Hyperactivity, also known as attention deficit disorder, is a common psychological and behavioral problem in childhood, mainly manifested by excessive activity and behavioral impulsivity incompatible with the situation, which may be accompanied by inattention, emotional excitement, anxiety, learning difficulties, adaptation difficulties or other behavioral symptoms. The prevalence of hyperactivity in school-age children is reported to be about 4%-20% abroad and 1.3%-15.9% in China, with complex etiology and various manifestations. The diagnosis is based on the medical history provided by teachers and parents, excessive activity and impulsivity, combined with clinical assessment and neurological and psychiatric examination results of the child, to make a correct judgment.
Diagnostic steps
(A) History taking
1.Onset of the disease Age of onset, duration of the disease, and whether there are any precipitating factors, such as excessive study load of school-age children.
2.Birth history To know whether there are any prenatal and natal abnormalities, such as premature or overdue infants, whether there is a history of prolonged labor, birth injury, asphyxia, infection, and the mode of delivery. The nutritional development and health condition at birth, whether the mother is of advanced maternal age, what kind of disease she had during pregnancy, any viral infection, miscarriage, bleeding, trauma, nutritional status during pregnancy, fetal movement. The mother has a history of long-term exposure to toxins, radiation, chemical drugs, smoking and alcohol abuse.
3.Growth and developmental history To understand whether there is excessive activity, impulsiveness, inattention; clumsy movements, fine motor and hand-eye coordination difficulties, balance and muscle strength; any learning difficulties, adaptation difficulties, behavioral problems and emotional disorders; intellectual development.
4. Past history In addition to motor, speech and intelligence, we should also ask about past illnesses and diseases, such as central nervous system infection, craniocerebral injury, epilepsy and other medical history. Any history of long-term medication and drug and food poisoning. Any history of hereditary metabolic diseases, etc.
5, family history family history of hyperactivity, inattention and behavior disorders, psychiatric and epileptic neurological diseases, congenital metabolic disorders and other genetic diseases.
6. Environmental factors Home environment, parents’ occupation, whether the parents are divorced, whether they lacked father’s love or mother’s love or were abused since childhood, etc.
(B) Physical examination
1.General physical examination Pay attention to the growth and development, nutritional status, hearing, vision, the presence of deformities, skin rashes, heart, liver, kidneys and other important organs have no abnormalities.
2.Neurological examination Any neurological localization signs; any uncoordinated fine movements, clumsy fast alternating movements, difficulty in copying figures, asymmetric reflexes on both sides, and other soft signs, such as joint band movements, dance-like movements, ataxia, etc. Any change in muscle tone and memory impairment.
(iii) Auxiliary examinations
The most commonly used tests are Wechsler Intelligence Scale (WISC) behavioral scale, attention concentration test, memory test, achievement test, etc. Some children with persistent hyperactivity may have low intelligence; children with hyperactivity disorder, behavior disorder, mental retardation and emotional disorder may have low scores on attention tests, but there is no specificity.
2, EEG Children with hyperactivity have EEG abnormalities, accounting for about 45%-90%. Most of them have mild to moderate abnormalities. They show an increase in slow waves, poor amplitude, baseline instability, and paroxysmal and diffuse Q increase. However, there is no specificity.
3. Brain evoked potentials Decreased response, reflected by long latency and low wave amplitude, provides further support for delayed brain development.
Thought process
(i) Determine whether the increased activity is pathological
It should be measured according to the age on the one hand and the presence of other symptoms on the other hand.
1.Diagnostic criteria
(1) Onset in preschool and duration of illness at least six months
(2) Symptom criteria: According to the Diagnostic and Statistical Manual of Mental Disorders (4th edition) published by the United States (1994), or (DSM-IV), the diagnosis of hyperactivity requires at least six or more manifestations in the hyperactivity-impulsivity item, and the diagnosis of attention deficit also requires six or more manifestations in the attention item, and reaches a level that is difficult to adapt and is inconsistent with the developmental level.
Hyperactivity items.
① Tend to have many small movements of the hands and feet, or squirm in their seats.
② Tend to leave their seats without permission in the classroom or other situations where sitting is required.
③ often inappropriate excessive movement in certain situations (adolescents or adults, it may just be a subjective feeling of fidgeting).
④ often jumping to answers before the question is finished
⑤ difficulty participating quietly in games or after-school activities.
(vi) Tend to be momentarily active.
⑦ tends to have difficulty waiting quietly for a turn.
⑧ tends to interrupt or interject when others are talking or playing.
⑨ talks too much.
Attentional items.
① Easily agitated by external influences.
(2) Tend not to pay close attention to details or make careless mistakes during study, work or other activities.
③ Difficulty in sustained concentration (when studying, working or playing).
④ having difficulty listening to what others are saying.
⑤ frequently loses school and household items.
⑥Distracted attention and poor performance in school classes.
(7) Tend to avoid assignments or tasks that require sustained energy, such as homework or housework.
(viii) Tend to have difficulty completing assignments or activities.
⑨ tend to forget daily activities.
2.Judging its severity
(1) Mild: symptoms less than or slightly more than the diagnostic criteria needle-like, with only minor or no impairment of school and social functioning.
(2) Moderate symptoms and impairment between mild and severe
(3) Severe: symptoms are numerous and severe, exceeding the symptoms required for diagnostic criteria, with significant and extensive impairment in school and social functioning of family and partnerships.
(ii) Differential diagnosis
In addition to attention deficit hyperactivity disorder, other childhood psychological disorders (such as affective disorders, anxiety disorders, conduct disorders or personality disorders), neurological disorders, genetic and metabolic disorders, and certain somatic diseases and adverse drug reactions can also be accompanied by hyperactivity, and should be differentiated.
1, naughty normal children generally occur in 3-6 years old boys are common, this child is very active, the action can also be a lot, short attention span. These children’s hyperactivity is often in too much irrelevant stimuli, fatigue, learning purpose is not clear, attention lack of training, not good at proper transfer, usually for the development of a regular life. The response to methylphenidate (Ritalin) appears as excitement insomnia.
2. Mental retardation Fidgeting, hyperactivity and inattention, and impulsiveness may occur. However, when taking medical history, these children often have growth disorders, such as starting to walk and talk are more complete than normal children, often accompanied by special facial and neurological signs, IQ test IQ below 70, and generally low social adaptation ability.
3, tic – obscene syndrome often accompanied by attention deficit hyperactivity disorder, but the main manifestation is involuntary, intermittent, repeated twitching, including the twitching of the articulatory organs, accompanied by paroxysmal obscene words, yelling, imitating speech and imitating actions, taking haloperidol effective, while methylphenidate ineffective.
4.Specific learning difficulties not accompanied by attention deficit hyperactivity disorder These children appear fidgety and inattentive because they are bored with learning for some reason and are repeatedly frustrated in their studies. This is a reaction to an inappropriate school situation.
5, character disorders Some children with character disorders also show uneasy learning, hyperactivity, but the prominent performance is to repeatedly and continuously violate social and moral standards, violate others and the public interest of anti-social behavior.
6, children’s anxiety disorder often caused by a variety of mental stress. Children show fidgeting, concentration difficulties, irritability and impulsiveness. But the prominent symptom is anxiety. If carefully understood, it can be seen that these emotional reactions have obvious socio-psychological factors and are closely related to the external environment.
In addition to excitement and activity, children with mania also have excessively pleasant moods and a significant increase in speech, but without central thought and shifting with the situation. There are often exaggerated colors, love to joke, busy all day long, but everything has a beginning but no end. Attention is lax and comprehension is superficial. The child’s sleep is often significantly reduced. Pre-morbid outgoing personality, often with a family history.
8, children with schizophrenia Early onset of the disease may have excessive activity or impulsive behavior, but generally late onset (after 6 years of age) and accompanied by schizophrenic features, such as personality changes, emotional indifference, bizarre behavior, thought disorders, delusions or hallucinations, etc., can be distinguished.
9, epilepsy often have excessive activity. However, there are paroxysmal seizure manifestations, and the EEG has spike waves, sharp waves, spike-slow waves and other changes unique to epilepsy. After seizure control, hyperactivity or impulsivity can be improved.
10, central nervous system infection, such as the sequelae of encephalitis, can be manifested as hyperactivity, inattention, etc., but the initial symptoms of systemic toxicity and neurological symptoms such as convulsions and coma, often with neurological localization signs, cerebrospinal fluid examination shows inflammatory changes, cranial CT can assist in the diagnosis.
11.Poisoning Certain drugs or food poisoning can cause secondary brain damage and hyperactivity, but careful history taking can reveal the history of misuse of drugs, consumption of toxic and spoiled food, often accompanied by vomiting, diarrhea and other symptoms, and blood drug concentration monitoring is beneficial to the diagnosis.
12, hepatomegaly (Wilson disease) is a disorder of copper metabolism, with liver damage, extra-pyramidal signs and heart disorders. The corneal K-F ring can be seen, and the characteristics of reduced serum copper cyanobacteria can be distinguished.
13, rheumatic fever chorea may have involuntary dance-like movements of the limbs and mood changes. Often accompanied by myocarditis, joint pain, laboratory tests ASO, ESR, CRP increased suggest the diagnosis of rheumatic fever.
Experience
Hyperactivity is a comprehensive disorder caused by a variety of biochemical, neuropsychological, environmental and genetic factors, either alone or in concert. The results of the study were presented. For children with moderate to severe hyperactivity, the diagnosis is easier to make according to the DSM-IV diagnostic criteria. However, for children with mild hyperactivity, especially in infancy, it is not easy to distinguish between normal hyperactivity and hyperactivity disorder, and the younger the child is, the easier it is to confuse, which often leads to misdiagnosis. Moreover, there are many clinical diseases (including neuropsychiatric diseases, genetic-metabolic diseases, etc.) that can be accompanied by hyperactivity and should be distinguished. Therefore, as a physician, you must take a detailed and patient medical history, based on the observations of parents and teachers, combined with the age, gender IQ and nature of the activity of the child, the environment, previous medical history, family history, to determine whether there are manifestations of hyperactivity and impulsivity, inattention, other systemic and psychological disorders. The clinical assessment is supplemented by psychological tests, cerebrospinal fluid and electroencephalography to make a correct diagnosis. In addition, attention deficit hyperactivity disorder is caused by biological-psychological-social factors, so the treatment should pay attention to the integrated treatment of these three aspects. In addition to medication, parents and teachers need to work closely with the child to provide patient education and management, behavior modification and educational guidance.