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Attention Deficit Hyperactive Disorder (ADHD)
is characterized by developmentally inappropriate poor attention
span, hyperactivity and impulsivity, or both. There are three types: combined,
inattentive, and the hyperactive.
Epidemiology
Incidence: 2-20% of grade school children in the
U.S.
3:1 Males to female ratio
Causative factors include prenatal/perinatal
insults, prenatal drug and alcohol exposure, and lead poisoning
ADHD children show an increased incidence of
sociopathy, alcohol use, and conversion disorders throughout life
Etiology
Exact cause unknown
Greater concordance in monozygotic twins as
compared to dizygotic twins
PET scans show decreased glucose metabolism in
frontal/prefrontal cortex
Dopamine, norepinephrine and serotonin thought to
be involved
Psychological factors – emotional deprivation,
stressful events, disrupted family dynamic can all induce and perpetuate ADHD
Clinical Features
Inattentive, distractible, impulsive
Explosive and irritable
Difficulty delaying gratification
75% of ADHD children show symptoms of aggression
and defiance
Diagnostic Criteria (DSM IV)
A. Either 1 or 2:
1. Six or more of the following symptoms of
inattention have persisted for at least six 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 when 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 difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as homework)
g. Often loses things necessary for tasks or activities (toys, school
assignments, pencils, books, or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
2. Six or more of the following symptoms of
hyperactivity-impulsivity have persisted for at least six 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 in which 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 before questions have
been completed
h. Often has difficulty awaiting turn
i. Often interrupts or intrudes on others (such as butting into conversations or
games)
B. Some
hyperactive, impulsive, or inattentive symptoms that caused impairment were
present before age 7 years
C. Some
impairment from the symptoms is present in two or more settings (such as in
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 another psychotic disorder and are not better
accounted for by another mental disorder (such as a mood, anxiety, dissociative,
or personality disorder)
ADHD Types Using DSM-IV criteria
ADHD, predominantly inattentive type meets
inattention criteria (section A1) for the past 6 month
ADHD, predominantly hyperactive-impulsive type
meets hyperactive-impulsive criteria (section A2) for the past 6 month
ADHD, combined type meets criteria for section A1
and section A2 for the past 6 month
ADHD, not otherwise specified, prominent symptoms
of inattention or hyperactivity-impulsivity that do not meet the criteria for
ADHD in partial remission
Differential Diagnosis (note the following
conditions may also be co-morbid with ADHD)
• Anxiety disorders
• Depression
• Conduct disorders
• Adjustment disorder
• Learning disorder
• Other: hearing
problems, impaired vision, poor nutrition, and thyroid dysfunction
Treatment
• Stimulants –
methylphenidate, dextroamphetamine, pemoline; effective in 90%
• SSRI or mixed
mechanism antidepressants (i.e., Welbutrin)
• Clonidine – used as
adjunct to stimulant
• Psychotherapy – note:
medication rarely sufficient by itself |
