History

Fact Explanation
Introduction These are neurobehavioural disorders of childhood and adolescence which may or may not prevail in adulthood. The characteristic symptoms are inattention, impulsivity and hyperactivity. The pathophysiology is attributed to abnormalities in neurobiological mechanisms in the frontal and striatal regions of brain which affect executive function. The differentiation between the disorder and normal behaviour is done in comparison to norms for age and IQ. These behaviour differences should be present in different settings. [1][2][3][4][5][6][9][10]
Impaired attention This is on of the two cardinal features required for diagnosis and has to be evident in more than one situation(home, school etc.). These children frequently change from one activity to another leaving activities unfinished. They seem to break off from one task, losing interest as they get diverted to another. [1][2][3][9][10]
Overactivity This is the other feature necessary for the diagnosis and should also be evident in more than one situation. The child is excessive restlessness, especially in situations requiring relative calm. Judgement is made in comparison with behavior of other children of the same age and IQ. The child may be running and jumping around, getting up from a seat when he or she was supposed to remain seated. Excessive talkativeness and noisiness, or fidgeting and wriggling is also seen.[1][2][3][9][10]
Recklessness These children are often impulsive and reckless, prone to accidents. They frequently get in to disciplinary trouble because they unthinkingly breach of rules. They intrude on or interrupt others' activities. Answer questions prematurely before they have been completed. They have difficulty in waiting turns.[1][2][3][9]
Socially disinhibition These children lack the normal caution and reserve. Their relationships with adults are often socially disinhibited but they are unpopular with other children and may be isolated.[1][2][3][4]
Age This disorder usually arise in the first five years of life, early in the child's development.[1][2][3][9]
Family history Some studies suggest of a genetic susceptibility to develop this disorder.Therefore it is important to determine the presence of a first or second degree relative with similar condition.[6][7][9]
Antenatal history Use of tobacco, alcohol, caffeine, and certain psychotropic medication by the mother during pregnancy, poor maternal nutrition, maternal stress during pregnancy,maternal gestational diabetes and exposure to lead or mercury have shown to increase risk of developing these disorders. [6][7]
Social history Social factors such as poor parenting, parental conflicts, home discord, low socioeconomic status, institutionalized care, exposure to violence and trauma etc. have shown to increase the risk of developing attention-deficit and disruptive behavior disorders. [6][7][8]
References
  1. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. World Health Organization publications.[online]. Released 1994; Updated in 2010[viewed on 17 Nov 2014] Available from; http://www.who.int/classifications/icd/en/bluebook.pdf
  2. BUITELAAR J, MEDORI R. Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants Eur Child Adolesc Psychiatry [online] 2010 Apr, 19(4):325-340 [viewed 17 November 2014] Available from: doi:10.1007/s00787-009-0056-1
  3. FARAONE SV, SERGEANT J, GILLBERG C, BIEDERMAN J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry [online] 2003 Jun, 2(2):104-113 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525089
  4. HONG SB, HARRISON BJ, FORNITO A, SOHN CH, SONG IC, KIM JW. Functional dysconnectivity of corticostriatal circuitry and differential response to methylphenidate in youth with attention-deficit/hyperactivity disorder. J Psychiatry Neurosci [online] 2014 Aug 19, 39(4):130290 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25266402
  5. ROHRER-BAUMGARTNER N, ZEINER P, EGELAND J, GUSTAVSON K, SKOGAN AH, REICHBORN-KJENNERUD T, AASE H. Does IQ influence Associations between ADHD Symptoms and other Cognitive Functions in young Preschoolers? Behav Brain Funct [online] :16 [viewed 25 November 2014] Available from: doi:10.1186/1744-9081-10-16
  6. HALPERIN JM, BéDARD AC, CURCHACK-LICHTIN JT. Preventive interventions for ADHD: a neurodevelopmental perspective. Neurotherapeutics [online] 2012 Jul, 9(3):531-41 [viewed 25 November 2014] Available from: doi:10.1007/s13311-012-0123-z
  7. NIGG J, NIKOLAS M, BURT SA. Measured Gene by Environment Interaction in Relation to Attention-Deficit/Hyperactivity Disorder (ADHD) J Am Acad Child Adolesc Psychiatry [online] 2010 Sep, 49(9):863-873 [viewed 25 November 2014] Available from: doi:10.1016/j.jaac.2010.01.025
  8. NIKOLAS M, KLUMP KL, BURT SA. Youth Appraisals of Inter-parental Conflict and Genetic and Environmental Contributions to Attention-Deficit Hyperactivity Disorder: Examination of G×E Effects in a Twin Sample J Abnorm Child Psychol [online] 2012 May, 40(4):543-554 [viewed 25 November 2014] Available from: doi:10.1007/s10802-011-9583-6
  9. MATTHEWS M, NIGG JT, FAIR DA. Attention Deficit Hyperactivity Disorder Curr Top Behav Neurosci [online] 2014:235-266 [viewed 25 November 2014] Available from: doi:10.1007/7854_2013_249
  10. SMUCKER WD, HEDAYAT M. Evaluation and Treatment of ADHD. Am Fam Physician.[online] 2001 Sep 1;64(5):817-830.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/0901/p817.html

Examination

Fact Explanation
Mental state examination There will be no significant clinical findings on physical examination. Mental state examination may reveal some important factors. These children will appear to be fidgety, impulsive. They usually are unable to sit still and run around the office. Mood will be congruent and euthymic or slightly elevated, but not euphoric. They may have low self-esteem. They can be easily irritable. Speech may be at normal rate or rapid and louder. May have difficulties in staying on one topic. There will be no hallucinations or delusions present. Thought content should be normal, with no suicidal/homicidal ideas. Attention, concentration and recent memory are affected but orientation, remote memory are normal. [1][2][3]
References
  1. BUITELAAR J, MEDORI R. Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants Eur Child Adolesc Psychiatry [online] 2010 Apr, 19(4):325-340 [viewed 17 November 2014] Available from: doi:10.1007/s00787-009-0056-1
  2. SMUCKER WD, HEDAYAT M. Evaluation and Treatment of ADHD. Am Fam Physician.[online] 2001 Sep 1;64(5):817-830.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/0901/p817.html
  3. MATTHEWS M, NIGG JT, FAIR DA. Attention Deficit Hyperactivity Disorder Curr Top Behav Neurosci [online] 2014:235-266 [viewed 25 November 2014] Available from: doi:10.1007/7854_2013_249

Differential Diagnoses

Fact Explanation
Anxiety disorder Restlessness can be part of severe anxiety. But presence of other symptoms discussed above sections should lead to the correct diagnosis.[1][2][3]
Conduct disorder Children with conduct disorders show repetitive and persistent pattern of dissocial, aggressive, or defiant conduct and milder degrees of overactivity and inattention are common. But when symptoms of attention deficit hyperkinetic disorder are predominant, diagnosis of it is made over conduct disorder.[1][2][3]
Depressive disorder Restlessness may be typically a part of an agitated depressive disorder. There may also be comorbid depression.[1][2]
Bipolar affective disorder Is consist of alternating phases of mania and depression. Symptoms such as restlesness, low self esteem, elated/depressed mood can be seen in both attention deficit hyperkinetic disorder and Bipolar affective disorder. Diagnosis should be based on presence of appropriate criteria for diagnosis of either disorder. [1][2][3]
Schizophrenia Acute onset of hyperactive behaviour in a child of school age should lead to suspicion of this condition.[1][2]
References
  1. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. World Health Organization publications.[online]. Released 1994; Updated in 2010[viewed on 17 Nov 2014] Available from; http://www.who.int/classifications/icd/en/bluebook.pdf
  2. SMUCKER WD, HEDAYAT M. Evaluation and Treatment of ADHD. Am Fam Physician.[online] 2001 Sep 1;64(5):817-830.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/0901/p817.html
  3. SZYMANSKI M, ZOLOTOR A. Attention-Deficit/Hyperactivity Disorder: Management. Am Fam Physician.[online] 2001 Oct 15;64(8):1355-1363.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/1015/p1355.html

Investigations - for Diagnosis

Fact Explanation
The Conners Parent-Teacher Rating Scale The diagnosis of these disorders is based on the history. This is a scale or a test in the form of a questionnaire about the behavior of the child that helps in the diagnosis. This is given to parents and teachers so that a comprehensive inventory about the child's behavior can be made and the psychiatrist evaluating the child can gain a full understanding about the behaviors and habits. This can also be used in the follow up after initiating treatment.[1][2]
References
  1. BUITELAAR J, MEDORI R. Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants Eur Child Adolesc Psychiatry [online] 2010 Apr, 19(4):325-340 [viewed 17 November 2014] Available from: doi:10.1007/s00787-009-0056-1
  2. SMUCKER WD, HEDAYAT M. Evaluation and Treatment of ADHD. Am Fam Physician.[online] 2001 Sep 1;64(5):817-830.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/0901/p817.html

Investigations - Fitness for Management

Fact Explanation
Electrocardiogram Done in children receiving stimulunt medication as they can cause arrhythmias.[1]
Liver function tests Done to assess baseline liver function because most of the drugs used for treatment are metabolized by the liver[4]
Vision testing Done to detect comorbid visual problems associated with this condition.[2]
Hearing testing Done to detect problems with auditory functioning that can be associated wih this condition. [3][5]
References
  1. LISA GRAHAM. AHA Releases Recommendations on Cardiovascular Monitoring and the Use of ADHD Medications in Children with Heart Disease. Practice Guidelines. Am Fam Physician.[online] 2009 May 15;79(10):905-910. [viewed on 17 Nov 2014]. Available from; http://www.aafp.org/afp/2009/0515/p905.html
  2. KIM S, CHEN S, TANNOCK R. Visual function and color vision in adults with Attention-Deficit/Hyperactivity Disorder J Optom [online] 2014 Jan, 7(1):22-36 [viewed 25 November 2014] Available from: doi:10.1016/j.optom.2013.07.001
  3. ROMERO AC, CAPELLINI SA, FRIZZO AC. Cognitive potential of children with attention deficit and hyperactivity disorder. Braz J Otorhinolaryngol [online] 2013 Sep-Oct, 79(5):609-15 [viewed 25 November 2014] Available from: doi:10.5935/1808-8694.20130109
  4. SZYMANSKI M, ZOLOTOR A. Attention-Deficit/Hyperactivity Disorder: Management. Am Fam Physician.[online] 2001 Oct 15;64(8):1355-1363.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/1015/p1355.html
  5. ABDO AG, MURPHY CF, SCHOCHAT E. Hearing abilities in children with dyslexia and attention deficit hyperactivity disorder. Pro Fono [online] 2010 Jan-Mar, 22(1):25-30 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20339804

Management - General Measures

Fact Explanation
Educating family, care givers and teachers The family, care givers and teachers should educated on the nature of the disease, available treatment, possible co-morbidities, prognosis etc. These children requires to work according to a schedule. They should be encouraged to work according to a time table every day. Same routine daily from wake-up time to bedtime with specific times for homework, outdoor play, meals etc. Everyday items should be kept in a well organized manner. The child should be encouraged to keep the items in place after use. Be clear and consistent with rules that are placed. Child should be praised and given rewards when rules are followed and work done as scheduled. These are some of the easy measures that can be taken.[1][2][3][4]
References
  1. BUITELAAR J, MEDORI R. Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants Eur Child Adolesc Psychiatry [online] 2010 Apr, 19(4):325-340 [viewed 17 November 2014] Available from: doi:10.1007/s00787-009-0056-1
  2. COGHILL D, SOUTULLO C, D'AUBUISSON C, PREUSS U, LINDBACK T, SILVERBERG M, BUITELAAR J. Impact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey Child Adolesc Psychiatry Ment Health [online] :31 [viewed 17 November 2014] Available from: doi:10.1186/1753-2000-2-31
  3. SMUCKER WD, HEDAYAT M. Evaluation and Treatment of ADHD. Am Fam Physician.[online] 2001 Sep 1;64(5):817-830.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/0901/p817.html
  4. SZYMANSKI M, ZOLOTOR A. Attention-Deficit/Hyperactivity Disorder: Management. Am Fam Physician.[online] 2001 Oct 15;64(8):1355-1363.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/1015/p1355.html

Management - Specific Treatments

Fact Explanation
Methylphenidate This is the most frequently prescribed psychostimulant. It is available in both short- and long-acting or extended-release formulations. It can help sustain attention, impulse and emotional control, reduction of task-irrelevant activity, diminishment of disruptive behavior, and aggression. This helps in compliance with behavior treatment.[1][2][4]
Atomoxetine This is a selective norepinephrine reuptake inhibitor, considered as second line treatment. It has shown to improve symptoms and help in compliance with behavior therapy.[3][5]
Tricyclic antidepressants Such as imipramine has shown to improve symptoms in children but are not commonly used due to their adverse event profile.[2][4] [5]
Behavioral psychotherapy Is shown to be most effective when used together with effective medication. This involves working with parents, teachers and care givers to create an environment which encourages appropriate behavior and focus.[2][4][5]
References
  1. HOSENBOCUS S, CHAHAL R. A Review of Long-Acting Medications for ADHD in Canada J Can Acad Child Adolesc Psychiatry [online] 2009 Nov, 18(4):331-339 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765387
  2. BUITELAAR J, MEDORI R. Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants Eur Child Adolesc Psychiatry [online] 2010 Apr, 19(4):325-340 [viewed 17 November 2014] Available from: doi:10.1007/s00787-009-0056-1
  3. NAGASHIMA M, MONDEN Y, DAN I, DAN H, TSUZUKI D, MIZUTANI T, KYUTOKU Y, GUNJI Y, HIRANO D, TANIGUCHI T, SHIMOIZUMI H, MOMOI MY, WATANABE E, YAMAGATA T. Acute neuropharmacological effects of atomoxetine on inhibitory control in ADHD children: A fNIRS study. Neuroimage Clin [online] 2014:192-201 [viewed 17 November 2014] Available from: doi:10.1016/j.nicl.2014.09.001
  4. SHAWN KLEIN S, TAZKARJI B, AUTEN B, Management of ADHD in Preschool-Aged Children. FPIN's Clinical Inquiries. Am Fam Physician.[online] 2013 Sep 15;88(6):398-400.[viewed on 17 Nov 2014]Available from;http://www.aafp.org/afp/2013/0915/p398.html
  5. SZYMANSKI M, ZOLOTOR A. Attention-Deficit/Hyperactivity Disorder: Management. Am Fam Physician.[online] 2001 Oct 15;64(8):1355-1363.[viewed on 25 Nov 2014] Available from; http://www.aafp.org/afp/2001/1015/p1355.html