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 ETIOLOGY Associated conditions learning disabilities oppositional defiant disorder conduct disorder tic disorders substance abuse 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 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 DIAGNOSIS Clinical diagnosis by above DSM-V criteria must also rule out other comorbid psychiatric disorders such as learning disabilities, mood disorders, or substance abuse 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 Prognosis ~50% will have symptoms into adulthood