Attention deficit hyperactivity disorder

The patient with attention deficit hyperactivity disorder (ADHD) has difficulty focusing his attention or engaging in quiet, passive activities, or both. Although the disorder is present at birth, diagnosis before age 4 or 5 is difficult unless the child shows severe symptoms. Some patients, though, aren’t diagnosed until adulthood. Males are three times more likely to be affected than females.

Causes
ADHD is commonly thought to be a physiologic brain disorder with a familial tendency. Some studies indicate that it may result from disturbances in neurotransmitter levels in the brain.

Signs and symptoms
Typically, the patient is characterized as someone who fidgets and daydreams. Other descriptive terms include inattentive and lazy. Although the patient may be highly intelligent, his school or work performance patterns are sporadic, and he may jump from one partly completed project, thought, or task to another. Some patients have an attention deficit without hyperactivity; they’re less likely to be diagnosed and treated.
In a younger child, signs and symptoms include an inability to wait in line, remain seated, wait his turn, or concentrate on one activity until it’s completed. An older child or an adult may be described as impulsive and easily distracted by irrelevant thoughts, sounds, or sights. He may also be characterized as emotionally labile or inattentive. His disorganization becomes apparent when he has difficulty meeting deadlines and keeping track of school or work tools and materials.

Diagnosis
Commonly, the child with ADHD is referred for evaluation by the school. Diagnosis of this disorder usually begins by obtaining data from several sources, including the parents, teachers, and the child himself. Complete psychological, medical, and neurologic evaluations rule out other problems. Then the child undergoes tests that measure impulsiveness, attention, and the ability to sustain a task. The combined findings portray a clear picture of the disorder and of the areas of support the child will need

Treatment

• Education represents the first step in effective treatment
• Treatment varies, depending on the severity of symptoms and their effects on the patient’s ability to function. Behavior modification, coaching, external structure, use of planning and organizing systems, and supportive psychotherapy help the patient cope with the disorder.
• Some patients benefit from medication to relieve symptoms. Ideally, the treatment team identifies the symptoms to be managed, selects the appropriate drug, and then tracks the patient’s symptoms to determine drug effectiveness. Stimulants, such as methylphenidate and dextroamphetamine, are the most commonly used drugs. However, other drugs—including tricyclic antidepressants (such as desipramine and nortriptyline), mood stabilizers, and beta-adrenergic blockers—sometimes help control symptoms.

Special considerations

1. Work with the individual to develop external structure and controls.
2. Set realistic expectations and limits because the patient with an attention deficit disorder is easily frustrated (which leads to decreased self-control).
3. Remain calm and consistent.
4. Keep instructions short and simple.
5. Provide praise, rewards, and positive feedback whenever possible.
6. Refer parents to Children and Adults with Attention-Deficit/Hyperactivity Disorder or other support groups.