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Deficit de Atencion con Hiperactividad en Niños y Adolescentes

Deficit de Atencion con Hiperactividad en Niños y Adolescentes

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Published by Franklin Aranda
Revision actualizada 2009 sobre Deficit de Atencion con Hiperactividad en Niños y Adolescentes.
Revision actualizada 2009 sobre Deficit de Atencion con Hiperactividad en Niños y Adolescentes.

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Published by: Franklin Aranda on May 23, 2009
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Attention deficit hyperactivity disorder in children and adolescents: Clinical features andevaluation
AuthorKevin R Krull, PhD Section EditorsMarilyn Augustyn, MDSteven Parker, MD Deputy EditorMary M Torchia, MDLast literature review version 17.1: January 2009 | This topic last updated: February 13,2009 (More)
INTRODUCTION
 
Attention-deficit/hyperactivity disorder (ADHD) is a disorder that manifestsin early childhood with symptoms of hyperactivity, impulsivity, and/or inattention. Thesymptoms affect cognitive, academic, behavioral, emotional, and social functioning (showtable 1) [1] .This topic review focuses on the clinical features and evaluation of ADHD. The epidemiology,pathogenesis, management, and prognosis of ADHD in children and adolescents and ADHD inadults are discussed separately. (See "Attention deficit hyperactivity disorder in children andadolescents: Epidemiology and pathogenesis" and see "Overview of the treatment andprognosis of attention deficit hyperactivity disorder in children and adolescents" and see"Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents" andsee "Adult attention deficit hyperactivity disorder").
CORE SYMPTOMS
 
ADHD is a syndrome composed of three categories of symptoms:hyperactivity, impulsivity, and inattention. The complaint regarding these symptoms mayoriginate from the parents, teachers, or other caregivers [2] . The symptoms may not beapparent in the structured setting of the clinic visit, but the pediatric care provider can ask theparents the following questions to elicit concerns regarding school performance and behavior[3] : How is your child doing at school? Have you or the teacher noticed any problems withlearning? Is your child happy in school? Does your child have any behavioral problems atschool, home, or when playing with friends? Does your child have problems completing schoolassignments at school or home?Each of the core symptoms of ADHD has its own pattern and course of development.Hyperactivity
Hyperactive behavior is identified through excessive fidgetiness or talking,difficulty remaining seated when required to do so, difficulty playing quietly, and frequentrestlessness or seeming to be always "on the go" (show table 1).The hyperactive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years [4] . They peak in severity when the childis seven to eight years of age, after which they begin to steadily decline. By the adolescentyears, the hyperactive symptoms are barely discernible.
 
 Impulsivity
Impulsive behavior, which almost always occurs in conjunction withhyperactivity in younger children, is manifested by difficulty waiting turns, blurting outanswers too quickly, disruptive classroom behavior, intruding or interrupting other's activities,peer rejection, and unintentional injury (show table 1).Similar to the hyperactive symptoms, the impulsive symptoms typically are observed by thetime the child is four years of age and increase during the next three to four years to peak inseverity when the child is seven to eight years of age [5] . In contrast to hyperactive symptoms,impulsive symptoms usually remain a problem throughout the life of the individual. (See"Overview of the treatment and prognosis of attention deficit hyperactivity disorder inchildren and adolescents", section on Prognosis).The focus of impulsivity is related to the environment. Adolescents with ADHD who areuntreated and in an environment where alcohol and other commonly abused substances arereadily available are at greater risk of engaging in drug use or experimentation than areadolescents without ADHD [6] . Adults with ADHD may find themselves with higher rates of financial mismanagement related to impulse buying.Inattention
Inattention may take many forms, including forgetfulness, being easilydistracted, losing or misplacing things, disorganization, academic underachievement, poorfollow-through with assignments or tasks, poor concentration, and poor attention to detail(show table 1).The symptoms of inattention typically are not apparent until the child is eight to nine years of age [7] . This delay may relate to reduced sensitivity of assessment of attention problems orincreased variability in the normal development of the cognitive skills. Similar to the pattern of impulsivity, symptoms of inattention usually are a lifelong problem. (See "Overview of thetreatment and prognosis of attention deficit hyperactivity disorder in children andadolescents", section on Prognosis).
DIAGNOSTIC CRITERIA
Attention deficit hyperactivity disorder
Consensus criteria for the diagnosis of ADHD havebeen defined by the American Psychiatric Association and published in the DSM-IV (show table1) [1,2,8] . Several features of the DSM-IV criteria deserve emphasis: The symptoms must bepresent in more than one setting (eg, school and home). The symptoms must persist for atleast six months. The symptoms must be present before the age of seven years. The symptomsmust impair function in academic, social, or occupational activities. The symptoms must beexcessive for the developmental level of the child. Other mental disorders that could accountfor the symptoms must be excluded. (See "Differential diagnosis" below).Adherence to the DSM-IV criteria can help to minimize over- and underdiagnosis of ADHD.However, several limitations of the criteria must be noted [2] . The criteria were derived fromstudies of children who were evaluated in psychiatric rather than primary care settings. Datasupporting the number of items required for diagnosis are lacking. Finally, the behavioralcharacteristics specified in the definition are subject to different interpretations by different
 
observers [2] . Nonetheless, the diagnostic criteria, as used by appropriate examiners,demonstrate high interrater reliability of individual items and of overall diagnosis [9,10] .Depending upon the predominant symptoms, three subtypes of ADHD have been identified [1]: Predominantly inattentive Predominantly hyperactive-impulsive CombinedThe subtype of ADHD in a given patient can change from one to another over the course of time [1,2,11] .Inattentive subtype
Children with the predominantly inattentive subtype of ADHD (ADHD-I)usually are diagnosed at 9 to 10 years of age, the age at which symptoms of inattentionbecome noticeable. Children with the ADHD-I have at least six of the symptoms of inattentionthat have persisted for at least six months and are present to a degree that is maladaptive andinconsistent with developmental level (show table 1) [1,2] : Often fails to give close attentionto details or makes careless mistakes in schoolwork or other activities Often has difficultysustaining attention in tasks or play activities Often does not seem to listen when spoken todirectly Often does not follow through on instructions and fails to finish schoolwork, chores, orduties (not because of oppositional behavior or failure to understand instructions) Often hasdifficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasksthat require sustained mental effort (such as schoolwork or homework) Often loses thingsnecessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) Often iseasily distracted by extraneous stimuli Often is forgetful in daily activitiesChildren with ADHD-I may have mild symptoms of hyperactivity or impulsivity, but inattentionis their primary problem. Children ADHD-I are characterized by reduced ability to focusattention and reduced speed of cognitive processing and responding [12,13] . They often aredescribed as having a sluggish cognitive tempo and frequently appear to be daydreaming or"off task" [14] . The typical presenting complaints center around cognitive and/or academicproblems. ADHD-I is not as well studied as the other subtypes [15] .Hyperactive-impulsive subtype
Children with the predominantly hyperactive-impulsivesubtype of ADHD (ADHD-HI) usually are diagnosed at six to seven years of age, whensymptoms of hyperactivity and impulsivity peak. Children with ADHD-HI have at least six of thesymptoms of hyperactivity-impulsivity that have persisted for at least six months and arepresent to a degree that is maladaptive and inconsistent with developmental level (show table1) [1,2] : Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom orin other situations in which remaining seated is expected Often runs about or climbsexcessively in situations in which it is inappropriate Often has difficulty playing or engaging inleisure activities quietly Often is "on the go" or often acts as if "driven by a motor" Often talksexcessively Often blurts out answers before questions have been completed Often hasdifficulty awaiting his or her turn Often interrupts or intrudes on others (eg, butts intoconversations or games)Children with ADHD-HI have relatively good attention skills; they simply cannot sit still orinhibit their behavior. Cognitive performance may be unaffected in children with ADHD-HI [16].

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