ATTENTION DEFICIT DISORDER I

Attention Deficit Disorder (ADHD) is an increasingly common problem in children, adolescents, and adults, but tends to manifest itself in early childhood. ADHD refers to a group of symptoms characterized by developmental inappropriate levels of inattention, impulsivity, or over activity. Individuals with ADHD show marked delays in academic and vocational achievement, poor social relationships, and the independent performance of daily living skills relative to their intellectual potential. Diagnosis is complicated because the symptoms of this disorder overlap and co-occur with a variety of psychiatric, learning, medical, and social problems. Early recognition is important because undiagnosed, the individual's school performance, social adjustments, and self-esteem may be affected. The primary care physician is often referred patients to evaluate for suspected ADHD.

Prevalence
1. 3-8% of school age children and about 40% will continue to display symptoms in adulthood leading to an incidence of 2-3% in adults.
2. 50% of children will display diagnostic criteria by four years of age
3. There is a higher incidence in males, especially hyperactivity, and impulsiveness. This may be related to a higher incidence of co-morbid conditions in boys.

Etiology
1. Genetic basis has been suggested because of high familial incidence
2. Organic or brain injury encephalopathy
3. Psychiatric disorders may mimic ADHD

Co morbidity
1. In children, disruptive disorders and learning disabilities occur in 25-40% and mood and anxiety disorders in 10-15%
2. In adults, 25-50% have mood and anxiety symptoms and personality and substance abuse are also common.

Diagnosis

Based on DSM IV criteria– Adherence to the DSM-IV criteria can minimize over and under diagnose ADHD. There are several limitations to the criteria such that it was derived from studies of children who were evaluated in psychiatry rather than primary care settings. Data supporting the number of items required for diagnosis are lacking. Also, the behavior characteristics specified in the definition are subject to different interpretations by different observers. However, the criteria helps demonstrate a higher inter-rater reliability and an overall diagnosis.

1. Six items or more from each of the following symptom list must be present for at least six months to a degree that is maladaptive and inconsistent with developmental level:

       a. Careless mistakes
       b. Difficulty sustaining attention
       c. Seems not to listen
       d. Fails to finish tasks
       e. Difficulty organizing
       f. Avoids tasks requiring sustained attention
       g. Loses things
       h. Easily distracted
       I. Forgetful

2. Six items or more of the followings symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity symptoms
       a. fidgets
       b. unable to stay in seat
       c. restless
       d. difficulty engaging in leisure activities
       e. "on the go"
       f. talks all the time

Impulsivity symptoms

       g. blurts out answers
       h. has difficulty waiting turn
       i. interrupting/intruding on others

3. Additional Criteria: The symptoms must occur in several settings with evidence of significant impairment. (Academic/vocational, social). Symptoms may be less evident during one-on-one situations or while the patient is being seen in the doctor's office. Parents often state that their child can watch TV or play video games for hours at a time and not display any symptoms. The symptoms will get worse when their are environmental demands placed on the child.

Differential Diagnosis- Overlaps with learning disabilities, behavior and emotional problems. These disorders frequently coexist with ADHD and are not necessarily the cause of symptoms.

       a. Developmental variations
         1. cognitive impairment
         2. learning disabilities
         3. language disorders
         4. gifted
         5. normal variations
       b. Medical disorders
         1. Seizure disorders
         2. lead poisoning
         3. malnutrition
         4. substance abuse
         5. thyroid disorders- rare
         6. Pervasive Developmental Delay (Autism)
         7. Absence seizures
       c. Emotional/Behavioral Disorders
         1. Depression
          2. Anxiety
          3. Conduct disorders
          4. Schizophrenia
          5. Mania
         6. Obsessional disorders
       d. Environmental Disorders
          1. Abuse
          2. Stressful home environment
          3. Poor parenting

Evaluation: A comprehensive evaluation is needed to confirm the complications of core symptoms and exclude any other explanations for symptoms or other co morbid disorders.

       a. Physical examination including hearing and vision
       b. Cognitive testing (IQ, WISC) and achievement tests
       c. Diagnostic interviews with parents, child, and teachers
       d. Behavior rating scales ( Connors )
       e. Psychosocial evaluation: ADHD-specific rating scales (Vanderbilt)- has a sensitivity and specificity                                            over 90% validated in a community setting.
       f. Family history
       g. There are NO routine labs, radiological evaluations, or EEGs necessary in most cases. If appropriate, ay rule out Fragile X, Lead poisoning, etc.

h. ADHD toolkit: Developed for Primary car practitioners to assist in the evaluation and management of children with ADHD. The toolkit has information for parents and ADHD specific questionnaires for parents teachers and initial primary care evaluation. Download at www.nichg.org/adhd.html (registration required).

Risk Factors
      a. Family History
      b.Comorbid conditions
        1. Learning disabilities
         2. Tourette's
         3. Mood disorders
         4. Oppositional defiant disorder
         5. Conduct disorder

References
1. Dunne JE. Attention-Deficit/Hyperactivity Disorder and Associated Childhood Disorders. Primary Care; Clinics in Office Practice. 1999; 26(2):349-372.
2. Miller KJ. and Castellanos FX. Attention Deficit/Hyperactivity Disorders. Pediatrics in Review. 1998; 19:373-384.
3. Zametkin, Alan J. and Ernst, Monique Problems in the Management of Attention-Deficit-Hyperactivity Disorder. NEJM Jan.7, 1999
4. Diagnosis and Evaluation of the child with Attention Deficit/Hyperactivity Disorder. American Academy of Pediatrics Pediatrics May 2000 pp1158-1170
5. Rappley M.D. Attention Deficit -Hyperactivity Disorder NEJM Vol 352 No. 2 January 13, 2005
6. Floet A. et. al. Attention Deficit/Hyperactivity disorders. Pediatrics in Review. Feb. 2010
7. www.nichq.org/adhd.html
8. American Academy of Pediatrics. Clinical Practice Guidelines for Diagnosis, Evaluation, and Treatment of ASttention Deficit/Hyperactivity in Children and Adolescents. Pediatrics Nov 2011