Key words
attention-deficit/hyperactivity disorder, children, cognitive disorders
The Attention-Deficit/Hyperactivity Disorder (ADHD) is a behavioral disorder characterized by inattention, impulsivity, and hyperactivity that makes it difficult and in some cases prevents normal development and social integration of children [1]. It is a heterogeneous
and complex disorder, multifactorial in that 70 - 80% of cases coexists
with another or other disorders (termed comorbidities). The coexistence
of multiple complaints aggravates the symptoms complicating both
diagnosis and therapy. Those are the most frequently associated with
oppositional defiant disorder and conduct disorder, specific learning
disorders (dyslexia, dysgraphia, etc..), Anxiety disorders, and, less
frequently, depression, obsessive-convulsive disorder, tic disorder,
bipolare [2].
The presence in the classroom of children with problems related to
ADHD is not uncommon. In the United States it is believed that 2-6%
of children suffer from the disorder and attention deficit hyperactivity
disorder (ADHD) and it is thought that in every classroom there are at
least 1 or 2.
The fundamental characteristic of the disorder is a persistent mode
of inattention often accompanied by hyperactivity and impulsivity.
Children with ADHD show very high levels of activity with respect to
their age, are unable to keep the attention, interest and perseverance in
what they are doing, they are games, activities, objectives long-term or
tasks that are assigned to them; impulsiveness and self-control delay
greatly to be compared with the present stage of development where
they belong.
It 'possible that manifest excessive anger and rage at both verbal and
physical instructions and orders given by adults, parents or teachers,
are ignored, challenged or disrespected. For this reason it is particularly
difficult to take care of children who experience this disorder, and their
behavior, with the reactions that accompany them, create a family
context in which relationships are characterized by a strong directivity
and control, anger and antagonism, even because the behaviors related
to the disorder, characterized by a certain degree of variability, often
are mistaken for volunteers and as a result the children are perceived
as hostile and rude.
Difficulties also arise among peers, siblings or classmates, both in
the sharing of space, toys and activities, and is at times playful, free
play, if they involve cooperation, observance of rules or social labels.
For adults, the problem does not change much, they continue to
experience a number of difficulties both in interpersonal and both in
study and work [3].
The level of emotional development of children with ADHD is 30%
slower than that of their peers, so a 10 year old child with ADHD act
with the maturity level of a child of about 7. There is no cure for ADHD
and an adult untreated live a very difficult life that has not always had
serious problems with the law or that is not landed in the world of
drug addiction or alcoholism. Adults depressed, anxious, emotionally
unstable and in their work, in social life, family, constantly changing
job, wife, car and who have frequent fines and traffic accidents, easily
addicted to alcohol or drugs, almost always heavy smokers, could be
ADHD [4].
ADHD etiology
It is important to note that currently the ADHD causes are
unknown. There is no doubt that the disorder has multiple etiology.
Initially it was thought that brain damage, due, for example, a brain
infection, a trauma or other damage and complications that occurred
during pregnancy or at birth, was the main cause of ADHD symptoms,
and many studies have found a correlation with complications
occurring during pregnancy or at birth (unusually short or long labor
pains during childbirth, fetal risk, difficult parts where you need the
help of forceps, toxiemia or eclampsia) [5-8]. Other studies have
found a relationship between smoking during and before pregnancy,
and the level of hyperactivity and inattention, and that exposure to
smoking, both direct and environmental during pregnancy is higher
in children with ADHD and that this can be associated with damage to
the brain from anoxia. Similar relationships were found with alcohol
consumption by the mother during pregnancy, and even if there are no
relations of cause and effect with respect to hyperactivity or inattention
in the offspring, we think of a teratogenic effect of alcohol on the
development of the brain. The amount of alcohol taken seems to be
directly proportional to the degree of distractibility of children to four
anni [5-8].
In summary were identified three possible etiological areas:
1) psychosocial
2) neurological
3) genetic
Psychosocial factors
It is important to note that environmental factors can strongly
affect the severity of the disorder and the occurrence of certain disorders associated considered, the latter, the strongest predictors
of subsequent developmental risks and negative outcomes. For this
reason, the environment in which the child is raised and educated has
an important role [9].
Neurological factors
Significant similarities were found between ADHD symptoms and
those produced by injury or injuries to the frontal lobes, especially
the prefrontal cortex, a figure which, together with the early onset of
symptoms, their nature relatively persistent over time, the association
with other developmental disorders (learning disabilities, speech
disorders, motor abnormalities and IQ) believed to be associated with
a neurological impediment to their significant relationship to peri-and
postnatal difficulties and, finally, the significant improvement with
pharmacological interventions have reinforced the idea that the cause
was from attributed to neurodevelopmental factors. Still, the results of
neuropsychological tests associated with the functions of the prefrontal
lobes (inhibition, planning, persistence, motor control and even verbal
fluency, etc..) Together with significantly greater risk of the disorder
in other family members proving the presence of factors biologic [8-
10]. A number of studies suggest the hypothesis that there are some
difficulties with brain neurotransmitters, and reactions to different
substances that subjects have ADHD, support this idea. Studies on
the liquid cefalospinale show that ADHD in children, a decrease of
dopamine may underlie the disorder. Experimental results conducted
on metabolites of neurotransmitters in the brain, present in the blood
and urine are not consistent and show a selective problem of availability
of dopamine and norepinephrine, but at present, these tests can not be
considered decisive [8]. Finally, some studies show a decrease in blood
flow in the prefrontal regions, in the circuits that connect these regions
to the limbic system, across the street caudata, specifically in the region
of striato10. From the point of view of morphological differences were
observed in the right hemisphere temporal plana, smaller in children
with ADHD [8]. Starting from the research of Lou et al. [11] on the
reduced blood flow in the caudate regions and streaked and in frontal
regions, studies have been concerned to assess the morphology of these
regions in children with ADHD and have demonstrated the presence
of a left caudate nucleus significantly smaller. In summary, it probably
has a significant role in ADHD a mechanism that involves the circuitry
between the prefrontal and limbic system, and especially the striatum,
the brain areas that are the basis of inhibitory reactions, distraction,
and that stimulate ' learning and sensitivity to rewards and who are
some of the richest areas of dopamine in the brain [8].
Genetic factors
There are no evidences that ADHD is the result of an abnormal
chromosome structure, but most of the research indicates that this
disorder is of hereditary nature [12]. The research is focused on the
gene of dopamine type 2, starting from the results about its association
with increased alcoholism, Tourette's syndrome and the same
ADHD. In the light of the latest research on the possibilities opened
up by the map of the human genome will be able to probably know
more precisely the mechanisms that lead to ADHD. ADHD is a
biological disorder rather than a learning disorder due to a variety of
neurological causes. Hereditary factors seem to play a large role in the
occurrence of these symptoms in the child. What is transmitted may
be genetically or the tendency to produce low amounts of dopamine
or a lower activity of the prefrontal areas, striata and the limbic brain
and their vast interconnections. Their condition may be exacerbated by
complications during pregnancy, exposure to toxins, or neurological diseases and social factors such as family and environmental adversity,
lack of child care in breeding or poor environmental education. There
may also be cases of children with ADHD in which there is not a genetic
predisposition to the disorder, but exhibiting a significant neurological
damage, although this seems to be true for a small minority of cases
of ADHD [12]. On the contrary, there is little evidence to support
the fact that ADHD may depend on social and environmental factors
such as poverty, family chaos, diet or lack of parental care of bambino
[8]. Regarding the affective and relational components of the disorder
ADHD in childhood, it seems that, with his tireless and relentless move
that no one seems able to stem the hyperkinetic child looks around
in circles, like a spinning top always on the same point: turning on
itself fills an empty space, and fills him with anguish. He appears as
the guardian of a world fantasized as catastrophic, dominated by the
destruction in the form of blast and fragmentation. The movement
does not result in anything and never never gradual or finalized. Never
stops: he wants to do only what he wants, always, first and foremost.
In dealing with these children we can better recognize and understand
archaic mechanisms of functioning of the mind, designed to protect
anguish, such as identification, projective identification, denial. In other
words, in these cases, more than ever, recognize countertransference
reactions can help to formulate hypotheses about the psychological
situation inherent in the relationship with these children and then to
identify the most appropriate ways to help them change their attitude.
Diagnosis
ADHD
is
"a situation / 2021 Copyright OAT. All rights reserv
persistent state
of inattention
and /
or
hyperactivity
and impulsivity
more frequent
and severe than is
typically
observed in
children
of the same level
of development."
Inattention,
hyperactivity, and
impulsivity
are commonly known as
the key
symptoms
of this syndrome.
They must be
present for at least
6 months
and have made
their appearance before the age of 7 years [13-25]
The International
Statistical
Classification of Diseases
and Related
Health
Problems (ICD-10)
World Health Organization
uses the term
"hyperkinetic disorder" for a more
narrowly
defined
diagnosis
(ICD-10
WHO
1994).
It differs from the
classification of the
DSM-IV
as
all three
problems
of attention, hyperactivity and impulsivity
must be
present
and
must be
simultaneously
satisfied
the
more stringent criterion
of
their presence
in
a variety of
setting,
while the presence
of another
disorder
constitutes
an exclusion criterion.
Based on the
diagnostic
criteria
systematized
in the
Diagnostic and Statistical
Manual of
Mental
Disorders (DSM-III,
DSM-IIIR,
DSM-IV) and in the Diagnostic and
Statistical Manual
for Primary
Care, child and adolescent
version
(DSM-PC) diagnosis of ADHD
is based
on the presence of:
6 or more of
9 symptoms of inattention
or
6 of
9 or more
symptoms of hyperactivity
\ impulsivity.
Therapies
ADHD patients maybe subjected to the followingtreatment:
ØPsycho-behavioral
ØPharmacological(methylphenidate, atomoxetine)
ØCombine(Psycho-behavioral +pharmacological).
Pharmacologicaltherapies
In recent years in the United States the use of psychostimulants,
including methylphenidate and amphetamines, for the pharmacological
treatment of ADHD, raised a strong debate focused mainly on the easy
availability and frequent prescription of these substances, as well as on Milano W
(2018) Neurological and behavioural symptoms of attention deficit hyperactivity disorder: from diagnosis to the treatment
Volume 2(1): 3-4
Alzheimers Dement Cogn Neurol,
2018
doi: 10.15761/ADCN.1000121
their potential abuse . In the U.S., the diagnosis of ADHD is made by
the physician and the first approach is pharmacological, it follows that
at a high rate of diagnosis, often incorrect, are associated treatments
inappropriati [13-25].
In the European context, however, the approach is multidisciplinary
ADHD and drug therapy is reserved for severe cases and in the context
of a multimodal program (psychotherapy and pharmacotherapy).
Methylphenidate is used in the treatment of patients suffering from
attention deficit disorder with or without hyperactivity disorder and
narcolepsy (uncontrollable desire for sleep or sudden attacks of deep
sleep). This medication is a central stimulant, amphetamine variant, and
as such belongs to the drugs of abuse regulated by Presidential Decree
309/90, recently amended by Law 21/02/2006 n. 49. Psychostimulants are
considered the most effective therapy for ADHD and methylphenidate
is the drug of which, until now, has been the largest collection used
[26]. Stimulants act on the monoamine transporters: methylphenidate
modulates especially the amount of dopamine and norepinephrine,
present in the inter-synaptic. Boost a deficient dopaminergic
transmission and attenuates a state of dopaminergic hyperactivity. It
can improve the inhibition of responses, the working memory and the
processes of discrimination of the stimuli [13-25].
The results of some
controlled clinical trials have shown that methylphenidate is effective
in about 70% of children with ADHD. The therapeutic effect is rapid.
A week of treatment is usually sufficient to achieve measurable benefits
even in the school environment: increased attention, the ability to
accomplish the assigned tasks, in addition to reducing impulsivity,
distraction and interactions interpersonal conflict. In studies conducted
to date it has been noticed that the same dose of methylphenidate can
however produce in children with ADHD changes in positive, negative
or zero, according to the evaluation method used [27]. This paradox
highlights the heterogeneity of the valuation methods used to date in
clinical trials, ranging from a subjective perception of improvement
on the part of parents, outpatient clinical assessments, analysis of the
child's academic performance.
The
most common side effects
of psychostimulants
and
methylphenidate
are
decreased appetite,
insomnia, and
gastrointestinal
irritation:
insomnia can be
prevented by avoiding
the
evening
dosing,
lack
of appetite
and
gastrointestinal disorders
by administering the
drug
after meals. When the drug
is administered incorrectly, headache
and abdominal pain
are rare,
temporary
and rarely
require
modification
or
discontinuation of therapy.
Rare, although documented,
are
neutropenia and
eosinophilia.
In
susceptible individuals,
may occur
or worsen
involuntary movements,
tics and
obsessive ideas.
In some
children,
can induce
rapid changes
in mood
with
increase or decrease
in
speech,
anxiety, excessive elation, irritability, sadness (dysphoria)
[13-25].
In children,
high doses
of the drug
can lead, paradoxically
sedation and
decreased
learning ability.
In children, the
abuse and
addiction are virtually non-existent
The subjects
treated with
psychostimulants
are at greater risk
of
cardiovascular events.
The risk is
a direct function
of age:
younger
children,
adolescents, and
greater
adulti
[28].
Numerous
drugs,
capable
of blocking
in a more or
less
selective
reuptake of norepinephrine,
are effective
in the treatment
of ADHD.
The
noradrenergic system
modulates the
function
of several
brain areas involved
in the
mechanisms of
vigilance,
alertness and
attention.
The drugs
can
modulate
the
noradrenergic
function
are:
tricyclic antidepressants,
?2
adrenergic
agonists,
selective
noradrenaline reuptake
blockers.
Some
of these drugs, however, have
less
tolerability
(desipramine:
anticholinergic effects
and
risk of cardiotoxicity),
tolerance
to the
therapeutic effects after a few months (clonidine).
The atomoxetine, a norepinephrine reuptake inhibitor, has shown
efficacy and tolerability similar to psychostimulants, without potential
abuso [29]. Atomoxetine was first introduced to the U.S.A market in
November 2002 and then subsequently in the UK in May 2004, the last
year has also been introduced in Italy.
To date the drugs registered in Italy for drug therapy of ADHD are
methylphenidate administered according to body weight, on average,
0.3 to 0.6 mg / kg / dose in 2:00 to 3:00 daily doses, and atomoxetine
administered in according to body weight, on average, 1.2 mg / kg /
dose in a single daily dose (rarely in two half doses) [29].
Other pharmacological treatments
Tricyclic antidepressants,
SSRIs, antipsychotics, neuroleptics,
benzodiazepines
and other
CNS-acting drugs are sometimes
used in
the
pharmacological treatment
of ADHG patients.
Typically
these are
cases
of comorbidity
in which you
need to associate
psychostimulants,
drugs
of choice for the ADHD,
other substances
for
specific
illnesses
associated with ADHD [30].
Combined treatments
The study
conducted
by the NIH
MTS
has shown
that the best
results
in the treatment
of ADHD
are obtained
with combination
therapy
(psycho-behavioral
and pharmacological).
Where the
psycho-
behavioral
therapy alone
is not sufficient
for the treatment
of the
syndrome,
should be implemented through
the combination therapy,
pharmacological and non-pharmacological [30].
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