Attention-Deficit/Hyperactivity Disorder
Prevalence: 3-5% of all school-age children (5% is safest bet)
boys girls (3:1) ; maybe because inattentiveness comes to diagnostic attention less than impulsivity, and impulsivity maybe more common in boys.
Occurs across cultures
50-80% have symptoms that persist into adolescence, 2/3ds into adulthood
Diagnosis: note that symptoms MUST cause problems and most younger children have some inattentiveness that improves with age, so be careful with this label.
- multiple symptoms in 3 clusters: inattention, hyperactivity, and impulsivity for at least 6 months;
- symptoms must be present by age 7;
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INATTENTION Symptoms (must be present for 6 months to a degree that is maladaptive and inconsistent with developmental level):: |
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Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities: |
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Difficulty sustaining attention in tasks or play activities: |
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Often does not seem to listen when spoken to directly: |
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Often not follow through on instructions, finish homework or work assignments: |
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Difficulty organizing tasks and activities: |
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Avoids, dislikes, or is reluctant to do tasks that require sustained concentration such as schoolwork or homework: |
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Often loses things such as toys, assignments, tools: |
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Easily distractible by extraneous stimuli: |
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Often forgetful in daily activities: |
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HYPERACTIVITY Symtoms (requires 6 of the Hyperactivity and Impulsivity Symptoms for ADHD diagnosis) : |
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Often fidgets with hands or feet or squirms in seat: |
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Often leaves seat in classroom or other situations in which being seated is expected: |
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Often runs about or climbs excessively in inappropriate or has a feeling of restlessness: |
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Often has difficulty playing in or engaging in leisure activities quietly: |
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Often "on the go" as if driven by a motor: |
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Often talks excessively: |
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IMPULSIVITY Symtoms: |
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Often blurts out answers before questions have been completed: |
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Often has difficulty awaiting turn: |
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Often interrupts or intrudes on others: |
Time criteria:
Symptoms present before 7 years old:
Some symptoms present in 2 or more settings:
Significant impairment in social, academic, or occupational functioning:
Not because of another disorder:
- source: DSM-IV
- Note that the child may have difficulty following commands (not due to conduct disorder), and this may be particularly true with multiple commands, e.g., "get a loaf of bread, a can of peas, and some corn" is much more challenging than "get a loaf of bread."
Diagnostic Tools:
History from parents, child, and teacher; teacher maybe best source of information.
Rating scale for parents, teachers and child, e.g. Conner's
Behavioral Observation
Family History
Physical and neurological exam
Allied professionals
Psychological Testing
Speech and Language Evaluation
Symptom variability is a hallmark.
Low self-esteem, demoralization, and inability to take responsibility are also common.
May be socially "out of synch," (so called "butt-insky" behavior)
Multiple sources of information are critical: parents, teachers, and patient interview. Note that a child who is quiet and attentive during the interview may still suffer from ADHD.
Genetic: increased incidence in first degree relatives
Increased incidence in patients with family histories of ADHD and conduct disorder
Biological: neuroimaging shows changes in frontal lobe function
Associated Biological Insults
Comorbidity: ** The Rule in Child Psychiatry **
Oppositional Defiant Disorder - perhaps 50% of ADHD children have ODD
Conduct Disorder - prhaps 20%
Mood and Anxiety Disorders
Learning Disabilities - up to 20-40% of children with ADHD have LD
Communication Disorders - 10-20% have
Mental Retardation
Pervasive Developmental Disorders
Drug abuse
Thyroid disease
Mismatch of Expectations and Ability or Ability and Classroom Placement
Treatment: Although there is some controversy as to whether ADHD is overdiagnosed especially over the past few years in the United States, it is clear that failure to diagnose and treat severe cases leads to profound social, educational, and probably developmental disruption. A hyperactive child may miss critical cognitive and social milestones because of the disorder. Although it was once thought that children should take a "drug holiday" during the summer, that is no longer standard practice, since even the summer months when the child is out of school are crucial for social development.
Stimulants:
Oppositional Defiant Disorder
A chronic pattern of stubborn, negativistic, profvocative, hostile, defiant behavior that does NOT violate the rights of others or the basic rules of society.
Treatment: behavior modification and parent educational training
Treat co-morbid disorders such as ADHD
Conduct Disorder
Repetitive and persistent patterns of behavior which violate the rights of others and the rules of society. (You can think of conduct disorder as a juvenile form of adult antisocial personality disorder; it has a negative, fatalistic connotation.)
Treatment: