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| | __NOTOC__ |
| '''For patient information click [[Attention-deficit hyperactivity disorder (patient information)|here]]''' | | '''For patient information click [[Attention-deficit hyperactivity disorder (patient information)|here]]''' |
| | {{ADHD}} |
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| {{Infobox_Disease | | {{CMG}}; {{AE}} {{KS}}, {{HW}} |
| | Name = Attention-Deficit Hyperactivity Disorder (USA)
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| | DiseasesDB = 6158
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| | ICD10 = {{ICD10|F|90||f|90}}
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| | ICD9 = {{ICD9|314.00}}, {{ICD9|314.01}}
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| | OMIM = 143465
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| | MedlinePlus = 001551
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| | eMedicineSubj =
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| }}
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| {{ADHD}} | |
| '''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Laura Tommaso, M.D.
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| {{SK}} ADHD | | {{SK}} Adult attention-deficit disorder; AADD; ADD; ADD/ADHD; ADHD; ADHD predominantly hyperactive-impulsive; ADHD predominantly inattentive; hyperactiveness; other specified attention-deficit/hyperactivity disorder; short attention span; unspecified attention-deficit/hyperactivity disorder; hyperkinetic syndrome; ADDH; childhood hyperkinesis |
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| ==[[Attention-deficit hyperactivity disorder overview|Overview]]== | | ==[[Attention-deficit hyperactivity disorder overview|Overview]]== |
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| ==[[Attention-deficit hyperactivity disorder pathophysiology|Pathophysiology]]== | | ==[[Attention-deficit hyperactivity disorder pathophysiology|Pathophysiology]]== |
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| ==[[Attention-deficit hyperactivity disorder epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Attention-deficit hyperactivity disorder causes|Causes]]== |
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| ==Symptoms== | | ==[[Attention-deficit hyperactivity disorder differential diagnosis|Differentiation Attention-Deficit Hyperactivity Disorder from Other Diseases]]== |
| The most common symptoms of ADHD are distractibility, difficulty with concentration and focus, short term memory slippage, procrastination, problems organizing ideas and belongings, tardiness, impulsivity, and weak planning and execution. Not all people with ADHD have all the symptoms. Most ordinary people exhibit some of these behaviors but not to the point where they seriously interfere with the person's work, relationships, or studies or cause anxiety or depression. Children do not often have to deal with deadlines, organization issues, and long term planning so these types of symptoms often become evident only during adolescence or adulthood when life demands become greater.
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| According to an advanced high-precision [[imaging]] study by researchers at the United States [[National Institutes of Health]]'s [[National Institute of Mental Health]], an actual delay in physical development in some brain structures, with a median value of three years, was observed in the brains of 223 ADHD patients beginning in elementary school, during the period when cortical thickening during childhood begins to change to thinning following [[puberty]]. The delay was most prominent in the [[frontal cortex]] and temporal cortex, which are believed responsible for the ability to control and focus thinking, attention and planning, suppress inappropriate actions and thoughts, remember things from moment to moment, and work for reward, all functions whose disturbance is associated with a diagnosis of ADHD; the region with the greatest average delay, the middle of the prefrontal cortex, lagged a full five years in development in the ADHD patients. In contrast, the [[motor cortex]] in the ADHD patients was seen to mature faster than normal, suggesting that both slower development of behavioral control and advanced motor development might both be required for the restlessness and fidgetiness that characterise an ADHD diagnosis. Aside from the delay, both groups showed a similar back-to-front development of brain maturation with different areas peaking in thickness at different times. This contrasts with the pattern of development seen in other disorders such as [[autism]], where the peak of cortical thickening occurs much earlier than normal.<ref>[http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-in-adhd-but-follows-normal-pattern.shtml Brain Matures a Few Years Late in ADHD, But Follows Normal Pattern] NIMH Press Release, November 12, 2007 </ref>
| | ==[[Attention-deficit hyperactivity disorder epidemiology and demographics|Epidemiology and Demographics]]== |
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| The same laboratory had previously found involvement of the "7-repeat" variant of the [[D4DR|dopamine D4 receptor]] gene, which accounts for about 30 percent of the genetic risk for ADHD, in unusual thinness of the cortex of the right side of the brain; however, in contrast to other variants of the gene found in ADHD patients, the region normalized in thickness during the teen years in these children, coinciding with clinical improvement.<ref>[http://www.nimh.nih.gov/science-news/2007/gene-predicts-better-outcome-as-cortex-normalizes-in-teens-with-adhd.shtml Gene Predicts Better Outcome as Cortex Normalizes in Teens with ADHD] NIMH Press Release, August 6, 2007 </ref> Hyperactivity is common among children with ADHD but tends to disappear during adulthood. However, over half of children with ADHD continue to have symptoms of inattention throughout their lives.
| | ==[[Attention-deficit hyperactivity disorder risk factors|Risk Factors]]== |
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| Inattention and "hyperactive" behavior are not the only problems with children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it. Many of these co-existing conditions require other courses of treatment and should be diagnosed separately instead of being grouped in the ADHD diagnosis. Some of the associated conditions are:
| | ==[[Attention-deficit hyperactivity disorder natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| a. Oppositional-Defiance Disorder (35%) and Conduct Disorder(26%). These are both characterized by extreme anti-social behaviors. These disorders are frequently characterized by aggression, frequent temper tantrums, deceitfulness, lying, or stealing.
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| b. Primary Disorder of Vigilance. Characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch, and appear to be hyperactive in order to remain alert.
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| c. Bi-polar disorder. As many as 25% of children with ADHD may have bipolar disorder. Children with this combination may demonstrate more aggression and behavioral problems than those with ADHD alone.
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| d. Anxiety Disorders. Commonly accompany ADHD, particularly Obsessive-Compulsive Disorder. OCD is believed to share a genetic component with ADHD, and shares many of its characteristics. Although children with ADHD have an inability to maintain attention, conversely, they may also fixate.
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| </ref?[http://www.nimh.nih.gov/healthinformation/adhdmenu.cfm]
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| ==Diagnosis== | | ==Diagnosis== |
| | | [[Attention-deficit hyperactivity disorder diagnostic criteria|Diagnostic Criteria]] | [[Attention-deficit hyperactivity disorder rating scales for diagnosis|Rating scales for diagnosis]] | [[Attention-deficit hyperactivity disorder history and symptoms|History and Symptoms]] | [[Attention-deficit hyperactivity disorder physical examination|Physical Examination]] | [[Attention-deficit hyperactivity disorder laboratory findings|Laboratory Findings]] | [[Attention-deficit hyperactivity disorder other imaging findings|Imaging Findings]] |
| Many of the symptoms of ADHD occur from time to time in everyone. In those with ADHD the frequency of these symptoms occurs frequently and impairs regular life functioning typically at school or at work. Not only will they perform poorly in task oriented settings but they will also have difficulty with social functioning with their peers. No objective physical test exists to diagnose ADHD in a patient. As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these critera are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders ([[DSM-IV]] ), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified:
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| # ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
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| # [[ADHD predominantly inattentive|ADHD Predominantly Inattentive]] Type: if criterion 1A is met but criterion 1B is not met for the past six months
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| # ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.
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| The terminology of ADD expired with the revision of the most current version of the DSM. Consequently, ADHD is the current nomenclature used to describe the disorder as one distinct disorder which can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD, predominately hyperactive-impulsive type) or inattention (ADHD predominately inattentive type) or both (ADHD combined type).
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| ===DSM-IV criteria for ADHD===
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| I. Either A or B:
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| :A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
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| :# Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
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| :# Often has trouble keeping attention on tasks or play activities.
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| :# Often does not seem to listen when spoken to directly.
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| :# Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
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| :# Often has trouble organizing activities.
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| :# Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
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| :# Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
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| :# Is often easily distracted.
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| :# Often forgetful in daily activities.
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| :B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
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| :# Often fidgets with hands or feet or squirms in seat.
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| :# Often gets up from seat when remaining in seat is expected.
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| :# Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
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| :# Often has trouble playing or enjoying leisure activities quietly.
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| :# Is often "on the go" or often acts as if "driven by a motor".
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| :# Often talks excessively.
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| :#Impulsiveness
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| :# Often blurts out answers before questions have been finished.
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| :# Often has trouble waiting one's turn.
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| :# Often interrupts or intrudes on others (e.g., butts into conversations or games).
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| II. Some symptoms that cause impairment were present before age 7 years.
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| III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
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| IV. There must be clear evidence of significant impairment in social, school, or work functioning.
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| V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, [[Schizophrenia]], or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
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| In the tenth edition of the ''[[International Statistical Classification of Diseases and Related Health Problems]]'' (ICD-10) the symptoms of ADD are given the name "Hyperkinetic disorders". When a [[conduct disorder]] (as defined by ICD-10<ref name=ICD10> [http://www.who.int/classifications/apps/icd/icd10online/ ICD Version 2006: F91.] [[World Health Organization]]. Retrieved on [[December 11]], [[2006]].</ref>) is present, the condition is referred to as "Hyperkinetic conduct disorder". Otherwise the disorder is classified as "Disturbance of Activity and Attention", "Other Hyperkinetic Disorders" or "Hyperkinetic Disorders, Unspecified". The latter is sometimes referred to as, "Hyperkinetic Syndrome".<ref name=ICD10/>
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| The [[American Academy of Pediatrics]] [[Guideline (medical)|Clinical Practice Guideline]] for children with ADHD emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria:<ref>Perrin JM, Stein MT, Amler RW, Blondius TA. 2001. "Clinical practice guideline: treatment of school-aged children with Attention Deficit/Hyperactivity Disorder". ''Pediatrics'' 108 (4):1033-1044. PMID 11581465</ref>
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| * The use of explicit criteria for the diagnosis using the [[DSM-IV-TR]].
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| * The importance of obtaining information about the child’s symptoms in more than one setting.
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| * The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.
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| The first criterion can be satisfied by using an ADHD-specific instrument such as the Conners' Rating Scale.<ref>{{cite journal |author=Conners CK, Sitarenios G, Parker JD, Epstein JN |title=Revision and restandardization of the Conners Teacher Rating Scale (CTRS-R): factor structure, reliability, and criterion validity |journal=Journal of abnormal child psychology |volume=26 |issue=4 |pages=279–91 |year=1998 |pmid=9700520}}</ref> The second criterion is best fulfilled by examining the individual's history. This history can be obtained from parents and teachers, or a patient's memory.<ref>Ratey, John; Hallowell, Edward. ''Driven to Distraction'' first edition, p. 42</ref> The requirement that symptoms be present in more than one setting is very important because the problem may not be with the child, but instead with teachers or parents who are too demanding. The use of [[intelligence test]]ing, [[psychological testing]], and [[neuropsychological test]]ing (to satisfy the third criterion) is essential in order to find or rule out other factors that might be causing or complicating the problems experienced by the patient.<ref>Ninivaggi, F. J. "Borderline intellectual functioning and academic problem." In: Sadock B.J. Sadock, V.A., eds. ''Kaplan & Sadock's Comprehensive Textbook of psychiatry. 8th ed.'' Vol. II. Baltimore: Lippincott William and Wilkins; 2005: 2272–76.</ref>
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| The [[Centers for Disease Control and Prevention]] (CDC) state that a diagnosis of ADD should only be made by trained health care providers, as many of the symptoms may also be part of other conditions, such as bodily illness or other physiological disorders, such as [[hypothyroidism]]. It is not uncommon that physically and mentally [[Pathology|nonpathological]] individuals exhibit at least some of the symptoms from time to time. Severity and pervasiveness of the symptoms leading to prominent functional impairment across different settings (school, work, social relationships) are major factors in a positive diagnosis.
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| Adults often continue to be impaired by ADD. Adults with ADD are diagnosed under the same criteria, including the stipulation that their symptoms must have been present prior to the age of seven.<ref name="DSM">[http://www.psychiatryonline.com/content.aspx?aID=7721 Attention-Deficit/Hyperactivity Disorder.] Psychiatry Online. Retrieved on 2007-08-13.</ref> Adults face some of their greatest challenges in the areas of self-control and self-motivation, as well as [[executive functioning]], usually having more symptoms of inattention and fewer of hyperactivity or impulsiveness than children do.<ref>Jensen, PS. [http://medoffice.medscape.com/viewarticle/530193_2 Exploring the Neurocircuitry of the Brain and Its Impact on Treatment Selections in ADD.] Medscape. Retrieved on 2007-08-13.</ref>
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| Common comorbid conditions are [[Oppositional Defiance Disorder]] (ODD). About 20% to 25% of children with ADD meet criteria for a [[learning disorder]].<ref>{{cite journal |author=Pliszka S |title=Patterns of psychiatric comorbidity with attention-deficit/hyperactivity disorder |journal=Child Adolesc Psychiatr Clin N Am |volume=9 |issue=3 |pages=525–40, vii |year=2000 |pmid=10944655}}</ref> Learning disorders are more common when there are inattention symptoms.<ref>{{cite journal|title= Attention deficit hyperactivity disorder subtypes: Are there differences in academic problems?|journal=Dev neuropsychology|date=1995|author=Lamminmäky T '' et al''|issue=11|pages=297–310}}</ref>
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| ==Treatment== | | ==Treatment== |
| {{main|Attention-deficit hyperactivity disorder treatments}}
| | [[Attention-deficit hyperactivity disorder combination therapy|Combination Therapy]] | [[Attention-deficit hyperactivity disorder medical therapy|Medical Therapy]] | [[Attention-deficit hyperactivity disorder psychotherapy|Psychotherapy]] | [[Attention-deficit hyperactivity disorder brain stimulation therapy|Brain Stimulation Therapy]] | [[Attention-deficit hyperactivity disorder future or investigational therapies|Future or Investigational Therapies]] | [[Attention-deficit hyperactivity disorder cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Attention-deficit hyperactivity disorder monitoring response to therapy|Monitoring Response to Therapy]] |
| Singularly, stimulant medication is the most efficient and cost effective method of treating ADHD. <ref>Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf</ref> <ref name = "Jensen">{{cite journal | author = Jensen, et al | title = Cost-Effectiveness of ADHD Treatments: Findings from the Multimodal Treatment Study of Children With ADHD | journal = American Journal of Psychiatry | volume = 162 | pages = 1628–1636 (Page:1633) | year = 2005 | pmid = 16135621 | doi = 10.1176/appi.ajp.162.9.1628}} [http://ajp.psychiatryonline.org/cgi/content/full/162/9/1628 Free full text]</ref> Over 200 controlled studies have shown that stimulant medication is an effective way to treat ADHD.<ref name="BarkleyContEd"/><ref>Barkley, Russell A. [http://www.continuingedcourses.net/active/courses/course006.php?PHPSESSID=169b92182fe1584725 Treating Children and Adolescents with ADHD: An Overview of Empirically Based Treatments.] ContinuingEdCourses.Net. Retrieved on 2007-08-13.</ref> Methods of treatment usually involve some combination of medications, behaviour modifications, life style changes, and counseling. Behavioral parent training, behavior therapy aimed at parents to help them understand ADHD has also shown short term benefits.<ref>Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf</ref> [[Omega-3 fatty acids]], [[zinc]] and [[magnesium]] may have benefits with regard to ADHD symptoms.<ref name="pmid16190793">{{cite journal |author=Arnold LE, DiSilvestro RA |title=Zinc in attention-deficit/hyperactivity disorder |journal=Journal of child and adolescent psychopharmacology |volume=15 |issue=4 |pages=619-27 |year=2005 |pmid=16190793 |doi=10.1089/cap.2005.15.619}}</ref><ref name="pmid16962757">{{cite journal |author=Antalis CJ, Stevens LJ, Campbell M, Pazdro R, Ericson K, Burgess JR |title=Omega-3 fatty acid status in attention-deficit/hyperactivity disorder |journal=Prostaglandins Leukot. Essent. Fatty Acids |volume=75 |issue=4-5 |pages=299-308 |year=2006 |pmid=16962757 |doi=10.1016/j.plefa.2006.07.004}}</ref>
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| [[Comorbid]] disorders or substance abuse can make finding the proper diagnosis and the right overall treatment more costly and time-consuming. Psychosocial therapy is useful in treating some comorbid conditions.<ref>{{cite journal | author =Foster, et al | title = Treatment of ADHD: Is More Complex Treatment Cost-Effective for More Complex Cases? | journal =HSR: Health Services Research | volume = 42 | issue = 1 | pages = 165–182 (Page:177) | year = 2007 | pmid = 17355587}}</ref>
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| ==Prognosis==
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| The diagnosis of ADHD implies an impairment in life functioning. Many adverse life outcomes are associated with ADHD.
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| During the elementary years an ADHD student will have more difficulties with work completion, productivity, planning, remembering things needed for school, and meeting deadlines. Oppositional and socially aggressive behavior is seen in 40-70 percent of children at this age. Even ADHD kids with average to above average intelligence show "chronic and severe under achievement". Fully 46% of those with ADHD have been suspended and 11% expelled.<ref>U.S. Department of Education [http://www.ed.gov/rschstat/research/pubs/adhd/adhd-identifying_pg4.html "How Does ADHD Affect School Performance?"], 2007</ref> Thirty seven percent of those with ADHD do not get a high school diploma even though many of them will receive special education services.<ref name="BarkleyContEd"/> The combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish highschool.<ref>{{PDFlink|http://eric.ed.gov/ERICDocs/data/ericdocs2/content_storage_01/0000000b/80/22/94/d6.pdf}}</ref> Only five percent of those with ADHD will get a college degree compared to twenty seven percent of the general population. ([[United States Census|US Census]], 2003)
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| ==See also==
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| '''General'''
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| * [[Adult attention-deficit disorder]]
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| * [[Developmental disability]]
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| * [[Educational psychology]]
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| * [[Sluggish cognitive tempo]]
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| '''Controversy'''
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| * [[Chemical imbalance]]
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| * [[Attention-deficit hyperactivity disorder controversies]]
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| '''Related disorders'''
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| * [[Auditory processing disorder]]
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| * [[Sensory integration disorder]]
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| * [[Oppositional defiant disorder|ODD]]
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| ==References==
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| {{reflist|2}}
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| ==Further reading==
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| *National Institute of Health
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| http://www.nlm.nih.gov/medlineplus/ency/article/001551.htm
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| *Hartmann,Thom "Attention Deficit Disorder, A Different Perception" subtitled "A Hunter in a Farmers World".
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| *Barkley, Russell A. ''Take Charge of ADHD: The Complete Authoritative Guide for Parents'' (2005) New York: Guilford Publications.
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| *Bellak L, Kay SR, Opler LA. (1987) "Attention deficit disorder psychosis as a diagnostic category". ''Psychiatric Developments'', 5 (3), 239-63. PMID 3454965
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| *Conrad, Peter ''Identifying Hyperactive Children'' (Ashgate, 2006).
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| *Green, Christopher, Kit Chee, ''Understanding ADD''; Doubleday 1994; ISBN 0-86824-587-9
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| *Hanna, Mohab. (2006) ''Making the Connection: A Parent's Guide to Medication in AD/HD'', Washington D.C.: Ladner-Drysdale.
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| *Joseph, J. (2000). "Not in Their Genes: A Critical View of the Genetics of Attention-Deficit Hyperactivity Disorder", ''Developmental Review'' 20, 539-567.
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| *Kelly, Kate, Peggy Ramundo. (1993) ''You Mean I'm Not Lazy, Stupid or Crazy?! A Self-Help Book for Adults with Attention deficit Disorder''. ISBN 0-684-81531-1
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| *Matlen, Terry. (2005) "Survival Tips for Women with AD/HD". ISBN 1886941599
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| *Ninivaggi, F.J. "Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: Rethinking Diagnosis and Treatment Implications for Complicated Cases", ''Connecticut Medicine''. September 1999; Vol. 63, No. 9, 515-521. PMID 10531701
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| *[http://www.cdc.gov/ncbddd/adhd/default.htm Attention-Deficit / Hyperactivity Disorder (ADHD)] at the Center for Disease Control
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| *[http://consensus.nih.gov/1998/1998AttentionDeficitHyperactivityDisorder110html.htm Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder] at NIH
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| *[http://www.nimh.nih.gov/publicat/adhd.cfm National Institute of Mental Health on ADHD]
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| {{WH}} | | {{WH}} |
| {{WS}}
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| [[Category:Overview complete]]
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| [[Category:Disease]]
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| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Pediatrics]]
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