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ADHD

Not all children with Attention Deficit Hyperactive Disorder (ADHD) will demonstrate obvious symptoms during a clinic visit. Therefore, certain academic, social, and emotional problems should prompt the evaluation for the three types of ADHD- inattentive, hyperactive-impulsivity, and combined types (Taylor, 2013). All Diagnostic & Statistical Manual for Mental Disorders Fifth Edition diagnostic criteria are outlined in a checklist published by the Center for Disease Control and Prevention (2014). 

The symptom triad of impulsivity, hyperactivity, and inattention must present before age 12, and be present in two different settings. Therefore, questions need to be posed to people who interact with the child in different domains of life. The questions involve such things as:

  • Interpersonal Interactions. Those with ADHD have a six times greater difficulty with friendships, and emotional and conduct problems (Burns et al, 2013, p. 281).
  • Home Environment and Stress. Those with ADHD have a nine times greater likelihood of family stress (Burns et al, 2013, p. 281).
  • Substance Use. Fifteen to 19% percent of adolescents with ADHD develop a substance abuse disorder (Burns et al, 2013, p. 285).
  • School Performance (Burns et al, 2013, p. 281).
  • Motor Coordination (Burns et al, 2013, p. 285).
  • Enuresis (Burns et al, 2013, p. 285).
  • frustation tolerance and distractibility
  • stimulus seeking, fidgeting, talkativeness
  • planning, organization, task performance
  • forgetfulness and loosing things
 
While some symptoms of ADHD are actually normal during certain stages of growth and development, those attributed to ADHD are not in line with the child's developmental level (Burns et al, 2013). Questions about family history are important because having a first degree relative with ADHD increases a child's risk by 2 to 8 fold (Family Practice Notebook, n.d.). There is strong evidence that ADHD is a genetic inheritable disorder with heterogenous (variable) phenotypic (muti-factorial risks) expression/penetrance (severity) (Burns et al, 2013, p. 282). Mothers should be questioned about perinatal history for such things as prematurity; tobacco and alcohol use; food additives; essential fatty acid, iron, and zinc deficiency (Burns et al, 2013, p. 282).

A child's behavior may be better accounted for by another mental health disorder (Burns et al, 2013). Five differential diagnosis are sensory impairment, sleep disorders, mood  disorders, learning disability, and conduct disorders (Taylor, 2013):

1. Sensory Impairments
This would require questions about and screens for hearing and vision impairment. Problems with either can mimic inattention (Taylor, 2013).

2. Sleep Disorders
Describe the child's sleep hygiene, sleep patterns, and daytime alertness. While children with ADHD often have poor sleep hygiene, they typically do not seem overtired (Taylor, 2013). Sleep disorders that may adversely affect school performance include obstructive sleep apnea, narcolepsy, and poor sleep hygiene (Taylor, 2013). 

3. Mood Disorders
Comorbidity such as depression and anxiety disorders (33%) may mimic or accompany ADHD (Burns et al, 2013, p. 285). The prevalence of mood disorders increases with age and type of disorder, with depression demonstrating a high rate of conversion to bipolar disorder (Taylor, 2013). A manic phase of manic-depression may resemble hyperactivity. Some questions about mood disorder also help determine which medications are contraindicated if the child is diagnosed with ADHD (Burns et al, 2013, p. 288).

Children may not present with the same symptoms of mood disorders compared to adults. The questions may be different than those posed to adults to screen for depression and mania (Xinran, n.d.). Or questions may be asked of the child's caregivers. Ideally an age/ situation/ disorder specific screening tool should be used. For example, the Vanderbilt Diagnostic Rating Scales, SNAP-IV-C, and SWAN screen for symptoms in the domains of ADHD, and are appropriate for children who are 6 years old and older (American Academy of Pediatrics, 2010, p. 8). There are Vanderbilt scales for teacher's / parents (Bright Futures, n.d.) and follow-ups. 

4. Learning Disability (reading speech, language)
School failure is a red flag for the evaluation of ADHD. Comorbidity between the two is common such that a differential requires evaluation, diagnosis, and documentation of a discrepancy between intelligence quotient (IQ) and academic achievement (Taylor, 2013). Implying that children with both behavioral and school performance problems should be evaluated for each individually, before diagnosing and treating either one.

5. Conduct Disorders
Oppositional defiant disorder (ODD) and Conduct disorder (CD) have a 30% to 84% comorbidity rate with ADHD  (Burns et al, 2013, p. 285). ODD is ascertained by asking questions and observing for negativistic, hostile, and defiant behavior; CD is a severe disorder ascertained by asking questions and observing for such things as habitual rule-breaking, lying, stealing, and/or truancy (Taylor, 2013).
 
References 
American Academy of Pediatrics. (2010). Mental health screening tools for primary care. Retrieved from www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf. 

Bright Futures. (n.d.). Vanderbilt ADHD Diagnostic Teacher Rating Scale. Retrieved from http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/adhd.pdf

Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier. 

Centers for Disease Control and Prevention. (2014). Attention deficit/hyperactivity disorder ADHD, is it ADHD?: Symptom checklist. Retreived from www.cdc.gov/ncbddd/adhd/documents/adhd-symptom-checklist.pdf

Family Practice Notebook. (n.d.).  ADHD in children: Epidemiolgy [android version].

Taylor, H. (2013). Case 4: 8-year-old well child check- Jimmy. In MedU Computer-assisted Learning in Pediatrics Program.

Xinran. (n.d.). Taking a depression history. In Underground Med. Retrieved from http://videos.undergroundmed.net/?user=cnordick@stfrancis.edu# 



























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