الفهرس 
HISTORY, NEUROBIOLOGY AND PATHOPHYSIOLGYOnly 14 pages are availabe for public view
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Abstract
Attention deficit hyperactivity disorder (ADHD is a very common disorder among children at school age and adolescents. Recent research indicates that this disorder is not outgrown in adulthood but it persists in many cases leading to serious consequences that affect the whole aspects of the patient’s life.
The prevalence rate of ADHD is 3-5 times more common in boys than in girls. ADHD is a developmental disorder that requires an onset of symptoms before age 7 years.
ADHD is considered a multifactorial neurobehavioral disorder. The dysregulation of neurotransmitters, namely norepinephrine and dopamine in the prefrontal cortex and subcortical structures, the prenatal, natal, postnatal risk factors like exposure to teratogen, birth hypoxia, and exposure to toxins in addition to genetic factors are all important factors in the etiology of this disorder.
ADHD subdivides into three types: a) predominantly inattentive type; b) predominantly hyperactive-impulsive type; c) combined type. The predominantly inattentive type is more common in females and, together with the combined type, seems to have a higher impact on academic performance. Children with the predominantly hyperactive-impulsive type are more aggressive and impulsive than those with the other two types of ADHD, and tend to be unpopular and highly rejected by their peers. The combined type causes more impairment to global functioning, comparatively to the other two types.
The core symptoms of ADHD which include inattention, hyperactivity and impulsivity all lead to marked psychological problems with social interactions, self esteem, leaning problems, academic difficulties, and underachievement, leading to marked dysfunction in the major domains of a person’s life. Thus a patient with ADHD has poor interpersonal relations in his family, marriage or work. This patient also has problems both in education and later in occupational functioning, such problems are substantial reasons for seeking medical advise.
The core symptoms of ADHD usually manifest differently in adulthood. Hyperactivity often changes to inner restlessness; the patient has constant activity, unable to sit still for long time, talks excessively leading to continuous tension both at home or work. Inattention usually manifests in disorganization, poor time management and forgetfulness. Impulsivity in adulthood usually manifests in poor decision making, poor capability to listen to others, risky driving and sexual behaviors.
The frequent complaints commonly presented by adults include cognitive complaints, such as inability to concentrate, forgetfulness, and confusion, complaints due to difficulties in self-regulation e.g., lack of organization, inability to establish and maintain a routine, poor discipline and complaints derived from both the cognitive and the self regulation issues. These take the form of problems at work.
Several diagnostic systems are proposed for diagnosis of ADHD including the DSM IV criteria, and the ICD 10 criteria however they are all in efficient to diagnose patients and lead to under diagnosis and misdiagnosis of the disorder. The diagnosis of ADHD is difficult as its core symptoms are experienced by every individual, also many disorders either psychiatric such as mood disorders, anxiety disorders, and borderline personality disorder or medical such as thyroid disease epilepsy and dementia may present with such symptoms, in addition to the high incidence of comorbidity with ADHD in the adulthood including antisocial personality disorder, substance use disorders, mood disorders, generalized anxiety disorder, learning disorders.
Steps of the diagnosis of ADHD in adults are:
• Asses current ADHD symptoms within the least 6months
• Establish a childhood history of ADHD
• Asses functional impairment at home, work and school and in relationships.
• Obtain developmental history, including during perinatal, childhood and school years.
• Obtain psychiatric history: rule out other psychiatric disorders or establish comorbid diagnosis
• Obtain family psychiatric history, especially concerning learning problems, attention and behavior problems, ADHD and tics. Inquire about all first degree relatives
• Perform physical examination: rule out medical causes of symptoms (e.g. serious head injury, seizures, heart problems, thyroid problems) or contraindications to medical problems (e.g. hypertension, glaucoma).
Many investigations are available for patients with patient with however none them is diagnostic. They include psychometric evaluation by various tests like continuous performance tests, the Stroop test, the Trial Making test, the controlled word association test and others, however ADHD can be diagnosed even when these tests are normal and they are all only good positive tests. Brain imaging MRI and PET scans have been useful to investigate the neuro anatomical basis of ADHD including the small size of the left-orbito-frontal cortex found in a small study done on 8 patients, the focal dysfunction in areas such as dorsal anterior cingulated cortex, dorsolateral prefrontal cortex and the striatum, however brain imaging studies can’t be used in diagnosis as there is currently a very little number of studies on adults and their results didn’t yield specific results that can be used for diagnosis.
The treatment of ADHD includes both pharmacological and psychotherapeutic approaches which help the patients hand in hand in improving the core symptoms of the disorder and in ameliorating the psychological impacts and improving the dysfunctional domains of the patient’s life.
Pharmacotherapy include both stimulant and non stimulant medications. For long time stimulants have been the mainstays for treating patients with ADHD, recent studies indicated it’s efficacy in treating the disorder however they are major concerns about its abuse potential especially in the presence of high incidence of comorbidity between ADHD and substance use disorders.
Non stimulant medications include tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRIs), Bupropion, Atomoxetine. Only one of them which is atomoxetine is approved by the FDA in 2003 in treating patients with adult ADHD. With regard to psychosocial interventions, it is fundamental that psychiatrists educate the family about the disorder, giving them clear and accurate information. It is important that parents know the best strategies so as to help their children organize and plan their activities. For instance, these children need a study environment that is quiet, consistent, and does not have many visual stimuli.
Interventions at school also are important. In this regard, teachers should ideally be aware of the necessity of a well-structured classroom, with few students. Consistent daily routines and a predictable school environment help these children to keep their emotional control.
In psychosocial interventions focused on children and adolescents, cognitive-behavioral therapy is the most widely studied modality, with scientifically proven efficacy in the treatment of central symptoms (inattention, hyperactivity, impulsivity), and associated behavioral symptoms (opposition, defiance, stubbornness), especially behavioral treatments. Among behavioral treatments, parental training seems to be the most efficient modality.
Congnitive behavioral therapy (CBT) is the most effective form of psychotherapy that can applied to patients with ADHD either on an individual or group basis. Also family therapy and marital therapy are essential.