ADHD Patient Management

Definition: diminished sustained attention + higher levels of Pharmacotherapeutic

impulsivity/hyperactivity than normal Meds are 1st line treatment
Several inattentive or hyperactive-impulsive symptoms must be present CNS stimulants first choice
by age 12 Nonstimulant medications
Three specifiers: Psychosocial Interventions
1. Combined presentation Psychoeducation
2. Predominantly inattentive presentation Organization skills
3. Predominantly hyperactive/impulsive presentation Parental training
Epidemiology Behavior modification
5-8% grade-school children in US CBT
60-85% continue to have diagnosis in adolescence Social skills training
60% continue to have diagnosis in adulthood Prognosis
Male > Female (2:1) Course is variable depends on life situation, genetics,
Rate of ADHD in parents and siblings of children with ADHD is 2-8x comorbidities, etc.
greater than gen. pop. Usually does not remit in mid-childhood
1st degree relatives at risk of developing AD/HD as well as Persists to adolescence or adulthood
other disorders Remits by puberty or early adulthood (12-20yo)
Etiology Some symptoms get better, some stay
Genetic 75% heritability estimate Those with symptoms persisting into adolescence are at risk for
Neurophysiologic factors conduct disorder & substance abuse disorders
Brain electrical activity (EEG studies)
Neuroanatomical aspects
Brain networks
Developmental factors
Premature birth, maternal infection, trauma, etc
Psychosocial factors
Abuse, neglect, etc.
Comorbid conditions:
Learning disorders
Anxiety disorders
Mood disorders
Disruptive behavior disorders
Clinical Presentation:
Onset: typically toddler age
Symptoms:
Inattention and/or hyperactivity/impulsivity
Attention deficit short attention span, distractibility,
does not complete tasks, poor concentration
Impulsivity abrupt shift in activity, action before
though, disorganization
Memory, thinking deficits
Learning disabilities
Speech and hearing deficits
Aggression, defiance
*Impulsiveness and inability to delay gratification are characteristic
Dx:
History from parents, caregivers, teachers, etc.
Criteria:
Impairment must be present in 2+ settings
Impairment must interfere with social/academic functioning
See DSM-5 Diagnostic Criteria Table 31.3-1
DDx:
Temperamental characteristics: Behaviors do not cause
impairment to the degree to meet DSM criteria
Anxiety
Depression
Mania
Bipolar
Oppositional defiant disorder
Diagnostic Work Up
Psych & medical history
Prenatal/perinatal/toddler and family history
Seizure work up
Hearing/visual eval
Thyroid eval
Hypoglycemia eval