ADHD

Exam Tips

• Etiology - Contributed by social/environmental factors

• Adults with ADHD vs Children with ADHD

  • Adult → restlessness, fidgeting, keep moving, more tune down, talk excessive, interupting, due to maturity in brain (prefrontal cortex) 24 or 25 years old, stop impulsivity, amygdala lower also pull down by prefrontal

  • Child → running here and there (more to behavioural)

  • Adult only diagnose could be seems like normal children, more aware of ADHD, need check back developmental history, whether across multiple settings

• Assessment on ADHD: CBCL, WISC / WPPSI / WAIS, Vineland

Overview: ADHD fundamentals

• ADHD stands for Attention-Deficit/Hyperactivity Disorder, a neurodevelopmental condition with early onset and a chronic course that affects attention, behavior, and executive functioning.

• Core framing from the transcript: ADHD is not simply a lack of knowing what to do; it is a difficulty in doing what you know.

• ADHD can disrupt daily life, energy, self-esteem, relationships, and school/work functioning; patterns vary widely between individuals due to heterogeneous underlying causes.

• The clinical view integrates symptoms, brain development, and environmental factors to explain the diverse presentations and outcomes.

Core characteristics and diagnostic framing

• ADHD is classified as a neurodevelopmental disorder with early onset and a persistent course.

• Often overlaps with other neurodevelopmental conditions (e.g., Autism Spectrum Disorder, Specific Learning Disorders).

• Core domains: inattention and hyperactivity–impulsivity; these dimensions are highly related but lead to different impairments.

• In DSM-5, two main dimensions are defined; relying solely on these two surface terms can oversimplify the underlying processes (e.g., planning, organizing, memory).

• Hidden brain processes: attention and impulse control are developmentally linked; regulation of input and response is a key mechanism.

Attention processes in ADHD

• Attentional capacity: amount of information that can be held briefly in working memory.

• Hyperfocus: intense absorption in an engaging task; common when the activity is stimulating.

• Selective attention: focusing on relevant stimuli while ignoring irrelevant ones.

• Distractibility: tendency to be pulled away by salient stimuli; ADHD individuals are more easily distracted.

• Sustained attention: maintaining focus over time on uninteresting tasks; primary attention deficit in ADHD; performance improves with self-paced, engaging tasks.

• Distinctions among attention types (summary):

  • Attentional capacity: how much information can be held

  • Selective attention: focusing on one thing, ignoring distractions

  • Sustained attention: maintaining focus over time

  • Distractibility: susceptibility to irrelevant stimuli

Inattention: features, impacts, and cognitive underpinnings

• What it looks like: zones out, easily distracted, disorganized, forgetful, difficulty with time management, misses details, and troubles following instructions.

• Inattention in ADHD is more than mere “not paying attention”; it reflects difficulties sustaining attention, following through on instructions, planning, organization, and time management.

• Children with ADHD may engage attention automatically with enjoyable tasks but struggle with less enjoyable tasks.

• Cognitive processes underlying inattention may be impaired in one or more domains; there can be heterogeneity in cognitive profiles.

• Types of attention related to inattention include:

  • Attentional capacity

  • Selective attention

  • Sustained attention

  • Distractibility

  • These domains interact developmentally with planning, memory, and executive control.

Hyperactivity and Impulsivity: characteristics and diagnostics

• Hyperactivity: constant movement, restlessness, and excessive activity—especially in situations requiring stillness; may be visible as fidgeting, running, climbing, or talking excessively.

• Impulsivity: acting without forethought, interrupting, difficulty waiting turns, intruding on others, and risky behaviors.

• Cognitive impulsivity: disorganized, hurried thinking; Behavioral impulsivity: premature actions; Emotional impulsivity: low frustration tolerance, irritability.

• ADHD often shows more motor activity and impulsivity in tasks requiring staying still or self-control; high activity levels may lessen as children grow older, but impairment can persist.

• Impulsivity impacts school performance, peer relations, and long-term outcomes.

DSM-5 and DSM-5-TR criteria: structure and presentations

• A: A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

  • Inattention (A1): Six or more symptoms for at least 6\text{ months}, to a degree inconsistent with developmental level, and causing impairment; for older adolescents/adults (age 17+), at least five symptoms.

  • Hyperactivity-impulsivity (A2): Six or more symptoms for at least 6\text{ months} (five symptoms if 17+).

• B: Symptoms present before age 12.

• C: Symptoms present in two or more settings (e.g., home, school, work).

• D: Clear evidence that symptoms interfere with social, academic, or occupational functioning.

• E: Not better explained by another mental disorder or by schizophrenia/psychotic disorders.

• Combined vs predominant presentations (as per DSM-5-TR):

  • Combined presentation (ADHD-C): meet both A1 and A2 criteria for past 6 months.

  • Predominantly inattentive (ADHD-PI): meet A1 but not A2 for past 6 months.

  • Predominantly hyperactive-impulsive (ADHD-HI): meet A2 but not A1 for past 6 months.

• Current severity (mild/moderate/severe) is rated by symptom count and impairment level.

• Presentation can change over time; about half of cases are reclassified at a later age; ADHD is heterogeneous and not a single subtype.

• DSM limitations discussed: not fully developmentally sensitive, largely categorical rather than dimensional; symptoms shift across ages; the DSM criteria have been adjusted (e.g., 6 to 5 symptoms for older ages), but validity remains debated.

Presentation types and their developmental trajectories

• ADHD-PI (Predominantly Inattentive):

  • Symptoms include easy distractibility, forgetfulness, disorganization; often lower academic performance; more anxious or withdrawn mood; more common in general population but less often referred for treatment.

  • Linked with negative parenting and anxiety; higher inattention correlates with school, social, and home difficulties.

• ADHD-HI (Predominantly Hyperactive-Impulsive):

  • Most rare, typically seen in preschoolers; features excessive movement, restlessness, impulsivity; often outgrown by older ages.

• ADHD-C (Combined):

  • Both inattentive and hyperactive-impulsive symptoms; most common type referred for treatment; associated with behavioral problems, peer rejection, and special education placements.

• Presentations are not fixed; individuals may shift between types over time (e.g., PI → C or HI → PI); 50% reclassification rate noted, reflecting heterogeneity.

• AuDHD: co-occurrence with Autism Spectrum Disorder is discussed later as a distinct but overlapping consideration.

What the DSM doesn’t tell us: cautions and dimensional view

• Developmental insensitivity: criteria often don’t perfectly map across ages; hyperactive symptoms decrease with age; teen/adult criteria were added with ongoing validity questions.

• Categorical vs dimensional view: ADHD often exists on a spectrum; many individuals near cutoff still experience impairment; diagnosis can change over time.

• Despite limitations, DSM criteria provide a practical framework for identifying those at higher risk and guiding treatment and services.

Assessment pathways and plan

• Assessment plans include government and non-government routes with different costs and steps.

• Government route (example):
  1) Primary concern raised by parent/teacher; book through app; referral letter to hospital if appropriate.
  2) Klinik Kesihatan (government clinic) visit: fee around RM 1; conduct clinical interviews, functional reviews, history; observations; behavioral rating scales.
  3) Comprehensive assessment at government hospital: diagnostic evaluation with a team; historical, medical, development, family, and social data; comorbidity assessment.
  4) Diagnosis based on DSM-5-TR criteria.
  5) Fees: around RM 5 per session for comprehensive assessment (example costs from the transcript).

• Non-government route (private/NGO):
  1) Initial intake and risk assessment; typical online fee around RM 195; in-person RM 250.
  2) Clinical intake interview: RM 1300–2600 (depends on tools).
  3) Comprehensive assessment: includes interviews, observations, rating scales, comorbidity evaluation; full report around RM 320.
  4) Briefing session and full report; results and treatment recommendations.

• Commonly used behavioral rating scales noted: CRS, CBCL, Vanderbilt ADHD Rating Scale, ADHD Rating Scale-5, SDQ, etc.

• Diagnostic process is informed by, but not limited to, DSM-5-TR criteria; rating scales supplement clinical interviews and observations.

Associated characteristics and cognitive profile

• ADHD often co-occurs with a range of cognitive, linguistic, medical, and psychosocial difficulties.

• Cognitive deficits span executive functions (EFs), intellectual functioning, academic performance, and self-perception.

• EF deficits are common (≈50% of children with ADHD show impairments in one or more EF domains).

• Inhibitory control is a key EF that develops early and predicts later symptoms; poor inhibition can create a feedback loop that worsens ADHD symptoms and impairs development of higher-level EF skills.

• Other EF domains affected later in childhood include working memory, planning, cognitive flexibility, task initiation/completion, and emotional regulation; these depend on strong early inhibitory control.

• Intellectual functioning: most children with ADHD have average IQ, but ADHD can be associated with IQ point declines on standardized tests (roughly 2–9 point drop; often 2–5 point drop for attention-related performance).

• Academic functioning: higher risk of lower productivity, grades, test scores; increased risk of grade retention, special education, expulsion, or dropout; with support, many achieve their potential.

• Learning disorders: up to about 45% of children with ADHD may have a specific learning disorder (dyslexia, dysgraphia, dyscalculia); diagnosing both conditions is crucial for targeted support.

• Distorted self-perceptions: some children show positive illusory bias (overly high self-esteem despite difficulties); common in hyperactive-impulsive presentations; may serve as a coping strategy or reflect EF deficits; linked to social problems and aggression over time.

• Speech and language impairments: 30–60% of children with ADHD have language difficulties; patterns vary by symptom type (e.g., inattentive vs hyperactive-impulsive).

  • Inattention: difficulties with understanding, listening, vocabulary, and recalling conversation flow.

  • Hyperactivity-impulsivity: excessive talking, interruptions, rapid shifts, and planning challenges in speech.

• Health, safety, and lifestyle risks: higher rates of enuresis/encopresis, asthma, eating problems, sleep disturbances; risk of accidents is elevated (over 50% of parents report their ADHD child is accident-prone; higher injury risk).

• Family and social dynamics: increased family stress, parental mental health concerns, sibling conflict, and potential social stigma; parents’ own ADHD can complicate management.

• Comorbidity profile (common): Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD); Anxiety Disorders; Mood Disorders; Developmental Coordination Disorder (DCD); Tic Disorders; Autism Spectrum Disorder (ASD).

  • ODD/CD: about 31% with ADHD for ODD and 10% for CD; symptoms can co-develop and worsen ADHD.

  • Anxiety: around 25–50% with ADHD; linked to inattention; anxiety can stem from school/social struggles.

  • Mood disorders: 20–30% with ADHD; depression risk higher with co-occurring conduct problems; risk of suicidality higher in this group.

  • DCD: 50–60% with ADHD also meet criteria for DCD; motor clumsiness and planning problems; overlapping brain activity in movement-related regions.

  • Tic disorders: ~20% of ADHD have tic disorders; tics peak in late childhood and may worsen with stress; stimulants can slightly increase tics in some cases.

  • AuDHD (ADHD + ASD) overlap around 30–65%; overlap can heighten social impairment and executive functioning difficulties; both conditions share genetic and neurobiological factors.

Prevalence, development, and lifespan trajectory

• Gender differences: in Malaysia, boys are 3–4 times more likely to be diagnosed than girls; boys show more externalizing behaviors; girls often have inattentive symptoms that are less disruptive and more easily overlooked; hyperactive-impulsive presentations in girls may carry increased risk for certain issues (e.g., eating disorders, self-harm, suicidality).

• Socioeconomic and cultural factors: ADHD occurs across SES, but is somewhat more common in lower SES groups; culture shapes how symptoms are perceived and treated; diagnosis and treatment access can vary by culture and education.

• Course across development:

  • Infancy: signs by age 2; diagnosis before age 3 is unreliable; high activity, irritability, sleep/feeding issues.

  • Preschool: ADHD becomes more noticeable (3–4 years) with hyperactive–impulsive symptoms; persistent symptoms predict later difficulties; poor self-control affects parent–child interactions.

  • Elementary: inattention becomes more evident with academic demands; hyperactivity/impulsivity may still disrupt; risk of oppositional behaviors increases.

  • Adolescence: ADHD persists in >50% of those diagnosed in childhood; hyperactivity may decline, but attention and impulse control difficulties continue; higher risk for risky behaviors (substance use, unsafe sex, accidents).

  • Adulthood: many continue to experience ADHD, especially those with severe childhood symptoms or conduct problems; some learn coping strategies; adult outcomes involve work, relationships, emotion regulation, and impulsivity challenges; many remain undiagnosed.

Causes: genetics, prenatal environment, neurobiology, and environment

• Genetic factors: ADHD has strong heritability; twin studies show substantial heritability (~h^2\approx 0.74); risk is elevated when a parent has ADHD; adoption studies show higher risk with biological than adoptive parents; multiple genes contribute (polygenic)

• Specific gene candidates: dopamine-regulating genes (DRD4, DAT1) implicated; pharmacological responses (dopamine/ norepinephrine pathways) relate to stimulant meds; no single gene causes ADHD; GWAS identifies multiple loci (e.g., ~27 loci with several gene associations; thousands of variants cumulatively contribute)

• Prenatal & early development: maternal smoking, alcohol, or drug exposure; prenatal exposure increases vulnerability; shared genetic/environmental factors; chaotic home environments amplify risks in combination with genetic predisposition

• Neurobiological findings: ADHD linked to differences in brain structure and networks

  • Brain structure: smaller overall brain volume; underactive or smaller prefrontal cortex; reduced size/function in basal ganglia; smaller cerebellum/vermian area; thinner corpus callosum; altered thalamus

  • Brain networks: DMN (default mode network) may be overactive during tasks (mind-wandering); CCN (cognitive control network) underactive or weak connections; Salience network impairment reduces efficient switching between networks; frontostriatal circuits show weaker connectivity affecting self-control and motivation

• Environmental factors: sugar intake, micronutrient status (omega-3, iron, magnesium, iodine) have small to moderate associations; lead exposure contributes to ADHD risk; inflammation may contribute to impulse control and attention issues; no simple sugar-to-ADHD causal link

• Family environment: harsh parenting and high family conflict can worsen symptoms; responsive parenting helps improve attention and self-control; parental mental health conditions influence outcomes

Neurocognitive theories and explanatory models

• Executive Dysfunction Theory: ADHD involves impairments in executive functions including inhibition, working memory, planning, organization; these deficits contribute to inattention, hyperactivity, and impulsivity

• Reward/Motivation Deficit Theory: ADHD involves dysregulation of the dopamine reward pathway (PFC, nucleus accumbens, ventral tegmental area); diminished responsiveness to typical rewards leads to preference for immediate, stimulating rewards and challenges with delayed gratification

• State Regulation Theory: ADHD is linked to arousal regulation problems; hypoarousal leads to seeking stimulation; hyperarousal leads to restlessness; dysregulated arousal affects attention, hyperactivity, and impulse control

• Self-Regulation Deficit: Core difficulty in regulating behavior, thoughts, and emotions; intersects with inhibition, attention, working memory, emotional regulation, and self-motivation

Treatments and management strategies

• Overall aim: ADHD is a chronic condition without a cure; goals are to improve symptoms, daily functioning, learning, and self-esteem

• Core treatment modalities (increasingly used in combination):

  • Medication (stimulants and non-stimulants)

  • Parent Management Training (PMT) and educational interventions

  • Intensive treatment programs (e.g., Summer Treatment Programs)

  • Family counseling, support groups, and individual therapy

• Medication specifics:

  • Stimulants (first line for children ≥5 years): Methylphenidate-based meds (Ritalin, Concerta, Medikinet MR); act on dopamine and norepinephrine reuptake inhibition; typical response window includes a 6-week trial; side effects can include abdominal pain, nausea, dyspepsia

  • If inadequate response to methylphenidate: consider lisdexamfetamine (LDX)

  • Atomoxetine (Strattera) as a non-stimulant alternative; selective norepinephrine reuptake inhibitor; may be used in adolescents

  • Some considerations: risk of misuse or comorbidity with tics or anxiety; treatment often tailored to each patient; switching strategies may be used when benefits are limited

• Psychoeducation: educate families on ADHD; emphasize neurological basis rather than blaming parenting; reduce guilt

• Behavioral/parenting strategies (PMT):

  • Clear, simple instructions; observe and record patterns/triggers; use positive reinforcement; immediate and specific praise

  • Time-outs and loss of privileges for disruptive behavior; avoid harsh punishment; use consistent, mild consequences

  • Focus on consistency, environment shaping, and positive parent–child interactions; stress management for parents

  • PMT is a long-standing, commonly used approach with demonstrated benefits for family functioning and behavior; ongoing effectiveness and scope of impact debated

• Educational interventions:

  • Classroom management with clear rules and expectations; reduced disruption and improved learning outcomes

  • Tools like token economies; instruction modification and study skills

  • Visual supports, explicit instructions, and frequent cues; allow extra time and space for processing; preferential seating or movement opportunities; repeat instructions as needed

  • Meta-analytic evidence suggests improvements in academic and behavioral outcomes with these strategies

• Intensive interventions: Summer Treatment Programs (STP)

  • Gold standard for intensive care; typically 10–12 children, ages about 6–12

  • Combines academics, behavior training, and social skills; often about 360 hours across 8 weeks

  • Reported benefits include short-term and sometimes longer-term symptom reductions; high costs; success often depends on continued supportive home environment

• Additional supports:

  • Family counseling and peer support groups to build coping skills and reduce isolation

  • Individual counseling to address self-esteem, coping with negative feedback, and emotional regulation

  • Emphasis on attention and self-regulation skills; strengthening parent–child relationships

• Common scales and assessments used in practice include CRS, CBCL, Vanderbilt ADHD Rating Scale, ADHD Rating Scale-5, SDQ; used to supplement clinical interviews and guide treatment decisions

Associated health and development considerations

• Speech and language: a notable minority (30–60%) experience language difficulties; inattentive symptoms more strongly linked to comprehension and recall; hyperactivity/impulsivity linked to disorganized speech and social language challenges

• Motor/coordination: Developmental Coordination Disorder (DCD) occurs in about half of children with ADHD; motor clumsiness, handwriting and daily living difficulties

• Sleep: sleep disturbances are common and can exacerbate attention problems and mood dysregulation

• Enuresis/encopresis and other physical health problems may co-occur; overall health monitoring is important

• Safety risks: accident-prone status; higher risk of injuries, accidents, and risky behaviors in adolescence and adulthood; higher likelihood of substance use and risky sexual behavior; frequent health costs

Social, family, and developmental implications

• Family dynamics: high parenting stress; parental mental health influences child outcomes; conflict and partial blame can arise; positive, supportive parenting improves attention and self-regulation

• Peer and school implications: social rejection and peer-relationship problems; impairment in peer interactions; can affect self-concept and school achievement; positive friendships can buffer negative effects

• Stigma and public perception: social stigma can impact access to care and self-esteem; education about ADHD can reduce stigma and improve outcomes

• AuDHD and diagnostic challenges: overlapping features with ASD can complicate diagnosis; awareness of shared genetic and neurobiological factors; careful differential diagnosis is necessary

Prevalence, culture, and life course considerations

• Gender differences: overall prevalence higher in boys; cultural expectations influence recognition and referral for assessment; girls may present more with inattention, leading to underdiagnosis

• Socioeconomic and cultural influences: ADHD occurs across SES; access to diagnosis/tunding varies; cultural norms influence help-seeking and acceptance of interventions

• Lifespan trajectory: ADHD can persist into adulthood; many individuals develop coping strategies; some remain undiagnosed; long-term outcomes are influenced by early intervention, family support, education, and comorbidity management

Key takeaways: integrating knowledge for exam preparedness

• ADHD is a multifactorial neurodevelopmental disorder with heterogeneous presentations and etiologies (genetic, neurobiological, environmental).

• Core symptoms cluster into inattention and hyperactivity–impulsivity; presentations can be combined or predominant, and they can shift over time.

• Diagnostic criteria (DSM-5/DSM-5-TR) balance symptom counts, onset timing, impairment across settings, and exclusion of other conditions; DSM limitations include developmental sensitivity and dimensionality considerations.

• Assessment integrates clinical interviews, behavior rating scales, observations, and consideration of comorbidities; costs and pathways differ across government vs non-government routes.

• Treatment is multimodal: medications (stimulants/non-stimulants), PMT, educational interventions, intensive programs like STP, and family/individual counseling.

• Cognitive and language profiles commonly show deficits in executive function and language; many children have co-occurring learning disorders or motor coordination difficulties.

• Comorbidity is common (anxiety, mood disorders, ODD/CD, ASD, DCD, tic disorders); these require integrated management.

• Lifespan considerations emphasize the need for ongoing support, with attention to safety, mental health, and functional goals in school and work settings.