Attention deficit hyperactivity disorder: diagnosis, pathogenesis, principles of treatment. ADHD (diagnosis by a neurologist) - what is it? signs, correction. attention deficit hyperactivity disorder in adults and children

Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders in children. Its diagnosis is based on the international criteria of ICD-10 and DSM-IV-TR, but should also take into account the age dynamics of ADHD and the characteristics of its manifestations in the preschool, primary school and adolescence periods. Additional difficulties in family, school and social adaptation in ADHD are often associated with comorbid disorders, which are observed in at least 70% of patients. The neuropsychological mechanisms of ADHD are considered from the standpoint of the insufficient formation of control functions provided by the prefrontal parts of the brain. ADHD is based on neurobiological factors: genetic mechanisms and early organic brain damage. The role of micronutrient deficiencies, in particular magnesium, which may have an additional effect on neurotransmitter balance and the manifestation of ADHD symptoms, is being studied. Treatment of ADHD should be based on an expanded therapeutic approach that involves addressing the social and emotional needs of the patient and assessing, in the process of dynamic observation, not only the reduction of the main symptoms of ADHD, but also functional outcomes and quality of life indicators. Drug therapy for ADHD includes atomoxetine hydrochloride (Strattera), nootropic drugs, neurometabolic drugs, including Magne B 6 . Treatment of ADHD should be comprehensive and long enough.

Keywords Key words: attention deficit hyperactivity disorder, children, diagnosis, treatment, magnesium, pyridoxine, Magne B 6

Attention deficit hyperactivity disorder: diagnosis, pathogenesis, principles of treatment

N.N.Zavadenko
N.I. Pirogov Russian National Research Medical University, Moscow

Attention deficit hyperactivity disorder (ADHD) is one of the common psychoneurological disorders in children. Its diagnosis is based on the international criteria ICD-10 and DSM-IV-TR, but also should be taken into account the age-related dynamics of ADHD and the specificities of its manifestations during the preschool, junior school and adolescent periods. Additional difficulties of intrafamilial, school and social adaptation in ADHD are often related to comorbid disorders, which are found in not less than 70% of patients. The neuropsychological mechanisms of ADHD are viewed from the positions of insufficient formation of the controlling functions that are ensured by the prefrontal regions of the brain. ADHD is based on neurobiological factors, such as genetic mechanisms and early organic damage of the brain. The role of micronutrient deficiency is studied, in particular, of magnesium that might have an additional effect on the neuromediatory balance and manifestation of ADHD symptoms. Treatment of ADHD should be based on a comprehensive therapeutic approach that presupposes taking into consideration the social and emotional needs of a patient and assessing, by dynamic observation, not only reduction of the major ADHD symptoms but also the functional outcomes, the indices of the quality of life. Drug therapy for ADHD includes atomoxetine hydrochloride (strattera), nootropic drugs, and neurometabolic medications, such as Magne B 6 . ADHD therapy should be complex and sufficiently long-term.

key words: attention deficit hyperactivity disorder, children, diagnosis, treatment, magnesium. pyridoxine, Magne B 6

Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders in childhood. ADHD is widely represented in the child population. Its prevalence ranges from 2 to 12% (average 3-7%), more common in boys than girls (average ratio - 3: 1). ADHD can occur both in isolation and in combination with other emotional and behavioral disorders, having a negative impact on learning and social adaptation.

The first manifestations of ADHD are usually observed from 3-4 years of age. But when a child gets older and enters school, he has additional difficulties, since the beginning of schooling makes new, higher demands on the child's personality and his intellectual abilities. It is during the school years that attention disorders become apparent, as well as difficulties in mastering school skills and poor academic performance, self-doubt and low self-esteem. In addition to the fact that children with ADHD misbehave and perform poorly at school, as they grow older, they may be at risk for the formation of deviant and antisocial forms of behavior, alcoholism, and drug addiction. Therefore, it is important for specialists to recognize the early manifestations of ADHD and to know about the possibilities of their treatment.

Symptoms of ADHD in a child may be the reason for the primary appeal to pediatricians, as well as speech therapists, defectologists, and psychologists. Often, teachers of preschool and school educational institutions first pay attention to the symptoms of ADHD.

Diagnosis Criteria. Diagnosis of ADHD is based on international criteria, including lists of the most characteristic and clearly traced signs of this disorder. The International Classification of Diseases of the 10th revision (ICD-10) and the classification of the American Psychiatric Association DSM-IV-TR approach the criteria for diagnosing ADHD from similar positions (table). The ICD-10 classifies ADHD as a hyperkinetic disorder (F90) under Behavioral and emotional disorders with onset in childhood and adolescence, and the DSM-IV-TR lists ADHD as category 314 under Disorders first diagnosed in infancy. , childhood or adolescence. Mandatory characteristics of ADHD are also:

• duration: symptoms have been observed for at least 6 months;
• constancy, distribution to all spheres of life: adaptation disorders are observed in two or more types of environment;
• severity of violations: significant violations in training, social contacts, professional activities;
• other mental disorders are excluded: the symptoms cannot be associated solely with the course of another disease.

The DSM-IV-TR classification defines ADHD as a primary disorder. At the same time, depending on the predominant symptoms, the following forms of ADHD are distinguished:

• combined (combined) form - there are all three groups of symptoms (50-75%);
• ADHD with predominant attention disorders (20-30%);
• ADHD with a predominance of hyperactivity and impulsivity (about 15%).

In ICD-10, which is used in the Russian Federation, the diagnosis of "hyperkinetic disorder" is approximately equivalent to the combined form of ADHD according to DSM-IV-TR. To make a diagnosis according to ICD-10, all three groups of symptoms must be confirmed, including at least 6 manifestations of inattention, at least 3 hyperactivity, and at least 1 impulsivity. Thus, the diagnostic criteria for ADHD in the ICD-10 are more stringent than in the DSM-IV-TR, and only define the combined form of ADHD.

Currently, the diagnosis of ADHD is based on clinical criteria. To confirm ADHD, there are no special criteria or tests based on the use of modern psychological, neurophysiological, biochemical, molecular genetic, neuroradiological and other methods. The diagnosis of ADHD is made by a doctor, but educators and psychologists should also be familiar with the diagnostic criteria for ADHD, especially since it is important to obtain reliable information about the child's behavior not only at home, but also at school or preschool in order to confirm this diagnosis.

Table. The main manifestations of ADHD according to ICD-10

Groups of symptoms	Characteristic symptoms of ADHD
1. Attention disorders	Does not pay attention to details, makes many mistakes. It is difficult to maintain attention when performing school and other tasks. He does not listen to what is said to him. Cannot follow instructions and follow through. Unable to independently plan, organize the execution of tasks. Avoids things that require prolonged mental stress. Often loses his things. Easily distracted. Shows forgetfulness.
2a. Hyperactivity	Often makes restless movements with arms and legs, fidgets in place. Cannot sit still when necessary. Often runs or climbs somewhere when it is inappropriate. Can't play quietly. Excessive aimless physical activity is persistent, it is not affected by the rules and conditions of the situation.
2b. Impulsiveness	Answers questions without listening to the end and without thinking. Can't wait for their turn. Interferes with other people, interrupts them. Chatty, unrestrained in speech.

Differential Diagnosis. In childhood, ADHD “imitators” are quite common: in 15-20% of children, forms of behavior outwardly similar to ADHD are periodically observed. In this regard, ADHD must be distinguished from a wide range of conditions that are similar to it only in external manifestations, but differ significantly both in causes and methods of correction. These include:

• individual characteristics of personality and temperament: the characteristics of the behavior of active children do not go beyond the age norm, the level of development of higher mental functions is good;
• anxiety disorders: features of the child's behavior are associated with the action of psychotraumatic factors;
• consequences of a traumatic brain injury, neuroinfection, intoxication;
• asthenic syndrome in somatic diseases;
• specific developmental disorders of school skills: dyslexia, dysgraphia, dyscalculia;
• endocrine diseases (pathology of the thyroid gland, diabetes mellitus);
• sensorineural hearing loss;
• epilepsy (absence forms; symptomatic, locally conditioned forms; side effects of anti-epileptic therapy);
• hereditary syndromes: Tourette, Williams, Smith-Mazhenis, Beckwith-Wiedemann, fragile X chromosome;
• mental disorders: autism, affective disorders (mood), mental retardation, schizophrenia.

In addition, the diagnosis of ADHD should be built taking into account the peculiar age dynamics of this condition. Symptoms of ADHD have their own characteristics in preschool, primary school and adolescence.

preschool age . Between the ages of 3 and 7, hyperactivity and impulsivity usually begin to appear. Hyperactivity is characterized by the fact that the child is in constant motion, cannot sit still during classes for even a short time, is too talkative and asks an endless number of questions. Impulsivity is expressed in the fact that he acts without thinking, cannot wait for his turn, does not feel restrictions in interpersonal communication, intervening in conversations and often interrupting others. Such children are often characterized as misbehaving or too temperamental. They are extremely impatient, arguing, making noise, shouting, which often leads them to outbursts of strong irritation. Impulsivity can be accompanied by "fearlessness", whereby the child endangers himself (increased risk of injury) or others. During games, energy is overflowing, and therefore the games themselves become destructive. Children are sloppy, often throw, break things or toys, are naughty, poorly obey the demands of adults, and can be aggressive. Many hyperactive children lag behind their peers in language development.

School age . After entering school, the problems of children with ADHD increase significantly. The learning requirements are such that a child with ADHD is not able to fulfill them fully. Since his behavior does not correspond to the age norm, he fails to achieve results in school that correspond to his abilities (the general level of intellectual development in children with ADHD corresponds to the age range). During the lessons, it is difficult for them to cope with the proposed tasks, as they experience difficulties in organizing the work and bringing it to the end, they forget in the course of fulfilling the conditions of the task, they do not master the training materials well and cannot apply them correctly. They quite soon turn off the process of doing the work, even if they have everything necessary for this, do not pay attention to details, show forgetfulness, do not follow the instructions of the teacher, switch poorly when the conditions of the task change or a new one is given. They are unable to do their homework on their own. Compared with peers, difficulties in the formation of writing, reading, and numeracy skills are much more often observed.

Relationship problems with others, including peers, teachers, parents, and siblings, are common among children with ADHD. Since all manifestations of ADHD are characterized by significant fluctuations in different periods of time and in different situations, the child's behavior is unpredictable. Hot temper, cockiness, oppositional and aggressive behavior are often observed. As a result, he cannot play for a long time, successfully communicate and establish friendly relations with peers. In the team, he serves as a source of constant anxiety: he makes noise without hesitation, takes other people's things, interferes with others. All this leads to conflicts, and the child becomes unwanted and rejected in the team. Faced with this attitude, children with ADHD often consciously choose to play the role of class jester, hoping to build relationships with their peers. A child with ADHD not only does not study well on his own, but often "breaks" the lessons, interferes with the work of the class, and therefore is often called to the director's office. In general, his behavior gives the impression of "immaturity", inconsistency with his age, that is, it is infantile. Only younger children or peers with similar behavior problems are usually ready to communicate with him. Gradually, children with ADHD develop low self-esteem.

At home, children with ADHD usually suffer constant comparisons to siblings who are well-behaved and learn better. Parents are annoyed by the fact that they are restless, obsessive, emotionally labile, undisciplined, disobedient. At home, the child is unable to take responsibility for the implementation of daily tasks, does not help parents, is sloppy. At the same time, comments and punishments do not give the desired results. According to the parents, “He is always unlucky”, “Something always happens to him”, that is, there is an increased risk of injuries and accidents.

Adolescence . It has been established that in adolescence, pronounced symptoms of impaired attention and impulsivity continue to be observed in at least 50-80% of children with ADHD. At the same time, hyperactivity in adolescents with ADHD is significantly reduced, replaced by fussiness, a sense of inner restlessness. They are characterized by lack of independence, irresponsibility, difficulties in organizing and completing the execution of assignments and especially long-term work, which they are often unable to cope with without outside help. School performance often worsens, as they cannot effectively plan their work and distribute it over time, they postpone the execution of necessary tasks from day to day.

Difficulties in relationships in the family and school, behavioral disorders are growing. Many adolescents with ADHD are distinguished by reckless behavior associated with unjustified risk, difficulties in following the rules of behavior, disobedience to social norms and laws, failure to comply with the requirements of adults - not only parents and teachers, but also officials, such as school administration representatives or police officers. At the same time, they are characterized by weak psycho-emotional stability in case of failures, self-doubt, low self-esteem. They are too sensitive to teasing and ridicule from peers who think they are stupid. Adolescents with ADHD continue to be characterized by peers as immature and inappropriate for their age. In everyday life, they neglect the necessary safety measures, which increases the risk of injury and accidents.

Adolescents with ADHD are prone to being involved in teen gangs that commit various offenses, they may develop cravings for alcohol and drugs. But in these cases, they, as a rule, turn out to be led, obeying the will of stronger peers or older people and not thinking about the possible consequences of their actions.

Disorders associated with ADHD (comorbid disorders). Additional difficulties in intra-family, school and social adaptation in children with ADHD may be associated with the formation of concomitant disorders that develop against the background of ADHD as the underlying disease in at least 70% of patients. The presence of comorbid disorders can lead to worsening of the clinical manifestations of ADHD, worsening of the long-term prognosis, and a decrease in the effectiveness of the main therapy for ADHD. Behavioral and emotional disturbances associated with ADHD are considered as unfavorable prognostic factors for the long-term, up to chronic, course of ADHD.

Comorbid disorders in ADHD are represented by the following groups: externalized (oppositional defiant disorder, conduct disorder), internalized (anxiety disorders, mood disorders), cognitive (speech development disorders, specific learning difficulties - dyslexia, dysgraphia, dyscalculia), motor (static-locomotor failure, developmental dyspraxia, tics). Other comorbid ADHD disorders can be sleep disturbances (parasomnias), enuresis, encopresis.

Thus, learning, behavioral, and emotional problems can be associated with both the direct influence of ADHD and comorbid disorders, which should be diagnosed in a timely manner and considered as indications for additional appropriate treatment.

Pathogenesis of ADHD. The formation of ADHD is based on neurobiological factors: genetic mechanisms and early organic damage to the central nervous system (CNS), which can be combined with each other. They determine the changes in the central nervous system, violations of higher mental functions and behavior, corresponding to the picture of ADHD. The results of modern research indicate the involvement of the system "associative cortex-basal ganglia-thalamus-cerebellum-prefrontal cortex" in the pathogenetic mechanisms of ADHD, in which the coordinated functioning of all structures ensures control of attention and organization of behavior.

In many cases, an additional impact on children with ADHD is exerted by negative socio-psychological factors (primarily family factors), which in themselves do not cause the development of ADHD, but always contribute to an increase in the child's symptoms and adaptation difficulties.

genetic mechanisms. The genes that determine the predisposition to the development of ADHD (the role of some of them in the pathogenesis of ADHD has been confirmed, while others are considered as candidates) include genes that regulate the metabolism of neurotransmitters in the brain, in particular dopamine and norepinephrine. Dysfunction of neurotransmitter systems of the brain plays an important role in the pathogenesis of ADHD. At the same time, disturbances in the processes of synaptic transmission are of primary importance, which entail dissociation, a break in connections between the frontal lobes and subcortical formations, and as a result of this, the development of ADHD symptoms. In favor of violations of neurotransmitter transmission systems as the primary link in the development of ADHD is evidenced by the fact that the mechanisms of action of drugs that are most effective in the treatment of ADHD are to activate the release and inhibition of dopamine and norepinephrine reuptake in presynaptic nerve endings, which increases the bioavailability of neurotransmitters at the level of synapses. .

In modern concepts, attention deficit in children with ADHD is considered as a result of disturbances in the functioning of the posterior cerebral attention system regulated by norepinephrine, while behavioral inhibition and self-control disorders characteristic of ADHD are considered as a lack of dopaminergic control over the flow of impulses to the forebrain attention system. The posterior cerebral system includes the superior parietal cortex, the superior colliculus, the thalamic cushion (the dominant role belongs to the right hemisphere); this system receives dense noradrenergic innervation from the locus coeruleus (blue spot). Norepinephrine suppresses spontaneous discharges of neurons, thereby preparing the posterior cerebral attention system, which is responsible for orienting to new stimuli, to work with them. This is followed by a switch in the mechanisms of attention to the anterior cerebral control system, which includes the prefrontal cortex and the anterior cingulate gyrus. The susceptibility of these structures to incoming signals is modulated by dopaminergic innervation from the ventral tegmental nucleus of the midbrain. Dopamine selectively regulates and limits excitatory impulses to the prefrontal cortex and cingulate gyrus, providing a reduction in excessive neuronal activity.

Attention deficit hyperactivity disorder (ADHD) is considered a polygenic disorder in which multiple disorders of dopamine and/or norepinephrine metabolism that exist simultaneously are due to the influence of several genes that override the protective effect of compensatory mechanisms. The effects of the genes that cause ADHD are additive, complementary. Thus, ADHD is considered as a polygenic pathology with a complex and variable inheritance, and at the same time as a genetically heterogeneous condition.

Pre- and perinatal factors play an important role in the pathogenesis of ADHD. A comparative analysis of anamnestic information in children with ADHD and their healthy peers showed that the formation of ADHD may be preceded by violations of the course of pregnancy and childbirth, in particular preeclampsia, eclampsia, the first pregnancy, the mother's age is younger than 20 years or older than 40 years, prolonged delivery , post-term pregnancy and prematurity, low birth weight, morphofunctional immaturity, hypoxic-ischemic encephalopathy, disease of the child in the first year of life. Other risk factors are the use of certain drugs by the mother during pregnancy, alcohol and smoking.

Apparently, some decrease in the size of the prefrontal areas of the brain (mainly in the right hemisphere), subcortical structures, corpus callosum, and cerebellum found in children with ADHD compared with healthy peers using magnetic resonance imaging (MRI) is apparently associated with early CNS damage. These data support the concept that the occurrence of ADHD symptoms is due to impaired connections between the prefrontal regions and subcortical ganglia, primarily the caudate nucleus. Subsequently, additional confirmation was obtained through the use of functional neuroimaging methods. Thus, when determining cerebral blood flow using single-photon emission computed tomography in children with ADHD, compared with healthy peers, a decrease in blood flow (and, consequently, metabolism) in the frontal lobes, subcortical nuclei and midbrain was demonstrated, and the changes were most pronounced at the level caudate nucleus. According to the researchers, changes in the caudate nucleus in children with ADHD were the result of its hypoxic-ischemic damage during the neonatal period. Having close connections with the thalamus, the caudate nucleus performs an important function of modulation (mainly of an inhibitory nature) of polysensory impulses, and the lack of inhibition of polysensory impulses may be one of the pathogenetic mechanisms of ADHD.

Subsequently, H.C. Lou et al. using positron emission tomography (PET), it was established that cerebral ischemia transferred at birth leads to persistent changes in dopamine receptors of the 2nd and 3rd types in the structures of the striatum. As a result, the ability of receptors to bind dopamine decreases and a functional insufficiency of the dopaminergic system is formed. These data were obtained from a survey of six adolescents with ADHD aged 12-14 years. Previously, these patients were included in a group of 27 children who were born prematurely at 28-34 weeks of gestation, they underwent PET within 48 hours after birth, which confirmed hypoxic-ischemic CNS damage; when re-examined at the age of 5.5-7 years, 18 of them were diagnosed with ADHD. The results obtained show that critical changes at the level of receptors (and, possibly, other protein structures involved in the metabolism of neurotransmitters) can be not only hereditary in nature, but also be the result of pre- and perinatal pathology.

Recently, P. Shaw et al. conducted a longitudinal comparative MRI study of children with ADHD, the purpose of which was to assess regional differences in the thickness of the cerebral cortex and compare their age dynamics with clinical outcomes. We examined 163 children with ADHD (mean age at inclusion in the study 8.9 years) and 166 children of the control group. The duration of follow-up was more than 5 years. According to the data obtained, children with ADHD showed a global decrease in the thickness of the cortex, most pronounced in the prefrontal (medial and upper) and precentral regions. At the same time, in patients with worse clinical outcomes during the initial examination, the smallest thickness of the cortex was found in the left medial prefrontal region. Normalization of the thickness of the right parietal cortex was associated with the best outcomes in patients with ADHD and may reflect a compensatory mechanism associated with changes in the thickness of the cerebral cortex.

Neuropsychological Mechanisms of ADHD are considered from the standpoint of violations (immaturity) of the functions of the frontal lobes of the brain, primarily the prefrontal region. Manifestations of ADHD are analyzed from the standpoint of a deficit in the functions of the frontal and prefrontal parts of the brain and insufficient formation of executive functions (EF). Patients with ADHD show "executive dysfunction" (in the English literature - executive dysfunction). The development of UV and the maturation of the prefrontal region of the brain are long-term processes that continue not only in childhood but also in adolescence. EF is a rather broad concept referring to the range of abilities that serve the task of maintaining the necessary sequence of efforts to solve a problem, aimed at achieving a future goal. Significant components of the EF that are affected in ADHD are: impulse control, behavioral inhibition (restraint); organization, planning, management of mental processes; maintaining attention, keeping from distractions; inner speech; working (operative) memory; foresight, forecasting, a look into the future; retrospective assessment of past events, mistakes made; change, flexibility, ability to switch and revise plans; choice of priorities, the ability to allocate time; separating emotions from real facts. Some UF researchers emphasize the "hot" social aspect of self-regulation and the child's ability to control their behavior in society, while others emphasize the role of regulation of mental processes - the "cold" cognitive aspect of self-regulation.

Influence of adverse environmental factors . Anthropogenic pollution of the human environment, largely associated with microelements from the group of heavy metals, can have negative consequences for children's health. It is known that in the immediate vicinity of many industrial enterprises, zones with a high content of lead, arsenic, mercury, cadmium, nickel and other microelements are formed. The most common heavy metal neurotoxicant is lead, and its sources of environmental pollution are industrial emissions and vehicle exhaust gases. Lead exposure to children can cause cognitive and behavioral problems in children. Thus, in a survey of 277 first-graders, a direct relationship was established between an increased lead content in the hair and an increase in hyperactivity, as assessed by a special questionnaire for teachers. This correlation remained significant after adjusting for other factors such as age, ethnicity, gender, and socioeconomic status. An even stronger relationship was observed between hair lead levels and an already diagnosed ADHD by a doctor.

The role of nutritional factors and unbalanced nutrition. Nutritional imbalances (e.g., protein deficiency with an increase in easily digestible carbohydrates, especially in the morning), as well as micronutrient deficiencies, including vitamins, folates, omega-3 polyunsaturated fatty acids (PUFAs) can contribute to the onset or exacerbation of ADHD symptoms. , macro- and microelements. Micronutrients such as magnesium, pyridoxine and some others directly affect the synthesis and degradation of monoamine neurotransmitters. Therefore, micronutrient deficiencies can affect the neurotransmitter balance and hence the manifestation of ADHD symptoms.

Of particular interest among micronutrients is magnesium, which is a natural lead antagonist and promotes the rapid elimination of this toxic element. Therefore, magnesium deficiency, among other effects, can contribute to the accumulation of lead in the body. Magnesium deficiency in ADHD has been found in several studies. According to B. Starobrat-Hermelin, in the study of the mineral status in a group of 116 children with ADHD aged 9-12 years, magnesium deficiency was most often detected - in 110 (95%) patients, according to the results of its determinations in blood plasma, erythrocytes and hair. In a survey of 52 hyperactive children, 30 (58%) of them had low levels of magnesium in erythrocytes. According to Russian researchers, magnesium deficiency is determined in 70% of children with ADHD.

Magnesium is an important element involved in maintaining the balance of excitatory and inhibitory processes in the central nervous system. There are several molecular mechanisms through which magnesium deficiency affects neuronal activity and neurotransmitter metabolism: magnesium is required to stabilize excitatory (glutamate) receptors; magnesium is an essential cofactor of adenylate cyclases involved in signal transmission from neurotransmitter receptors to controlling intracellular cascades; magnesium is a cofactor for catechol-O-methyltransferase, which inactivates excess monoamine neurotransmitters. Therefore, magnesium deficiency contributes to the imbalance of the "excitation-inhibition" processes in the CNS towards excitation and can affect the manifestation of ADHD.

Magnesium deficiency in ADHD can be associated not only with its insufficient intake with food, but also with an increased need for it during critical periods of growth and development, with severe physical and neuropsychic stress, and stress. Under conditions of environmental stress, nickel and cadmium, along with lead, act as magnesium displacing metals. In addition to a lack of magnesium in the body, the manifestation of ADHD symptoms can be influenced by zinc, iodine, and iron deficiencies.

Thus, ADHD is a neuropsychiatric disorder with a complex pathogenesis, accompanied by structural, metabolic, neurochemical, neurophysiological changes in the central nervous system, as well as neuropsychological disorders in the processes of information processing and UV.

Treatment. At the present stage, it becomes obvious that the treatment of ADHD should be aimed not only at controlling and reducing the main manifestations of this disorder, but also at solving other important tasks: improving the functioning of the patient in various areas and his fullest realization as a person, the emergence of his own achievements, improvement self-assessment, normalization of the situation around him, including within the family, the formation and strengthening of communication skills and contacts with people around him, recognition by others and increasing satisfaction with his life. Our study confirmed the significant negative impact of the difficulties experienced by children with ADHD on their emotional state, family life, friendships, schooling, and leisure activities. In this regard, the concept of an expanded therapeutic approach has been formulated, which implies the extension of the influence of treatment beyond the reduction of the main symptoms and taking into account functional outcomes and quality of life indicators. Thus, the concept of an expanded therapeutic approach involves addressing the social and emotional needs of a child with ADHD, which should be given special attention both at the stage of diagnosis and treatment planning, and in the process of dynamic monitoring of the patient and evaluation of the results of therapy.

The most effective for ADHD is complex assistance, which combines the efforts of doctors, psychologists, teachers working with the child, and his family. Treatment for ADHD should be timely and must include:

• helping the family of a child with ADHD - family and behavioral therapy techniques that provide better interaction in families of children suffering from ADHD;
• developing parenting skills for children with ADHD, including parenting training programs;
• educational work with teachers, correction of the school curriculum - through a special presentation of educational material and the creation of such an atmosphere in the classroom that maximizes the chances of successful education of children;
• psychotherapy of children and adolescents with ADHD, overcoming difficulties, developing effective communication skills for children with ADHD during special remedial classes;
• drug therapy, which should be long enough, since improvement extends not only to the main symptoms of ADHD, but also to the socio-psychological side of the patients' lives, including their self-esteem, relationships with family members and peers, usually starting from the third month of treatment. Therefore, it is advisable to plan drug therapy for several months up to the duration of the entire academic year.

An effective drug specifically designed for the treatment of ADHD is atomoxetine hydrochloride. The main mechanism of its action is associated with the blockade of norepinephrine reuptake, which is accompanied by an increase in synaptic transmission involving norepinephrine in various brain structures. In addition, experimental studies have found an increase in the content of not only norepinephrine, but also dopamine selectively in the prefrontal cortex under the influence of atomoxetine, since in this area dopamine binds to the same transport protein as norepinephrine. Since the prefrontal cortex plays a leading role in providing executive functions of the brain, as well as attention and memory, an increase in the concentration of norepinephrine and dopamine in this area under the action of atomoxetine leads to a decrease in the manifestations of ADHD. Atomoxetine has a beneficial effect on the behavioral characteristics of children and adolescents with ADHD, its positive effect is usually manifested already at the beginning of therapy, but the effect continues to increase during the month of continuous use of the drug. In most patients with ADHD, clinical efficacy is achieved by prescribing the drug in the dose range of 1.0-1.5 mg/kg of body weight per day with a single dose in the morning. The advantage of atomoxetine is its effectiveness in cases of comorbidity of ADHD with destructive behavior, anxiety disorders, tics, enuresis.

Domestic specialists in the treatment of ADHD traditionally use nootropic drugs. Their use in ADHD is pathogenetically justified, since nootropic drugs have a stimulating effect on cognitive functions that are not sufficiently formed in children of this group (attention, memory, organization, programming and control of mental activity, speech, praxis). Given this circumstance, the positive effect of drugs with a stimulating effect should not be taken as paradoxical (given the hyperactivity in children). On the contrary, the high efficiency of nootropics seems to be natural, especially since hyperactivity is only one of the manifestations of ADHD and is itself caused by violations of higher mental functions. In addition, these drugs have a positive effect on metabolic processes in the central nervous system and contribute to the maturation of the inhibitory and regulatory systems of the brain.

At the same time, it should be noted the need for new studies to clarify the optimal timing of the appointment of nootropic drugs in the treatment of ADHD. So, in the course of a recent study, the good potential of the drug hopantenic acid in the long-term treatment of ADHD has been confirmed. A positive effect on the main symptoms of ADHD was achieved after 2 months of treatment, but continued to increase after 4 and 6 months of its use. Along with this, the beneficial effect of long-term use of the hopantenic acid preparation on adaptation and functioning disorders characteristic of children with ADHD in various areas, including difficulties in behavior in the family and in society, schooling, reduced self-esteem, and lack of basic life skills, was confirmed. However, in contrast to the regression of the main symptoms of ADHD, longer periods of treatment were needed to overcome the disorders of adaptation and socio-psychological functioning: a significant improvement in self-esteem, communication with others and social activity was observed according to the results of parental questionnaires after 4 months, and a significant improvement in behavioral and schooling, basic life skills along with a significant regression of risk-taking behavior - after 6 months of using the drug hopantenic acid.

Another direction of ADHD therapy is to control negative nutritional and environmental factors that lead to the intake of neurotoxic xenobiotics (lead, pesticides, polyhaloalkyls, food dyes, preservatives) into the child's body. This should be accompanied by the inclusion in therapy of the necessary micronutrients that help reduce ADHD symptoms: vitamins and vitamin-like substances (omega-3 PUFAs, folate, carnitine) and essential macro- and microelements (magnesium, zinc, iron).

Among the micronutrients with a proven clinical effect in ADHD, magnesium preparations should be noted. In the treatment of ADHD, only organic magnesium salts (lactate, pidolate, citrate) are used, which is associated with a high bioavailability of organic salts and the absence of side effects when they are used in children. The use of magnesium pidolate with pyridoxine in solution (ampoule form of Magne B 6 (Sanofi-Aventis, France)) is allowed from the age of 1 year, lactate (Magne B 6 in tablets) and magnesium citrate (Magne B 6 forte in tablets) - from 6 years old. The magnesium content in one ampoule is equivalent to 100 mg of ionized magnesium (Mg 2+), in one tablet of Magne B 6 - 48 mg of Mg 2+, in one tablet of Magne B 6 forte (618.43 mg of magnesium citrate) - 100 mg of Mg 2+ . A large concentration of Mg 2+ in Magne B 6 forte allows you to take 2 times fewer tablets than when taking Magne B 6. The advantage of Magne B 6 in ampoules is also the possibility of more accurate dosing. As a study by O.A. Gromova et al. showed, the use of the ampoule form of Magne B 6 provides a rapid increase in the level of magnesium in the blood plasma (within 2-3 hours), which is important for the rapid elimination of magnesium deficiency. At the same time, taking Magne B 6 tablets contributes to a longer (within 6-8 hours) retention of an increased concentration of magnesium in erythrocytes, that is, its deposition.

The emergence of combined preparations containing magnesium and vitamin B6 (pyridoxine) has significantly improved the pharmacological properties of magnesium salts. Pyridoxine is involved in the metabolism of proteins, carbohydrates, fatty acids, the synthesis of neurotransmitters and many enzymes, has a neuro-, cardio-, hepatotropic, and hematopoietic effect, contributes to the replenishment of energy resources. The high activity of the combined preparation is due to the synergistic action of the components: pyridoxine increases the concentration of magnesium in plasma and erythrocytes and reduces the amount of magnesium excreted from the body, improves magnesium absorption in the gastrointestinal tract, its penetration into cells, and fixation. Magnesium, in turn, activates the process of transformation of pyridoxine into its active metabolite pyridoxal-5-phosphate in the liver. Thus, magnesium and pyridoxine potentiate each other's action, which allows their combination to be successfully used to normalize magnesium balance and prevent magnesium deficiency.

Data on the positive clinical effect of Magne B 6 in the treatment of ADHD children with confirmed magnesium deficiency in the body are presented in several foreign studies. The combined intake of magnesium and pyridoxine for 1-6 months reduced the symptoms of ADHD and restored normal values ​​of magnesium in erythrocytes.

O.R. Nogovitsina and E.V. Levitina compared the results of therapy of 31 children with ADHD aged 6-12 years with Magne B 6 and 20 patients in the control group who received a multivitamin preparation. The duration of the observation period was one month. According to the survey of parents, by the 30th day of treatment in the main group, scores on the scales "anxiety", "attention disorders and hyperactivity" significantly decreased. A decrease in the level of anxiety was also confirmed by the results of the Luscher test. During psychological testing in patients of the main group, concentration of attention, accuracy and speed of completing tasks improved significantly, and the number of errors decreased. Neurological examination showed an improvement in gross and fine motor skills, a positive dynamics of EEG characteristics in the form of the disappearance of signs of paroxysmal activity against the background of hyperventilation, as well as bilateral-synchronous and focal pathological activity in most patients. At the same time, taking Magne B 6 was accompanied by the normalization of magnesium concentration in erythrocytes and blood plasma of patients. Thus, the proportion of cases of severe magnesium deficiency in blood plasma decreased by 13% (from 23 to 10%), moderate deficiency - by 4% (from 37 to 33%), and the number of patients with normal values ​​increased from 40 to 57%.

Replenishment of magnesium deficiency should last at least two months. Considering that alimentary deficiency of magnesium occurs most often, when drawing up nutritional recommendations, one should take into account not only the quantitative content of magnesium in foods, but also its bioavailability. So, fresh vegetables, fruits, herbs (parsley, dill, green onions) and nuts have the maximum concentration and activity of magnesium. When preparing products for storage (drying, canning), the concentration of magnesium decreases slightly, but its bioavailability drops sharply. This is important for children with ADHD who have a deepening of magnesium deficiency that coincides with the period of schooling from September to May. Therefore, the use of combined preparations containing magnesium and pyridoxine is advisable during the school year.

Thus, the efforts of specialists should be aimed at early detection of ADHD in children. The development and application of complex correction should be carried out in a timely manner, be of an individual nature. Treatment for ADHD, including drug therapy, should be long enough.

List of used literature

1. Baranov AA, Belousov YuB, Bochkov NP, etc.. Attention deficit hyperactivity disorder: etiology, pathogenesis, clinic, course, prognosis, therapy, organization of care (expert report). Moscow, Attention program of the Charities Aid Foundation in the Russian Federation. M 2007;64.
2. Zavadenko NN. Hyperactivity and attention deficit in childhood. M.: "Academy", 2005.
3. International Classification of Diseases (10th revision). Classification of mental and behavioral disorders. Research diagnostic criteria. SPb., 1994; 208.
4. Diagnostic and Statistical Manual of Mental Disorders (4th edition Revision) (DSM-IV-TR). American Psychiatric Association. Washington, DC, 2000;943.
5. Nigg GT. What causes ADHD? New York, London: The Guilford Press, 2006;422.
6. Pennington B.F. Diagnosing Learning Disorders. A Neuropsychological Framework. New York, London, 2009;355.
7. Barkley RA
8. Lou HC. Etiology and pathogenesis of ADHD: significance of prematurity and perinatal hypoxic-haemodynamic encephalopathy. Acta Paediatr. 1996;85:1266-71.
9. Lou HC, Rosa P, Pryds O, et al. ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology. 2004;46:179-83.
10. . Longitudinal Mapping of Cortical Thickness and Clinical Outcome in Children and Adolescents With Attention-Deficit/ /Hyperactivity Disorder. Arch General Psychiatry. 2006;63:540-9.
11. Denckla MB
12. Tuthill RW. Hair lead levels related to children "s classroom attention-deficit behavior. Arch Environ Health. 1996; 51: 214-20.
13. Kudrin AV, Gromova OA. Microelements in neurology. Moscow: GeotarMed; 2006.
14. Rebrov VG, Gromova OA. Vitamins, macro- and microelements. Moscow: GeotarMed; 2008.
15. Starobrat-Hermelin B
17. Zavadenko NN, Lebedeva TV, Happy OV, etc. Attention deficit hyperactivity disorder: the role of questioning parents and teachers in assessing the socio-psychological adaptation of patients. Journal. nevrol. and a psychiatrist. them. S.S.Korsakov. 2009; 109(11): 53-7.
18. Barkley RA. Children with defiant behavior. Clinical guidelines for child assessment and parent training. Per. from English. M.: Terevinf, 2011; 272.
19. Zavadenko NN, Suvorinova NYu. Comorbid disorders in attention deficit hyperactivity disorder in children. Journal. nevrol. and a psychiatrist. them. S.S.Korsakov. 2007;107(7):39-44.
20. Zavadenko NN, Suvorinova NU. Attention deficit hyperactivity disorder: the choice of the optimal duration of drug therapy. Journal. nevrol. and a psychiatrist. them. S.S.Korsakov. 2011;111(10):28-32.
21. Kuzenkova LM, Namazova-Baranova LS, Balkanskaya NE, Uvakina EV. Multivitamins and polyunsaturated fatty acids in the treatment of attention deficit hyperactivity disorder in children. Pediatric pharmacology. 2009;6(3):74-9.
22. Gromova OA, Torshin IYu, Kalacheva AG, etc. The dynamics of the concentration of magnesium in the blood after taking various magnesium-containing drugs. Pharmateka. 2009;10:63-8.
23. Gromova OA, Skoromets AN, Egorova EY, etc. Prospects for the use of magnesium in pediatrics and pediatric neurology. Pediatrics. 2010;89(5):142-9.
24. Nogovitsina OR, Levitina EV. Effect of Magne-B 6 on clinical and biochemical manifestations of attention deficit hyperactivity disorder in children. Experiment. and wedge. pharmacology. 2006;69(1):74-7.
25. Akarachkova EU. The use of Magne-B 6 in therapeutic practice. Difficult patient. 2007;5:36-42.

References

1. Baranov AA, Belousov YuB, Bochkov NP, i dr. Sindrom defitsita vnimaniya s giperaktivnostyu: etiologiya, patogenez, klinika, techeniye, prognoz, terapiya, organizatsiya pomoshchi (ekspertnyy doklad). Moscow, programma "Vnimaniye" "Charitiz Eyd Faundeyshn" v RF. M., 2007;64. Russian.
2. Zavadenko NN. Giperaktivnost i defitsit vnimaniya v detskom vozraste. M.: "Akademiya", 2005. Russian.
3. Mezhdunarodnaya klassifikatsiya bolezney (10th peresmotr). Klassifikatsiya psikhicheskikh i povedencheskikh rasstroystv. Issledovatelskiye diagnosticheskiye kriterii. SPb., 1994;208.
4. Diagnostic and Statistical Manual of Mental Disorders (4th edition Revision) (DSM-IV-TR). American Psychiatric Association. Washington, DC, 2000;943. Russian.
5. Nigg GT. What causes ADHD? New York, London: The Guilford Press, 2006;422.
6. Pennington BF. Diagnosing Learning Disorders. A Neuropsychological Framework. New York, London, 2009;355.
7. Barkley RA. Issues in the diagnosis of attention-deficit/hyperactivity disorder in children. Brain & Development. 2003;25:77-83.
8. Lou HC. Etiology and pathogenesis of ADHD: significance of prematurity and perinatal hypoxic-haemodynamic encephalopathy. Acta Paediatr. 1996;85:1266-71.
9. Lou HC, Rosa P, Pryds O, et al. ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology. 2004;46:179-83.
10. Shaw P, Lerch J, Greenstein D, et al. Longitudinal Mapping of Cortical Thickness and Clinical Outcome in Children and Adolescents With Attention-Deficit/ Hyperactivity Disorder. Arch General Psychiatry. 2006;63:540-9.
11. Denckla MB. ADHD: topic update. Brain & Development. 2003;25:383-9.
12. Tuthill RW. Hair lead levels related to children "s classroom attention-deficit behavior. Arch Environ Health. 1996; 51: 214-20.
13. Kudrin AV, Gromova OA. Microelementy v neurology. Moscow: GeotarMed; 2006. Russian.
14. Rebrov VG, Gromova OA. Vitaminy, makro- i mikroelementy. Moscow: GeotarMed; 2008. Russian.
15. Starobrat-Hermelin B. The effect of deficiency of selected bioelements on hyperactivity in children with certain specified mental disorders. Ann Acad Med Stetin. 1998;44:297-314.
16. Mousain-Bosc M, Roche M, Rapin J, Bali JP. Magnesium VitB6 intake reduces central nervous system hyperexcitability in children. J Am Call Nutr. 2004;23:545-8.
17. Zavadenko NN, Lebedeva TV, Schasnaya OV, et al. Zhurn. neurol. i psychiatry. im. S.S. Korsakova. 2009; 109(11): 53-7. Russian.
18. Barkley RA. Children s vyzyvayushchim povedeniyem. Klinicheskoye rukovodstvo po obsledovaniyu rebenka i treningu roditeley. per. s engl. M.: Terevinf, 2011;272. Russian.
19. Zavadenko NN, Suvorinova NYu. Zhurn. neurol. i psychiatry. im. S.S. Korsakova. 2007;107(7):39-44. Russian.
20. Zavadenko NN, Suvorinova NYu. Zhurn. neurol. i psychiatry. im. S.S. Korsakova. 2011;111(10):28-32. Russian.
21. Kuzenkova LM, Namazova-Baranova LS, Balkanskaya SV, Uvakina YeV. Pediatricheskaya farmakologiya. 2009;6(3):74-9. Russian.
22. Gromova OA, Torshin lYu, Kalacheva AG, et al. Farmateka. 2009;10:63-8. Russian.
23. Gromova OA, Skoromets AN, Yegorova YeYu, et al. Pediatrics. 2010;89(5):142-9. Russian.
24. Nogovitsina OR, Levitina YeV. Experiment. i klin. farmakologiya. 2006;69(1):74-7. Russian.
25. Akarachkova YeS. Hardyy patsiyent. 2007;5:36-42. Russian.

ADHD (diagnosis by a neurologist) - what is it? This topic is of interest to many modern parents. For childless families and people who are far from children in principle, this issue is not so important. The named diagnosis is a fairly common chronic condition. It occurs in both adults and children. But at the same time, attention should be paid primarily to the fact that minors are more susceptible to the negative influence of the syndrome. For adults, ADHD is not so dangerous. Nevertheless, sometimes it is useful to understand such a common diagnosis. What does he represent? Is it possible to somehow get rid of such a disorder? Why does it appear? All of this really needs to be sorted out. It should be noted right away - if there are suspicions of hyperactivity in a child, this should not be ignored. Otherwise, until the moment of entry into adulthood, the baby will have some problems. Not the most serious, but they will bring trouble to the child, and parents, and people around them.

Syndrome Definition

ADHD (diagnosis by a neurologist) - what is it? It has already been said that this is the name of a neurological-behavioral disorder common throughout the world. It stands for "syndrome and hyperactivity". In common parlance, this syndrome is often referred to simply as hyperactivity.

ADHD (diagnosis by a neurologist) - what is it from a medical point of view? The syndrome is a special work of the human body, in which there is a disorder of attention. We can say that this is absent-mindedness, restlessness and the inability to concentrate on anything.

In principle, not the most dangerous disorder. This diagnosis is not a sentence. In childhood, hyperactivity can cause a lot of trouble. But in adult life, as a rule, ADHD fades into the background.

The studied disease is most often found in children of preschool and school age. Many parents believe that ADHD is a real death sentence, an end to a child's life. In fact, as already mentioned, this is not the case. In fact, hyperactivity is treatable. And again, for an adult, this syndrome will not cause so many problems. Therefore, you should not panic and upset.

Causes

Diagnosis of ADHD in a child - what is it? The concept has already been disclosed previously. But why does this phenomenon occur? What should parents pay attention to?

Doctors still cannot say for sure why a child or an adult develops hyperactivity. The fact is that there are many options for its development. Among them are the following:

1. Complicated pregnancy of the mother. This also includes difficult births. According to statistics, children whose mothers gave birth according to a non-standard option are more likely to be affected by this syndrome.
2. The presence of chronic diseases in the child.
3. Severe emotional shock or change in a person's life. Particularly the baby. It doesn't matter if it was good or bad.
4. Heredity. This is the option most often considered. If the parents had hyperactivity, then it is not excluded in the child.
5. Lack of attention. Modern parents are constantly busy. Therefore, children quite often suffer from ADHD precisely because of the fact that this is how the body reacts to the lack of parental care.

Hyperactivity should not be confused with being spoiled. These are completely different concepts. The diagnosis being studied is not a sentence, but omissions in education quite often cannot be corrected.

Manifestations

Now it’s a little clear why Attention Deficit Hyperactivity Disorder occurs. Its symptoms are clearly visible in children. But not the little ones. It should be remembered that babies under 3 years old cannot be diagnosed appropriately. Because these are normal.

How does ADHD manifest itself? The following distinguishing features that are found in children can be distinguished:

1. The child is too active. He runs and jumps all day without any purpose. That is, to just run and jump.
2. The baby is observed. It is very difficult for him to concentrate on anything. It should also be noted that the child will be extremely restless.
3. Schoolchildren often have poor school performance. Poor grades are the result of problems concentrating on tasks. But as a sign, such a phenomenon is also isolated.
4. Aggression. The baby may be aggressive. Sometimes it's just unbearable.
5. Disobedience. Another seems to understand that he should calm down, but he cannot do this. Or generally ignores any comments addressed to him.

This is how you define ADHD. Symptoms in children resemble spoilage. Or banal disobedience. That is why at the first signs it is recommended to consult a doctor. But more on that later. First, it is worth understanding how the studied condition manifests itself in adults.

Symptoms in adults

Why? ADHD is diagnosed without much problem in children. But, as already mentioned, it is not so easy to detect it in an adult. After all, he seems to fade into the background. It takes place, but does not play an important role. ADHD in adults can often be confused with, for example, an emotional disorder. Therefore, it is recommended to pay attention to some common symptoms.

Among them are the following components:

• the first person begins to conflict over trifles;
• there are unreasonable and sharp outbursts of anger;
• when talking with someone, a person "hovers in the clouds";
• easily distracted while performing a task;
• even during intercourse, a person can be distracted;
• there is a failure to fulfill previous promises.

All of these points to the presence of ADHD. Not necessarily, but it is a possibility. You need to see a doctor for a complete examination. And if the diagnosis of ADHD in adults is confirmed, a course of treatment will be required. If you follow the recommendations, you can quickly get rid of the disorder. True, in the case of children, you will have to show perseverance and determination. Childhood hyperactivity is difficult to treat.

Who to contact

The next question is which specialist to contact? At the moment, medicine has a huge number of doctors. Which of them is able to make the correct diagnosis? Attention deficit hyperactivity disorder in adults and children can be recognized by:

• neurologists (it is to them that they come with the disease most often);
• psychologists;
• psychiatrists;
• social workers.

This also includes family doctors. It should be noted that social workers and psychologists only make a diagnosis. But they do not have the right to prescribe medication. It's not in their jurisdiction. Therefore, most often parents and already adults simply go for a consultation with neurologists.

About diagnostics

Recognition with hyperactivity (ADHD) occurs in several stages. An experienced doctor will definitely follow a certain algorithm.

At the very beginning, you need to tell about yourself. If we are talking about children, the doctor asks to make a psychological portrait of a minor. The story will also need to include details of the patient's life and behavior.

The next step is the appointment of additional studies. For example, a neurologist may ask for an ultrasound of the brain and tomography. Attention deficit hyperactivity disorder in adults and children in these pictures will be clearly visible. With the disease being studied, the work of the brain changes slightly. And this is reflected in the results of ultrasound.

Perhaps that's all. In addition, the neurologist will study the patient's disease map. After all of the above, a diagnosis is made. And, accordingly, treatment is prescribed. Correction of ADHD is a very long process. In any case, in children. Treatment is prescribed differently. It all depends on the cause of hyperactivity.

Medicines

Now it’s clear what the attention deficit hyperactivity disorder is. Treatment, as already mentioned, for children and adults is prescribed varied. The first method is medical correction. As a rule, this option is not suitable for very young children.

What can be prescribed for a child or adult diagnosed with ADHD? Nothing dangerous. As a rule, among the medicines there are only vitamins, as well as sedatives. Sometimes antidepressants. Signs of ADHD are eliminated in this way quite successfully.

No other essential drugs are prescribed. All pills and drugs prescribed by a neurologist are aimed at calming the nervous system. Therefore, you should not be afraid of the prescribed sedative. Regular intake - and soon the disease will pass. Not a panacea, but this kind of solution works quite effectively.

Folk methods

Some people do not trust the action of medicines. Therefore, you can consult a neurologist and use alternative methods of treatment. They often turn out to be no less effective than pills.

What can be advised if ADHD is observed? Symptoms in children and adults can be relieved by taking:

• chamomile tea;
• sage;
• calendula.

Baths with essential oils help well, as well as salt with a calming effect. Children can be given warm milk with honey at night. However, the medical effectiveness of these techniques has not been proven. The person will act at their own peril and risk. However, many adults refuse any treatment for ADHD in themselves. But in the case of children, as already mentioned, the problem under study should not be overlooked.

Treatment of children without pills

What other treatments are available for ADHD? The drugs prescribed by doctors are, as already mentioned, sedatives. Something like Novopassit. Not all parents are ready to give their children this kind of pills. Some point out that sedatives are addictive. And by getting rid of ADHD in this way, it is possible to provide the child with dependence on antidepressants. Agree, not the best solution!

Fortunately, in children, hyperactivity can be corrected even without pills. The only thing to consider: parents must be patient. After all, hyperactivity is not quickly treated. And this must be remembered.

1. Spend more time with children. Especially if hyperactivity is a consequence of a lack of attention from parents. It's good when one of the parents can stay "on maternity leave". That is, not to work, but to deal with the child.
2. Send the baby to educational circles. A good way to increase the attention of the child, as well as to develop him comprehensively. You can even find specialized centers that organize classes for children with hyperactivity. Now this is not such a rarity.
3. Students need to do more. But do not force him to sit for days on homework. It should also be understood that poor grades are a consequence of ADHD. And scolding a child for it is at least cruel.
4. If you need to find a use for his energy. In other words, sign up for some sports activities. Or just give a day to run enough. The idea with sections interests parents the most. A good way to spend time usefully, and at the same time throw out the accumulated energy.
5. Calmness is another point that should take place. The fact is that when correcting ADHD in children who show aggression, parents scold them for bad behavior, and as a result, they cannot cope with the child's condition. Only in a calm environment is it possible to heal.
6. The last point that helps parents is to support the child's hobbies. If the baby is interested in something, it must be supported. Do not confuse this with permissiveness. But it is not necessary to suppress the desire of children to explore the world, even if it is too active. You can try to interest the baby in some more peaceful activity. Things that you can do with your child help a lot.

By following these rules, parents have a high likelihood of success in treating ADHD in children. Rapid progress, as already mentioned, will not come. Sometimes it takes up to several years to correct. If you start treatment on time, you can easily defeat such a chronic condition completely.

conclusions

Diagnosis of ADHD in a child - what is it? What about an adult? The answers to these questions are already known. In fact, you should not be afraid of the syndrome. No one is safe from him. But with timely access to a specialist, as practice shows, there is a high probability of successful treatment.

Self-medication is not recommended. Only a neurologist is able to prescribe the most effective therapy, which will be selected on an individual basis, based on the reasons that led to the diagnosis. If a doctor prescribes a sedative for a very young child, it is better to show the baby to another specialist. It is possible that parents communicate with a non-professional who is not able to distinguish spoiled from ADHD.

It is not necessary to get angry at the child and scold him for his activity. Punish and intimidate - too. Under any circumstances, it should be remembered that hyperactivity is not a sentence. And in adulthood, this syndrome is not so noticeable. Often with age, hyperactive behavior normalizes on its own. But it can show up at any time.

In fact, ADHD is observed most often in schoolchildren. And do not consider it a shame or some kind of terrible sentence. Children with hyperactivity are often more talented than their peers. The only thing that prevents them from succeeding is the problem of concentration. And if you help to solve it, the child will please his parents more than once. ADHD (diagnosis by a neurologist) - what is it? which does not surprise modern doctors and is corrected with the right treatment!

At the site "Our inattentive hyperactive children", when the most active parents from among the members of the forum decided to unite in order to help their own and other people's children and other parents together.

In fact, it has been operating since the autumn of 2006, and was registered in the spring of 2007 with the organizational and financial support of the Attention Program of the Russian office of the British Charities Aid Foundation. Now Impulse includes parents living in Moscow and the Moscow region, and work is underway to open branches in St. Petersburg and Arkhangelsk. The organization includes about 40 families where children grow up with attention deficit hyperactivity disorder and other learning and behavioral problems.

What does a child with ADHD need?

Families that are part of the organization and come to the site and forum are united not only by a common diagnosis (diagnoses may just differ), but also by common problems. Inattentive, hyperactive, impulsive children urgently need adequate medical and educational assistance, proper upbringing at home and opportunities for self-realization - including in circles and sections. However, children are often deprived of all this.

Typical problems of a family where a child with ADHD grows up

• Misunderstanding of the child's difficulties in society, family, school
• Frequent conflicts
• Social isolation of the child and family
• Violation of the child's right to education
• Uncoordinated work of specialists
• Unavailability of help
• Insufficiency of information

Most often, the family is left alone with their problems. We are trying to solve them together.

Mom's troubles

It is especially difficult for mothers who single-handedly create and coordinate a treatment and correction plan for a child, without possessing the knowledge and methods necessary for this. Mothers are most often met with judgment from others and carry a heavy burden of responsibility and guilt; mothers of children with ADHD are significantly more likely than others to suffer from depression.

Helping a child is impossible without the help of a mother. To relieve her of despair, to give her confidence in her strength and ability, to equip her with knowledge, to help her find joy in everyday life with a difficult child is one of our main goals.

Our main areas of work

• Informational and moral support for families of children with ADHD and other learning and behavioral problems
• Educational work
• Human rights activities
• Children's programs

What we can

• Publication of information materials and their distribution to parents
• Organization of events (including lectures, seminars, consultations, etc.)
• Collection and analysis of information in families, identification of the most important problems and key needs
• Exchange of experience with similar foreign organizations, analysis of their experience

What is already being done

• Lectures by specialists for parents
• Support groups with the participation of a psychologist
• Regular exchange of experience: online and offline meetings
• Online consultations of specialists (including permanently consulting psychologist)
• Children's activities
• Legal training for parents is planned.

Areas of cooperation with professionals: where we need help

• Conducting lectures, seminars, information campaigns for parents
• Expert assistance in the development of programs and materials
• Direct work with families

Where do we need volunteer help?

• Organizational work on projects
• Help of a lawyer

Information about upcoming and past Impulse events - lectures, seminars, consultations, meetings, joint trips - is posted on the forum in the Events Calendar section.

You can contact us by mail: [email protected]

Unfortunately, the organization does not yet have a permanent premises and a landline phone. But we are always in touch via the Internet.

Someone thinks that this is just a character, someone considers it a wrong upbringing, but many doctors call it Attention Deficit Hyperactivity Disorder. Attention deficit hyperactivity disorder (ADHD) is a dysfunction of the central nervous system (mainly the reticular formation of the brain), manifested by difficulties in concentrating and maintaining attention, learning and memory disorders, as well as difficulties in processing exogenous and endogenous information and stimuli. This is one of the most common neuropsychiatric disorders in childhood, its prevalence ranges from 2 to 12% (average 3-7%), and is more common in boys than girls. ADHD can occur both in isolation and in combination with other emotional and behavioral disorders, having a negative impact on the child's learning and social adaptation.

The first manifestations of ADHD are usually observed from 3-4 years of age. But when a child gets older and enters school, he has additional difficulties, since the beginning of schooling makes new, higher demands on the child's personality and his intellectual abilities. It is during the school years that attention disorders become apparent, as well as difficulties in mastering the school curriculum and poor academic performance, self-doubt and low self-esteem.

Children with Attention Deficit Disorder have normal or high intelligence, but tend to do poorly in school. In addition to learning difficulties, attention deficit disorder is manifested by motor hyperactivity, attention defects, distractibility, impulsive behavior, and problems in relationships with others. In addition to the fact that children with ADHD misbehave and perform poorly at school, as they grow older, they may be at risk for the formation of deviant and antisocial forms of behavior, alcoholism, and drug addiction. Therefore, it is important to recognize the early manifestations of ADHD and be aware of the possibilities for their treatment. It should be noted that attention deficit disorder is observed in both children and adults.

Causes of ADHD

A reliable and unique cause of the syndrome has not yet been found. It is believed that the formation of ADHD is based on neurobiological factors: genetic mechanisms and early organic damage to the central nervous system, which can be combined with each other. They determine the changes in the central nervous system, violations of higher mental functions and behavior, corresponding to the picture of ADHD. The results of modern research indicate the involvement of the system "associative cortex-basal ganglia-thalamus-cerebellum-prefrontal cortex" in the pathogenetic mechanisms of ADHD, in which the coordinated functioning of all structures ensures control of attention and organization of behavior.

In many cases, an additional impact on children with ADHD is exerted by negative socio-psychological factors (primarily family factors), which in themselves do not cause the development of ADHD, but always contribute to an increase in the child's symptoms and adaptation difficulties.

genetic mechanisms. Among the genes that determine the predisposition to the development of ADHD (the role of some of them in the pathogenesis of ADHD is confirmed, while others are considered as candidates), include genes that regulate the metabolism of neurotransmitters in the brain, in particular dopamine and norepinephrine. Dysfunction of neurotransmitter systems of the brain plays an important role in the pathogenesis of ADHD. At the same time, disturbances in the processes of synaptic transmission are of primary importance, which entail dissociation, a break in connections between the frontal lobes and subcortical formations, and as a result of this, the development of ADHD symptoms. In favor of disorders of neurotransmitter transmission systems as the primary link in the development of ADHD is evidenced by the fact that the mechanisms of action of drugs that are most effective in the treatment of ADHD are to activate the release and inhibition of the reuptake of dopamine and norepinephrine in presynaptic nerve endings, which increases the bioavailability of neurotransmitters at the level of synapses. .

In modern concepts, attention deficit in children with ADHD is considered as a result of disturbances in the functioning of the posterior cerebral attention system regulated by norepinephrine, while disorders of behavioral inhibition and self-control characteristic of ADHD are considered as a lack of dopaminergic control over the flow of impulses to the forebrain attention system. The posterior cerebral system includes the superior parietal cortex, the superior colliculus, the thalamic cushion (the dominant role belongs to the right hemisphere); this system receives dense noradrenergic innervation from the locus coeruleus (blue spot). Norepinephrine suppresses spontaneous discharges of neurons, thereby preparing the posterior cerebral attention system, which is responsible for orienting to new stimuli, to work with them. This is followed by a switch in the mechanisms of attention to the anterior cerebral control system, which includes the prefrontal cortex and the anterior cingulate gyrus. The susceptibility of these structures to incoming signals is modulated by dopaminergic innervation from the ventral tegmental nucleus of the midbrain. Dopamine selectively regulates and limits excitatory impulses to the prefrontal cortex and cingulate gyrus, providing a reduction in excessive neuronal activity.

Attention deficit hyperactivity disorder (ADHD) is considered a polygenic disorder in which multiple disorders of dopamine and/or norepinephrine metabolism that exist simultaneously are due to the influence of several genes that override the protective effect of compensatory mechanisms. The effects of the genes that cause ADHD are complementary. Thus, ADHD is considered as a polygenic pathology with a complex and variable inheritance, and at the same time as a genetically heterogeneous condition.

Pre- and perinatal factors play an important role in the pathogenesis of ADHD. The formation of ADHD may be preceded by disturbances in the course of pregnancy and childbirth, in particular preeclampsia, eclampsia, the first pregnancy, the age of the mother is younger than 20 years or older than 40 years, prolonged labor, post-term pregnancy and prematurity, low birth weight, morphofunctional immaturity, hypoxic ischemic encephalopathy, a disease of a child in the first year of life. Other risk factors are the use of certain drugs by the mother during pregnancy, alcohol and smoking.

Apparently, a slight decrease in the size of the prefrontal areas of the brain (mainly in the right hemisphere), subcortical structures, corpus callosum, and cerebellum found in children with ADHD compared with healthy peers using magnetic resonance imaging (MRI) is apparently associated with early CNS damage. These data support the concept that the occurrence of ADHD symptoms is due to impaired connections between the prefrontal regions and subcortical ganglia, primarily the caudate nucleus. Subsequently, additional confirmation was obtained through the use of functional neuroimaging methods. Thus, when determining cerebral blood flow using single-photon emission computed tomography in children with ADHD, compared with healthy peers, a decrease in blood flow (and, consequently, metabolism) in the frontal lobes, subcortical nuclei and midbrain was demonstrated, and the changes were most pronounced at the level caudate nucleus. According to the researchers, changes in the caudate nucleus in children with ADHD were the result of its hypoxic-ischemic damage during the neonatal period. Having close connections with the thalamus opticus, the caudate nucleus performs an important function of modulation (mainly of an inhibitory nature) of polysensory impulsations, and the absence of inhibition of polysensory impulsations may be one of the pathogenetic mechanisms of ADHD.

With the help of positron emission tomography (PET), it was found that cerebral ischemia transferred at birth leads to persistent changes in dopamine receptors of the 2nd and 3rd types in the structures of the striatum. As a result, the ability of receptors to bind dopamine decreases and a functional insufficiency of the dopaminergic system is formed.

A recent comparative MRI study of children with ADHD, the purpose of which was to assess regional differences in the thickness of the cerebral cortex and compare their age dynamics with clinical outcomes, showed that children with ADHD showed a global decrease in cortical thickness, most pronounced in the prefrontal (medial and upper) and precentral regions. At the same time, in patients with worse clinical outcomes during the initial examination, the smallest thickness of the cortex was found in the left medial prefrontal region. Normalization of the thickness of the right parietal cortex was associated with the best outcomes in patients with ADHD and may reflect a compensatory mechanism associated with changes in the thickness of the cerebral cortex.

The neuropsychological mechanisms of ADHD are considered from the standpoint of disorders (immaturity) of the functions of the frontal lobes of the brain, primarily the prefrontal area. Manifestations of ADHD are analyzed from the standpoint of a deficit in the functions of the frontal and prefrontal parts of the brain and insufficient formation of executive functions (EF). Patients with ADHD present with "executive dysfunction". The development of UV and the maturation of the prefrontal region of the brain are long-term processes that continue not only in childhood but also in adolescence. EF is a rather broad concept referring to the range of abilities that serve the task of maintaining the necessary sequence of efforts to solve a problem, aimed at achieving a future goal. Significant components of the EF that are affected in ADHD are: impulse control, behavioral inhibition (restraint); organization, planning, management of mental processes; maintaining attention, keeping from distractions; inner speech; working (operative) memory; foresight, forecasting, a look into the future; retrospective assessment of past events, mistakes made; change, flexibility, ability to switch and revise plans; choice of priorities, the ability to allocate time; separating emotions from real facts. Some UF researchers emphasize the "hot" social aspect of self-regulation and the child's ability to control their behavior in society, while others emphasize the role of regulation of mental processes - the "cold" cognitive aspect of self-regulation.

Influence of adverse environmental factors. Anthropogenic pollution of the human environment, largely associated with microelements from the group of heavy metals, can have negative consequences for children's health. It is known that in the immediate vicinity of many industrial enterprises, zones with a high content of lead, arsenic, mercury, cadmium, nickel and other microelements are formed. The most common heavy metal neurotoxicant is lead, and its sources of environmental pollution are industrial emissions and vehicle exhaust gases. Lead exposure to children can cause cognitive and behavioral problems in children.

The role of nutritional factors and unbalanced nutrition. Nutritional imbalances (e.g., protein deficiency with an increase in easily digestible carbohydrates, especially in the morning), as well as micronutrient deficiencies, including vitamins, folates, omega-3 polyunsaturated fatty acids (PUFAs) can contribute to the onset or exacerbation of ADHD symptoms. , macro- and microelements. Micronutrients such as magnesium, pyridoxine and some others directly affect the synthesis and degradation of monoamine neurotransmitters. Therefore, micronutrient deficiencies can affect the neurotransmitter balance and hence the manifestation of ADHD symptoms.
Of particular interest among micronutrients is magnesium, which is a natural lead antagonist and promotes the rapid elimination of this toxic element. Therefore, magnesium deficiency, among other effects, can contribute to the accumulation of lead in the body.

Magnesium deficiency in ADHD can be associated not only with its insufficient intake with food, but also with an increased need for it during critical periods of growth and development, with severe physical and neuropsychic stress, and stress. Under conditions of environmental stress, nickel and cadmium, along with lead, act as magnesium displacing metals. In addition to a lack of magnesium in the body, the manifestation of ADHD symptoms can be influenced by zinc, iodine, and iron deficiencies.

Thus, ADHD is a complex neuropsychiatric disorder, accompanied by structural, metabolic, neurochemical, neurophysiological changes in the CNS, as well as neuropsychological disorders in the processes of information processing and UV.

Symptoms of ADHD in children

Symptoms of ADHD in a child may be the reason for the primary appeal to pediatricians, speech therapists, defectologists, psychologists. Often it is teachers of preschool and school educational institutions who first pay attention to the symptoms of ADHD, and not parents. The detection of such symptoms is a reason to show the child to a neurologist and neuropsychologist.

Main manifestations of ADHD

1. Attention disorders
Does not pay attention to details, makes many mistakes.
It is difficult to maintain attention when performing school and other tasks.
He does not listen to what is said to him.
Cannot follow instructions and follow through.
Unable to independently plan, organize the execution of tasks.
Avoids things that require prolonged mental stress.
Often loses his things.
Easily distracted.
Shows forgetfulness.
2a. Hyperactivity
Often makes restless movements with arms and legs, fidgets in place.
Cannot sit still when necessary.
Often runs or climbs somewhere when it is inappropriate.
Can't play quietly.
Excessive aimless physical activity is persistent, it is not affected by the rules and conditions of the situation.
2b. Impulsiveness
Answers questions without listening to the end and without thinking.
Can't wait for their turn.
Interferes with other people, interrupts them.
Chatty, unrestrained in speech.

The essential characteristics of ADHD are:

Duration: symptoms persist for at least 6 months;
- constancy, distribution to all spheres of life: adaptation disorders are observed in two or more types of environment;
- severity of violations: significant violations in training, social contacts, professional activities;
- other mental disorders are excluded: the symptoms cannot be associated exclusively with the course of another disease.

Depending on the predominant symptoms, there are 3 forms of ADHD:
- combined (combined) form - there are all three groups of symptoms (50-75%);
- ADHD with predominant attention disorders (20-30%);
- ADHD with a predominance of hyperactivity and impulsivity (about 15%).

Symptoms of ADHD have their own characteristics in preschool, primary school and adolescence.

Preschool age. Between the ages of 3 and 7, hyperactivity and impulsivity usually begin to appear. Hyperactivity is characterized by the fact that the child is in constant motion, cannot sit still during classes for even a short time, is too talkative and asks an endless number of questions. Impulsivity is expressed in the fact that he acts without thinking, cannot wait for his turn, does not feel restrictions in interpersonal communication, intervening in conversations and often interrupting others. Such children are often characterized as misbehaving or too temperamental. They are extremely impatient, arguing, making noise, shouting, which often leads them to outbursts of strong irritation. Impulsivity can be accompanied by recklessness, as a result of which the child endangers himself (increased risk of injury) or others. During games, energy is overflowing, and therefore the games themselves become destructive. Children are sloppy, often throw, break things or toys, are naughty, poorly obey the demands of adults, and can be aggressive. Many hyperactive children lag behind their peers in language development.

School age. After entering school, the problems of children with ADHD increase significantly. The learning requirements are such that a child with ADHD is not able to fulfill them fully. Because his behavior does not correspond to the age norm, he fails to achieve results in school that correspond to his abilities (while the general level of intellectual development in children with ADHD corresponds to the age range). During the lessons, they do not hear the teacher, it is difficult for them to cope with the proposed tasks, as they experience difficulties in organizing work and bringing it to the end, they forget in the course of fulfilling the conditions of the task, they do not master the teaching materials well and cannot apply them correctly. They quite soon turn off the process of doing the work, even if they have everything necessary for this, do not pay attention to details, show forgetfulness, do not follow the instructions of the teacher, switch poorly when the conditions of the task change or a new one is given. They are unable to do their homework on their own. Compared with peers, difficulties in the formation of writing, reading, counting, and logical thinking skills are much more common.

Relationship problems with others, including peers, teachers, parents, and siblings, are common among children with ADHD. Since all manifestations of ADHD are characterized by significant mood swings at different times and in different situations, the child's behavior is unpredictable. Hot temper, cockiness, oppositional and aggressive behavior are often observed. As a result, he cannot play for a long time, successfully communicate and establish friendly relations with peers. In the team, he serves as a source of constant anxiety: he makes noise without hesitation, takes other people's things, interferes with others. All this leads to conflicts, and the child becomes unwanted and rejected in the team.

Faced with this attitude, children with ADHD often consciously choose to play the role of class jester, hoping to build relationships with their peers. A child with ADHD not only does not study well on his own, but often "breaks" the lessons, interferes with the work of the class, and therefore is often called to the director's office. In general, his behavior creates the impression of "immaturity", inconsistency with his age. Only younger children or peers with similar behavior problems are usually ready to communicate with him. Gradually, children with ADHD develop low self-esteem.

At home, children with ADHD usually suffer constant comparisons to siblings who are well-behaved and learn better. Parents are annoyed by the fact that they are restless, obsessive, emotionally labile, undisciplined, disobedient. At home, the child is unable to take responsibility for the implementation of daily tasks, does not help parents, is sloppy. At the same time, comments and punishments do not give the desired results. According to the parents, “Something always happens to him”, that is, there is an increased risk of injuries and accidents.

Adolescence. In adolescence, pronounced symptoms of impaired attention and impulsivity continue to be observed in at least 50-80% of children with ADHD. At the same time, hyperactivity in adolescents with ADHD is significantly reduced, replaced by fussiness, a sense of inner restlessness. They are characterized by lack of independence, irresponsibility, difficulties in organizing and completing the execution of assignments and especially long-term work, which they are often unable to cope with without outside help. School performance often worsens, as they cannot effectively plan their work and distribute it over time, they postpone the execution of necessary tasks from day to day.

Difficulties in relationships in the family and school, behavioral disorders are growing. Many adolescents with ADHD are distinguished by reckless behavior associated with unjustified risk, difficulties in following the rules of behavior, disobedience to social norms and laws, failure to comply with the requirements of adults - not only parents and teachers, but also officials, such as school administration representatives or police officers. At the same time, they are characterized by weak psycho-emotional stability in case of failures, self-doubt, low self-esteem. They are too sensitive to teasing and ridicule from peers who think they are stupid. Adolescents with ADHD continue to be characterized by peers as immature and inappropriate for their age. In everyday life, they neglect the necessary safety measures, which increases the risk of injury and accidents.

Adolescents with ADHD are prone to being involved in teen gangs that commit various offenses, they may develop cravings for alcohol and drugs. But in these cases, they, as a rule, turn out to be led, obeying the will of stronger peers or older people and not thinking about the possible consequences of their actions.

Disorders associated with ADHD (comorbid disorders). Additional difficulties in intra-family, school and social adaptation in children with ADHD may be associated with the formation of concomitant disorders that develop against the background of ADHD as the underlying disease in at least 70% of patients. The presence of comorbid disorders can lead to worsening of the clinical manifestations of ADHD, worsening of long-term prognosis, and reduced effectiveness of treatment for ADHD. Behavioral and emotional disturbances associated with ADHD are considered as unfavorable prognostic factors for the long-term, up to chronic, course of ADHD.

Comorbid disorders in ADHD are represented by the following groups: externalized (oppositional defiant disorder, conduct disorder), internalized (anxiety disorders, mood disorders), cognitive (speech development disorders, specific learning difficulties - dyslexia, dysgraphia, dyscalculia), motor (static-locomotor failure, developmental dyspraxia, tics). Other comorbid ADHD disorders can be sleep disturbances (parasomnias), enuresis, encopresis.

Thus, learning, behavioral, and emotional problems can be associated with both the direct influence of ADHD and comorbid disorders, which should be diagnosed in a timely manner and considered as indications for additional appropriate treatment.

Diagnosis of ADHD

In Russia, the diagnosis of "hyperkinetic disorder" is approximately equivalent to the combined form of ADHD. To make a diagnosis, all three groups of symptoms (table above) must be confirmed, including at least 6 manifestations of inattention, at least 3 - hyperactivity, at least 1 - impulsiveness.

To confirm ADHD, there are no special criteria or tests based on the use of modern psychological, neurophysiological, biochemical, molecular genetic, neuroradiological and other methods. The diagnosis of ADHD is made by a doctor, but educators and psychologists should also be familiar with the diagnostic criteria for ADHD, especially since it is important to obtain reliable information about the child's behavior not only at home, but also at school or preschool in order to confirm this diagnosis.

In childhood, ADHD “imitators” are quite common: in 15-20% of children, forms of behavior outwardly similar to ADHD are periodically observed. In this regard, ADHD must be distinguished from a wide range of conditions that are similar to it only in external manifestations, but differ significantly both in causes and methods of correction. These include:

Individual characteristics of personality and temperament: the characteristics of the behavior of active children do not go beyond the age norm, the level of development of higher mental functions is good;
- Anxiety disorders: the characteristics of the child's behavior are associated with the action of psychotraumatic factors;
- consequences of traumatic brain injury, neuroinfection, intoxication;
- asthenic syndrome in somatic diseases;
- specific disorders of the development of school skills: dyslexia, dysgraphia, dyscalculia;
- endocrine diseases (pathology of the thyroid gland, diabetes mellitus);
- sensorineural hearing loss;
- epilepsy (absence forms; symptomatic, locally conditioned forms; side effects of anti-epileptic therapy);
- hereditary syndromes: Tourette, Williams, Smith-Mazhenis, Beckwith-Wiedemann, fragile X-chromosome;
- mental disorders: autism, affective disorders (mood), mental retardation, schizophrenia.

In addition, the diagnosis of ADHD should be built taking into account the peculiar age dynamics of this condition.

Treatment for ADHD

At the present stage, it becomes obvious that the treatment of ADHD should be aimed not only at controlling and reducing the main manifestations of the disorder, but also at solving other important tasks: improving the functioning of the patient in various areas and his fullest realization as a person, the emergence of his own achievements, improving self-esteem , normalization of the situation around him, including within the family, the formation and strengthening of communication skills and contacts with people around him, recognition by others and increasing satisfaction with his life.

The study confirmed the significant negative impact of the difficulties experienced by children with ADHD on their emotional state, family life, friendships, schooling, and leisure activities. In this regard, the concept of an expanded therapeutic approach has been formulated, which implies the extension of the influence of treatment beyond the reduction of the main symptoms and taking into account functional outcomes and quality of life indicators. Thus, the concept of an expanded therapeutic approach involves addressing the social and emotional needs of a child with ADHD, which should be given special attention both at the stage of diagnosis and treatment planning, and in the process of dynamic monitoring of the child and evaluation of the results of therapy.

The most effective for ADHD is complex assistance, which combines the efforts of doctors, psychologists, teachers working with the child, and his family. It would be ideal if a good neuropsychologist takes care of the child. Treatment for ADHD should be timely and must include:

Helping the family of a child with ADHD - family and behavioral therapy techniques that provide better interaction in families of children with ADHD;
- development of parenting skills for children with ADHD, including parent training programs;
- educational work with teachers, correction of the school curriculum - through a special one - the presentation of educational material and the creation of such an atmosphere in the classroom that maximizes the chances of successful education of children;
- psychotherapy of children and adolescents with ADHD, overcoming difficulties, developing effective communication skills in children with ADHD during special remedial classes;
- drug therapy and diet, which should be long enough, since improvement extends not only to the main symptoms of ADHD, but also to the socio-psychological side of the patients' lives, including their self-esteem, relationships with family members and peers, usually starting from the third month of treatment . Therefore, it is advisable to plan drug therapy for several months up to the duration of the entire academic year.

Medications to treat ADHD

An effective drug specifically designed for the treatment of ADHD is atomoxetine hydrochloride. The main mechanism of its action is associated with the blockade of norepinephrine reuptake, which is accompanied by an increase in synaptic transmission involving norepinephrine in various brain structures. In addition, experimental studies have found an increase in the content of not only norepinephrine, but also dopamine selectively in the prefrontal cortex under the influence of atomoxetine, since in this area dopamine binds to the same transport protein as norepinephrine. Since the prefrontal cortex plays a leading role in providing executive functions of the brain, as well as attention and memory, an increase in the concentration of norepinephrine and dopamine in this area under the action of atomoxetine leads to a decrease in the manifestations of ADHD. Atomoxetine has a beneficial effect on the behavioral characteristics of children and adolescents with ADHD, its positive effect is usually manifested already at the beginning of treatment, but the effect continues to grow during the month of continuous use of the drug. In most patients with ADHD, clinical efficacy is achieved by prescribing the drug in the dose range of 1.0-1.5 mg/kg of body weight per day with a single dose in the morning. The advantage of atomoxetine is its effectiveness in cases of ADHD combined with destructive behavior, anxiety disorders, tics, enuresis. The drug has many side effects, so the reception is strictly under the supervision of a doctor.

Russian specialists in the treatment of ADHD traditionally use nootropic drugs. Their use in ADHD is justified, since nootropic drugs have a stimulating effect on cognitive functions that are not sufficiently formed in children of this group (attention, memory, organization, programming and control of mental activity, speech, praxis). Given this circumstance, the positive effect of drugs with a stimulating effect should not be taken as paradoxical (given the hyperactivity in children). On the contrary, the high efficiency of nootropics seems to be natural, especially since hyperactivity is only one of the manifestations of ADHD and is itself caused by violations of higher mental functions. In addition, these drugs have a positive effect on metabolic processes in the central nervous system and contribute to the maturation of the inhibitory and regulatory systems of the brain.

Recent study confirms good potential hopantenic acid preparation in the long-term treatment of ADHD. A positive effect on the main symptoms of ADHD is achieved after 2 months of treatment, but continues to increase after 4 and 6 months of its use. Along with this, the beneficial effect of long-term use of the hopantenic acid preparation on adaptation and functioning disorders characteristic of children with ADHD in various areas, including difficulties in behavior in the family and in society, schooling, reduced self-esteem, and lack of basic life skills, was confirmed. However, in contrast to the regression of the main symptoms of ADHD, longer periods of treatment were needed to overcome the disorders of adaptation and socio-psychological functioning: a significant improvement in self-esteem, communication with others and social activity was observed according to the results of parental questionnaires after 4 months, and a significant improvement in behavioral and schooling, basic life skills along with a significant regression of risk-taking behavior - after 6 months of using the drug hopantenic acid.

Another direction of ADHD treatment is to control negative nutritional and environmental factors that lead to the intake of neurotoxic xenobiotics (lead, pesticides, polyhaloalkyls, food colorings, preservatives) into the child's body. This should be accompanied by the inclusion in the diet of the necessary micronutrients that help reduce ADHD symptoms: vitamins and vitamin-like substances (omega-3 PUFAs, folates, carnitine) and essential macro- and microelements (magnesium, zinc, iron).
Among the micronutrients with a proven clinical effect in ADHD, magnesium preparations should be noted. Magnesium deficiency is determined in 70% of children with ADHD.

Magnesium is an important element involved in maintaining the balance of excitatory and inhibitory processes in the central nervous system. There are several molecular mechanisms through which magnesium deficiency affects neuronal activity and neurotransmitter metabolism: magnesium is required to stabilize excitatory (glutamate) receptors; magnesium is an essential cofactor of adenylate cyclases involved in signal transmission from neurotransmitter receptors to controlling intracellular cascades; magnesium is a cofactor for catechol-O-methyltransferase, which inactivates excess monoamine neurotransmitters. Therefore, magnesium deficiency contributes to the imbalance of the "excitation-inhibition" processes in the CNS towards excitation and can affect the manifestation of ADHD.

In the treatment of ADHD, only organic magnesium salts (lactate, pidolate, citrate) are used, which is associated with a high bioavailability of organic salts and the absence of side effects when they are used in children. The use of magnesium pidolate with pyridoxine in solution (ampoule form of Magne B6 (Sanofi-Aventis, France)) is allowed from the age of 1 year, lactate (Magne B6 in tablets) and magnesium citrate (Magne B6 forte in tablets) - from 6 years . The magnesium content in one ampoule is equivalent to 100 mg of ionized magnesium (Mg2+), in one tablet of Magne B6 - 48 mg of Mg2+, in one tablet of Magne B6 forte (618.43 mg of magnesium citrate) - 100 mg of Mg2+. The high concentration of Mg2+ in Magne B6 forte allows you to take 2 times fewer tablets than when taking Magne B6. The advantage of the drug Magne B6 in ampoules is also the possibility of more accurate dosing, the use of the Magne B6 ampoule form provides a rapid increase in the level of magnesium in the blood plasma (within 2-3 hours), which is important for the rapid elimination of magnesium deficiency. At the same time, taking Magne B6 tablets contributes to a longer (within 6-8 hours) retention of an increased concentration of magnesium in erythrocytes, that is, its deposition.

The emergence of combined preparations containing magnesium and vitamin B6 (pyridoxine) has significantly improved the pharmacological properties of magnesium salts. Pyridoxine is involved in the metabolism of proteins, carbohydrates, fatty acids, the synthesis of neurotransmitters and many enzymes, has a neuro-, cardio-, hepatotropic, and hematopoietic effect, contributes to the replenishment of energy resources. The high activity of the combined preparation is due to the synergistic action of the components: pyridoxine increases the concentration of magnesium in plasma and erythrocytes and reduces the amount of magnesium excreted from the body, improves magnesium absorption in the gastrointestinal tract, its penetration into cells, and fixation. Magnesium, in turn, activates the process of transformation of pyridoxine into its active metabolite pyridoxal-5-phosphate in the liver. Thus, magnesium and pyridoxine potentiate each other's action, which allows their combination to be successfully used to normalize magnesium balance and prevent magnesium deficiency.

The combined intake of magnesium and pyridoxine for 1-6 months reduces the symptoms of ADHD and restores normal values ​​of magnesium in red blood cells. Already after a month of treatment, anxiety, attention disorders and hyperactivity decrease, concentration of attention, accuracy and speed of task performance improve, and the number of errors decreases. There is an improvement in gross and fine motor skills, a positive dynamics of EEG characteristics in the form of the disappearance of signs of paroxysmal activity against the background of hyperventilation, as well as bilateral-synchronous and focal pathological activity in most patients. At the same time, taking Magne B6 is accompanied by the normalization of magnesium concentration in erythrocytes and blood plasma of patients.

Replenishment of magnesium deficiency should last at least two months. Considering that alimentary deficiency of magnesium occurs most often, when drawing up nutritional recommendations, one should take into account not only the quantitative content of magnesium in foods, but also its bioavailability. So, fresh vegetables, fruits, herbs (parsley, dill, green onions) and nuts have the maximum concentration and activity of magnesium. When preparing products for storage (drying, canning), the concentration of magnesium decreases slightly, but its bioavailability drops sharply. This is important for children with ADHD who have a deepening of magnesium deficiency that coincides with the period of school from September to May. Therefore, the use of combined preparations containing magnesium and pyridoxine is advisable during the school year. But, alas, the problem cannot be solved by drugs alone.

Home psychotherapy

Any classes are desirable to be carried out in a playful way. Any games where you need to hold and switch attention will do. For example, the game "find the pairs", where cards with images are opened and turned over in turn, and you need to remember and open them in pairs.

Or even take the game of hide and seek - there is a sequence, certain roles, you need to sit in the shelter for a certain time, and you also need to figure out where to hide and change these places. All this is a good training of programming and control functions, moreover, it takes place when the child is emotionally involved in the game, which helps to maintain the optimal tone of wakefulness at this moment. And it is needed for the emergence and consolidation of all cognitive neoplasms, for the development of cognitive processes.

Remember all the games that you played in the yard, they are all selected by human history and are very useful for the harmonious development of mental processes. Here, for example, is a game where you need to "do not say yes and no, do not buy black and white" - after all, this is a wonderful exercise for slowing down a direct answer, that is, for training programming and control.

Teaching Children with Attention Deficit Hyperactivity Disorder

With such children, a special approach to learning is needed. Often children with ADHD have problems maintaining optimal tone, which causes all other problems. Due to the weakness of the inhibitory control, the child is overexcited, restless, cannot concentrate on anything for a long time, or, conversely, the child is lethargic, he wants to lean against something, he quickly gets tired, and his attention can no longer be collected by any means until some upswing and then downswing again. The child cannot set tasks for himself, determine how and in what order he will solve them, do this work without being distracted and test himself. These children have difficulties in writing - omissions of letters, syllables, merging two words into one. They do not hear the teacher or are accepted for the task without listening to the end, hence, the problems in all school subjects.

We need to develop in the child the ability to program and control their own activities. While he himself does not know how to do this, these functions are taken over by the parents.

Preparation

Choose a day and address the child with these words: "You know, they taught me how to do homework quickly. Let's try to do them very quickly. It should work out!"

Ask the child to bring a portfolio, lay out everything you need to complete the lessons. Say: well, let's try to set a record - do all the lessons in an hour (let's say). Important: the time while you are preparing, clearing the table, laying out textbooks, figuring out the task, is not included in this hour. It is also very important that the child has all the tasks recorded. As a rule, children with ADHD do not have half of the tasks, and endless calls to classmates begin. Therefore, we can warn you in the morning: today we will try to set a record for completing tasks in the shortest possible time, only one thing is required of you: carefully write down all the tasks.

First item

Let's get started. Open the diary, see what is given. What will you do first? Russian or math? (It does not matter what he chooses - it is important that the child chooses himself).

Take a textbook, find an exercise, and I time it. Read the assignment aloud. So, I did not understand something: what needs to be done? Explain please.

You need to reformulate the task in your own words. Both - both the parent and the child - must understand what exactly needs to be done.

Read the first sentence and do what needs to be done.

It is better to first do the first trial action orally: what do you need to write? Speak aloud, then write.

Sometimes a child says something correctly, but immediately forgets what was said - and when it is necessary to write it down, he no longer remembers. Here the mother should work as a voice recorder: to remind the child what he said. The most important thing is to be successful from the very beginning.

It is necessary to work slowly, not to make mistakes: pronounce it as you write, Moscow - "a" or "o" next? Speak in letters, in syllables.

Check this out! Three and a half minutes - and we have already made the first offer! Now you can easily finish everything!

That is, the effort should be followed by encouragement, emotional reinforcement, it will allow maintaining the optimal energy tone of the child.

The second sentence takes a little less time than the first.

If you see that the child began to fidget, yawn, make mistakes - stop the clock. "Oh, I forgot, I have something left unfinished in my kitchen, wait for me." The child should be given a short break. In any case, you need to ensure that the first exercise is done as compactly as possible, in fifteen minutes, no more.

Turn

After that, you can already relax (the timer turns off). You are hero! You did the exercise in fifteen minutes! So, in half an hour we will do the whole Russian! Well, you already deserve compote. Instead of compote, of course, you can choose any other reward.

When you give a break, it is very important not to lose your mood, not to let the child be distracted during the rest. Well, are you ready? Let's do two more exercises the same way! And again - we read the condition aloud, we pronounce it, we write it.

When the Russian is finished, you need to rest more. Stop the timer, take a break of 10-15 minutes - like a school break. Agree: at this time you can’t turn on the computer and TV, you can’t start reading a book. You can do physical exercises: leave the ball, hang on the horizontal bar.

Second item

We do the same math. What is given? Open textbook. Let's start time again. Separately, we retell the conditions. We pose a separate question that needs to be answered.

What is asked in this problem? What is needed?

It often happens that the mathematical part is perceived and reproduced easily, but the question is forgotten, formulated with difficulty. The question should be given special attention.

Can we answer this question right away? What needs to be done for this? What do you need to know first?

Let the child tell in the simplest words: what needs to be done in what order. At first it is external speech, then it will be replaced by internal. Mom should insure the child: in time to hint to him that he went the wrong way, that it is necessary to change the course of reasoning, not to let him get confused.

The most unpleasant part of a mathematical task is the rules for solving problems. We ask the child: did you solve a similar problem in class? Let's see how to write so as not to make a mistake. Let's take a look?

You need to pay special attention to the recording form - after that it costs nothing to write down the solution to the problem.

Then check. Did you say you need to do this and that? Did it? And this? This? Checked, now you can write the answer? Well, how long did the task take us?

How did you do it in such a short amount of time? You deserve something delicious!

The task is done - we take up the examples. The child dictates and writes to himself, the mother checks the correctness. After each column we say: amazing! Are we taking on the next column or compote?

If you see that the child is tired - ask: well, will we work some more or will we go to drink compote?

Mom should be in good shape on this day herself. If she is tired, wants to get rid of it as soon as possible, if her head hurts, if she cooks something in the kitchen at the same time and runs there every minute - this will not work.

So you need to sit with the child once or twice. Then the mother should begin to systematically eliminate herself from this process. Let the child tell his mother the whole semantic part in his own words: what needs to be done, how to do it. And the mother can go away - go to another room, to the kitchen: but the door is open, and the mother imperceptibly controls whether the child is busy with work, whether he is distracted by extraneous matters.

It is not necessary to focus on mistakes: it is necessary to achieve the effect of effectiveness, it is necessary that the child has the feeling that he is succeeding.

Thus, early detection of ADHD in children will prevent future learning and behavioral problems. The development and application of complex correction should be carried out in a timely manner, be of an individual nature. Treatment for ADHD, including drug therapy, should be long enough.

Prognosis for ADHD

The prognosis is relatively favorable, and in a significant proportion of children, even without treatment, symptoms disappear during adolescence. Gradually, as the child grows, disturbances in the neurotransmitter system of the brain are compensated, and some of the symptoms regress. However, clinical manifestations of attention deficit hyperactivity disorder (excessive impulsivity, irascibility, absent-mindedness, forgetfulness, restlessness, impatience, unpredictable, rapid and frequent mood changes) can also be observed in adults.

The factors of the unfavorable prognosis of the syndrome are its combination with mental illness, the presence of mental pathology in the mother, as well as the symptoms of impulsivity in the patient himself. Social adaptation of children with attention deficit hyperactivity disorder can only be achieved with the interest and cooperation of the family and school.

Attention deficit hyperactivity disorder (ADHD), similar to ICD-10 hyperkinetic disorder), is an evolving neuropsychiatric disorder in which there are significant problems with executive functions (for example, attention-related control and inhibitory control) that cause attention deficit hyperactivity or impulsiveness inappropriate for the person's age. These symptoms may begin between the ages of six and twelve and persist for more than six months from the time of diagnosis. In school-aged subjects, symptoms of inattention often lead to poor school performance. While this is uncomfortable, particularly in today's society, many children with ADHD have good attention spans for tasks they find interesting. Although ADHD is the most well-studied and diagnosed psychiatric disorder in children and adolescents, the cause is unknown in most cases. The syndrome affects 6–7% of children when diagnosed using the criteria of the manual for the diagnosis and statistical registration of mental illness, revision IV and 1–2% when diagnosed using the ICD-10 criteria. The prevalence is similar among countries, depending largely on how the syndrome is diagnosed. Boys are approximately three times more likely to be diagnosed with ADHD than girls. About 30–50% of people diagnosed in childhood have symptoms in adulthood, and approximately 2–5% of adults have the condition. The condition is difficult to distinguish from other disorders, as well as from a state of normal increased activity. Management of ADHD usually involves a combination of psychological counseling, lifestyle changes, and medications. Medications are only recommended as first-line treatment in children who show severe symptoms and may be considered for children with moderate symptoms who refuse or do not respond to psychological counseling. Therapy with stimulant drugs is not recommended for preschool children. Treatment with stimulants is effective up to 14 months; however, their long-term effectiveness is not clear. Adolescents and adults tend to develop coping skills that apply to some or all of their disabilities. ADHD, its diagnosis and treatment have remained controversial since the 1970s. The controversy spans practitioners, teachers, politicians, parents and the media. Topics include the cause of ADHD and the use of stimulant drugs in its treatment. Most medical professionals recognize ADHD as a congenital disorder, and the debate in the medical community is largely focused on how it should be diagnosed and treated.

Signs and symptoms

ADHD is characterized by inattention, hyperactivity (an agitated state in adults), aggressive behavior, and impulsivity. Often there are learning difficulties and relationship problems. Symptoms can be difficult to define as it is difficult to draw the line between normal levels of inattention, hyperactivity and impulsivity and significant levels requiring intervention. DSM-5-diagnosed symptoms must have been present in a variety of environments for six months or more, and to a degree that is significantly greater than in other subjects of the same age. They can also cause problems in a person's social, academic and professional life. Based on the symptoms present, ADHD can be divided into three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and mixed.

A subject with inattention may have some or all of the following symptoms:

Easily distracted, missing details, forgetting things, and frequently switching from one activity to another

He finds it difficult to keep his attention on the task

The task becomes boring after only a few minutes if the subject is not doing something pleasurable.

Difficulty focusing on organizing and completing tasks, learning new things

Has trouble completing or turning in homework, often loses items (eg, pencils, toys, assignments) needed to complete an assignment or activity

Doesn't listen when talking

Soaring in the clouds, easily confused and moving slowly

Has difficulty processing information as quickly and accurately as others

Difficulty following instructions

A subject with hyperactivity may have some or all of the following symptoms:

Restlessness or fidgeting in place

Talks non-stop

Throws at everything, touches and plays with everything in sight

Difficulty sitting during lunch, in class, doing homework and while reading

Constantly on the move

Difficulty doing quiet tasks

These symptoms of hyperactivity tend to disappear with age and turn into "inward restlessness" in adolescents and adults with ADHD.

A subject with impulsivity may have all or more of the following symptoms:

Be very impatient

Spout inappropriate comments, express emotion without restraint, and act without regard for the consequences

Difficulty looking forward to the things he wants or looking forward to returning to the game

Frequently interrupts communication or activities of others

People with ADHD are more likely to have difficulty with communication skills, such as social interaction and education, and maintaining friendships. This is true for all subtypes. About half of children and adolescents with ADHD exhibit social withdrawal compared to 10-15% of non-ADHD children and adolescents. People with ADHD have an attention deficit that causes difficulty with verbal and non-verbal language, which negatively affects social interaction. They may also fall asleep during social interaction and lose social stimulus. Difficulty managing anger is more common in children with ADHD, as are poor handwriting and slow speech, language, and motor development. While this is a significant inconvenience, particularly in today's society, many children with ADHD have good attention spans for tasks they find interesting.

Associated violations

In children with ADHD, other disorders are observed in about ⅔ of cases. Some common violations include:

Learning disabilities occur in approximately 20–30% of children with ADHD. Learning disabilities can include speech and language disorders, as well as learning disabilities. ADHD, however, is not considered a learning disability, but often causes learning difficulties.

Oppositional defiant disorder (ODD) and conduct disorder (CD), which are observed in ADHD in approximately 50% and 20% of cases, respectively. They are characterized by antisocial behavior such as stubbornness, aggression, frequent temper tantrums, duplicity, lying and stealing. Approximately half of those with ADHD and ODD or CD develop antisocial personality disorder in adulthood. Brain scans prove that conduct disorder and ADHD are separate disorders.

Primary attention disorder, which is characterized by low attention and concentration, as well as difficulty staying awake. These children tend to fidget, yawn, and stretch, and have to be hyperactive in order to remain alert and active.

Hypokalemic sensory overstimulation is present in less than 50% of people with ADHD and may be the molecular mechanism for many ADHD sufferers.

Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the mixed subtype of ADHD are more likely to have a mood disorder. Adults with ADHD also sometimes have bipolar disorder, which requires careful evaluation to make an accurate diagnosis and treat both conditions.

Anxiety disorders are more common in ADHD sufferers.

Disorders caused by the use of psychoactive substances. Adolescents and adults with ADHD are at increased risk of developing a substance use disorder. For the most part, it is associated with and. The reason for this may be a change in the reinforcement pathway in the brain of subjects with ADHD. This makes ADHD more difficult to identify and treat, with serious substance use problems usually being treated first due to the higher risk.

There is an association with persistent bedwetting, slow speech and dyspraxia (DCD), with about half of people with dyspraxia having ADHD. Slow speech in people with ADHD may include problems with hearing impairments such as poor short-term auditory memory, difficulty following instructions, slow speed in processing written and spoken language, difficulty hearing in distracting environments such as in the classroom, and difficulty understanding read.

Causes

The cause of most cases of ADHD is not known; however, environmental involvement is assumed. Certain cases are associated with a previous infection or brain injury.

Genetics

See also: Hunter-Farmer Theory Twin studies show that the disorder is often inherited from one parent, with genetics accounting for about 75% of cases. Siblings of children with ADHD are three to four times more likely to develop the disorder than siblings of non-ADHD children. Genetic factors are thought to be relevant to whether ADHD persists into adulthood. Usually several genes are involved, many of which directly affect dopamine neurotransmission. Genes involved in dopamine neurotransmission include DAT, DRD4, DRD5, TAAR1, MAOA, COMT, and DBH. Other genes associated with ADHD include SERT, HTR1B, SNAP25, GRIN2A, ADRA2A, TPH2, and BDNF. A common gene variant called LPHN3 is estimated to be responsible for approximately 9% of cases, and when this gene is present, people respond partially to the stimulant drug. Since ADHD is widespread, natural selection is likely to favor traits, at least individually, and these may provide a survival advantage. For example, some women may be more attractive to male risk-takers by increasing the frequency of genes that predispose to ADHD in the genetic pool. Since the syndrome is most common in children of anxious or stressed mothers, some have suggested that ADHD is an adaptation that helps children cope with stressful or dangerous environmental conditions, such as increased impulsivity and exploratory behavior. Hyperactivity can be useful from an evolutionary perspective in situations that involve risk, competition, or unpredictable behavior (such as exploring new places or finding new food sources). In these situations, ADHD can be beneficial to society as a whole, even if harmful to the subject himself. In addition, in certain environments, it can confer benefits on the subjects themselves, such as quick responses to predators or superior hunting skills.

Environment

Environmental factors are thought to play a lesser role. Alcohol use during pregnancy can cause fetal alcohol spectrum disorder, which may include ADHD-like symptoms. Exposure to tobacco smoke during pregnancy can cause problems with the development of the central nervous system and increase the risk of ADHD. Many children exposed to tobacco smoke do not develop ADHD or have only mild symptoms that do not reach the limit of a diagnosis. A combination of genetic predisposition and exposure to tobacco smoke may explain why some children exposed during pregnancy may develop ADHD while others do not. Children exposed to even low levels of lead or PCBs can develop problems that resemble ADHD and lead to a diagnosis. Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate has been associated with an increased risk; however, the evidence is not conclusive. Very low birth weight, preterm birth, and early exposure to adverse factors also increase risk, as do infections during pregnancy, birth, and early childhood. These infections include, among others, various viruses (finnosis, varicella, rubella, enterovirus 71) and streptococcal bacterial infection. At least 30% of children with traumatic brain injury later develop ADHD, and about 5% of cases are associated with brain damage. Some children may react negatively to food coloring or preservatives. It is possible that certain colored foods may act as a trigger in those with a genetic predisposition, but the evidence is weak. The UK and the EU have introduced regulation based on these issues; The FDA didn't.

Society

A diagnosis of ADHD may be indicative of family dysfunction or a poor educational system rather than an individual's problems. Some cases may be explained by heightened educational expectations, with the diagnosis in some cases representing a way for parents to obtain additional financial and educational support for their children. The youngest children in a class are more likely to be diagnosed with ADHD, presumably because they lag behind their older classmates in development. Behavior typical of ADHD is more common in children who have experienced abuse and moral humiliation. According to social order theory, societies define the boundary between normal and unacceptable behavior. Members of the community, including physicians, parents, and teachers, determine which diagnostic criteria to use and thus the number of people affected by the syndrome. This has led to the present situation where the DSM-IV shows an ADHD level three to four times the ICD-10 level. Thomas Szasz, who supports this theory, argued that ADHD was "made up, not discovered."

Pathophysiology

Current models of ADHD suggest that it is associated with functional impairments in several brain neurotransmitter systems, in particular those involving dopamine and norepinephrine. Dopamine and norepinephrine pathways, which originate in the ventral tegmental region and the locus coeruleus, target different regions of the brain and mediate many cognitive processes. Dopamine and norepinephrine pathways, which target the prefrontal cortex and striatum (particularly the pleasure center), are directly responsible for regulation of executive function (cognitive control of behavior), motivation, and reward perception; these pathways play a major role in the pathophysiology of ADHD. Larger models of ADHD with additional pathways have been proposed.

Structure of the brain

Children with ADHD have a general decrease in the volume of certain brain structures, with a proportionately large decrease in the volume of the left-sided prefrontal cortex. The posterior parietal cortex also shows thinning in ADHD subjects compared to controls. Other brain structures in the prefrontal-striate-cerebellar and prefrontal-striate-thalamic circuits also differ between people with and without ADHD.

Neurotransmitter pathways

It used to be thought that the increased number of dopamine transporters in people with ADHD was part of the pathophysiology, but the increased number appears to be related to adaptation to stimulant exposure. Current models include the mesocorticolimbic dopamine pathway and the coeruleus-noradrenergic system. Psychostimulants for ADHD are effective treatments because they increase the activity of neurotransmitters in these systems. Additionally, pathological abnormalities in the serotonergic and cholinergic pathways may be observed. Also relevant is the neurotransmission of glutamate, a dopamine cotransmitter in the mesolimbic pathway.

Executive function and motivation

Symptoms of ADHD include problems with executive function. Executive function refers to several mental processes that are required to regulate, control, and manage the tasks of daily life. Some of these impairments include problems with organization, timing, excessive procrastination, concentration, execution speed, emotion regulation, and short-term memory use. People generally have good long-term memory. 30-50% of children and adolescents with ADHD meet the criteria for executive function deficit. One study found that 80% of subjects with ADHD were impaired in at least one executive function task compared to 50% of subjects without ADHD. Due to the degree of brain maturation and the increased demand for executive control as people get older, ADHD disorders may not fully manifest themselves until adolescence or even late adolescence. ADHD is also associated with motivational deficits in children. Children with ADHD have difficulty focusing on long-term rewards over short-term rewards and also show impulsive behavior towards short-term rewards. In these subjects, a large amount of positive reinforcement effectively increases performance. ADHD stimulants can increase resilience in children with ADHD equally.

Diagnostics

ADHD is diagnosed through an assessment of a person's childhood behavior and mental development, including ruling out exposure to drugs, medications, and other medical or psychiatric problems as explanations for symptoms. Feedback from parents and teachers is often taken into account, with most diagnoses made after the teacher has raised concerns about it. It can be seen as an extreme manifestation of one or more permanent human traits found in all humans. The fact that someone responds to medication does not confirm or rule out a diagnosis. Since brain imaging studies did not provide reliable results in subjects, they were only used for research purposes and not diagnosis. The DSM-IV or DSM-5 criteria are often used for diagnosis in North America, while European countries generally use the ICD-10. At the same time, the DSM-IV criteria make the diagnosis of ADHD 3-4 times more likely than the ICD-10 criteria. The syndrome is classified as a developmental neurodevelopmental disorder. In addition, it is classified as a social conduct disorder along with oppositional defiant disorder, conduct disorder, and antisocial personality disorder. The diagnosis does not suggest a neurological disorder. Comorbid conditions that should be screened for include anxiety, depression, oppositional defiant disorder, conduct disorder, learning and speech impairment. Other conditions to be considered are other neurodevelopmental disorders, tics and sleep apnea. The diagnosis of ADHD using quantitative electroencephalography (QEEG) is an area of ​​ongoing research, although the value of QEEG in ADHD is not clear to date. In the United States, the Food and Drug Administration has approved the use of QEEG to estimate the prevalence of ADHD.

Diagnostics and statistical guidance

As with other psychiatric disorders, a formal diagnosis is made by a qualified professional based on a combination of several criteria. In the United States, these criteria are defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Illness. Based on these criteria, three subtypes of ADHD can be distinguished:

Predominantly inattentive ADHD (ADHD-PI) presents with symptoms including mild distractibility, forgetfulness, daydreaming, disorganization, low concentration, and difficulty completing tasks. Often people refer to ADHD-PI as "attention deficit disorder" (ADD), however, the latter has not been formally approved since the 1994 revision of the DSM.

ADHD predominantly hyperactive-impulsive type manifests as excessive anxiety and agitation, hyperactivity, difficulty waiting, difficulty staying still, infantile behavior; destructive behavior can also be observed.

Mixed ADHD is a combination of the first two subtypes.

This division is based on the presence of at least six of the nine long-term (lasting at least six months) symptoms of inattention, hyperactivity-impulsivity, or both. To be taken into account, symptoms must appear between the ages of six and twelve and be observed at more than one environmental stop (for example, at home and at school or at work). The symptoms must not be acceptable to children at this age, and there must be evidence that they cause school or work-related problems. Most children with ADHD are mixed. Children with the inattentive subtype are less likely to pretend or have difficulty getting along with other children. They may sit quietly but not paying attention, whereby difficulties may be overlooked.

International classifier of diseases

In the ICD-10, the symptoms of "hyperkinetic disorder" are similar to ADHD in the DSM-5. When a conduct disorder (as defined by ICD-10) is presented, the condition is referred to as hyperkinetic conduct disorder. Otherwise, the impairment is classified as activity and attention impairment, other hyperkinetic disorders, or unspecified hyperkinetic disorders. The latter are sometimes referred to as the hyperkinetic syndrome.

adults

Adults with ADHD are diagnosed according to the same criteria, including signs that may be present between the ages of six and twelve. Questioning parents or caregivers about how the person behaved and developed as a child may form part of the assessment; a family history of ADHD also contributes to the diagnosis. While the main symptoms of ADHD are the same in children and adults, they often manifest themselves differently, for example, excessive physical activity observed in children can manifest as a feeling of restlessness and constant mental activity in adults.

Differential Diagnosis

Symptoms of ADHD that may be associated with other disorders

Depression:

Feelings of guilt, hopelessness, low self-esteem, or unhappiness

Loss of interest in hobbies, ordinary activities, sex, or work

Fatigue

Too short, poor or excessive sleep

Appetite changes

Irritability

Low stress tolerance

Suicidal thoughts

unexplained pain

Anxiety disorder:

Restlessness or a persistent feeling of anxiety

Irritability

Inability to relax

overexcitation

easy fatigue

Low stress tolerance

Difficulty paying attention

Excessive feeling of happiness

Hyperactivity

Leap of ideas

Aggression

Excessive talkativeness

Big crazy ideas

Decreased need for sleep

Unacceptable social behavior

Difficulty paying attention

Symptoms of ADHD such as low mood and low self-esteem, mood swings and irritability can be confused with dysthymia, cyclothymia or, as well as borderline personality disorder. Some symptoms that are associated with anxiety disorders, antisocial personality disorder, developmental or mental retardation, or chemical dependency effects such as intoxication and withdrawal may overlap with some of the symptoms of ADHD. These disorders sometimes occur along with ADHD. Medical conditions that can cause ADHD symptoms include: hypothyroidism, epilepsy, lead toxicity, hearing loss, liver disease, sleep apnea, drug interactions, and traumatic brain injury. Primary sleep disturbances can affect attention and behavior, and ADHD symptoms can affect sleep. Thus, it is recommended that children with ADHD be monitored regularly for sleep problems. Sleepiness in children can lead to symptoms ranging from classic yawning and eye rubbing to hyperactivity with inattention. Obstructive sleep apnea can also cause ADHD-type symptoms.

Control

Management of ADHD usually involves psychological counseling and medication, alone or in combination. While treatment may improve long-term outcomes, this does not rule out negative outcomes in general. Drugs used include stimulants, atomoxetine, alpha-2 adrenergic agonists, and sometimes antidepressants. Dietary changes may also be helpful, with evidence supporting free fatty acids and reduced exposure to food coloring. Removing other foods from the diet is not supported by the evidence.

Behavioral Therapy

There is strong evidence for the use of behavioral therapy for ADHD, and it is recommended as a first-line treatment for those with mild symptoms or for preschool children. Physiological therapies used include: psychoeducational stimulus, behavioral therapy, cognitive behavioral therapy (CBT), interpersonal therapy, family therapy, school interventions, social skills training, parenting training, and neural feedback. The preparation and education of parents has short-term benefits. There is little high-quality research on the effectiveness of family therapy for ADHD, but the evidence suggests that it is equivalent to health care and better than placebo. There are some specific ADHD support groups as information sources that can help families deal with ADHD. Social skills training, behavioral modification, and drugs may have limited benefits to some extent. The most important factor in alleviating late psychological problems such as major depression, delinquency, school failure, and substance use disorder is the formation of friendships with people who are not involved in delinquent activities. Regular exercise, in particular aerobic exercise, is an effective adjunct to the treatment of ADHD, although the best type and intensity is not currently known. In particular, physical activity causes better behavior and motor abilities without any side effects.

Medications

Stimulant drugs are the preferred pharmaceutical treatment. They have at least a short-term effect in about 80% of people. There are several non-stimulant medications such as atomoxetine, bupropion, guanfacine, and clonidine that can be used as alternatives. There are no good studies comparing different drugs; however, they are more or less equal in terms of side effects. Stimulants improve academic performance while atomoxetine does not. There is little evidence regarding its effect on social behavior. Drugs are not recommended for preschool children, as long-term effects in this age group are not known. The long-term effects of stimulants are generally unclear, with only one study finding beneficial effects, another finding no benefit, and a third finding harmful effects. Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate reduces the pathological abnormalities in brain structure and function found in subjects with ADHD. Atomoxetine, due to the lack of addictive potential, may be preferable for those at risk of addiction to stimulant drugs. Recommendations for when to use drugs vary between countries, with the UK's National Institute for Health and Care Excellence recommending their use only in severe cases, while US guidelines recommend the use of drugs in almost all cases. While stimulants are generally safe, there are side effects and contraindications to their use. Stimulants can cause psychosis or mania; however, this is a relatively rare occurrence. For those undergoing long-term treatment, regular check-ups are recommended. Stimulant therapy should be temporarily discontinued to assess the subsequent need for the drug. Stimulant drugs have the potential to develop addiction and dependency; Several studies suggest that untreated ADHD is associated with an increased risk of chemical dependency and conduct disorders. The use of stimulants either reduces this risk or does not affect it. The safety of these medicinal products during pregnancy has not been determined. Deficiency has been associated with symptoms of inattention, and there is evidence that zinc supplementation is beneficial for children with ADHD who have low zinc levels. , and may also have an effect on ADHD symptoms. There is evidence of modest benefit from taking omega-3 fatty acids, but they are not recommended as a substitute for conventional medications.

Forecast

An 8-year study of children diagnosed with ADHD (mixed type) found that adolescents often have difficulty with or without treatment. In the US, less than 5% of subjects with ADHD receive a college degree, compared to 28% of the general population aged 25 and over. The proportion of children meeting the criteria for ADHD drops to about half within three years of diagnosis, regardless of the treatment used. ADHD persists in about 30–50% of adults. Sufferers of the syndrome are likely to develop coping mechanisms as they grow older, thus compensating for previous symptoms.

Epidemiology

It is estimated that ADHD affects about 6-7% of people aged 18 years and over when diagnosed using the DSM-IV criteria. When diagnosed using the ICD-10 criteria, the estimated prevalence in this age group is 1–2%. Children in North America have a higher prevalence of ADHD than children in Africa and the Middle East; this is presumably due to differing diagnostic methods rather than differences in the incidence of the syndrome. If the same diagnostic methods were used, the prevalence in different countries would be more or less the same. The diagnosis is made approximately three times more often in boys than girls. This gender difference may reflect either a difference in predisposition or that girls with ADHD are less likely to be diagnosed with ADHD than boys. The intensity of diagnosis and treatment has increased in both the UK and the US since the 1970s. This is presumably related initially to changes in the diagnosis of the disease and how willing people are to take medication, rather than to changes in the prevalence of the disease. Changes in diagnostic criteria in 2013 with the release of the DSM-5 are expected to have increased the percentage of people diagnosed with ADHD, especially among adults.

Story

Hyperactivity has long been part of human nature. Sir Alexander Crichton describes "mental agitation" in his book An Inquiry into the Nature and Origin of Mental Disorder, written in 1798. ADHD was first clearly described by George Still in 1902. The terminology used to describe the condition has changed over time and includes: in the DSM -I (1952) "minimal brain dysfunction", in DSM-II (1968) "hyperkinetic childhood reaction", in DSM-III (1980) "attention deficit disorder (ADD) with or without hyperactivity" . In 1987, it was renamed ADHD to the DSM-III-R, and the DSM-IV in 1994 reduced the diagnosis to three subtypes, ADHD of the inattentive type, ADHD of the hyperactive-impulsive type, and ADHD of the mixed type. These concepts were retained in the DSM-5 in 2013. Other concepts included "minimal brain damage" used in the 1930s. The use of stimulants for the treatment of ADHD was first described in 1937. In 1934, benzedrine became the first amphetamine drug approved for use in the United States. was discovered in the 1950s and enantiopure dextroamphetamine in the 1970s.

Society and culture

controversy

ADHD, its diagnosis and treatment have been the subject of debate since the 1970s. Doctors, teachers, politicians, parents and the media are involved in the controversy. Opinions about ADHD range from being merely the extreme limit of normal behavior to being the result of a genetic condition. Other areas of controversy include the use of stimulant drugs and especially their use in children, as well as the method of diagnosis and the likelihood of overdiagnosis. In 2012, the UK National Institute for Health and Care Excellence, acknowledging the controversy, argues that current treatments and diagnostics are based on the prevailing academic literature. In 2014, Keith Conners, one of the first advocates for disease confirmation, spoke out against overdiagnosis in an article in the NY Times. On the contrary, in 2014 a peer-reviewed review of the medical literature found that ADHD is rarely diagnosed in adults. Due to the widely varying intensity of diagnosis among countries, states within countries, races, and ethnic groups, several confounding factors other than the presence of ADHD symptoms play a role in diagnosis. Some sociologists believe that ADHD is an example of the medicalization of "deviant behavior" or, in other words, the transformation of a previously non-medical problem of school performance into one. Most medical professionals recognize ADHD as a congenital disorder, at least in a small number of people with severe symptoms. The controversy among healthcare professionals is mainly focused on diagnosing and treating a larger population of people with less severe symptoms. In 2009, 8% of all US Major League Baseball players were diagnosed with ADHD, making the syndrome highly prevalent in this population. The raise coincides with the League's 2006 ban on stimulants, raising concerns that some players were faking or faking ADHD symptoms to get around the ban on stimulant use in sports.

Media comments

Several famous people have made conflicting statements regarding ADHD. Tom Cruise referred to the drugs Ritalin and Aderal as "street drugs". Ushma S. Neil criticized this view, stating that the doses of stimulants used in the treatment of ADHD are non-addictive and that there is some evidence of a relatively low risk of subsequent chemical dependence in children treated with stimulants. In the UK, Susan Greenfield spoke publicly in 2007 in the House of Lords about the need for a large-scale study into the dramatic increase in ADHD diagnoses in the UK and the possible reasons for this. Later on on the BBC's Panorama, she claimed a compelling study showing that drugs are no better than other forms of therapy in the long term. In 2010 The BBC Trust criticized the 2007 BBC Panorama program for summarizing the study as "no apparent improvement in children's behavior after taking ADHD medication for three years" when, in fact, "the study found that the drug did not provide significant improvement over time." ”, although the long-term benefit of the drugs was defined as “no better than in children treated with behavioral therapy.”

Specific populations

adults

It has been estimated that 2-5% of adults have ADHD. Approximately half of children with ADHD persist into adulthood. Approximately 25% of children continue to show symptoms of ADHD during puberty, while the remaining 75% show fewer or no symptoms. Most adults remain untreated. Many lead disorganized lives and use non-prescribed drugs or alcohol as coping mechanisms. Other problems may include relationship and work difficulties, as well as an increased risk of criminal activity. Associated mental health problems include: depression, anxiety disorder, and learning disabilities. Some of the symptoms of ADHD in adults are different from those in children. While children with ADHD may run and climb excessively, adults may experience an inability to relax or talk excessively in social situations. Adults with ADHD may impulsively initiate relationships, exhibit thrill seeking, and be short tempered. Behaviors such as substance abuse and gambling are common. The DSM-IV criteria have been criticized for being inappropriate for adults; subjects showing differing symptoms may lead to a claim that they have outgrown the diagnosis.

Children with a high IQ

The diagnosis of ADHD and its relevance to children with a high intelligence quotient (IQ) is controversial. Most studies have found similar impairments regardless of IQ, with a high degree of repetitive stages and social complexity. In addition, more than half of people with high IQs and ADHD experience major depressive disorder or oppositional defiant disorder at some point in their lives. General anxiety disorder, separation anxiety disorder, and social phobia are common. There is some evidence that subjects with high IQ and ADHD have a lower risk of developing chemical dependency and antisocial behavior compared to children with low and moderate IQ and ADHD. Children and adolescents with high IQs may have incorrectly measured IQ in the standard assessment process and may require more in-depth testing.

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