attention deficit hyperactivity disorder attention deficit hyperactivity disorder attention deficit hyperactivity disorder (adhd) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inappropriate. attention deficit hyperactivity disorderpeople with adhd may struggle more than others to focus on some tasks (such as schoolwork), but can maintain an unusually intense level of attention for tasks they find rewarding or interesting.specialtypsychiatrypediatricssymptomsinattentioncarelessnesshyperactivityexecutive dysfunctionimpulsivitycausesboth genetic and environmental factorsdiagnostic methodbased on symptoms after other possible causes have been ruled outdifferential diagnosisnormally active childbipolar disorderconduct disordermajor depressive disorderautism spectrum disorderoppositional defiant disorderlearning disorderintellectual disabilityanxiety disorderborderline personality disorderfetal alcohol spectrum disordertreatmentpsychotherapylifestyle changesmedicationmedicationcns stimulants (e.g., methylphenidate, amphetamine)atomoxetineguanfacineclonidinefrequency1.1319% (2019, using dsm-iv-tr and icd-10) adhd symptoms arise from executive dysfunction, and emotional dysregulation is often considered a core symptom. in children, problems paying attention may result in poor school performance. adhd is associated with other neurodevelopmental and mental disorders as well as some non-psychiatric disorders, which can cause additional impairment, especially in modern society. although people with adhd struggle to focus on tasks they are not particularly interested in completing, they are often able to maintain an unusually prolonged and intense level of attention for tasks they do find interesting or rewarding; this is known as hyperfocus. the precise causes of adhd are unknown in the majority of cases. genetic factors play an important role; adhd tends to run in families and has a heritability rate of 74%. toxins and infections during pregnancy as well as brain damage may be environmental risks. it affects about 5–7% of children when diagnosed via the dsm-iv criteria, and 1–2% when diagnosed via the icd-10 criteria. rates are similar between countries and differences in rates depend mostly on how it is diagnosed. adhd is diagnosed approximately twice as often in boys than in girls, and 1.6 times more often in men than in women, although the disorder is overlooked in girls or diagnosed in later life because their symptoms sometimes differ from diagnostic criteria. about 30–50% of people diagnosed in childhood continue to have adhd in adulthood, with 2.58% of adults estimated to have adhd which began in childhood. in adults, hyperactivity is usually replaced by inner restlessness, and adults often develop coping skills to compensate for their impairments. the condition can be difficult to tell apart from other conditions, as well as from high levels of activity within the range of normal behaviour. adhd has a negative impact on patient health-related quality of life that may be further exacerbated by, or may increase the risk of, other psychiatric conditions such as anxiety and depression. adhd management recommendations vary and usually involve some combination of medications, counseling, and lifestyle changes. the british guideline emphasises environmental modifications and education about adhd for individuals and carers as the first response. if symptoms persist, parent-training, medication, or psychotherapy (especially cognitive behavioural therapy) can be recommended based on age. canadian and american guidelines recommend medications and behavioural therapy together, except in preschool-aged children for whom the first-line treatment is behavioural therapy alone. stimulant medications are the most effective pharmaceutical treatment, although there may be side effects and any improvements will be reverted if medication is ceased. adhd, its diagnosis, and its treatment have been considered controversial since the 1970s. these controversies have involved doctors, teachers, policymakers, parents, and the media. topics have included causes of adhd and the use of stimulant medications in its treatment. adhd is now a well-validated clinical diagnosis in children and adults, and the debate in the scientific community mainly centers on how it is diagnosed and treated. adhd was officially known as attention deficit disorder (add) from 1980 to 1987; prior to the 1980s, it was known as hyperkinetic reaction of childhood. symptoms similar to those of adhd have been described in medical literature dating back to the 18th century. signs and symptoms inattention, hyperactivity (restlessness in adults), disruptive behaviour, and impulsivity are common in adhd. academic difficulties are frequent as are problems with relationships. the symptoms can be difficult to define, as it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring interventions begin. according to the fifth edition of the diagnostic and statistical manual of mental disorders (dsm-5) and its text revision (dsm-5-tr), symptoms must be present for six months or more to a degree that is much greater than others of the same age. this requires at least six symptoms of either inattention or hyperactivity/impulsivity for those under 17 and at least five symptoms for those 17 years or older. the symptoms must be present in at least two settings (e.g., social, school, work, or home), and must directly interfere with or reduce quality of functioning. additionally, several symptoms must have been present before age twelve. subtypes adhd is divided into three primary presentations: predominantly inattentive (adhd-pi or adhd-i) predominantly hyperactive-impulsive (adhd-ph or adhd-hi) combined type (adhd-c). the table "symptoms" lists the symptoms for adhd-i and adhd-hi from two major classification systems. symptoms which can be better explained by another psychiatric or medical condition which an individual has are not considered to be a symptom of adhd for that person. symptoms presentations dsm-5 and dsm-5-tr symptoms icd-11 symptoms inattention six or more of the following symptoms in children, and five or more in adults, excluding situations where these symptoms are better explained by another psychiatric or medical condition: frequently overlooks details or makes careless mistakes often has difficulty maintaining focus on one task or play activity often appears not to be listening when spoken to, including when there is no obvious distraction frequently does not finish following instructions, failing to complete tasks often struggles to organise tasks and activities, to meet deadlines, and to keep belongings in order is frequently reluctant to engage in tasks which require sustained attention frequently loses items required for tasks and activities is frequently easily distracted by extraneous stimuli, including thoughts in adults and older teenagers often forgets daily activities, or is forgetful while completing them. multiple symptoms of inattention that directly negatively impact occupational, academic or social functioning. symptoms may not be present when engaged in highly stimulating tasks with frequent rewards. symptoms are generally from the following clusters: struggles to maintain focus on tasks that aren't highly stimulating/rewarding or that require continuous effort; details are often missed, and careless mistakes are frequent in school and work tasks; tasks are often abandoned before they are completed. easily distracted (including by own thoughts); may not listen when spoken to; frequently appears to be lost in thought often loses things; is forgetful and disorganised in daily activities. the individual may also meet the criteria for hyperactivity-impulsivity, but the inattentive symptoms are predominant. hyperactivity-impulsivity six or more of the following symptoms in children, and five or more in adults, excluding situations where these symptoms are better explained by another psychiatric or medical condition: is often fidgeting or squirming in seat frequently has trouble sitting still during dinner, class, in meetings, etc. frequently runs around or climbs in inappropriate situations. in adults and teenagers, this may be present only as restlessness. often cannot quietly engage in leisure activities or play frequently seems to be "on the go" or appears uncomfortable when not in motion often talks excessively often answers a question before it is finished, or finishes people's sentences often struggles to wait their turn, including waiting in lines frequently interrupts or intrudes, including into others' conversations or activities, or by using people's things without asking. multiple symptoms of hyperactivity/impulsivity that directly negatively impact occupational, academic or social functioning. typically, these tend to be most apparent in environments with structure or which require self-control. symptoms are generally from the following clusters: excessive motor activity; struggles to sit still, often leaving their seat; prefers to run about; in younger children, will fidget when attempting to sit still; in adolescents and adults, a sense of physical restlessness or discomfort with being quiet and still. talks too much; struggles to quietly engage in activities. blurts out answers or comments; struggles to wait their turn in conversation, games, or activities; will interrupt or intrude on conversations or games. a lack of forethought or consideration of consequences when making decisions or taking action, instead tending to act immediately (e.g., physically dangerous behaviours including reckless driving; impulsive decisions). the individual may also meet the criteria for inattention, but the hyperactive-impulsive symptoms are predominant. combined meet the criteria for both inattentive and hyperactive-impulsive adhd. criteria are met for both inattentive and hyperactive-impulsive adhd, with neither clearly predominating. girls and women with adhd tend to display fewer hyperactivity and impulsivity symptoms but more symptoms of inattention and distractibility. symptoms are expressed differently and more subtly as the individual ages.: 6 hyperactivity tends to become less overt with age and turns into inner restlessness, difficulty relaxing or remaining still, talkativeness or constant mental activity in teens and adults with adhd.: 6–7 impulsivity in adulthood may appear as thoughtless behaviour, impatience, irresponsible spending and sensation-seeking behaviours,: 6 while inattention may appear as becoming easily bored, difficulty with organization, remaining on task and making decisions, and sensitivity to stress.: 6 although not listed as an official symptom for this condition, emotional dysregulation or mood lability is generally understood to be a common symptom of adhd.: 6 people with adhd of all ages are more likely to have problems with social skills, such as social interaction and forming and maintaining friendships. this is true for all presentations. about half of children and adolescents with adhd experience social rejection by their peers compared to 10–15% of non-adhd children and adolescents. people with attention deficits are prone to having difficulty processing verbal and nonverbal language which can negatively affect social interaction. they also may drift off during conversations, miss social cues, and have trouble learning social skills. difficulties managing anger are more common in children with adhd as are delays in speech, language and motor development. poorer handwriting is more common in children with adhd. poor handwriting in many situations can be a side effect of adhd in itself due to decreased attentiveness but when it's a constant problem it may also be in part due to both dyslexic and dysgraphic individuals having higher rates of adhd than the general population, with 3 in 10 people who have dyslexia also having adhd. although it causes significant difficulty, many children with adhd have an attention span equal to or greater than that of other children for tasks and subjects they find interesting. psychiatric in children, adhd occurs with other disorders about two-thirds of the time. other neurodevelopmental conditions are common comorbidities. autism spectrum disorder (asd), co-occurring at a rate of 21% in those with adhd, affects social skills, ability to communicate, behaviour, and interests. both adhd and asd can be diagnosed in the same person. learning disabilities have been found to occur in about 20–30% of children with adhd. learning disabilities can include developmental speech and language disorders, and academic skills disorders. adhd, however, is not considered a learning disability, but it very frequently causes academic difficulties. intellectual disabilities and tourette's syndrome are also common. adhd is often comorbid with disruptive, impulse control, and conduct disorders. oppositional defiant disorder (odd) occurs in about 25% of children with an inattentive presentation and 50% of those with a combined presentation. it is characterised by angry or irritable mood, argumentative or defiant behaviour and vindictiveness which are age-inappropriate. conduct disorder (cd) occurs in about 25% of adolescents with adhd. it is characterised by aggression, destruction of property, deceitfulness, theft and violations of rules. adolescents with adhd who also have cd are more likely to develop antisocial personality disorder in adulthood. brain imaging supports that cd and adhd are separate conditions, wherein conduct disorder was shown to reduce the size of one's temporal lobe and limbic system, and increase the size of one's orbitofrontal cortex, whereas adhd was shown to reduce connections in the cerebellum and prefrontal cortex more broadly. conduct disorder involves more impairment in motivation control than adhd. intermittent explosive disorder is characterised by sudden and disproportionate outbursts of anger and co-occurs in individuals with adhd more frequently than in the general population. anxiety and mood disorders are frequent comorbidities. anxiety disorders have been found to occur more commonly in