Attention Deficit Hyperactivity Disorder

Snapshot

• An 11-year-old boy presents with a chief complaint of poor performance in school.  History obtained from the mother reveals that he often is disorganized and turns in assignments late, incomplete, or not at all.  He has also had trouble making friends as he cannot participate in organized play, nor can he follow the rules of any games during recess.  His father explains that he does not listen at home, cannot sit still to complete his homework, never completes his chores, and is always interupting his siblings at the dinner table. Upon examining the child you discover a fidgety, young boy who talks non-stop and has trouble staying on topic when you ask him questions.

Introduction

• Overview
  • a neurodevelopmental/psychiatric disorder characterized by hyperactivity, impulsivity, and inattention
• Epidemiology
  • demographics
    • 10:1 male:female ratio
    • onset before age 12
• 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
  • most common symptoms include
    • 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

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) 
    • increase presynaptic norepinephrine and dopamine by inhibiting the reuptake resulting in increased frontal lobe activity and impulse control  
      • methylphenidate
      • dextroamphetamine
  • nonstimulants
    • second-line therapy for school-aged children
      • atomoxetine
        • prefered in cases of substance abuse
        • selective norepinephrine reuptake inhibitor
      • guanfacine
        • sympatholytic
        • α₂-agonist
      • clonidine
        • α₂-agonist
        • G_i coupled
        • decreases NE release
      • others
        • bupropion, nortriptyline, and other selective serotonin reuptake inhibitors