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ATTENTION DEFICIT HYPERACTIVITY DISORDER
 



SYNOPSIS

Hyperkinetic Disorders F90 - ICD10 Description, World Health Organization

A group of disorders characterized by an early onset (usually in the first five years of life), lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing any one, together with disorganized, ill-regulated, and excessive activity. Several other abnormalities may be associated. Hyperkinetic children are often reckless and impulsive, prone to accidents, and find themselves in disciplinary trouble because of unthinking breaches of rules rather than deliberate defiance. Their relationships with adults are often socially disinhibited, with a lack of normal caution and reserve. They are unpopular with other children and may become isolated. Impairment of cognitive functions is common, and specific delays in motor and language development are disproportionately frequent. Secondary complications include dissocial behaviour and low self-esteem.

    Disturbance of Activity And Attention F90.0
    Attention deficit disorder with hyperactivity.
Attention-Deficit/Hyperactivity Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with attention-deficit/hyperactivity disorder needs to meet all of the following criteria:

  • A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by inattention and/or hyperactivity and impulsivity:

    • Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
      Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

      • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

      • Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

      • Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

      • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily side-tracked).

      • Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

      • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

      • Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

      • Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

      • Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

    • Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
      Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

      • Often fidgets with or taps hands or feet or squirms in seat.

      • Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

      • Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

      • Often unable to play or engage in leisure activities quietly.

      • Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

      • Often talks excessively.

      • Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation).

      • Often has difficulty awaiting his or her turn (e.g., while waiting in line).

      • Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

  • Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

  • Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

  • The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

This disorder must be present by age 12, and in 60%-70% of patients it persists into adulthood. It is characterized by inattention, hyperactivity, and/or impulsivity. Many children have just inattention (attention deficit disorder [ADD] and not attention deficit hyperactivity disorder [ADHD]). Surprisingly, individuals with ADD or ADHD can concentrate well on activities that really interest them (e.g., computer games), but quickly become bored with routine activities (e.g., school). Many of these individuals develop oppositional defiant disorder in childhood. In adulthood, much of the hyperactivity disappears, but their impulsivity and inattention often persists. Some adults with adult ADD have been wildly successful, but usually adult ADD interferes with vocational and social performance.

Effective Therapies

Stimulant medications (methylphenidate and amphetamine) are the first line of treatment, followed by atomoxetine, and then alpha-2-adrenergic agonists, tricyclic antidepressants, and bupropion. Long-acting (once a day) preparations are recommended. These medications are effective in 85% of patients. Stimulant medications can cause cardiovascular side effects; hence must be closely monitored in patients with heart conditions.

Ineffective Therapies

Other than these pharmaceutical treatments, no other treatments have robust evidence of their effectiveness on the core features of this disorder. However, behavioral interventions (such as parental training and classroom management techniques) can minimize the associated oppositional defiant behavior and anxiety; even though it does not treat the core features of this disorder. Playing mindless brain training games is ineffective.

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