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ADHD Part 1

Todd Flosi MD, Rob Orman, MD, and Stephanie D'Augustine MD
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Discuss different ADHD presentations.

There are many different labels or terms used for ADD (ADHD, ADD with impulsivity, etc.). Is it important to distinguish between these or are they all pretty much variants of the same disorder?

  • They are  all variants of the same disorder.  
  • In the DSM-5, it is all described as ADHD with different types of presentations. 
  • There can be an inattentive presentation, a hyperactive impulsive presentation, or a combined presentation.   

Is the specific classification of ADHD important to know for treatment?

  • The treatment for ADHD is going to be similar for all of the different subtypes in term of medication and behavioral support.
  • The impairment associated with the different classifications can lend to different thresholds for starting medication. 
  • For example, a primarily inattentive presentation of ADHD might not be quite as impairing at a younger age as a hyperactivity or impulsivity. threshold to start medication might be higher for an inattentive-type presentation in younger patients.

Is this something that a general practitioner or pediatrician can diagnose?

  • The diagnosis of ADHD is primarily a historical diagnosis. 
  • For professionals in primary care, it's a matter of how comfortable they are with making the diagnosis and starting treatment.
  • With appropriate education and experience it can be diagnosed and treated by primary care providers

How do you draw the line on what behavior is within the normal range and what is a disorder?

  • This is a clinical diagnosis and there is some subjectivity involved in deciding if behavior is within the normal range or not. This is a spectrum and different people will have different characteristics.
  • Much depends on the family/teacher threshold of tolerance. This makes doing a health history important because you want to document and see that the pattern of behavior has been pervasive over a period of time.
    • Possibly the single most important thing for physicians to look at is: how impairing are the behaviors. Everyone has a little bit of difficulty focusing at times, or a little bit of impulsivity.
    • The issue is how impairing are these behaviors to the child's ability to function within the expectations of their families and society. 
    • The impairment level of the child guides treatment planning.
    • For example: a preschool-age child who's been kicked out of 3 different preschools because he is not able to sit down, is constantly blurting out, making noises, hitting other kids, and having excessive amounts of hyperactive and impulsive behaviors, versus a second grader who is just chitchatting with his friends from time to time but for the most part is learning what he needs to learn, getting along socially well, not having a lot of anxiety, going to school and is functioning within his expectations for himself, his family and his society.  

What is the actual process of diagnosing ADHD?

  • First visit: patient history, physical exam and neurological exam.
    • A detailed history about what the main concerns are for the parents and teachers, if any. This includes when the concerns arose
    • A detailed past medical history including what other evaluations the child has had and if the child has ever been on medications. 
    • Include a detailed nutritional history, sleep history and family history (there can be some important information in the family history).
    • Routine physical examination, including a vision and hearing screen.
    • A neurologic examination 
  • Send the family home with an assessment tool, such as a Vanderbilt Assessment Scale, as well as the Child Behavior Checklist as a starting point for evaluation of ADHD symptoms.  
  • Have the patient return for a follow-up visit with the completed questionnaires for review with the family and discussion about the next step in diagnosis and treatment.

Assessment Tools

  • These tools give more information that can help identify and gauge the severity of the problem.
  • The Vanderbilt Assessment Scale
    • A 2-page questionnaire giving ratings on different behaviors.
    • Behaviors are rated on a severity scale and include items such as has difficulty organizing tasks and activities, runs about or climbs too much when remaining seated as expected, is a bully, is cruel to animals, is spiteful. 
    • There are inattentive questions, hyperactivity questions, oppositional defiant, conduct disorder, and mood disorder questions. 
    • It's a general behavioral questionnaire where multiple different potential behavioral issues can be assessed.
    • The caveat is that it shouldn't be used in isolation and should be evaluated in the context of the child's age.
  • The Child Behavioral Checklist is similar, but slightly more involved.  

Are the results of the questionnaires (or scales/ inventories) taken in the context of your gestalt or is there a particular level at which a higher score indicates the patient definitely has ADHD and a lower score indicates they do not?

  • There are diagnostic criteria that are outlined in the DSM-5. 
    • Inattentive symptoms: easily distracted, trouble organizing, losing things for necessary tasks and activities like pencils and wallets, often doesn’t follow through on instructions and fails to finish work, chores, etc. 
    • Hyperactive symptoms: taps of the hands or feet, squirms in the seat, trouble waiting their turn, blurts out answers, talks excessively.
    • A child needs to have at least 6 out of 9 inattentive symptoms, 6 out of 9 hyperactive impulsive symptoms, or a combination of 6 symptoms from the two subtypes in order to meet criteria for one of the presentations of ADHD. 
    • Older adolescents and adults age 17 and up must have 5 out of 9 to get the diagnosis.
  • You arrive at the diagnosis by obtaining the criteria from at least 2 different environments. Symptoms must be present before age 12 (old criteria was before age 7).

What are you looking for in the nutritional history?

  • Look for balance and variety in the diet, including fruits, vegetables and meats.
    • Evaluate if the child consumes an excessive amount of carbohydrates. For example, if the child has a pop tart for breakfast and then goes to school and has difficulty with focus at 10am, the problem may be diet related.
    • Evaluate for protein consumption throughout the day. 
    • Evaluate for diets excessively high in artificial colorings and high glycemic index foods.

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These Crazy Kids Are All Elbows and Rashes Full episode audio for MD edition 203:42 min - 96 MB - M4AHippo Peds RAP February 2015 Summary 498 KB - PDF