The main clinical manifestations of attention deficit and hyperactivity disorder (ADHD) are marked inattention and short attention span, hyperactivity and impulsivity, often accompanied by learning difficulties or conduct disorders.
I. Epidemiology
Recent epidemiological studies have shown a prevalence of 10% in males and 5% in females among elementary school children.
Second, the etiology and pathogenesis
The etiology and pathogenesis of the disease are unclear, and it is believed that a variety of factors interact with each other. The factors associated with the pathogenesis are as follows.
1, genetic this disease has a family aggregation phenomenon.
In recent years, the dopamine, norepinephrine and 5-hydroxytryptamine (5-HT) hypotheses have been put forward successively. Patients have low dopamine and norepinephrine function in blood and urine and hyperactive 5-HT function.
3. Neuroanatomical and neurophysiological magnetic resonance imaging revealed abnormal frontal lobe development and bilateral caudate nucleus cephalad asymmetry in the patient. Positron emission tomography study revealed reduced perfusion in the patient’s premotor area and prefrontal cortex, presumably with reduced metabolic rate, which are brain areas associated with central control of attention and movement. The EEG showed an increase in slow waves and a decrease in fast waves, most pronounced in the frontal leads.
4. Patients with developmental abnormalities have more maternal pregnancy or perinatal complications, uncoordinated movements in early childhood, and delayed language development.
5. Family and psychosocial factors such as parental discord, family breakup, inappropriate parenting style, poor parental personality, mother suffering from depression or dysthymia or substance addiction, family economic difficulties, overcrowded housing, childhood separation from parents, abuse, inappropriate educational methods in school and poor social climate may serve as the trigger for the onset or the persistence of symptoms. In addition, some patients were found to have elevated blood lead levels and decreased blood zinc levels, but elevated zinc levels in hair.
III. Clinical manifestations
1. Attention disorder is the main symptom of this disease.
It is difficult to sustain attention when listening to lectures, doing homework or other activities, easily distracted by external stimuli, or often constantly shifting from one activity to another. Patients are unable to pay attention to details during activities and often make mistakes due to carelessness. The patient is distracted during conversations with adults and seems to listen. Often intentionally avoids or is unwilling to engage in tasks that require longer periods of sustained concentration, such as classroom assignments or homework, and is unable to complete these or other tasks as assigned on time. Patients usually tend to lose things, often losing toys, learning aids or other belongings, and forgetting the daily schedule of activities.
2. Excessive activity and impulsivity Patients often seem restless.
There are many small movements of the hands and feet, twisting and turning in the sitting position, leaving the sitting position without permission in the classroom or other occasions that require quietness, running or climbing around, and having difficulty engaging in quiet activities or games, as if they are particularly energetic. Lack of thinking before taking action, act on the spur of the moment without considering the consequences, and often get into fights or disputes with peers, resulting in negative consequences. Talks a lot in any situation, interrupts or interrupts others while they are talking, is eager to answer before the teacher finishes her question, or rashly disrupts the play of peers, or cannot wait patiently in line. Emotionally unstable, easily overexcited, easily frustrated and depressed, or defiant and aggressive. Demands must be met immediately, otherwise they cry and throw tantrums.
3. Learning difficulties.
Because the attention deficit and hyperactivity affect the patient’s effectiveness in listening in class and the speed and quality of completing homework, resulting in poor academic performance, which is lower than the academic performance that should be achieved by their intelligence.
4. Patients with neurological and mental developmental abnormalities have fine motor skills.
Patients with neurological and mental developmental abnormalities have poor development of fine motor, coordination motor, spatial location awareness, etc. For example, they have difficulty in hand turning, finger movement, tying shoelaces and buttoning, and have difficulty in distinguishing left from right. A small number of patients have delayed speech development, poor language expression, and low intelligence. IQ tests show that some patients have low IQ, higher verbal IQ than operational IQ, and lower scores on the attentional concentration subscale.
5, conduct disorder attention deficit and hyperactivity disorder and conduct disorder co-morbidity rate of up to 30% ~ 50%.
Conduct disorder is characterized by aggressive behaviors, such as verbal abuse, hitting, wounding, destruction of objects, abuse of others and animals, sexual assault, robbery, etc., or behaviors that do not conform to moral norms and social norms, such as lying, truancy, vagrancy, arson, theft, deception, and indecent behavior toward the opposite sex.
IV. Course and prognosis
Nearly half of the patients start before the age of 4 years, but many patients enter elementary school with attention deficits that lead to learning difficulties, or they are seen because they exhibit severe behavioral problems. About 30% of patients have symptoms that gradually disappear after adolescence, but most of them will continue to have symptoms into adolescence. 40% to 50% of patients will still have clinical symptoms in adulthood, and 20% to 30% of patients will not only have clinical symptoms, but also have a combination of antisocial behavior, substance dependence, and alcohol dependence. The factors that lead to poor prognosis include combination of conduct disorder, dyslexia, emotional disorder, poor family and psychosocial factors, and low intelligence.
V. Diagnosis
Attention deficit and hyperactivity disorder is diagnosed when a child begins to show significant attention deficit and hyperactivity problems before the age of 7 years, when these clinical manifestations persist for more than 6 months at school, at home, and in other settings, and when they have a negative impact on social functioning (e.g., academic performance, interpersonal relationships, etc.). Clinical manifestations such as learning difficulties and neurological and psychiatric developmental abnormalities are not diagnostic, but help to clarify the diagnosis. If the patient also has clinical manifestations of conduct disorder and reaches the degree of diagnosing conduct disorder, the diagnosis of attention deficit and hyperactivity disorder combined with conduct disorder is made.
Differential diagnosis
1. Patients with mental retardation may have attention deficit and hyperactivity.
Patients with mild mental retardation are easily mistaken for attention deficit and hyperactivity disorder at the beginning of elementary school, before the diagnosis of mental retardation is clear. However, patients with attention deficit and hyperactivity disorder can improve their academic performance and reach a level comparable to their intelligence after their attention is improved through treatment. In contrast, the academic performance of people with mental retardation always corresponds to the level of intelligence, and they also have language and motor delays, and their judgment ability, comprehension ability and social adaptation ability are generally low.
2.Character disorders
3.Mood disorder children in anxiety.
Depression or mania will show excessive activity and inattentiveness. Patients with attention deficit and hyperactivity disorder may also suffer from anxiety and depression because they are often criticized by teachers and parents or because their demands are not met. The difference between the two is that the first and main symptom in patients with mood disorders is emotional problems, and the course of the disorder is episodic and short-lived. Attention deficit and hyperactivity disorder is characterized by long-term persistent attention deficit and hyperactivity.
4. Patients with tic disorder mainly present with head and face.
The involuntary rapid, brief, irregular twitching of the limbs or trunk muscles, such as eyebrow squeezing, shrugging, crooked neck, hand waving, foot stomping and twisting, etc., can also be accompanied by involuntary vocal twitching, easily mistaken for hyperactivity or naughtiness. The characteristics of tic symptoms can be easily identified by careful mental examination and distinguished from attention deficit and hyperactivity disorder. However, it is important to note that about 20% of patients with tic disorder have a combination of attention deficit and hyperactivity disorder.
5, schizophrenia in the early stages of schizophrenia patients may manifest as non-compliance with school discipline.
Too much activity, inattentiveness in class, and a decline in academic performance are easily confused with attention deficit and hyperactivity disorder. However, schizophrenia will gradually appear the characteristic symptoms of schizophrenia, such as hallucinations, delusions, emotional indifference, isolation and dissociation, strange behavior, etc., while attention deficit and hyperactivity disorder will not appear these symptoms, according to this differentiation.
Most autistic children have symptoms such as hyperactivity, impulsivity and attention deficit disorder. However, autistic patients also show interpersonal and communication difficulties, speech disorders, limited interests and activities, etc., which are distinguished from attention deficit and hyperactivity disorders.
VII. Treatment
A comprehensive treatment plan is developed according to the characteristics of the patient and his or her family. Medication can relieve some of the symptoms in the short term, but for a series of adverse effects on patients and their families, we rely more on non-pharmacological treatment methods.
1. Psychological treatment mainly includes behavioral and cognitive-behavioral therapy. Patients usually lack appropriate social interaction skills, such as not knowing how to initiate, maintain and end interpersonal communication processes, poor peer relationships, aggressive language and behavior toward others, and poor self-control. Behavioral therapy uses the principle of operant conditioning to provide positive or negative reinforcement of the patient’s behavior in a timely manner so that the patient learns appropriate social skills and replaces inappropriate behavior patterns with new and effective behaviors. Cognitive-behavioral therapy addresses the impulsivity of the patient and includes learning how to solve problems, pre-estimating the consequences of one’s behavior, restraining one’s impulsive behavior, recognizing the appropriateness of one’s behavior, and choosing appropriate behaviors. Psychotherapy can take the form of individual therapy or group therapy. The group therapy setting is more beneficial for patients to learn appropriate social skills.
2. Special education patients should be included in special education.
Teachers need to educate patients according to their characteristics, avoid discrimination, corporal punishment or other rough educational methods, appropriately use praise and encouragement to improve patients’ self-confidence and self-awareness, negate patients’ bad behaviors through language or interrupting activities, etc. The curriculum should be arranged in a way that gives patients sufficient time for activities.
3. Medication Medication can improve attention deficits.
Reduce the activity level, improve academic performance to some extent, and improve the patient’s relationship with family members in the short term. Under the guidance of the doctor with small doses of central stimulants, small doses of antidepressants, small doses of antipsychotics, brain cell function rehabilitation drugs.
4. Education and training for parents are suitable for those with character disorders or other psychological problems.
Patients whose parents do not agree to receive medication or whose parental education is inappropriate. Education and training can take the form of individual families or small groups. The content mainly includes: providing parents with a good supportive environment, allowing them to learn skills to solve family problems, learning to work out clear agreements on rewards and punishments with their children, effectively avoiding conflicts and contradictions with their children, mastering the correct use of positive reinforcement to encourage their children’s good behavior and using punishment to eliminate their children’s bad behavior.