Child Psychiatry – Attention Deficit Hyperactivity Disorder

By Brennan Williams And Krystal Cardis

Introduction
 Dsm 5 Classification
Diagnostic Criteria:
A. A persistent pattern of inattention and/or hyperactivity-
impulsivity that interferes with functioning or development,
as characterized by (1) and/or (2):
c) Often does not seem to listen when spoken to directly
1. Inattention: Six (or more) of the following symptoms have d) Often does not follow through on instructions and fails
persisted for at least 6 months to a degree that is to finish schoolwork, chores, or duties in the workplace
inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational
activities: e) Often has difficulty organizing tasks and activities
Note: The symptoms are not solely a manifestation of
oppositional behavior, defiance, hostility, or failure to
understand tasks or instructions. For older adolescents and f) Often avoids, dislikes, or is reluctant to engage in tasks
adults (age 17 and older), at least five symptoms are that require sustained mental effort
required.
g) Often loses things necessary for tasks or activities
h) Is often easily distracted by extraneous stimuli (for older
a) Often fails to give close attention to details or makes adolescents and adults, may include unrelated
careless mistakes in schoolwork, at work, or during other thoughts).
activities
i) Is often forgetful in daily activities
b) Often has difficulty sustaining attention in tasks or play
activities
 2. Hyperactivity and impulsivity: Six (or more) of the
following symptoms have persisted for at least 6 months to
a degree that is inconsistent with developmental level and
that negatively impacts directly on social and
academic/occupational activities:
d) Often unable to play or engage in leisure activities
quietly.
e) Is often “on the go,” acting as if “driven by a motor”

Note: The symptoms are not solely a manifestation of

oppositional behavior, defiance, hostility, or a failure to f) Often talks excessively.
understand tasks or instructions. For older adolescents and
adults (age 17 and older), at least five symptoms are g) Often blurts out an answer before a question has been
required. completed

a) Often fidgets with or taps hands or feet or squirms in h) Often has difficulty waiting his or her turn
seat.
i) Often interrupts or intrudes on others
b) Often leaves seat in situations when remaining seated is
expected

c) Often runs about or climbs in situations where it is

inappropriate. (Note: In adolescents or adults, may be
limited to feeling restless.)
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at
home, school, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or
occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic
disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder,
dissociative disorder, personality disorder, substance intoxication or withdrawal).
Specify whether: Specify current severity:

•Mild: Few, if any, symptoms in excess of those required

314.01 (F90.2) Combined presentation
to make the diagnosis are present, and symptoms result in

no more than minor impairments in social or occupational

314.00 (F90.0) Predominantly inattentive presentation
functioning.
314.01 (F90.1) Predominantly hyperactive/impulsive
presentation

Specify if: in partial remission •Moderate: Symptoms or functional impairment between

“mild” and “severe” are present.

•Severe: Many symptoms in excess of those required to

make the diagnosis, or several symptoms that are

particularly severe, are present, or the symptoms result in

marked impairment in social or occupational functioning

 TYPES
314.01 (F90.2) Combined presentation

314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met

but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.

314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2

(hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6
months.
 Risk Factors
-Gender: males> female
- Genetics
-First degree biological relatives (5-6 x increased risk)

-Neurobiology
-Race (identification): Caucasians > African American and Latino

Environmental:
⁻Low birth weight
⁻Smoking during pregnancy
⁻Neurotoxin exposure and alcohol exposure in utero
 Comorbidities
-Oppositional defiant disorder
-Conduct disorder
-Specific learning disorder
-Anxiety disorder
-Major Depressive disorder
-Intermittent explosive disorder
-Substance Use disorder
-Antisocial and other Personality disorders
-OCD
-Tic disorder
-Autism Spectrum disorder
 Primary :
-Oppositional defiant disorder
-Intermittent explosive disorder
-Other neurodevelopmental
disorders
-Specific learning disorder
Differentia
Intellectual disability
l Diagnosis -Autism Spectrum disorder
-Reactive attachment disorder
-Substance use disorders
-Personality disorders
-Psychotic disorders
Secondary
Medication induced Akathisia:
-bronchodilators
-Isoniazid
-Thyroid replacement medication

-Anxiety d/o -Neuroleptics

-Depressive d/o
-Bipolar d/o
-Disruptive mood dysregulation
disorder (“temper”)
General Management
Detailed History and observation.
School history and detailed history from the teacher.
Mental Status may show a secondarily depressed mood.
EEG:
Short absence spell
Temporal Lobe seizure focus can have a secondary behavior disorder.
General Management
Multimodal treatment plan:
1. keep the ADHD diagnostic criteria in mind
2. rule out other physical problems that could cause inattentiveness like: auditory or
visual impairment, specific learning disabilities, absent seizures, language disorders.
3. rule out social and environmental stressors- home situation, bullying at school etc.
4. consider the differentials; and also assessing for comorbidities;
5. Following the diagnosis a multimodal treatment plan is to be employed consisting of:
• Pharmacotherapy
• Education- specifically for the family members and Educators
• Behavioral intervention and social skills training
6. follow up
Pharmacotherapy:
Firstline: Stimulants
• Methylphenidate compounds
• Dextroamphetamine and mixed amphetamine salts

Second-line:
• Atomoxetine (moa: Norepinephrine reuptake
inhibitor)
• Alpha 2 agonist: clonidine and Guanfacine
Drug Mechanism of action Dosage Adverse drug effect

Methylphenidate Inhibit Norepinephrine and Initial, 20 mg PO qAM; may adjust dose in weekly 10-mg • Insomnia
(Ritalin) dopamine reuptake increments, not to exceed 60 mg/day (patients requiring a • Decreased appetite
transporters causing both lower initial dose may begin with 10 mg)
to accumulate.
Amphetamines Decrease dopamine reuptake Initial Dose: 5 mg orally 1 or 2od/BID • High abuse potential
And increases dopamine raised in 5 mg increments at weekly intervals until optimal • Growth suppression
release response is obtained. • Headache
-Maximum 40 mg per day. • Insomnia

Patients starting treatment for the first time or switching from

another medication: -Initial Dose: 20 mg orally once a day

Atomoxetine Norepinephrine reuptake 40mg initial; increase in 3 days to 80mg; OD ; Up to 100mg • Increased risk of suicidal
inhibitor) in 2-4 weeks if unresponsive to previous amounts. ideations in children and
If under 70kg: 0.5mg/kg; 1.2mg/kg after 3 days and adolescents (no actual
1.4mg/kg after 2-4 weeks or 100mg max. reported suicides)
• Constipation; insomnia,
decreased appetite

Clonidine alpha 2 Agonist 0.1mg at bedtime; increase by 0.1 every 7 days as needed; • Fatigue
Guanfacine max o.4mg/day divided in two doses. • Hypotension
Behavior therapy
Modifications in physical and social environment using
rewards and nonpunitive consequences
o Positive reinforcement, time-out, token economy
o Small reachable goals
o Keep organized: maintaining daily schedule,
charts/checklists
o Keep on task: minimum distractions, limiting choices
School based interventions
o Qualifications for special ed
o Tutoring/resource room support
o Classroom modifications
o Extended time to complete tasks
Behavioral techniques cont.
-Individual psychotherapy
-Parental counseling and training
-Treatment for comorbidities/ specifiic learning disorders
-Group therapy (social skills, and increase selfesteem)
 -With aging Impulsivity increases; hyperactivity is
confined to inner jitters/impatience and fidgetiness
in adolescence and decreases into adulthood;
inattentiveness persists.

Course/
-Usually stays relatively stable through adolescence.
Prognosis
-Some have a worsened course and further
development into antisocial behaviors
References
•First Aid for the Psychiatry Clerkship
•Diagnostic and Statistical manual of Mental disorders fifth edition- DSM5 by APA
2012-2013
•Drugs.com
•Kaplan Sadocks Synopsis of Psychiatry 11th Ed