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PediatricAttentionDeficitHyperactivityDisorder(ADHD):PracticeEssentials,Background,Pathophysiology

PediatricAttentionDeficitHyperactivityDisorder
(ADHD)
Author:MaggieAWilkes,MDChiefEditor:CarolyPataki,MDmore...
Updated:Apr07,2016

PracticeEssentials
Attentiondeficithyperactivitydisorder(ADHD)isadevelopmentalconditionof
inattentionanddistractibility,withorwithoutaccompanyinghyperactivity.

Signsandsymptoms
AccordingtotheDiagnosticandStatisticalManualofMentalHealthDisorders,Fifth
Edition(DSM5),the3typesofattentiondeficit/hyperactivitydisorder(ADHD)are
(1)predominantlyinattentive,(2)predominantlyhyperactive/impulsive,and(3)
combined.ThecurrentDSM5criteriaareprovidedbelow. [1]
Inattentive
Thismustincludeatleast6ofthefollowingsymptomsofinattentionthatmusthave
persistedforatleast6monthstoadegreethatismaladaptiveandinconsistentwith
developmentallevel:
Oftenfailstogivecloseattentiontodetailsormakescarelessmistakesin
schoolwork,work,orotheractivities
Oftenhasdifficultysustainingattentionintasksorplayactivities
Oftendoesnotseemtolistentowhatisbeingsaid
Oftendoesnotfollowthroughoninstructionsandfailstofinishschoolwork,
chores,ordutiesintheworkplace(notduetooppositionalbehaviororfailure
tounderstandinstructions)
Oftenhasdifficultiesorganizingtasksandactivities
Oftenavoidsorstronglydislikestasks(suchasschoolworkorhomework)that
requiresustainedmentaleffort
Oftenlosesthingsnecessaryfortasksoractivities(schoolassignments,
pencils,books,tools,ortoys)
Ofteniseasilydistractedbyextraneousstimuli
Oftenforgetfulindailyactivities
Hyperactivity/impulsivity
Thismustincludeatleast6ofthefollowingsymptomsofhyperactivityimpulsivity
thatmusthavepersistedforatleast6monthstoadegreethatismaladaptiveand
inconsistentwithdevelopmentallevel:
Fidgetingwithortappinghandsorfeet,squirminginseat
Leavingseatinclassroomorinothersituationsinwhichremainingseatedis
expected
Runningaboutorclimbingexcessivelyinsituationswherethisbehavioris
inappropriate(inadolescentsoradults,thismaybelimitedtosubjective
feelingsofrestlessness)
Difficultyplayingorengaginginleisureactivitiesquietly
Unabletobeoruncomfortablebeingstillforextendedperiodsoftime(may
beexperiencedbyothersasonthegoordifficulttokeepupwith)
Excessivetalking
Blurtingoutanswerstoquestionsbeforethequestionshavebeencompleted
Difficultywaitinginlinesorawaitingturningamesorgroupsituations
Interruptingorintrudingonothers(foradolescentsandadults,mayintrude
intoortakeoverwhatothersaredoing)
Other
Onsetisnolaterthanage12years
Symptomsmustbepresentin2ormoresituations,suchasschool,work,or
home
Thedisturbancecausesclinicallysignificantdistressorimpairmentinsocial,
academic,oroccupationalfunctioning
Disorderdoesnotoccurexclusivelyduringthecourseofschizophreniaor
otherpsychoticdisorderandisnotbetteraccountedforbymood,anxiety,
dissociative,personalitydisorderorsubstanceintoxicationorwithdrawal
SeeClinicalPresentationformoredetail.

Diagnosis
PsychometricandeducationaltestingisoftenimportantforthediagnosisofADHD.
Thepatient'sinitialhistorymayindicateaneedforadditionaltests,asfollows:

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PediatricAttentionDeficitHyperactivityDisorder(ADHD):PracticeEssentials,Background,Pathophysiology

ExaminechildrenbyusingtheConners'ParentandTeacherRatingScale
andexamineadolescentsaccordingtotheBrownAttentionDeficitDisorder
Scale(BADDS)forAdolescentsandAdults [2]
Assessimpulsivityandinattentionusingtimedcomputertestssuchasthe
ConnersContinuousPerformanceTest(CPT),theIntegratedVisualand
Auditory(IVA)CPT,orboth
AssessgirlsusingtheNadeau/Quinn/LittmanADHDSelfRatingScalefor
Girls
Assessthepatient'sexecutivefunctionbyusingvariousneuropsychological
tests
Performalearningdisabilityevaluation(intelligencequotient[IQ]vs
achievement)
SeeWorkupformoredetail.

Management
Behavioralandpharmaceuticalstrategiesarethe2majorcomponentsinthe
medicalcareofpatientswithADHD.
Behavioralinterventions
Behavioralpsychotherapyofteniseffectivewhenusedincombinationwith
medication. [3,4]Behavioraltherapyormodificationprogramscanhelpdiminish
uncertainexpectationsandincreaseorganization.Workingwithparentsandschools
throughbehavioralparenttrainingandbehavioralclassroommanagementtoensure
environmentsareconducivetofocusandattentionisnecessary.
Medicationregimens
PsychostimulantsareeffectiveinpatientswithADHD.However,complianceisan
issue,particularlyinchildren.Therefore,theuseoflongactingmedicationsatonce
adaydosingtotreatADHDhasbeenshowntohaveadvancesovershorteracting
drugs.Theirusehasbeenmarkedtohigherratesofremissionandbetter
adherence,andtheyhavebeendemonstratedtobelessstigmatizing.
SeeTreatmentandMedicationformoredetail.

Background
Thetermattentiondeficitismisleading.Ingeneral,thecurrentpredominating
theoriessuggestthatpersonswithattentiondeficithyperactivitydisorder(ADHD),
attentiondeficitdisorder(ADD),actuallyhavedifficultyregulatingtheirattention
inhibitingtheirattentiontononrelevantstimuli,and/orfocusingtoointenselyon
specificstimulitotheexclusionofwhatisrelevant.Inonesense,ratherthantoo
littleattention,manypersonswithADHD(ADD)paytoomuchattentiontotoomany
things,leadingthemtohavelittlefocus.
ThreebasicformsofADHD(ADD)aredescribedintheDiagnosticandStatistical
ManualofMentalDisorders,FifthEdition(DSM5)oftheAmericanPsychiatric
Association(APA). [1]Theyare(1)predominantlyinattentive,(2)predominantly
hyperactive/impulsive,and(3)combined.
Themajorneurologicfunctionsdisturbedbytheneurotransmitterimbalanceof
ADHD(ADD)fallintothecategoryofexecutivefunction.The6majortasksof
executivefunctionthataremostcommonlydistortedwithADHD(ADD)include(1)
shiftingfromonemindsetorstrategytoanother(ie,flexibility),(2)organization(eg,
anticipatingbothneedsandproblems),(3)planning(eg,goalsetting),(4)working
memory(ie,receiving,storing,thenretrievinginformationwithinshortterm
memory),(5)separatingaffectfromcognition(ie,detachingone'semotionsfrom
one'sreason),and(6)inhibitingandregulatingverbalandmotoricaction(eg,
jumpingtoconclusionstooquickly,difficultywaitinginlineinanappropriate
fashion).
Contrarytosomemediaaccounts,ADHD(ADD)isnotnew.Intheearly1900s,
diagnosisemphasizedthehyperactivitycomponent.Today,hyperactivity,impulsivity,
andinattentionaretheareasoffocus.However,reportshavealludedtodisorders
involvinghyperactivity,impulsivity,andinattentioninconjunctionwithdistractibility
andinappropriatearousalpatternsthroughoutmedicalhistory.Whatisnewisthe
enhancedawarenessofADHD(ADD)secondarytorapidlyaccumulatingresearch
findingsanditsadditiontotheDSMin1980.

Pathophysiology
Findingsfromneuropsychologicalstudiessuggestthatthefrontalcortexandthe
circuitslinkingthemtothebasalgangliaarecriticalforexecutivefunctionand,
therefore,toattentionandexercisinginhibition.Manyfindingssupportthisview,
includingthosedescribedbelow.
Executivefunctionsaremajortasksofthefrontallobes.MRIoftherightmesial
prefrontalcortexinpersonswithADHD(ADD)stronglysupportsdecreased
activation(lowarousal)duringtasksthatrequireinhibitionofaplannedmotor
responseandtimingofamotorresponsetoasensorycue.MRIinpersonswith
ADHD(ADD)alsostronglysupportsweakenedactivityintherightinferiorprefrontal
cortexandleftcaudateduringataskthatinvolvestimingofamotorresponsetoa
sensorycue.

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PediatricAttentionDeficitHyperactivityDisorder(ADHD):PracticeEssentials,Background,Pathophysiology

Inanefforttoexploreneuralcorrelatesthatmediateresponseinhibitiondeficitsin
childrenwithADHD,Spinelli,etal(2011)examinedfunctionalMRIbrainactivation
patternsofchildrenaged813yearswithandwithoutADHDonago/nogotask.
Whilelapsesinattentionprecededresponseinhibitionerrorsinthechildrenwithout
ADHD,braincircuitryinvolvedinresponseselectionandcontrolwasactivatedprior
toerrorsinthechildrenwithADHD. [5]
Thecatecholaminesarethemainneurotransmitterswithfrontallobefunction.
Catecholaminecontrolleddopaminergicandnoradrenergicneurotransmission
appeartobethemaintargetsformedicationsusedtotreatADHD(ADD).
A10yearstudybyNationalInstituteofMentalHealth(NIMH)demonstratedthat
thebrainsofchildrenandadolescentswithADHD(ADD)are34%smallerthan
thoseofchildrenwithoutthedisorder,andthatpharmacologictreatmentisnotthe
cause.Themoreseverepatients'ADHD(ADD)symptomswere,asratedbyparents
andclinicians,thesmallertheirfrontallobes,temporalgraymatter,caudate
nucleus,andcerebellumwere.
Datafrom357healthysubjects,obtainedfromtheNIHMRIStudyofNormalBrain
Development,notedthatathinnercortexandslowercorticalthinningwas
associatedwithhigherattentionproblemscores,suggestingalinkbetween
attentionandcorticalmaturation. [6]
Inadditiontotheroleoftheneurotransmittersmostcommonlyassociatedwiththe
frontallobesandthepathwaysmentionedabove,someinvestigationshavebegun
exploringapossiblerolefor5hydroxytryptamine(5HT).Althoughthebrainsmotor
regionsareinnervatedby5HTprojections,noconnectionbetween5HTandADHD
(ADD)motorpathologyhasyetbeenidentified.However,connectionshavebeen
madetoattentionrelatedprocesses.Altered5HTactivitydoesappeartobeat
leastpartofthecausefordifficultieswithperceptualsensitivityandtheappropriate
recognitionoftherelativesignificanceofstimulation.

Epidemiology
Frequency
UnitedStates
TheprevalenceofADHD(ADD)inchildrenappearstobe37%.ADHD(ADD)is
associatedwithsignificantpsychiatriccomorbidity.Approximately5060%of
individualswiththisdisordermeetDSM5criteriaforatleastoneofthepossible
coexistingconditions,whichincludelearningdisorders,restlesslegssyndrome,
ophthalmicconvergenceinsufficiency,depression,anxietydisorders,antisocial
personalitydisorder,substanceabusedisorder,andconductdisorder.Thelikelihood
ofapersonhavingADHD(ADD)ifafamilymemberhasADHD(ADD)oroneofthe
disorderscommonlyassociatedwithADHD(ADD)issignificant.
International
PeoplewithADHD(ADD)havebeenidentifiedineverycountrystudied,with
comparablefrequency.

Mortality/Morbidity
ThemorbidityforADHD(ADD)widelyvaries.Thisrangeisafunctionofmany
factors,includingthespecificareaofdeficit,thepatient'senvironmentalresponseto
andinteractionwiththedeficits,thetherapyprovided,andthepresenceof
coexistentconditions.

Sex
ADHD(ADD)ismorefrequentlydiagnosedinboysthaningirls.Mostestimatesof
themaletofemaleratiorangebetween3:1and4:1inclinicpopulations.However,
manycommunitybasedsamplesproducearatioof2:1.RecognitionofADHD
(ADD)hasimprovedoverthelastdecade,andthemaletofemaleratiohasbeen
decreasingthismaybetheresultoftheincreasedrecognitionofinattentiveADHD
(ADD).

Age
DataconcerningthelikelihoodthatachildwithADHD(ADD)willalsohavethe
disorderasanadultareconflicting.AsdefinitionsofADHD(ADD)subtypes
improve,somesubtypesthatcausemoreadultdysfunctionthanotherswilllikelybe
found.
Approximately3080%ofchildrenwithADHD(ADD)havethedisorderasadults.
Mostexpertsbelievethattherateiswellabove50%.
Hyperactivesymptomsmaydecreasewithagebecauseofdevelopmentaltrends
towardselfcontrolandchangesinbraincomposition(ie,pruningofabundantneural
connections)thatoccurduringlateadolescence.However,personswithADHD
(ADD)developmentallymaturelaterthantheaveragepopulation.Inattentive
symptomsdonotappeartohaveasimilardevelopmentaladvantageandtendto
remainconstantintoadulthood.
ClinicalPresentation

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ContributorInformationandDisclosures
Author
MaggieAWilkes,MDResidentPhysician,DepartmentofPsychiatry,MedicalUniversityofSouthCarolina
CollegeofMedicine
MaggieAWilkes,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofChildand
AdolescentPsychiatry,AmericanMedicalAssociation,AmericanPsychiatricAssociation
Disclosure:Nothingtodisclose.
Coauthor(s)
EveGSpratt,MD,MScProfessorofPediatricsandPsychiatry,DivisionofDevelopmentalPediatrics,Medical
UniversityofSouthCarolinaDirector,PediatricConsultationLiaisonPsychiatry,MedicalUniversityofSouth
CarolinaChildren'sHospitalatCharleston
EveGSpratt,MD,MScisamemberofthefollowingmedicalsocieties:AmericanAcademyofChildand
AdolescentPsychiatry
Disclosure:Nothingtodisclose.
StaceyMCobb,MDFellowinDevelopmentalandBehavioralPediatrics,ClinicalInstructor,Departmentof
Pediatrics,MedicalUniversityofSouthCarolinaCollegeofMedicine
StaceyMCobb,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyof
Pediatrics,SocietyforDevelopmentalandBehavioralPediatrics
Disclosure:Nothingtodisclose.
ChiefEditor
CarolyPataki,MDHealthSciencesClinicalProfessorofPsychiatryandBiobehavioralSciences,Universityof
California,LosAngeles,DavidGeffenSchoolofMedicine
CarolyPataki,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofChildandAdolescent
Psychiatry,NewYorkAcademyofSciences,PhysiciansforSocialResponsibility
Disclosure:Nothingtodisclose.
Acknowledgements
ZainabPContractor,MDMedicalDirector,TheAffinityCenter
Disclosure:Nothingtodisclose.
ChetJohnson,MDProfessorandChairofPediatrics,AssociateDirector,DevelopmentalPediatrician,Center
forChildHealthandDevelopment,ShiefelbuschInstituteforLifeSpanStudies,UniversityofKansasSchoolof
MedicineLENDDirector,UniversityofKansasMedicalCenter
ChetJohnson,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics
Disclosure:Nothingtodisclose.
ChristineAMayhall,PhDClinicalPsychologist,TheAffinityCenter
ChristineAMayhall,PhDisamemberofthefollowingmedicalsocieties:AmericanPsychologicalAssociation
Disclosure:Nothingtodisclose.
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.

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