IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read
Identifying the most common causes of reversible dementias: A review; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to
www.aapa.org and searching for keyword
JAAPA post-tests. All others may complete and submit the post-test online at no charge at
www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.
KEY POINTS
■ Early identification and management of attention-deficit/hyperactivity disorder (ADHD) can have a positive effect on academic, behavioral, and social performance.
■ The etiology of ADHD is related to low levels of neurotransmitters such as dopamine, norepinephrine, and serotonin.
■ The diagnosis of ADHD is made on clinical suspicion and should include evidence from family members, caretakers, and teachers.
■ The management of ADHD must be a collaborative effort between family, school, and clinician focusing on target outcomes.
Attention-deficit/hyperactivity disorder (ADHD) is a common childhood behavioral disorder encountered in primary care with a prevalence of 4% to 12% in the United States.1 It is characterized by inappropriate behavior (hyperactivity, impulsivity, poor social skills), and struggles in school (difficulty maintaining focus and conforming to classroom decorum). This article reviews the identification, diagnosis, and management of ADHD. With early recognition and management, many of the academic and social difficulties associated with ADHD can be overcome.2 Left untreated, ADHD can have devastating consequences that persist into adolescence and adulthood, increasing the risk of academic and employment failure, self-deprecation, criminal behavior, and substance abuse.3,4
ETIOLOGY AND PATHOPHYSIOLOGY
The cause of ADHD is not completely understood.5,6 It is thought to be a neurologic disorder originating in the frontal, prefrontal, and/or basal ganglia regions of the brain.7 These areas of the brain are responsible for executive function, attention, and inhibition.8 Dysfunction can lead to symptoms associated with ADHD. The most widely accepted theory explains the etiology of ADHD as related to low levels of the neurotransmitters dopamine, norepinephrine, and serotonin.6 Decreased levels of dopamine are linked to inattention, impulsivity, and hyperactivity; decreased norepinephrine to poor concentration; and low serotonin to hyperactivity and impulsivity.5,6
Research by Faraone and colleagues7 and De Young and colleagues9 offers insight into the role of the dopamine receptor gene DRD4 in the pathophysiology of ADHD. These studies found that a mutation in the DRD4 gene, repeat allele of the dopamine receptor (DRD4-7), results in less efficient dopamine receptors in the prefrontal cortex and a decrease in dopamine neurotransmission.7,9 However, it cannot be assumed that this allele is required or sufficient on its own to explain the pathophysiology of ADHD. Although research does support a genetic component to ADHD, further study is necessary to understand the pathophysiology.8
EPIDEMIOLOGY
The incidence of ADHD in the United States varies depending on method of diagnosis, population characteristics, and cultural behavioral norms and ranges from 2% to 26%. Most studies are qualitative and rely heavily on parental reporting of diagnosis, medical records, and medication usage to identify prevalence.10 Reporting discrepancies can skew the incidence numbers. A cross-sectional study by Froehlich and colleagues found that 8.7% of children (2.4 million children aged 8-15 years) meet the diagnostic criteria for ADHD.11 Prevalence is usually reported highest for the combined type with symptoms of both inattention and hyperactivity.11 A study by Polanczyk and colleagues estimated the prevalence of ADHD worldwide to be as high as 5.9%.10 The high prevalence of ADHD increases the likelihood that a physician assistant will routinely encounter children with ADHD and diagnose the disorder in practice.