ATTENTION DEFICIT HYPERACTIVITY DISORDER

What is ADHD?
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A neurodevelopmental disorder
An unspecified communication disorder
People with this disorder show impairing levels of inattention,
hyperactivity and/or impulsivity
1. Inattention - being disorganized, lacking persistence and having
difficulty in sustaining focus especially during tasks but this is not
due to difficulties in comprehension
2. Hyperactivity - inappropriate and/or excessive exercise of motor
activities such as fidgeting, tapping, or talkativeness; extreme
restlessness and wearing others out with activities which are most
common in adults.
3. Impulsivity - ones tendency to act with little or no forethought
that could harm the individual. It may also reflect as a desire for
immediate rewards or an inability to delay gratification, or social
intrusiveness.

Etiology & Pathomechanics of ADHD

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There is no definitive cause of ADHD, however there are a lot of studies

and theories surrounding its causation.
Both genetic and environmental etiologies seem to contribute to the
neurobiological differences of people with ADHD which in turn manifest
as ADHD symptoms
There are numerous of ways in which genetic and environmental
factors might go hand-in-hand to Neurobiological Factors which in turn
causes ADHD symptoms
1. Genes may convey a risk for ADHD but exposure to a particular
biological or experiential stressors is necessary to activate that
risk and set the child on a path towards the disorder
2. Genetic and environmental may combine to elevate ones risk for
ADHD
3. Certain genes or gene combinations can render some individuals
susceptible to particular neurotoxic factors in the environment
Genetics
Genetics seems to be the largest contributor to ADHD
It should be noted that ADHD is not a genetic disorder (e.g.
Trisomy, Mosaicism, etc.) rather it is familial and highly heritable
Evidences for this support was done through family, twin and
adoption studies which suggests that heritability of ADHD
estimates around 60-90%

Family studies - parents with ADHD have a two-to eightfold increased risk of passing the behavior down to their
children

One family study by Biederman et. al (1995) reported

that the incidence of ADHD among children of parents
with ADHD is 55%

Twin studies - compared identical (monozygotic) to

fraternal (dizygotic) twins to estimate heritability or the
proportion of individual differences in ADHD

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The results suggested that regardless of type of twin,

the average heritability of ADHD is at least 80-90%

Thus, regardless of belonging to a twin or non-twin

sibling the risk of having ADHD is the same

Adoption studies - done to confirm that families that are

biologically related more likely to have hyperactivity than
families who have adopted children
To identify the specific chromosome regions or specific genes that
are associated with this ADHD, genome and candidate gene
search studies were done

The studies identified five different gene regulating

neurotransmitter systems that appears to be substantial
evidence in the etiology of ADHD namely:

Dopamine D4 receptor (DRD4) - associated with the

personality trait of novelty seeking (personality trait
associated with exploratory activity in response to novel
stimulation, impulsive decision making, extravagance in
approach to reward cues, and quick loss of temper and
avoidance of frustration)

Dopamine D5 Receptor (DRD5) - subtype of the dopamine

receptor

Dopamine SLC6A3 Transporter - regulates dopamine and

is affected by stimulant medication

Synaptosomal-Associated Protein of 25kD (SNAP-25) affects dopamine and serotonin levels

Serotonin HTR1B Receptor - thought to underlie the

impulsive symptom of ADHD

Environment
Some environmental Factors associated with ADHD
Prenatal
Perinatal
Postnatal
Alcohol
Smoking
Prescribed drugs (especially
psychotropics and
anticonvulsants)
Illegal drugs
Toxaemia
Hemorrhage
Rashes and fever
Psychological stress
Fetal distress

Gestational age
and birth weight
Apgar below 5
Hypoglycaemia
Respiratory distress
Encephalopathy
(e.g. fits)

A number of environmental factors have been found to be linked

with ADHD, spanning from pre- and perinatal events to post-natal
Prenatal anything that affects the mothers body chemistry and
biology will also affect the fetus. If a babys brain is damaged
during pregnancy this is likely to increase the risk of that baby
growing up to develop ADHD

Toxaemia - blood poisoning by toxins from a local bacterial

infection
Perinatal
Hypoglycemia - deficiency of glucose in the bloodstream
important to keep blood sugar balanced

Encephalopathy - general term describing a disease that

affects the function or structure of your brain
Also, some ADHD cases might be due to injuries of the brain
suffered during early pre- or postnatal development
Most complications are associated with hypoxic insults, low
birth weight, and prematurity that affect the brain structures
associated in the acquisition of ADHD.
Other Environmental Theories that have no evidence

Bad parenting - The parents of children with the disorder

can sometimes exhibit traits that might be considered bad
parenting (e.g. they are short tempered and highly stressed),
but this is most often due to dealing with their childs
behavior.

Gestational age
and birth weight
Apgar below 5
Hypoglycemia
Respiratory distress
Encephalopathy
(e.g. fits)

C.

Diet - sugar is not believed to be a cause of ADHD, but it

may be true that some food additives increase hyperactivity.
Television Viewing early television viewing (at ages 1-3)
causes attention problems

Neurobiological Factors
Decreased overall brain size that affects both structures and
functions of the frontal striatal cerebellar circuits

Individuals with ADHD, when compared to age- and sexmatched peers, have about 3-8% smaller brain volume
Prefrontal Cortex

'brain center' because it takes in information through senses,

like touch and sight, and processes it to make decisions
about reactions and behaviors. It is more than just a
personality center. The activity in this region is an important
decision maker, often called executive function.

Since the prefrontal cortex is significantly smaller, executive

function, attention and self-regulation are affected
Basal Ganglia - composed of neurological structures namely the
caudate nucleus, lentiform nucleus, claustrum and amygdaloid
nucleus

Connects the cerebrum and the cerebellum and regulates

the connections of the substantia nigra that is responsible
for producing dopamine (regulate movement and emotional
responses and reward and pleasure centers)

Thus, damage in this area has been found to produce

hyperactivity

But researchers also found that the caudate nucleus

appears to normalize in size by mid-adolescence, this may
be the neurophysiological basis why symptoms of
hyperactivity diminished with increasing age
Cerebellum

Damage in this area is believed to be involved in

problematic timing and attention shifting
Inattention, hyperactivity, and impulsivity are the results of
underlying deficits in behavioral inhibition, resistance to
distraction, and executive functioning
Neurotransmitters - play an important role in influencing the
brain functioning

The primary neurotransmitters involved are dopamine and

serotonin but other researches have included
norepinephrine, acetylcholine, GABA, MAOs and nicotinic
receptors

These evidences were found through the responses of

children with ADHD to medications like Ritalin, Cylert and
Dextrine which increase the release and inhibit the reuptake
of dopamine, and Strattera which inhibits norepinephrine

Raising the level of serotonin in the brain seems to lessen

the hyperactivity associated with ADHD by causing the
dopamine levels and serotonin levels to reach a proper
balance.
All these anatomic and physiological variations may all affect a
sort of braking system in the brain as it is constantly coursing
with many overlapping thoughts, emotions, impulses, and sensory
stimuli

Boys were more likely than girl to have ever been diagnosed with
ADHD with 13.2% and 5.6% rate respectively
A census done by the US Census Bureau in 2004, the prevalence of
ADHD in the Philippines is at 1,046,314 out of 86, 241, 697 or 1.21% of
the population. Due to lack of information, awareness and resources,
no incidence rates are available

Signs & Symptoms of ADHD

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There must be an indication of the symptoms before the age of 12

Manifestation of the disorder must be present in more than one setting
but may vary depending on the context within a given setting
Require high frequency (must be present for more than 6 months
There must be clear evidence of clinically significant impairment in
social, academic or occupational functioning
There are 18 symptoms divided into two groups:
a. Inattention
Fails to give close attention to details
Problems in sustaining attention
Problems with listening when spoken directly
Fails to follow through instructions & finish activities
Difficulty in organization
Avoids tasks that entails sustained mental effort
Loses necessary items
Easily distracted by external stimuli
Forgetful
b. Hyperactivity-Impulsivity
Fidgets/Squirms/Tap hands and feet
Problems staying seated
Often rubs about or climbs
Unable to engage in leisure activities quietly
On the go or driven by a motor
Talks extensively
Blurts out answers before a question has been completed
Problems waiting for his turn
Interrupts or intrudes

Classifications for ADHD

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Children 16 years and younger, at least 6 symptoms must be present

People aged 17 and older, at least 5 symptoms must be present
a. ADHD with predominantly inattention
At least 6 inattention symptoms
b. ADHD with predominantly hyperactivity-impulsivity
At least 6 hyperactivity-impulsivity symptoms
c. ADHD with combined presentation
At least 6 mixed symptoms of inattention & Hyperactivityimpulsivity
Other Classifications used by clinicians:
a. Other Specified ADHD
offers clinicians a way to identify ADHD in a person who may
not meet full criteria but whose presentation is otherwise
consistent with the diagnosis
b. Unspecified ADHD
used to offer a way for clinicians to indicate their initial
impressions when were unable to complete a full evaluation

Prevalence of ADHD

SLP Problems

As of 2011, 11% or 6.4 million children ages 4-17 have been diagnosed
with ADHD in USA
Percentage of children diagnosed with ADHD continues to increase,
from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011
Rates of ADHD diagnosis continues to increase with an average of 3%
per year from 1997 to 2006 and an average of approximately 5% per
year from 2003 to 2011
Population surveys suggest that ADHD occurs in most cultures in about
5% of children and about 2.5% of adults.

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People with ADHD may experience speech, gross, and fine motor
delays due to having smaller brain volume and problem with the flow of
neurotransmitters that play essential roles in attention and thinking.
People with ADHD can have a delay in their gross motor development
due to their inability to slow down and focus on their movements. In
addition, a study conducted by Curtin University of Technology,
demonstrates that people with ADHD have less developed fine motor
skills.

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Delay in both fine and gross motor movements can affect speech and
language. Since we acquire language through play and exploration
using gross motor movements and we use fine motor movements for
speech production.
Auditory Processing Disorder
Although their sensory language processing is generally not
impaired, they may still have problems processing auditory stimuli
or difficulties in differentiating important speech sounds due to
inattention.
Social/Pragmatic Disorder
It can manifest deficits in social communication and participation,
understanding, and difficulty in following the social use of verbal
and nonverbal communication.
Examples of pragmatic issues we can see are:

Talking at inappropriate times,

Interrupting people when theyre talking,

Speaking too loudly during conversations,

Having trouble filtering our background noise to pay

attention,

Problems in reading facial expressions, and

Make unrelated comments or talk about things out of context

Difficulties in receptive language acquisition and expressive
language may arise because of problems in pragmatics.
Speech sound disorders specifically phonological disorder
Due to problems acquiring language.
Hoarseness or trouble speaking at the right volume
This can be due to involuntary vocal tics such as clearing their
throat repeatedly, grunting or coughing or because of vocal abuse
such as frequent screaming or yelling.
Fluency
Attention issues can also make it hard for kids to organize their
thoughts and slow down their speech. For some kids this means
they say everything that comes to mind, for others it means their
mouth cant keep up with the pace of their thoughts. Both
situations can cause kids to stammer or stutter as they try to get
their thoughts out.

Rehabilitation Team
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Developmental pediatricians
focus is on developmental, behavioral and learning issues from
infancy through young adulthood.
hey are highly trained and experienced in identifying a range of
developmental and behavioral differences which includes ADHD
Can evaluate the childs overall development, give a diagnosis,
and recommend specific treatment plans
They are usually the head of a medical team providing
intervention for our clients with ADHD.
Speech-Language Pathologists
Specializes in communication and swallowing problems. The SLP
can address all the issues mentioned above, particularly problems
in auditory processing and pragmatics.
They may also address fluency, persisting phonological
processes, articulation and voice problems if any were observed.
Occupational therapists
can give therapy programs that can address the childs sensory
processing issues and help the child become more attentive by
adapting the environment and activities
They can also provide the child with tools and coping techniques
for use within school, home and other settings

Joan is the prettiest

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Can also target self-regulating behaviors or the ability of a person

to identify and adjust their level of alertness
Psychologists
help in addressing the clients external behavior problems.
These problems involved a host of oppositional behaviors
including willful noncompliance or defiance in response to adult
directives or rules, disruption of on-going activities,
argumentativeness, stubbornness, temper outbursts, verbal
hostility and physical aggression
Conduct problems such as lying, stealing, fighting, truancy, and
vandalism can also be address as well
Moreover, 50% of children with ADHD have oppositional defiant
disorder (ODD) and over 20% have conduct disorder (CD)
Teachers
Difficulties with learning may arise like difficulties in attending and
focusing on topics in class and long conversations with
classmates or teachers will be hard to sustain
In comparison with their peers, lesser efforts and motivation when
it comes to studying and poor academic performances are usually
seen with students having ADHD that causes poor academic
performances and low grades
Guidance Counselors
May play a big role for ADHD clients in the school setting. It is
found that most of ADHD clients have struggle with emotional
regulation
They may also have problems with peer relations including
difficulties forming and maintaining friendships 5. Some of them
may also results in smoking and drinking abuse and substance
use
Guidance counsellors in schools may help them in coping with
these issues.
Family
Will always be one of the most, if not the most, important part of
the rehabilitation team.
They are with the kid almost 24/7.
They are responsible for continuing the therapy at home. If they
family is not compliant with what the medical team will provide for
the client, any intervention will be rendered useless.
A highly cooperative and accepting family member is a good
prognosticating factor for the clients faster development.

Support Groups
CHADD (International Organization)
Membership organization that produces the bi-monthly Attention
magazine (for members) and sponsors an annual conferences about
ADHD
Attention Deficit Disorder Association (ADDA) (International
Organization)
Provides information, resources and networking opportunities to help
adults with Attention Deficit Hyperactivity Disorder lead better lives
ADHD Society of the Philippines (Local Organization)
Parent-based organization that gives support, seminars, national
conferences, articles and discussions for not only persons with ADHD
but also their family and the general public
ADHD Society - ADHD Parents Association (Local Organization)
By Kenneth Ostranger - Ateneo, Loyola
Provides articles to raise awareness of the condition, parenting tips and
intervention tips for individuals with ADHD and their family