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Attention-Deficit/Hyperactivity Disorder (ADHD)

Key Features

  • Common neurodevelopmental disorder that may affect about 7–8% of children and 2.5% of adults

  • Associated with a triad of symptoms: impulsivity, inattention, and hyperactivity

  • Most children have a combined type with symptoms of inattention as well as hyperactivity and impulsivity

  • Girls have a higher prevalence of the inattentive subtype; boys have a higher prevalence of the hyperactive subtype

  • Although symptoms begin in early childhood, they can diminish between ages 10 and 25 years

    • Hyperactivity declines more quickly

    • Impulsivity and inattentiveness often persist into adolescence and adulthood

Clinical Findings

  • May be combined with other psychiatric conditions, such as

    • Mood disorder in approximately 20% of patients

    • Conduct disorders in 20%

    • Oppositional defiant disorder in up to 40%

  • Up to 25% of children with ADHD have tics or Tourette syndrome; conversely, well over 50% of individuals with Tourette syndrome also have ADHD

  • ADHD is also associated with a variety of genetic disorders including

    • Fragile X syndrome

    • Williams syndrome

    • Angelman syndrome

    • XXY syndrome (Klinefelter syndrome)

    • Turner syndrome

  • Fetal alcohol syndrome (FAS) is also strongly associated with ADHD

  • CNS trauma, CNS infections, prematurity, and a difficult neonatal course with brain injury can also be associated with later ADHD

  • Metabolic problems such as hyperthyroidism can sometimes cause ADHD

Diagnosis

  • Significant challenges in academic functioning and social interactions are present

  • DSM-5 describes three ADHD subtypes: hyperactive-impulsive, inattentive, and combined

  • To be classified according to one or another of these subtypes, the child must exhibit six or more of the symptoms listed in Table 3–3

  • DSM-5 continues to include the same 18 symptoms, 2 symptom domains, and require 6 symptoms from each domain for children younger than 17

  • DSM-5 includes the following changes:

    • Criteria will address symptoms across the life span

    • Symptoms causing the impairment will need to be present prior to age 12 instead of age 7

    • Some symptoms need to be present across more than one setting

Table 3–2.1Revised Cardiac Risk Index.
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Table 3–2. Revised Cardiac Risk Index.
Independent Predictors of Postoperative Cardiac Complications
1. Intrathoracic, intraperitoneal, or suprainguinal vascular surgery
2. History of ischemic heart disease
3. History of heart failure
4. Insulin treatment for diabetes mellitus
5. Serum creatinine level > 2 mg/dL [> 176.8 mcmol/L]
6. History of cerebrovascular disease
Scoring (Number of Predictors Present) Risk of Major Cardiac Complications1
None 0.4%
One 1%
Two 2.4%
More than two 5.4%
1

Cardiac death, myocardial infarction, or nonfatal cardiac arrest.

Data from Devereaux PJ et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ. 2005 Sept 13;173(6):627–34.

Table 3–3.1Indications for prophylactic perioperative beta-blockade.1
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Table 3–3. Indications for prophylactic perioperative ...

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