Attention-deficit hyperactivity disorder

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Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by significant problems with attention, hyperactivity, or impulsivity. ADHD is one of the most common childhood disorders and frequently continues through adolescence and into adulthood. In the US, approximately 11% of children 4-17 years old and about 4.4% of adults are diagnosed with the disorder. ADHD diagnosis rates vary based on the specific criteria used for diagnosis, so these figures are not exact and may vary by a few percent. Although ADHD's diagnoses are disproportionately male, evidence suggests ADHD is often overlooked and subsequently underdiagnosed in females due to differences in how ADHD symptoms present themselves.

Newly-emerging evidence suggests ADHD may be overdiganosed. However, there may well be small-scale (regional) cases of both underdiagnosis and overdiagnosis. Although the number of people diagnosed by ADHD has risen in recent decades, research suggests the actual prevalence of the disorder has not increased in the past three decades. Evidence of physical changes in the brains of people with ADHD exist.

Symptoms and diagnostic criteria

Under the DSM-5's guidelines for diagnosis, ADHD is separated into the primarily inattentive presentation (ADHD-PI), the primarily hyperactive/impulsive presentation (ADHD-H), and the combined type presentation (ADHD-C). Diagnosis requires a certain number of symptoms of either inattention or hyperactivity listed in the DSM to be present for at least six months. Additionally, diagnosis requires the symptoms to be impairing, are not consistent with the patient's developmental level, are present in multiple settings, and were present prior to age 12.

Symptoms of inattention include paying poor attention to details, making careless mistakes, difficulty with sustained attention, being easily distracted, being unable to follow through on tasks, difficulty with organization, avoiding or disliking sustained mental effort, losing things, and forgetfulness.

Symptoms of hyperactivity/impulsivity include fidgeting, restlessness, an inability to stay seated, an inability to play quietly, excessive talking, having trouble waiting, and interrupting people.

Although most people will experience one or more of these symptoms in their lifetime, a diagnosis of ADHD is only made if all of the DSM criteria is met (and the symptoms listed in the DSM are more specific than the ones listed here).

Causes

Brain imaging studies have revealed that people with ADHD have delayed brain maturation rates, especially in areas associated with thinking, paying attention, and planning. Many have speculated genes have a large part to play; researchers are also looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.

There are cases where the person only struggles with attention, which is called ADHD Primarily Inattentive-type (ADHD-PI) or Attention Deficit Disorder (ADD). These children have real difficulty in school, not because they do not understand the lessons, but because they have an inability to focus on a subject. This is why these children were often called "underachievers" in the past. Recently research shows dopaminergic transportation issue (1a). This is directly related to an iron deficiency in certain parts of the brain. Dopamine-enhancing drugs are often prescribed as a matter of course for many sufferers of this condition.

There is very little evidence that food dyes cause ADHD as opposed to the rigorous 35 years of being tested by the FDA and other regulatory bodies.

Treatments

ADHD is commonly treated with behavioral therapy, medication (often stimulants), or some combination of both. The nonexistence of a cure is agreed upon by medical scientists; treatment targets symptoms or aims to reduce symptoms' effects, and any treatment's efficacy varies from individual to individual.

Behavioral Therapy

Whereas medication has been used to treat ADHD since the 1950s, cognitive behavioral therapy (CBT) took its modern form in the late 20th century and began to be used to target ADHD even more recently. Its effects are quite different from those of medication. Medication targets ADHD's primary symptoms; CBT involves training the recipient to act and think in ways which diminish the effects of ADHD, and may also be used to treat common comorbid disorders. Likely due to its relative novelty and peripheral role, CBT tends to be regarded as an optional tool to be used in concert with medication. Research suggests cognitive behavioral therapy may be able to play a positive role in minimizing the effects of ADHD (once it advances further).

Medication

The most common drugs prescribed to treat ADHD are methylphenidate (Ritalin/Concerta), amphetamine salts (Adderall) and dextroamphetamine (Vyvanse/Dexedrine/Dextrostat). In rare cases, methamphetamine (Desoxyn) may be used as a treatment. There are also non-stimulant medications for ADHD, such as atomoxetine (Strattera), guanfacine (Intuniv/Tenex), and clonidine (Kapvay). Antidepressants and blood pressure medication are also used to treat some cases of ADHD. Everyone responds differently to different medications at different doses, so it often takes a while to find a medication that works.

Although stimulant medications tend to be the preferred treatment due to their strong and immediate effects (75-90% of patients respond well to stimulant medications), they do have side effects, and a potential for misuse and abuse exists. The most common side effects of stimulant medications include insomnia, reduced appetite/weight loss, headaches, stomach aches, mood changes, dry mouth, and an increase in heart rate/blood pressure, but there are many other common side effects, far too many to list here. Although a detailed discussion of how ADHD medications work is far beyond the scope of this article, their primary function is to increase levels of dopamine and norepinephrine by inhibiting reuptake or increasing release of those neurotransmitters.

Unfortunately, stimulant medications are frequently misused and abused in order to pull all nighters, function with little sleep, study for exams, or even just for the euphoria larger doses can provide. When abused, they are usually taken at much larger doses than those prescribed for the treatment of ADHD, sometimes by snorting or injecting ground-up pills. This can lead to serious health complications and severe side effects such as psychosis, addiction, and sudden death, especially at higher doses. Because of this, the stimulant medications commonly used to treat ADHD are classified as controlled substances. When prescribed by a doctor (and taken as prescribed), stimulants are considered a safe and effective treatment for ADHD.

The stimulants used to treat ADHD can benefit everyone to some extent, which has led to some people questioning the validity of treating ADHD, and others to call for unrestricted access to stimulants for everyone. However, prescribing medication requires a risk-benefit analysis. Patients with ADHD benefit drastically from ADHD medication and have a legitimate medical need for the medication. People who do not have ADHD will not benefit as drastically from medication, and do not have a legitimate medical need for the medication. Therefore, the benefit outweighs the risks only in the case of patients with ADHD. In addition, it is unclear how much these stimulants can actually benefit people who don't have ADHD. Research on stimulants and arousal theory suggests too much activation or arousal has negative effects on cognition, which supports the hypothesis that stimulants benefit people with ADHD far more than people with no attention issues.

There is some evidence that ADHD medication can have short-term effects on growth in children, but new research suggests stimulant medication does not have an effect on adult height or growth rate. ADHD treatment reduces the rate of substance abuse by 31%.

Controversies

There are a great number of myths and controversy around ADHD medications. Doctors are often criticized for prescribing potent psychostimulants to children. Although these stimulants have a long record of safety, they do carry risks, and people tend to ignore how much untreated ADHD can impair a child's life. Some people believe ADHD is not a real disorder and medications are used to turn kids into obedient zombies. The evidence that ADHD is a real disorder is robust, and it's quite simply absurd to claim that these stimulants are turning kids into zombies. Others believe ADHD can be easily overcome without drugs. While it's true some people with ADHD do not require medication, especially those with a less severe presentation, this does not mean everyone with ADHD can get by without medication, even if they use behavioral therapy.

Many people believe ADHD medication is overprescribed to varying degrees, but the evidence does not support the view that ADHD medication is systemically oversubscribed. Even more blame ADHD on poor parenting, poor discipline, sugar, not enough exercise, too much TV, not enough reading, western society, school, not enough time outside in nature, bad teachers, boring curriculum, or laziness. All of those "causes" are ridiculous and lack supporting evidence. All these proposed causes are not only disproven, but since they are a widespread attitude, they are damaging to the person's mental health and self confidence (imagine having poor eyesight and 20/20 people constantly berate you for being lazy and not seeing hard enough) and can promote a self fulfilling prophecy, and it also unfairly blames the parents and overlooks the children by treating children as extensions of the parents. Some people believe ADHD can be cured via diet, exercise, fish oil, supplements, nootropics, etc. While there is some limited evidence to support these "cures", they are nowhere near as effective as medication and will do little for most people with ADHD and will continue allowing people with ADHD to struggle.

For a summary of antipsychiatry talking points about the scientific status of ADHD and the use of stimulant drugs in its treatment, Stephen Barrett of Quackwatch (who is a psychiatrist himself) offers a refutation of them on his page.

Adult ADHD

Though most commonly thought of as a disorder of childhood, about 4% of American adults suffer from ADHD. If left untreated, adults with ADHD may have difficulty retaining a job, maintaining relationships, managing finances, or managing similar responsibilities requiring organization and focus. In particular, adults suffering from ADHD may find the Americans with Disabilities Act does little to protect them in the workplace, since organization and time management can be argued to be essential duties of almost any job. Untreated or undiagnosed adults sometimes attempt to self-medicate using caffeine or other stimulants.

Pseudoscience

Because the actual cause of ADHD remains elusive to medical science (although the consensus is that genes play a large role), that leaves plenty of room for quack doctors to speculate all the livelong day on what causes it and offer up their own dangerous advice on how to treat it.

• Joseph Mercola - states ADHD is over-diagnosed because of Big Pharma, speculates that anything from food additives, wheat gluten, high-fructose corn syrup, vaccines, and/or water fluoridation causes ADHD. Suggests that ADHD can be treated nutritionally by cutting out sweeteners and processed foods.

• NaturalNews - says ADHD is a scam of Big Pharma and psychiatry, speculates that mercury from vaccines, common non-organic pesticides, and anesthesia cause ADHD. States that homeopathic cures work better than Ritalin and that eating organic food treats it.

• Infowars - says prescribing kids ADHD drugs is "chemical warfare" and mass murder and Big Pharma is intentionally diagnosing kids for increased profits.

• Conservapedia - states that methamphetamine is prescribed for ADHD (true, under the brand name Desoxyn, but relegated to extremely rare and treatment-resistant cases and subject to heavy monitoring and intense scrutiny; Ritalin and Adderall are far more common) and attempts to correlate methamphetamine with homosexuality.

• Scientology - has always opposed psychiatry and its proponents believe all psychological conditions are scams, including ADHD.

• A popular meme/claim amongst armchair proponents of evolutionary psychology is that ADHD is not a disorder but an adaptation from the good old days when we hunted mammoths with spears or something (explaining its higher prevalence among boys, which as stated above may just be an artifact of missed diagnoses in girls). Although the hypothesis that ADHD may have an evolutionary origin is not pseudoscientific in and of itself, it is a misunderstanding of evolutionary theory to claim anything which was once adaptive at some point in our history is adaptive in our current society (compare the once-adaptive predilection for high-calorie foods full of salt and sugar that now leads to overeating and obesity).

• Not to mention the ever-so-prevalent idea that those with ADHD should just get over their issues and learn to focus and be happy like everyone else by using the amazing self-control that they apparently have by the standards of others.

• Men's rights activists will occasionally point to higher diagnosis rates in boys and claim that ADHD is used to "pathologize masculinity" or otherwise punish boys for being boys. In reality this disparity is thought to be a result of ADHD being underdiagnosed in girls due to differences in presentation.

• There are people who insist that the symptoms are caused by a thyroid disease instead. While both can have similar symptoms, patients are usually sent through a blood test to check if there's something wrong with their thyroid before their doctor decides where the patient should be treated, and thyroid issues are usually accompanied by various physical symptoms as well. It probably has turned into outright denialism if the "Blame the thyroid" people start ignoring the lack of physical symptoms, the omnipresentness of the mental symptoms, completely normal blood test results and the psychiatrist/psychologist's word. Depending on the person, expect hypothyroidism woo as well.

• Various fad diets have achieved popularity for their purported effects in reducing symptoms. However, there is no evidence that nutrients play a significant role in reducing ADHD symptoms.

That effing 'ficticious disease' deathbed confession myth that just won't lie on its deathbed

A popular claim, made mainly by cranks and Big Pharma Nutters^TM is that Dr. Leon Eisenberg, a prominent child psychologist who made numerous contributions to understanding ADHD, confessed to ADHD being a fictitious disease. Unsurprisingly, this is textbook quote mining: he merely said he thought it was over-diagnosed; he never said it was fake. This hasn't stopped cranks from claiming otherwise, however.

See also

For those of you in the mood, RationalWiki has a fun article about Attention Deficit Disorder.

• Autism and pseudoscience
• Big Pharma
• Mental illness denial

Further reading

• "RSNA Press Release: MRI Technique Reveals Low Brain Iron in ADHD Patients". RSNA Press Release. 2 December 2013. Retrieved 18 March 2014.