ArticleAttention Deficit/Hyperactivity Disorder: A Review and Update
Section snippets
Historical Context of ADHD
Hyperactivity in children was first described clinically in 1902, and the first report of stimulant use to treat hyperactivity in that condition was in 1937 (Bradley, 1937). Initially, the condition was called minimal brain dysfunction due to the high frequency of “soft” neurological findings and the expectation that consistent neurological legions would eventually be found (Clements, 1966). As the association of brain damage became less certain, the nomenclature changed to reflect an emphasis
Diagnostic Criteria for ADHD
In DSM-IV-TR (APA, 2000), diagnostic decision-making centers on two 9-item symptom listings––one related to inattention symptoms and the other to hyperactivity-impulsivity concerns (Table 1). Parents and/or teachers must report the presence of at least six of nine behaviors from either list to warrant consideration of an ADHD diagnosis of predominantly inattentive type or hyperactive/impulsive type. For a diagnosis of ADHD combined type, more than six symptoms must be present from both lists.
Prevalence
Estimates of the incidence of ADHD vary considerably, ranging 2% to 16%, depending on the diagnostic criteria and assessment tools employed (Brown et al., 2001, Faraone et al., 2003). Using the criteria specified by DSM-IV-TR, approximately 3% to 7% of school-age children meet requirements for some type of ADHD diagnosis (Sciutto & Eisenberg, 2007). Predominantly hyperactive/impulsive and combined subtypes are more common than the inattentive subtypes among younger children (Egger et al., 2006
Developmental Course and Outcome
Many parents of children with ADHD recall that their child was excessively active, intense, and demanding as an infant and toddler (Bussing, Lebninger, & Eyberg, 2006). Most, however, first display clear signs of developmentally inappropriate inattentive and overactive behavior suggestive of ADHD between 3 and 4 years of age (Barkley, 2006). For a smaller number of children, ADHD symptoms may not be evident until 5 or 6 years of age, corresponding with school entry. The ability to sit still,
Comorbidity with ADHD
It is now well established that ADHD is usually associated with the presence of one or more major psychiatric disorders and that these problems are at least as important as ADHD in predicting the long-term outcome of the individual child. It is estimated that as many as two in three children with ADHD in the general population meet criteria for one or more DSM-IV-TR diagnoses (Gillberg et al., 2004, Jensen et al., 2001, Jensen et al., 1997, Kadesjo & Gillberg, 2001). The most common coexisting
Etiology
Over the past 15 years, significant progress has been made in understanding the etiology of childhood ADHD, largely due to the publication of family, twin, and adoption studies, which are consistent in suggesting genetic and neurological influences (Brassett-Harknett & Butler, 2007, Waldman & Gizer, 2006). About one fourth to one third of biological parents with an ADHD child are affected by ADHD themselves. A dopamine transmitter gene (DAT-1) and dopamine receptor gene (DAT-4) have been linked
Assessment of ADHD
Primary care providers see a variety of school-age children with developmental and behavioral concerns. Based on the high prevalence of ADHD in this population, AAP (2000) recommends asking parents about behavioral and/or learning problems at school during routine visits. In many cases, requests for evaluation of the child for ADHD derive from parents, teachers, other professionals, or nonparental caregivers, who have identified problems in the school setting such as inattentiveness, disruptive
Treatment
Factors that complicate the assessment process such as the situational variability of primary ADHD symptoms, the likelihood of comorbid conditions, and race/ethnicity, also affect the treatment process. These issues make it improbable that any one primary care provider or treatment approach can respond to all of the clinical management needs of the child with ADHD. Parents are key partners in the treatment plan, and ongoing communication among parents, teachers, and other school-based
Implications for Primary Care Providers
The aim of this paper was to provide primary care clinicians with a current and evidence-based review of ADHD, which they could use to educate families and involve them in treatment decisions. Primary care clinicians routinely encounter ADHD, yet approaches to diagnosis and treatment of the disorder vary considerably in primary care settings (Connors et al., 2001, Magyary & Brandt, 2002, Rushton et al., 2004). The guidelines provided by the AAP (2000) recommend applying DSM-IV diagnostic
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