By Stephen Brian Sulkes , MD, Golisano Children’s Hospital at Strong, University of Rochester School of Medicine and Dentistry Clinically evaluated Feb 2022 PATIENT EDUCATION VISION Signals and symptons Diagnosis Prognosis Treatment
Attention deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity and impulsivity. There are 3 types of ADHD, those that are predominantly inattentive, hyperactive/impulsive and combined. Clinical criteria provide the diagnosis. Treatment includes stimulant medication, behavioral therapy, and interventions and ed considered a neurodevelopmental disorder.
Attention Deficit/Hyperactivity Disorder (ADHD) is considered a neurodevelopmental disorder. Neurodevelopmental disorders are neurological conditions that appear early in childhood, usually before school age, and impair the development of personal, social, academic, and/or professional functioning. They typically involve difficulties in acquiring, retaining, or applying specific skills or information sets. Neurodevelopmental disorders may involve impairments in one or more of the following: attention, memory, perception, language, problem solving, or social interaction. Other common neurodevelopmental disorders include autism spectrum disorders, learning disorders (eg, dyslexia), and intellectual disability. Some experts previously considered attention-deficit/hyperactivity disorder (ADHD) to be a behavioral disorder, likely because children often exhibit negligent, impulsive, and overly active behavior, and because comorbid behavioral disorders, particularly oppositional-defiant disorder and conduct disorder , are common. However, attention-deficit/hyperactivity disorder (ADHD) has well-established neurological underpinnings and is not simply "bad behavior." ADHD affects about 5 to 15% of children (1). However, many experts believe that ADHD is overdiagnosed, largely because the criteria are applied imprecisely.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), there are 3 types:
Predominant inattention
Predominant hyperactivity/impulsivity
Combined
Overall, attention-deficit/hyperactivity disorder (ADHD) is about twice as common in boys, although rates vary by type. The predominantly hyperactive/impulsive type occurs 2 to 9 times more often among boys, while the predominantly inattentive type occurs with equal frequency in both sexes. Attention Deficit/Hyperactivity Disorder (ADHD) does not have a single known specific cause.
Potential causes of attention-deficit/hyperactivity disorder (ADHD) include genetic, biochemical, sensorimotor, physiological, and behavioral factors. Some risk factors include low birth weight < 1500 g at birth, head trauma, iron deficiency, obstructive sleep apnea, lead exposure, and also fetal exposure to alcohol, tobacco, and cocaine. ADHD is also associated with adverse childhood experiences (ECA; 2). Just over 5% of children with attention-deficit/hyperactivity disorder (ADHD) have evidence of neurological damage. Evidences point to differences in the dopaminergic and noradrenergic systems with decrease or stimulation of the activity of the upper brainstem and mid-frontal cerebral tracts. General references:
1. Boznovik K, McLamb F, O'Connell K, et al: U.S. national, regional, and state‑specific socioeconomic factors correlate with child and adolescent ADHD diagnoses. Sci Rep 11:22008, 2021. doi: 10.1038/s41598-021-01233-2 2. Brown N, Brown S, Briggs R, et al: Associations between adverse childhood experiences and ADHD diagnosis and severity. Acad Pediatr 17(4):349–355, 2017. doi: 10.1016/j.acap.2016.08.013
Attention deficit/hyperactivity disorder (ADHD) in adults Although ADHD is considered a disorder of children and always begins during childhood, underlying neurophysiological differences persist into adulthood and behavioral symptoms remain evident into adulthood in about half of cases. Although the diagnosis can sometimes only be recognized in adolescence or adulthood, some manifestations should have occurred before 12 years of age.
In adults, symptoms include:
Difficulty concentrating
Difficulty completing tasks (impaired executive function)
Mood swings
Impatience
Difficulty maintaining relationships
Hyperactivity in adults usually manifests itself as agitation and restlessness rather than the overt motor hyperactivity that occurs in young children. Adults with attention-deficit/hyperactivity disorder (ADHD) tend to be at greater risk for unemployment, lower educational attainment, and higher rates of substance abuse and criminality. Accidents and traffic violations are more common. ADHD can be more difficult to diagnose during adulthood. Symptoms can be similar to those of mood disorders, anxiety disorders, and substance abuse disorders. Because self-reports of childhood symptoms may be unreliable, clinicians may need to review school records or interview family members to confirm manifestations before age 12 years. Adults with ADHD can benefit from the same types of stimulant drugs used by children with ADHD. They may also benefit from counseling to improve time management and other coping skills.
ADHD signs and symptoms:
Onset usually occurs before 4 years of age and invariably before 12 years of age. The peak for diagnosis is between 8 and 10 years of age, however those with predominant attention deficit are only diagnosed after adolescence.
The core signs and symptoms of attention-deficit/hyperactivity disorder (ADHD) involve:
Inattention
Impulsivity
Hyperactivity
Inattention tends to appear when the child is involved in tasks that require vigilance, quick reaction, visual and perceptual investigation, and systematic and constant attention. Impulsivity refers to rash actions with the potential for a negative outcome (eg, in children, crossing the street without looking; in adolescents and adults, suddenly dropping out of school or work without thinking about the consequences). Hyperactivity involves excessive motor activity. Children, especially younger ones, may have trouble sitting still when expected to do so (eg, at school or church). Older patients can simply be agitated, restless, or talkative—sometimes to the point where other people feel tired just watching them. Inattention and impulsivity impede the development of academic skills and thinking and reasoning strategies, school motivation and social demands. Children with predominant attention deficit tend to give up when faced with situations that require continuous performance to complete tasks. Overall, about 20 to 60% of children with attention-deficit/hyperactivity disorder (ADHD) have learning deficits, but some school dysfunction occurs in most children with ADHD due to inattention (which results in loss of details) and impulsiveness (resulting in answers without thinking about the question).
Behavioral history may reveal low tolerance for frustrations, disagreements, stubborn temperament, aggressiveness, poor social skills and peer relationships, sleep disturbances, anxiety, dysphoria, depression, indecisive temperament.
Although there is no specific physical or laboratory test associated with attention-deficit/hyperactivity disorder (ADHD), signs and symptoms may include:
Motor incoordination, awkward posture
Non-localized mild neurological disorders
Dysfunctions of motor perception
ADHD Diagnosis:
Clinical criteria based on DSM-5
The diagnosis of ADHD is clinical and is based on comprehensive medical, developmental, educational, and psychological assessments (see also the 2019 American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis, Assessment, and Treatment of Attention Deficit Disorder/ hyperactivity in children and adolescents).
DSM-5 diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD)
The DSM-5 diagnostic criteria include 9 signs and symptoms of inattention and 9 of hyperactivity and impulsivity. Diagnosis using these criteria requires ≥ 6 signs and symptoms from one or both groups. In addition, it is necessary that the symptoms:
Are present many times for ≥ 6 months
Are more pronounced than expected for the child's developmental level
Occur in at least 2 situations (eg, home and school)
Are present before age 12 (at least some symptoms)
Interfere with your ability to function at home, school, or work
Symptoms of inattention:
Does not pay attention to details or makes careless mistakes in schoolwork or other activities
Has difficulty sustaining attention on assignments at school or during games
Doesn't seem to pay attention when approached directly
Does not follow instructions and does not complete tasks
Has difficulty organizing tasks and activities
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort over a long period of time
Often loses objects needed for homework or school activities easily distracted
Is forgetful in daily activities
Symptoms of hyperactivity and impulsivity:
Moves or twists hands and feet frequently
Often moves around the classroom or other locations
Runs and climbs too often when this type of activity is inappropriate
Has difficulty playing quietly
Often moves around and acts as if "plugged in" tend to talk too much
Often responds to questions abruptly before they are completed
Often has difficulty waiting his turn
Often interrupts others or intrudes
Diagnosis of the predominant inattentive type requires ≥ 6 signs and symptoms of inattention. Diagnosis of the hyperactive/impulsive type requires ≥ 6 signs and symptoms of hyperactivity and impulsivity. The combined type diagnosis requires ≥ 6 signs and symptoms of each inattention and hyperactivity/impulsivity criteria. Other diagnostic considerations:
Differentiating between attention-deficit/hyperactivity disorder (ADHD) and other conditions can be challenging. Overdiagnosis should be avoided, and other conditions should be accurately identified. Many signs of attention-deficit/hyperactivity disorder (ADHD) expressed in the preschool period may reflect a communication problem that also occurs in other neurodevelopmental disorders (eg, autism spectrum disorders) or certain behavioral disorders. learning, anxiety, depression, or behavioral disorders (eg, conduct disorders). The doctor needs to observe whether the child is distracted by external factors (occurrences in the environment) or by internal factors (thoughts, anxieties, worries). However, in the late childhood period, the signs of ADHD become more qualitatively distinct; children with the hyperactive/impulsive type or the combined type often exhibit persistent persistent motor movements of the lower limbs (eg, disoriented movements and writhing of the hands), compulsive talking, and apparent lack of attention to the environment. Children with the predominantly inattentive type may have no physical signs. The medical evaluation focuses on identifying conditions that may potentially contribute and are treatable, or identifying signs and symptoms that may worsen. Assessment should include looking for history of prenatal exposure (eg, drugs, alcohol, tobacco), perinatal complications or infections, central nervous system infections, head injury, heart disease, breathing during sleep, lack of appetite and/or selective eating and a family history of ADHD.
Developmental assessment focuses on determining the onset and course of signs and symptoms. Assessment includes assessment of developmental milestones, particularly language milestones, and use of attention-deficit/hyperactivity disorder (ADHD)-specific rating scales (eg, Vanderbilt Assessment Scale, Conners Comprehensive Behavior Rating Scale, ADHD Rating Scale IV). Versions of these scales are available for both families and school staff, enabling assessment across different situations, as required by DSM-5 criteria. Note that the scales should not be used alone to make a diagnosis. Educational assessment documents core signs and symptoms that may involve reviewing educational records and use of rating scales. However, these scales alone cannot distinguish attention-deficit/hyperactivity disorder (ADHD) from other developmental or behavioral disorders. ADHD prognosis: Traditional classrooms and academic activities exacerbate the signs and symptoms of children with untreated or inadequately treated attention-deficit/hyperactivity disorder (ADHD). Social and emotional immaturity can be persistent. Poor acceptance by peers and loneliness tend to increase with age and exposure to symptoms. Attention Deficit/Hyperactivity Disorder (ADHD) can lead to substance abuse if not identified and treated properly because many teens and adults with Attention Deficit/Hyperactivity Disorder (ADHD) self-medicate with both legal substances (e.g. (eg, caffeine) and illegal (eg, cocaine, amphetamines). Although the signs and symptoms of hyperactivity tend to decrease with age, adolescents and adults may manifest residual difficulties. Indicators of poor adolescent and adult outcomes include:
Coexistence of low intelligence
Aggressiveness
Social and relationship problems
Parental psychopathological problems
Problems among adolescents and adults manifest themselves predominantly as academic deficiencies, low self-esteem and difficulties in assimilating appropriate social behavior. Adolescents and adults who have predominantly impulsive Attention Deficit/Hyperactivity Disorder (ADHD) may have an increased incidence of personality disorders and antisocial behavior, may continue to display impulsiveness, agitation, and poor social skills. People with ADHD seem to adjust better to work than to academic and home situations, particularly if they find work that does not require attention to perform. ADHD treatment:
Behavioral therapy
Drug therapy with stimulants such as methylphenidate or dextroamphetamine (in short- and long-acting preparations)
Randomized controlled studies show that behavior therapy alone is less effective than drug-only therapy for school-aged children, but behavioral and combination therapy is recommended for younger children. Although correction of baseline neurophysiological differences in patients with attention-deficit/hyperactivity disorder (ADHD) does not occur with drugs, these are effective in alleviating ADHD symptoms and allowing participation in activities previously inaccessible because of poor attention and impulsivity. Drugs break the cycle of inappropriate behavior, improving academic conduct and interventions, motivation, and self-esteem.
Treatment of attention-deficit/hyperactivity disorder (ADHD) in adults follows similar principles, but pharmacological selection and dosage are determined individually, depending on other medical conditions.
Stimulant Drugs: The most widely used are the methylphenidate and amphetamine salts. Responses are highly variable and doses depend on the severity of the behavior and drug tolerance. The dose amount and frequency are adjusted until an optimal balance is reached between response and adverse effects.
The starting dose of methylphenidate is 0.3 mg/kg once daily orally (quick-release form), which is increased every week to about 2 to 3 times daily or every 4 hours during waking hours ; many doctors try to administer the dose in the morning and at noon. The dose can be increased if it has been inadequate, but it is well tolerated. Most children achieve an optimal balance between beneficial and adverse effects at doses between 0.3 and 0.6 mg/kg. The dextro isomer of methylphenidate is the active portion and is available by prescription at half dose.
The usual dose of dextroamphetamine (often in combination with racemic amphetamine) is 0.15 to 0.2 mg/kg once daily orally, which may be increased to 2 or 3 times daily or every 4 hours for the waking hours. Single doses in the range of 0.15 to 0.4 mg/kg are generally effective. You have to balance effectiveness vs. adverse effects when titrating the dose; effective doses vary significantly between individuals, but generally higher doses increase the likelihood of unacceptable adverse effects. In general, dextroamphetamine doses are about two-thirds of methylphenidate doses.
Once the optimal dose is achieved, an equivalent dose of the same drug is substituted for a long-acting form to avoid the need to administer the drug at school. Long-acting preparations include slow-release tablets, biphasic capsules containing the equivalent of 2 doses, and osmotic-release pills, transdermal patches that allow coverage for up to 12 h. Short-acting and long-acting liquid preparations are now available. Pure dextro preparations (eg, dextromethylphenidate) are often used to minimize adverse effects such as anxiety; doses are usually half those of mixed preparations. Prodrug preparations are also sometimes used because of their smoother release, longer duration of action, fewer adverse effects, and less potential for abuse. Learning improves with low doses, but behavior requires higher doses.
Dosing schedules for stimulant drugs can be adjusted to cover special days and times (eg, school and homework hours). Illicit drugs can be tried on weekends, holidays or during summer school breaks. On the other hand, to ensure the reliability of the observations, periods of placebo administration (5 to 10 days) are recommended to determine if the medication is still necessary. The most common side effects are:
Sleep disorders (eg, insomnia)
headache
Stomachache
loss of appetite
Tachycardia and elevation of blood pressure and heart rate
Depression is a less common adverse effect and can often represent an inability to easily shift focus (hyperfocus) May manifest as numb behavior (sometimes described by family members as "zombie-like") rather than depression infant clinic itself. Indeed, stimulant drugs are sometimes used as an adjunctive treatment for depression. Numbing behavior can sometimes be addressed by lowering the dose of the stimulant drug or trying a different drug.
Studies have shown that height growth decreases over 2 years of stimulant drug use and the deceleration apparently persists into adulthood with chronic stimulant drug use. Non-stimulant drugs:
Atomoxetine, a selective norepinephrine reuptake inhibitor, is also used. The drug is effective, but the data are equivocal as to its effectiveness compared to stimulant drugs. Some children have nausea, sedation, irritability, tantrums; rarely liver toxicity and suicidal ideation. The starting dose is 0.5 mg/kg orally once daily, titrated weekly to 1.2 to 1.4 mg/kg once daily. Its long half-life allows for once-daily use, but requires continued use to be effective. The maximum recommended daily dose is 100 mg.
Selective norepinephrine reuptake inhibitor antidepressants such as bupropion and venlafaxine, alpha-2 agonists such as clonidine and guanfacine, and other psychoactive drugs are sometimes used in cases of stimulant ineffectiveness or unacceptable side effects, but are less effective and are not recommended. as first-line drugs. Sometimes these drugs are used in combination with stimulants to achieve synergistic effects; it is essential to monitor closely for adverse effects.
Adverse drug interactions are a concern in the treatment of attention-deficit/hyperactivity disorder (ADHD). Drugs that inhibit the metabolic enzyme CYP2D6, including certain selective serotonin reuptake inhibitors (SSRIs) that are sometimes used in patients with attention-deficit/hyperactivity disorder (ADHD), can potentiate the effect of stimulant drugs. Reviewing potential drug interactions (usually using a computer program) is an important part of drug management for patients with attention-deficit/hyperactivity disorder (ADHD). Behavior control:
Counseling, including cognitive-behavioral therapy (eg, goal setting, self-monitoring, modeling, role-playing), is usually effective and helps the child understand attention-deficit/hyperactivity disorder (ADHD) and how to cope. it. Organization and routine are essential.
Classroom behavior improves with control of ambient noise and visual stimulation, appropriate task duration, novelty, training, and proximity to the teacher.
When difficulties persist at home, parents should be encouraged to seek professional assistance and training in behavioral control techniques. In addition, symbolic incentives and rewards reinforce behaviors and are generally effective. In the home environment, children with attention-deficit/hyperactivity disorder (ADHD) with predominant hyperactivity and poor impulse control are helped when the environment is orderly, parenting techniques are firm, and boundaries are well defined.
Dietary restrictions, multivitamin treatment, use of antioxidants or other compounds, nutritional and biochemical interventions (eg, administration of chemicals) have not the slightest effect. Biofeedback can be useful in some cases, but is not routinely recommended because evidence of sustained benefits is lacking. Key points:
Attention-deficit/hyperactivity disorder (ADHD) involves inattention, hyperactivity/impulsivity, or a combination; it usually appears before age 12, including preschool age.
The cause is unknown, but there are several suspected risk factors.
Diagnose using clinical criteria and remain alert for other disorders that may initially manifest similarly (eg, autism spectrum disorders, certain learning or behavioral disorders, anxiety, depression).
Manifestations tend to decrease with age, but adolescents and adults may have residual difficulties.
Treat with stimulant drugs and cognitive-behavioral therapy; only behavioral therapy may be appropriate for preschool-aged children.
https://www.msdmanuals.com/pt-br/professional/pediatrics/dist%C3%BArbios-de-aprendizagem-e-desenvolvimento/transtorno-de-d%C3%A9ficit-de-aten%C3%A7% C3%A3o-hyperactivity-add-addh
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