dyslimbic
04-28-2007, 05:16 PM
Diagnosing Attention-Deficit Hyperactivity Disorder
http://psychiatricresourceforum.blogs.com/my_weblog/2007/04/diagnosing_atte.html
We have had a great many requests to talk more about attention-deficit/hyperactivity disorder (ADHD): what it is, and what it is not; when is it a problem and when is it just “normal” childhood or adolescent behavior? And what evidence is there for non-pharmacological approaches?
Although there is a lot of information about ADHD available in books and on line, some of the information is conflicting
The first point is this: it is often extremely difficult to come to an accurate diagnosis in anyone and particularly in a child. In a later post we shall look at the problem of differentiating ADHD and bipolar disorder in children. It is only in recent years that specialists have begun to recognize that bipolar disorder may start in childhood, and that not all attentional problems are ADHD. Some are just kids being kids.
1. The History of Attention-Deficit/Hyperactivity Disorder (ADHD)
It is probably not a new disorder. Something that looks very similar, and may be identical, has been recognized for well over a hundred years.
Mid-1800s: Minimal Brain Damage
1902 Defects in moral character
1934 Organically driven
1940 Minimal Brain Syndrome
1957 Hyperkinetic Impulse Disorder
1960 Minimal Brain Dysfunction (MBD)
1968 Hyperkinetic Reaction of Childhood (DSM II)
1980 Attention-Deficit Disorder - ADD (DSM III): with-hyperactivity OR without-hyperactivity OR residual type
1994-present: Attention-Deficit/Hyperactivity Disorder:
DSM-IV code 314.01: ADHD, Combined Type
314.00: ADHD, Predominantly Inattentive type
314.01: ADHD, Predominantly Hyperactive-Impulsive Type
ADHD Statistics
3-5% of all U.S. school-age children are estimated to have this disorder
5-10% of the entire U.S. population
Males are 3 to 6 times more likely to have diagnosed ADHD than are females: boys are more likely to be hyperactive, and there major gender differences in the manifestations of ADHD.
At least 50% of ADHD sufferers have another diagnosable mental disorder
Diagnostic Features of ADHD
Persistent pattern of:
Inattention
Hyperactivity
Impulsivity
What are the Critical Components of Attention?
Arousal and alertness
External or receptive attention: sensory processing and interpretation
Internal or reflective attention
Processing attention or selective attention
Focus
Filtering
Inhibition of sensation
External or expressive attention
Working memory
Diagnosing ADHD: DSM-IV
Inattentiveness:
Has a minimum of 6 symptoms regularly for the past six months
Symptoms are present at abnormal levels for stage of development
Lacks attention to detail; makes careless mistakes
Has difficulty sustaining attention
Doesn’t seem to listen
Fails to follow through/fails to finish projects
Has difficulty organizing tasks
Avoids tasks requiring mental effort
Often loses items necessary for completing a task
Easily distracted
Is forgetful in daily activities
Hyperactivity/ Impulsivity:
Fidgets or squirms excessively
Leaves seat when inappropriate
Runs about/climbs extensively when inappropriate
Has difficulty playing quietly
Often “on the go” or “driven by a motor”
Talks excessively
Blurts out answers before question is finished
Cannot await turn
Interrupts or intrudes on others
Additional Criteria:
Symptoms causing impairment present before age 7
Impairment from symptoms occurs in two or more settings
Clear evidence of significant impairment (social, academic, etc.)
Symptoms not better accounted for by another mental disorder
Problems of Diagnosis
There can be a great deal of subjectivity of criteria
Inconsistent evaluations--presence of symptoms usually given by teacher or parent
Studies have shown that the number of diagnosed cases of ADHD decreased 80% when the observations of parent, teacher and physician were used rather than just one source
Symptoms in females are more subtle, and this may lead to under-diagnosis
ADHD and the Brain
Diminished arousal of some regions of the nervous system
Decreased blood flow to prefrontal cortex and pathways connecting to limbic system (caudate nucleus and striatum)
PET scan shows decreased glucose metabolism throughout brain
There are similarities of ADHD symptoms to those from injuries and lesions of frontal lobe and prefrontal cortex
MRI scans of ADHD patients consistently show:
Smaller anterior right frontal lobe
Abnormal development in the frontal and striatal regions
A significantly smaller splenium of corpus callosum
Decreased communication and processing of information between hemispheres
Smaller caudate nucleus
Non-progresive loss of volume in the cerebellar vermis and in those with a worse outcome, loss of volume in the inferior-posterior cerebellar lobes
None is diagnostic
Although one expert has claimed to be able to diagnose ADHD from single photon emission computed tomography SPECT studies, and even to recognize different subtypes of ADHD, others have so far failed to replicate his work.
What Causes ADHD?
Underlying cause of these differences is still unknown; there is much conflicting data between studies
Strong evidence of genetic component
Predominant theory: catecholamine neurotransmitter dysfunction or imbalance
Decreased dopamine and/or norepinephrine uptake in brain
Theory supported by positive response to stimulant treatment
Diet
Constant over-stimulation
http://psychiatricresourceforum.blogs.com/my_weblog/2007/04/diagnosing_atte.html
We have had a great many requests to talk more about attention-deficit/hyperactivity disorder (ADHD): what it is, and what it is not; when is it a problem and when is it just “normal” childhood or adolescent behavior? And what evidence is there for non-pharmacological approaches?
Although there is a lot of information about ADHD available in books and on line, some of the information is conflicting
The first point is this: it is often extremely difficult to come to an accurate diagnosis in anyone and particularly in a child. In a later post we shall look at the problem of differentiating ADHD and bipolar disorder in children. It is only in recent years that specialists have begun to recognize that bipolar disorder may start in childhood, and that not all attentional problems are ADHD. Some are just kids being kids.
1. The History of Attention-Deficit/Hyperactivity Disorder (ADHD)
It is probably not a new disorder. Something that looks very similar, and may be identical, has been recognized for well over a hundred years.
Mid-1800s: Minimal Brain Damage
1902 Defects in moral character
1934 Organically driven
1940 Minimal Brain Syndrome
1957 Hyperkinetic Impulse Disorder
1960 Minimal Brain Dysfunction (MBD)
1968 Hyperkinetic Reaction of Childhood (DSM II)
1980 Attention-Deficit Disorder - ADD (DSM III): with-hyperactivity OR without-hyperactivity OR residual type
1994-present: Attention-Deficit/Hyperactivity Disorder:
DSM-IV code 314.01: ADHD, Combined Type
314.00: ADHD, Predominantly Inattentive type
314.01: ADHD, Predominantly Hyperactive-Impulsive Type
ADHD Statistics
3-5% of all U.S. school-age children are estimated to have this disorder
5-10% of the entire U.S. population
Males are 3 to 6 times more likely to have diagnosed ADHD than are females: boys are more likely to be hyperactive, and there major gender differences in the manifestations of ADHD.
At least 50% of ADHD sufferers have another diagnosable mental disorder
Diagnostic Features of ADHD
Persistent pattern of:
Inattention
Hyperactivity
Impulsivity
What are the Critical Components of Attention?
Arousal and alertness
External or receptive attention: sensory processing and interpretation
Internal or reflective attention
Processing attention or selective attention
Focus
Filtering
Inhibition of sensation
External or expressive attention
Working memory
Diagnosing ADHD: DSM-IV
Inattentiveness:
Has a minimum of 6 symptoms regularly for the past six months
Symptoms are present at abnormal levels for stage of development
Lacks attention to detail; makes careless mistakes
Has difficulty sustaining attention
Doesn’t seem to listen
Fails to follow through/fails to finish projects
Has difficulty organizing tasks
Avoids tasks requiring mental effort
Often loses items necessary for completing a task
Easily distracted
Is forgetful in daily activities
Hyperactivity/ Impulsivity:
Fidgets or squirms excessively
Leaves seat when inappropriate
Runs about/climbs extensively when inappropriate
Has difficulty playing quietly
Often “on the go” or “driven by a motor”
Talks excessively
Blurts out answers before question is finished
Cannot await turn
Interrupts or intrudes on others
Additional Criteria:
Symptoms causing impairment present before age 7
Impairment from symptoms occurs in two or more settings
Clear evidence of significant impairment (social, academic, etc.)
Symptoms not better accounted for by another mental disorder
Problems of Diagnosis
There can be a great deal of subjectivity of criteria
Inconsistent evaluations--presence of symptoms usually given by teacher or parent
Studies have shown that the number of diagnosed cases of ADHD decreased 80% when the observations of parent, teacher and physician were used rather than just one source
Symptoms in females are more subtle, and this may lead to under-diagnosis
ADHD and the Brain
Diminished arousal of some regions of the nervous system
Decreased blood flow to prefrontal cortex and pathways connecting to limbic system (caudate nucleus and striatum)
PET scan shows decreased glucose metabolism throughout brain
There are similarities of ADHD symptoms to those from injuries and lesions of frontal lobe and prefrontal cortex
MRI scans of ADHD patients consistently show:
Smaller anterior right frontal lobe
Abnormal development in the frontal and striatal regions
A significantly smaller splenium of corpus callosum
Decreased communication and processing of information between hemispheres
Smaller caudate nucleus
Non-progresive loss of volume in the cerebellar vermis and in those with a worse outcome, loss of volume in the inferior-posterior cerebellar lobes
None is diagnostic
Although one expert has claimed to be able to diagnose ADHD from single photon emission computed tomography SPECT studies, and even to recognize different subtypes of ADHD, others have so far failed to replicate his work.
What Causes ADHD?
Underlying cause of these differences is still unknown; there is much conflicting data between studies
Strong evidence of genetic component
Predominant theory: catecholamine neurotransmitter dysfunction or imbalance
Decreased dopamine and/or norepinephrine uptake in brain
Theory supported by positive response to stimulant treatment
Diet
Constant over-stimulation