attention deficit hyperactivity disorder or adhd is a neurodevelopmental disorder that begins in childhood it involves signs and symptoms in one or both of two domains inattention and hyperactivity children with adhd are most often brought to clinical attention due to poor school performance disruptive behavior or both we should note right off the bat that adhd is a somewhat controversial disorder this is because there are significant downsides to both under diagnosis and over diagnosis on the one hand children with untreated adhd often have severe impairment in multiple areas of life as a direct consequence of this disorder including low academic achievement unstable peer relationships and frequent run-ins with authority some of which can have lasting consequences for this reason it seems cool to deprive these individuals at the benefits of diagnosis such as access to effective treatment on the other hand over-diagnosis of adhd can also be a problem if it inappropriately stigmatizes a child's behavior communicates that there's something wrong with them or takes away their sense of self-efficacy if they begin to believe that they're unable to do things without medication there's also a risk of medicalizing structural problems such as a child growing up in poverty who has trouble paying attention in school due to hunger for whom a diagnosis of adhd is missing the real problem because the risks of both over-diagnosis and under diagnosis are so profound taking the time to gain a good understanding about how to evaluate the signs and symptoms of adhd across the lifespan is absolutely essential with this in mind let's look at each of the core symptom domains of adhd in more detail first inattention involves difficulties in maintaining focus on a particular thought or task while most people have a train of thought that's able to stay on track for at least a few minutes at a time when someone with adhd the train of thought is very easily derailed this lack of ability to sustain attention leads to specific behaviors which are captured in the dsm-5 criteria for inattention in adhd you can remember these signs and symptoms using the mnemonic details off which will remind you that patients with adhd often struggle with details of their work being sloppy are easily distracted tend to engage in task avoidance especially if the task requires continuous attention appear to ignore instructions frequently lose things have trouble sustaining attention on the same task lack personal organization are forgetful when it comes to appointments or other responsibilities and generally fail to finish tasks once they've started them of note some people with adhd can still show good attention for subjects or tasks that they find intrinsically interesting suggesting that it is not impossible for someone with adhd to focus is just much much harder that for them than for most people next hyperactivity involves a high level of energy that makes it difficult to sit still or to keep from acting impulsively the specific behaviors associated with hyperactivity and adhd are captured in the mnemonic he riled up which will remind you that patients with adhd are hyperactive often fidgeting or squirming in their seat energetic with some describing them as acting as if driven by a motor prone to running around or climbing even in situations where it's inappropriate such as the middle of class predisposed interrupting or intruding upon others conversations loud with difficulty doing activities quietly effusive and talkative in their speech intolerant of delays or waiting unseated or up and about at times when they should stay in place and incline to prematurely answer questions even before the person is done asking them these behaviors can be a problem in the patient's home life but they tend to become particularly pronounced when the child is placed in structured environments like school that rely upon a certain level of order and cooperation between the teacher and the students in class importantly children with adhd generally do not necessarily intend to be disruptive but they find themselves unable to stop from acting impulsively while the name attention deficit hyperactivity disorder suggests that both inattention and hyperactivity are required for a diagnosis the truth is that these two symptom domains do not always coexist in the same person in fact the most common form of adhd involves inattention without hyperactivity this brings up an important question if these two symptom domains can occur in the absence of the other why are they lumped together in the first place there are two reasons first inattention and hyperactivity co-occur in the same person more often than would be predicted by chance second both symptoms appear to respond to the same kinds of treatment together these facts suggest a shared mechanism between inattention and hyperactivity it's important to keep in mind that neither inattention nor hyperactivity are problematic in and of themselves a certain level of inattention for tasks and subjects that we don't find interesting is completely normal and hyperactivity is one of the perks of being a kid however when these traits become persistent and inflexible adhd can result to use an example it's not a problem to be loud and hyperactive in places that can accommodate this like a theme park but it can be disruptive in places that cannot like a funeral another caveat when diagnosing adhd is that it is a diagnosis of exclusion this means that other medical environmental and social reasons for inattention and hyperactivity must be ruled out first for example a child who is stressed due to watching their parents fight every evening will likely have difficulty sleeping at night leading to fatigue and trouble staying awake during class this may manifest his inattention but it should not be automatically assumed to be adhd while this is a rather obvious example more subtle forms may exist as well for example adhd is diagnosed more frequently in the youngest children in each class due to their earlier stage of cognitive development compared to their peers illustrating how unconscious expectations play a large role in diagnosis as well to lower the risk of diagnosing a child with a disorder when the problem is actually in the environment the dsm requires that the signs of adhd must be present in at least two different settings such as at home and at school before assigning the diagnosis putting this all together you can use the mnemonic fidgety to remember the diagnostic criteria as listed in the dsm the first half of the word will remind you that the core pattern of adhd involves functionally impairing levels of either impulsivity and or distractibility the second half of the word includes a few caveats to remember that the symptoms must be greater than expected and not just the usual running around that it's completely normal part of growing up that you need to exclude other possible causes such as mood or anxiety disorders that these patterns must be observed in two or more settings such as at school and at home and then finally that the patient must have been young at the first onset of the disorder with signs and symptoms first appearing before the age of 12 if not even earlier next let's look at the data behind adhd including who gets it what happens once they have it and what forms of treatment are effective adhd affects approximately ten percent of children and five percent of adults making it a common condition with a high base rate in the population the inattentive subtype is the most common accounting for over two-thirds of all cases compared to the hyperactive subtype which accounts for only around 10 the combined subtype featuring both inattention and hyperactivity rounds out the remaining 20 of cases of note adhd patients may shift between different subtypes over time such as a child with both hyperactivity and inattention who slowly becomes less behaviorally disinhibited but still struggles with maintaining focus adhd is one of the most heritable psychiatric conditions with studies showing that genes account for about 75 percent of the variance between different people however environmental factors are also believed to play a large role within utero tobacco exposure maternal stress premature delivery low birth weight poverty and weirdly enough growing up in an english-speaking household all being risk factors for adhd cultural factors are likely involved as well as rates of diagnosis vary from country to country and even from place to place within the same country you'll remember from the why of the fidgety mnemonic the adhd is a neurodevelopmental disorder that begins in childhood with an age of onset around three to eight years the age of diagnosis varies by how impairing the symptoms are as children who have severe symptoms are often diagnosed by the age of 5 while those who have only mild symptoms may not be diagnosed until age 8 or even after adhd is more common in males compared to females with a gender ratio of over two to one boys are more likely than girls to have the hyperactive subtype which is reflected by the he in the he riled up mnemonic however this may make adhd females more likely to go unrecognized as inattentive symptoms are often quieter than the disruptive behavior that characterizes the hyperactive subtype once symptoms appear they are chronic and enduring rather than episodic or fluctuating which further helps to solidify adhd status as a neurodevelopmental disorder roughly two-thirds of children diagnosed with adhd continue to show signs of the condition as adults either as a full-blown disorder or in a sub-syndromal form that falls short of the diagnostic criteria but still remains impairing to some degree however this also means that up to one third of children diagnosed with adhd will show no signs of the disorder as adults so the diagnosis should not be assumed to be lifelong in every case interestingly the two domains of adhd tend to follow different trajectories with hyperactivity often being prominent during childhood but then slowly decreasing with age whereas inattention tends to remain at roughly the same level throughout life untreated adhd can have profoundly impairing effects both during childhood and later in life school children with adhd tend to have worse educational outcomes greater stress and family and peer relationships and increased rates of other psychiatric disorders including anxiety and depression compared to those without the disorder for cases of adhd that persist into adulthood there is an association with worse long-term outcomes in academic achievement job performance addictive behaviors marital problems unwanted pregnancies and car accidents treatment of adhd consists of therapy medications or both the most commonly used therapies are in behavioral management and training including cbt and family therapy in general behavioral therapies for adhd are associated with medium effect sizes in the range of 0.6 to 0.7 like most psychotherapies the beneficial effects of treatment last even after the treatment is discontinued drug treatment of adhd involves medications known as stimulants stimulants generally work by increasing the levels of the neurotransmitters dopamine and norepinephrine which together help to improve both inattention and hyperactivity the two most commonly used stimulants are methylphenidate commonly known as ritalin and amphetamine salts known as adderall as a class stimulants are very effective with very large effect sizes above 1.0 in fact stimulants are among the most effective treatments for any psychiatric syndrome with over 70 percent of people treated with these medications showing significant improvement however they are not without risk including the possibility of growth restriction although these children often catch up in height once the medication stopped as well as appetite suppression insomnia and the potential for addiction and abuse at higher doses given these risks behavioral therapy should generally be considered first especially for those who are younger or only have mild symptoms a variety of non-stimulant medications are available as well such as atomoxetine guanfacine and clonidine however the effect size for these medications is lower than for stimulants at around 0.5 this makes them comparable an efficacy to behavioral therapies but without the benefit of long-lasting changes because of this non-stimulants are generally used only in cases where medication is necessary but a stimulant cannot be used or to help increase the effect of stimulant when additional improvement is needed to wrap up let's review what we've learned adhd is a neurodevelopmental disorder that begins in childhood and in many cases continues on into adulthood signs and symptoms of adhd involve either inattention as captured in the details of mnemonic and or hyperactivity as captured in the herald up mnemonic when diagnosing adhd use the fidgety mneumonic to remember the core pattern of symptoms as well as important conditions to exclude while symptoms of adhd can be incredibly impairing effective treatments are available including both behavioral therapy and medications the availability of treatment underscores the need to carefully screen for the condition as untreated adhd is associated with poor outcomes in various areas of life however there are also significant downsides to diagnosing someone with adhd including a risk of overtreatment and stigma for that reason you should always rule out other factors that can mimic adhd provided that these conditions are met however working with someone who has adhd can be a very gratifying experience as treatment often leads to improvements in functioning that are both immediate and dramatic and that's it thanks for watching i hope this video helped you to understand how to diagnose adhd as well as the pros and cons of doing so if you'd like to learn more consider picking up my book memorable psychiatry which dives deeper into the differential diagnosis of adhd along with a bunch of practice questions to help solidify your knowledge good luck in your studies