Pediatric Attention Deficit Hyperactivity Disorder (ADHD) Clinical Presentation

Updated: Apr 24, 2017
  • Author: Maggie A Wilkes, MD; Chief Editor: Caroly Pataki, MD  more...
  • Print
Presentation

History

The DSM-5 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).

Diagnostic Criteria (DSM-5)

The DSM-5 criteria are as follows: [1]

Inattentive

This must include at least 6 of the following symptoms of inattention that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

  • 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 activities
  • Often does not seem to listen to what is being said
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  • Often has difficulties organizing tasks and activities

Hyperactivity/impulsivity

This must include at least 6 of the following symptoms of hyperactivity-impulsivity that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

  • Fidgeting with or tapping hands or feet, squirming in seat
  • Leaving seat in classroom or in other situations in which remaining seated is expected
  • Running about or climbing excessively in situations where this behavior is inappropriate (in adolescents or adults, this may be limited to subjective feelings of restlessness)
  • Difficulty playing or engaging in leisure activities quietly
  • Unable to be or uncomfortable being still for extended periods of time (may be experienced by others as “on the go” or difficult to keep up with)
  • Excessive talking
  • Blurting out answers to questions before the questions have been completed
  • Difficulty waiting in lines or awaiting turn in games or group situations
  • Interrupting or intruding on others (for adolescents and adults, may intrude into or take over what others are doing)

Other

  • Onset is no later than age 12 years
  • Symptoms must be present in 2 or more situations, such as school, work, or home
  • The disturbance causes clinically significant distress or impairment in social, academic, or occupational functioning
  • Disorder does not occur exclusively during the course of schizophrenia or other psychotic disorder and is not better accounted for by mood, anxiety, dissociative, personality disorder or substance intoxication or withdrawal
  •  
  • Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
  • Often loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys)
  • Often is easily distracted by extraneous stimuli
  • Often forgetful in daily activities

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:

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)
Next:

Physical

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
Previous
Next:

Causes

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).

Previous