Management of Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder,or ADHD, is the mostcommonly diagnosed behavioraldisorder in children andteenagers. According to the Centers forDisease Control and Prevention (CDC),nearly 2 million children in the UnitedStates have ADHD. A survey by theCDC also found that parents of 7% ofchildren aged 6 to 11 years have beentold by a physician that their child hasADHD. The disorder affects boys 3times more often than girls. ADHD alsois receiving more attention as a conditionaffecting adults, with an estimated2% of adults afflicted.

The exact cause of ADHD is unknown.Although a specific gene hasnot been identified, the condition isknown to run in families. Studies showthat, if one twin has ADHD, the othertwin commonly has symptoms as well.Many parents do not recognize thesymptoms in themselves until theirchildren are diagnosed with ADHD.

What Are the Symptoms?

The symptoms of ADHD are classifiedinto 3 groups: inattention, hyperactivity,and impulsiveness.

Inattention

People with this ADHD symptomoften have difficulty staying focused,paying close attention to details, ororganizing tasks. They do not seem tolisten when addressed directly and areeasily distracted by external stimuli.They often lose items and are forgetful.

Hyperactivity

Children with hyperactivity mayfidget and squirm or leave their seat.They tend to run and climb excessively,as if "driven by a motor." They alsomay talk excessively. Adults withADHD feel restless and fidgety. Theyare unable to enjoy reading or otherquiet activities.

Impulsivity

Children prone to impulsivenessoften blurt out answers before thequestion is completed and have difficultywaiting their turn. They oftenbutt into conversations. As adults,these people may have difficulty maintainingrelationships or keeping a job.

Some people with ADHD exhibit primarilyinattentive symptoms, whereasothers mostly display hyperactivityand impulsiveness. The majority ofpeople with ADHD have symptomsfrom all 3 categories. Girls are morelikely to have symptoms of inattentionthan hyperactivity.

To meet the criteria for ADHD, theindividual must have experienced inattentiveor hyperactive?impulsive symptomsthat caused impairment before 7years of age. These symptoms must bepresent in 2 or more settings, typicallyschool/work and home, and clearlyimpair social, academic, or occupationalfunctioning.

The symptoms of ADHD are moreeasily identified in children during theirelementary school years. Before thatage, many of the symptoms are consideredage-appropriate during variousstages of development. In a controlledsetting, such as school, the symptomsof inattentiveness, hyperactivity, andimpulsiveness become obvious. Childrenwith ADHD often are disruptive tothe class and have difficulty focusing.

How Is ADHD Diagnosed?

If parents are concerned that theirchild is showing symptoms of ADHD,the pharmacist should refer them to adoctor for a complete medical examination.The pharmacist may recommenda pediatrician, psychologist, neurologist,or child psychiatrist.

The first step involves performing afull physical examination, includingscreenings of vision, hearing, and verbaland motor skills. The physician alsomay check for low red blood cellcounts, thyroid disease, and lead poisoning.A complete neurologic examinationshould be performed. Thesechecks are necessary to rule out otherhealth or psychological problems.

Next the physician will gather informationfrom the parents, other familymembers, and teachers. The physicianalso will want to interview the childand observe his or her behavior. Asocial and family history is obtained.Evaluations to assess intelligence, aptitude,and personality traits are completedby the parents and teachers.This information gathering is necessaryto assess whether the child meets thecriteria for ADHD listed in theAmerican Psychiatric Association'sDiagnostic and Statistical Manual ofMental Disorders, Fourth Edition.

How Is ADHD Treated?

Currently there is no cure for ADHD,but treatment can control the symptoms.Treatment can involve behaviormodification and medications.

Behavior Modification

Although using both behavior modificationand medications may provemore effective, some parents are concernedabout having their child takemedications and prefer to use behaviormodification alone. Only a small percentageof children will benefit frombehavioral therapy alone, however.This therapy involves learning techniquesto control behavior. Parentswill learn to set a routine and makeinstructions simple and specific, alongwith rewarding good behaviorpromptly. They also will learn to promotethe child's self-esteem by recognizingand promoting his or herstrengths. Often behavioral therapy iscombined with emotional counseling,because children with ADHD tend tohave low self-esteem.

Medications

The use of medications to treatADHD is increasing. Researchers fromthe Center for Health Care Policy andEvaluation, studying prescriptions duringa 5-year period, found that the useof stimulants for this disorder hadincreased by 26% and the use of antidepressantsby 62%.

Stimulant medications?such asamphetamine, dextroamphetaminesulfate, and methylphenidate?are themost prescribed treatments. Althoughthese medications currently are approvedonly for use in children, theyhave been shown to be effective inadults. Adults may prefer the longeractingformulations that allow foronce-daily administration.

Parents should expect to see a suddenand dramatic improvement intheir children's behavior after initiatingtherapy. Doses usually are startedlow and are titrated to meet thedesired outcomes. If the child does notrespond to one agent, he or she usuallywill respond to another one. Thepharmacist should inform the parentsthat side effects may occur early intherapy but tend to disappear. Themost common adverse effects includedecreased appetite, sleep disturbances,headache, and jitteriness.

The use of atomoxetine is rapidlyincreasing, because it is not a stimulantand has not been associated with drugdependence. It is the only medicationapproved for use in children andadults. The exact mechanism of actionremains unknown, but atomoxetine isbelieved to regulate norepinephrine, achemical responsible for activity andattention. Adverse effects include nausea,decreased appetite, and dizziness.

Other medications, including antidepressantsand antihypertensives,often are used to control symptoms ifother medications are ineffective.Many children with ADHD also haveother psychological conditions thatbenefit from antidepressants in combinationwith stimulant therapy. Someantihypertensives, such as clonidineand guanfacine, help control aggressiveand impulsive behaviors.

The pharmacist should remind parentsto give all medications on a consistentschedule. If doses will be givenat school, the pharmacist shouldadvise the parents to send only a limitedquantity to school to make surethat they will not run out of medicationat home. The parents should workwith the physician to closely monitorthe child for desired outcomes andadverse effects.

What Are the Desired TreatmentOutcomes?

Although it cannot cure the condition,treatment should help controlsymptoms, including reducing disruptivebehavior and improving attentionspan. Parents also should notice animprovement in the child's relationshipswith family members andfriends, along with improved self-esteem.With treatment, the child'sperformance in school shouldimprove, including the quality ofwork, ability to work independently,and ability to complete tasks.

What Role Can the Family Play?

Because ADHD can add stress to thehousehold, family members can helpby learning about the condition. Thepharmacist should provide parentswith information about medications,including monitoring and drug interactions.Many Web sites contain furtherinformation about the conditionand various treatment options (Table).Support groups also are available forfamilies dealing with ADHD.

In addition, pharmacists can adviseparents to learn what rights are federallymandated for children withADHD. As of the 1997 reauthorizationof the Individuals with Disabilities Act,some children with ADHD qualify forspecial education services, under thecategory of "Other Health Impaired."For children who qualify, an individualizededucation plan is designed byschool administrators, teachers, psychologists,and parents.

Parents should understand thatsymptoms of ADHD in their childrenoften continue into adulthood. Withappropriate treatment, however, ADHDdoes not need to be a life sentence.

Dr. Schlesselman is a clinical pharmacistbased in Niantic, Conn.

For a list of suggested reading, send astamped, self-addressed envelope to:References Department, Attn. A. Stahl,Pharmacy Times, 241 Forsgate Drive,Jamesburg, NJ 08831; or send ane-mail request to: astahl@mwc.com.