In the United States, it is estimated that around 9.8% of children (ages 3-17 years) have been diagnosed with Attention-deficit hyperactivity disorder (ADHD) at some point (Centers for Disease Control and Prevention [CDC], 2023) and that 4.4% of adults (18-44 years) have ADHD (National Institute of Mental Health [NIMH], n.d.).
In Puerto Rico, there are no studies that report recent statistics regarding the prevalence of ADHD. In the summary of the Health Needs Assessment in Puerto Rico for 2020, a prevalence of 26.6% is reported among the ages of 2-17 years according to the data obtained in the Jurisdictional Survey – Maternal and Child Health (MCH-JS) of 2019. Within the adult population, in 2012, an estimated prevalence of ADHD symptoms of 5.6% was identified between the ages of 18 and 64 years (Toro-Mejías et al. 2012).
Understanding ADHD is important. In this blog post, I offer you basic information regarding its symptoms, diagnosis, and treatment.
What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity that interferes with functioning or development. It typically manifests in childhood and can continue into adulthood, affecting various aspects of an individual's life, including academic, occupational, and social functioning.
Types of ADHD:
Predominantly Inattentive Presentation: characterized mainly by symptoms of inattention. Individuals may struggle with organizing tasks, following through on instructions, or paying attention to details. They may be easily distracted and forgetful in daily activities.
Predominantly Hyperactive-Impulsive Presentation: marked primarily by hyperactivity and impulsivity. Individuals may fidget, talk excessively, or have difficulty remaining seated in situations where it is expected. They may also act without thinking, interrupt others, or struggle with waiting their turn.
Combined Presentation: includes symptoms of both inattention and hyperactivity-impulsivity. It is the most common presentation and reflects a mixture of the symptoms described in the other two types.
Symptoms of ADHD
Inattention:
Difficulty Sustaining Attention: Individuals with ADHD often have trouble focusing on tasks or activities for extended periods. They may find it challenging to stay engaged in conversations, reading, or lectures.
Forgetfulness: Frequent forgetfulness in daily activities, such as forgetting appointments, to complete tasks or misplacing items, is a common symptom.
Disorganization: Struggling with organizing tasks and activities is typical. This may manifest as a messy workspace, difficulty prioritizing tasks, or problems with time management.
Hyperactivity:
Fidgeting: Continuous fidgeting with hands or feet, or an inability to stay seated, is a hallmark of hyperactivity. Individuals may tap their fingers, bounce their legs, or move around excessively.
Inability to Stay Seated: In situations where staying seated is expected, such as in the classroom or during meetings, individuals with ADHD may find it difficult to remain seated.
Excessive Talking: Talking excessively and having difficulty engaging in quiet activities can suggest hyperactivity. Individuals may dominate conversations or have trouble waiting their turn to speak.
Impulsivity:
Interrupting Others: Impulsivity often leads to interrupting or intruding on others' conversations or activities. Individuals may have difficulty waiting for their turn in discussions or games.
Difficulty Waiting Turns: Waiting in line or waiting for their turn in group activities can be challenging for individuals with ADHD.
Making Hasty Decisions: Impulsivity can result in making quick decisions without considering the consequences. This may lead to taking risks or engaging in potentially harmful behaviors without thinking them through.
Causes and Risk Factors
No exact causes have been identified for ADHD. Research has shown a strong genetic component to ADHD, with over 20 studies confirming it is highly inherited. However, ADHD is a complex disorder influenced by multiple interacting genes and environmental factors such as early childhood exposure to lead, premature birth, or brain injury. Scientists continue to investigate how these factors contribute, recognizing that no single cause explains all cases of ADHD.
Brain Structure and Function
Over time, various investigations have associated ADHD with structural differences in the caudate nucleus, globus pallidus, and prefrontal cortex, including but not limited to reduced size and hypoactivity. Mehta et al. (2019) offer a summary of the relationship and neurochemical activity between the different areas of the brain involved. The prefrontal cortex stands out for its connection with other essential areas in the regulation of attention and behavior and its role in working memory. This review also mentions structural alterations in the cerebellum, as well as functional and structural alterations in the anterior cingulate cortex. Thus, from initial models more focused on the prefrontal cortex and higher cognitive functions, over the years, new studies have focused on circuits and systems throughout the brain (Cortese et al., 2012).
On the other hand, when talking about neurochemical processes, we can highlight the role of dopamine and norepinephrine. ADHD has been associated with dopaminergic dysfunction in the brain, particularly in the mesocortical (motivation), mesolimbic (reward), and nigrostriatal (cognitive functioning and control of voluntary movements) circuits (Mehta et al., 2019). According to the dopamine hypothesis, the reduction in dopamine is due to increased dopamine reuptake, resulting in low levels of extracellular dopamine. The authors (Mehta et al. 2019) conclude that this is confirmed by the efficacy of methylphenidate (a dopamine reuptake inhibitor psychostimulant) in the treatment of ADHD.
Diagnosis of ADHD
The diagnosis of ADHD is based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (American Psychiatric Association [APA], 2022). These criteria require a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Symptoms must be present in multiple (at least two) settings (e.g., at home, school, or work) and should have been evident before the age of 12.
Process:
Medical Evaluation: A thorough medical evaluation can help to rule out other potential causes of the symptoms. This evaluation may include a physical exam, a review of medical history, and possibly lab tests to check for conditions like thyroid problems or lead poisoning.
Psychological Assessment: A psychologist or psychiatrist may conduct assessments to evaluate attention, hyperactivity, and impulsivity. These assessments often involve questionnaires, behavioral checklists, and structured interviews with the individual and others who know them well (such as parents, teachers, or partners).
Observation and Interviews: Observations in different settings and interviews with the individual and their family members help gather information about how symptoms manifest across various aspects of life. This step is crucial in understanding the impact of ADHD on daily functioning.
Diagnosing ADHD can be challenging, particularly in adults, as the symptoms can overlap with other mental health conditions such as anxiety, depression, or learning disabilities. Additionally, adults may have developed coping mechanisms that mask their symptoms, making it harder to identify the disorder. Misdiagnosis or underdiagnosis is also a concern, highlighting the importance of a comprehensive evaluation by a trained professional.
Management and Treatment
ADHD management and treatment is not a one-size-fits-all and requires a holistic and multidisciplinary approach.
The preferred treatment for ADHD and with the greatest scientific basis (studied since the 1970s) is pharmacological, specifically stimulants and atomoxetine, being the most effective treatments (Connor, 2014; Wolraich et al., 2019), at least in the short term (Buoli et al., 2015; Mechler et al., 2022). There is a wide variety of formulations for these medications that allow patients to adapt the treatment to their different needs (Mattingly et al., 2017).
In any case, the ideal would be a combination that works with the symptoms, healthy lifestyles, and the presence of other comorbid diagnoses or as a consequence of ADHD.
Medications:
Stimulants (e.g., methylphenidate, amphetamines, lisdexamfetamine)
Non-stimulants (e.g., atomoxetine, guanfacine, and clonidine)
Therapies:
Behavioral Therapy
Cognitive Behavioral Therapy (CBT)
Social Skills Training
Mindfulness-based Interventions
Lifestyle Changes:
Diet and Nutrition
Exercise
Sleep Hygiene
Support Systems:
Family and Friends (e.g., Parenting Skills Training)
Support Groups
Educational Support (e.g., Classroom Programs for Teachers)
Additional Resources
Books and Articles:
Driven to Distraction by Dr. Edward M. Hallowell and Dr. John J. Ratey: A classic guide to understanding ADHD, offering practical strategies for managing symptoms.
Taking Charge of ADHD by Dr. Russell A. Barkley: A comprehensive resource for parents of children with ADHD, focusing on evidence-based strategies.
The ADHD Effect on Marriage by Melissa Orlov: A guide to navigating relationships where one or both partners have ADHD.
Organizations and Support Groups:
CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder): Offers resources, support groups, and advocacy for individuals with ADHD and their families. Visit CHADD
ADDA (Attention Deficit Disorder Association): Provides support, webinars, and resources specifically for adults with ADHD. Visit ADDA
Understood.org: A resource for parents, educators, and individuals with ADHD, offering personalized support and tools. Visit Understood
Living with ADHD can be challenging, but it’s important to remember that having ADHD does not define your abilities or potential. Many people with ADHD lead successful, fulfilling lives by understanding their strengths and learning to manage their symptoms effectively. Whether you’re just beginning your journey or have been managing ADHD for years, know that you are not alone. With the right support, tools, and strategies, you can achieve your goals and succeed.
If you suspect that you or a loved one may have ADHD, seeking professional help is a crucial first step. A proper diagnosis can open the door to effective treatments and strategies that can significantly improve quality of life. Additionally, spreading awareness about ADHD helps reduce stigma and encourages a more supportive and understanding environment for everyone affected by the condition.
References
American Psychiatric Association. (2022). Neurodevelopmental disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).
Buoli, M., Serati, M., & Cahn, W. (2016). Alternative pharmacological strategies for adult ADHD treatment: a systematic review. Expert Review of Neurotherapeutics, 16(2), 131–144. https://doi.org/10.1586/14737175.2016.1135735.
Centers for Disease Control and Prevention. (2023, October 16). Data and Statistics About ADHD. Retrieved April 9, 2024, from https://www.cdc.gov/ncbddd/adhd/data.html.
Connor, D. (2014). Medications for Children, In Barkley, R. A. (Ed.), Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford.
Cortese, S., Kelly, C., Chabernaud, C., Proal, E., Di Martino, A., Milham, M. P., & Castellanos, F. X. (2012). Toward systems neuroscience of ADHD: a meta-analysis of 55 fMRI studies. American Journal of Psychiatry, 169(10), 1038-1055. https://doi.org/10.1176/appi.ajp.2012.11101521.
Del Toro-Mejías, L., Venegas-Ríos, H., Reyes, J. C., & Colón, H. (2012, October 29). Prevalence of Attention Deficit-Hyperactivity Disorder symptoms among 18-64 year-olds in Puerto Rico [Conference Paper]. 140st APHA Annual Meeting and Exposition 2012, San Francisco, CA, United States.
Maternal, Child and Adolescent Health Division. (n.d.). Puerto Rico 2020 Health Needs Assessment. Puerto Rico Department of Health. Retrieved April 10, 2024, from https://www.salud.pr.gov/CMS/DOWNLOAD/6822.
Mattingly, G. W., Wilson, J., & Rostain, A. L. (2017). A clinician’s guide to ADHD treatment options. Postgraduate medicine, 129(7), 657-666. https://doi.org/10.1080/00325481.2017.1354648
Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2022). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & therapeutics, 230, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940.
Mehta, T. R., Monegro, A., Nene, Y., Fayyaz, M., & Bollu, P. C. (2019). Neurobiology of ADHD: a review. Current Developmental Disorders Reports, 6, 235-240. https://doi.org/10.1007/s40474-019-00182-w.
National Institute of Mental Health. (n.d.) Attention-Deficit/Hyperactivity Disorder (ADHD). U.S. Department of Health and Human Services, National Institutes of Health. Retrieved April 9, 2024, from https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd.
Wolraich, M. L., Chan, E., Froehlich, T., Lynch, R. L., Bax, A., Redwine, S. T., ... & Hagan, J. F. (2019). ADHD diagnosis and treatment guidelines: a historical perspective. Pediatrics, 144(4). https://doi.org/10.1542/peds.2019-1682.
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