environmental Health Perspectives, 2006 Dec; 114(12):1904-1909.

8 Wolraich M, Milich R, Stumbo P, Schultz F. The effects of sucrose ingestion on the behavior of hyperactive boys. Pediatrics, 1985 Apr; 106(4):657-682.

09 Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interaction. Journal of Abnormal Child Psychology, 1994; 22:501-515.

10 McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, Kitchin E, Lok E, Porteous L, Prince E, Sonuga-Barke E, Warner JO. Stevenson J. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet, 2007 Nov 3; 370(9598):1560-1567.

11 The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder. Archives of General Psychiatry, 1999; 56:1073-1086.

12 U.S. Department of Transportation, National Highway Traffic Safety Administration, Legislative Fact Sheets. Traffic Safety Facts, Laws. Graduated Driver Licensing System. January 2006.

13 Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 2002; 53:113-131.

14 Wilens TE, Haight BR, Horrigan JP, Hudziak JJ, Rosenthal NE, Connor DF, Hampton KD, Richard NE, Modell JG. Biological Psychiatry, 2005 Apr 1; 57(7):793-801.

15 Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, Chuang S, Vitiello B, Skroballa A, Posner K, Abikoff H, Oatis M, McCracken J, McGough J, Riddle M, Ghouman J, Cunningham C, Wigal S. Stimulant-related reductions in growth rates in the PATS. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1304-1313.

16 Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle