Attention-Deficit/Hyperactivity

Disorder
Suryadi Susanto
Pediatric Department
Krida Wacana Christian University

ADHD
The most common neurobehavioral disorder of
childhood
Among the most prevalent chronic
conditions affecting school-aged children

health

The most extensively studied mental disorder of

childhood

ADHD
Characteristics:
Inattention, including increased distractibility
and difficulty sustaining attention
Poor impulse control
inhibitory capacity

and

decreased

Motor overactivity and motor restlessness

self-

DSM-IV DIAGNOSTIC CRITERIA FOR ATTENTIONDEFICIT/HYPERACTIVITY DISORDER

A. Either 1 or 2
1. Six (or more) of the following symptoms of inattention have
persisted for 6mo to a degree that is maladaptive and
inconsistent with development level:
Inattention
a. Often fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play
activities
c. Often does not seem to listen when spoken to directly
d. 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)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort (such as schoolwork
or homework)
g. Often loses things necessary for tasks or activities (e.g.,
toys, school assignments, pencils, books, tools)

2. Six (or more) of the following symptoms of hyperactivityimpulsivity have persisted for 6mo to a degree that is
maladaptive and inconsistent with developmental level:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in
which remaining seated is expected
c. Often runs about or climbs excessively in situations in
which it is inappropriate (in adolescents or adults, may
be limited to subjective feelings of restlessness)
d. Often has difficulty playing or engaging in leisure
activities quietly
e. Is often on the go or often acts as if driven by a
motor
f. Often talks excessively
Impulsivity
g.
Often blurts out answers before questions have been
completed
h.
Often has difficulty awaiting turn
i.
Often interrupts or intrudes on others (e.g., butts into

B. Some hyperactive-impulsive or inattentive symptoms that

caused impairment were present before 7yr of age
C. Some impairment from the symptoms is present in 2 or more
settings (e.g., at school [or work] or at home)
D. There must be clear evidence of clinically significant impairment
in social, academic, or occupational functioning
E. Symptoms do not occur exclusively during the course of a
pervasive developmental disorder, schizophrenia, or other
psychotic disorder, and are not better accounted for by another
mental disorder (e.g., mood disorder, anxiety disorder,
dissociative disorder, personality disorder)

CODE BASED ON TYPE

314.01 Attention-deficit/hyperactivity disorder, combined type: if
both criteria A1 and A2 are met for the past 6mo
314.00 Attention-deficit/hyperactivity disorder, predominantly
inattentive type: if criterion A1 is met but criterion A2 is
not met for the past 6mo
314.01 Attention-deficit/hyperactivity disorder, predominantly
hyperactive-impulsive type: if criterion A2 is met but
criterion A1 is not met for the past 6mo

DIFFERENTIAL DIAGNOSIS OF ATTENTIONDEFICIT/HYPERACTIVITY DISORDER

PSYCHOSOCIAL FACTORS
Response to physical or sexual
abuse
Response to inappropriate
parenting practices
Response to parental
psychopathology
Response to acculturation
Response to inappropriate
classroom setting
DIAGNOSES ASSOCIATED WITH
ADHD BEHAVIORS
Fragile X syndrome
Fetal alcohol syndrome
Pervasive developmental disorders
Obsessive-compulsive disorder
Tourette's syndrome
Attachment disorder with mixed

MEDICAL AND NEUROLOGIC

CONDITIONS
Thyroid disorders (including
general resistance to thyroid
hormone)
Heavy metal poisoning
(including lead
Adverse effects of medications
Effects of abused substances
Sensory deficits (hearing and
vision)
Auditory and visual processing
disorders
Neurodegenerative disorder
Post-traumatic head injury
Post-encephalitic disorder

Etiology
Risk Factors and Association
multifactorial
birth complications
maternal drug use
maternal smoking and alcohol use
food colorings and preservatives
abnormal brain structures/functions
psychological stressors

Genetic Studies
dopamine transporter gene (DAT1)
dopamine 4 receptor gene (DRD4
Additional genes (might contribute):
DOCK2
associated with a pericentric inversion 46N
inv(3)(p14:q21) involved in cytokine regulation,
a sodium-hydrogen exchange gene
DRD5, SLC6A3, DBH, SNAP25, SLC6A4, and
HTR1B.

Epidemiology
5-10% of school-aged children are affected
2-6% in adolescent
2% of adults

Pathogenesis
MRI studies
loss of normal asymmetry in the brain
smaller brain volumes of specific structures

Functional MRI findings

low blood flow to the striatum
deficits functional striatum, prefrontal regions,
parietal lobe, and temporal lobe
dopamine hypothesis

Clinical Manifestations
Age 5-12yo
The behavior must be developmentally inappropriate
Must begin before age 7yo
Must be present for at least 6mo,
Must be present in 2 or more settings
Must not be secondary to another disorder.

DSM-IV: 3 subtypes of ADHD.

1st subtype: attention-deficit/hyperactivity
disorder, predominantly inattentive type
often includes cognitive impairment
more common in females
Attention-deficit/hyperactivity disorder,
predominantly hyperactive-impulsive type
Attention deficit/hyperactivity disorder,
combined type
more common in males

Symptoms
Motor restlessness
Aggressive and disruptive behavior
Disorganized
Distractible
Inattentive symptoms

Diagnosis and Differential Diagnosis

Made primarily in clinical settings
Completion of behavior rating scales
A physical examination
Any necessary or indicated laboratory tests

Treatment
Psychosocial Treatments
Behaviorally Oriented Treatments
Medications

Cardiac evaluation of children and adolescents

receiving or being considered for stimulant
medications.

Prognosis
Persistent ADHD throughout the life span.
60-80% of children with ADHD continue to experience
symptoms in adolescence
40-60% of adolescents exhibit ADHD symptoms into
adulthood
Reduction in hyperactive behavior often occurs with age
Other symptoms associated with ADHD can become
more prominent with age

 Untreated ADHD
Engaging in risk-taking behaviors (sexual
activity, delinquent behaviors, substance use)
Educational underachievement or employment
difficulties
Relationship difficulties

Prevention
Parent training
Earlier detection, diagnosis, and treatment and
prevention of long-term adverse effects