Attention Deficit Disorder

Aka: Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, ADHD, Attentional Disorders, Attention Deficit Disorder in Children

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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
    1. Heterability rate as high as 74% based on family, adoption and twin studies
    2. Faraone (2019) Mol Psychiatry 24(4): 562-75 [PubMed]
  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

  1. See ADHD Non-Pharmacologic Management
  2. See ADHD Medications

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

  1. See ADHD Resources

XVIII. References

  1. Culbert (Dec 1993) Pediatrics in Review
  2. King (1999) Pediatric Subspecialty for Primary Care
  3. Sykora (2000) Capital Conference, Washington, DC
  4. Cantwell (1996) J Am Acad Child Adolesc Psychiatry 35 [PubMed]
  5. Chang (2020) Am Fam Physician 102(10):592-602 [PubMed]
  6. Felt (2014) Am Fam Physician 90(7): 456-64 [PubMed]
  7. Herrerias (2001) Am Fam Physician 63(9):1803-10 [PubMed]
  8. Smucker (2001) Am Fam Physician 64:817-32 [PubMed]

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