Attention DeficitHyperactivity Disorder

Key Points

• Consider ADHD in a child presenting with hyperactivity, impulsivity, inattentiveness, academic underachievement, or behavior problems.

• Use the DSM-IV-TR diagnostic criteria when assessing for ADHD.

• Obtain information from the parents, child, and teacher, using standardized behavior reports, if possible.

• When planning treatment, recognize that ADHD is a chronic condition for which medication only temporarily decreases symptoms and improves functioning.

• Stimulants are the first and second lines of medication treatment.

Attention-defitit/hyperactivity disorder (ADHD) is the most frequently diagnosed behavioral disorder of childhood, with a prevalence of 4% to 12% (DSM-IV-TR, 2000). At least 10% of behavior problems seen in a general pediatric practice are caused by ADHD. Boys are seen more frequently than girls. ADHD should be considered and assessed in a child who presents with inattention, hyperactivity, impulsiv-ity, academic underachievement, or behavior problems (AAP, 2000; AHCPR, 1999). ADHD is a chronic disorder persisting from childhood into adolescence and adulthood. In general, symptoms decrease by half every 5 years between ages 10 and 25 (Goldman et al., 1998). Obvious hyperactivity disappears while inattention persists.

Research suggests that ADHD has a central nervous system (CNS) basis; however, no specific etiology has been discovered. Family genetic studies have shown up to 92% concordance in monozygotic twins and 33% concordance in dizygotic twins. Clinicians should keep in mind that the child's parents may also have ADHD. Various brain imaging studies of ADHD patients have demonstrated abnormalities of brain metabolism, supporting the validity of ADHD as a disorder. However, the strongest evidence of validity has been course prediction and treatment response to medication.

Box 24-2 DSM-IV-TR Diagnostic Criteria For Attention-Deficit/ Hyperactivity Disorder

1. Inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) Often has difficulty sustaining attention in tasks or play activities

(c) Often does not seem to listen to what is being spoken to directly

(d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

(e) Often has difficulties organizing tasks and activities

(f) Often avoids, strongly dislikes or is reluctant to engage in tasks (such as schoolwork or homework) that require sustained mental effort

(g) Often loses things necessary for tasks or activities (e.g., school assignments, pencils, books, tools, or toys)

(h) Is often easily distracted by extraneous stimuli

(i) Often forgetful in daily activities

2. Hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

(a) Often fidgets with hands or feet or squirms in seat

(b) Often leaves seat in classroom or in other situations in which remaining seated is expected

(c) Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) Often has difficulty playing or engaging in leisure activities quietly

(e) Is often "on the go" or often acts as if "driven by a motor"

(f) Often talks excessively Impulsivity

(g) Often blurts out answers to questions before the question has been completed

(h) Often has difficulty awaiting turn

(i) Often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before seven years of age.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work], and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder, and are not better accounted for by a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder.

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders, 4th ed, Text Revision (DSM-IV-TR). Washington, DC, American Psychiatric

Association, 2000.

Comorbidity is common in ADHD; 65% of children diagnosed with ADHD have more than one psychiatric diagnosis (Biederman et al., 1991), including about 30% with more than one comorbid condition. Of children diagnosed with ADHD, 35% also have oppositional defiant disorder; 25% have conduct disorder; 18% have a depressive disorder; 25% have an anxiety disorder; and 12% to 60% have a learning disorder (AHCPR, 1999).

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