Attention deficit hyperactivity disorder (ADHD): Clinical sciences

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Introduction0:00–0:33

Attention-deficit hyperactivity disorder, or ADHD, is a common neurodevelopmental disorder characterized by excessive levels of inattention, hyperactivity, and impulsivity.
As a result of these symptoms, children with ADHD experience impaired social, emotional, and academic functioning; and many exhibit poor impulse control.
Timely diagnosis, and age-appropriate management of ADHD, improve long-term social, emotional, academic, and occupational outcomes.

H&P0:33–1:51

Now, if a pediatric patient presents with a chief concern suggesting ADHD, you should first obtain a focused history and physical exam.
Most patients present after four years of age, and caregivers or teachers report excessive hyperactivity, impulsivity, or inattention.
These children often demonstrate academic underachievement and poor emotional regulation, as well as delayed social and play skills.
The history may also reveal risk factors for ADHD, such as prematurity, low birth weight, or adverse childhood experiences; while the family history often reveals one or more family members with ADHD.
The physical exam is often unremarkable unless the patient has a coexisting condition with distinct phenotypic features, such as fetal alcohol syndrome or fragile X syndrome.
Here’s a clinical pearl! Toddlers tend to have high energy levels and short attention spans, so it can be challenging to determine whether their behaviors are developmentally appropriate.
For this reason, ADHD is not usually diagnosed before 4 years of age. However, any child with concerning behaviors should be referred for evaluation and early intervention services.
Alright, with these findings, you should suspect ADHD and arrange for a comprehensive psychoeducational evaluation. This evaluation includes a developmental and behavioral history that focuses on early childhood development, troublesome behaviors, and academic performance.

Comprehensive psychoeducational evaluation1:51–3:20

Parent- and teacher-reported behavioral rating scales can be used during the initial evaluation to identify symptoms of inattention, hyperactivity, and impulsivity within different settings.
Children who demonstrate academic underachievement might also benefit from a school-based educational assessment to identify and address any coexisting language disorders or learning disabilities.
Additionally, since ADHD frequently occurs in tandem with developmental, mood, and behavioral disorders, such as anxiety and autism spectrum disorder, these children should be screened for comorbid conditions during the initial diagnostic evaluation.
For example, you should consider oppositional defiant disorder if your patient demonstrates hostility and intentional defiance of authority.
Here’s a high-yield fact! ADHD often co-occurs with Tourette syndrome, which is a tic disorder characterized by frequent uncontrollable repetitive movements and vocalizations for at least one year.
Tourette syndrome typically has an onset between middle childhood and late adolescence and is more prevalent in biological males.

Assess DSM-5 Criteria3:20–5:14

Now, using the information you gathered from the comprehensive psychoeducational evaluation, you can assess whether your patient fulfills the ADHD diagnostic criteria from the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition, or DSM-5.
First, determine whether your patient exhibits six or more moderate-to-severe symptoms from at least one of the two categories.
The first category contains symptoms related to hyperactivity and impulsivity. Hyperactive symptoms include constant fidgeting, difficulty remaining seated, difficulty staying still, and appearing to be “on the go”.
Additional symptoms include excessive talkativeness and the inability to play quietly. Impulsive symptoms include blurting out answers before being called on, having difficulty taking turns, and interrupting others frequently.
Now, let’s look at the second category, which consists of symptoms related to inattention. These include difficulty sustaining attention, avoidance of tasks that require focus, and high distractibility.
Additionally, these children might appear as if they are not listening, even when spoken to directly, and they may frequently fail to complete tasks and lack attention to detail.
Other inattentive symptoms include forgetfulness, poor organizational skills, and a tendency to lose important items and belongings.
In order to diagnose ADHD, the symptoms must have started before 12 years of age and must be present for more than six months, in at least two settings, such as home and school.
Finally, these symptoms must be severe enough to impair academic, social, or adaptive functioning. Now, if your patient does not meet these criteria, consider an alternative diagnosis, such as a mood, anxiety, or personality disorder.
On the other hand, if your patient meets these criteria, you can diagnose ADHD. Depending on their symptoms, you can classify your patient’s ADHD as predominantly hyperactive-impulsive, predominantly inattentive, or combined type ADHD.

ADHD5:14–5:51

Even though characterizing the ADHD subtype does not change medical management, doing so may help you target specific behavioral interventions.
Once you’ve diagnosed ADHD, you’ll need to assess your patient’s age before starting treatment. First, let’s discuss patients who receive a diagnosis between four and five years of age.

4-5 years5:51–6:27

At this age, ADHD treatment relies on behavioral management. If it’s available, behavioral management training can equip caregivers with techniques that positively reinforce age-appropriate behaviors and discourage maladaptive behaviors.
However, if a child’s ADHD-related behaviors do not improve with these interventions, or if behavioral management training is not available, you can consider starting a stimulant medication.
Methylphenidate is the recommended choice for preschool-aged children. Moving on, let’s discuss management for children who are diagnosed between six and eleven years of age.

6-11 years6:27–7:51

For this age group, stimulant medication should be used as a first-line treatment to support focus and learning during school hours.
When compared with children who do not take medications for their ADHD, those who are medicated have improved social functioning and academic outcomes, as well as lower rates of mood disorders and substance use.
There are two classes of stimulant medications, amphetamine and methylphenidate, both of which come in long and short-acting forms.
The medication dose should be increased as tolerated over the first several weeks, in order to manage ADHD symptoms effectively while minimizing side effects like appetite suppression, headaches, and sleep disturbance.
In addition to medication, children with ADHD should receive educational support, to promote academic, adaptive, and social skill development.
These children may benefit from a high teacher-to-student ratio, an orderly classroom environment, a predictable schedule, and clear expectations.
Finally, since behavioral management training can provide additional benefits for pre-adolescent children when paired with stimulant medication, you may choose to offer this to your patient’s caregiver.
Keep in mind that behavioral management becomes less effective as children grow older and increasingly self-reliant. Finally, let’s discuss management for children 12 years of age and older.

12 years of age and older7:51–8:29

Although symptoms of hyperactivity often wane during adolescence, symptoms of inattention tend to persist into adulthood.
For this reason, adolescents with ADHD should continue to receive stimulant medication and educational support in order to facilitate learning and academic success.
Additionally, older children may benefit from skills training, which can help them improve planning and organization, time management, emotional regulation, and other skills related to academic, social, and executive functioning.
Alright, as a quick recap… If a pediatric patient presents with a chief concern suggesting ADHD, start with a focused history and physical exam.

Review8:29–9:01

Symptoms of inattention, hyperactivity, or impulsivity, with academic underachievement, suggest a diagnosis of ADHD. Next, arrange for a comprehensive psychoeducational evaluation, and if the patient meets the DSM-5 diagnostic criteria, you can diagnose ADHD.
Finally, ADHD management depends on the
Attention deficit hyperactivity disorder (ADHD) | Osmosis