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It’s important to break it down this way because children look very different at various ages, their developmental tasks are different, and the environment in which they are behaving and living is different. Consequently, the underlying disorders of ADHD will manifest themselves uniquely at those ages and have a distinct effect on the most crucial aspects of development.When ADHD presents itself in an older school-age child, an adolescent, or even an adult, so much has gone into developing that person’s character that to say ADHD is the only force at work is extremely simplistic. We must go back to the beginning and look at how the syndrome first appeared, as well as how the difficulties related to it interacted with the child’s environment to distort his development right from the start.It often helps to think of attention deficit hyperactivity disorder as an onion, made up of layers, each having a dramatic impact on the next. Parents need to have a strong understanding of this multilayered aspect of ADHD in order to design the treatment approach that will be most helpful for their child.*14\173\2*

The diagnosis of peritonitis is based on analysis of ascitic fluid obtained by abdominal paracentesis. Paracentesis has been found to be safe, even in cirrhotic patients with coagulopathy. There is an approximately 1% chance of abdominal wall hematoma, 0.01% chance of hemoperitoneum, and 0.01% chance of iatrogenic infection.The ascitic fluid should be sent for cell count, differential, Gram stain, and bacterial culture. Ten to 20 mL of fluid should be inoculated into blood-culture bottles at the bedside, which yields bacterial growth in about 80% of cases of neutrocytic (neutrophil-predominant) ascites, compared to less than 50% with conventional culture techniques. If there is a suspicion for tuberculous peritonitis, fluid should be sent for mycobacterial smear and culture, although the sensitivity of these tests is very low. In contrast, a peritoneal biopsy for tuberculosis approaches a sensitivity of 100%. Measurement of adenosine deaminase activity in peritoneal fluid has been found to be an insensitive test for tuberculous peritonitis in the United States, especially in cirrhotic patients, but is helpful if the result is positive.The diagnosis of SBP is confirmed by an ascitic fluid polymorphonuclear (PMN) count of 250 cells/mm3 or greater and a positive bacterial culture. Two other variants of primary peritonitis exist that do not meet these criteria:• Culture-negative neutrocytic ascites (CNNA) is present when there is a PMN count of 250 cells/mm3 or greater but a negative bacterial culture. This may also occur in the setting of peritoneal carcinomatosis, pancreatitis, and tuberculous peritonitis, and these conditions must be ruled out. CNNA has similar clinical and prognostic features as SBP and is treated in the same way.• Bacterascites is defined as the isolation of bacteria in ascitic fluid cultures with a PMN count of less than 250 cells/mm3. The clinical course of bacterascites depends on whether or not the patient is symptomatic. If signs and symptoms of infection are present, the clinical course, mortality, and treatment are similar to SBP and CNNA. In the absence of symptoms, the colonization usually resolves without antibiotics.*89/348/5*