Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder defined by inattention, hyperactivity, and impulsivity. It has genetic and environmental causes and affects the dopaminergic and noradrenergic neurotransmitter systems in the brain. ADHD is diagnosed clinically based on the number of symptoms present over several months in multiple environments for children or adolescents. The primary treatment is stimulant medication, though nonstimulants may also be used. Left untreated, ADHD can lead to academic underachievement, low self-esteem, interpersonal issues, and higher risk behaviors as an adolescent.

1. ADHD
Attention-Deficit / Hyperactivity
Disorder

2. ADHD:
 Attention deficit/hyperactivity disorder is a neurobehavioral disorder
defined by symptoms of :
 Inattention
 Hyperactivity
 And impulsivity.

3. Etiology:
 It is multifactorial in origin.
 Has genetic, environmental and neural contributions.
 Candidate genes include those involving the dopaminergic & noradrenergic
neurotransmitter systems.
 Prenatal exposure to substances (e.g., nicotine, alcohol) and damage to the central
nervous system from trauma or infection, increase the risk of ADHD.

4. Epidemiology:
 The male to female ratio is 2 to 6:1,
 with greater male predominance for the hyperactive/impulsive & combined types.
 Girls often present with inattentive symptoms.
 More likely to be underdiagnosed or to receive later diagnoses.

5. Diagnosis:
 Diagnosis of children (< 16 years) requires:
• At least 6 symptoms of inattention
• Or 6 symptoms of hyperactivity-impulsivity
– For at least 6 months
– In two or more environments.
 Children (17 years or older) must exhibit:
• At least 5 symptoms of inattention
• Or at least 5 symptoms of hyperactivity-impulsivity.

6. Diagnosis:
 Symptoms of inattention:
 Experiencing frequent forgetfulness in daily activities
 Becoming easily distracted
 Frequently losing things required for tasks & activities
 Avoiding/disliking activities that require sustain mental effort
 Having difficulty organizing tasks or activities
 Having difficulty sustaining attention during tasks or play
 Failing to follow through on instructions or finish assigned work
 Appearing to not listen when spoken to directly
 And failing to pay close attention to details.

7. Diagnosis:
 Symptoms of hyperactivity:
 Talking excessively
 Acting as if “driven by motor”
 Having difficulty in playing quiet
 Running or climbing excessively in inappropriate situations
 Leaving a seat when expected to remain seated
 And being fidgety or restless
 Symptoms of impulsivity:
 Causing frequent interruptions or intrusions
 Having difficulty waiting for his/her turn
 And blurting out answers before a question has been completed.

8. Diagnosis:
 Symptoms of ADHD, particularly impulsivity & inattention, persist into
adolescence and adulthood in 60-80% of patients.
 In addition to diagnosing ADHD;
 Several symptoms must have been present prior to 12 years of age,
 With evidence of significant impairment in social, academic, or work settings must
occur;
 And other mental disorders must be excluded.

9. Clinical Manifestations:
 ADHD is diagnosed clinically by history.
 A physical exam is essential to identify medical (e.g., neurologic, genetic)
or development problems (e.g., cognitive impairment, language disorder,
learning disability, autism spectrum disorder).
 Observation of the child, the parents, & their interaction is part of the evaluation.
 Laboratory & imaging studies are not routinely recommended but may help
exclude other conditions.
 Consider thyroid function tests, blood lead levels, genetic studies, & brain imaging
studies if indicated by history.

10. Differential Diagnosis:
 Psychiatric conditions
 Oppositional defiant disorder
 Conduct disorder
 Anxiety disorder
 Depression
 Learning disabilities
 Language disorders
 And tic disorders
 *coexisting conditions are present in up to 60% of children with ADHD.
 Physician should first determine child’s development level to determine whether
behaviors are within normal range.
 Medical conditions, such as seizure disorders, sleep disordered breathing,
hyperthyroidism, lead intoxication, substance use & sensory deficits, should be
considered as possible causes for a child’s hyperactivity & distractibility.

11. Treatment:
Generic Medication Brand Name Initial Max Dose Duration (h)
Stimulants
Mixed amphetamine
salts
Adderall 2.5 mg-40 mg 6
Lisdexamfetamine Vyvanse 20 mg-70 mg 10-12
Methylphenidate Concerta
Methylin
Ritalin
18 – 54 mg
10 – 60 mg
5 – 60 mg
12
8
3-5
Dexmethylphenidate Focalin
Focalin XR
2.5 – 20 mg
5 – 30 mg
3-5
8-12
Norepinephrine Reuptake Inhibitor
Atomoxetine Strattera 0.5 mg/kg then
increase to 1.2 mg/kg
with max 1.4 mg/kg
At least 10-12
Alpha Agonists
Clonidine Kapvay 0.1 – 0.4 mg/d At least 10-12
Guanfacine Intuniv 1 – 4 mg/d At least 10-12

12. Treatment:
 Stimulant medications are the first-line agents for treatment of ADHD.
 Stimulant medications are available in short-acting, intermediate-acting,
and long-acting forms.
 Preparations include liquid, tablets, capsules, and a transdermal patch.
 These options allow the physician to tailor the choice of medications to the child’s needs.
 Nonstimulant medications, including NE-reuptake inhibitors & alpha
agonists may be helpful in situations such as nonresponse to stimulant
meds, family preference, concerns about medication abuse or diversion, &
coexisting tic or sleep problems.

13. Complications:
• ADHD may be associated with:
• Academic underachievement
• Poor self-esteem
• And difficulties in interpersonal relationships.
– These can have long-reaching effects (e.g., employment attainment,
lower levels of education)
• Adolescents with untreated ADHD are at increased risk of:
• Automobile accidents
• Early sexual activity
• And drug use
• *There is actually a decreased risk in those who are medically managed.

14. Prevention:
 Limit television & video game times as these activities reinforce
short attention span.
 Child-rearing practices including promoting calm environment &
opportunities for age-appropriate activities that require increasing
levels of focus may be helpful.
 Secondary disabilities can be prevented by educating medical
professionals & teachers about signs & symptoms of ADHD.
 Collaboration between health care providers, educational
professionals, & mental health physicians will enhance early
identification of and provision of services to children at risk of
ADHD.

15. The End