ADHD: Hyperactivity and Impulsivity Symptoms

Hyperactivity and Impulsivity Symptoms

• At least six symptoms of hyperactivity-impulsivity must persist for a minimum of six months.
• These symptoms must be maladaptive and inconsistent with the individual's developmental level.
• Hyperactivity symptoms manifest as fidgeting, squirming, leaving seat, restlessness, difficulty in quiet play, being "on the go", and excessive talking.
• Impulsivity symptoms include blurting out answers, difficulty waiting turn, and interrupting others.

Diagnostic Criteria for ADHD

• Some hyperactive-impulsive or inattentive symptoms causing impairment were present before the age of 7.
• Impairment from the symptoms is present in at least two settings, such as school, work, or home.
• Clear evidence of significant impairment exists in social, academic, or occupational functioning.
• Symptoms must not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or Psychotic Disorder.
• Symptoms should not be better accounted for by another mental disorder.

ADHD Types

• Combined Type: Both Criteria A1 (inattention) and A2 (hyperactivity-impulsivity) are met for the past six months, coded as 314.01.
• Predominantly Inattentive Type: Criterion A1 is met, but Criterion A2 is not met for the past six months, coded as 314.00.
• Predominantly Hyperactive-Impulsive Type: Criterion A2 is met, but Criterion A1 is not met for the past six months, coded as 314.01.
• Coding note: "In Partial Remission" should be specified for individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria.

Differentiating ADHD from Other Conditions

• Oppositional behavior involves resisting tasks due to unwillingness to conform, unlike the avoidance of tasks in ADHD.
• Secondary oppositional attitudes may develop in individuals with ADHD as a rationalization for failure.
• Increased motor activity in ADHD differs from the focused and fixed repetitive movements seen in Stereotypic Movement Disorder.
• ADHD is not diagnosed if symptoms are better accounted for by another mental disorder or if inattention symptoms have an onset after age 7 except in certain circumstances.
• Symptoms related to medication use in children under 7 are diagnosed as Other Substance-Related Disorder Not Otherwise Specified.

Inattention Symptoms

• Six or more symptoms of inattention must persist for at least six months to a degree that is maladaptive and inconsistent with the individual's developmental level.
• Inattention symptoms include failure to pay close attention to details, difficulty sustaining attention, not listening when spoken to directly, not following through on instructions, difficulty organizing tasks, avoiding tasks requiring sustained mental effort, losing things, being easily distracted, and forgetfulness.

Prevalence of ADHD

• Prevalence estimates range from 3-7% in school-age children.
• These rates vary depending on the population sampled and the method of ascertainment.
• Data on prevalence in adolescence and adulthood are limited.
• The prevalence might be greater under DSM-IV criteria due to the inclusion of predominantly hyperactive-impulsive and predominantly inattentive types.
• ADHD may be more frequent in males, with male-to-female ratios ranging from 2:1 to 9:1, with gender differences depending on the ADHA type and sample ascertainment.

Course of ADHD

• Excessive motor activity is often first observed in toddlers, coinciding with the development of walking.
• Special attention should be paid to differentiate normal overactivity from the hyperactivity characteristic of ADHD.
• The disorder is usually first diagnosed during elementary school years when school adjustment is compromised.
• The inattentive type may come to clinical attention until late childhood or early signs may be overlooked.
• Symptoms attenuate during adolescence and adulthood in most individuals especially hyperactivity symptoms, a minority experience the full complement of symptoms into mid adulthood.
• Diagnosis of "In Partial Remission" is applicable when individuals no longer have the full diagnosis and retained some significant symptoms that cause functional impairment.

Familial Pattern

• ADHD is more common in first-degree biological relatives of children with ADHD than in the general population.
• Genetic factors strongly influence hyperactivity, impulsivity, and inattention, along with family, school, and peer influences.
• There is a higher prevalence of Mood and Anxiety Disorders, Learning Disorders, Substance-Related Disorders, and Antisocial Personality Disorder in family members of individuals with ADHD

Differential Diagnosis

• It may be difficult to distinguish symptoms of ADHD from age-appropriate behaviors in active children.
• Symptoms of inattention may be common among children with low IQ placed in academic settings inappropriate to their abilities.
• In children with Mental Retardation, ADHD should be diagnosed only if symptoms exceed what's expected for the child's mental age.
• ADHD must be distinguished from difficulty in goal-directed behavior in children from inadequate, disorganized, or chaotic environments.
• Thorough histories from multiple informants are helpful in providing observations about a child's inattention, hyperactivity, and self-regulation.

Associated Laboratory Findings

• There are no laboratory tests, neurological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of ADHD.
• Tests requiring effortful mental processing may be noted to be abnormal in groups of individuals with ADHD compared with peers.

Associated physical examination findings and general medical conditions

• There are no specific physical features associated with ADHD, although minor physical anomalies may occur at a higher rate than in the general population.
• There may also be a higher rate of accidental physical injury.

Specific Culture, Age, and Gender Features

• ADHD is known to occur in various cultures, with differences in reported prevalence among Western countries probably more from differences in diagnostic practices than clinical presentation.
• It is more difficult to establish the diagnosis in children younger than age 4 or 5 years, because their characteristic behavior is much more variable than that of older children.
• In school-age children, symptoms affect classroom work and academic performance, while impulsive symptoms break familial, interpersonal, and education rules.
• Late childhood reduces gross motor activity signs, it may be confined to fidgetiness; adults manifest restlessness, and social dysfunction among comorbid diagnoses
• Caution should be exercised in adults based. on retrospective data validity and improvement of the accuracy of the diagnosis using corroborating information may be difficult

Subtypes of ADHD

• While many people present with both inattention and hyperactivity-impulsivity patterns, there are individuals in whom one or the other pattern is predominant.
• The subtype should be indicated based on the predominant symptom pattern for the past 6 months.
• Attention-Deficit/Hyperactivity Disorder, Combined Type: Six or more symptoms of inattention and hyperactivity-impulsivity have persisted for at least 6 months. This subtype occurs in many children and adolescents with the disorder.
• Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: Six or more symptoms of inattention have persisted for at least 6 months, but not hyperactivity-impulsivity symptoms.
• Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: Six or more symptoms of hyperactivity-impulsivity have persisted for at least 6 months, but not inattention symptoms.
• Individuals with varying subtypes may go on to develop different ADHD types. The applicable subtype for the current evaluation should be documented to represent the predominant symptom expression over the past 6 months.

Associated descriptive features and mental disorders

• The associated ADHD characteristics are very depending on age and developmental stage. They include low frustration tolerance, temper outbursts, bossiness, stubbornness, excessive and frequent insistence
• Academic achievement in children with ADHD may be impaired and devalued, typically leading to conflict with family and school authorities.
• Family relationships can be characterized by resentment and antagonism. However, negative interactions often improve with successful treatment.
• On average, individuals with ADHD obtain less schooling than their peers have lower IQ's.
• The severe form is markedly impairing and effects social, familial, and scholastic adjustment affecting the Combined Types).
• Deficient academic and school skills are seen in the types marked by inattention (Predominantly Inattentive and Combined Types). While, peer rejection and, accidental injury may be seen in type by hyperactivity and impulsivity.
• Clinic-referred children with ADHD may also have Oppositional Defiant or Conduct Disorder
• Other disorders include Mood, Anxiety, Learning, and Communication Disorders in children with ADHD.
• Attention-Deficit/Hyperactivity Disorder appears in at least 50% of clinic-referred individuals with Tourette's Disorder.
• ADHD may be linked to child abuse or neglect, multiple foster placements, infections exposure, drug use, or Mental Retardation. However most children with these history doesn't develop ADHD.

ADHD: Detailed Symptoms and Manifestations

• Inattention leads to difficulty paying attention & easily diverted.
• Inattention manifests as an individual who may not pay attention with schoolwork or tasks. In social, inattention may be expressed as frequent shifts in conversa not listening to others.
• Hyperactivity may vary with the individual's age and developmental level.
• Toddlers to adolescents have trouble participating in sedentary classes. Adolescents and adults may also have difficulty engaging in sedentary activities.
• Impulsivity manifests itself as impatience, difficulty responding by butting into situations.
• Individuals with ADHD typically make comments; they initiate conversations at inappropriate times.
• Attentional and behavioral manifestations usually appear in multiple contexts. Some impairment must be present in at least two settings.
• Symptoms typically worsen in situations that require sustained attention or mental effort.
• Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behavior