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We expect our children to be active and energetic, but when they exceed the norms for their age in their displays of activity, their lack of impulse control, or their inability to focus attention, they are likely to experience problems in social, familial, academic, and emotional interactions. Self-esteem is adversely affected, and these individuals are at greater risk of developing antisocial disorders, substance abuse disorders, academic failure, employment failure, and secondary mood and anxiety disorders. These behavioral variants, therefore, cause a significant social burden and are often brought to the attention of primary care physicians. This chapter addresses three Axis I childhood behavioral problems likely to be encountered in the primary care setting: attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).

The controversies surrounding behavioral problems and their treatments have generated several comprehensive reviews that have improved understanding of these conditions. In 1998, the American Medical Association Council on Scientific Affairs concluded that there was little evidence of overtreatment with neurostimulants in the United States. That same year, the National Institutes of Health (NIH) conducted a Consensus Conference on the Diagnosis and Treatment of ADHD that concluded "there is validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics that define the disorder." Details are available at http://odp.od.nih.gov/concensus/cons/110/110_statement.htm. An International Consensus Letter from prominent leaders in the field in 2002 concluded decisively that "All the major medical associations and government health agencies recognize ADHD as a genuine disorder because of the scientific evidence indicating it is so overwhelming."

Essentials of Diagnosis

  • A persistent pattern of inattention, hyperactivity, or both; more frequent and severe displays of impulsivity.
  • Academic underachievement and behavioral problems.

General Considerations

Up to 20% of school-aged children in the United States have behavioral problems and at least half of these involve attention of hyperactivity difficulties. ADHD is the most common and well-studied of the childhood behavioral disorders. All family physicians have encountered the classically hyperactive child and his or her beleaguered parents and teachers in practice and in social interactions, but, likewise, may have overlooked the quiet but inattentive "daydreamer." The seeming dichotomy between the hyperactive and the inattentive types of ADHD can be confusing to both clinicians and the public. Primary care physicians should be familiar with the features of this disorder and are ideally positioned to evaluate and treat the majority of children and families dealing with this condition.

Pathogenesis

Neurophysiologic data suggest that there is no single cognitive or behavioral deficit common to all individuals with ADHD. Emerging data suggest that individuals with ADHD have abnormalities in the frontal-striatal circuits but the exact problem has not been isolated.

Individuals diagnosed with ADHD are likely to experience significant difficulties with executive functioning which impairs academic performance, social relationships, self-control, and memory. Thomas Brown, Ph. D. outlines six ...

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