Attention deficit hyperactivity disorder (ADHD) is a chronic behavioral disorder of childhood onset (by age seven). It is characterized by behavior that is hyperactive, impulsive, and/or inattentive. These behaviors must persist for at least six months and be present in two environments (home, work, or school). ADHD affects children, adolescents, and adults.

Causes

The cause of ADHD is unknown. It most likely is caused by a chemical imbalance in the brain. There also appears to be a genetic factor since ADHD can run in families.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. Risk factors for ADHD are:

• Male sex

• Parent or sibling with ADHD

Symptoms

All children display some of the symptoms of ADHD sometimes. Children with ADHD, however, have symptoms that are noticeably more severe and consistent. Unlike normal children with lots of energy, children with ADHD often have difficulty in school and with their family and peers.

Behaviors linked to ADHD can last into adulthood. In adulthood, ADHD symptoms can continue to cause relationship difficulties as well as problems with job performance and retention.

The year 2000 Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) provides criteria for diagnosing ADHD. The criteria are presented here in modified form in order to make them more accessible to the general public. They are listed here for information purposes and should be used only by trained health care providers to diagnose or treat ADHD.

DSM-IV Criteria for ADHD
I. Either A or B:

1. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

2. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat.

2. Often gets up from seat when remaining in seat is expected.

3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4. Often has trouble playing or enjoying leisure activities quietly.

5. Is often "on the go" or often acts as if "driven by a motor".

6. Often talks excessively.

Impulsivity

1. Often blurts out answers before questions have been finished.

2. Often has trouble waiting one's turn.

3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

2. Some symptoms that cause impairment were present before age 7 years.

3. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

4. There must be clear evidence of significant impairment in social, school, or work functioning.

5. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

2. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 

3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

Diagnosis

There is no standard test to diagnose ADHD. The diagnosis is made by a trained mental health professional. Family and teachers are involved as well.

The American Academy of Pediatrics recommends that the following guidelines be used for diagnosis in children 6-12 years of age:

• Diagnosis should be initiated if a child shows signs of difficulty in:

• • School

• • Academic achievement

• • Relationships with peers and family

• During diagnosis, the following information should be gathered directly from parents, caregivers, teachers, or other school professionals:

• • Assessment of symptoms of ADHD in different settings (home and school)

• • Age at which symptoms started

• • How much the behavior affects the child's ability to function

• The healthcare professional should examine the child for:

• • Other conditions that might be causing or aggravating symptoms

• • Learning and language problems

• • Aggression

• • Disruptive behavior

• • Depression or anxiety

• For a diagnosis of ADHD to be made, symptoms must:

• • Be present in two or more of the child's settings

• • Interfere with the child's ability to function for at least six months

• • Fit a list of symptoms detailed in the most recent version of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association

ADHD diagnosis is often complicated by the presence of other, sometimes co-existing, disorders such as learning disorder, conduct disorder, depression, anxiety disorder, and adjustment disorder.

Treatment

Therapies aim to improve the child's ability to function. Guidelines from the American Academy of Pediatrics encourage physicians to work as a team with parents and school personnel. Together they can set realistic treatment goals and evaluate the child's response.

Treatments include:

Prevention

There are no guidelines for preventing ADHD because the cause is unknown. Proper treatment can prevent problems later in life with school, relationships, and drug and alcohol abuse.

RESOURCES:

Attention Deficit Disorder Association (ADDA)
http://www.add.org

Attention Deficit Disorder Resources
http://www.addresources.org

Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD)
http://www.chadd.org

References:

American Academy of Child and Adolescent Psychiatry website. Available at: http://www.aacap.org/.

American Academy of Pediatrics website. Available at: http://www.aap.org/.

American Psychiatric Association website. Available at: http://www.psych.org/.

The National Mental Health Association website. Available at: http://www.nmha.org/.

Rappley M. Attention deficit-hyperactivity disorder. NEJM. 2005; 352:165-173.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.