Pediatric Attention Deficit Hyperactivity Disorder Clinical Presentation

The DSM-IV criteria, in conjunction with a thorough clinical interview regarding daily functioning, are important in the diagnosis of attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD). Of note, some of the DSM-IV criteria have been revised to reflect state-of-the-art knowledge, including data regarding ADHD (ADD) in girls and women. The clinician should also gather information that helps to identify any coexisting conditions.

History of present illness

All of the following DSM-IV criteria for ADHD (ADD) must be present:

• Either the criteria for inattention or the criteria for hyperactivity/impulsivity must be met.

  • Inattention: At least 6 of the 9 symptoms of inattention listed below must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the patient's developmental level.
    1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
    2. Often has difficulty sustaining attention in tasks or play activities
    3. Often does not seem to listen when spoken to directly
    4. Often does not follow through with instructions and often fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
    5. Often has difficulty organizing tasks and activities
    6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg, schoolwork, homework); often loses things necessary for tasks or activities (eg, school assignments, pencils, books, tools, toys)
    7. Often is easily distracted by extraneous stimuli (eg, toys, school assignments, pencils, books, tools)
    8. Often is forgetful in daily activities
  • Hyperactivity/impulsivity: At least 6 of the 9 symptoms of hyperactivity (symptoms 1-6) and impulsivity (symptoms 7-9) listed below have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the patient's developmental level.
    1. Often fidgets with hands or feet or squirms in seat
    2. Often leaves seat in classroom or in other situations in which remaining seated is expected
    3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents and adults, may be limited to subjective feelings of restlessness)
    4. Often has difficulty quietly playing or engaging in leisure activities
    5. Often on the go or often acts as if driven by a motor
    6. Often talks excessively
    7. Often blurts out answers before questions have been completed
    8. Often has difficulty awaiting turn
    9. Often interrupts or intrudes on others (eg, butts into conversations or games)
• Some hyperactive-impulsive or inattentive symptoms that caused impairment are present before age 7 years
• Symptoms must be present in 2 or more situations (eg, school, work, home).
• The disturbance causes clinically significant distress or impairment in social, academic, or occupational function.
• Behavior does not exclusively occur during the course of pervasive developmental disorder, premenstrual dysphoric disorder, schizophrenia, or other psychotic disorder. No mood disorder, anxiety dissociative disorder, or personality disorder accounts for the behavior.

Past medical history

• Screen for the following medications or supplements that may have negative interactions with ADHD (ADD)-related medications:

  • Anticonvulsant agents
  • Antihypertensive agents
  • Caffeine-containing drugs
  • Pseudoephedrine
  • Ephedra
  • Monoamine oxidase inhibitors (MAOIs)
  • All medications known to be metabolized by means of the cytochrome P450 (CYP) 2D6 hepatic pathway (See the discussion about atomoxetine in the Medication section.)
• Screening for medical concerns that may have negative interactions with ADHD (ADD) medications (Drugs of concern are shown in parentheses.)

  • Major arterial disease (stimulants)
  • Narrow-angle glaucoma (stimulants, imipramine, desipramine)
  • Heart disease (clonidine, desipramine, guanfacine, imipramine, stimulants)
  • Heart palpitations (stimulants)
  • Hepatic disease (atomoxetine)
  • Hypertension (stimulants, atomoxetine, bupropion)
  • Orthostasis (atomoxetine, bupropion, stimulants)
  • Pregnancy (all)
  • Renal disease (bupropion, clonidine)
  • Seizure disorder (bupropion, desipramine, imipramine)
  • Urinary retention or hesitancy (atomoxetine, bupropion, stimulants)
• Approximately 30-50% of people with ADHD (ADD) have other significant psychiatric comorbidities. Consider screening patients for the following:

  • Anxiety disorders (generalized anxiety disorder [GAD], obsessive-compulsive disorder [OCD], panic disorder, social phobia)
  • Bipolar disorder
  • Communication disorder (receptive, expressive)
  • Conduct disorder (oppositional defiant disorder in children)
  • Depression
  • Dissociative disorders
  • Eating disorder
  • Enuresis/encopresis
  • Learning disability
  • Pervasive developmental disorder including Asperger syndrome
  • Posttraumatic stress disorder (PTSD)
  • Psychotic disorders
  • Sleep disorder (sleep apnea, restless leg syndrome, delayed sleep phase syndrome)
  • Substance-related disorders
  • Thought disorder
  • Tourette syndrome or other tic disorders
  • Somatic comorbidity (No somatic comorbidities are significantly associated with ADHD [ADD].)

Family history

Inquire about a family history of ADHD (ADD) and of the coexistent conditions listed under History of present illness.

Social history

Inquire about the following:

• Home and family interactions consistent with ADHD (ADD)

  • Disorganization of personal space is the norm.
  • Anger or rage reactions are prevalent.
  • The child usually seems most awake in the late evening.
  • Awakening the child for school causes major problems.
  • The child is often unable to complete what appear to be developmentally appropriate chores.
  • Homework organization and completion are often a problem.
  • High activity level is noted.
  • Completion of multistep directions is difficult.
  • Losing or forgetting material or conversations is observed.
• Problems with the legal system

  • Arrests
  • Traffic tickets
  • Motor vehicle accidents
• School performance

  • Report cards
  • Reprimands or notes sent home
  • Homework completion and/or turning homework in on time
  • Extracurricular activities
• Family dysfunction

  • Drug abuse, alcohol abuse, or both
  • Parent(s) with ADHD (ADD)
  • Physical abuse
  • Sexual abuse
  • Recent death of loved one or friend
  • Severe chronic illness
  • Severe financial problems
• Social skills

  • Friendships
  • Group cohesion
  • Strengths and interests
• Pregnancy, potential for pregnancy, or safe-sex practices

  • Previous intercourse
  • Birth control
  • Condom use
• Work performance

  • Type of work
  • Promptness
  • Overall work performance
• Abuse of substances by patient or his or her friends (if the patient is an adolescent)

  • Alcohol
  • Caffeine
  • Marijuana
  • Other illicit drugs
  • Snorting stimulants
  • Prescription medications
  • Tobacco (eg, cigarettes, chewing tobacco, snuff)

A focused physical examination is recommended if none has been performed within the last year or if suggested by history. Although a child or adolescent with ADHD (ADD) may exhibit few symptoms in a clinical setting, careful observation of behavior is important. The following should be included at onset of medication use and periodically to assess for medication-related negative effects:

• Vital signs

  • Height
  • Weight
  • Blood pressure
  • Pulse
• General appearance

  • Fidgeting
  • Impulse control
  • State of arousal
• Mental status examination

  • Affect
  • Cognition
  • Speech patterns
  • Thought patterns

At present, genetic loading appears to be the primary and perhaps only cause of ADHD (ADD). However, many environmental factors have been correlated with ADHD (ADD), and future research may prove these to be etiologic factors. Morbidity, as evidenced by signs and symptoms in people with ADHD (ADD), may be strongly correlated with the patient's home and school environments.

Genetic causes

Family, twin, adoption, and segregation analysis, as well as molecular genetic studies, show that ADHD (ADD) has a substantial genetic component. Molecular genetic studies have revealed several genes that appear to be associated with ADHD (ADD) because of their effect on dopamine receptors, dopamine transport, and dopamine beta-hydroxylase.

Research by the NIHM has shown that variants of the gene for catecho-O-methyltransferase (COMT) are associated with different levels of prefrontal dopamine activity. COMT metabolizes dopamine.

People with the val/val variant metabolize dopamine rapidly. Because fast metabolism of a substrate decreases the amount of substrate that is biologically available, these people have reduced prefrontal dopamine activity. This reduction, in turn, impairs prefrontal information processing.

Individuals with the val/met variant have fairly efficient prefrontal function.

Patients with the met/met variant have the most efficient prefrontal function. In fact, this variant results in an enzyme that is 3-4 times weaker than the product of the val/val variant.

Environmental causes

No environmental causes have been clearly identified. However, problems with pregnancy (including cigarette smoking during pregnancy) and/or delivery, head injuries, toxin exposure, heavy marijuana use beginning in early adolescence, marital or family dysfunction, and low social class have all been associated with ADHD (ADD).