Attention Deficit/Hyperactivity Disorder

(ADHD)

Overview

Definition

Epidemiology

Pathophysiology

Causes

Presentation

Diagnostic Criteria (DSM-5)

Workup

Treatment-Medication

Definition

Is a developmental condition of inattention and distractibility

that can present with or without hyperactivity.
3 basic forms of ADHD are described in the DSM-5:

Predominantly inattentive

Predominantly hyperactive-impulsive

Combined

Epidemiology

United States:

Incidence in school-age children is estimated to be 3-7%.

From 1998-2000 through 2007-2009 - Percentage of children ever

diagnosed with ADHD increased from 7-9%

ADHD prevalence varies by race and ethnicity, with Mexican

children having consistently lower prevalence compared with
other racial or ethnic groups.

From 1998 to 2009 - Prevalence of ADHD increased to 10% for

children with family incomes less than 100% of the poverty level
and to 11% for those with family income from 100-199% of the
poverty level.

Pathophysiology

Psychostimulants tricyclics and noradrenergic

tricyclics used to treat ADHD have led to

functional

speculation that certain brain areas related to

circuitry but recent studies have demonstrated

attention are deficient in neural transmission.

changes just outside that region.

The

neurotransmitters

dopamine

and

norepinephrine have been associated with

ADHD.

ADHD has been associated with structural and

alterations

in

the

frontostriatal

more specifically in the cerebellum and the

parietal lobes.

Another

study

using

magnetic

right

prefrontal

Brain regions predominantly thought to be

spectroscopy

involved are frontal and prefrontal.

neurochemical changes in adolescents with

The parietal lobe and cerebellum may also

be involved.

ADHD.

demonstrated

proton

Pathophysiology

Work

by

Sobel

et

al

has

demonstrated

Adults with ADHD also have been reported to

deformations in the basal ganglia nuclei in

have deficits in anterior cingulate activation

children with ADHD.

while performing similar tasks.

The more prominent the deformations, the

greater the severity of symptoms.

Furthermore, Sobel et al have shown that

stimulants may normalize the deformations.

A PET scan study by Volkow et al revealed that

in adults with ADHD, depressed dopamine
activity in caudate and preliminary evidence in
limbic regions was associated with inattention
and

enhanced

reinforcing

responses

to

intravenous methylphenidate.

This concludes that dopamine dysfunction

may be involved with symptoms of
inattention.

Presentation

Affect/mood:

Affect usually is appropriate and

may be elevated, but it should not
be euphoric.

Mood usually is euthymic, except

for periods of low self-esteem and
decreased (dysthymic) mood.

Irritability may frequently

associated with ADHD.

be

Speech/thought processes:

Speech is of normal rate but may

be louder due to impulsivity.

Thought processes are goaldirected

but
may
reflect
difficulties staying on a topic or
task.

Evidence of racing thoughts or

pressured speech should not be
present.

Diagnostic Criteria
Inattentive

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
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

Causes

Genetics

Enviroment

Personality

Diagnostic Criteria
Hyperactivity/impulsivity

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
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

Diagnostic Criteria
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.
Disorder is not better accounted for by
mood, anxiety, dissociative, personality
disorder or substance intoxication or
withdrawal

In addition, ADHD is specified by the

severity based on social or occupational
functional impairment:

Mild (minor impairment)

Moderate (impairment between
mild and severe)
Severe (symptoms in excess of those
required to meet diagnosis; marked
impairment)

Workup

No laboratory-based medical tests are available to confirm the

diagnosis.
Basic laboratory studies that may help confirm diagnosis and aid in
treatment are as follows:

Serum CBC count with differential

Electrolyte levels

Liver function tests (before beginning stimulant therapy)

Thyroid function tests

Treatment

References:

Stephen Soreff Attention Deficit/ Hyperactivity Disorder. [internet]

, 2014. [citado el 1

de junio

de 2016]; Medscape, 2016,

Disponible

en:

http://emedicine.medscape.com/article/289350-overview

Rosack J. PET Scans Reveal Action of Methylphenidate in Brain. Psychiatric

News. Sept 21, 2001. 36, 18:

Cherkasova MV, Hechtman L. Neuroimaging in attention-deficit hyperactivity disorder:

beyond the frontostriatal circuitry. Can J Psychiatry. 2009 Oct. 54(10):651-64. [Medline].

Sobel LJ, Bansal R, Maia TV, Sanchez J, Mazzone L, Durkin K, et al. Basal Ganglia surface
morphology and the effects of stimulant medications in youth with attention deficit