We searched PubMed for articles published between Jan 1, 1980, and March 1, 2019, with an emphasis on the previous 10 years. English and non-English language publications were considered in our search. We included primary and review articles resulting from these searches, along with relevant references cited within those articles. Given the broad scope, yet restricted space, of our review, we occasionally cite review papers in place of primary reports. We used the search terms: “ADHD”,
SeminarAttention-deficit hyperactivity disorder
Introduction
Attention-deficit hyperactivity disorder (ADHD), like other psychiatric syndromes, has been refined and developed over the past 50 years, from its first contemporary description in the Diagnostic and Statistical Manual of Mental Disorders (second edition; DSM-II) as a hyperkinetic reaction of childhood to its current inclusion in DSM-51 as a lifespan neurodevelopmental condition with specific criteria for children and adults, a change reflected in its counterpart, the International Classification of Diseases (11th revision; ICD-11).2 This process of diagnostic evolution has been the result of periodic review and reformulation shaped by both research and clinical drivers. From a research perspective, the ADHD diagnostic formulation can be considered a part of a larger working hypothesis about the nature and structure of the disorder.3 As such, this diagnostic formulation is tested against empirical evidence so that it represents an increasingly accurate approximation of nosological reality as reflected in established research findings. Because the primary purpose of diagnostic systems is to provide intuitive and implementable guides for clinical decision making, the threshold for diagnostic innovation is set high and the pace of diagnostic evolution has been incremental in nature.4 Furthermore, as diagnostic systems in psychiatry have adopted a descriptive or phenomenological approach, considerations of the underlying causes of ADHD have been excluded from this process of re-evaluation and refinement. However, this diagnostic framework might be set to change. Progress in the aetiology and pathophysiology of ADHD challenges our current ways of thinking about the condition, while raising the prospect of new and potentially more effective clinical approaches.
Developing a broader range of more effective clinical approaches for people with ADHD, through the use of scientific discoveries, represents an important goal for the field.
ADHD is a prevalent, impairing condition that is frequently comorbid with other psychiatric disorders and creates a substantial burden for the individual, their family, and the community.5 Medication-based treatment strategies have proven efficacious and cost-effective in the short term and a number of compounds are available, recommended, and widely used.6, 7 However, the long-term effectiveness of these treatments on key educational, vocational, and social outcomes remains uncertain.8, 9 Furthermore, such effects are compounded by low adherence, especially after extended use in adolescence.10 These limitations are probably the result of both biological and psychosocial processes (eg, the build up of medication tolerance, ADHD-related stigma, and social resistance to medication).8, 11 Clearly, there is a pressing need for better long-term treatments for ADHD. By changing the way the field thinks about the causes of ADHD, scientific progress might help stimulate the development of new strategies for increasing the effectiveness of current treatments or the evolution of new alternatives. This Seminar will explore the issue of long-term treatment in three sections. The first section provides an account of the consensus about the clinical condition of ADHD, its diagnosis, epidemiology, developmental course, and treatment. The second section presents an up-to-date overview of ADHD science, focusing on advancements in aetiology and pathophysiology. The final section briefly explores how some of the most important scientific discoveries are beginning to challenge conceptions of ADHD in specific ways and examines the prospect that they will encourage new clinical perspectives and approaches.
Section snippets
Diagnosis
ADHD is a clinical diagnosis requiring a detailed evaluation of current and previous symptoms and functional impairment. A full family, gestational, and developmental history should be taken.12 The American Psychiatric Association's DSM-5 defines ADHD in children (younger than age 17 years) as the presence of six or more symptoms in either the inattentive or hyperactive and impulsive domains, or both (panel 1). Fewer symptoms (ie, at least five symptoms in either domain) are required to meet
Scientific progress in understanding the causes of ADHD
Having reviewed the clinical consensus about ADHD as represented in DSM-5 and ICD-11, we now provide an overview of scientific developments in our understanding of the pathogenesis, causes, and pathophysiology of ADHD. Through this overview, we want to convey the great strides made by researchers in understanding the disorder. These developments will create a platform for our exploration of the ways in which science is challenging our conceptions of ADHD and how these insights might stimulant
What are the prospects for clinical advances in response to scientific advances?
In this final section, we briefly discuss four means by which scientific findings are challenging the way ADHD is conceptualised and explore the prospect that these can improve the diagnosis and treatment of ADHD in the future.
Conclusions
ADHD is a common, highly heritable, and impairing condition. Efficacious treatments are available but limited in many ways. We believe that the enormous strides made over the past 10 years by scientists in understanding the nature and causes of ADHD challenge accepted models of ADHD and might have the potential to encourage new clinical improvement. However, this advancement will take both time and considerable investment to identify the specific processes and systems to target, develop new and
Search strategy and selection criteria
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