ADHD: CLINICAL REVIEW 1

Attention Deficit/Hyperactivity Disorder: Clinical Review

PNWU School of Occupational Therapy

Ruby Guevara and Adriana Turtura

OTH 525: Human Capacities II

Dr. Wendell Nakamura

March 24, 2024

ADHD: CLINICAL REVIEW 2

Attention Deficit/Hyperactivity Disorder: Clinical Review

Part I: Overview of the Condition

General Description

According to the National Institute of Mental Health (NIMH; 2023), attention-deficit

hyperactivity disorder (ADHD) affects 11% of school-age children. Indications typically arise in

early childhood, with three presentations: Predominantly Inattentive, Hyperactive-Impulsive, and

Combined. Symptoms include difficulty paying attention, sustaining attention, listening,

following instructions, organization, mental effort, losing things, distraction, forgetfulness, and

hyperactivity (NIMH, 2023). Researchers are not sure what causes ADHD, however Faraone et

al. (2021) noted many studies suggest genes play a large part. In addition to genetics, researchers

are also studying how brain injuries, nutrition, and social environments might play a role in

developing the condition (Farone et al., 2021). While some research indicates that boys are more

likely to develop ADHD than girls, other studies suggest that since the disorder is commonly

associated with hyperactivity symptoms, many girls who suffer from Predominantly Inattentive

ADHD may miss receiving a diagnosis (Mowlem et al., 2019). It is common for these girls to

manifest the condition as adolescents or young adults upon reaching adulthood (NIMH, 2023).

ADHD is a neurodevelopmental disorder linked to executive functioning, which is

regulated by the brain's prefrontal cortex. Wilkins (2023) states research has shown that this part

of the brain is smaller in kids with ADHD. According to Thomas (2022), ADHD is associated

with low levels of dopamine and noradrenaline leading to dysfunctional neural networking in the

prefrontal cortex and basal ganglia. This leads to decreased alertness, attention span, and

working memory, difficulty initiating and sustaining activities, and difficulty staying still or in

one place. One piece of evidence for this theory is that stimulant medications such as Adderall
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are often successful in reducing ADHD symptoms, and these medications suppress the reuptake,

or removal, of dopamine (Wilkins, 2023).

Global Burden of Disease

In recent years, the number of people diagnosed with ADHD has increased (Abdelnour et

al., 2022). This trend has sparked a debate about the reasons behind it. Some people are

concerned that there may be over-diagnosis and over-prescription of stimulant medications.

Others have raised the issue of diagnostic disparities, particularly among underrepresented

populations (Abdelnour et al., 2022). In 2020, the Centers for Disease Control and Prevention

(CDC) reported that between 2016 and 2019, seven percent of Washingtonians aged 3-17 years

were diagnosed by providers with ADHD. These figures were reported by parents and obtained

through the National Survey of Children’s Health. The CDC theorizes that ADHDs increased

prevalence is likely due to changing diagnostic criteria and greater awareness of the disorder

among marginalized groups, including people of color and females. The media and social media

have also played a role in raising public awareness of ADHD, which in turn has led more people

to bring up their concerns with physicians (Abdelnour et al., 2022).

Childhood ADHD is associated with numerous negative outcomes, including poor

academic performance, increased healthcare costs, and caregiver burdens (Schein et al., 2022).

These negative outcomes may continue into adulthood and manifest in similar ways, such as

poor performance at work and difficulties with social relationships (Schein et al., 2022). The

total societal costs associated with ADHD in the United States in 2018 were $19.4 billion among

children and $13.8 billion among adolescents (Schein et al., 2022). Education costs accounted

for roughly half of the total burden in both populations, followed by direct healthcare costs and

caregiving costs. The main driver of education costs was special education, which resulted in
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additional days spent on education and expenses related to tutoring and special education

services.

Health Disparities

ADHD is more frequently diagnosed in males than females; however, a higher ratio of

males to females is found in clinical samples as opposed to population samples, suggesting that

clinical diagnoses of ADHD are subject to sex bias. Mowlem et al. (2019) investigated sex

differences concerning ADHD symptoms, conduct problems, and learning difficulties in a large

Swedish population-based sample. The findings indicated that females have a stronger predictive

association with hyperactive/impulsive and conduct symptoms on ADHD diagnosis and

treatment status and that clinically diagnosed males and females show comparable symptom

severity.

Similarly, ADHD was previously believed to affect children of all social classes equally,

but recent evidence suggests that it is more common among the poor. Rowland et al (2018)

conducted a joint analysis of family income and parental history of ADHD diagnosis and

discovered both were strong predictors of ADHD prevalence, with low-income children having a

6.2-fold higher risk than those from high-income families without a parental history. The

interaction between family income and parental history of ADHD diagnosis was statistically

significant, indicating that the relationship between family income and childhood ADHD was

weaker among children with a parental history of ADHD diagnosis.

Part II: Clinical Presentation

Signs and Symptoms

Hyperactive-impulsive behavior and inattention are the most common symptoms of

ADHD and are usually seen by the time a child is four years old (Wolraich et al., 2019). The
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symptoms typically increase over the next three to four years, peaking when the child is seven to

eight years of age. Most children with ADHD will continue to have symptoms and impairment

through adolescence and into adulthood (Wolraich et al., 2019). The three subtypes of ADHD

are: predominantly hyperactive/impulsive, predominantly inattentive, and combined (a mix of

inattentive symptoms and hyperactive/impulsive symptoms; ) (NMIA, 2023).

Children who display a pattern of hyperactive/impulsive may: squirm in their seats or

fidget with their hands and feet, find it difficult to remain seated in a classroom, be in constant

motion (e.g., run around or climb when it's inappropriate to do so), find it difficult to play or do

an activity quietly, tend to talk excessively, have difficulty waiting for their turn, or frequently

interrupt others' conversations (Mayo Clinic Staff, 2019). Children who display a pattern of

inattention may: make careless mistakes in schoolwork or fail to pay close attention to details, be

unable to remain focused on tasks or play, appear not to listen when spoken to directly, have

difficulty following instructions, avoid tasks such as homework that require concentrated mental

effort, be prone to losing items needed for tasks, be easily distracted, or inadvertently neglect

daily activities such as chores (Mayo Clinic Staff, 2019).

As individuals with ADHD enter adolescence, their overt hyperactive and impulsive

symptoms tend to decline, whereas their inattentive symptoms tend to persist (Wolraich, 2019).

With age, hyperactivity tends to become restlessness, which isn't as apparent to a casual observer

(Arnold, 2020). An indication of this can be checking the time frequently during a boring lecture

or talking excessively but not interrupting as one would do in childhood. An adult who suffers

from inattention may exhibit more persistent or obvious symptoms (Arnold, 2020), such as

making mistakes on the job, forgetting to pay bills, or constantly losing keys or glasses.

Neuropathophysiologyical
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ADHD is a neurological condition that impacts various areas of the brain responsible for

functions such as problem-solving, memory, language, motivation, judgment, impulse control, social

behavior, planning, decision-making, attention, ability to delay gratification, and time perception.

Research has indicated that individuals with ADHD exhibit differences in brain structure, with certain

areas being smaller in comparison to those without the condition. People with ADHD may experience

challenges with attention, concentration, organization, following directions, remaining still, impulsive

behavior, and emotional regulation at home and school (American Academy of Child and Adolescent

Psychiatry, 2017).

One key distinction between an ADHD brain and a typical brain is the variance in norepinephrine

levels, a neurotransmitter that is synthesized from dopamine. Experts suggest that lower levels of both

dopamine and norepinephrine may be linked to ADHD. Irregularities in dopamine transmission in the

brain may contribute to ADHD symptoms, including impulsivity and inattention. This disruption can also

alter the dopamine reward pathway, impacting how the ADHD brain perceives pleasure and reward.

Additionally, ADHD brains may exhibit structural and functional differences in certain areas, such as the

frontal lobe, which is responsible for decision-making, organization, attention, and planning. In those

with ADHD, this region may mature later than in non-ADHD individuals. The limbic system, which

affects emotions and motivation, may also be impacted by ADHD-related changes, potentially

contributing to hyperactivity, inattention, and poor decision-making. Finally, the basal ganglia,

responsible for motor learning, behavior regulation, and multitasking, can also be affected by ADHD

(Attention Deficit Disorder Association Editorial Team, 2022).

Motor Performance Skills

Individuals with ADHD may experience deficiencies in gross motor skills, including difficulties

with balance and performing simple tasks. These abilities can be crucial for daily activities such as

biking, dressing, feeding oneself, swimming, playing ball sports, and using tools. Those who struggle

with motor skills may be more susceptible to learning difficulties, challenges with lifestyle skills, and less

favorable social interactions (Pila-Nemutandani et al., 2018). The coordination between the brain, nervous
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system, and muscles is what enables us to perform motor skills. These skills involve precise movements

of the muscles with a specific intention. There are two types of motor skills: gross motor skills and fine

motor skills. Gross motor skills involve the coordination of arms and legs in actions like running,

crawling, and swimming. Fine motor skills, on the other hand, involve smaller movements in the wrists,

hands, fingers, feet, and toes, like picking up objects between the thumb and finger or writing carefully.

Difficulties with fine motor skills can hinder cognitive learning and performance as these skills play a

crucial role in cognitive activities (Mokobane et al., 2019).

Process Performance Skills

Impairments in processing speed and reaction time variability (RTV) are consistently observed

and frequently reported in individuals with ADHD (Butzbach et al., 2019). To assess processing speed,

participants' reaction time (RT) to simple stimuli is commonly measured, and those with ADHD often

exhibit slower RTs compared to matched healthy controls. This RT slowing in adult ADHD has been

linked to abnormal neural activation during perception and response selection stages. Therefore,

processing speed assessed by RT and distractibility assessed by the combination of RTV and omission

errors may reflect fundamental cognitive processes in adult ADHD, which can interact with other

functions to affect behavior (Butzbach et al., 2019).

Social Interaction Performance Skills

People with ADHD may encounter challenges when engaging in social situations,

including sharing, taking turns, listening, and interpreting nonverbal cues. They may struggle to

remain focused or engaged in conversations, and managing their emotions can be tricky when

interacting with peers. Unfortunately, these difficulties can cause them to come across as

uninterested or unkind, causing their peers to avoid them. As a result, they may miss out on

valuable opportunities to develop social skills and may even experience a decline in their self-

confidence. In some cases, people with ADHD may avoid social interactions altogether to

prevent further rejection (Gill et al., 2021).

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Medical Management and Alternative Therapies

Emerging evidence suggests that a combination of medication, behavioral intervention,

and skills training is often the most effective way to treat ADHD symptoms in school-age

children (Drechsler et al., 2020). The psychostimulants methylphenidate (Ritalin) and

amphetamine (Adderall) are the most common type of prescription medications (for children

over 6 years of age) and work to reduce the symptoms of ADHD by increasing levels of certain

chemicals (neurotransmitters) in the brain called dopamine and norepinephrine (Mechler et al.,

2022). These neurotransmitters play important roles in controlling brain states, vigilance, action,

reward, learning, and memory processes (Bromberg-Martin et al., 2010). The most frequent side

effects of psychostimulant therapy are reduced appetite and sleep disturbances (Mechler et al.,

2022). Researchers do not yet know whether stimulants can affect the long-term development of

the brain in children and teenagers, so it is recommended that young people only receive these

medications if the ADHD symptoms are causing a persistent significant impairment in at least

one life domain after environmental modifications have been implemented and evaluated

(Drechsler et al., 2020).

Based on how they affect the brain, non-stimulant medications fit into two categories:

norepinephrine modulators and alpha agonists. Atomoxetine (Strattera) is the most prescribed

norepinephrine modulator and works by boosting norepinephrine in the brain to facilitate better

signaling between nerves and areas of the brain. It achieves this goal by blocking a mechanism

that removes norepinephrine (Mechler et al., 2022). The other two commonly used non-stimulant

medications are Clonidine and Guanfacine. They are called alpha agonists because they

selectively target the Alpha-2 adrenergic receptors in the brain, which can enhance attention and

decrease impulsivity and hyperactivity symptoms in children with ADHD. These medications
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may also cause reduced appetite and sleep disturbances, but it is less common than with

stimulants (Mechler et al., 2022).

Behavioral interventions and skills training can also help children with ADHD manage

their symptoms. Cognitive Behavioral Therapy (CBT) is a behavioral intervention used to reduce

ADHD behaviors by enhancing positive behaviors and creating situations in which desired

behaviors may occur (Miller, 2023). A CBT program for preschoolers and young children

involves instructing and training parents and educators to act in accordance with CBT principles.

In contrast, older children and adolescents may be taught behavioral strategies directly (Miller,

2023). Skills-based interventions teach children how to maximize their strengths and compensate

for their weaknesses. Taught by learning specialists, this training teaches techniques to improve

executive function and includes planning, organizing time and materials, making decisions, as

well as controlling emotions, and learning from past mistakes (Miller, 2023). These therapies do

not affect core symptoms, but they teach children skills they can use to control them. Other

alternative non-pharmacological treatment methods such as mindfulness training, physical

activity, and yoga seem to have positive effects on ADHD behavior, but the scientific evidence is

weak, and these treatments are seen at best as complementary to other interventions (Drechsler et

al., 2020).
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American Academy of Child and Adolescent Psychiatry. (2017, February). ADHD & the brain.

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Part 2: Clinical Presentation

Criteria Score
Signs and symptoms
1. Summarizes commonly associated signs and symptoms of the condition. 15/15
2. Includes early signs of the condition. 5/5
3. Includes progression of symptoms over time (if applicable). If not applicable, 10/10
describes stability of condition over time.
Subtotal 30/30
Very well presented! I especially like that you took a developmental approach
and discussed how presentation changes from childhood to adolescence to
adulthood.
Neuropathophysiology
4. Identifies the anatomical structures of the central nervous system that are 10/10
affected by the condition.
5. Identifies the motor skills that are affected by the condition. 10/10
6. Identifies the process skills that are affected by the condition. 10/10
7. Identifies the social interaction skills that are affected by the condition. 10/10
Subtotal 40/40
Again, very well-presented! I just added Level 3 headings to make your
discussion points really stand apart.
Medical management and alternative therapies
8. Identifies medical management of the condition (e.g., pharmacology, device 15/15
implant, etc.).
9. Identifies complementary approaches to which individuals with the condition 10/10
may subscribe.
Subtotal 25/25
Just really well done. Organization and flow makes sense.
Composition
10. Writing style and grammar follow APA (7th ed.) guidelines 4/5
11. Uses bias-free language according to APA (7th ed.) guidelines 5/5
12. Mechanics of style follows APA (7th ed.) guidelines 5/5
13. In-text citations follow APA (7th ed.) guidelines 4/5
14. Reference list follows APA (7th ed.) guidelines 4/5
Subtotal 22/25
SUMMATIVE TOTAL 117/120
97.50%
Feedback: Ruby and Annie, really an amazing paper. It is well-written and comprehensive.
You’ve hit all the discussion points well. I know that you’ve both put a lot of work into this; it
shows. Great work!