15 Cognitive-Perceptual Disorders
Attention-Deficit/Hyperactivity Disorder, Learning Problems, Sensory Processing Disorder, Autism Spectrum Disorder, Blindness, and Deafness
Cognitive development is the foundation for intelligence (Wilks et al, 2010), and cognition and perception affect a child’s ability to learn, comprehend and use information to understand and follow directions, retain information, make decisions, and solve problems. Cognition and general knowledge represent the accumulation and reorganization of experiences that result from participating in a rich learning setting with skilled and appropriate adult interventions. From these experiences children construct knowledge of patterns and relations, cause and effect, and methods of solving problems of everyday life.
Gordon (2010) describes the cognitive-perceptual functional health pattern to include the adequacy of sensory modes, such as vision, hearing, taste, touch, or smell, as well as the cognitive functional abilities such as language, memory, and decision-making. Sensory experiences such as pain (see Chapter 22) and altered sensory input may also be identified.
Piaget’s theory of cognitive development is probably the most classic (see Chapter 4). Newer theories and ideas related to the development of cognition and sensory awareness are emerging and being developed. Neurodevelopmental functioning of the brain uses a model of a tool kit full of basic instruments (functions) with different functions working in clusters (like tools) in different kinds of learning. The concept of multiple intelligences was introduced to describe different ways a child may be hard-wired to process information. Information processing looks at human learning with a computer as a model. Social cognition looks at the spectrum of social behaviors and affiliation with others.
Facilitating and monitoring cognitive-perceptual developmental progress as well as ensuring the maximum function of all the senses should be an integral part of primary care. Screening hearing and vision is a recognized standard of care. Following cognitive development in infancy and early childhood is primarily done by monitoring language and problem-solving domains integral to the other developmental parameters and should ideally be performed with standardized screening tools. As the child enters school, monitoring the adaptation to and performance in school becomes the key. Soliciting information about school performance from preschool through high school shows interest in the child’s mastery of educational tasks and managing academic challenges. Primary care providers may be consulted for guidance about appropriate timing and school placement for a child, performance more or less than expectations, problems, and the need for further assessment. As developmental experts, primary care providers need to be able to identify problems; advise, counsel, and educate parents; participate on interdisciplinary teams for diagnosis and management; and mediate and advocate for children and their learning needs.
Standards for Care
Healthy People 2020: Health Promotion and Disease Prevention Objectives for the Year 2020 supports the need for visual and hearing screening in children (U.S. Department of Health and Human Services [USDHHS], 2010). New objectives for 2020 include “increase the proportion of children who are ready for school in all five domains of healthy development”; “increase educational achievement of adolescents and young adults”; and “increase the percentage of young children with autism spectrum disorder (ASD) and other developmental delays who are screened, evaluated, and enrolled in early intervention services in a timely manner” (USDHHS, 2010).
The U.S. Preventive Services Task Force’s (USPSTF) (2010) Child and Adolescent Recommendations for Development and Behavior states that there is “insufficient evidence to recommend for or against routine, brief, formal screening instruments in primary care to detect speech and language delays in children up to 5 years of age.”
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan et al, 2008) addresses health promotion to ensure physical, cognitive, and socioemotional health, supporting the healthy development of the child. This includes surveillance and screening for early identification and intervention of any problems. Specific cognitive skills in infancy, early childhood, middle childhood, and adolescence are identified in the Child Development section. Screening for vision and hearing is recommended and considered effective.
Theories of Normal Cognitive-Perceptual Development
Piaget: Cognitive Development
Piaget’s learning model is discussed in detail in Chapter 4, but key concepts include assimilation (taking in information through any and all the senses), accommodation (taking one’s current abilities/understanding and modifying them to adjust to the new circumstance or challenge), schema (organizing this into a new mental structure or physical action), and equilibrium (a new level of cognition).
Neurodevelopmental Framework
A neurodevelopmental framework is a model of learning based on a synthesis of research from neuroscience, cognitive psychology, and child and adolescent development explaining how the brain functions and how these functions affect student learning and performance. Every person has strengths and weaknesses that influence learning, as well as particular affinities—subjects, ideas, and pursuits they’re drawn to. “Collectively, these strengths, weaknesses, and affinities shape both how we learn and what engages us—which, in turn, influence how much we actually learn and thrive in a given situation” (All Kinds of Minds, 2010).
There are eight constructs to the neurodevelopmental framework, which are listed in Table 15-1. Identifying a child’s strengths and weaknesses by using these constructs provides a method to describe, organize, and address individual students’ learning needs.
TABLE 15-1 Constructs of the Neurodevelopmental Framework
CNS, Central nervous system; REM, rapid eye movement.
Multiple Intelligences
In 1983 Dr. Howard Gardner, a professor of education at Harvard University, developed the theory of multiple intelligences to account for the broad range of human potential in children and adults. Gardner believed the traditional measure of intelligence, based on IQ testing, was inadequate and left many talented and intelligent children and adults floundering (Smith, 2010). He identified eight different intelligences (Table 15-2) that many educational systems have begun to use.
TABLE 15-2 Multiple Intelligences
| Intelligence | Description |
|---|---|
| Linguistic | Sensitivity to language; language-based function (word smart) |
| Logical-mathematical | Abstract reasoning, manipulation of symbols, detection of patterns, logical reasoning (number/reasoning smart) |
| Musical | Detection and production of musical structures and patterns; appreciation of pitch, rhythm, musical expressiveness (music smart) |
| Spatial | Visual memory, visual-spatial skills, visualization (picture smart) |
| Body-kinesthetic | Representation of ideas, feeling in movement; use of body, coordination, goal-directed activities (body smart) |
| Naturalistic | Classification and recognition of animals, plants (nature smart) |
| Social/interpersonal | Sensitivity and responsiveness to moods, motives, intentions and feelings of others (people smart) |
| Personal/intrapersonal | Sensitivity to self, feelings, strengths, desires, weaknesses and understanding of intention and motivation of others (self smart) |
Information-Processing Theories
Information processing (IP), which is thinking or problem-solving, looks at information presented, processes used to transform information, and memory limits that constrain the amount of information that can be represented and processed. A child’s ability to encode—identify and use critical information to create internal representations—is critical. If children fail to identify or comprehend critical elements, or do not know how to encode them efficiently, they do not learn from potentially useful experiences.
Structural components include sensory register with visual and auditory registers (like input devices for a computer), short-term storage/memory (like the central processing unit of a computer), and long-term storage/memory (like hard drive storage).
Process components include rehearsal activity—used to keep information in the short-term store, the working memory; automatic processing—transforms information outside the direct control of the individual to retain information not consciously remembered; and the task environment or the context of the child—for example, a particular solution to a problem may create moral conflicts and thus alter the child’s options. Figure 15-1 illustrates an information-processing model.
Social Cognition
Social cognition, also called intuition or common sense, is the ability to interpret behavior and emotions of self and others. It is not well documented and difficult to measure or assess, so exists on a spectrum. There is a neural overlap with intellectual cognition, but social cognition also has distinct processes. Components of social cognition include the ability to:
• Understand thoughts, intentions, and emotions of self and others
• Follow the rules of social play, to regulate one’s own responses to unstructured or ambiguous social environments
• Understand/anticipate how peers feel (empathy)
• Communicate and comprehend social meaning; understand body language and perceive faces
A spectrum of developmental skills for each age cluster has been identified (Hansen and Ulrey, 2009), but in general includes:
• Infancy—eye contact, social smile, reaching, emerging joint attention, use of others’ emotions to regulate self
• Toddler/preschool—emerging empathy, understanding social rules, constructing narratives and reciprocity in play
• School age—functioning successfully and flexibly in both structured and unstructured situations; “street smart”
• Adolescence—forming social group affiliations and emerging sexual identity; social testing and teasing
Sensory Processing
All humans receive information from their environment through their senses: vision, hearing, touch, taste, smell, position (proprioception), and movement (vestibular). Sensory processing, also known as sensory integration, has to do with how individuals respond to, process, and/or organize sensory information for use in functional daily life routines and activities. Three processes of sensory integration have been described (Miller et al, 2009): sensory modulation—the regulation of responses to sensory stimulation; sensory discrimination—interpreting the specific characteristics of sensory stimuli (intensity, duration, spatial and temporal elements); and sensory-based motor, which include balance and core stability, as well as motor planning and sequencing movements.
The Societal-Familial-Individual Matrix of School Achievement
Wegner (2009) proposes a matrix of societal, family, and individual elements that affect a child’s ability to achieve academically. Success can be defined as “successful attainment of skills commensurate with the child’s cognitive profile” and is often measured by passing all grades in school. This matrix offers a way to examine the interplay of a child’s individual profile, family factors, and community characteristics.
Individual characteristics affecting academic performance include: (1) cognition—often considered the predictor of academic success; (2) developmental skills—play a role in contributing to intelligence; (3) resilience—contributes to a child’s motivation to succeed or ability to persevere through failure; and (4) desire for education—a personal belief that education is important and contributes to the future.
Family factors that influence student educational achievement include: (1) community acceptance of varied types of family structures; (2) family values at odds with the larger community causing missed opportunities for the child; (3) performance expectations out of line with a child’s capabilities, either too high or too low; and (4) parental academic abilities that not only genetically influence a child’s capability but also affect the home support a child may receive.
Societal factors that influence educational systems include: (1) economic—the affluence of the community affects resources and experiences as well as, potentially, the quality of teachers attracted; (2) political—politicians may be hesitant to promote tax increases to provide needed resources for schools; (3) religious—a preponderance of a specific religious group may exert influence on a school’s curricula, policy, and procedures; and (4) cultural—as with religion, ethnic and cultural groups may exert pressure on a school.
Effects of Cognitive-Perceptual Problems on the Child and Family
Although most children develop according to normal patterns, developmental delays, specific deficits, and alterations in cognitive-perceptual development sometimes occur. Delays from environmental deprivation or neglect are frequently reversible, once identified.
Feedback provides information to the child, positive reinforcement for correct responses to stimuli, and negative reinforcement for behaviors that are not appropriate. Parents, peers, and others provide important feedback to the child. For some children with perceptual problems, not only is the initial cue missed but also the feedback cues. This feedback is an essential component of the learning process.
Knafl and colleagues (1996, 2001) identified the following family management styles when a child has a chronic or disabling condition: thriving, accommodating, enduring, struggling, and floundering. Each management style described how parents perceived the child (normal, problematic, tragic), the parenting philosophy and view of illness, and their perception and approach to managing the illness. For example, parents who embraced a thriving family management style viewed the condition from a “life goes on” perspective and normalized the child’s illness as best they could. They had a parenting philosophy that was able to accommodate the condition into parenting activities and a confident mind-set, and they were proactive in their management approach.
Other typologies have been described for families with children with other cognitive-perceptual problems. Kendall (1998) described four types of families of children with attention-deficit/hyperactivity disorder (ADHD) along a trajectory: the chaotic family, the ADHD-controlled family, the surviving family, and the reinvested family. Other studies of families living with ADHD indicate considerable disruption to family routines and an inability to achieve some sense of “normalcy.” Some families describe family life as a “nightmare,” despite outward indicators (intact marriage, stable residence, adequate income, resources to manage the ADHD, etc.) that the family is doing well (Shelton, 2001). Families of learning-disabled children have been described as healthy, split, chaotic, and blaming (Ziegler and Holden, 1988).
Cognitive-Perceptual Development Problems and Primary Care
Assessment
Assessment of cognitive-perceptual development should be incorporated at every well-child visit from birth through young adulthood. Assessment of a child’s cognitive-perceptual development includes consideration of risk factors and current performance as elicited by history, actual assessment via screening tools, direct observation of the child and caregiver, as well as review of school data.
History
The provider should be alert to risk factors related to problems in cognitive-perceptual development.
• Genetic elements—any disorder, condition, or malformation with identifiable cognitive effect (e.g., trisomy 21, velocardiofacial syndromes)
• Prenatal factors—risk factors such as maternal/paternal age at conception; maternal use of tobacco or alcohol; maternal hypertension and other complications; fetal hypoxemia or suboptimal growth
• Birth and perinatal events—adverse events during delivery; prematurity; prolonged neonatal complications
• Infancy to 3 years—maternal depression; family wellness indicators; parental literacy, child deprivation, neglect, or abuse
• Three years through kindergarten entry—child interaction difficulties in larger group settings; lack of independent play or sustained interest in preferred activity, lack of expanding conversation and interactions with adult
• School age and adolescence—difficulties in academic settings, problems with interactions with peers or in large group settings
Screening
A developmental screening tool should be used consistently throughout the first 6 years of life to monitor children for any delay or lagging performance. Developmental screening is discussed in detail in Chapters 4 through 8. Cognitive red flags are listed in Box 15-1. Screening for autism using the M-CHAT is recommended at 18 and 24 months (see later section on Autism). Concerns about a child’s ability to deal with sensory input from either a learning or behavioral standpoint can be evaluated with a screening tool (see later section on Sensory Processing Disorder).
• 4 months—lack of visual tracking
• 6 months—failure to turn to sound or voice
• 9 months—lack of babbling consonant sounds
• 24 months—failure to use single words
Data from Wilks T, Gerber R, Erdie-Lalena C: Developmental milestones: cognitive development, Pediatr Rev 31(9):364-367, 2010; American Academy of Neurology and the Child Neurology Society: Guideline summary for clinicians: screening and diagnosis of autism, 2010. Available at http://aan.com/professionals/practice/guidelines/guideline_summaries/Autism_Guideline_for_Clinicians.pdf (accessed Jan 5, 2011).
• Early elementary (grades 1 through 3) lays the foundation for the remainder of a child’s schooling. Differentiating early struggles due to temperament, environment or cognitive-perceptual weaknesses may be difficult.
• Later elementary (grades 4 through 6) is characterized by increasing demands and needed independence. Complaints of being bored (gifted versus overwhelmed child); and difficulty with emerging complex social hierarchy and peer influences are important to detect.
• During middle school, demands on the child’s independent direction increase, parental and teacher direction decreases, and physical and cognitive changes occur. This may cause some children to struggle academically, have poor outcomes related to peer influence, and have worsening of any chronic health condition.
• High school results in greater grade pressure as students compete for university and vocational school placements and scholarships. Adolescents have a need for autonomy and individuation as well as identification of personal strengths and goals.
If any problems or concerns are identified, further evaluation should be undertaken. This is discussed later in the chapter.
Monitoring hearing and vision is the first step in assessment of perception. It is of note that children with cognitive-perceptual variations may achieve motor milestones on time, but experience delays in speech, social, and emotional areas of development.
Management Strategies
Children and families with problems in this domain generally need support in four areas: social and adaptive skills, education, family support, and multidisciplinary health care team consultations. Many families find this support lacking from their primary care providers. Satisfaction with primary care received by families of children with developmental disabilities including both physical and mental problems was studied by Liptak and colleagues (2006). They found that most families felt satisfied with physicians’ abilities to keep up with new aspects of care and with their sensitivity to the needs of the children. They indicated dissatisfaction with the ability of physicians to put them in touch with other parents, understand the effect of the condition on the family, answer questions about the condition, and provide information and guidance. They rated physicians’ knowledge about complementary and alternative medicine and their qualifications to manage children with developmental disabilities most negatively. Families with a child with autism rated primary care physicians worse on several factors than did other families.
Social and Adaptive Strategies
Social and adaptive care relates to helping children achieve maximal independence in living and learning in order to get along with family members and others in a variety of social environments. The family delivers most of this care, but some parents need help with knowing what social and adaptive developmental steps children should master at various ages. Sorting out normal developmental variations from dysfunction, disability, or handicap requires thoughtful analysis (see Learning Disorders and Neurodevelopmental Dysfunctions). Strategies to help the child learn new skills are often learned by trial and error or can be gleaned from parents of children with similar challenges. Physical therapists, occupational therapists, and teachers with special education and skills to help children with cognitive-perceptual impairments can be important resources. The primary care provider can serve as case manager, help parents explore other options, or act as a conduit to help parents find others who have solved similar problems.
Educational Strategies
Children with cognitive-perceptual problems are entitled to special education opportunities to maximize their learning potential. Infant stimulation opportunities are extremely important and early-intervention preschool programs are essential (see Chapter 4).
Two federal laws, the Americans with Disabilities Act (ADA), passed in 1990, and the Individuals with Disabilities Education Act (IDEA), reauthorized in 1997, provide mandates for reasonable accommodations that schools must provide to help children with disabilities to achieve meaningful, equal opportunity to benefit from educational services. Free and appropriate public education (FAPE) and least restrictive environment (LRE) are ideas that are built into the special education system. A response to intervention (RTI) approach is a tiered response to determining if a child has a disability and qualifies for special education. It is more effective in identifying students with learning disabilities than the traditional IQ discrepancy model. Once a child has been identified with special learning needs, an Individualized Education Plan (IEP) or a 504 plan are two means of delineating help for the child. Table 15-3 provides a differentiation of services.
• The IEP originates from the IDEA and is designed for children who demonstrate a gap between learning potential and actual academic performance. An IEP is a written plan defining the child’s disabilities, current level of educational performance, educational needs, and specific annual goals developed by a multidisciplinary team with parent involvement. An IEP includes specific academic, communication, motor, learning, functional, and socialization goals.
• The Section 504 plan specifies “reasonable accommodations” to help children with disabilities benefit from their education. Eligibility is based on the existence of an identified physical or mental condition that “substantially limits a major life activity” (learning). Each school district handles 504 plans differently, but there should be a 504 coordinator that oversees the process. Many children with ADHD and learning disabilities who do not have cognitive deficits but do have learning weaknesses, or behavioral or emotional problems that interfere with learning are eligible for a 504 plan.
TABLE 15-3 504 and Individualized Educational Plan (IEP) Evaluation and Educational Plans
ADHD, Attention-deficit/hyperactivity disorder; IDEA, Individuals with Disabilities Education Act; IEP, Individualized Educational Plan.
When children reach school age, decisions are made collaboratively between parents and school personnel about the best placement of the child (mainstream classroom, special classroom, or combination of settings). A wealth of information about these legal rights and provisions can be found on the Internet.
Family Support Strategies
Living with a child with a cognitive-perceptual problem generally requires an environment that offers consistency for the child. The family must also develop a structure with organization to support the child without becoming overprotective or intrusive.
Social support has been shown to provide significant benefits to families with children with health problems of all sorts. National organizations provide information and expert advice, and local groups can facilitate direct help.
Multidisciplinary Team Strategies
The use of a variety of specialists can provide the best resources for children with special needs. Generally, these include medical specialists, physical and occupational therapists, social workers, and specially educated teachers. The primary care provider helps families identify appropriate teams, serves as a case manager among the parties, and ensures that primary health care needs are integrated with the special services provided.
Cognitive-Perceptual Problems of Children
Attention-Deficit/Hyperactivity Disorder
Description
ADHD is one of the most commonly diagnosed behavioral disorders in childhood. It is considered a neurobiologic condition because it has a clear neurologically based etiology with symptoms that profoundly affect the behavior of individuals across many settings in their lives (Pliszka and American Academy of Child and Adolescent Psychiatry [AACAP], 2007). The symptoms of ADHD can affect cognitive, educational, behavioral, emotional, and social functioning in individuals with ADHD.
The core symptoms of ADHD are inattention, hyperactivity, and impulsivity. In ADHD these symptoms occur at a developmentally inappropriate level. There is a range of severity of symptoms from one individual to the next. Also, the scope and severity of behaviors may change within an individual as maturation occurs. The criteria defining ADHD were established by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (APA, 2000) (Table 15-4).
TABLE 15-4 DSM-IV-TR Criteria for Attention-Deficit/Hyperactivity Disorder
| Domain | Criteria |
|---|---|
| Essential features |
• Some symptoms that caused impairment were present before age 7 years • Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home) • There must be clear evidence of significant impairment in social, academic, or occupational function • The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder) |
| Six or more of the following symptoms of inattention: | |
| Hyperactivity/Impulsivity traits | Six or more of the following symptoms of hyperactivity-impulsivity: |
From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Arlington, VA, 2000, American Psychiatric Association.
ADHD has three different diagnostic subtypes depending on the number of positive symptoms in each category (Box 15-2).
BOX 15-2 Attention-Deficit/Hyperactivity Disorder (ADHD) Diagnostic Subtypes
Data from Lollar DJ: Function, impairment, and long-term outcomes in children with ADHD and how to measure them, Pediatr Ann 37(1):28-36, 2008.
ADHD is now understood to be a chronic condition with persistence in many individuals into adolescence and adulthood (Van Cleave and Leslie, 2008). Approximately 60% to 85% of children with ADHD continue to have symptoms into adolescence (Pliszka and AACAP, 2007). Factors that increase the risk of ADHD persisting into adolescence and adulthood include a strong family history of ADHD and the comorbidities of aggression and other conduct problems. Multiple studies cited by Spencer and colleagues (2007) show that untreated adults with ADHD struggle with a great many social difficulties including higher rates of marital discord and divorce, lower socioeconomic status, higher unemployment rates, higher rates of substance abuse, poor self-esteem, and higher rates of traffic violations and motor vehicle accidents.
Etiology
Prevalence in the U.S
ADHD prevalence rates vary depending on the source, criteria used to make the diagnosis, and the ages sampled. Overall, the rate of ADHD diagnosis is increasing at a higher rate among teenagers than among younger children (Centers for Disease Control and Prevention [CDC], 2010b; Pastor and Reuben, 2008). There is a 9.5% prevalence for children between 4 and 17 years (5.4 million children), based on parental report of their child having been diagnosed with ADHD (CDC, 2010a). Rates by age are cited as 4- to 10-year-olds, 6.6%; 11- to 14-year-olds, 11.2%; and 15- to 17-year-olds, 13.6%. In 2007, 4.8% of children diagnosed with ADHD were being treated with medication for this condition. ADHD has always been more prevalent in boys than in girls. Current rates show the prevalence in boys at 13.2% and in girls at 5.6% (CDC, 2010a). Girls are more likely than boys to have the symptoms of ADHD, predominantly inattention. This subtype also has greater academic difficulty than ADHD, predominantly hyperactive/impulsive. About 4% of children with ADHD also have a diagnosed learning disability (Pastor and Reuben, 2008).
Cross-Cultural Considerations
In the U.S. the incidence of ADHD in Hispanic children is 5.6%, compared with 10.5% among non-Hispanic children (CDC, 2010a). Those most to least likely to be diagnosed with ADHD are multiracial, African-American, and Caucasian. ADHD has been well documented outside of the U.S. Studies show a similar range of rates of ADHD incidence occurring in children internationally (Buitelaar et al, 2006; Faraone et al, 2003). Although there is agreement across cultures about the presence of ADHD, perceptions often vary by culture, with a paucity of ADHD research from developing countries.
Although ADHD is a condition with a proven neurobiologic basis, it occurs within a sociocultural framework. This is an important consideration for providers in giving sensitive care to families. Perceptions about parenting and childrearing, beliefs about medication and the health care system in general, family and social networking roles in managing child behavior problems, and parents’ own experiences with school are all factors that shape the approach to seeking care, diagnosis, and treatment. Families may have differing understandings of what constitutes behavior problems. Studies show that providers who are most sensitive and successful in working with families are open and honest in the discussion of diagnoses and all treatment options, include key family members in collaborative decision making, and strive to become more aware of the community and cultural values of the populations with which they work (Olaniyan et al, 2007).
Effect on Individuals, Families, and Communities
Because ADHD symptoms cross over so many settings and are chronic, often into adulthood, this condition has a major effect on the individual as well as on his or her family and community. Table 15-5 summarizes impairments across the life span. In families in which ADHD is present, significantly higher levels of stress (than in the general population) are reported. Individuals with ADHD (with and without comorbid conditions) have six times greater difficulty in the areas of friendship with peers, and emotional, and conduct problems than their nonaffected peers. There is a nine times greater likelihood of family stress; problems with classroom learning and conduct; and difficulties with leisure activities (e.g., playing with friends or participating on a sports team) (Strine et al, 2006).
TABLE 15-5 Summary of ADHD Impairments Across the Life Span
| Life Stage | Impairment |
|---|---|
| Childhood | |
| Adolescence | |
| Adulthood |
ADHD, Attention-deficit/hyperactivity disorder.
Adapted from Pliszka S, American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder, J Am Acad Child Adolesc Psychiatry 46(7):894-921, 2007; Spencer TJ, Biederrman J, Mick E: Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities and neurobiology, Ambul Pediatr 7(3):73-81, 2007.
The injury rates among children with ADHD are higher than in the general population. Emergency department admissions rates for children and teens with ADHD are 81% compared with 74% in the general population. Serious accidents such as motor vehicle accidents occur at a higher rate for individuals with ADHD. Adolescents with ADHD also have a greater incidence of traffic violations and driving while under the influence of drugs or alcohol (CDC, 2010a).
ADHD is a chronic health condition and has significant direct and indirect costs at all levels of society. On an individual level ADHD significantly affects self-esteem, peer relationships, educational achievement, and prospective employment possibilities. ADHD, primarily the combined and hyperactive/impulsive subtypes, are predictors of substance abuse, criminal behaviors, marital difficulties, and divorce. Thus the condition can be seen as having indirect costs to society and the legal and criminal justice systems.
ADHD is also a significant cause of family stress and financial burden. Parents of children with ADHD report days of missed work due to the child’s school and medical appointments. Many of the services required for adequate evaluation and treatment of ADHD are not covered by health insurance (e.g., psychological testing, mental health care, or educational testing beyond that done at the school). The average annual direct health care costs for an individual with ADHD are $1,574 compared with $541 for a matched control without ADHD (CDC, 2010a).
Pathophysiology
ADHD is an extremely heterogeneous disorder, meaning there is a wide spectrum of symptoms and severity. Increasingly, neurobiologic research provides strong evidence that ADHD is primarily a genetic, inheritable disorder. There also appears to be a number of environmental factors that may play into the disorder by modulating (i.e., increasing or decreasing) one’s predisposition to underlying biochemical vulnerability (Krull, 2010a; Singh, 2008).
Complex neurobiologic activity that takes place in the prefrontal cortex (PFC) is called “executive functioning.” The PFC is a highly specialized region where organization and regulation of information and stimuli occur. Executive functioning refers to the interwoven processes continually occurring in the PFC: organizing and making sense of input received, sustaining focus on relevant stimuli, suppressing irrelevant stimuli (distractions), drawing on memory to understand stimuli, planning and organizing for future goals and consequences of actions, and regulating emotional and behavioral responses. The PFC in turn transmits information to, and receives input from, other brain areas such as the sensory cortices, basal ganglia, and cerebellum (for attention regulation and motor response) and to the amygdala, hypothalamus, and brainstem nuclei (where emotions and attention/arousal maintenance are regulated) (Arnsten, 2009; Krull, 2010a; National Resource Center on ADHD, 2009).
Genetics and Neurobiologic Pathophysiology
ADHD appears to be caused by deletions or duplications in a number of genes. The genes that are affected are those that regulate the manufacturing of the catecholamine (noradrenergic) neurotransmitters noradrenaline and dopamine in the brain (Arnsten, 2009). The net result of the genetic irregularities is that these neurotransmitters are less available in certain brain regions in individuals with ADHD. Both dopamine and noradrenaline (dopamine more strongly in ADHD) are known to be essential for healthy brain function, especially for alerting to and maintaining attention, maintaining an appropriate level of internal arousal, and inhibiting external distraction. Attention is a complex and multilayered neurologic activity requiring the function and interconnection of a number of different areas of the brain.
Brain imaging shows structural and chemical differences in the temporal and parietal cortices and the PFC in individuals with ADHD compared with those without this condition. The temporal and parietal regions of the brain are responsible for sensory awareness—recognizing and perceiving incoming information, orienting in time and space. Structurally, imaging has shown the brains of individuals with ADHD have smaller prefrontal cortical volumes. Neurochemically, there is also reduced catecholamine activity, particularly in the areas of the basal ganglia and the PFC. It is now felt that these “under-activated” brain regions and the pathways interconnecting them account for the symptoms of ADHD.
Environmental Factors
In many areas the research on environmental factors that contribute to ADHD is inconclusive. Some of the areas that have been or are being researched include:
• Prenatal maternal tobacco use. Prenatal maternal tobacco use is associated with a 2.4-fold increased risk of ADHD (Froehlich et al, 2009).
• Prenatal alcohol use. Direct association with ADHD is not as well established in the literature (DynaMed Database, 2010).
• Lead exposure. Froehlich and associates (2009) report a direct correlation between early lead exposure and later ADHD diagnosis even with low lead levels (<10 mcg/dL).
• Prematurity and low birthweight. Prematurity and low birthweight increase ADHD risk by 2.64-fold (DynaMed Database, 2010).
• Food additives (artificial colors and flavors). There have been a number of studies in this area and none have shown a causal connection between food additives and ADHD. Elimination of food additives is not a recommended part of any ADHD practice guidelines (Krull, 2010b).
• Refined sugar. Although some children respond to excessive sugar with an increased activity level, reviews of many studies fail to show an association with sugar and ADHD (Krull, 2010b).
• Essential fatty acids (omega 3 and omega 6). These nutrients are integral in the development and functioning of neuronal membranes. Three studies showed no benefit to fatty acid supplementation for children with ADHD, although benefits were found in one study (Krull, 2010b).
• Iron deficiency. Low serum ferritin is associated with learning difficulties. One study showed that children with ADHD had lower serum ferritin levels than matched non-ADHD children. Another study (Krull, 2010b) showed that iron supplementation in children with low serum ferritin levels improved ADHD symptoms.
• Zinc. Limited research has demonstrated zinc deficiency in children with ADHD and/or a benefit from zinc supplementation on ADHD symptoms (Krull, 2010b).
Environmental factors such as family adversity and stress, violence in the home, parenting style, and poverty have been studied with regard to how they may contribute to the etiology of ADHD. There is no clear evidence about these factors causing ADHD. However, any of these factors can be seen as modifying or modulating ADHD, as well as other childhood psychiatric conditions (Spencer et al, 2007).
Clinical Findings
Often the patient presents to the provider after having been referred by a child care provider, the school, or the parent/guardian for concerns about excessive energy and activity, fidgety behavior, distractibility, poor school performance, poor relations with peers, aggressive behavior, failure to organize or complete tasks, or some variation of these symptoms. ADHD symptoms can affect the very domains of life where children and adolescents are working on developmental mastery—school, peers, family life, sports, and recreational activities. If the presenting complaint/visit is not specifically about school or behavioral concerns, it is important for the provider to inquire about those areas of the patient’s life.
Assessment
The diagnosis and management of ADHD can be made in the primary care pediatric office, but involves working with the child’s school and other domains where the child regularly spends time (e.g., after-school or childcare programs, sports activities, etc.). There is no “one” assessment tool to diagnose ADHD though there are a number of tools and evidence-based practice guidelines that are available to help clinicians develop an organized, efficient, and safe practice in assessing, diagnosing, and caring for children and adolescents with ADHD. Table 15-6 provides resource information for the four main guidelines.
TABLE 15-6 Clinical Tools and Evidence-Based Guidelines for ADHD Assessment and Treatment
| Name of Tool or Guideline | Age Applicable | What Is Included |
|---|---|---|
| National Initiative for Children’s Healthcare Quality (NICHQ) and American Academy of Pediatrics (AAP): Caring for children with ADHD: a resource toolkit for clinicians (www.nichq.org/resources/ADHD_toolkit.html) | School-age children and adolescents | Materials for ADHD diagnosis and management based on the DSM-IV criteria for school-age children and adolescents; Vanderbilt ADHD assessment tool and scoring information |
| Ages 6 to 12 years | Algorithm and practice recommendations for assessment, diagnosis, and treatment | |
| Ages 3 through 17 years | Recommendations about assessment, diagnosis and treatment | |
| Institute for Clinical Systems Improvement (ICSI) Health care guideline: Diagnosis and management of attention-deficit/hyperactivity disorder in primary care for school-age children and adolescents, March 2010 (www.icsi.org) | School-age children and adolescents | Algorithms for diagnosis and treatment, background on ADHD, tables about ADHD medications, table of the full DSM-IV-TR diagnostic criteria |
ADHD, Attention-deficit/hyperactivity disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
The components of the ADHD assessment include:
• Interview of parent and child or adolescent for history gathering
• Gathering information about symptoms on standardized ADHD behavioral assessment scales from several different sources (parents, caregivers, teachers, sports coaches)
• Gathering other pertinent evaluations (if done) such as school testing and psychological or other mental health evaluations
History
Table 15-7 outlines many of the areas for assessment and suggested topics to explore in taking a history when evaluating for ADHD.
TABLE 15-7 Attention-Deficit/Hyperactivity Disorder History
| Assessment Area | Suggested Topics to Explore |
|---|---|
| Chief complaint and history of present problem | Major areas of concern |
| First awareness of problem | |
| Beliefs about causation of problem | |
| Previous evaluations and results | |
| Medication history for behavioral, emotional, or learning problems | |
| Birth history* | Prenatal history; maternal health; use of medications, recreational drugs, alcohol, and tobacco during pregnancy |
| Prematurity, low birthweight or IUGR | |
| Birth and postpartum complications, anoxia, difficult delivery, birth defects | |
| Neonatal behavior: feeding, sleep, temperament problems | |
| Medical history | Chronic diseases, ongoing medications |
| Hospitalizations, prolonged illness | |
| Trauma history (head injury, frequent injuries) | |
| Poisoning or lead or environmental exposures | |
| Neurologic status, seizures, tics, habit spasms, uncontrolled twitches, outbursts of uncontrollable sounds or words | |
| Environmental allergies | |
| Cardiovascular history (see section about cardiovascular risks with stimulants) | |
| General health* | Vision, hearing |
| ADHD history | Attention: paying attention, sustaining attention, listening, following through, organization, reluctant to engage in activities that need sustained attention, loses things, distracted, forgetful |
| Activity: fidgets, leaves seat, runs or climbs when inappropriate, has difficulty with quiet games, talks excessively, has problems waiting turn, interrupts, “on the go” | |
| Developmental history* | Milestones: motor, personal-social, language, cognitive |
| Strengths (e.g., personality, activities, friendliness) | |
| Weaknesses | |
| Behavioral history* | Frequency with which child complies when told to do something |
| Methods used at home to improve behavior and effectiveness | |
| Parenting skills and style, cultural beliefs | |
| Parental agreement about child management | |
| Counseling history for child or family (or both) | |
| Academic history | Child’s progress at each grade level (strengths seen) |
| Adjustment problems at school, child’s history with peers, friendships | |
| Difficulties with specific skills: reading, writing, spelling, math, concepts | |
| Performance problems: attention, grades, participation, excessive talking, disturbing others, fighting, bullying, teasing, abusive language, not completing work | |
| School assistance: tutoring, counseling, special help | |
| Functional Health Patterns | |
| Feeding | Not able to sit through a complete meal |
| Messy and clumsy with utensils, dishes, and glasses | |
| Inadequate caloric intake can be result of symptoms and further exacerbated by medications used to treat ADHD | |
| Gastric distress may be a side effect of stimulant medication | |
| Elimination | Enuresis, encopresis |
| Sleeping | Difficulty falling asleep, night waking, needs less sleep than other family members |
| Complains about fatigue interfering with completion of tasks | |
| Activity | Difficulty maintaining routines for activities of daily living |
| Cognitive | Level of performance is below potential for achievement |
| Tends to miss the point of conversations and activities | |
| Often does things the hard way in absence of established routines | |
| Self-concept | Struggles with low self-esteem, moodiness |
| Role relationships | Births, deaths, deployment |
| Marriage and family transitions: separation, divorce, remarriage | |
| Violence: domestic, current or past abuse of parent or child; problems with the law; weapons in the home | |
| Inadequate social and relational skills | |
| Lies, steals, plays with fire, hurts animals, is aggressive with other children, talks back to adults | |
| Coping and stress tolerance | Family stress and coping patterns |
| Stressors: parent job loss or change, financial problems | |
| Outbursts of temper, low tolerance for frustration | |
| Moody, worried, sad, quiet, destructive, fearful or fearless, self-deprecating | |
| Somatic complaints | |
| Social and environmental history* | General family relationships (child and parents/siblings) |
| Home, daycare, and school environments | |
| Family social risk factors: recent moves, financial stress, parental job losses, births, deaths, divorces, remarriages, alcohol and drug use, involvement with law enforcement, weapons in the home | |
| Family history* | ADHD, neurologic problems, learning difficulties |
| Mental health history of close family members, health or behavior problems in other family members | |
| Genetic disorders: cognitive disabilities, growth disorders, neurofibromatosis | |
| Drug or alcohol abuse (current and/or past) | |
| Teacher history | Obtain information from school about child’s problems, strengths, weaknesses, academic management of issues |
ADHD, Attention-deficit/hyperactivity disorder; IUGR, intrauterine growth retardation.
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