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©Advance Educational Institute & Research Centre                                                 Annals of Psychophysiology 

www.aeirc-edu.com                                                                                                       Volume 2, December 2015 

 

ISSN 2412-3188 
 

Short Communication 

Attention Deficit Hyperactivity Disorder (ADHD)- a matter of concern. 

Maria Mirza 

Dadabhoy Institute of Higher Education 

Corresponding Author: maria@aeirc-edu.com 

Attention deficit hyperactivity disorder (ADHD), a 

serious neurodevelopmental disorder that is associated 

with deterioration in various domains of major life 

activities. However, various exceptional cases with the 

disorder may be observed functioning well in some 

areas of life (e.g., Michael Phelps and swimming, Ty 

Pennington and destroying and rebuilding houses, 

Glenn Beck and political commentary, etc.), they 

probably have conflicts with other areas of functioning 

(DWIs, managing money, social relationships, etc.) 

But even if well-altered, these exceptional success 

stories do not represent the more typical reactions of 

children with ADHD followed to adulthood. It is one 

of the most difficult diagnoses to classify as evident 

from changing definition norm observed in the 

revisions of Diagnostic and statistical manual (APA 

1980, APA 1987, APA 1994). ADHD is reportedly the 

most pervasive disorder of childhood influencing 

approximately 3% to 5% of school-aged children with 

prevalence rates increasing significantly over the past 

two decades (Pastor & Reuben, 2008; Timimi & 

Radcliffe, 2005). Children with ADHD struggle with 

symptoms of inattention, hyperactivity, or impulsivity 

above and beyond what is developmentally 

appropriate. ADHA is diagnosed in childhood, most of 

the children diagnosed with ADHD exhibit symptoms 

that persist into adolescence and adulthood (Langley 

et al., 2010). 

Inattention in ADHD patients can be seen in social, 

occupational, and academic settings, accompanied 

with difficulty sustaining attention, difficulty in 

completing tasks, not following through on 

instructions and requests, and inability to complete 

chores and schoolwork. Hyperactivity symptoms may 

include wiggling fidgeting, inability to sit still in 

classroom settings, being always “on the go,” and 

excessive talking, while a symptom of impulsivity is 

difficulty waiting their turn and restlessness. It should 

be noted that in the new Diagnostic and Statistical 

Manual of Mental Disorders (5th ed.; DSM-5; 

American Psychiatric Association [APA], 2013) 

criteria, an individual can be easily diagnosed with 

ADHD to the age of 12 years but not at 6 years as was 

previously mentioned, while most of the symptoms 

must occur in more than one setting (Yousesf M et al 

2015). 

According to Pliszka children with ADHD suffer from 

conduct disorder and have a higher possibility of 

developing antisocial and uncommunicative 

personality disorder as adults, they also have anxiety 

and bipolar disorders with significant behavioral and 

emotional sequels. However the comorbidity of 

ADHD and major depression is not much studied. 20% 

to 25% children also have difficulty learning (Pliszka 

SR 1998). Previously Biederman, Newcorn and 

Sprich, have formulated that children with ADHD 

have heterogeneous disorder, the available literature 

supports that there is a noticeable amount of 

Comorbidity of ADHD with conduct disorder, 

oppositional defiant disorder, mood swings, anxiety 

disorder, learning disabilities and other conditions like 

Intellectual disability (Biederman J et al 1991). 

Even with lack of some neurophysiological or 

neurochemical basis for ADHD, it is predictably 

accompanied with conditions causing minimal brain 

damage. Hence, the possible factors for the developing 

ADHD may include any prenatal, perinatal and 

postnatal problem that can be peered with brain 

damage. Serious head injuries, meningitis, 

hydrocephalus, and brain surgery can also increase the 

risk of developing ADHD (Pasquale Accardo 1999).                     

ADHD is best manipulated by a multidisciplinary 

team effort accompanied with pharmacotherapy 

usually with stimulant medications, behavioral 

interventions and environmental changes. In a 

developing country like Pakistan there are few allied 

specialist services. Dilemma is associated with poor 

awareness and acceptance on part of parents, teachers 

and health professionals. This is evident from low 

referral rate from schools and inadequate follow-up 

seen at our clinic. Pharmacological management of 

ADHD calls for prescription of stimulant medication 

like methylphenidate. There is significant refusal and 

controversy regarding the use of stimulant medication 

both on part of physicians and parents. There lies a 

battle against the use of chemical methods for 

management of ADHD and a call upon a need to 

establish awareness regarding the prevalence of 

ADHD and co morbid conditions and make efforts to 

developed links with the services and resource persons 

that are available both within the country and abroad 

(Syed, E. U et al 2006). 

School teachers play a vital role 

Argument notwithstanding, the interruption produced 

by ADHD typed nature is undisputed. ADHD 

behavior tends to worsen in ambiance where attention 

for long periods of time, silent activities, and waiting 

one’s turn is enforced (APA, 2013). Such behaviors 

are needed within the formal classroom setting, and if 

other opportunities such as physical activity are not 

provided to equalize learning approaches, behavioral 

frustration can often first be encountered in school. 

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Maria Mirza 21 

 

©Advance Educational Institute & Research Centre                                                 Annals of Psychophysiology 

www.aeirc-edu.com                                                                                                       Volume 2, December 2015 

 

ISSN 2412-3188 
 

Children with ADHD are classified as being 

destructive in the classroom, have conflictual 

relationships with family and friends, and are 

incapable to understand social cues and experience 

academic combat, which ultimately affect their life’s 

aspect (Bender & Smith, 1990; Frick et al., 1991; 

Hinshaw, Heller, & McHale, 1992). While the initial 

challenges of inattention and classroom disruption 

along with primary school decline in secondary 

school, as well as secondary school students with 

ADHD often face an academic challenge and the 

dissatisfaction associated with declined conduct 

(Travell & Visser, 2006). All of these conditions mean 

that students with ADHD are often at greater risk of 

school dropout and academic defeat (Bussing, Mason, 

Bell, Porter, & Garvan, 2010). These findings depicts 

the important role that teachers play in identifying 

children who need extraordinary support, making 

referrals for their assessment, and being able to 

incorporate them in the classroom (Sherman, 

Rasmussen, & Baydala, 2008). As such, within 

upcoming years, there has been a huge emphasis on 

teachers’ knowledge and practice toward ADHD. 

Conclusion of several studies from different parts of 

the world shows that teachers’ knowledge is at best 

reasonable and in many cases, insufficient, requiring 

intervention (Ghanizadeh, Bahredar, & Moeini, 2006; 

Nur & Kavakc, 2010; Perold, Louw, & Kleynhans, 

2010; West, Taylor, Houghton, & Hudyma, 2005). 

The prevalence of ADHD 

The prevalence is conservatively estimated as being 

from 3% to 7% of the school age children in the United 

States (APA 2000). The prevalence of ADHD in 

Pakistan has been found to be around 2.49% (Karim R 

et al.1998). Boys with ADHD outnumber girls, but 

ratio varies significantly from 2:1 to 9:1. Gender 

differences are less obvious for inattentive type of 

ADHD. Boys are more likely to be aggressive and to 

have other behavioral problems (Guab M et al 1997). 

ADHD children make up 30-40% of referrals to child 

mental health Practitoners (Barkely RA 1998). ADHA 

was believed to be outgrown in mid to late 

Adolescence. It is now declared that two thirds of 

children with ADHD will continue to have problems 

leading ADHD as adults and because ADHD is a 

chronic disorder, will require treatment throughout 

their lives (Resnik RJ 2000). 

The causes of ADHD 

The etiological pathways for ADHD are not known 

but the recent hypotheses regarding etiology of ADHD 

are as follows: 

Genetic Factors:  

Parents having children with ADHD are affected by 

ADHD themselves, suggesting a significant genetic 

component (Biederman J et al 1992). The random 

chance of Parents with a child who has ADHD, having 

another child with ADHD is about 1 in 3(Breslau N et 

al. 1996). 

Brain Damage:  

It has been suggested that some children affected by 

ADHD suffered serious damage to the central nervous 

system and brain development during their fetal and 

perinatal periods. It may be associated with 

circulatory, toxic, metabolic, mechanical or physical 

insult to the brain during early infancy caused by 

infection, inflammation, and trauma. (Milberger S et 

al. 1997; Thapar A et al. 2003) 

Neurochemical Factors:  

The most widely studied drugs in the treatment of 

ADHD, the stimulants, alter both dopamine and 

norepinephrine, leading to neurotransmitter 

hypothesis that include possible decline in both 

dopaminergic and noradrenergic systems. 

Neurophysiological Factors:  

EEG event related potentials suggest an arousal 

dysfunction related to hypo reactivity to salient 

informative stimuli. Thus the individual with ADHD 

is relatively unable to recognize his or her sensations 

of salient informative stimuli. This results in the 

paradoxical reaction to stimulant medication, where 

individuals with ADHD become less instead of more 

active after taking stimulant medication, as they 

become more attentive to salient informative stimuli 

(Cohen RA 1993). 

Psychosocial Factors:  

As per Beiderman family-circumstances variables 

such as severe marital discord, large family size, 

paternal misconduct, maternal mental disorder and 

anxiety, and foster care placement are associated with 

the possibility factors in the development of ADHD. 

Diagnosis 

According to Diagnostic and Statistical Manual of 

Mental disorders-1V (APA 2000). 

* Children having six of nine symptoms to qualify for 

either the inattentive or hyperactive/ impulsive 

subtypes of ADHD, or six of nine symptoms of both 

subtypes to qualify for the combined type. 

* Symptoms must have been present before the age of 

seven. 

* Symptoms must create impairment in two or more 

settings (e.g. home, school, and neighborhood). 

* Symptoms must cause clinically significant 

deterioration in social, academic or occupational 

functioning. 

ADHD symptoms fall into two major categories as 

shown below in the table. DSM-1V identifies three 

subtypes of ADHD as predominantly inattentive type, 

predominantly hyperactive/ impulsive type and 

combined types. The ICD 10 (International 

Classification of DiseasesWHO) diagnosis of 

hyperkinetic disorder is the briefer category. In ICD 

10, all three problems of inattention, hyperactivity and 

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Maria Mirza 22 

 

©Advance Educational Institute & Research Centre                                                 Annals of Psychophysiology 

www.aeirc-edu.com                                                                                                       Volume 2, December 2015 

 

ISSN 2412-3188 
 

impulsivity should be present, the presence of another 

disorder such as anxiety state is in itself an exclusion 

criteria the expectation is that most cases will have a 

single diagnosis. 

Inattention Hyperactivity/Impul

sivity 
* Failing to concentrate 

for details or making 

careless mistakes when 

doing schoolwork or other 

activities. 

* Difficulty retaining 

attention in tasks.      

* Appearing not to listen, 

when spoken to. 

* Failing to follow 

instructions or finishing 

tasks. 

* Problematic for 

organizing tasks and 

activities. 

* Avoidance of the tasks 

requiring high amount of 

mental effort. 

* Frequently losing items 

required to facilitate tasks 

or activities. 

* Distractibility. 

* Forgetful in daily 

chores. 

* Fidgeting with hands 

or feet or squirming in 

seat. 

* Leaving seat often, 

even when 

inappropriate. 

* Running or climbing 

at inappropriate times. 

* Difficulty in quiet 

play. 

* Often on the go. 

* Excessive talking. 

* Answering a 

question before the 

speaker has finished. 

* Failing to wait one’s 

turn. 

* distracting the 

activities of others at 

inappropriate times. 

 

Management 

ADHD children have many problems which can 

usually be managed along with psycho education, 

behavioral intervention, medication and diet also used 

for children with hyperkinetic disorders, multimodal 

intervention is usually indicated (NICE 2002).  

Psycho educational Measures 

Awareness regarding illness symptoms, etiology, 

clinical course, prognosis, and treatment should be 

provided. Counseling with school after parental 

allowance is mostly needed.  

Parent training and behavioral interventions in the 

family:  

These interventions have been shown to be very 

effective (Pelham WE et al 1998).According to expert 

consensus Guidelines (conners CK et al 2001) 

behavioral-psychosocial treatment is an effective first 

level treatment in the following instances: 

* For milder ADHD. 

* For pre-school–age children with ADHD. 

* When there is the presence of co-morbid 

internalizing disorders and social skills deficits. 

* When the family prefers psychosocial treatment. 

The most effective and relevant technique is to pay 

positive attention to appropriate behavior and 

compliance, giving commands more effectively, and 

using appropriate negative consequences for problem 

behaviors. 

Behavioral interventions in the school: 

It is effective in minimizing hyperactive behavior and 

promoting social adjustment. Some behavioral 

interventions which are found to be helpful in 

classrooms include (Austin VL 2003). 

* Child should be seated near to the teacher. 

* Brief academic assignments. 

* Reinforcement and reiteration. 

* Posting daily schedules and assignments. 

* Using graphic organizers. 

* Providing a notebook for writing down the 

homework assignments. 

* Interspersing classroom lectures with short periods 

of physical exercises, may be useful 

Psychopharmacological Treatment 

There is significant evidence for the use of 

medications in the treatment of ADHD. The challenge 

for the doctor is to establish a treatment regimen that 

has a rapid predictable onset of action, duration of 

action that does not require re dosing, no negative side 

effects (e.g. sleep problems, eating disorders, mood 

swings) and advantageous effect on co morbidities. 

Conclusions 

ADHD has proceeded from the 20th century with a 

huge amount of scientific work questioning and 

investigating its validity and simplifying clinical 

controversies.  The disorder is greatly prevalent 

worldwide, is associated with significant impairments 

and frequently persists in adulthood. The emerging 

knowledge about the causes and pathophysiology of 

ADHD should lead to an improved understanding of 

the neural mechanisms underlying the disorder, which 

should upgrade and promote diagnostic and treatment 

strategies. 

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©Advance Educational Institute & Research Centre                                                 Annals of Psychophysiology 

www.aeirc-edu.com                                                                                                       Volume 2, December 2015 

 

ISSN 2412-3188 
 

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www.aeirc-edu.com                                                                                                       Volume 2, December 2015 

 

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