Attention deficit hyperactivity disorder (ADHD): Clinical sciences

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.

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.

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.

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.