Attention Deficit

Hyperactivity
Disorder
What does ADHD mean to you?
Definition & Features
• ADHD is a cognitive disorder characterized by inattention,
hyperactivity, and impulsivity
• Impairment in multiple functional domains, including school,
friendship and home life
• Moderate to severe levels present in at least two settings
• Onset generally <7 years of age

• Prevalent in approximately 5% of school aged children (M:F =

3:1)

• Subtypes divided based on predominantly inattentive,

hyperactive/impulsive or combined features
Case
Timmy is a new child coming into clinic. He is an 8 year old boy
that hasn’t been keeping up in his third grade class, and he
never seems to want to do his homework. His parents are
concerned he may have ADHD.

What questions would you ask on history?

Symptoms
Inattention
“He often makes careless mistakes, even when he knows better”
“He gets very easily distracted”
“He never finishes any work, his tests/assignments are almost always
incomplete”
“He never listens to anything we say, or the teacher!”
Hyperactivity/Impulsivity
“He is always interrupting people”
“He seems to always be talking, he is never quiet”
“He never seems to wait his turn, he gets angry if he isn’t served first”
“He seems to always be moving or fidgeting”
Symptoms

“But he can sit and play video games for hours, how could
he have ADHD?”
Symptoms

• Concentration will be inconsistent from one area to another

• Certain scenarios, including fun, high energy, one-on-one, and
immediate consequence, can still show very normal levels of
concentration
 Symptoms – DSM V List
Inattention:
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other
activities.
• Often has trouble holding attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
(e.g., loses focus, side-tracked).
• Often has trouble organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as
schoolwork or homework).
• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
• Is often easily distracted
• Is often forgetful in daily activities.
Hyperactivity and Impulsivity:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling
restless).
• Often unable to play or take part in leisure activities quietly.
• Is often "on the go" acting as if "driven by a motor".
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)
Diagnosis
• A child up to the age of 16 needs to demonstrate six or more
symptoms of inattention that interfere with daily functioning
or development in order to be diagnosed with inattentive type
ADHD
• Similarly, 6+ symptoms of hyperactivity/impulsivity are
required for hyperactive/impulsive type

• Additional Conditions:
• Several symptoms were present before age 12
• Present in 2+ settings
• Symptoms interfere with quality of social/school functioning
• Not better explained by another mental disorder
Differential Diagnosis

After collecting a careful history, you discover that Timmy has a

number of both inattentive and hyperactive symptoms. Before
jumping to a diagnosis of ADHD, what are some other conditions
on your differential?
Differential Diagnosis
• Psychiatric
• Bipolar Disorder, generalized anxiety disorder, specific learning
disorder, conduct disorder, language disorder
• Medication related
• Mood stabilizers, psychomotor (decongestants, beta agonists)
• Metabolic
• Thyroid dysfunction, hypoglycemia, lead poisoning
• Congenital/Genetic
• Fragile X syndrome, fetal alcohol spectrum disorder,
phenylketonuria
• Neurologic
• Head trauma/concussion, sleep disorders, seizure disorders
Comorbidities
• 50-90% of children with ADHD have 1+ comorbid condition
• Approximately half have two or more

• ADHD is 2-3x more common in children with developmental

disabilities or borderline IQ
• Early years of ADHD show a significant amount of ODD and language
disorders
• Later years of childhood show more anxiety and then mood
disorders

• Many psychiatric, neurologic and learning disorders can complicate

the management of ADHD
• General principle is to treat most impairing disorder first, with suicidal
ideation or dangerous behavior being the priority
Unmanaged ADHD
• Hyperactivity can decrease by age 12-13
• Only approx. 30% of children will outgrow the ADHD
• DSM-V: 2.5% of adults fit diagnosis, most often undiagnosed from
childhood
• ADHD can and often will lead to the previously mentioned
comorbidities
References
• "Resource Alliance (CADDRA)." Canadian ADHD practice
guidelines (2011).
• American Psychiatric Association. Diagnostic and statistical
manual of mental disorders (DSM-5®). American Psychiatric
Pub, 2013.
• Ougrin, Dennis, Sandie Chatterton, and Ricky Banarsee.
"Attention deficit hyperactivity disorder (ADHD): review for
primary care clinicians." London journal of primary care 3.1
(2010): 45-51.