Attention Deficit Hyperactivity Disorder is ADD real
Attention Deficit Hyperactivity Disorder
Synonyms: ADHD, attention deficit hyperactivity disorder, attention deficit disorder (ADD), hyperkinetic syndrome (HKS), fidgety philipp syndrome
English: attention deficit hyperactivity disorder (ADHD), attention deficit disorder (ADD)
The Attention Deficit Hyperactivity Disorder is a behavioral disorder that occurs mainly in children and is associated with impaired concentration, motor hyperactivity and increased excitability. Motor hyperactivity is, however, to be regarded as an optional symptom, since it is probably just as common in a manifestation without hyperactivity (dreamers). It is not uncommon to find additional disorders of social behavior. The severity and distribution of the various symptoms varies with the age of the affected patient.
In addition to the term "attention deficit hyperactivity disorder", the literature also contains the terms "attention deficit disorder" or "attention deficit disorder" for short ADS. In some cases they are used synonymously, in some cases they are intended to express the fact that the symptom of those affected is primarily the attention disorder, not the hyperactivity. So far (2018), however, the designation ADS has not been able to establish itself as a separate disease entity.
The information on the prevalence of ADHD differs depending on the underlying diagnostic criteria. The DSM-IV criteria are lower than the diagnostic criteria according to ICD-10. According to DSM-IV, the prevalence of cross-situational attention deficit hyperactivity disorder is estimated to be 3 to 15% of school-age children. According to the guidelines of an expert consensus, most symptoms persist - partly in a milder form - into adulthood (Ebert et al., 2003).
The causes that lead to ADHD are currently (2018) not yet fully understood. In general, a multifactorial pathogenesis is assumed in which both biological and psychosocial factors play a role.
Recent work suggests that neurobiological factors have a far greater influence than psychosocial ones. Family and twin studies as well as molecular genetic studies have shown that genetic factors play a major role in the pathogenesis.
Damage to the central nervous system during pregnancy or childbirth has also been linked to the occurrence of ADHD.
The diagnosis builds on the general basic diagnosis of mental disorders in childhood and adolescence, as described in the guidelines (Döpfner et al., 2000). The diagnosis should be made by a specialist doctor, in most cases by a psychiatrist or a pediatrician or general practitioner experienced in the field of ADHD. Given the high prevalence of the disease, the latter will become the rule, as the comparatively small number of psychiatrists, especially child and adolescent psychiatrists, cannot cover the need.
The diagnosis of ADHD is complex and requires information from several sources through a combination of interviews, clinical as well as psychiatric and psychological examinations. In interviews with both the legal guardian and the child's teacher, the current hyperkinetic symptoms, the disorder-specific development history and specific medical anamnesis are explored. Standardized questionnaires and validated checklists are helpful. This information is then used to make a diagnosis according to ICD-10 or DSM-IV.
According to the ICD-10, a diagnosis of simple activity and attention disorder requires attention deficit as well as hyperactivity and impulsivity.
DSM-IV, on the other hand, provides three diagnoses:
- Mixed typewhere there is both attention deficit and hyperactivity and impulsivity
- predominantly inattentive type, in which hyperactivity and impulsiveness are not or not noticeably pronounced
- predominantly hyperactive-impulsive typein which the attention deficit is not or not very pronounced.
The classification according to DSM-IV rather reflects reality. The hyperactive type is mostly the mixed type. Experts assume that the pure hyperactive-impulsive type practically does not occur. The inattentive type is numerically underestimated because a visit to the pediatrician or family doctor is less frequent due to the inconspicuousness of the person concerned and the diagnosis is more difficult.
A differential diagnostic delimitation and examination of psychological comorbid disorders is absolutely necessary.
5.1 Symptoms according to ICD-10
At least six of the following symptoms of inattentiveness to an inconsistent and unreasonable degree inconsistent with the child's level of development for at least six months.
- are often inattentive to details or make mistakes in schoolwork and other work and activities,
- are often unable to maintain alertness while doing tasks and playing,
- often do not seem to hear what they are being told
- are often unable to follow explanations or fail to complete their schoolwork, tasks or duties in the workplace (not because of oppositional behavior or because the explanations are not understood),
- are often impaired in organizing tasks and activities,
- often avoid unloved work such as homework that requires mental stamina,
- often lose objects that are important for certain tasks, e.g. for schoolwork, pencils, books, toys and tools,
- are often distracted by external stimuli,
- are often forgetful in the course of everyday activities.
At least three of the following symptoms of overactivity to an inconsistent and unreasonable level inconsistent with the child's level of development for at least six months.
- often wave their hands and feet or squirm on the seats,
- leave their place in the classroom or in other situations where it is expected to remain seated,
- frequently walk around or climb excessively in situations where this is inappropriate (in adolescents and adults this is just a feeling of restlessness),
- are often unnecessarily loud when playing or have difficulties with quiet leisure activities,
- show a persistent pattern of excessive motor activity that cannot be thoroughly influenced by the social context or prohibitions.
At least one of the following symptoms of impulsiveness to an inconsistent and unreasonable level inconsistent with the child's level of development for at least six months.
- often burst out with the answer before the question is finished,
- often cannot wait in a row or wait for their turn to play in games or in group situations,
- often interrupt and disturb others (e.g. interfering with someone else's conversation or game),
- often talk excessively without responding adequately to social constraints.
G4. Onset of the disorder before the age of seven.
G5. Symptom severity: The criteria should be fulfilled in more than one situation, e.g. the combination of inattentiveness and overactivity should exist both at home and in school or in school and in another place where the children can be observed, e.g. in the clinic . (Evidence of cross-situational symptoms usually requires information from more than one source. Parental reports on classroom behavior are often inadequate.)
G6. The symptoms of G1. - G3. cause significant suffering or impairment of social, academic or professional functioning.
G7. The disorder does not meet the criteria for a profound developmental disorder (F84.-), a manic episode (F30.-), a depressive episode (F32.-) or an anxiety disorder (F41.-).
5.2 Symptoms according to DSM-IV
A. Either point (1) or point (2) must apply:
A.1 Six (or more) of the following symptoms of inattentiveness have been consistently present to an inconsistent and inadequate level with the child's developmental level over the past six months:
- often does not pay attention to details or makes careless mistakes in schoolwork, at work or in other activities,
- often has difficulty maintaining alertness while doing tasks or playing games
- often does not seem to listen when others speak to him / her,
- often does not completely follow the instructions of others and cannot complete schoolwork, other work or duties in the workplace (not due to oppositional behavior or difficulties in understanding),
- often has difficulty organizing tasks and activities,
- often avoids, has an aversion to or reluctantly engages in tasks that require prolonged mental effort such as participation in class or homework),
- Often loses items that he / she needs for tasks or activities (e.g. toys, homework books, pens, books or tools),
- is often easily distracted by external stimuli,
- is often forgetful in everyday activities.
A.2 Six (or more) of the following symptoms of hyperactivity and impulsiveness have been consistently present to an inconsistent and inadequate level with the child's developmental level over the past six months.
- often fidgeting hands or feet or sliding around in the chair,
- gets up frequently in class and in other situations where sitting down is expected,
- frequently runs around or climbs excessively in situations where this is inappropriate (in adolescents or adults this can be limited to a subjective feeling of restlessness),
- often has difficulty playing calmly or engaging in leisure activities calmly,
- is often "on the move" or often acts as if he / she were "driven",
- often talks excessively (counted as an impulsivity characteristic in ICD-10).
- often blurts out with the answers before the question is finished,
- can hardly wait for his / her turn
- often interrupts and disturbs others (e.g. bursts into other people's conversations or games).
B. Some symptoms of hyperactivity, impulsiveness, or inattentiveness that cause impairment appear before the age of seven (or six years according to ICD-10).
C. Impairments caused by these symptoms show up in two or more areas (e.g. at school or at work or at home).
D. There must be clear indications of clinically significant impairments to social, academic or professional functioning.
E. The symptoms do not arise exclusively in the course of a profound developmental disorder, schizophrenia, or any other psychotic disorder, nor can they be better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
ADHD is treated with a comprehensive treatment program. This treatment program usually includes psychological, educational and social measures and is often supplemented by drug therapy.
Medication is often a necessary support for psychotherapy or educational counseling and pedagogy, as the children can better implement the instructions and measures conveyed and have improved self-control.
6.1 Drug therapy
The current guideline recommends drug treatment starting with a moderate form of the disease. First and foremost, methylphenidate is used and the dose is adapted to the requirements of the individual case. Therapy with methylphenidate should be started with a low dose and increased in small steps until a tolerable and sufficiently effective dose is reached.
The principle here is to keep the dose as small as possible without dosing too low. Treatment should be started gradually. We recommend starting with 5 mg and taking it at intervals of 3.5 - 4 hours. The following scheme has proven to be practicable (data in mg):
- 1-3 Day: 5-0-0
- 4th-6th Day: 5-5-0
- 7th-9th Day: 5-5-5
- from 10th day: 10-5-5
The daily dose can then be increased at one to two-week intervals by 5-10 mg, based on the total daily dose, whereby a maximum daily dose of 60 mg should not be exceeded.
The total daily dose is usually taken throughout the day. After the setting has been made, a check is carried out to determine whether compliance is good, since the necessary intake of the second dose is often not carried out during school days. In this case, you can switch to a long-term or medium-term effective sustained-release preparation that covers school and homework time. However, it seems important to consider that coverage over the greater part of the day is necessary for the development of the person concerned, since an improved ability to control in family and peer groups is at least as desirable for the development of social skills and the reduction of the potential for conflict that usually exists Improvement of educational ability.
6.2 Neurofeedback therapy
So-called neurofeedback is used as a non-drug therapy, primarily by specially trained occupational therapists or as part of project studies at university hospitals. In the process, an abnormality in the area of brain frequency distribution that is largely symptomatic in people with ADHD is normalized by EEG-supported training. Improvements in alertness, activity regulation, and impulse control usually occur after about ten to 20 one-hour sessions. The recommended duration of therapy is around 40 hours. Due to the neuroplasticity, the results should be permanent and, in appropriate cases, make further treatment with psychotropic drugs superfluous. However, the method is not undisputed and is still the subject of clinical research.
The drug treatment of ADHD, like the diagnosis itself, is not without controversy and is discussed controversially - also within medical circles. Some critics do not consider ADHD to be an independent clinical picture, but rather a vague collective term for very different behavioral disorders. Others warn that pharmacotherapy is often prescribed without an adequate diagnosis and could be used to mask other types of problems, particularly disorders in the family environment.
8 Literature and Sources
- American Academy of Child and Adolescent Psychiatry (1997). Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit / hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 85S-121S.
- American Academy of Child and Adolescent Psychiatry (2002). Practice Parameters for the Use of Stimulant Medications in the Treatment of Children, Adolescents, and Adults. Journal of the American Academy of Child and Adolescent Psychiatry 41, 2 Supplement, 26-49.
- American Academy of Pediatrics (2001). Clinical Practice guideline: Treatment of the school-aged child with attention-deficit / hyperactivity disorder. Pediatrics 108, 1033-1044.
- American Academy of Pediatrics (2000). Clinical practice guideline: diagnosis and eva-luation of the child with attention-deficit / hyperactivity disorder. Pediatrics 105, 1158-1170
- German Society for Child and Adolescent Psychiatry and Psychotherapy, Professional Association of Doctors for Child and Adolescent Psychiatry and Psychotherapy in Germany, Federal Working Group of Leading Clinical Physicians for Child and Adolescent Psychiatry and Psychotherapy (2000). Guidelines for the diagnosis and therapy of mental disorders in infants, children and adolescents. Cologne: Deutscher Ärzte Verlag.
- Döpfner, M., Frölich, J. & Lehmkuhl, G. (2000). Hyperkinetic disorders. Guide to Child and Adolescent Psychotherapy, Volume 1. Göttingen, Hogrefe.
- Döpfner, M. & Lehmkuhl, G. (2002). ADHD from childhood to adulthood - introduction to the main topic. Childhood and Development, 11, 67-72. Döpfner, M. & Lehmkuhl, G. (2003). Hyperkinetic disorders (F90).In: German Society for Child and Adolescent Psychiatry and Psychotherapy, Professional Association of Doctors for Child and Adolescent Psychiatry and Psychotherapy in Germany, Federal Working Group of Leading Clinical Doctors for Child and Adolescent Psychiatry and Psychotherapy (Ed.) Guidelines for the diagnosis and treatment of mental disorders in infants -, Childhood and Adolescence (2nd revised edition), 237-249. Cologne: Deutscher Ärzte Verlag.
- Döpfner et al .: Diagnostics of mental disorders in children and adolescents. Guide to Child and Adolescent Psychotherapy, Volume 2. Göttingen, Hogrefe, 2000.
- Ebert et al .: ADHD in adulthood - guidelines based on an expert consensus with the support of the DGPPN, Der Nervenarzt 10, 939-946, 2003.
- Taylor, E., Sergeant, J., Doepfner, M., Gunning, B., Overmeyer, S., Möbius, H. & Eisert, H. G. (1998). Clinical guidelines for hyperkinetic disorder. European Child & Adolescent Psychiatry, 7, 184-200.
- German Medical Association: Statement on "Attention Deficit / Hyperactivity Disorder (ADHD)" (long version)
- Behavioral Therapy & Psychosocial Practice. Focus: ADHD from childhood to adulthood. 2015: 4.
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