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What is attention-deficit/hyperactivity disorder?

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, impulsivity, and/or hyperactivity. The prevalence of ADHD is roughly 5-9% for children and adolescents and 3-5% for adults.

What does ADHD look like?

Risk Factors

  • Heritability is 76% based on twin studies
  • Implicated genes: DAT1, DRD4, DRD5, DBH, 5-HTT, HTR1B, and SNAP-25
  • Perinatal stress
  • Low birth weight
  • Traumatic brain injury
  • Maternal smoking during pregnancy
  • Severe early deprivation
  • Frequent digital media use

Prognosis

  • Generally considered a lifelong condition, but 1/3 to 1/2 of individuals with experience remission of symptoms by adulthood
  • Childhood ADHD is associated with worse educational, occupational, economic, social, and health-related outcomes
  • Children are two times more prone to all types of accidental injuries
  • Adolescents are at higher risk of earlier substance use and greater difficulty with substance use
  • Can negatively affect the ability to drive safely
  • Deficits in executive function, including inhibitory control, working memory, and effortful attention

Differential Diagnosis

  • Oppositional defiant disorder
  • Conduct disorder
  • Disruptive mood dysregulation disorder
  • Specific learning disorder
  • Generalized anxiety disorder
  • Obsessive-compulsive disorder
  • Major depressive disorder
  • Autism spectrum disorder
  • Bipolar I/II disorder
  • Borderline personality disorder
  • Psychotic disorder
  • Substance use disorders
  • Medication with cognitive dulling side effect
  • Medication with psychomotor activation
  • Unsafe or disruptive learning environment
  • Family dysfunction or poor parenting
  • Child abuse or neglect
  • Attachment disorders
  • Intellectual giftedness
  • Sleep disorders
  • Traumatic brain injury
  • Seizure disorders
  • Hearing impairment or vision impairment
  • Thyroid disorders
  • Hypoglycemia
  • Anemia
  • Lead poisoning
  • Fragile X syndrome
  • Phenylketonuria
  • Neurofibromatosis
  • Fetal alcohol spectrum disorder
  • Intellectual disability

How is ADHD investigated?

Thorough assessment of psychosocial factors, including:

  • Medical history
    • Rule out other medical conditions
    • Nutrition and lifestyle - sleep, exercise, screen time, high risk activities
  • Complete childhood developmental history
    • Having third party objective perspective is critical
    • Perinatal history
    • Developmental milestones
    • Psychoeducational assessments and report cards
    • Impact of symptoms on learning, socialization, and independent functioning
    • Temperament
    • Symptoms of ADHD prior to age 12
    • Presence of any life events that were of emotional concern in childhood (e.g. abuse, bullying, divorce, loss, deaths, attachment issues)

ADHD Checklist

  • Clinican/client rater
  • Checklist of the 9 DSM items

SNAP-IV 26

  • Teacher/parent rater
  • 26-item rating scale

Conner's Rating Scale-Revised

  • Teacher/parent/client rater

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Karam, R. G., Breda, V., Picon, F. A., Rovaris, D. L., Victor, M. M., Salgado, C. A., Vitola, E. S., Silva, K. L., Guimarães-da-Silva, P. O., Mota, N. R., Caye, A., Belmonte-de-Abreu, P., Rohde, L. A., Grevet, E. H., & Bau, C. H. (2015). Persistence and remission of ADHD during adulthood: A 7-year clinical follow-up study. Psychological medicine45(10), 2045–2056.

[4] Ra, C. K., Cho, J., Stone, M. D., De La Cerda, J., Goldenson, N. I., Moroney, E., Tung, I., Lee, S. S., & Leventhal, A. M. (2018). Association of digital media use with subsequent symptoms of attention-deficit/hyperactivity disorder among adolescents. JAMA320(3), 255–263. 

[5] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.