II. Epidemiology

  1. Prevalence
    1. Diagnosed at one point in up to 11% of school children ages 4 to 17 years old (1-2 per classroom)
      1. At a given time 8.8% of school children have the diagnosis and 6.1% are on medication
      2. Visser (2014) J Am Acad Child Adolesc Psychiatry 53(1): 34-46 [PubMed]
    2. More commonly diagnosed in boys than girls (4 - 8:1)
      1. However girls are more often of the inattentive type, and may be underdiagnosed
    3. First degree relative with ADHD increases patient risk by 2-8 fold
  2. Overlap with other Learning Disability
    1. Other Learning Disability: 10% of children with ADHD
    2. Learning disabled children with ADHD: 33%

III. Risk Factors

  1. Family History
  2. Preterm birth (OR 1.6) with higher risk in more severe prematurity
  3. Maternal Tobacco Abuse
  4. Maternal hypertensive disorder

IV. Pathophysiology

  1. Neurobehavioral disorder of
    1. Inattention
    2. Distractibility
    3. Impulsivity
    4. Hyperactivity
  2. Associated problems
    1. Academic problems
    2. Social problems
    3. Emotional problem

V. Signs: Inattention and Distractibility

  1. Greatest for tasks requiring vigilance
  2. Poor persistence in tasks without appeal
  3. Poor organization and follow-through
  4. Parents report:
    1. "Doesn't listen"
    2. "Can't concentrate and easily distracted"
    3. "Can't work without supervision"
    4. "Fails to finish tasks"
    5. "Daydreams, confused, in a fog"
    6. "Loses things"

VI. Signs: Impulsivity

  1. Risk taking
  2. Can't wait
  3. Parent's Report
    1. "Won't share"
    2. "Constantly interrupts"
    3. "Doesn't think first"
    4. "Has to be first"
    5. "Reacts emotionally"

VII. Signs: Hyperactivity/Overactivity

  1. Speech overactivity, interrupting
  2. Motor overactivity, fidgeting
  3. Overactivity may be situational
  4. Parent's Report
    1. "Always on the go"
    2. "Constantly talking"
    3. "Loud"
    4. "Won't settle down"

VIII. Associated Conditions

  1. School failure (held back a grade)
  2. Poor planning, organization and task performance
  3. Speech and language problems
  4. Poor motor coordination
  5. Enuresis
  6. Insatiability
  7. High stimulus seeking
  8. Low frustration tolerance
  9. Emotional problems as listed below may coexist

IX. History

  1. Consider other organic abnormality
    1. See ADHD Differential Diagnosis
    2. Perinatal complications
      1. Maternal Substance Abuse (e.g. Tobacco Abuse, Alcohol Abuse, Drug Abuse)
      2. Preterm delivery
      3. Low birth weight
      4. Maternal hypertensive disorder
    3. Developmental Delay (esp. language, speech)
    4. Vision or Hearing Deficits
    5. Medical history
    6. Family History of Attention Deficit Disorder
      1. First degree relative with ADHD increases patient risk by 2-8 fold
  2. Consider Learning Disability
    1. Ask educational history
      1. Is child reading at grade level?
      2. Is child's language at grade level?
      3. School grades
    2. Consider cognitive testing
  3. Consider home environment
    1. Assess family stressors (e.g. financial, illness, single parent)
    2. Assess family coping mechanisms
  4. Behavioral disorders
    1. School Truancy or absenteeism
    2. Legal problems
    3. What is child's temperament
  5. Consider comorbid psychiatric condition (comorbidity present in up to one third of ADHD patients)
    1. Major Depression or Anxiety Disorder
      1. Excessive crying or worry
      2. Preoccupation with death or Suicide
    2. Conduct Disorder
      1. Cruelty toward people or animals
      2. Destruction of property or stealing
      3. Delinquent behavior
    3. Oppositional Defiant Disorder
      1. Frequent rule breaking or arguments with adults
      2. Frequently loses temper
    4. Tourette's Syndrome
      1. Repetitive vocal or Motor Tics
    5. Sexual abuse history
      1. Inappropriate sexual behavior
  6. Other neurologic disorders
    1. Seizure Disorder
    2. Head Trauma
    3. CNS Infection
    4. Tic Disorder
  7. Other contributing conditions
    1. See ADHD Comorbid Conditions
    2. Sleep problems (e.g. Obstructive Sleep Apnea, Insomnia)

X. Examination

  1. Complete Physical exam
  2. Emphasis areas
    1. Vital Signs
    2. Hearing Screening
      1. Formal Audiogram if failed Hearing screening
    3. Vision Test
    4. Height, weight and Body Mass Index
      1. Review in context of prior growth curves
    5. Thyroid Examination
    6. Cardiovascular examination
    7. Neurological exam
      1. Observe for verbal or Motor Tics
      2. Evaluate fine motor tasks and coordination
    8. Neurocutaneous lesions (e.g. Neurofibromatosis)
  3. Observation
    1. Distractibility
    2. Fidgeting
    3. Hyperactivity
    4. Interpersonal interactions
    5. Loud speech
    6. Interrupts

XI. Diagnostics

  1. Lab tests or imaging are not routinely recommended unless dictated by history or examination
  2. Electrocardiogram (EKG)
    1. Not required prior to starting Stimulant Medications, unless specific indications
    2. EKG Indications (and consider cardiology Consultation)
      1. Heart disease
      2. Palpitations
      3. Syncope
      4. Seizure Disorder
      5. Family History of Sudden Cardiac Death
      6. Wolff-Parkinson-White Syndrome (WPW Syndrome)
      7. Hypertrophic Cardiomyopathy
      8. Long QT Syndrome
      9. Perrin (2008) Pediatrics 122(2): 451-3 [PubMed]

XII. Diagnosis

  1. See ADHD Diagnosis
  2. See ADHD Differential Diagnosis
  3. See ADHD Comorbid Conditions
  4. Attention Deficit Disorder cannot be reliably diagnosed under age 4 years old

XIII. Management: General

XIV. Management: Follow-up

  1. Medication list
  2. Medication side effects
  3. Medication Compliance
  4. Target Symptom Effect (choose 3 symptoms to follow)
  5. Track Medication dispensed
  6. Document Informed Consent by Parents, Guardian

XV. Prognosis

  1. Life long disorder
  2. Hyperactivity decreases
  3. Other features continue into adulthood in 50-60%
    1. Academic difficulty
    2. Social problems
    3. Conduct problems
    4. Accidents and risk taking

XVI. Complications

  1. Poor academic performance and higher school drop-out rates
  2. Motor Vehicle Accidents
  3. Substance Abuse
  4. Difficult personal relationships

XVII. Resources

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Attention Deficit Disorder (C0041671)

Definition (NCI) A mental disorder characterized by inattention, easy distraction, careless mistakes and avoidance of tasks that require sustained mental focus. These behaviors can lead to maladaptive consequences in the affected individual's life.
Definition (PSY) A disorder characterized by persistent developmentally inappropriate inattention and impulsivity.
Definition (CSP) behavior disorder originating in childhood in which the essential features are signs of developmentally inappropriate inattention, impulsivity, and hyperactivity; although most individuals have symptoms of both inattention and hyperactivity-impulsivity, one or the other pattern may be predominant; symptoms often attenuate during late adolescence although a minority experience the full complement of symptoms into mid-adulthood.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D001289
English Attention-Deficit Disorder NOS, Attention Deficit Disorders, Attention deficit disorder, Deficit Disorder, Attention, Deficit Disorders, Attention, Disorder, Attention Deficit, Disorders, Attention Deficit, Attention deficits, ATTENTION DEFICIT DIS, ADD - Attention deficit disord, ADD - Attention deficit disorder, Attention deficit, attention deficit disorder add, attention deficit disorder, attention deficit disorders, attention-deficit disorder, add attention deficit disorder, ADD, deficit; attention, disorder; attention deficit, Attention Deficit Disorder
Dutch aandachtstekortstoornis, stoornis; aandachtstekort, tekort; aandacht, Aandachtstekortstoornis
German Aufmerksamkeitsdefizitstoerung, Aufmerksamkeitsstörung, ADS, Aufmerksamkeitsdefizitsyndrom
Portuguese Perturbação de défice de atenção, Transtorno do Deficit de Atenção
Spanish Trastorno por déficit de atención, Trastorno por Déficit de Atención
Japanese 注意欠陥障害, チュウイケッカンショウガイ
French Déficit de l'attention, Trouble de déficit de l'attention, Trouble déficitaire de l'attention
Czech Porucha se zhoršenou pozorností, syndrom snížené pozornosti, ADD
Hungarian Figyelemhiányos betegség
Norwegian Oppmerksomhetsforstyrrelse
Italian Disturbo da deficit di attenzione, Disturbo da deficit d'attenzione

Ontology: Attention deficit hyperactivity disorder (C1263846)

Definition (MEDLINEPLUS)

Is it hard for your child to sit still? Does your child act without thinking first? Does your child start but not finish things? If so, your child may have attention deficit hyperactivity disorder (ADHD). Nearly everyone shows some of these behaviors at times, but ADHD lasts more than 6 months and causes problems in school, at home and in social situations.

ADHD is more common in boys than girls. It affects 3-5 percent of all American children.

The main features of ADHD are

  • Inattention
  • Hyperactivity
  • Impulsivity

No one knows exactly what causes ADHD. It sometimes runs in families, so genetics may be a factor. There may also be environmental factors.

A complete evaluation by a trained professional is the only way to know for sure if your child has ADHD. Treatment may include medicine to control symptoms, therapy, or both. Structure at home and at school is important. Parent training may also help.

NIH: National Institute of Mental Health

Definition (NCI) A disorder characterized by a marked pattern of inattention and/or hyperactivity-impulsivity that is inconsistent with developmental level and clearly interferes with functioning in at least two settings (e.g. at home and at school). At least some of the symptoms must be present before the age of 7 years.
Definition (MSH) A behavior disorder originating in childhood in which the essential features are signs of developmentally inappropriate inattention, impulsivity, and hyperactivity. Although most individuals have symptoms of both inattention and hyperactivity-impulsivity, one or the other pattern may be predominant. The disorder is more frequent in males than females. Onset is in childhood. Symptoms often attenuate during late adolescence although a minority experience the full complement of symptoms into mid-adulthood. (From DSM-IV)
Definition (PSY) A behavior disorder in which the essential features are signs of developmentally inappropriate inattention, impulsivity, and hyperactivity.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D001289
ICD9 314.9, 314.01, 314
ICD10 F90.9 , F90
SnomedCT 7461003, 154940006, 154952004, 192634008, 42584006, 154951006, 192126003, 192592000, 192134009, 192596002, 229717000, 192129005, 229713001, 406506008
DSM4 314.9, 314.01
English Attention Deficit Disorder with Hyperactivity, Attention Deficit Disorders with Hyperactivity, Attention Deficit Hyperactivity Disorder, Attention Deficit Hyperactivity Disorders, Hyperkinetic Syndrome, Syndromes, Hyperkinetic, Hyperkinetic syndrome of childhood, Unspecified hyperkinetic syndrome of childhood, Attention deficit disorder of childhood with hyperactivity, Attention-Deficit Disorder, Predominantly Hyperactive-Impulsive Type, Attention-Deficit/Hyperactivity Disorder NOS, Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type, HYPERKINETIC SYNDROME, Hyperactivity Disorder NOS, Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type, Hyperactive child syndrome, Att deficit hyperactivity dis, Attentn deficit hyperkin disor, Childhood hyperkinetic syndr., Childhood hyperkinetic syndrome, Hyperkinetic disorder, unsp, Hyperkinetic disorder, unspecified, [X]Hyperkinetic disorder, unsp, [X]Hyperkinetic disorder, unspecified, Hyperkinetic disorders, HYPERACTIVITY OF CHILDHOOD, ATTENTION DEFICIT-HYPERACTIVITY DISORDER, Attention deficit hyperactivity disorder (ADHD), ATTENTION DEFICIT HYPERACTIVITY DIS, ATTENTION DEFICIT DIS WITH HYPERACTIVITY, ADD - Attention deficit disorder with hyperactivity, ADD-Attn def dis with hyperact, ADDH, ADHD (attention deficit hyperactivity disorder), unspecified hyperkinetic syndrome of childhood (diagnosis), attention deficit hyperactivity disorder, hyperactive child syndrome, childhood hyperkinetic syndrome, unspecified hyperkinetic syndrome of childhood, attention-deficit hyperactivity disorder (diagnosis), ADHD (attention-deficit hyperactivity disorder), attention-deficit hyperactivity disorder, Attention deficit-hyperactivity disorder, Attention deficit/hyperactivity disorder, Attention deficit/hyperactivity disorder NOS, ADHD, predominantly hyperactive-impulsive type, Syndrome hyperkinetic, Hyperkinetic synd NOS, Attn deficit w hyperact, attention deficit disorder with hyperactivity, Attention-deficit hyperactivity disorders, Attention-deficit hyperactivity disorder NOS, Attention Deficit Disorder with Hyperactivity [Disease/Finding], minimal brain dysfunction, attention deficits disorder hyper, disorder hyperactivity, hyperkinetic disorder, attention deficit hyper disorder, hyperactivity disorder, addh, attention deficit(hyper) disorder, attention deficit hyperactivity disorder (ADHD), Attention deficit hyperactivity disorder, hyperactive impulsive type, Attention deficit disorder with hyperactivity, Unspecified hyperkinetic syndrome, Disorders, Attention Deficit-Hyperactivity, Deficit-Hyperactivity Disorders, Attention, Deficit-Hyperactivity Disorder, Attention, Attention Deficit-Hyperactivity Disorders, Attention Deficit-Hyperactivity Disorder, Disorder, Attention Deficit-Hyperactivity, ADD, Attention deficit disorder (disorder), Childhood hyperkinetic syndrome (disorder), Hyperkinetic syndrome NOS (disorder), Attention deficit disorder, [X]Hyperkinetic disorder, unspecified (disorder), Attention deficit-hyperactivity disorder (ADHD), Attention-deficit hyperactivity disorder, Attention deficit hyperactivity disorder, predominantly hyperactive impulsive type, Attention deficit hyperactivity disorder, predominantly hyperactive impulsive type (disorder), Hyperkinetic syndrome, Overactive child syndrome, Attention deficit hyperkinetic disorder, Hyperkinetic disorder, Attention deficit hyperactivity disorder (disorder), ADHD - Attention deficit disorder with hyperactivity, Attention deficit hyperactivity disorder, attention deficit disorder; with hyperactivity, child; hyperactivity, disorder; attention deficit, with hyperactivity (ADHD), disorder; hyperactivity, disorder; hyperkinetic, hyperactivity; child, hyperactivity; disorder, hyperkinetic; disorder, hyperkinetic; syndrome, syndrome; hyperkinetic, ADHD, Hyperkinetic syndrome NOS, attention deficit disorder, Disorder;attent deficit(hyper), hyperkinetic syndrome
Italian Disturbo da deficit di attenzione/iperattività, Sindrome del bambino iperattivo, ADHD, Sindrome ipercinetica non specificata dell'infanzia, Disturbo da deficit di attenzione-iperattività, Disturbo da deficit di attenzione associato ad iperattività, Disturbo da deficit di attenzione/iperattività NAS, Disturbo da deficit di attenzione dell'infanzia con iperattività, Sindrome ipercinetica dell'infanzia, Sindrome ipercinetica, Disturbi da deficit di attenzione con iperattività, ADHD, con predominanaza del tipo iperattivo-impulsivo, Disturbo da deficit di attenzione con iperattività
Dutch aandachtstekort-hyperactiviteitsstoornis NAO, hyperkinetisch syndroom, niet-gespecificeerd hyperkinetisch syndroom op kinderleeftijd, aandachtstekort-hyperactiviteitsstoornis, hyperkinetisch syndroom van de kinderleeftijd, syndroom hyperkinetisch, hyperactief kindsyndroom, ADHD, aandachtstekortstoornis met hyperactiviteit op kinderleeftijd, ADHD, overwegend hyperactief-impulsief type, Hyperkinetische stoornis, aandachtstekortstoornis; met hyperactiviteit, hyperactiviteit; kind, hyperactiviteit; stoornis, hyperkinetisch; stoornis, hyperkinetisch; syndroom, kind; hyperactiviteit, stoornis; aandachtstekort, met hyperactiviteit (ADHD), stoornis; hyperactiviteit, stoornis; hyperkinetisch, syndroom; hyperkinetisch, Hyperkinetische stoornis, niet gespecificeerd, aandachtstekortstoornis met hyperactiviteit, Hyperkinetische stoornissen, Aandachtstekortstoornis met hyperactiviteit, Syndroom, hyperkinetisch
French Hyperactivité avec déficit de l'attention, Trouble d'hyperactivité avec déficit de l'attention (ADHD), Trouble déficitaire de l'attention avec hyperactivité SAI, Syndrome d'hyperkinésie, Trouble déficitaire de l'attention de l'enfance avec hyperactivité, Syndrome d'hyperactivité de l'enfant, Syndrome hyperkinétique de l'enfance non précisé, Syndrome hyperkinétique de l'enfance, Trouble hyperkinétique, Trouble d'hyperactivité avec déficit de l'attention, SYNDROME D'HYPERKINESIE, ADHD, type prédominant hyperactif/impulsif, Déficit de l'attention/hyperactivité, Syndrome hyperkinétique, Déficit de l'attention avec hyperactivité, Syndrome de l'enfant hyperactif, Trouble de déficit de l'attention avec hyperactivité, Trouble déficitaire de l'attention avec hyperactivité, Déficit d'attention et hyperactivité, TDHA, THADA
German hyperkinetisches Syndrom des Kindesalters, Aufmerksamkeitsdefizit-Hyperaktivitaetsstoerung, ADDH, hyperaktives Kind-Syndrom, hyperkinetisches Syndrom, unspezifisches hyperkinetisches Syndrom des Kindesalters, Aufmerksamkeitsdefizitstoerung des Kindesalters mit Hyperaktivitaet, Aufmerksamkeitsdefizit/Hyperaktivitaetsstoerung NNB, Syndrom hyperkinetisch, ADHD, HYPERKINETISCHES SYNDROM, Hyperkinetische Stoerung, nicht naeher bezeichnet, Hyperkinetische Stoerungen, ADHD, vorwiegend hyperaktiv-impulsiver Typ, Aufmerksamkeitsdefizit/Hyperaktivitaetsstoerung, Hyperkinetisches Syndrom, ADHS, Aufmerksamkeitsdefizitsyndrom mit Hyperaktivität, Aufmerksamkeitsstörung mit Hyperaktivität
Portuguese Síndrome hiperquinética na infância, Síndrome hiperquinética, Perturbação de défice de atenção com hiperactividade, Perturbação de défice de atenção da infância com hiperactividade, Perturbação de défice de atenção/hiperactividade, Perturbação de défice de atenção/hiperactividade NE, Síndrome de criança hiperactiva, Síndrome hiperquinética NE da infância, Síndrome hipercinética, SINDROME HIPERCINETICO, ADHD, tipo predominantemente hiperactivo/impulsivo, Transtorno do Deficit de Atenção com Hiperatividade, Disfunção Cerebral Mínima, Transtorno da Falta de Atenção com Hiperatividade, ADHD, TDAH, Transtorno da Falta de Atenção, Défice de atenção/perturbação de hiperactividade, Síndrome Hipercinética, Transtorno de Hiperatividade e Falta de Atenção
Spanish Síndrome hipercinético de la infancia, Síndrome hipercinético no especificado de la infancia, Síndrome hipercinético, Síndrome hipercinético infantil, Trastorno por déficit de atención de la infancia con hiperactividad, Trastorno por déficit de atención con hiperactividad NEOM, HIPERCINETICO SINDROME, TDAH, con predominio hiperactivo-impulsivo, trastorno de hiperactividad con déficit de atención, con predominio de hiperactividad-impulsividad (trastorno), TDAH, con predominio hiperactivo - impulsivo, trastorno por déficit de atención con hiperactividad, con predominio hiperactivo - impulsivo, trastorno de hiperactividad con déficit de atención, con predominio de hiperactividad-impulsividad, trastorno por déficit de atención con hiperactividad, con predominio hiperactivo - impulsivo (trastorno), síndrome del niño hiperactivo, TDAH, síndrome hipercinético, SAI (trastorno), síndrome hiperquinético, SAI, trastorno por déficit de atención con hiperactividad (trastorno), [X]trastorno hipercinético, no especificado, síndrome hiperquinético, síndrome hipercinético, SAI, [X]trastorno hiperquinético, no especificado, [X]trastorno hipercinético, no especificado (trastorno), trastorno por déficit de atención con hiperactividad, Disfunción Cerebral Mínima, Perturbación de la Actividad y de la Atención, Trastorno o Síndrome Deficitario de la Atención con Hiperactividad, ADHD, Trastorno de Déficit de Atención con Hiperactividad, Trastorno de Hiperactividad con Déficit de Atención, Trastorno de Hiperactividad y Déficit de Atención, síndrome hiperquinético, SAI (trastorno), Trastorno por déficit de atención con hiperactividad, trastorno de hiperactividad con déficit de atención (trastorno), trastorno de hiperactividad con déficit de atención, Síndrome Hipercinético, Trastorno por Déficit de Atención con Hiperactividad, Trastorno Hipercinético con Déficit de la Atención
Japanese 過活動を伴う小児期の注意欠陥障害, 運動過多症候群, 注意欠陥多動性障害NOS, 過活動を伴う注意欠陥障害, ADHD, 小児の過活動症候群, 児童期の過動症候群、詳細不明, 小児期の運動過多症候群, チュウイケッカンタドウセイショウガイ, カカツドウヲトモナウショウニキノチュウイケッカンショウガイ, ショウニキノウンドウカタショウコウグン, チュウイケッカンタドウセイショウガイNOS, ウンドウカタショウコウグン, ショウニノカカツドウショウコウグン, ADHD, カカツドウヲトモナウチュウイケッカンショウガイ, ジドウキノカドウショウコウグンショウサイフメイ, 注意欠陥性行動異常障害, 注意欠損多動障害, 注意欠陥障害, 注意欠陥多動障害, 脳損傷-微細, 活動過剰性注意集中障害, 多動症候群, 注意不足活動亢進症, 最小脳機能不全, 微細脳損傷, ADHD、多動性−衝動性優勢型, ADHDタドウセイショウドウセイユウセイガタ, 注意欠陥多動性障害, 活動過剰性注意欠陥障害
Swedish ADHD
Finnish Aktiivisuuden ja tarkkaavuuden häiriö
Czech Syndrom hyperaktivního dítěte, Syndrom hyperkinetický, Hyperkinetický syndrom v dětství, Blíže neurčený hyperkinetický syndrom v dětství, Porucha se zhoršenou pozorností/hyperaktivitou NOS, Porucha se zhoršenou pozorností v dětství s hyperaktivitou, Porucha se zhoršenou pozorností/hyperaktivitou, Porucha se zhoršenou pozorností-hyperaktivitou, Porucha se zhoršenou pozorností a hyperaktivitou, Hyperkinetický syndrom, ADHD, převážně hyperaktivně-impulzivní typ, pozornost snížená spojená s hyperaktivitou, hyperkinetická porucha, ADHD, hyperkinetický syndrom
Korean 과운동성 장애, 상세불명의 과운동성 장애
Polish Zespół nadpobudliwości psychoruchowej, Zespół hiperkinetyczny, Zespół nadpobudliwości psychoruchowej z deficytem uwagi, Zaburzenia uwagi z nadpobudliwością, Zespół deficytu uwagi z nadruchliwością, Zespół minimalnego uszkodzenia mózgu, ADHD
Hungarian Figyelemhiányos/hyperactivitasos zavar, Gyermekkori figyelemhiányos zavar hyperactivitással, ADHD, Hyperkinetikus syndroma, ADHD, praedominalisan hyperactív-impulsív típus, Figyelemhiány-hiperaktivitás zavar, Hyperactiv gyermek syndroma, Hiperkinetikus tünetegyüttes, Gyermekkori hiperkinetikus tünetegyüttes, Figyelem hiányos hyperactivitas betegség, Figyelemhiányos/hyperactivitasos zavar k.m.n., A gyermekkor nem meghatározott hyperkinetikus syndromája
Norwegian Oppmerksomhetsforstyrrelse med hyperaktivitet, ADHD, Hyperaktivitet