Attention Deficit/Hyperactivity Disorder (ADHD)

Attention Deficit/Hyperactivity Disorder (ADHD): Excerpt from The 5-Minute Pediatric Consult

William G. McNett, MD

Attention Deficit/Hyperactivity Disorder - BASICS

Attention Deficit/Hyperactivity Disorder - description

• Attention-deficit hyperactivity disorder (ADHD) is a syndrome characterized by persistent and developmentally inappropriate levels of inattention and/or hyperactivity and impulsivity. It can be classified into 3 subtypes:
  • Hyperactive/impulsive
  • Inattentive
  • Combined
• DSM-IV criteria for diagnosis:
  • At least 6 of 9 behaviors in inattention and/or hyperactivity/impulsivity
  • Persisting for at least 6 months that is maladaptive and inconsistent with developmental level
  • Some symptoms present before age 7 years
  • Impairment from symptoms present in 2 or more settings
  • Clear evidence of clinically significant impairment in social, academic, or occupational functioning

Attention Deficit/Hyperactivity Disorder - epidemiology

Attention Deficit/Hyperactivity Disorder - prevalence

• 3–7% of school-aged children
• 3–4 times more common in males than females
• Females more likely to have inattentive type

Attention Deficit/Hyperactivity Disorder - risk-factors

Attention Deficit/Hyperactivity Disorder - genetics

• Risk of ADHD in 1st-degree relatives is ~25%.
• Concordance in monozygotic twins: 59–81%; dizygotic twins: 33%

Attention Deficit/Hyperactivity Disorder - associated-conditions

• Learning disorders
• School failure
• Tic disorder
• Oppositional defiant disorder and conduct disorder
• Mood disorders: Anxiety and depression
• Poor peer relations

Attention Deficit/Hyperactivity Disorder - DIAGNOSIS

• Typically, patients are brought to medical attention during the early school years because their behavior falls out of normal range in their ability to pay attention in class, to avoid class disruption, and/or to control impulsive behavior.
• Patients with ADHD can be diagnosed and treated in the pediatrician’s office.
• A large percentage of patients with ADHD may have associated conditions and will need multidisciplinary pediatric teams of developmental pediatrics, psychologists, neurologists, and/or psychiatrists for assessment and treatment.

Attention Deficit/Hyperactivity Disorder - signs & symptoms

Attention Deficit/Hyperactivity Disorder - history

• A detailed history of the child’s behavior at home, school, and with peers is needed.
• Onset and duration of noted behaviors
• Ability to make and keep friends
• Academic progress
• Birth history with details about prematurity, in utero drug exposure, and perinatal asphyxia
• Developmental history, specifically language acquisition, and fine motor skills
• Sleep history
• Family history of ADHD or learning disorders
• Social history: Who lives with patient, recent family discord, separation, recent death in the family, recent change in schools
• Past medical history and medication history

Attention Deficit/Hyperactivity Disorder - physical exam

• Hearing and vision testing to rule out vision disturbances or hearing impairment as a cause of inattention
• Weight and height measurements for baseline prior to starting medication and to help rule out thyroid dysfunction as cause
• Vital signs including BP and pulse are important for baseline measurements.
• Examination of neck to ensure no obvious thyroid enlargement or change in thyroid gland
• Skin exam to rule out neurocutaneous syndromes
• Thorough neurological exam to rule out an intracranial process that may cause similar symptoms or evidence of cerebral palsy

Attention Deficit/Hyperactivity Disorder - tests

• Rating scales:
  • Multiple scales available including Connor Rating Scales-Revised, Vanderbilt ADHD Rating Scales, Child Behavior Checklist
  • Both parent and teacher ratings are routine components of the assessment.
  • Some assess only ADHD (Connor); others include assessment of possible comorbidities (Vanderbilt and Child Behavior Checklists).
  • Most scales may be used by clinicians for follow-up to assess effectiveness of treatment.
  • All three scales have similar reliability and validity; most clinicians choose a single tool and gain familiarity with it.
• IQ and Achievement Testing:
  • Necessary to rule out mental retardation and learning disorder that may mimic ADHD or be a comorbidity of ADHD
  • An evaluation for an Individual Educational Plan (IEP) should be obtained following parental request of the child’s school. Note: Federal law mandates that all school-age children have an IEP based upon written request by the parent. Who administers the IEP depends on whether the school is public or private, and on the school district.

Attention Deficit/Hyperactivity Disorder - lab

Laboratory tests: Based on history and/or physical exam. Consider:

• Thyroid function tests: If growth curves show unexpected acceleration or deceleration of growth
• Blood lead level to rule out lead toxicity
• CBC to rule out anemia

Attention Deficit/Hyperactivity Disorder - differencial diagnosis

• Medical:
  • Seizures
  • Sleep disorder
  • Sensory impairment (vision, hearing)
  • Thyroid disorder
  • Medication side effects
  • Toxins (lead)
  • Iron deficiency anemia
• Developmental:
  • Mental retardation
  • Autistic spectrum disorder
  • Language or speech disorder
• Educational:
  • Learning disabilities
  • Inappropriate school environment
• Psychiatric:
  • Depression
  • Mania
  • Anxiety disorders
  • Obsessive-compulsive disorder
  • Oppositional defiant disorder
  • Conduct disorder
• Social:
  • Disorganized/chaotic family environment
  • Physical abuse/neglect
  • Sexual abuse
  • Psychosocial stressors

Attention Deficit/Hyperactivity Disorder - TREATMENT

Attention Deficit/Hyperactivity Disorder - general measures

• 3 treatment modalities in combination:
  • Medication (usually stimulant)
  • Educational support
  • Behavior modification/psychological counseling
• Although all 3 modalities may not be necessary, they all should be discussed with the patient and parents.

NON-PHARMACOLOGIC

Educational:

• Proper educational placement
• Small teacher-to-student ratio in classroom
• Good communication between school and home
• Homework log monitored by teacher and parent

Psychological support may be helpful for:

• Patient who has poor peer relations
• Families who are having difficulty with parenting issues
• Patient with a comorbidity

Attention Deficit/Hyperactivity Disorder - medication

Attention Deficit/Hyperactivity Disorder - first-line

• Stimulant: Methylphenidate (Ritalin, Methylin, Metadate, Focalin, Concerta, Daytrana Patch), dextroamphetamine (Dexedrine, Dextrostat), and amphetamine (Adderall)
• Efficacy: 80% of children with ADHD show significant improvement with use of stimulant medication soon after proper dosing is achieved.
• Pharmacokinetics: Individual response is highly variable. Onset is within 20–30 minutes. Stimulants have different duration of action. Short acting lasts 3–5 hours (Ritalin, Adderall) with dosing 2–3 times/d. Long acting lasts 6–8 hours (Dexadrine Spanules, Adderall LR), and extended release lasts 10–12 hours (Concerta, Focalin XR, Daytrana) needing once-a-day dosing.
• Dose: Weight-based dosing is not effective because of differences in metabolism. Start with smallest dose and titrate up for effect. Start with short-acting medication. For some younger children, this may provide a sufficient duration of therapy for school. If a second dose is needed, converting to a longer-acting medication is reasonable. Start medication when the parents are available to watch for side effects and duration of action (typically over a weekend). Follow closely with the parents; ask them to get feedback from school on a weekly basis until dose is properly adjusted. This process may take 1–2 months to be completed.
• Side effects: Decreased appetite, abdominal pain, weight loss, tics, headache, difficulty falling asleep, and jitteriness. Most stimulant-related side effects are short-lived and are responsive to dose or timing adjustments. Severe movement disorders, obsessive-compulsive ruminations, or psychotic symptoms are very rare and disappear when medication is stopped.
• Contraindications: Glaucoma, symptomatic cardiovascular disease, hyperthyroidism, hypertension

Attention Deficit/Hyperactivity Disorder - second-line

• Atomoxetine (Strattera): SSRI. Once-a-day dosing, same side effect profile as stimulants, not as efficacious as a stimulant but may be a viable alternative for patients who don’t tolerate stimulant medication or if a patient’s family is hesitant to use stimulants. Effects of medication may not be seen for several weeks after starting.
• Others: Alpha-adrenergic (Clonidine, Guanfacine), tricyclic antidepressants (Imipramine, nortriptyline, desipramine), atypical antidepressants (Wellbutrin, Effexor). Usually prescribed by specialists, including psychiatrists and behavioral specialists.

Pemoline has been taken off the market due to liver toxicity.

Attention Deficit/Hyperactivity Disorder - FOLLOW UP

• Initially, follow-up should be every 1–2 weeks until proper dosing is achieved.
• After initial stabilization, patients should be seen every 3–4 months.
• Monitor weight, height, BP, and heart rate.
• Assess for change in growth velocity.
• Assess family and peer relationships.
• Assess school performance.
• Check for medication side effects.
• Assess for ongoing need for medication.

Attention Deficit/Hyperactivity Disorder - disposition

Attention Deficit/Hyperactivity Disorder - issues for referral

• When comorbidities are suspected
• If patient is not responding to increasing strength of stimulant
• If the patient is having difficulty tolerating different stimulants
• Onset of symptoms beyond grade school

Attention Deficit/Hyperactivity Disorder - bibliography

1. American Academy of Pediatrics. Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158–1170.
2. American Academy of Pediatrics. Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108:1033–1044.
3. Collett BR, Ohan JL, Myers KM. Ten-year review of rating scales. V: Scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003;42:1015–1037.
4. Gardner W, Kelleher KJ, Pajer K, et al. Follow-up care of children identified with ADHD by primary care clinicians: A prospective cohort study. J Pediatr. 2004;145:767–771.
5. Greenhill LL. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002;41:26S–49S.
6. Greydanus DE, Pratt HD, Sloane MA, et al. Attention-deficit/hyperactivity disorder in children and adolescents: Interventions for a complex costly clinical conundrum. Pediatr Clin North Am. 2003;50:1049–1092.

Attention Deficit/Hyperactivity Disorder - CODES

Attention Deficit/Hyperactivity Disorder - icd9

• 314.01 C Attention-deficit/hyperactivity, Combined
• 314.00 I Attention-deficit/hyperactivity, Inattentive
• 314.01 H Attention-deficit/hyperactivity, Hyperactive/Impulsive

Attention Deficit/Hyperactivity Disorder - FAQ

• Q: Does diet play a role in ADHD?
• A: Although in the past it has been thought that certain foods and additives caused ADHD, we now know that this is not the case. However, it is reasonable to refrain from caffeine and other agents associated with behavioral and/or appetite changes (sleep disturbance, etc.).
• Q: Is medication needed every day?
• A: This depends on the needs of the patient. Some patients need medication daily in order to function successfully with peers or in structured environments, like team sports or weekend schools. Other patients who need help mainly with focusing attention do well with medication during learning periods (school days). Many patients will not need medication during the summer holiday or during school breaks.
• Q: How long will my child be on medication?
• A: A large percentage of children with ADHD will continue to have symptoms as adults. Although every patient is different, many children may need to continue medication through formal learning (high school and college). During this time, they should be able to learn some coping strategies to minimize the effects of their symptoms. There are some adults who benefit from continued stimulants in order to function in the workplace. If treatment goals are being met, it is reasonable to have a trial off medications to see if performance off medications can be sustained (sometimes called a drug holiday).
• Q: Are there support groups available?
• A: Online resources are plentiful, but may not be helpful to every family. An organization that is widely recognized as an advocacy and support group for families is www.chadd.org (Children and Adults with Attention Deficit/hyperactivity Disorder). This organization provides links to local groups that meet regularly, and provides a forum for parents to discuss having a child with ADHD. Another Web site that provides helpful information is www.add.about.com, developed by parents for parents. Many online resources advocate for alternatives to medication and actively discourage use of currently recommended medications.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Attention Deficit Hyperactivity Disorder

• Back to disease: Attention Deficit Hyperactivity Disorder: Introduction
• Next Book Extract About Attention Deficit Hyperactivity Disorder: Surveys relating to Attention Deficit Hyperactivity Disorder
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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