Updated: 4/23/2020

Attention-Deficit/Hyperactivity Disorder

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Snapshot
  • An 8-year-old boy is brought to the pediatrician by his mother for behavioral concerns. His mother states that she has always had trouble with him at home. He cannot sit still, he loses things all the time, and he is very disorganized. Sometimes when she reprimands him it seems like he is not even paying attention. He has also had trouble making friends. Recently, the patient's teacher called because he has not been turning in assignments, he blurts out things without being called on, and he disrupts the students next to him by talking. 
Introduction
  • Overview
    • a neurodevelopmental/psychiatric disorder characterized by hyperactivity, impulsivity, and inattention
  • Epidemiology
    • demographics
      • 10:1 male:female ratio
      • onset before age 12 years of age
  • Associated conditions
    • learning disabilities
    • oppositional defiant disorder
    • conduct disorder
    • tic disorders
    • substance abuse
  • Prognosis
    • 50% will have symptoms into adulthood
Presentation
  • Symptoms
    • 18 symptoms exist in the DSM-V (6 symptoms must be present in children and 5 in adults for diagnosis)
    • symptoms must 
      • occur in at least 2 different settings (e.g., home and school) 
      • be present before the age of 12
      • last for 6 months or longer
    • common symptoms: 
      • hyperactivity and impulsivity
        • excessive fidgetiness
        • difficulty remaining seated
        • feelings or restlessness or inappropriate running around
        • difficulty playing quietly
        • always seeming "on the go"
        • excessive talking
        • difficulty waiting turns
        • blurting out answers
        • interruption of others
      • inattention
        • makes careless mistakes
        • difficulty maintaining attention
        • seems not to listen
        • fails to follow through
        • difficulty organizing
        • avoids tasks that require consistent mental effort
        • loses objects
        • easily distracted
        • forgetful in routine activities
Studies
  • Clinical diagnosis by above DSM-V criteria
    • must also rule out other comorbid psychiatric disorders such as learning disabilities, mood disorders, or substance abuse
  • Hearing and vision test
    • to rule out hearing or visual impairments
  • Serum labs
    • thyroid hormone levels
      • consider in patient with other symptoms of thyroid disease
Treatment
  • Medical 
    • cognitive behavioral therapy
      • first-line for preschool-aged children (< 6 years of age)
      • adjunct therapy for school-aged children, adolescents, and adults
    • stimulants
      • first-line therapy for school-aged children (6 years of age or older)
        • methylphenidate 
        • dextroamphetamine
    • nonstimulants
      • second-line therapy for school-aged children
        • atomoxetine
          • prefered in cases of substance abuse
          • selective norepinephrine reuptake inhibitor
        • guanfacine
          • α2-agonist
        • clonidine
          • α2-agonist
        • others
          • bupropion, nortriptyline, and other selective serotonin reuptake inhibitors
 

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