Diagnosis and Treatment of Attention-Deficit/ Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 4% to 12% of school-aged children. Boys are affected more frequently than girls. Children with ADHD may have difficulty getting along with other children both at home and at school. They also may have problems with learning due to difficulty paying attention in school. If ADHD is left untreated, the child may have long-term problems, such as poor academic performance, difficulty maintaining relationships, and inability to keep a job.^1,2

Variations in Medical Practice

The number of children treated for ADHD has increased over the past decade. Media attention and public interest also have increased, and there have been large variations in medical practice related to the diagnosis and management of ADHD. All of these factors have led to concern that children are being overdiagnosed and overtreated. The American Academy of Pediatrics (AAP) has addressed the issue of variations in medical practice. The AAP has made recommendations that include using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria to diagnose ADHD, as well as basing the assessment on evidence obtained from parents and teachers.^1,2 ADHD is now among the most common and well-studied disorders of childhood. As a result of increased awareness and improved tools for diagnosing and treating this condition, more children are receiving help.

What Is ADHD?

ADHD is a disorder of the brain that results in difficulty controlling behavior. The cause of ADHD is unknown. Factors that affect brain development in utero and during early postnatal life, as well as genetic factors, may be involved with the etiology of ADHD.³

There are 3 types of ADHD. These include inattentive only (formerly referred to as attention-deficit disorder/ADD), hyperactive/ impulsive, and combined inattentive/hyperactive/impulsive. ^1,2 The corresponding symptoms associated with the 3 types of ADHD are listed in Table 1.

Diagnosis

ADHD is defined as persistent inattentive and/or hyperactive behavior that is not age-appropriate. These behaviors are present in more than 1 setting (ie, school, home, and social situations) and are significant enough to interfere with social skills and/or academic performance.

There is no single test for ADHD. The diagnosis comes from multiple sources of information, including parents, the child, the child?s school, and other caregivers. The diagnosis of ADHD requires that the child meet the DSM-IV criteria. In order to confirm this diagnosis, the symptoms must be present before the age of 7 (these may not be recognized until the child is older and school assignments become more difficult) and must continue for at least 6 months.^1,2

The evaluation of ADHD also should include assessment for coexisting conditions. Approximately 40% of children with ADHD have at least 1 other condition. These conditions include oppositional defiant disorder, conduct disorder, mood disorders/depression, anxiety disorders, and learning disabilities.^1,2

Treatment

Once the diagnosis of ADHD has been made, a treatment plan should be identified. There is no cure for ADHD, but many treatment options are available. Treatment should include education about the disorder, a plan for longterm management, identification of target outcomes, medication and/or behavior therapy, and follow-up with regard to outcomes and side effects. Teamwork among physicians, parents, teachers, caregivers, other health care professionals, and the child also is extremely important.¹

Stimulant medications generally are a safe and effective way to treat ADHD. Approximately 80% of children treated with stimulants will respond to 1 of these medications. Stimulants help children with ADHD focus their thoughts, ignore distractions, pay attention, and control behavior. Different types of stimulant medications are available on the market, in short-, intermediate-, and long-acting forms. Long-acting stimulants are advantageous in that children can avoid taking medication at school or after school.^1,3 The stimulant medications are listed in Table 2.

Atomoxetine HCl (Strattera) is an agent that has recently been approved for the treatment of ADHD. This agent is not a controlled substance and has not been associated with drug dependence. The exact mechanism of atomoxetine is unknown, but it is thought to be a selective norepinephrine reuptake inhibitor.⁴

It may take time to find the best medication, dosage, and schedule for the individual child. Children who fail to respond to 1 stimulant medication or experience intolerable side effects should be tried on another of the recommended stimulants. Most children who do not respond to 1 stimulant medication usually will respond to an alternative stimulant. Children who do not respond to 2 stimulant medications can be tried on a third type or formulation of stimulant. Lack of response to treatment, however, should lead to reassessment of the accuracy of the diagnosis of ADHD or consideration of the potential for an undiagnosed coexisting condition.

The dosages of stimulant medications are not weight-dependent. Dosages should be started low and titrated upward to obtain the dose that leads to optimal effects with minimal side effects.1,3

Side Effects

Side effects usually occur early in therapy and tend to be mild and shortlived. The most common side effects include decreased appetite/weight loss, sleep disturbances, headaches, jitteriness, stomachaches, and social withdrawal. Less common side effects include dry mouth, rebound effect (increased activity or bad mood as medication wears off), and transient tics. Very rare side effects include stuttering, hypertension, tachycardia, and growth delay. Most of these side effects can be managed by dosage adjustments, schedule adjustments, or the use of a different stimulant medication.

Approximately 50% of patients with Tourette?s syndrome (an inherited disorder associated with frequent tics and unusual vocal sounds) also have ADHD. The effect of stimulant medications on tics is unpredictable, but most studies have shown that stimulants are safe in children with ADHD and tic disorders.^1,3

Stimulants are Schedule II drugs, and there have been reports of abuse with this class of agents. Parents should carefully monitor the use of these agents. Stimulants do not tranquilize children and do not cause addiction.

Drug ?holidays? during the summers have been recommended for children treated with stimulants. There have, however, been no controlled trials that support either benefits or risks associated with drug holidays.¹

Target Outcomes

Target outcomes should be identified at the initiation of therapy to help guide the management of ADHD. Target outcomes should be realistic for the child and should be behaviors that can be measured and observed. Examples of target outcomes include improved relationships, decreased disruptive behaviors, improved academic performance, improved self-care and homework performance, and improvement in following safety rules. Input from parents, teachers, and the child should be used to develop these outcomes. Between 3 and 6 outcomes should be identified to help guide the treatment plan.¹

Behavior Therapy

Most experts recommend using a combination of medication and behavior therapy to manage ADHD. Behavior therapy seeks to alter the child?s physical and social environments so that it is easier for the child to control behavior. This type of therapy involves teaching parents, teachers, and caregivers ways to improve interactions with the child with ADHD. The principles of behavior therapy include setting specific and clear goals, providing rewards and consequences, and continuing to use the rewards and consequences. Techniques for behavior therapy include positive reinforcement (giving rewards/privileges in response to desired behavior), time-out (removing access to activity due to undesirable behavior), response cost (withholding rewards/privileges as a result of unwanted behavior), and token economy (combining positive reinforcement/rewards and response cost/consequences).¹

Long-Term Monitoring and Management

Effective management of ADHD requires long-term monitoring of the child?s behavior and dedicated efforts from both the child?s parents and school. Monitoring plans should include physician office visits, telephone conversations, teacher narratives, and report cards concerning behavior.

In most cases, ADHD continues into adulthood. With proper management, however, adults with ADHD can lead very productive lives.¹

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