Attention Deficit/Hyperactivity Disorder
Syllabus: Floet et al. Attention Deficit/Hyperactivity Disorder. Pediatrics in Review.
2010;31(2):56.
American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the
Diagnosis, Evaluation and Treatment of Attention‐Deficit/Hyperactivty Disorder in
Children and Adolescents. Pediatrics. 2011;128(5):1007.
Introduction
• ADHD is a neurobehavioral disorder defined by symptoms of
inattention, hyperactivity, and impulsivity.
• There is a two‐ to three‐fold higher prevalence in boys than girls with
girls being more likely to be diagnosed with the inattentive‐type ADHD
• Can profoundly effect academic performance, social interactions and
well being
DSM5
Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder
A. A persistent pattern of inattention and/or hyperactivity‐impulsivity
that interferes with functioning or development, as characterized by
(1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social
and academic/occupational activities:
a. Often fails to give close attention to details or makes careless
mistakes in schoolwork, at work, or during other activities (e.g.,
overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play
activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind
seems elsewhere, even in the absence of any obvious
distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks
but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and
belongings in order; messy, disorganized work; has poor time
management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (e.g., schoolwork or homework;
for older adolescents, preparing reports, completing forms,
reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older
adolescents, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running
errands; for older adolescents, returning calls, paying bills,
keeping appointments).
j. Hyperactivity and impulsivity: Six (or more) of the following
symptoms have persisted for at least 6 months to a degree that
is inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational activities:
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is
expected (e.g., leaves his or her place in the classroom, in the
office or other workplace, or in other situations that require
remaining in place).
c. Often runs about or climbs in situations where it is
inappropriate. (Note: In adolescents, may be limited to feeling
restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often "on the go," acting as if "driven by a motor" (e.g., is
unable to be or uncomfortable being still for extended time, as
in restaurants, meetings; may be experienced by others as being
restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been
completed (e.g., completes people's sentences; cannot wait for
turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in
line).
i. Often interrupts or intrudes on others (e.g., butts into
conversations, games, or activities; may start using other
people's things without asking or receiving permission; for
adolescents, may intrude into or take over what others are
doing).

B. Several inattentive or hyperactive‐impulsive symptoms were present
prior to age 12 years.
C. Several inattentive or hyperactive‐impulsive symptoms are present in
two or more settings (e.g., at home, school, or work; with friends or
relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the
quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of
schizophrenia or another psychotic disorder and are not better
explained by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder, personality disorder, substance
intoxication or withdrawal).

Types
• Combined presentation: If both Criterion A1 (inattention) and
Criterion A2 (hyperactivity‐impulsivity) are met for the past 6 months.
• Predominantly inattentive presentation: If Criterion A1
(inattention) is met but Criterion A2 (hyperactivity‐impulsivity) is not
met for the past 6 months.
• Predominantly hyperactive/impulsive presentation: If Criterion A2
(hyperactivity‐impulsivity) is met and Criterion A1 (inattention) is not
met for the past 6 months.
Risk Factors
• Genetic factors: heritability is approximately 75%
• Nongenetic factors: perinatal stress and low birth weight, traumatic
brain injury, maternal smoking during pregnancy, severe early
deprivation
Physical Exam
A physical examination is important in ruling out underlying medical or
developmental problems such as the following:
• emotional or behavioral (eg. anxiety, depression, oppositional defiant
and conduct disorders)
• developmental (eg. learning and language disorders or other
neurodevelopmental disorders)
• physical conditions (eg. tics, sleep apnea)
Examination should include observation of the child and the parent and
their relationship.

Investigations
• Laboratory and imaging studies are not routinely recommended.
However, consideration of hearing and vision tests, thyroid function
studies, blood lead levels, genetic karyotyping and brain imaging
studies if indicated by past medical history or physical examination
• In most cases, laboratory investigations will not be necessary
• Consider a psycho‐educational evaluation including both cognitive and
academic testing to assess for learning problems

Management
Syllabus: Belanger et al. Cardiac risk assessment before the use of stimulant
medications in children and youth. Paediatrics and Child Health. 2009;14(9):579.
Feldman et al. Extended‐release medications for children and adolescents with
attention‐deficit hyperactivity disorder. Paediatrics and Child Health.
2009;14(9):593.
Bernard‐Bonnin A‐C et al. The use of alternative therapies in treating children with
attention deficit hyperactivity disorder. Paediatrics and Child Health.
2002;7(10):710zXXZas Paediatrics and Child Health. 2009;14(9):593.F.
• Approach to treatment is multidisciplinary
• Psychoeducation and support for patient and family
• In cases of ADHD without co‐morbidity, behavioural therapies have not
been shown to be helpful for the core symptoms of ADHD
• School aged children (6‐18 yrs):
o First line is stimulant medication(s)
o Second line is non‐stimulant medications
o Third line is behavior management: positive reinforcement, time
out, response cost, token economy
• Pre‐school aged children (4‐5 yrs):
o First line is behavior management: positive reinforcement, time out,
response cost, and token economy
o Second line is stimulant medication(s)
• Dietary interventions such as the elimination of sugar have NOT
proven to have an observable effect. Other dietary interventions (i.e.,
elimination of food additives or addition of dietary supplements)
require evidence‐based research
• Follow‐up and long‐term management are required as ADHD does not
resolve with age
Medications
• Stimulants (methylphenidate, dextroamphetamine) are considered
first line because they are highly efficacious in reducing symptoms
• Extended release stimulant medications are associated with decreased
use of street drugs among adolescents with ADHD, decrease in rate of
injuries, STI’s and unwanted pregnancies
• Immediate‐release medications such as Ritalin should be avoided as
they are much easier to divert, crushed Ritalin may be snorted or made
into an injectible form, mixed with narcotics and taken as a ‘speed‐ball’
• Medications should be used 365 days per year in adolescents
• Careful titration of medication to optimize effects, minimize side effects
and enhance compliance is essential.