What Is Attention Deficit Hyperactivity Disorder?

ADHD is a neurobehavioral disorder that occurs in 3% to 7% of school-aged children. The disorder is often suspected by parents, teachers, and other adults who work with children because of concerns about hyperactivity, inattentiveness, impulsivity, and poor progress in school. Behaviors such as anger and aggressiveness may also prompt concern, but these are not part of the ADHD spectrum. The physician’s role is to ensure that the proper diagnosis has been made and that any other comorbid conditions are addressed. In addition, it is critical to monitor the child’s response to treatment and tolerance of medical therapy, if that is prescribed.

How Is Attention Deficit Hyperactivity Disorder Classified?

ADHD has three categories in the DSM-PC:

How Do I Diagnosis Attention Deficit Hyperactivity Disorder?

In general, the diagnosis of ADHD should only be made in children after age 7 years, even when symptoms occur earlier. Age-appropriate development of young children often includes impulsive, inattentive, and highly energetic behaviors. A child suspected of having ADHD must demonstrate the behaviors listed in the DSM-IV criteria for one of the subtypes (Table 55-1). The concerning behaviors also must meet the following criteria:

Table 55-1 DSM-IV Classification of Attention Deficit Hyperactivity Disorder (ADHD)

Of primary importance is that the symptoms must cause significant functional impairment that does not allow the child to perform up to full potential in two different environments. For most children, these environments are home and school. You should consider alternative diagnoses if symptoms are only present in one environment.

How Are Behaviors Identified and Documented?

Parent and teacher behavioral rating scales (such as the Vanderbilt or Connors scales) are very useful for collecting information. These scales ask the parent and teacher to identify a child’s behaviors, including those commonly associated with ADHD. The frequency of behaviors can then be compared with age- and gender-specific norms to ascertain whether the child meets criteria for the various types of ADHD in all settings. Parents should make observations at home of daily activities, common family situations, and anything that seems to trigger a concerning behavior. The teacher who spends the most time with the child in school should fill out the forms. Often, school psychologists may have been consulted by teachers and can provide additional information.

What Other Problems Occur with Attention Deficit Hyperactivity Disorder?

ADHD occurs in approximately 50% of patients with conduct disorder. Children with learning disorders may be misdiagnosed as having ADHD. Children with ADHD occasionally manifest a variety of tics, and Tourette disorder may coexist with ADHD. A number of serious mental health problems, including substance abuse, autism, and major depression, may cause behaviors that resemble those of ADHD.

What Is the Medical Evaluation of Attention Deficit Hyperactivity Disorder?

The concerns identified by parents and teachers must be taken seriously and evaluated carefully. History must be comprehensive and must focus on the behavior, its patterns, triggers, and reinforcers. In addition, the environments in which problem behaviors occur must be identified (see Chapter 22). Growth, development, behavior, and the family, school, and social environments must be evaluated. Detailed past medical history and a thorough review of systems are also needed. The physical examination must focus on observed behaviors plus the details of all organ systems, especially neurologic findings. Laboratory testing, if any is needed, will be based on clinical suspicions. This approach should identify problems that mimic ADHD, including hyperthyroidism, absence seizures, hearing loss, and learning disorders. Syndromes that are associated with increased frequency of ADHD, such as fragile X or fetal alcohol syndrome, must also be identified. You will use the information gathered from parents, teachers, and the medical evaluation to decide if one of the ADHD subtypes is a possible diagnosis and if referral to a psychologist is needed for further psychometric evaluation. If the diagnosis is clear from the evaluation, you will then decide whether medication is appropriate. Comorbid problems such as depression or tics may also be identified and require management.

What Treatment Options Are Available for Attention Deficit Hyperactivity Disorder?

The goal of treatment is to improve a child’s ability to function in the multiple environments in which learning occurs. Successful treatment includes the combination of behavioral management, family and teacher education, and selective use of medication. Behavioral management helps children improve their social skills and learning strategies both at home and at school. Parent and teacher education will ensure that a consistent approach will be taken in the home and school and will also counter the misinformation that abounds in public media and on the Internet. Medication should be viewed as an adjunct to behavioral and environmental management, not as a panacea. In addition, it is important that medical professionals serve as advocates for children with behavioral and other mental health problems in schools, communities, and society at large.