Improve the medical assessment of young people with ADHD: II. Genetic, psychosocial or metabolic issues?

A good understanding of the origin of symptoms is essential to ensure the optimization of therapeutic treatments. This article proposes a critical re-evaluation of the behaviours associated with attention deficit hyperactivity disorder (ADHD) to avoid over-diagnosis and over-medication as observed in Quebec. We explore in depth the pathophysiological, nutritional, environmental and behavioral factors that may contribute to the emergence and persistence of symptoms-like of ADHD presented as a neurodevelopmental disorder of genetic origin. It appears that in fact, the symptoms may reflect a multifactorial imbalance, affecting dopaminergic and noradrenergic neurotransmission. However, it is important to consider the essential role of nutrition in neurotransmitter synthesis, as deficiencies in amino acids, vitamins, minerals, and essential fatty acids can impair executive and attentional functions. Among the factors of vulnerability, it is necessary to consider the long-term consequences of child malnutrition on cognitive functioning. In optimal therapeutic management, it is therefore necessary to consider the symptoms of ADHD on the continuum of metabolic dysfunction, associated with conditions such as insulin resistance, glycemic fluctuation, childhood obesity and disorders of the gut microbiota. These imbalances affect neuroinflammation, neuronal energy production, and neurotransmitter synthesis. In this sense, it seems important to consider the role of the microbiota and intestinal permeability in the appearance of symptoms associated with ADHD, evoking elimination diets and the effect of dyes/additives on behavior, emphasizing the importance of personalizing the approach for everyone. Finally, sleep-disordered breathing in children, which has multiple causes, is also common among children with ADHD and can exacerbate neurocognitive symptoms. To ensure optimal therapeutic direction, it is therefore recommended to evaluate nutritional, metabolic, digestive, respiratory and environmental factors before making a diagnosis of ADHD. All in all, mental health should not be considered as an isolated entity, but as the expression of a neuro-metabolic imbalance modulated by lifestyle habits on which it is possible to act effectively.