Hyperactivity and inattention

4.3 Hyperactivity and inattention



Jill Sewell


Hyperactive and inattentive behaviours are common in children, ranging in a continuum from normal behaviours, especially in young children, to developmentally inappropriate behaviours that impair daily activities at home and at school.


Developmentally inappropriate levels of hyperactivity and inattention may be the result of many factors, both intrinsic and environmental. These risk factors (Box 4.3.1) must all be considered in the assessment of children with difficult behaviour, especially when considering the diagnosis of attention-deficit/hyperactivity disorder (ADHD).



Box 4.3.1 Risk factors for hyperactivity and inattention




• Difficult temperament


• Poor parenting skills


• Family dysfunction


• Child abuse, particularly deprivation


• Developmental delay


• Language disorders


• Learning difficulties


• Anxiety/mood disorders


• Sleep disorders


• Medical conditions, e.g.


• very low birth weight or small for gestational age

• fetal alcohol syndrome

• prenatal exposure to smoking and stress

• lead poisoning

• acquired brain syndrome (head injury)

• chromosomal abnormalities (e.g. fragile X, velocardiofacial syndrome)

• food intolerance (rare)


Definition of attention-deficit/hyperactivity disorder


ADHD is considered to be a developmental disorder of self-regulation, characterized by inattention and hyperactivity/impulsivity. The underlying neurobiological pathway involves the frontal–striatal–cerebellar networks, with deficits occurring in executive functioning, particularly response inhibition, vigilance, working memory and planning.


The diagnosis of ADHD is made using DSM-IV criteria. It is a descriptive diagnosis without implying cause, as it is not a discrete entity and has multiple causes. There must be developmentally inappropriate symptoms of inattention (Box 4.3.2) and/or hyperactivity/impulsivity (Box 4.3.3) with onset before 7  years of age, impairing social, academic or occupational functioning across multiple settings, and these symptoms are not a result of pervasive developmental disorder, psychosis or severe emotional disorders. Subtypes include mainly inattentive, mainly hyperactive or combined.



Box 4.3.2 DSM-IV: Symptoms of inattention




• Poor attention to detail, careless mistakes


• Difficulty sustaining attention


• Seems not to listen


• Seems not to follow through


• Difficulty with organization


• Avoids tasks requiring sustained attention


• Loses things


• Easily distracted


• Forgetful



Box 4.3.3 DSM-IV: Symptoms of hyperactivity/impulsivity




• Fidgets


• Often leaves seat


• Runs, climbs excessively


• Difficulty playing quietly


• ‘On the go’


• Talks excessively


• Blurts out answers


• Difficulty awaiting turn


• Interrupts others


ADHD is common. The prevalence in the school-aged population generally is considered to be 3–5%. Boys are affected more commonly, particularly with hyperactivity. There is a higher incidence in disrupted families and in those with low incomes, again particularly with hyperactivity. There is a strong genetic factor, with about 30% of siblings, 25% of parents and 80% of identical twins affected. Molecular genetic studies have focused on chromosomes that regulate dopamine, the neurotransmitter most associated with learning, motivation, goals and movement, and noradrenaline (norepinephrine), involved in maintaining alertness and attention, particularly with novel stimuli. Two candidate genes, the dopamine transporter and dopamine receptor genes, are reported to be associated with ADHD.



image Clinical example


Sammy, aged 6  years, was in his second year of school. His teacher complained that he never sat still, did not complete tasks, talked too much, interrupted, and was well behind with reading.


His mother recalled that he had been ‘on the go’ since about 2  years of age, always preferred playing outdoors rather than settling to games inside, never seemed to remember instructions or the house rules, and acted without thinking about the consequences. He hated homework and ‘often forgot’ to bring home his school reader.


Sammy’s problems are consistent with a diagnosis of ADHD and learning difficulties. Stimulant medication and consistent structure at home and at school helped his behavioural symptoms, but he also required educational assessment and specific reading support in the classroom.


Many children with ADHD have associated neurodevelopmental or mental health problems (co-morbidities) (Box 4.3.4). Because of overlapping features, separation into these diagnostic categories is complex; however, it is helpful when completing a descriptive assessment and recommending specific management programmes.



Box 4.3.4 Co-morbidities with attention-deficit/hyperactivity disorder




• Learning difficulties (10–30%)


• Language disorder (30–50%)


• Oppositional defiant disorder (30–50%)


• Conduct disorder (16–20%)


• Anxiety, mood disorders


• Developmental coordination disorder


• Tics, Tourette syndrome

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Aug 4, 2016 | Posted by in PEDIATRICS | Comments Off on Hyperactivity and inattention

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