Chapter 8: Behavioral Disorders in Children

ATTENTION DEFICIT–HYPERACTIVITY DISORDER

General Considerations

Up to 20% of school-aged children in the United States have behavioral problems, at least half of which involve attention and/or hyperactivity difficulties. Attention Deficit Hyperactivity Disorder (ADHD) is the most common and well-studied of the childhood behavioral disorders.

Clinical Findings

Individuals diagnosed with ADHD are likely to experience significant difficulties with executive functioning, which impairs academic performance, social relationships, self-control, and memory. Brown (2005) outlines six executive function deficits that are observed in individuals diagnosed with ADHD: (1) organizing and prioritizing (difficulty getting started on tasks); (2) focusing and sustaining attention (easily distracted); (3) regulating alertness, sustaining effort (drowsiness); (4) managing frustration (low frustration tolerance or disproportionate emotional reactions); (5) working memory (difficulty retrieving information); and (6) self-regulation (difficulty inhibiting verbal and behavior responses).

There is no single diagnostic test or tool for ADHD. The diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) are the current basis for the identification of individuals with ADHD. There is rarely a need for extensive laboratory analysis, but screening for iron deficiency and thyroid dysfunction is reasonable.

The American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics (AAP), with input from members of the American Academy of Family Physicians, have formulated evidence-based practice guidelines to aid in the improvement of current diagnostic and treatment practices.

Differential Diagnosis

The diagnosis is made by parent interview, direct observation, and the use of standardized and scored behavioral checklists such as the Connors Parent and Teacher Rating Scales, Child Behavior Checklist (CBCL), Vanderbilt ADHD Diagnostic Parent and Teacher Scales, Achenbach, along with computerized tests (Gordon Diagnostic Testing, Connors Continuous Performance Task, and Test of Variables of Attention) measuring impulsivity and inattention that are specific for ADHD and should include input from both parents and teachers.

Complications

Attention deficit–hyperactivity disorder is often associated with other Axis I diagnoses. From 35% to 60% of referred ADHD children have oppositional defiant disorder (ODD), and 25-50% will develop conduct disorder (CD). Of these, 15–25% progress to antisocial personality disorder in adulthood. Of all referred ADHD children, 25–40% have a concurrent anxiety disorder. As many as 50% of referred children with ADHD eventually develop a mood disorder—most commonly depression, diagnosed in adolescence. The diagnosis of bipolar disease in childhood increases the risk of concurrent label of ADHD because of the overlap of behaviors. ...