In recent years, children have been increasingly diagnosed with Attention Deficit Hyperactivity Disorder.

Many do not take this disease seriously, meanwhile, the problem is much more serious than it seems. Not only those around, but the child himself suffers from his condition.

Adults must clearly understand where the line between bad parenting and true illness lies in order to help the child cope with the situation.

About the causes and symptoms of attention deficit hyperactivity disorder (ADHD) in children under one year old (infants), preschool and school age, what is this diagnosis (its decoding) and how dangerous is it for a child?

What is it, ICD-10 code

Hyperactivity Syndrome is a neurological and behavioral disorder, which consists in increased excitability of the nervous system.

Pathology is expressed in excessive impulsivity, difficulty concentrating, poor controllability. According to ICD 10, the disease has the code F90.0- Violation of activity and attention.

This disease manifests itself in childhood. For the first time they started talking about it in the 70s of the 20th century. However, many doctors still doubt that such a diagnosis exists.

They explain all manifestations by heredity, the results of upbringing, the influence of others and the environment. Statistically, the disorder is present in about 5% of the population, most of which are males.

In medicine, there are three types of syndrome:

• Hyperactivity with a predominance of attention deficit.
• Disorder with a predominance of hyperactivity and impulsivity.
• Mixed type.

Causes of ADHD in childhood

ADHD is diagnosed between the ages of 4 and 7. This is due to the need to observe the behavior of the child in different settings: at home, in kindergarten, on the street.

For young children, especially under one year old, the pathology is not diagnosed, even if there are manifestations. Increased excitability of newborns may be a sign of other diseases.

• impulsiveness;
• restlessness;
• increased anxiety;
• sleep problems;
• developmental delay;
• difficulty concentrating;
• uncontrollability.

pathology is expressed in the fact that he sleeps little, wakes up from any rustle, often cries for no apparent reason.

The brightest objects and toys arouse his interest for a second. These children often show increased muscle tone.

Hyperactivity in children 2-3 years old manifests itself brighter. Children cannot concentrate, while eating or other activities they constantly spin in a chair. They are distinguished by excessive capriciousness.

It is difficult to captivate such children with games, books, even cartoons do not attract their attention for long. Another characteristic feature is mood swings. The baby may suddenly become silent, refuse to communicate and play.

At 3-4 years old, a child with hyperactivity shows aggression towards others, strives to be the first, freaks out when he is not allowed to. He often comes into conflict with peers, fights.

At the age of 5-7 years, the disease is expressed in disobedience, tantrums unwillingness to obey the accepted rules of conduct.

Children with ADHD can make a scandal in the store, kindergarten, while no persuasion works on the child. hyperactive child may, in a fit of anger, injure himself or others.

In schoolchildren, ADHD is expressed in the following symptoms:

• Aimless motor activity: running, dangling legs, moving in a chair, trying to climb where they should not.
• Can't wait for your turn.
• Talkativeness, intervening in other people's conversations.
• Inability to play quiet games.
• Mood swings.
• No sense of danger.
• Difficulties in concentration, performing school tasks.
• Constant forgetfulness, loss of personal belongings.
• Disorganization, failure to complete work on time.
• Distraction to foreign objects (phone games in class).
• Aggressive behavior.
• Suicidal thoughts.
• Carelessness, carelessness.
• Delayed emotional development.

Children with ADHD do not study well, miss classes at school, constantly conflict with teachers and classmates.

They can skip school, leave home. Although the intellectual abilities of these guys are at a normal level.

Differences from activity

A healthy temperamental child can be distinguished from a hyperactive one by the following features:

• After active games, he calms down and rests on his own.
• He falls asleep normally and sleeps according to his age.
• Has a sense of danger and fear, will not repeatedly climb into a dangerous place.
• Quickly understands the word "no."
• He can easily be distracted from hysteria by another irritant.
• Easily agrees to an alternative.
• Does not show aggression towards parents and peers.

Learn more about the symptoms and signs of hyperactivity in children in the following video:

Possible consequences

A person suffers from such a disease at any age.. He has difficulties with social adaptation, starting from kindergarten.

He cannot find mutual language with peers, constantly conflicts. Parents of other children complain about him, classmates constantly set him up as an example, thereby lowering his self-esteem.

Students have learning difficulties, they lag behind in development, skip classes. Going to school turns into torture. This leads to isolation and aggression.

Due to impulsivity, situations often arise that threaten the health of the child and others. If the disease is not treated, then a psychopathic personality type will form in an adult.

How to Diagnose

Parents notice signs of pathology in children as early as 2-3 years. A neurologist together with a psychologist can accurately establish the diagnosis.

The doctor listens to the complaints of the parents, conducts a conversation with the child. For a psychologist, it is important to know how the adaptation went in the kindergarten or school, what is the situation in the family.

Older patients are given a computer-based attention test.

It consists of 8 levels, stimuli appear on the screen, to which the patient must either press the buttons or not respond.

In addition to this test, the doctor may prescribe an encephalogram, a blood test for hormones.

Drug therapy for patients with ADHD is prescribed as a last resort, when other methods fail.

Usually used Desipramine and Atomoxetine, which stimulate the blood vessels of the brain, relieve intracranial pressure. They also use psychostimulants (Levamphetamine), nootropics (Cerebrolysin, Pantogam).

In most cases, doctors try to do without drugs, using methods of psychocorrection. Parents are also taught these methods.

The most effective methods: The child is offered life situations, he must model his behavior.

Nutrition and daily routine

It is important for the baby to organize the correct daily routine. He should sleep, walk and eat at the same time. Before going to bed, it is advisable to play a quiet board game or read a book.

In the house, the child should have a personal space, a room or a corner, you need to teach him to collect things, toys every day.

Proper nutrition plays a big role. Doctors say that the rapid increase in cases of hyperactivity is associated with the use of fast food and foods with preservatives.

The diet of the child should consist of lean meat, vegetables, fruits, dairy products. Sweets and junk food should be kept to a minimum.

What Not to Do

In contact with

Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders in children. Its diagnosis is based on the international criteria of the ICD-10 and DSM-IV-TR, but should also take into account the age dynamics of ADHD and the characteristics of its manifestations in the preschool, primary school and adolescence periods. Additional difficulties of intrafamily, school and social adaptation in ADHD are often associated with comorbid disorders, which are observed in at least 70% of patients. The neuropsychological mechanisms of ADHD are considered from the standpoint of insufficient formation of control functions provided by the prefrontal parts of the brain. ADHD is based on neurobiological factors: genetic mechanisms and early organic brain damage. The role of micronutrient deficiencies, in particular magnesium, which may have an additional effect on neurotransmitter balance and the manifestation of ADHD symptoms, is being studied. Treatment of ADHD should be based on an expanded therapeutic approach that involves addressing the patient's social and emotional needs and assessing, in the process of dynamic observation, not only the reduction of the main symptoms of ADHD, but also functional outcomes and quality of life indicators. Drug therapy for ADHD includes atomoxetine hydrochloride (Strattera), nootropic drugs, neurometabolic agents, including Magne B 6 . Treatment of ADHD should be comprehensive and long enough.

Keywords Key words: attention deficit hyperactivity disorder, children, diagnosis, treatment, magnesium, pyridoxine, Magne B 6

Attention deficit hyperactivity disorder: diagnosis, pathogenesis, principles of treatment

N.N.Zavadenko
N.I. Pirogov Russian National Research Medical University, Moscow

Attention deficit hyperactivity disorder (ADHD) is one of the common psychoneurological disorders in children. Its diagnosis is based on the international criteria ICD-10 and DSM-IV-TR, but also should be taken into account the age-related dynamics of ADHD and the specificities of its manifestations during the preschool, junior school and adolescent periods. Additional difficulties of intrafamilial, school and social adaptation in ADHD are often related to comorbid disorders, which are found in not less than 70% of patients. The neuropsychological mechanisms of ADHD are viewed from the positions of insufficient formation of the controlling functions that are ensured by the prefrontal regions of the brain. ADHD is based on neurobiological factors, such as genetic mechanisms and early organic damage of the brain. The role of micronutrient deficiency is studied, in particular, of magnesium that might have an additional effect on the neuromediatory balance and manifestation of ADHD symptoms. Treatment of ADHD should be based on a comprehensive therapeutic approach that presupposes taking into consideration the social and emotional needs of a patient and assessing, by dynamic observation, not only reduction of the major ADHD symptoms but also the functional outcomes, the indices of the quality of life. Drug therapy for ADHD includes atomoxetine hydrochloride (strattera), nootropic drugs, and neurometabolic medications, such as Magne B 6 . ADHD therapy should be complex and sufficiently long-term.

key words: attention deficit hyperactivity disorder, children, diagnosis, treatment, magnesium. pyridoxine, Magne B 6

Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders in childhood. ADHD is widely represented in the child population. Its prevalence ranges from 2 to 12% (average 3-7%), more common in boys than girls (average ratio - 3: 1). ADHD can occur both in isolation and in combination with other emotional and behavioral disorders, having a negative impact on learning and social adaptation.

The first manifestations of ADHD are usually observed from 3-4 years of age. But when a child gets older and enters school, he has additional difficulties, since the beginning of schooling makes new, higher demands on the child's personality and his intellectual capabilities. It is during the school years that attention disorders become apparent, as well as difficulties in mastering school skills and poor academic performance, self-doubt and low self-esteem. In addition to the fact that children with ADHD misbehave and study poorly at school, as they grow older, they may be at risk for the formation of deviant and antisocial forms of behavior, alcoholism, and drug addiction. Therefore, it is important for specialists to recognize the early manifestations of ADHD and to know about the possibilities of their treatment.

Symptoms of ADHD in a child may be the reason for the primary appeal to pediatricians, as well as speech therapists, defectologists, and psychologists. Often, teachers of preschool and school educational institutions first pay attention to the symptoms of ADHD.

Diagnosis Criteria. Diagnosis of ADHD is based on international criteria, including lists of the most characteristic and clearly traced signs of this disorder. The 10th revision of the International Classification of Diseases (ICD-10) and the DSM-IV-TR classification of the American Psychiatric Association approach the criteria for diagnosing ADHD from similar positions (table). In ICD-10, ADHD is categorized as hyperkinetic disorders(Category F90) under 'Behavioral and emotional disorders with onset in childhood and adolescence', and in the DSM-IV-TR ADHD is listed under 314 under 'Disorders first diagnosed in infancy, childhood or adolescence'. Mandatory characteristics of ADHD are also:

• duration: symptoms have been observed for at least 6 months;
• constancy, distribution to all spheres of life: adaptation disorders are observed in two or more types of environment;
• severity of violations: significant violations in training, social contacts, professional activities;
• other mental disorders are excluded: the symptoms cannot be associated solely with the course of another disease.

• combined (combined) form - there are all three groups of symptoms (50-75%);
• ADHD with predominant attention disorders (20-30%);
• ADHD with a predominance of hyperactivity and impulsivity (about 15%).

Currently, the diagnosis of ADHD is based on clinical criteria. To confirm ADHD, there are no special criteria or tests based on the use of modern psychological, neurophysiological, biochemical, molecular genetic, neuroradiological and other methods. The diagnosis of ADHD is made by a doctor, but educators and psychologists should also be familiar with the diagnostic criteria for ADHD, especially since it is important to obtain reliable information about the child's behavior not only at home, but also at school or a preschool institution in order to confirm this diagnosis.

Table. The main manifestations of ADHD according to ICD-10

Differential Diagnosis. In childhood, ADHD “imitators” are quite common: in 15-20% of children, forms of behavior outwardly similar to ADHD are periodically observed. In this regard, ADHD must be distinguished from a wide range of conditions that are similar to it only in external manifestations, but differ significantly both in causes and methods of correction. These include:

• individual characteristics of personality and temperament: the characteristics of the behavior of active children do not go beyond the age norm, the level of development of higher mental functions is good;
• anxiety disorders: features of the child's behavior are associated with the action of psychotraumatic factors;
• consequences of a traumatic brain injury, neuroinfection, intoxication;
• asthenic syndrome in somatic diseases;
• specific developmental disorders of school skills: dyslexia, dysgraphia, dyscalculia;
• endocrine diseases (pathology of the thyroid gland, diabetes);
• sensorineural hearing loss;
• epilepsy (absence forms; symptomatic, locally conditioned forms; side effects of anti-epileptic therapy);
• hereditary syndromes: Tourette, Williams, Smith-Mazhenis, Beckwith-Wiedemann, fragile X chromosome;
• mental disorders: autism, affective disorders (mood), mental retardation, schizophrenia.

preschool age . Between the ages of 3 and 7, hyperactivity and impulsivity usually begin to appear. Hyperactivity is characterized by the fact that the child is in constant motion, cannot sit still during classes for even a short time, is too talkative and asks an endless number of questions. Impulsivity is expressed in the fact that he acts without thinking, cannot wait for his turn, does not feel restrictions in interpersonal communication, intervening in conversations and often interrupting others. Such children are often characterized as misbehaving or too temperamental. They are extremely impatient, arguing, making noise, shouting, which often leads them to outbursts of strong irritation. Impulsivity can be accompanied by "fearlessness", whereby the child endangers himself (increased risk of injury) or others. During games, energy is overflowing, and therefore the games themselves become destructive. Children are sloppy, often throw, break things or toys, are naughty, poorly obey the demands of adults, and can be aggressive. Many hyperactive children lag behind their peers in language development.

School age . After entering school, the problems of children with ADHD increase significantly. The learning requirements are such that a child with ADHD is not able to fulfill them fully. Since his behavior does not correspond to the age norm, he fails to achieve results in school that correspond to his abilities (the general level of intellectual development in children with ADHD corresponds to the age range). During the lessons, it is difficult for them to cope with the proposed tasks, as they experience difficulties in organizing the work and bringing it to the end, they forget in the course of fulfilling the conditions of the task, they do not master the training materials well and cannot apply them correctly. They quite soon turn off the process of doing the work, even if they have everything necessary for this, do not pay attention to details, show forgetfulness, do not follow the instructions of the teacher, switch poorly when the conditions of the task change or a new one is given. They are unable to do their homework on their own. Compared with peers, difficulties in the formation of writing, reading, and numeracy skills are much more often observed.

Relationship problems with others, including peers, teachers, parents, and siblings, are common in children with ADHD. Since all manifestations of ADHD are characterized by significant fluctuations in different periods of time and in different situations The child's behavior is unpredictable. Hot temper, cockiness, oppositional and aggressive behavior are often observed. As a result, he cannot play for a long time, successfully communicate and establish friendly relations with peers. In the team, he serves as a source of constant anxiety: he makes noise without hesitation, takes other people's things, interferes with others. All this leads to conflicts, and the child becomes unwanted and rejected in the team. Faced with this attitude, children with ADHD often consciously choose to play the role of class jester, hoping to build relationships with their peers. A child with ADHD not only does not study well on his own, but often "breaks" the lessons, interferes with the work of the class, and therefore is often called to the director's office. In general, his behavior creates the impression of "immaturity", inconsistency with his age, that is, it is infantile. Only younger children or peers with similar behavior problems are usually ready to communicate with him. Gradually, children with ADHD develop low self-esteem.

At home, children with ADHD usually suffer constant comparisons to siblings who are well-behaved and learn better. Parents are annoyed by the fact that they are restless, obsessive, emotionally labile, undisciplined, disobedient. At home, the child is unable to take responsibility for the implementation of daily tasks, does not help parents, is sloppy. At the same time, comments and punishments do not give the desired results. According to the parents, “He is always unlucky”, “Something always happens to him”, that is, there is an increased risk of injuries and accidents.

Adolescence . It has been established that in adolescence, pronounced symptoms of impaired attention and impulsivity continue to be observed in at least 50-80% of children with ADHD. At the same time, hyperactivity in adolescents with ADHD is significantly reduced, replaced by fussiness, a sense of inner restlessness. They are characterized by lack of independence, irresponsibility, difficulties in organizing and completing assignments and especially long-term work, which they are often unable to cope with without outside help. School performance often worsens, as they cannot effectively plan their work and distribute it over time, they postpone the execution of necessary tasks from day to day.

Difficulties in relationships in the family and school, behavioral disorders are growing. Many adolescents with ADHD are distinguished by reckless behavior associated with unjustified risk, difficulties in following the rules of behavior, disobedience to social norms and laws, failure to comply with the requirements of adults - not only parents and teachers, but also officials, such as school administration representatives or police officers. At the same time, they are characterized by weak psycho-emotional stability in case of failures, self-doubt, low self-esteem. They are too sensitive to teasing and ridicule from peers who think they are stupid. Adolescents with ADHD continue to be characterized by peers as immature and inappropriate for their age. In everyday life, they neglect the necessary safety measures, which increases the risk of injury and accidents.

Adolescents with ADHD are prone to being involved in teen gangs that commit various offenses, they may develop cravings for alcohol and drugs. But in these cases, they, as a rule, turn out to be led, obeying the will of stronger peers or older people and not thinking about the possible consequences of their actions.

Disorders associated with ADHD (comorbid disorders). Additional difficulties in intra-family, school and social adaptation in children with ADHD may be associated with the formation of concomitant disorders that develop against the background of ADHD as the underlying disease in at least 70% of patients. The presence of comorbid disorders can lead to worsening of the clinical manifestations of ADHD, worsening of the long-term prognosis, and a decrease in the effectiveness of the main therapy for ADHD. Behavioral and emotional disturbances associated with ADHD are considered as unfavorable prognostic factors for the long-term, up to chronic, course of ADHD.

Comorbid disorders in ADHD are represented by the following groups: externalized (oppositional defiant disorder, conduct disorder), internalized (anxiety disorders, mood disorders), cognitive (speech development disorders, specific learning difficulties - dyslexia, dysgraphia, dyscalculia), motor (static-locomotor failure, developmental dyspraxia, tics). Other comorbid ADHD disorders can be sleep disturbances (parasomnias), enuresis, encopresis.

Thus, learning, behavioral and emotional problems can be associated with both the direct influence of ADHD and comorbid disorders, which should be diagnosed in a timely manner and considered as indications for additional appropriate treatment.

Pathogenesis of ADHD. The formation of ADHD is based on neurobiological factors: genetic mechanisms and early organic damage to the central nervous system (CNS), which can be combined with each other. It is they who determine the changes in the central nervous system, violations of higher mental functions and behavior, corresponding to the picture of ADHD. The results of modern research indicate the involvement of the “associative cortex-basal ganglia-thalamus-cerebellum-prefrontal cortex” system in the pathogenetic mechanisms of ADHD, in which the coordinated functioning of all structures ensures control of attention and organization of behavior.

In many cases, an additional impact on children with ADHD is exerted by negative socio-psychological factors (primarily family factors), which in themselves do not cause the development of ADHD, but always contribute to an increase in the child's symptoms and adaptation difficulties.

genetic mechanisms. The genes that determine the predisposition to the development of ADHD (the role of some of them in the pathogenesis of ADHD has been confirmed, while others are considered as candidates) include genes that regulate the metabolism of neurotransmitters in the brain, in particular dopamine and norepinephrine. Dysfunction of neurotransmitter systems of the brain plays an important role in the pathogenesis of ADHD. At the same time, disturbances in the processes of synaptic transmission are of primary importance, which entail dissociation, a break in connections between the frontal lobes and subcortical formations, and as a result of this, the development of ADHD symptoms. The fact that the mechanisms of action of medicines, the most effective in the treatment of ADHD, are to activate the release and inhibition of the reuptake of dopamine and norepinephrine in presynaptic nerve endings, which increases the bioavailability of neurotransmitters at the level of synapses.

In modern concepts, attention deficit in children with ADHD is considered as a result of disturbances in the functioning of the posterior cerebral attention system regulated by norepinephrine, while behavioral inhibition and self-control disorders characteristic of ADHD are considered as a lack of dopaminergic control over the flow of impulses to the forebrain attention system. The posterior cerebral system includes the superior parietal cortex, the superior colliculus, the thalamic cushion (the dominant role belongs to the right hemisphere); this system receives dense noradrenergic innervation from the locus coeruleus (blue spot). Norepinephrine suppresses spontaneous discharges of neurons, thereby preparing the posterior cerebral attention system, which is responsible for orienting to new stimuli, to work with them. This is followed by a switch in the mechanisms of attention to the anterior cerebral control system, which includes the prefrontal cortex and the anterior cingulate gyrus. The susceptibility of these structures to incoming signals is modulated by dopaminergic innervation from the ventral tegmental nucleus of the midbrain. Dopamine selectively regulates and limits excitatory impulses to the prefrontal cortex and cingulate gyrus, providing a reduction in excessive neuronal activity.

Attention deficit hyperactivity disorder (ADHD) is considered a polygenic disorder in which multiple disorders of dopamine and/or noradrenaline metabolism that exist simultaneously are due to the influence of several genes that override the protective effect of compensatory mechanisms. The effects of the genes that cause ADHD are additive, complementary. Thus, ADHD is considered as a polygenic pathology with a complex and variable inheritance, and at the same time as a genetically heterogeneous condition.

Pre- and perinatal factors play an important role in the pathogenesis of ADHD. A comparative analysis of anamnestic information in children with ADHD and their healthy peers showed that the formation of ADHD may be preceded by violations of the course of pregnancy and childbirth, in particular preeclampsia, eclampsia, the first pregnancy, the mother's age is younger than 20 years or older than 40 years, prolonged delivery , post-term pregnancy and prematurity, low birth weight, morphofunctional immaturity, hypoxic-ischemic encephalopathy, disease of the child in the first year of life. Other risk factors are the use by the mother during pregnancy of certain medicines, alcohol and smoking .

Apparently, some decrease in the size of the prefrontal areas of the brain (mainly in the right hemisphere), subcortical structures, corpus callosum, and cerebellum found in children with ADHD compared with healthy peers using magnetic resonance imaging (MRI) is apparently associated with early CNS damage. These data support the concept that the occurrence of ADHD symptoms is due to impaired connections between the prefrontal regions and subcortical ganglia, primarily the caudate nucleus. Subsequently, additional confirmation was obtained through the use of functional neuroimaging methods. Thus, when determining cerebral blood flow using single-photon emission computed tomography in children with ADHD, compared with healthy peers, a decrease in blood flow (and, consequently, metabolism) in the frontal lobes, subcortical nuclei and midbrain was demonstrated, and the changes were most pronounced at the level caudate nucleus. According to the researchers, changes in the caudate nucleus in children with ADHD were the result of its hypoxic-ischemic damage during the neonatal period. Having close connections with the thalamus, the caudate nucleus performs an important function of modulation (mainly of an inhibitory nature) of polysensory impulses, and the lack of inhibition of polysensory impulses may be one of the pathogenetic mechanisms of ADHD.

Subsequently, H.C. Lou et al. using positron emission tomography (PET), it was established that cerebral ischemia transferred at birth leads to persistent changes in dopamine receptors of the 2nd and 3rd types in the structures of the striatum. As a result, the ability of receptors to bind dopamine decreases and a functional insufficiency of the dopaminergic system is formed. These data were obtained from a survey of six adolescents with ADHD aged 12-14 years. Previously, these patients were included in a group of 27 children who were born prematurely at 28-34 weeks of gestation, they underwent PET within 48 hours after birth, which confirmed hypoxic-ischemic CNS damage; when re-examined at the age of 5.5-7 years, 18 of them were diagnosed with ADHD. The results obtained show that critical changes at the level of receptors (and, possibly, other protein structures involved in the metabolism of neurotransmitters) can be not only hereditary in nature, but also be the result of pre- and perinatal pathology.

Recently, P. Shaw et al. conducted a longitudinal comparative MRI study of children with ADHD, the purpose of which was to assess regional differences in the thickness of the cerebral cortex and compare their age dynamics with clinical outcomes. We examined 163 children with ADHD (mean age at inclusion in the study 8.9 years) and 166 children of the control group. The duration of follow-up was more than 5 years. According to the data obtained, children with ADHD showed a global decrease in the thickness of the cortex, most pronounced in the prefrontal (medial and upper) and precentral regions. At the same time, in patients with worse clinical outcomes during the initial examination, the smallest thickness of the cortex was found in the left medial prefrontal region. Normalization of the thickness of the right parietal cortex was associated with the best outcomes in patients with ADHD and may reflect a compensatory mechanism associated with changes in the thickness of the cerebral cortex.

Neuropsychological Mechanisms of ADHD are considered from the standpoint of violations (immaturity) of the functions of the frontal lobes of the brain, primarily the prefrontal region. Manifestations of ADHD are analyzed from the standpoint of a deficit in the functions of the frontal and prefrontal parts of the brain and insufficient formation of executive functions (EF). Patients with ADHD show "executive dysfunction" (in the English literature - executive dysfunction). The development of UV and the maturation of the prefrontal region of the brain are long-term processes that continue not only in childhood but also in adolescence. EF is a rather broad concept referring to the range of abilities that serve the task of maintaining the necessary sequence of efforts to solve a problem, aimed at achieving a future goal. Significant components of the EF that are affected in ADHD are: impulse control, behavioral inhibition (restraint); organization, planning, management of mental processes; maintaining attention, keeping from distractions; inner speech; working (operative) memory; foresight, forecasting, a look into the future; retrospective assessment of past events, mistakes made; change, flexibility, ability to switch and revise plans; choice of priorities, the ability to allocate time; separating emotions from real facts. Some UF researchers emphasize the "hot" social aspect of self-regulation and the child's ability to control their behavior in society, while others emphasize the role of regulation of mental processes - the "cold" cognitive aspect of self-regulation.

Influence of adverse environmental factors . Anthropogenic pollution of the human environment, largely associated with microelements from the group of heavy metals, can have negative consequences for children's health. It is known that in the immediate vicinity of many industrial enterprises, zones with a high content of lead, arsenic, mercury, cadmium, nickel and other microelements are formed. The most common heavy metal neurotoxicant is lead, and its sources of environmental pollution are industrial emissions and vehicle exhaust gases. Lead exposure to children can cause cognitive and behavioral problems in children. Thus, in a survey of 277 first-graders, a direct relationship was established between an increased lead content in the hair and an increase in hyperactivity, as assessed by a special questionnaire for teachers. This correlation remained significant after adjusting for other factors such as age, ethnicity, gender, and socioeconomic status. An even stronger relationship was observed between hair lead levels and an already diagnosed ADHD by a physician.

The role of nutritional factors and unbalanced nutrition. Nutritional imbalances (e.g., protein deficiency with an increase in easily digestible carbohydrates, especially in the morning), as well as micronutrient deficiencies, including vitamins, folates, omega-3 polyunsaturated fatty acids (PUFAs) can contribute to the onset or exacerbation of ADHD symptoms. , macro- and microelements. Micronutrients such as magnesium, pyridoxine and some others directly affect the synthesis and degradation of monoamine neurotransmitters. Therefore, micronutrient deficiencies can affect the neurotransmitter balance and hence the manifestation of ADHD symptoms.

Of particular interest among micronutrients is magnesium, which is a natural lead antagonist and promotes the rapid elimination of this toxic element. Therefore, magnesium deficiency, among other effects, can contribute to the accumulation of lead in the body. Magnesium deficiency in ADHD has been found in several studies. According to B. Starobrat-Hermelin, in the study of the mineral status in a group of 116 children with ADHD aged 9-12 years, magnesium deficiency was most often detected - in 110 (95%) patients, according to the results of its determinations in blood plasma, erythrocytes and hair. In a survey of 52 hyperactive children, 30 (58%) of them had low levels of magnesium in erythrocytes. According to Russian researchers, magnesium deficiency is determined in 70% of children with ADHD.

Magnesium is an important element involved in maintaining the balance of excitatory and inhibitory processes in the central nervous system. There are several molecular mechanisms through which magnesium deficiency affects neuronal activity and neurotransmitter metabolism: magnesium is required to stabilize excitatory (glutamate) receptors; magnesium is an essential cofactor of adenylate cyclases involved in signal transmission from neurotransmitter receptors to controlling intracellular cascades; magnesium is a cofactor for catechol-O-methyltransferase, which inactivates excess monoamine neurotransmitters. Therefore, magnesium deficiency contributes to the imbalance of the "excitation-inhibition" processes in the CNS towards excitation and can affect the manifestation of ADHD.

Magnesium deficiency in ADHD can be associated not only with its insufficient intake with food, but also with an increased need for it during critical periods of growth and development, with severe physical and neuropsychic stress, and stress. Under conditions of environmental stress, nickel and cadmium, along with lead, act as magnesium displacing metals. In addition to a lack of magnesium in the body, the manifestation of ADHD symptoms can be influenced by zinc, iodine, and iron deficiencies.

Thus, ADHD is a neuropsychiatric disorder with a complex pathogenesis, accompanied by structural, metabolic, neurochemical, neurophysiological changes in the CNS, as well as neuropsychological disorders in the processes of information processing and UV.

Treatment. At the present stage, it becomes clear that ADHD treatment should be aimed not only at controlling and reducing the main manifestations of this disorder, but also at solving other important tasks: improving the functioning of the patient in various areas and his fullest realization as a person, the emergence of his own achievements, improving self-esteem, normalizing the situation around him, including including within the family, the formation and strengthening of communication skills and contacts with other people, recognition by others and increased satisfaction with their lives. Our study confirmed the significant negative impact of the difficulties experienced by children with ADHD on their emotional state, family life, friendships, schooling, and leisure activities. In this regard, the concept of an expanded therapeutic approach has been formulated, which implies the extension of the influence of treatment beyond the reduction of the main symptoms and taking into account functional outcomes and quality of life indicators. Thus, the concept of an expanded therapeutic approach involves addressing the social and emotional needs of a child with ADHD, which should be given special attention both at the stage of diagnosis and treatment planning, and in the process of dynamic monitoring of the patient and evaluation of the results of therapy.

The most effective for ADHD is complex assistance, which combines the efforts of doctors, psychologists, teachers working with the child, and his family. Treatment for ADHD should be timely and must include:

• helping the family of a child with ADHD - family and behavioral therapy techniques that provide better interaction in families of children suffering from ADHD;
• developing parenting skills for children with ADHD, including parenting training programs;
• educational work with teachers, correction of the school curriculum - through a special presentation of educational material and the creation of such an atmosphere in the classroom that maximizes the chances of successful education of children;
• psychotherapy of children and adolescents with ADHD, overcoming difficulties, developing effective communication skills for children with ADHD during special remedial classes;
• drug therapy, which should be long enough, since improvement extends not only to the main symptoms of ADHD, but also to the socio-psychological side of the patients' lives, including their self-esteem, relationships with family members and peers, usually starting from the third month of treatment. Therefore, it is advisable to plan drug therapy for several months up to the duration of the entire academic year.

Domestic specialists in the treatment of ADHD traditionally use nootropic drugs. Their use in ADHD is pathogenetically justified, since nootropic drugs have a stimulating effect on cognitive functions that are not sufficiently formed in children of this group (attention, memory, organization, programming and control of mental activity, speech, praxis). Given this circumstance, the positive effect of drugs with a stimulating effect should not be taken as paradoxical (given the hyperactivity in children). On the contrary, the high efficiency of nootropics seems to be natural, especially since hyperactivity is only one of the manifestations of ADHD and is itself caused by violations of higher mental functions. In addition, these drugs have a positive effect on metabolic processes in the central nervous system and contribute to the maturation of the inhibitory and regulatory systems of the brain.

At the same time, it should be noted the need for new studies to clarify the optimal timing of the appointment of nootropic drugs in the treatment of ADHD. So, in the course of a recent study, the good potential of the drug hopantenic acid in the long-term treatment of ADHD has been confirmed. A positive effect on the main symptoms of ADHD was achieved after 2 months of treatment, but continued to increase after 4 and 6 months of its use. Along with this, the beneficial effect of long-term use of hopantenic acid on adaptation and functioning disorders characteristic of children with ADHD in various areas, including behavioral difficulties in the family and in society, schooling, reduced self-esteem, and lack of basic life skills, was confirmed. However, in contrast to the regression of the main symptoms of ADHD, longer periods of treatment were needed to overcome the disorders of adaptation and socio-psychological functioning: a significant improvement in self-esteem, communication with others and social activity was observed according to the results of parental questionnaires after 4 months, and a significant improvement in behavioral and schooling, basic life skills along with a significant regression of risk-taking behavior - after 6 months of using the drug hopantenic acid.

Another direction of ADHD therapy is to control negative nutritional and environmental factors that lead to the intake of neurotoxic xenobiotics (lead, pesticides, polyhaloalkyls, food dyes, preservatives) into the child's body. This should be accompanied by the inclusion in therapy of the necessary micronutrients that help reduce ADHD symptoms: vitamins and vitamin-like substances (omega-3 PUFAs, folates, carnitine) and essential macro- and microelements (magnesium, zinc, iron).

Among the micronutrients with a proven clinical effect in ADHD, magnesium preparations should be noted. In the treatment of ADHD, only organic magnesium salts (lactate, pidolate, citrate) are used, which is associated with a high bioavailability of organic salts and the absence of side effects when used in children. The use of magnesium pidolate with pyridoxine in solution (ampoule form of Magne B 6 (Sanofi-Aventis, France)) is allowed from the age of 1 year, lactate (Magne B 6 in tablets) and magnesium citrate (Magne B 6 forte in tablets) - from 6 years old. The magnesium content in one ampoule is equivalent to 100 mg of ionized magnesium (Mg 2+), in one tablet of Magne B 6 - 48 mg of Mg 2+, in one tablet of Magne B 6 forte (618.43 mg of magnesium citrate) - 100 mg of Mg 2+ . A large concentration of Mg 2+ in Magne B 6 forte allows you to take 2 times fewer tablets than when taking Magne B 6. The advantage of Magne B 6 in ampoules is also the possibility of more accurate dosing. As a study by O.A. Gromova et al. showed, the use of the ampoule form of Magne B 6 provides a rapid increase in the level of magnesium in the blood plasma (within 2-3 hours), which is important for the rapid elimination of magnesium deficiency. At the same time, taking Magne B 6 tablets contributes to a longer (within 6-8 hours) retention of an increased concentration of magnesium in erythrocytes, that is, its deposition.

The emergence of combined preparations containing magnesium and vitamin B6 (pyridoxine) has significantly improved the pharmacological properties of magnesium salts. Pyridoxine is involved in the metabolism of proteins, carbohydrates, fatty acids, the synthesis of neurotransmitters and many enzymes, has a neuro-, cardio-, hepatotropic, and hematopoietic effect, contributes to the replenishment of energy resources. The high activity of the combined drug is due to the synergism of the action of the components: pyridoxine increases the concentration of magnesium in plasma and erythrocytes and reduces the amount of magnesium excreted from the body, improves magnesium absorption in the gastrointestinal tract, its penetration into cells, and fixation. Magnesium, in turn, activates the process of transformation of pyridoxine into its active metabolite pyridoxal-5-phosphate in the liver. Thus, magnesium and pyridoxine potentiate each other's action, which allows their combination to be successfully used to normalize magnesium balance and prevent magnesium deficiency.

Data on the positive clinical effect of Magne B 6 in the treatment of ADHD children with confirmed magnesium deficiency in the body are presented in several foreign studies. The combined intake of magnesium and pyridoxine for 1-6 months reduced the symptoms of ADHD and restored normal values ​​of magnesium in erythrocytes.

O.R. Nogovitsina and E.V. Levitina compared the results of therapy of 31 children with ADHD aged 6-12 years with Magne B 6 and 20 patients in the control group who received a multivitamin preparation. The duration of the observation period was one month. According to the survey of parents, by the 30th day of treatment in the main group, scores on the scales "anxiety", "attention disorders and hyperactivity" significantly decreased. A decrease in the level of anxiety was also confirmed by the results of the Luscher test. During psychological testing in patients of the main group, concentration of attention, accuracy and speed of completing tasks improved significantly, and the number of errors decreased. Neurological examination showed an improvement in gross and fine motor skills, a positive dynamics of EEG characteristics in the form of the disappearance of signs of paroxysmal activity against the background of hyperventilation, as well as bilateral-synchronous and focal pathological activity in most patients. At the same time, taking Magne B 6 was accompanied by the normalization of magnesium concentration in erythrocytes and blood plasma of patients. Thus, the proportion of cases of severe magnesium deficiency in blood plasma decreased by 13% (from 23 to 10%), moderate deficiency - by 4% (from 37 to 33%), and the number of patients with normal values ​​increased from 40 to 57%.

Replenishment of magnesium deficiency should last at least two months. Considering that alimentary deficiency of magnesium occurs most often, when drawing up nutritional recommendations, one should take into account not only the quantitative content of magnesium in foods, but also its bioavailability. So, fresh vegetables, fruits, herbs (parsley, dill, green onions) and nuts have the maximum concentration and activity of magnesium. When preparing products for storage (drying, canning), the concentration of magnesium decreases slightly, but its bioavailability drops sharply. This is important for children with ADHD who have a deepening of magnesium deficiency that coincides with the period of schooling from September to May. Therefore, the use of combined preparations containing magnesium and pyridoxine is advisable during the school year.

Thus, the efforts of specialists should be directed to early detection ADHD in children. The development and application of complex correction should be carried out in a timely manner, be of an individual nature. Treatment for ADHD, including drug therapy, should be long enough.

List of used literature

1. Baranov AA, Belousov YuB, Bochkov NP, etc.. Attention deficit hyperactivity disorder: etiology, pathogenesis, clinic, course, prognosis, therapy, organization of care (expert report). Moscow, Attention program of the Charities Aid Foundation in the Russian Federation. M 2007;64.
2. Zavadenko NN. Hyperactivity and attention deficit in childhood. M.: "Academy", 2005.
3. International Classification of Diseases (10th revision). Classification of mental and behavioral disorders. Research diagnostic criteria. SPb., 1994; 208.
4. Diagnostic and Statistical Manual of Mental Disorders (4th edition Revision) (DSM-IV-TR). American Psychiatric Association. Washington, DC, 2000;943.
5. Nigg GT. What causes ADHD? New York, London: The Guilford Press, 2006;422.
6. Pennington B.F. Diagnosing Learning Disorders. A Neuropsychological Framework. New York, London, 2009;355.
7. Barkley RA
8. Lou HC. Etiology and pathogenesis of ADHD: significance of prematurity and perinatal hypoxic-haemodynamic encephalopathy. Acta Paediatr. 1996;85:1266-71.
9. Lou HC, Rosa P, Pryds O, et al. ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology. 2004;46:179-83.
10. . Longitudinal Mapping of Cortical Thickness and Clinical Outcome in Children and Adolescents With Attention-Deficit/ /Hyperactivity Disorder. Arch General Psychiatry. 2006;63:540-9.
11. Denckla MB
12. Tuthill RW. Hair lead levels related to children "s classroom attention-deficit behavior. Arch Environ Health. 1996; 51: 214-20.
13. Kudrin AV, Gromova OA. Microelements in neurology. Moscow: GeotarMed; 2006.
14. Rebrov VG, Gromova OA. Vitamins, macro- and microelements. Moscow: GeotarMed; 2008.
15. Starobrat-Hermelin B
17. Zavadenko NN, Lebedeva TV, Happy OV, etc. Attention deficit hyperactivity disorder: the role of questioning parents and teachers in assessing the socio-psychological adaptation of patients. Journal. nevrol. and a psychiatrist. them. S.S.Korsakov. 2009; 109(11): 53-7.
18. Barkley RA. Children with defiant behavior. Clinical guidelines for child assessment and parent training. Per. from English. M.: Terevinf, 2011; 272.
19. Zavadenko NN, Suvorinova NYu. Comorbid disorders in attention deficit hyperactivity disorder in children. Journal. nevrol. and a psychiatrist. them. S.S.Korsakov. 2007;107(7):39-44.
20. Zavadenko NN, Suvorinova NU. Attention deficit hyperactivity disorder: the choice of the optimal duration of drug therapy. Journal. nevrol. and a psychiatrist. them. S.S.Korsakov. 2011;111(10):28-32.
21. Kuzenkova LM, Namazova-Baranova LS, Balkanskaya NE, Uvakina EV. Multivitamins and polyunsaturated fatty acids in the treatment of attention deficit hyperactivity disorder in children. Pediatric pharmacology. 2009;6(3):74-9.
22. Gromova OA, Torshin IYu, Kalacheva AG, etc. The dynamics of the concentration of magnesium in the blood after taking various magnesium-containing drugs. Pharmateka. 2009;10:63-8.
23. Gromova OA, Skoromets AN, Egorova EY, etc. Prospects for the use of magnesium in pediatrics and pediatric neurology. Pediatrics. 2010;89(5):142-9.
24. Nogovitsina OR, Levitina EV. Effect of Magne-B 6 on clinical and biochemical manifestations of attention deficit hyperactivity disorder in children. Experiment. and wedge. pharmacology. 2006;69(1):74-7.
25. Akarachkova EU. The use of Magne-B 6 in therapeutic practice. Difficult patient. 2007;5:36-42.

References

1. Baranov AA, Belousov YuB, Bochkov NP, i dr. Sindrom defitsita vnimaniya s giperaktivnostyu: etiologiya, patogenez, klinika, techeniye, prognoz, terapiya, organizatsiya pomoshchi (ekspertnyy doklad). Moscow, programma "Vnimaniye" "Charitiz Eyd Faundeyshn" v RF. M., 2007;64. Russian.
2. Zavadenko NN. Giperaktivnost i defitsit vnimaniya v detskom vozraste. M.: "Akademiya", 2005. Russian.
3. Mezhdunarodnaya klassifikatsiya bolezney (10th peresmotr). Klassifikatsiya psikhicheskikh i povedencheskikh rasstroystv. Issledovatelskiye diagnosticheskiye kriterii. SPb., 1994;208.
4. Diagnostic and Statistical Manual of Mental Disorders (4th edition Revision) (DSM-IV-TR). American Psychiatric Association. Washington, DC, 2000;943. Russian.
5. Nigg GT. What causes ADHD? New York, London: The Guilford Press, 2006;422.
6. Pennington BF. Diagnosing Learning Disorders. A Neuropsychological Framework. New York, London, 2009;355.
7. Barkley RA. Issues in the diagnosis of attention-deficit/hyperactivity disorder in children. Brain & Development. 2003;25:77-83.
8. Lou HC. Etiology and pathogenesis of ADHD: significance of prematurity and perinatal hypoxic-haemodynamic encephalopathy. Acta Paediatr. 1996;85:1266-71.
9. Lou HC, Rosa P, Pryds O, et al. ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology. 2004;46:179-83.
10. Shaw P, Lerch J, Greenstein D, et al. Longitudinal Mapping of Cortical Thickness and Clinical Outcome in Children and Adolescents With Attention-Deficit/ Hyperactivity Disorder. Arch General Psychiatry. 2006;63:540-9.
11. Denckla MB. ADHD: topic update. Brain & Development. 2003;25:383-9.
12. Tuthill RW. Hair lead levels related to children "s classroom attention-deficit behavior. Arch Environ Health. 1996; 51: 214-20.
13. Kudrin AV, Gromova OA. Microelementy v neurology. Moscow: GeotarMed; 2006. Russian.
14. Rebrov VG, Gromova OA. Vitaminy, makro- i mikroelementy. Moscow: GeotarMed; 2008. Russian.
15. Starobrat-Hermelin B. The effect of deficiency of selected bioelements on hyperactivity in children with certain specified mental disorders. Ann Acad Med Stetin. 1998;44:297-314.
16. Mousain-Bosc M, Roche M, Rapin J, Bali JP. Magnesium VitB6 intake reduces central nervous system hyperexcitability in children. J Am Call Nutr. 2004;23:545-8.
17. Zavadenko NN, Lebedeva TV, Schasnaya OV, et al. Zhurn. neurol. i psychiatry. im. S.S. Korsakova. 2009; 109(11): 53-7. Russian.
18. Barkley RA. Children s vyzyvayushchim povedeniyem. Klinicheskoye rukovodstvo po obsledovaniyu rebenka i treningu roditeley. per. s engl. M.: Terevinf, 2011;272. Russian.
19. Zavadenko NN, Suvorinova NYu. Zhurn. neurol. i psychiatry. im. S.S. Korsakova. 2007;107(7):39-44. Russian.
20. Zavadenko NN, Suvorinova NYu. Zhurn. neurol. i psychiatry. im. S.S. Korsakova. 2011;111(10):28-32. Russian.
21. Kuzenkova LM, Namazova-Baranova LS, Balkanskaya SV, Uvakina YeV. Pediatricheskaya farmakologiya. 2009;6(3):74-9. Russian.
22. Gromova OA, Torshin lYu, Kalacheva AG, et al. Farmateka. 2009;10:63-8. Russian.
23. Gromova OA, Skoromets AN, Yegorova YeYu, et al. Pediatrics. 2010;89(5):142-9. Russian.
24. Nogovitsina OR, Levitina YeV. Experiment. i klin. farmakologiya. 2006;69(1):74-7. Russian.
25. Akarachkova YeS. Hardyy patsiyent. 2007;5:36-42. Russian.

Attention deficit hyperactivity disorder (ADHD), similar to ICD-10 hyperkinetic disorder), is an evolving neuropsychiatric disorder in which there are significant problems with executive functions (for example, attention-related control and inhibitory control) that cause attention deficit hyperactivity or impulsiveness inappropriate for the person's age. These symptoms may begin between the ages of six and twelve and persist for more than six months from the time of diagnosis. In school-aged subjects, symptoms of inattention often lead to poor school performance. While this is uncomfortable, particularly in today's society, many children with ADHD have good attention spans for tasks they find interesting. Although ADHD is the most well-studied and diagnosed psychiatric disorder in children and adolescents, the cause is unknown in most cases.

The syndrome affects 6-7% of children when diagnosed using the criteria of the manual for the diagnosis and statistical accounting of mental illness, revision IV and 1-2% when diagnosed using the criteria. The prevalence is similar among countries, depending largely on how the syndrome is diagnosed. Boys are approximately three times more likely to be diagnosed with ADHD than girls. About 30-50% of people diagnosed in childhood have symptoms in adulthood, and approximately 2-5% of adults have the condition. The condition is difficult to distinguish from other disorders, as well as from a state of normal increased activity. Management of ADHD usually involves a combination of psychological counseling, lifestyle changes, and medications. Medications are only recommended as first-line treatment in children who show severe symptoms and may be considered for children with moderate symptoms who refuse or do not respond to psychological counseling.

Therapy with stimulant drugs is not recommended for preschool children. Treatment with stimulants is effective up to 14 months; however, their long-term effectiveness is not clear. Adolescents and adults tend to develop coping skills that apply to some or all of their disabilities. ADHD, its diagnosis and treatment have remained controversial since the 1970s. The controversy spans practitioners, teachers, politicians, parents and the media. Topics include the cause of ADHD and the use of stimulant drugs in its treatment. Most of medical workers recognize ADHD as a congenital disorder, and the debate in the medical community is largely focused on how it should be diagnosed and treated.

Signs and symptoms

ADHD is characterized by inattention, hyperactivity (an agitated state in adults), aggressive behavior, and impulsivity. Often there are learning difficulties and relationship problems. Symptoms can be difficult to define as it is difficult to draw the line between normal levels of inattention, hyperactivity, and impulsivity and significant levels requiring intervention. DSM-5-diagnosed symptoms must have been present in a variety of settings for six months or more, and to a degree that is significantly greater than in other subjects of the same age. They can also cause problems in a person's social, academic and professional life. Based on the symptoms present, ADHD can be divided into three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and mixed.

A subject with inattention may have some or all of the following symptoms:

Easily distracted, missing details, forgetting things, and frequently switching from one activity to another

He finds it difficult to keep his attention on the task

The task becomes boring after only a few minutes if the subject is not doing something pleasurable.

Difficulty focusing on organizing and completing tasks, learning new things

Has trouble completing or turning in homework, often loses items (eg, pencils, toys, assignments) needed to complete an assignment or activity

Doesn't listen when talking

Soaring in the clouds, easily confused and moving slowly

Has difficulty processing information as quickly and accurately as others

Difficulty following instructions

A subject with hyperactivity may have some or all of the following symptoms:

Restlessness or fidgeting in place

Talks non-stop

Throws at everything, touches and plays with everything in sight

Difficulty sitting during lunch, in class, doing homework and while reading

Constantly on the move

Difficulty doing quiet tasks

These symptoms of hyperactivity tend to disappear with age and turn into “inward restlessness” in adolescents and adults with ADHD.

A subject with impulsivity may have all or more of the following symptoms:

Be very impatient

Spout inappropriate comments, express emotion without restraint, and act without regard for the consequences

Difficulty looking forward to the things he wants or looking forward to returning to the game

Frequently interrupts communication or activities of others

People with ADHD are more likely to have difficulty with communication skills, such as social interaction and education, and maintaining friendships. This is true for all subtypes. About half of children and adolescents with ADHD exhibit social withdrawal compared to 10-15% of non-ADHD children and adolescents. People with ADHD have an attention deficit that causes difficulty with verbal and non-verbal language, which negatively affects social interaction. They may also fall asleep during social interaction and lose social stimulus. Difficulty managing anger is more common in children with ADHD, as are poor handwriting and slow speech, language, and motor development. While this is a significant inconvenience, particularly in today's society, many children with ADHD have good attention spans for tasks they find interesting.

Associated violations

In children with ADHD, other disorders are observed in about ⅔ of cases. Some common violations include:

1. Learning disabilities occur in approximately 20-30% of children with ADHD. Learning disabilities can include speech and language disorders, as well as learning disabilities. ADHD, however, is not considered a learning disability, but often causes learning difficulties.
2. Tourette's syndrome is more common among ADHD sufferers.
3. Oppositional defiant disorder (ODD) and conduct disorder (CD), which are observed in ADHD in approximately 50% and 20% of cases, respectively. They are characterized by antisocial behavior such as stubbornness, aggression, frequent temper tantrums, duplicity, lying and stealing. Approximately half of those with ADHD and ODD or CD develop antisocial personality disorder in adulthood. Brain scans prove that conduct disorder and ADHD are separate disorders.
4. Primary attention disorder, which is characterized by low attention and concentration, as well as difficulty staying awake. These children tend to fidget, yawn, and stretch, and have to be hyperactive in order to remain alert and active.
5. Hypokalemic sensory overstimulation is present in less than 50% of people with ADHD and may be the molecular mechanism for many ADHD sufferers.
6. Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the mixed subtype of ADHD are more likely to have a mood disorder. Adults with ADHD also sometimes have bipolar disorder, which requires careful evaluation to make an accurate diagnosis and treat both conditions.
7. Anxiety disorders are more common in ADHD sufferers.
8. Obsessive-compulsive disorder (OCD) can occur with ADHD and shares many of its characteristics with it.
9. Disorders caused by the use of psychoactive substances. Adolescents and adults with ADHD are at increased risk of developing a substance use disorder. Most of it is associated with alcohol and cannabis. The reason for this may be a change in the reinforcement pathway in the brain of subjects with ADHD. This makes ADHD more difficult to identify and treat, while serious problems associated with substance use are usually treated first due to the higher risk.
10. Restless legs syndrome is more common in people with ADHD and is often associated with iron deficiency anemia. However, restless leg syndrome may be just a subset of ADHD and requires precise evaluation to distinguish between the two disorders.
11. Sleep disorders and ADHD usually coexist. They can also occur as a side effect of drugs used to treat ADHD. In children with ADHD, insomnia is the most common sleep disorder, with behavioral therapy as the treatment of choice. Trouble falling asleep is common among ADHD sufferers, but more often they are deep sleepers and have significant difficulty waking up in the morning. Melatonin is sometimes used to treat children who have difficulty falling asleep.

There is an association with persistent bedwetting, slow speech and dyspraxia (DCD), with about half of people with dyspraxia having ADHD. Slow speech in people with ADHD may include problems with hearing impairments such as poor short-term auditory memory, difficulty following instructions, slow speed in processing written and spoken language, difficulty hearing in distracting environments such as in the classroom, and difficulty understanding read.

The reasons

The cause of most cases of ADHD is not known; however, environmental involvement is assumed. Certain cases are associated with a previous infection or brain injury.

Genetics

See also: Hunter-Farmer Theory Twin studies show that the disorder is often inherited from one parent, with genetics accounting for about 75% of cases. Siblings of children with ADHD are three to four times more likely to develop the disorder than siblings of non-ADHD children. Genetic factors are thought to be relevant to whether ADHD persists into adulthood. Usually several genes are involved, many of which directly affect dopamine neurotransmission. Genes involved in dopamine neurotransmission include DAT, DRD4, DRD5, TAAR1, MAOA, COMT, and DBH. Other genes associated with ADHD include SERT, HTR1B, SNAP25, GRIN2A, ADRA2A, TPH2, and BDNF. A common gene variant called LPHN3 is estimated to be responsible for approximately 9% of cases, and when this gene is present, people respond partially to the stimulant drug. Since ADHD is widespread, natural selection likely favors characteristic features, at least individually, and they may provide a survival advantage. For example, some women may be more attractive to male risk-takers by increasing the frequency of genes that predispose to ADHD in the genetic pool.

Since the syndrome is most common in children of anxious or stressed mothers, some have suggested that ADHD is an adaptation that helps children cope with stressful or dangerous environmental conditions, such as increased impulsivity and exploratory behavior. Hyperactivity can be useful from an evolutionary perspective in situations that involve risk, competition, or unpredictable behavior (such as exploring new places or finding new food sources). In these situations, ADHD can be beneficial to society as a whole, even if harmful to the subject himself. In addition, in certain environments, it can confer benefits on the subjects themselves, such as quick responses to predators or superior hunting skills.

Environment

Environmental factors are thought to play a lesser role. Alcohol use during pregnancy can cause fetal alcohol spectrum disorder, which may include ADHD-like symptoms. Exposure to tobacco smoke during pregnancy can cause problems with the development of the central nervous system and increase the risk of ADHD. Many children exposed to tobacco smoke do not develop ADHD or have only mild symptoms that do not reach the limit of a diagnosis. A combination of genetic predisposition and exposure to tobacco smoke may explain why some children exposed during pregnancy may develop ADHD while others do not. Children exposed to even low levels of lead or PCBs can develop problems that resemble ADHD and lead to a diagnosis. Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate has been associated with an increased risk; however, the evidence is not conclusive.

Very low birth weight, preterm birth, and early exposure to adverse factors also increase risk, as do infections during pregnancy, birth, and early childhood. These infections include, among others, various viruses (finnosis, varicella, rubella, enterovirus 71) and streptococcal bacterial infection. At least 30% of children with traumatic brain injury later develop ADHD, and about 5% of cases are associated with brain damage. Some children may react negatively to food coloring or preservatives. It is possible that certain colored foods may act as a trigger in those with a genetic predisposition, but the evidence is weak. The UK and the EU have introduced regulation based on these issues; The FDA didn't.

Society

A diagnosis of ADHD may be indicative of family dysfunction or a poor educational system rather than an individual's problems. Some cases may be explained by heightened educational expectations, with the diagnosis in some cases representing a way for parents to obtain additional financial and educational support for their children. The youngest children in a class are more likely to be diagnosed with ADHD, presumably because they lag behind their older classmates in development. Behavior typical of ADHD is more common in children who have experienced abuse and moral humiliation. According to social order theory, societies define the boundary between normal and unacceptable behavior. Members of the community, including physicians, parents, and teachers, determine which diagnostic criteria to use and thus the number of people affected by the syndrome. This has led to the present situation where the DSM-IV shows an ADHD level three to four times the ICD-10 level. Thomas Szas, who supports this theory, argued that ADHD was "invented, not discovered."

Pathophysiology

Current models of ADHD suggest that it is associated with functional impairments in several brain neurotransmitter systems, in particular those involving dopamine and norepinephrine. Dopamine and norepinephrine pathways, which originate in the ventral tegmental region and the locus coeruleus, target different regions of the brain and mediate many cognitive processes. Dopamine and norepinephrine pathways, which target the prefrontal cortex and striatum (particularly the pleasure center), are directly responsible for regulation of executive function (cognitive control of behavior), motivation, and reward perception; these pathways play a major role in the pathophysiology of ADHD. Larger models of ADHD with additional pathways have been proposed.

Structure of the brain

Children with ADHD have a general decrease in the volume of certain brain structures, with a proportionately large decrease in the volume of the left-sided prefrontal cortex. The posterior parietal cortex also shows thinning in ADHD subjects compared to controls. Other brain structures in the prefrontal-striate-cerebellar and prefrontal-striate-thalamic circuits also differ between people with and without ADHD.

Neurotransmitter pathways

It used to be thought that the increased number of dopamine transporters in people with ADHD was part of the pathophysiology, but the increased number appears to be related to adaptation to stimulant exposure. Current models include the mesocorticolimbic dopamine pathway and the coeruleus-noradrenergic system. Psychostimulants for ADHD effective treatment, since they increase the activity of neurotransmitters in these systems. Additionally, pathological abnormalities in the serotonergic and cholinergic pathways may be observed. Also relevant is the neurotransmission of glutamate, a dopamine cotransmitter in the mesolimbic pathway.

Executive function and motivation

Symptoms of ADHD include problems with executive function. Executive function refers to several mental processes that are required to regulate, control, and manage the tasks of daily life. Some of these impairments include problems with organization, timekeeping, excessive procrastination, concentration, execution speed, emotion regulation, and use short term memory. People generally have good long-term memory. 30-50% of children and adolescents with ADHD meet the criteria for executive function deficit. One study found that 80% of subjects with ADHD were impaired in at least one executive function task compared to 50% of subjects without ADHD. Due to the degree of brain maturation and the increased demand for executive control as people get older, ADHD disorders may not fully manifest until adolescence or even late adolescence. ADHD is also associated with motivational deficits in children. Children with ADHD have difficulty focusing on long-term rewards over short-term rewards and also show impulsive behavior towards short-term rewards. In these subjects, a large amount of positive reinforcement effectively increases performance. ADHD stimulants can increase resilience in children with ADHD equally.

Diagnostics

ADHD is diagnosed through an assessment of a person's childhood behavior and mental development, including ruling out exposure to drugs, medications, and other medical or psychiatric problems as explanations for symptoms. Feedback from parents and teachers is often taken into account, with most diagnoses made after the teacher has raised concerns about it. It can be seen as an extreme manifestation of one or more permanent human traits found in all humans. The fact that someone responds to medication does not confirm or rule out a diagnosis. Since brain imaging studies did not provide reliable results in subjects, they were only used for research purposes and not diagnosis.

The DSM-IV or DSM-5 criteria are often used for diagnosis in North America, while European countries generally use the ICD-10. At the same time, the DSM-IV criteria make the diagnosis of ADHD 3-4 times more likely than the ICD-10 criteria. The syndrome is classified as a developmental neurodevelopmental disorder. In addition, it is classified as a social conduct disorder along with oppositional defiant disorder, conduct disorder, and antisocial personality disorder. The diagnosis does not suggest a neurological disorder. Comorbid conditions that should be screened for include anxiety, depression, oppositional defiant disorder, conduct disorder, learning and speech impairment. Other conditions to be considered are other neurodevelopmental disorders, tics and sleep apnea. The diagnosis of ADHD using quantitative electroencephalography (QEEG) is an area of ​​ongoing research, although the value of QEEG in ADHD is not clear to date. In the United States, the Food and Drug Administration has approved the use of QEEG to estimate the prevalence of ADHD.

Diagnostics and statistical guidance

As with other psychiatric disorders, a formal diagnosis is made by a qualified professional based on a combination of several criteria. In the United States, these criteria are defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Illness. Based on these criteria, three subtypes of ADHD can be distinguished:

Predominantly inattentive ADHD (ADHD-PI) presents with symptoms including mild distractibility, forgetfulness, daydreaming, disorganization, low concentration, and difficulty completing tasks. Often people refer to ADHD-PI as "attention deficit disorder" (ADD), however, the latter has not been formally approved since the 1994 revision of the DSM.

ADHD predominantly hyperactive-impulsive type manifests as excessive anxiety and agitation, hyperactivity, difficulty waiting, difficulty staying still, infantile behavior; destructive behavior can also be observed.

Mixed ADHD is a combination of the first two subtypes.

This division is based on the presence of at least six of the nine long-term (lasting at least six months) symptoms of inattention, hyperactivity-impulsivity, or both. To be taken into account, symptoms must appear between the ages of six and twelve and be observed at more than one environmental stop (for example, at home and at school or at work). The symptoms must not be acceptable to children at this age, and there must be evidence that they cause school or work-related problems. Most children with ADHD have a mixed type. Children with the inattentive subtype are less likely to pretend or have difficulty getting along with other children. They may sit quietly but not paying attention, whereby difficulties may be overlooked.

International classifier of diseases

In the ICD-10, the symptoms of "hyperkinetic disorder" are similar to ADHD in the DSM-5. When a conduct disorder (as defined by ICD-10) is presented, the condition is referred to as hyperkinetic conduct disorder. Otherwise, the impairment is classified as activity and attention impairment, other hyperkinetic disorders, or unspecified hyperkinetic disorders. The latter are sometimes referred to as the hyperkinetic syndrome.

adults

Adults with ADHD are diagnosed according to the same criteria, including signs that may be present between the ages of six and twelve. Questioning parents or caregivers about how the person behaved and developed as a child may form part of the assessment; a family history of ADHD also contributes to the diagnosis. While the main symptoms of ADHD are the same in children and adults, they often manifest themselves differently, for example, excessive physical activity observed in children can manifest as a feeling of restlessness and constant mental activity in adults.

Differential Diagnosis

Symptoms of ADHD that may be associated with other disorders

Depression:

Feelings of guilt, hopelessness, low self-esteem, or unhappiness

Loss of interest in hobbies, ordinary activities, sex, or work

Fatigue

Too short, poor or excessive sleep

Appetite changes

Irritability

Low stress tolerance

Suicidal thoughts

unexplained pain

Anxiety disorder:

Restlessness or a persistent feeling of anxiety

Irritability

Inability to relax

overexcitation

easy fatigue

Low stress tolerance

Difficulty paying attention

Mania:

Excessive feeling of happiness

Hyperactivity

Leap of ideas

Aggression

Excessive talkativeness

Big crazy ideas

Decreased need for sleep

Unacceptable social behavior

Difficulty paying attention

Symptoms of ADHD such as low mood and low self-esteem, mood swings and irritability can be confused with dysthymia, cyclothymia or bipolar disorder, as well as borderline personality disorder. Some symptoms that are associated with anxiety disorders, antisocial personality disorder, developmental or mental retardation, or chemical dependency effects such as intoxication and withdrawal may overlap with some of the symptoms of ADHD. These disorders sometimes occur along with ADHD. Medical conditions that can cause ADHD symptoms include: hypothyroidism, epilepsy, lead toxicity, hearing loss, liver disease, sleep apnea, drug interactions, and traumatic brain injury. Primary sleep disturbances can affect attention and behavior, and ADHD symptoms can affect sleep. Thus, it is recommended that children with ADHD be monitored regularly for sleep problems. Sleepiness in children can lead to symptoms ranging from classic yawning and eye rubbing to hyperactivity with inattention. Obstructive sleep apnea can also cause ADHD-type symptoms.

Control

Management of ADHD usually involves psychological counseling and medication, alone or in combination. While treatment may improve long-term outcomes, this does not rule out negative outcomes in general. Drugs used include stimulants, atomoxetine, alpha-2 adrenergic agonists, and sometimes antidepressants. Dietary changes may also be helpful, with evidence supporting free fatty acids and reduced exposure to food coloring. Removing other foods from the diet is not supported by the evidence.

Behavioral Therapy

There is strong evidence for the use of behavioral therapy for ADHD, and it is recommended as a first-line treatment for those with mild symptoms or for preschool children. Physiological therapies used include: psychoeducational stimulus, behavioral therapy, cognitive behavioral therapy (CBT), interpersonal therapy, family therapy, school interventions, social skills training, parenting training, and neural feedback. The preparation and education of parents has short-term benefits. There is little high-quality research on the effectiveness of family therapy for ADHD, but the evidence suggests that it is equivalent to health care and better than placebo. There are some specific ADHD support groups as information sources that can help families deal with ADHD.

Social skills training, behavioral modification, and drugs may have limited benefits to some extent. The most important factor in alleviating late psychological problems such as major depression, delinquency, school failure, and substance use disorder is forming friendships with people who are not involved in delinquent activities. Regular exercise, in particular aerobic exercise, is an effective adjunct to the treatment of ADHD, although the best type and intensity is not currently known. In particular, physical activity causes better behavior and motor abilities without any side effects.

Medications

Stimulant drugs are the preferred pharmaceutical treatment. They have at least a short-term effect in about 80% of people. There are several non-stimulant medications such as atomoxetine, bupropion, guanfacine, and clonidine that can be used as alternatives. There are no good studies comparing different drugs; however, they are more or less equal in terms of side effects. Stimulants improve academic performance while atomoxetine does not. There is little evidence regarding its effect on social behavior. Drugs are not recommended for preschool children, as long-term effects in this age group are not known. The long-term effects of stimulants are generally unclear, with only one study finding beneficial effects, another finding no benefit, and a third finding harmful effects. Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate reduces the pathological abnormalities in brain structure and function found in subjects with ADHD.

Atomoxetine, due to the lack of addictive potential, may be preferable for those at risk of addiction to stimulant drugs. Recommendations for when to use drugs vary between countries, with the National Institute for Health and Excellence medical care The UK recommends their use only in severe cases, while US guidelines recommend the use of drugs in almost all cases. While atomoxetine and stimulants are generally safe, there are side effects and contraindications to their use.

Stimulants can cause psychosis or mania; however, this is a relatively rare occurrence. For those undergoing long-term treatment, regular check-ups are recommended. Stimulant therapy should be temporarily discontinued to assess the subsequent need for the drug. Stimulant drugs have the potential to develop addiction and dependency; Several studies suggest that untreated ADHD is associated with an increased risk of chemical dependency and conduct disorders. The use of stimulants either reduces this risk or does not affect it. The safety of these medicinal products during pregnancy has not been determined.

Zinc deficiency has been associated with symptoms of inattention, and there is evidence that zinc supplementation is beneficial for children with ADHD who have low zinc levels. Iron, magnesium, and iodine may also have an effect on ADHD symptoms.

Forecast

An 8-year study of children diagnosed with ADHD (mixed type) found that adolescents often have difficulty with or without treatment. In the US, less than 5% of subjects with ADHD receive a college degree, compared to 28% of the general population aged 25 and over. The proportion of children meeting the criteria for ADHD drops to about half within three years of diagnosis, regardless of the treatment used. ADHD persists in adults in about 30-50% of cases. Sufferers of the syndrome are likely to develop coping mechanisms as they grow older, thus compensating for previous symptoms.

Epidemiology

It is estimated that ADHD affects about 6-7% of people aged 18 and over when diagnosed using the DSM-IV criteria. When diagnosed using the ICD-10 criteria, the prevalence in this age group is estimated to be 1-2%. Children in North America have a higher prevalence of ADHD than children in Africa and the Middle East; this is presumably due to differing diagnostic methods rather than differences in the incidence of the syndrome. If the same diagnostic methods were used, the prevalence in different countries would be more or less the same. The diagnosis is made approximately three times more often in boys than girls. This gender difference may reflect either a difference in predisposition or that girls with ADHD are less likely to be diagnosed with ADHD than boys. The intensity of diagnosis and treatment has increased in both the UK and the US since the 1970s. This is presumably related initially to changes in the diagnosis of the disease and how willing people are to take medication, rather than to changes in the prevalence of the disease. Changes in diagnostic criteria in 2013 with the release of the DSM-5 are expected to have increased the percentage of people diagnosed with ADHD, especially among adults.

Story

Hyperactivity has long been part of human nature. Sir Alexander Crichton describes "mental agitation" in his book An Inquiry into the Nature and Origin of Mental Disorder, written in 1798. ADHD was first clearly described by George Still in 1902. The terminology used to describe the condition has changed over time and includes: in the DSM -I (1952) "minimal brain dysfunction", in DSM-II (1968) "hyperkinetic childhood reaction", in DSM-III (1980) "attention deficit disorder (ADD) with or without hyperactivity" . In 1987, it was renamed ADHD to the DSM-III-R, and the DSM-IV in 1994 reduced the diagnosis to three subtypes, ADHD of the inattentive type, ADHD of the hyperactive-impulsive type, and ADHD of the mixed type. These concepts were retained in the DSM-5 in 2013. Other concepts included "minimal brain damage" used in the 1930s. The use of stimulants for the treatment of ADHD was first described in 1937. In 1934, benzedrine became the first amphetamine drug approved for use in the United States. Methylphenidate was discovered in the 1950s and enantiopure dextroamphetamine in the 1970s.

Society and culture

controversy

ADHD, its diagnosis and treatment have been the subject of debate since the 1970s. Doctors, teachers, politicians, parents and the media are involved in the controversy. Opinions about ADHD range from being merely the extreme limit of normal behavior to being the result of a genetic condition. Other areas of controversy include the use of stimulant drugs and especially their use in children, as well as the method of diagnosis and the likelihood of overdiagnosis. In 2012, the UK National Institute for Health and Care Excellence, acknowledging the controversy, argues that current treatments and diagnostics are based on the prevailing academic literature.

In 2014, Keith Conners, one of the first advocates for disease confirmation, spoke out against overdiagnosis in an article in the NY Times. On the contrary, in 2014 a peer-reviewed review of the medical literature found that ADHD is rarely diagnosed in adults. Due to the widely varying intensity of diagnosis among countries, states within countries, races, and ethnic groups, several confounding factors other than the presence of ADHD symptoms play a role in diagnosis. Some sociologists believe that ADHD is an example of the medicalization of "deviant behavior" or, in other words, the transformation of a previously non-medical problem of school performance into one. Most medical professionals recognize ADHD as a congenital disorder, at least in a small number of people with severe symptoms. The controversy among healthcare professionals is mainly focused on diagnosing and treating a larger population of people with less severe symptoms.

In 2009, 8% of all US Major League Baseball players were diagnosed with ADHD, making the syndrome highly prevalent in this population. The raise coincides with the League's 2006 ban on stimulants, raising concerns that some players were faking or faking ADHD symptoms to get around the ban on stimulant use in sports.

ADHD is a polymorphic clinical syndrome, the main manifestation of which is a violation of the child's ability to control and regulate their behavior, which results in motor hyperactivity, impaired attention and impulsivity. I would like to put special emphasis on the word polymorphic, because in reality no two children with ADHD are the same, this syndrome has many faces and a wide range of possible manifestations.

This is a psychiatric disorder - contrary to popular myths, its cause is the features of the structure and functioning of the brain, and not poor education, allergies, etc. The real reason is either genetic factors (in the majority of cases) or perinatal damage to the central nervous system. That is why ADHD is a developmental disorder, and not just "innocent" features of the child's temperament, and its manifestations are present from early childhood, they are "built into" the child's temperament, and are not acquired over time and are not temporary. In this, ADHD differs from "episodic" psychiatric disorders such as depression, post-traumatic stress disorder, and others. We speak of a disorder because traits such as hyperactivity, impulsivity, and attention deficits are expressed inappropriately for the age of the child, and these traits lead to serious impairment of the child's functioning in the main areas of life.

This point needs additional explanation, since such features as physical activity, inattention, impulsivity are normal (especially in preschool and primary school age). In children with the so-called "active" temperament, these traits are more pronounced. However, if they generally do not create big problems for children and their environment - neither in the family, nor at school, nor among peers and do not lead to behavioral disorders, learning, social development So it's not about ADHD. ADHD is an extreme manifestation of the “active” temperament spectrum, in which hyperactivity, impulsivity, and attention disturbances are so pronounced that they significantly impede learning, social adaptation, and, in general, the psychological development of the child. This is a specific characteristic of ADHD because, unlike many other disorders with abnormal manifestations (such as hallucinations in schizophrenia), ADHD is more of a spectrum disorder, an overexpression of features that are also characteristic of normal behavior. This creates certain difficulties in diagnosis, especially in mild forms of ADHD, because the boundary between the norm and pathology is very conditional... In this, ADHD can be compared with other spectrum medical disorders, in particular, obesity - the boundaries between normal weight, overweight, and obesity as a disease are rather conditional; however, the reality of obesity as a disease cannot be underestimated or dismissed.

This feature of ADHD also gives a certain opportunity to destigmatize such children, allows parents and children to present this problem not as a psychiatric diagnosis-label indicating their "defectiveness" and "abnormality" (in Ukrainian society, as in the societies of most post-Soviet countries, the stigmatization of persons with psychiatric disorders is unfortunately very common), but rather as a disorder that is an extension of the spectrum of active temperament, while, of course, not downplaying either the reality of the disorder and the problems associated with it, or the importance of timely and effective intervention.

ADHD is a developmental disorder and can be compared to other developmental disorders such as mental retardation. With mental retardation, the level of intellectual development of the child is lower than that of peers, and this leads to difficulties associated with social adaptation, independence, etc. Growing up, such a child acquires new knowledge, his intellectual level rises, but still remains lower than that of his peers. With ADHD, control, the ability of the brain to organize and self-control behavior, is impaired. Accordingly, with age, this ability also improves in children with ADHD, but remains lower than in peers. According to recent studies (their detailed analysis is presented in the chapter on the etiology of the disorder), in children with ADHD, there is a delayed maturation of the functions of the frontal cortex. Studies have shown that their brain develops according to the same features and patterns as their peers, but the maturation of the functions of the frontal cortex is slower. In milder forms of ADHD (about 30-40% of the total) by adolescence, these children catch up with their peers, while in other cases, children with ADHD will have signs of impaired self-control in adulthood.

The spectrum of ADHD has led to different views in child psychiatry regarding the boundaries of the spectrum that can, in fact, be called a disorder. There are two most common diagnostic classifications, DSM-IV and ICD-10, which approach the diagnosis of ADHD in somewhat different ways. The boundaries of DSM-IV are broader and also include those milder forms of the disorder in which only symptoms of attention deficit or only hyperactivity-impulsivity are present. Accordingly, there are three subtypes of ADHD in this system: a combined form, a form with dominant attention impairment, and a form with dominant hyperactivity-impulsivity.

The ICD-10 criteria are more narrow, strict (in this system, the term hyperkinetic disorder is used as a synonym for ADHD) and cover only those more severe forms of the disorder that correspond to the combined form of ADHD according to DSM-IV.

It is not surprising that the DSM-IV system is used more often in clinical practice, because it allows the identification of milder forms of ADHD and the correct choice of correction methods, since these conditionally "mild" forms can nevertheless be accompanied by serious secondary problems and lead to significant impairment of the child's functioning. in the main areas of life.

However, the question of the existence of ADHD subtypes, their etiopathogenetic and prognostic differences is currently in the focus of scientific research, and in the near future this may lead to a new understanding of the nature of the disorder and its polymorphism, as well as to changes in the classification system.

Now it is important to realize that the essence of diagnostic labels is not to “hang” them on children, ceasing to see individuality in its uniqueness, but to be able to understand the characteristics of a particular child and know how to help him overcome difficulties. .

Diagnostic criteria for ADHD/hyperkinetic disorders according to the International Classification of Diseases (ICD-10, WHO, 1999)

/F90/ Hyperkinetic disorders

The disorders belonging to this group are characterized by early onset; a combination of excessively active, poorly controllable behavior with marked inattention and lack of perseverance in the child's tasks, and these characteristics of behavior are consistent in different situations and over time.

It is believed that constitutional anomalies play a key role in the genesis of these disorders, but their specific etiology is still unknown. AT last years to designate these syndromes, it was proposed to use the diagnostic term "attention deficit disorder". It was never implemented, because it implied the presence of knowledge about psychological processes that we do not yet possess. This term also assumed the inclusion in its scope of anxious, preoccupied, "dreamy" or apathetic children, who are also distinguished by reduced attention that arose in connection with completely different problems (disorders). Nevertheless, it is clear that, from a behavioral point of view, attention disorders are a central feature of hyperkinetic disorders.

Hyperkinetic disorders always begin early in development (usually within the first five years of life). Their main characteristics are the lack of persistence in activities that require the use of cognitive functions, and the tendency to move from one activity to another without completing the work begun. Along with this, disorganized, almost uncontrollable, excessive activity is typical. These problems usually continue throughout the school years and sometimes into adulthood, but many people with these disorders experience improvements in both behavior and attention.

These violations can be combined with many other deviations. Hyperactive children are often reckless and impulsive, prone to accidents and injury. Often they bring trouble and punishment upon themselves, more from a thoughtless violation of the rules than from conscious disregard for them or deliberate disobedience. In relationships with adults, these children are often characterized by social disinhibition, excessive swagger in communication, they lack natural caution and restraint. They are usually not popular with their peers, they are not liked, which can, in the end, lead to social isolation. Among these children, cognitive impairment is common, and specific delays in motor and speech development are disproportionately common.

The frequency of hyperkinetic disorders in boys is several times higher than in girls. Often, these disorders are accompanied by difficulty in reading (and/or other learning difficulties).

Diagnostic criteria

The main symptoms are impaired attention and excessive activity. Both of these must be present for a diagnosis to be made, and they must be present in more than one setting (eg, at home, in the classroom, in the clinic).

Violation of attention is expressed in the fact that the child interrupts the execution of tasks in the middle and does not complete the work begun, constantly moves from one lesson to another, and it looks as if he is losing interest in the previous case, being distracted by the next (although the results laboratory research do not always show a significant degree of sensory or perceptual distractibility). Such a deficit in persistence and attention should only be taken into account in the diagnosis if it is excessive for a child of that age and with an appropriate IQ.

Excessive activity implies excessive mobility and restlessness, especially in situations requiring relative rest. Depending on the situation, the child may run and jump, jump up when he should be sitting, talk and make too much noise, or move his arms and legs restlessly, twist and fidget in his chair. The standard for diagnosis should be the hyperactivity of the child compared to what is expected in the situation and with other children of the same age and level of intellectual development. This feature of behavior becomes especially noticeable in structured, organized situations that require a high level of self-control of behavior.

Accompanying symptoms are not sufficient or even necessary to establish a diagnosis, but help to confirm it. Disinhibition in social relationships, recklessness in situations of danger, and impulsive violation of social rules (manifested, for example, in the fact that the child interferes in the affairs of other people or interferes with them, “blurts out” the answer when the question has not yet been asked to the end, not can wait their turn) - all these features are characteristic of children with this disorder.

Characteristic behavioral problems should be characterized by early onset (before 6 years of age) and persistence over time. However, prior to school entry, hyperactivity is difficult to recognize due to wide range variants of the norm: only its most pronounced forms lead to the establishment of this diagnosis in preschool children.

conclusions

• The main manifestations of ADHD are hyperactivity, attention deficits, and impulsivity.
• In ADHD, these symptoms are expressed inappropriately for age and lead to significant impairment of the child's functioning in the main areas of life.
• ADHD is a spectrum disorder and represents the extremes of a continuum of "active" temperament and normal behavioral patterns in children.
• In order to accurately diagnose and differentiate between ADHD and normal behavior, diagnostic systems with well-defined criteria are used.
• The two main diagnostic systems DSM-IV and ICD-10 cover the spectrum of this disorder in slightly different ways: the former is broader, while the latter includes only the more severe forms of the disorder.

The medical and social significance of the problem of attention deficit hyperactivity disorder (ADHD) is extremely high, as a result of which this condition is in the sphere of professional interests not only of child neurologists, psychiatrists and pediatricians, but also of teachers and psychologists.

The Russian name ADHD is an adapted version of the English term "attention deficit/hyperactivity disorder". ADHD is a widespread condition among children who have reached senior preschool and school age. The fact that ADHD is not a disabling disease does not mean that it does not require therapy.

ADHD is the name for an etiologically heterogeneous group of behavioral disorders in children older than 5 years of age. These behavioral changes are accompanied by impaired attention and hyperactivity (in children older than five years), potentially leading to academic failure (learning disorders), antisocial behavior, and reduced quality of life. Currently, the neurobiological nature of ADHD has been established, and its pathogenesis has been partially studied.

According to modern concepts, the genetic mediation of ADHD is characteristic of 40% to 75% of cases of the disease. The biochemical substrate in the pathogenesis of ADHD is catecholamine metabolism disorders. Environmental and other factors (prematurity, low birth weight, maternal smoking during pregnancy, etc.) are recognized but considered less significant.

According to Zuddas A. et al. (2005), psychosocial environmental factors interact with genetic predisposition to ADHD to cause biological damage. ADHD can be considered as an outcome perinatal lesion nervous system or a defect in the formation of a stereotype of behavior in children with psychomotor development disorders. In the first case, there are environmental effects of the intrauterine environment (including hypoxia, exposure of the fetus to bacterial, viral, and other pathogens), and in the second, environmental factors play a major role in the postnatal life of the child.

Environmental factors presumably influencing the formation of ADHD can be conditionally divided, firstly, into endogenous and exogenous, and secondly, into prenatal and postnatal. The prenatal factors in the formation of ADHD include the following: gestational (aggravated obstetric and gynecological history, toxicosis, gestosis, threatened miscarriage, etc.), maternal smoking during pregnancy, birth trauma (obstetric), exposure of the fetus to infectious pathogens (viruses, bacteria, viral-viral and viral-bacterial associations), toxic effects on the fetus (heavy metals, intoxicants of plant and synthetic origin, etc.), intrauterine fetal hypoxia (acute and / or chronic), disorders of neurochemical and / or neurophysiological parameters of the central nervous system, Rhesus conflict (intrauterine formation of a stable titer of specific antibodies), intrauterine neuroinfections.

Postnatal factors in the formation of ADHD: prematurity, morphofunctional immaturity, intrauterine growth retardation (IUGR), artificial feeding, intranatal or postnatal anoxia/asphyxia/hypoxia, specific patterns of upbringing in the family, features of individual temperament, alimentary deficiencies (vitamins, minerals, other nutrients), imitative behavior of children, features of cerebral metabolism of various genesis (dopamine, serotonin, glucose, etc. ), morphometric features of the central nervous system (cerebellum, basal ganglia, other cerebral structures), dysfunctions of the thyroid gland and other endocrine organs, toxic factors, emotional difficulties in relations between parents, upbringing and living in out-of-family conditions ("institutional"), as well as treatment ADHD (medicated or non-medicated). There is an opinion that ADHD can be formed due to excessive consumption of sugar, food and drinks. industrial production containing in in large numbers extractives, preservatives and dyes. The impact on ADHD of many hours of television viewing from early childhood is no longer considered to be a significant factor.

Many authorities in the field of the study of ADHD recognize that children with this pathology have a number of features of cerebral structures and functions (lesion of prefrontal striato-thalamocortical structures). In ADHD, descending projections of catecholaminergic and serotonergic neurons are very likely to be involved in the pathological process.

The clinical manifestations of ADHD appear and change throughout an individual's life. ADHD is often part of a symptom complex that includes specific learning disabilities and other neurobiological disorders. Although ADHD was originally described as a disorder exclusively of childhood, it has now been confirmed that the condition can persist into adulthood.

American specialists present the standards for diagnosing ADHD in the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-IV), where ADHD is divided into 3 types based on the patient's behavioral characteristics (attention deficit-predominant type, predominantly hyperactive type, combined type). In the Russian Federation, it is customary to use the criteria not for DSM-IV, but for the International Classification of Diseases of the Xth Revision (ICD-10), which have some differences (see below).

The classic triad of ADHD includes hyperactivity, impulsivity, and inattention (attention deficit). Hyperactivity is manifested in children by an inability to sit still or focus on a task, with a visible presence motor activity. Upon reaching adulthood, these patients are characterized by motor restlessness and a tendency to simultaneously perform several tasks without completing them at once. Impulsivity is defined by the difficulty of prioritizing and suppressing immediate responses to environmental factors competing for attention with more significant matters and events. Inattention in children and adults is manifested in the inability to suppress their own behavioral response to less significant stimuli in family, school, work and social situations. As nervous system matures, hyperactivity and impulsivity become less problematic for the individual, although inattention remains a problem for many adults and often manifests itself in the form of violations of the strategy of using time.

Concomitant (comorbid) conditions in ADHD may include: disorders of emotional control (affective - dysrhythmia, depression, bipolar disorders, anxiety, panic disorders, obsessive-compulsive disorders); motor control disorders (ticosis - motor tics, vocal tics, Gilles de la Tourette syndrome; paroxysmal - usually primary generalized epilepsy of the absence type; sleep disturbances with periodic movements of the limbs); comfort disturbances (headaches such as migraine, enuresis, irritable bowel syndrome, etc.); violations associated with the use of intoxicants (inhalants, tobacco, alcohol, drugs, etc.); disorders with disruptive (destructive) behavior (three types: oppositional defiant, conductive disorders, antisocial behavior) (Table).

At the same time, it is proposed to pay attention to a score of 3 points if it occurs 6 times or more, as well as to the total score (if it is equal to 25 points or more).

Diagnostic criteria for ADHD according to ICD-10 are as follows:

Inattention/Attention Deficit (requires at least 6 signs):

Frequent inability to pay close attention to details or making careless mistakes in school curriculum, work or other activities;

Often fails to maintain attention on tasks or play activities;

It is often noticeable that the child does not listen to what is said to him;

The child is often unable to follow instructions or complete school work, daily activities, and workplace duties (not due to oppositional behavior or inability to understand instructions);

The organization of tasks and activities is often disturbed;

Often avoids or strongly dislikes tasks such as homework that requires constant mental effort;

Often loses items needed for certain tasks or activities, such as school items, pencils, books, toys, or tools;

Often easily distracted by external stimuli;

Often forgetful during daily activities.

Hyperactivity (requires at least three signs):

Often moves arms or legs restlessly or fidgets in place;

Leaves his seat in a classroom or other situation where he is required to remain seated;

Often begins to run or climb when it is inappropriate (in adolescence or adulthood, only a feeling of restlessness may be present);

Often inappropriately noisy in games or has difficulty spending leisure time quietly;

A persistent nature of excessive motor activity is found, which is not significantly influenced by social situations and requirements.

Impulsivity (requires at least one feature):

Often blurts out answers before questions are completed;

Often unable to wait in lines, wait their turn in games or group situations;

Frequently interrupts or interferes with others (for example, in other people's conversations or games);

Often talks too much without adequate response to social restrictions.

Symptoms depend on the type of ADHD. The diagnosis is established on the basis of characteristic complaints (of parents) and registration of signs of existing disorders (according to the criteria of the current ICD-10) not earlier than 5-6 years of age).

"Pure" forms of ADHD are not as common as the combination of ADHD with additional learning, motor and/or communication impairments.

Learning disorders are divided into the following main categories: reading disorders (dyslexia), counting disorders (dyscalculia), writing disorders (dysgraphia), and dysorthography (problems with character recognition and their arrangement, indispensable for spelling).

Motor skill impairments are predominantly limited to problems with the development of gross motor control (general awkwardness and clumsiness that does not allow one to engage in physical activity that requires a certain level of skill and preparedness).

Communication disorders in ADHD include the following 4 categories: expressive speech disorder, mixed receptive-expressive speech disorder, phonation disorders, and stuttering. These conditions occur in approximately 5-10% of school-age children.

It is believed that a child diagnosed with ADHD, as well as in the presence of manifestations of oppositional defiant behavior before the age of 10 years, has a high risk of developing an addiction to the use of intoxicants and antisocial behavior.

As patients with ADHD grow older, attention deficit gradually becomes the main problem; usually signs of hyperactivity and impulsivity gradually decrease.

The treatment of ADHD uses the principles of behavior modification as well as differentiated learning strategies. In a number of countries, pharmacological agents related to CNS stimulants (methylphenidate, dextroamphetamine, pemoline), tricyclic antidepressants (imipramine, desipramine), clonidine (central alpha2-agonist), newer antidepressants (bupropion) and anxiolytics (buspirone) are quite widely used. CNS stimulants (methylphenidate, amphetamines) were not registered in our country as of the beginning of 2010; the use of clonidine, antidepressants and anxiolytics has serious age restrictions and is accompanied by a large number of side effects.

A newer drug for the treatment of ADHD is atomoxetine, the therapeutic effect of which is based on the pre- and postsynaptic modulation of dopamine and norepinephrine at the receptor level. The drug atomoxetine (Strattera), the only purpose of which is the treatment of ADHD, has passed clinical trials, was registered in the Russian Federation in 2005 and managed to prove itself well in Russia.

Strattera is used from the age of 6, is available in the form of capsules (10, 18, 25, 40 and 60 mg each). The drug is intended for single (in the morning) or double (morning and late afternoon/early evening) intake. When administered to children weighing< 70 кг рекомендуется начальная доза 0,5 мг/кг, в дальнейшем терапевтическая доза наращивается до 1,2 мг/кг (не ранее чем через 3 дня); максимальная доза — 1,8 мг/кг или 120 мг/сут (не ранее чем через 2-4 недели после начала лечения). Для детей с массой тела >70 kg and adults, the initial dose is 40 mg / day, the therapeutic dose is 80 mg / day (not earlier than 3 days), the maximum dose is 120 mg / day (not earlier than 2-4 weeks after the start of therapy). The recommended duration of treatment should not be less than 6 months.

If it is not possible to provide treatment with atomoxetine, nootropic and / or neurometabolic agents, multivitamin preparations, as well as sedative and vascular agents are prescribed. Treatment of comorbid conditions is carried out in accordance with their leading manifestations.

Of the non-drug methods of treatment, in addition to psychotherapy methods, the biofeedback method is used, as well as diet therapy methods. So, Schnoll R. et al. (2003) consider that the nature of nutrition in the treatment of ADHD is an "often overlooked, but important" aspect. There are reasons to consider food allergy as a potential cause of the formation of hyperactivity. In the 1980s It has been shown that hypoallergenic diets with the exclusion of potentially allergenic whole foods led not only to the correction of ADHD symptoms, but also to an improvement in mood and a decrease in allergic symptoms. In addition, the observed patients showed improvement in other symptoms (headache, migraine, irritable bowel syndrome, motion sickness), suggesting an immunological component of the action of hypoallergenic diets. With ADHD, the Feingold "low salicylate" diet, based on the principle of maximum exclusion from the diet of foods with food additives, synthetic food colors, as well as sugar and artificial sweeteners, is most widely used. The Feingold Diet treatment regimen a diet that excludes foods containing natural salicylates (apples, apricots, cherries, blackberries, raspberries, strawberries, gooseberries, grapes and raisins, oranges and other citrus fruits, nectarines, plums and prunes, cucumbers, tomatoes, nuts, etc. ) . It is recommended to avoid food and dishes containing artificial flavors and dyes (ice cream, margarine, flour products of industrial production - except for bread, sweets, caramel, chewing gum, cloves, jams, jellies, smoked sausages and sausages, etc.). All carbonated drinks are excluded, as well as all types of tea. Feingold's low salicylate diet is accompanied by a limited intake of vitamin C (correction is required).

The fact that the consumption of sugar (sucrose) and foods high in it can cause ADHD was previously reported by Krummel D.?A. et al. (1996). Therefore, it is advisable to reduce the consumption of sweets, limit sugar (twice) and increase the proportion of more than complex carbohydrates with ADHD in school-age children.

Vitamin therapy is an essential element in the treatment of ADHD (prevention of vitamin deficiency conditions, correction of cognitive deficits). There is experience of the positive use of multivitamin preparations with lecithin in ADHD (the latter takes an active part in the transfer of physiologically active substances, including vitamins, through biological membranes).

As one of the options for vitamin therapy in the relatively recent past, "megavitamins" were considered (the appointment of vitamin preparations - niacinamide, ascorbic acid, calcium pantothenate and pyridoxine, in doses many times higher than the physiological need), but Cott A. (1977) and Varley C. ( 1984) demonstrated that such a tactic (the "orthomolecular" approach) does not lead to a significant reduction in the severity of ADHD, but can cause toxic effects (hypervitaminosis) . Therefore, in addition to the subsidies of ascorbic acid (affects the hydroxylation reactions) provided for in the Feingold diet, vitamins B12 and folates (affect transmethylation reactions), vitamin B6 (affect behavioral reactions) are used in neurodietology for ADHD.

Adequate treatment of ADHD (atomoxetine) contributes to the normalization of the behavioral pattern of patients and their academic performance. With age, the manifestations of ADHD can be partially leveled and / or transformed, not completely disappearing even after reaching adulthood.

Literature

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Attention deficit hyperactivity disorder (ADHD): etiology, pathogenesis, clinic, course, prognosis, therapy, organization of care (expert report). M.: CAF. 2007. 64 p.

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V. M. Studenikin,doctor of medical sciences, professor
S. V. Balkanskaya, Candidate of Medical Sciences
V. I. Shelkovsky,Candidate of Medical Sciences

NTsZD RAMS, Moscow