ADHD is defined by early onset (before age 12) of persistent (six months or longer) symptoms of inattention and/or hyperactivity and impulsivity that are not consistent with development, causing impairment of normal functioning in at least two settings (home, school). It is the most common psychiatric disorder in children, mostly in school-age boys.1
Generally, the diagnosis of ADHD is based on the presentation of impairing levels of attention, hyperactivity, and impulsivity. However, ADHD can present with different symptoms such as irritability, emotional dysregulation, mood lability, low frustration tolerance, low self-esteem, and sleep problems, making the diagnosis difficult because of overlap with mood disorders and personality disorders (Table).
Onset and course. ADHD onset is generally before age 12 years, with a prevalence of 1.7% to 16%.2 ADHD follows a chronic and unremitting course, persisting into adulthood in half of the cases.3 The hyperactive-impulsive type is associated with trajectories of improvement while the inattentive type is often associated with negative outcomes. ADHD hyperactive type is more prevalent in males, while ADHD inattentive type is more common in girls. The persistence and severity of ADHD during development are associated with adult antisocial and criminal behaviors.
Clinical picture. Hyperactivity in ADHD is characterized by restlessness, fidgeting, talkativeness due to lack of inhibition (but may be sometimes redirected), engaging in risky behaviors (without being aware of the consequences); hyperactivity is present all day and can worsen when prolonged attention or on-task behavior is expected, especially in structured activities.
In children with ADHD, difficulties with attention, resistance to completing homework and poor concentration often interfere with academic achievement. School and social relationships can be impaired by inappropriate behaviors that are accidental, related to inattention, impulsivity, and poor motor coordination. Mood fluctuations are common in children and adolescents with ADHD, with self-esteem worsening over time, but generally do not have dysphoric mood as predominant symptom; mood shifts are usually related to demands of learning and irritability is often worsened by withdrawal from stimulants.
ADHD patients are generally good sleepers, tend to rise quickly, and are alert in minutes; circadian rhythms are normal and there isn’t a decreased need for sleep. Parents can report bedtime resistance but without sleep problems such as middle and late insomnia or nightmares. Psychotic symptoms and hyper-sexual behavior are not part of the ADHD clinical presentation.
Dr Marangoni is Attending Psychiatrist, Department of Mental Health, Mater Salutis Hospital, Azienda ULSS 9, Legnago, Italy. Dr Marangoni reports no conflicts of interest concerning the subject matter of this article.
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