Attention deficit hyperactivity disorder

Specialties > Child health

Background knowledge 🧠

Definition

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by persistent patterns of inattention and/or hyperactivity-impulsivity that interfere with functioning or development.
Symptoms typically present before the age of 12.
It affects cognitive, academic, behavioural, emotional, and social functioning.

Epidemiology

ADHD is one of the most common neurodevelopmental disorders in children, affecting approximately 5-7% of school-aged children.
More common in males than females, with a ratio of about 2:1.
Symptoms may persist into adulthood in about 50-60% of cases.
Prevalence in adults is estimated to be around 2-5%.

Aetiology and Pathophysiology

Exact cause unknown; believed to be multifactorial.
Genetic factors play a significant role; heritability is estimated at 70-80%.
Environmental factors: prenatal exposure to tobacco, alcohol, and drugs; low birth weight; and psychosocial adversity.
Neurobiological abnormalities: reduced dopaminergic and noradrenergic activity in the prefrontal cortex and basal ganglia.
Brain imaging studies show differences in brain structure, particularly in the frontal lobe, basal ganglia, and cerebellum.

Types

Predominantly Inattentive Presentation: Difficulty sustaining attention, forgetfulness, disorganisation.
Predominantly Hyperactive-Impulsive Presentation: Hyperactivity, fidgeting, impulsivity.
Combined Presentation: Both inattentive and hyperactive-impulsive symptoms.
The presentation may change over time.

Clinical Features 🌡️

Symptoms

Inattention: Difficulty sustaining attention, careless mistakes, difficulty organising tasks, easily distracted.
Hyperactivity: Fidgeting, inability to stay seated, excessive talking, running/climbing in inappropriate situations.
Impulsivity: Blurting out answers, difficulty waiting turn, interrupting others.
Symptoms must be present in two or more settings (e.g., home, school, work).

Signs

Restlessness and an inability to sit still.
Inappropriate running or climbing.
Difficulty engaging in quiet activities.
Difficulty with following instructions or completing tasks.
Disruptive behaviour in social settings.

Investigations 🧪

Tests

ADHD is a clinical diagnosis based on history and observation.
Use of standardised diagnostic tools, such as the Conners’ Rating Scales, ADHD Rating Scale IV, and SNAP-IV.
Assessment of comorbid conditions (e.g., learning disabilities, mood disorders).
Consider neuropsychological testing in complex cases.
Rule out other conditions that may mimic ADHD (e.g., anxiety, depression).

Management 🥼

Management

Multimodal approach: Behavioural therapy, educational interventions, and pharmacotherapy.
First-line pharmacotherapy: Stimulants (e.g., methylphenidate, dexamfetamine).
Non-stimulant options: Atomoxetine, guanfacine, clonidine.
Behavioural interventions: Parent training programmes, school-based interventions.
Monitoring for side effects of medication: growth retardation, sleep disturbances, cardiovascular effects.
Regular follow-up to assess treatment efficacy and adherence.

Complications

Increased risk of comorbid psychiatric disorders: anxiety, depression, oppositional defiant disorder.
Educational underachievement and school failure.
Increased risk of substance misuse.
Interpersonal relationship difficulties.
Occupational and social impairments in adulthood.

Prognosis

Symptoms may persist into adolescence and adulthood.
Approximately 30-50% of individuals diagnosed in childhood continue to meet the diagnostic criteria in adulthood.
Some may experience a reduction in hyperactive and impulsive symptoms over time, while inattentive symptoms may persist.
Early intervention and treatment improve long-term outcomes.
Ongoing management is often necessary.

Key Points

ADHD is a common, chronic neurodevelopmental disorder.
It significantly impacts social, academic, and occupational functioning.
Diagnosis is clinical, supported by standardised tools.
Management includes behavioural therapy and pharmacotherapy.
Early diagnosis and treatment improve outcomes.

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