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Attention Deficit Hyperactivity Disorder (ADHD) is characterized by developmentally-inappropriate inattention, impulsivity, or over-activity. It tends to manifest itself in early childhood. Individuals with ADHD show marked delays in academic and vocational achievement, poor social relationships, and performance with daily living skills. Diagnosis is complicated because the symptoms of this disorder overlap and co-occur with a variety of psychiatric, learning, medical, and social problems. Early recognition is important because undiagnosed, the individual's school performance, social adjustments, and self-esteem may be continually affected.
Epidemiology
1. In the United States, 5.4 million children between 6-17 years of age (9.5% of children) have been diagnosed with ADHD.
2. Prevalence of ADHD increased by 33% between 1997-1999 and 2006-2008.
* Some experts attribute this increase in ADHD prevalence to overdiagnosis
http://www.cdc.gov/ncbddd/adhd/timeline.html
Diagnosis
Evaluation for ADHD should include:
- interviewing child’s caregiver
- mental status examination of the child
- general health and neurological status exam
- cognitive assessment of ability and achievement
- use of ADHD-focused parent and teacher rating scales
- school reports and other adjunctive evaluations if necessary (speech, language assessment)
DSM-5 Criteria for ADHD
The American Psychiatric Association's Diagnostic and Statistical Manual, Fifth edition (DSM-5) is used to diagnose ADHD.
People with ADHD show consistent inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The criteria for diagnosis are as follows:
1. Inattention
- At least 6 of the following symptoms of inattention for children up to age 16, or at least 5 for adolescents 17 and older; symptoms have been present for at least 6 months:
- Fails to give close attention to details or makes careless mistakes
- Trouble holding attention on tasks or play activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- Trouble organizing tasks and activities.
- Reluctant to do tasks that require mental effort over a long period of time (e.g. homework
- Loses things necessary for tasks and activities (e.g. school materials)
- Easily distracted
2. Hyperactivity and Impulsivity
- At least 6 symptoms of hyperactivity-impulsivity for children up to age 16, or at least 5 for adolescents 17 and older; symptoms of hyperactivity-impulsivity have been present for at least 6 months:
- Fidgets or taps hands/feet, or squirms in seat
- Leaves seat in situations when remaining seated is expected
- Runs about or climbs in situations where it is not appropriate
- Unable to play or take part in leisure activities quietly
- Talks excessively
- Blurts out an answer before a question has been completed
- Has trouble waiting turn
- Interrupts others during conversations
- In addition, the following conditions must also be met:
- Several inattentive or hyperactive-impulsive symptoms were present before 12 years of age
- Several symptoms are present in two or more settings, (e.g. home, school or work)
- There is clear evidence that the symptoms interfere with social, school, or work functioning.
- The symptoms do not happen only during the course of schizophrenia or another psychotic disorder
Based on the types of symptoms, 3 different presentations of ADHD can occur:
1) Combined Presentation: if enough symptoms of both inattention and hyperactivity-impulsivity were present for the past 6 months
2) Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
3) Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Differential Diagnosis
Overlaps with learning disabilities, behavior and emotional problems. These disorders frequently coexist with ADHD and are not necessarily the cause of symptoms.
a. Developmental variations
1. cognitive impairment
2. learning disabilities
3. language disorders
4. gifted
5. normal variations
b. Medical disorders
1. Seizure disorders
2. lead poisoning
3. malnutrition
4. substance abuse
5. thyroid disorders- rare
6. Pervasive Developmental Delay (Autism)
7. Absence seizures
c. Emotional/Behavioral Disorders
1. Depression
2. Anxiety
3. Conduct disorders
4. Schizophrenia
5. Mania
6. Obsessional disorders
d. Environmental Disorders
1. Abuse
2. Stressful home environment
3. Poor parenting
Evaluation
A comprehensive evaluation is needed to confirm the complications of core symptoms and exclude any other explanations for symptoms or other co morbid disorders.
a. Physical examination including hearing and vision
b. Cognitive testing (IQ, WISC) and achievement tests
c. Diagnostic interviews with parents, child, and teachers
d. Behavior rating scales ( Connors )
e. Psychosocial evaluation: ADHD-specific rating scales (Vanderbilt)- has a sensitivity and specificity over 90% validated in a community setting.
f. Family history
g. There are NO routine labs, radiological evaluations, or EEGs necessary in most cases. If appropriate, ay rule out Fragile X, Lead poisoning, etc.
h. ADHD toolkit: Developed for Primary car practitioners to assist in the evaluation and management of children with ADHD. The toolkit has information for parents and ADHD specific questionnaires for parents teachers and initial primary care evaluation. Download at www.nichg.org/adhd.html (registration required).
Risk Factors
a. Family History
b.Comorbid conditions
1. Learning disabilities
2. Tourette's
3. Mood disorders
4. Oppositional defiant disorder
5. Conduct disorder
References
1. Dunne JE. Attention-Deficit/Hyperactivity Disorder and Associated Childhood Disorders. Primary Care; Clinics in Office Practice. 1999; 26(2):349-372.
2. Miller KJ. and Castellanos FX. Attention Deficit/Hyperactivity Disorders. Pediatrics in Review. 1998; 19:373-384.
3. Zametkin, Alan J. and Ernst, Monique Problems in the Management of Attention-Deficit-Hyperactivity Disorder. NEJM Jan.7, 1999
4. Diagnosis and Evaluation of the child with Attention Deficit/Hyperactivity Disorder. American Academy of Pediatrics Pediatrics May 2000 pp1158-1170
5. Rappley M.D. Attention Deficit -Hyperactivity Disorder NEJM Vol 352 No. 2 January 13, 2005
6. Floet A. et. al. Attention Deficit/Hyperactivity disorders. Pediatrics in Review. Feb. 2010
7. www.nichq.org/adhd.html
8. American Academy of Pediatrics. Clinical Practice Guidelines for Diagnosis, Evaluation, and Treatment of ASttention Deficit/Hyperactivity in Children and Adolescents. Pediatrics Nov 2011