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Attention-deficit /hyperactivity disorder

evaluation and diagnosis

A practical approach

Dev Paeds

Attention deficit/hyperactivity disorder (ADHD) is the

most commonly diagnosed biological-behavioral disorder
of childhood.
Prevalence -6% to 9% of school-aged children. M>F
Persistence of symptoms in 60% to 80% of these
children as they become adolescents.

1918 George still observed an influenza pandemic with
extreme hyperactivity in children and termed it as MBD.

In mid-1970s, largely through the work of researchers

like neuro-psychologist Virginia Douglas, the core
symptoms of ADHD have been considered to be
problems with attention, impulse control, and

Uncertainty remains about whether ADHD represents the

dysfunctional end of a continuum of normal
temperamental characteristics or whether it represents a
discrete qualitatively different biological or psychological
1998 NIH agreed that ADHD is separate clinical entity.

Attention deficit/hyperactivity disorder can be
conceptualized as a cluster of behaviors that are the final
common pathway for a number of heterogeneous
biopsychosocial problems and brain developmental

Because of this heterogeneity, no single factor can be

considered the cause.

Brain dysfunction
In the 1960s, the concept of MBD evolved, associating
impairments in perception, conceptualization, language,
memory, and the control of attention,impulses, or motor
activities with functional problems in the central nervous
This concept was positive in that it focused attention on
brain mechanisms and away from the prevalent view that
ADHD was caused by poor parenting.

Anatomical lesions
Singlele-photon emission computed tomography (SPECT) studies have
shown cerebral hypoperfusion in the striatum and hyperperfusion in sensory
and sensorimotor areas.
Recent studies have shown the right frontal anterior lobes to be decreased
6% to 8% with asymmetry in volume and the caudate nucleus to be
compromised in children with ADHD compared with controls.
MRI - found smaller brain volumes in all regions in children with ADHD
(independent of whether thechildren had taken stimulant medication).
Preliminary fMRI studies have shown adolescents with ADHD to
demonstrate decreased activity in several right hemispheric areas, including
the right frontal region, and increased activity in some subcortical areas,
particularly the right insula and left caudate nucleus during a task of visual
inhibitory control .

QEEG activity during an attentional load task, with

increased slow cortical activity (mainly over the frontal
areas) and decreased fast cortical activity.

This pattern indicates a different arousal level in children

with ADHD, and suggests a delay in functional cortical

Genetics and biochemical alterations

ADHD relatives are at five times higher risk.

There is strong evidence that the catecholamines

dopamine (DA) and norepinepherine (NE) are
components in the pathopysiology of ADHD and in
clinical response to stimulants.

DA D4 transporter gene implicated in ADHD.

Presence of this gene produces a blunted intracellular
response to DA.
1.5 times more frequency in individuals with ADHD than
in the general population.
Lack results in increased DA availability at the synapse
resulting in hyperactivity.

The role of NE in the pathophysiology of ADHD also is

being considered.

Researchers have suggested that an overactivity of the

locus ceruleus may result in hyperactivity and irritability,
and that subsequent down-regulation of frontal lobe
alpha2a receptors may lead to poor concentration and
working memory deficits.

Deficits in neuropsychological functioning

ADHD children encounter similar problems to those
individuals with frontal lobe deficits (abnormalities in
executive functions).

Alterations of executive function are associated with

difficulties with organizing, planning, attending,
controlling impulsive response and setting maintenance.

Disordered adaptation theory

In ancestral environments, when foraging was

necessary, response readiness likely may have included
a high motor activity, hypervigilant, rapid, novel-stimulus
seeking style that is no longer adaptive, particularly to
present lifestyles, including school.
This model suggests that some individuals may retain
these traits because of a lag in remodeling our genome.

Behavioral inhibition theory

Barkley has proposed a model that identifies behavioral
inhibition as the major core deficit in ADHD.
In this theory, the ability to inhibit behavior includes being
able to delay gratification and not respond immediately
to a stimulus, the ability to interrupt ongoing responses,
and to remain focused on a thought or action in the
presence of a distractor.
This behavioral inhibition is postulated to have a direct
effect on blocking immediate motor responses, allowing
time for four major executive functions to operate

These executive functions include

a. nonverbal working memory (such as having
a sense of time, hindsight,forethought, and selfawareness)
b. internalization of speech (including
description,reflection, instructions, and reading
c.self-regulation of affect / motivation /arousal
(social perspective taking, objectivity, and self-regulation
of goal-directed actions)
d. reconstitution (analysis, synthesis, syntax
and fluency of behavior, and goal-directed creativity).

There is no definitive diagnostic test for ADHD, it
remains a behavioral diagnosis.

DSM IV of the American Psychiatric Association, which is

a descriptive diagnostic classification system, remains
the most widely accepted diagnostic tool for ADHD

Requirement for diagnosis

Onset of symptoms occurs before age 7.
symptoms present for 6 months or longer
Symptoms should be pervasive across two or more
major life settings (like home and school)
The frequency and severity are greater than those of
children at a compatible developmental age.
symptoms cause significant impairment in functioning.
Out of the nine symptoms listed for each dimension, six
are required to be present before a diagnosis is made.

Often fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play
Often does not seem to listen when spoken to directly
Often does not follow through on instructions, and fails
to finish schoolwork or duties in the workplace (not
because of oppositional behavior or failure to understand
the instructions)

Often has difficulty organizing tasks and

Often avoids, dislikes, or is reluctant to engage
in tasks that require sustained mental effort
(such as schoolworkor homework)
Often loses things necessary for tasks or
activities (eg, toys,
school assignments, pencils, books, or tools)
Often easily distracted by extraneous stimuli
Often forgetful in daily activities

a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in
which remaining seated is expected
c. Often runs about or climbs excessively in situations in
which it is inappropriate (in adolescents, may be limited
to subjective feelings of restlessness
d. Often has difficulty playing or engaging in leisure
activities quietly
e. Often on the go or often acts as if driven by a
f. Often talks excessively

a. Often blurts out answers before questions have been
b. Often has difficulty awaiting turn
c. Often interrupts or intrudes on others (eg, butts into
conversations or games)

Combined type -adolescents predominantly
Predominantly inattentive type
Predominantly hyperactiveimpulsive type

Functional Impairment
Family relationships, peer status and social skills, academic
achievement, self-esteem and self perception and accidental
Disabilities in these areas can be pervasive,severe, and debilitating.
Parents of children with ADHD experience greater stress, cope less
adaptively, display more negative behavior toward their children and
have more marital discord than parents of children without ADHD .
Children with ADHD are more likely to experience peer disapproval
at extremely high levels and often are rejected by peers after only
brief interactions.

AAP recommends six steps
Primary care clinicians should initiate an
evaluation for ADHD in a child 6 to 12
years old who presents with inattention,
hyperactivity, impulsivity, academic
underachievement or behavior problems.

Recommendation 1
Screening questions.
1. How is your child doing in school?
2. Are there any problems with learning that you or the
teacher have seen?
3. Is your child happy in school?
4. Are you concerned with any behavioral problems in
school, at home, or when your child is playing with
5. Is your child having problems completing classwork or

Recommendation 2
The diagnosis of ADHD requires that a child meet DSMIV criteria.
A critical part of the diagnostic process is that the
clinician must ask about or have parents fill out DSMbased checklists that include all of the 18 behaviors.
Equally important, the behaviors should be endorsed as
occurring often (or usuallyor frequently).
Ascertaining the duration of symptoms is crucial.

Recommendation 3
Evidence directly obtained from parents or caregivers.
Use of scales that screen for multiple behavioral and
developmental problems (broadband scales) is not
recommended in the diagnosis of children for ADHD

Recommendation 4
Information from the childs teacher or
other school personnel who have
observed the child in the classroom may
be obtained from a verbal narrative,
telephone calls, written narrative, and
rating scales.

Recommendation 5
Evaluation of the child with ADHD should
include assessment for coexisting
Coexisting conditions refer to specific
clinical diagnoses with symptoms that may
mimic ADHD or be associated with ADHD

Recommedation 6
Evidence-based studies do not support
the routine use of other diagnostic tests
Laboratory tests
Imaging studies.