ATTENTION DEFICIT-HYPERACTIVITY DISORDER


I. Epidemiology

  1. Various studies have found prevalence of 5-10% in school-aged children but used self-reporting rather than direct testing to confirm the diagnosis.
  2. Some studies suggest frequent comorbidities including oppositional defiant disorder and conduct disorder
  3. Risk factors include possibly some genetic factors, perinatal stres, low birth weight, traumatic brain injury, and maternal smoking during pregnancy.

II. DSM-IV-TR diagnostic criteria (2000):

  1. EITHER (1) or (2) below
    1. Six or more of the following symptoms of inattention for > 6mos to a degree that is maladaptive and inconsistent with developmental level:
      1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
      2. Often has difficulty sustaining attention in tasks or play activities
      3. Often does not seem to listen when spoken to directly
      4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
      5. Often has difficulty organizing tasks and activities
      6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
      7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
      8. Is often easily distracted by extraneous stimuli
      9. Is often forgetful in daily activities
    2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      1. Often fidgets with hands or feet or squirms in seat
      2. Often leaves seat in classroom or in other situations in which remaining seated is expected
      3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
      4. Often has difficulty playing or engaging in leisure activities quietly
      5. Often "on the go" or often acts as if "driven by a motor"
      6. Often talks excessively
      7. Often blurts out answers before questions have been completed
      8. Often has difficulty awaiting turn
      9. Often interrupts or intrudes on others (e.g., butts into conversations or games)
  2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
  3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
  4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
  5. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

III. Differential diagnosis/comorbidities to consider

  1. Vision, hearing, or speech problems
  2. Learning disabilities
  3. Other psychiatric conditions especially anxiety disorders, adjustment disorders, depression/dysthymia, mania, or oppositional-defiant disorder
  4. Chronic physical illness
  5. Iron deficiency
  6. Endocrinopathies e.g. hypothyroidism
  7. Neurologic disorders e.g. seizure disorders
  8. Sleep disorders
  9. Abuse/neglect
  10. Disruptive home environment or family stressors
  11. Substance abuse

IV. Helpful rating scales in assessing children with suspected ADHD (per AACAP guidelines 2008):

V. Pharmacologic treatment:

  1. Stimulants (e.g. methylphenidate, amphetamines e.g. lisdexamfetamine dimesylate (Vyvanse))
  1. Primarily alter dopaminergic transmission
  2. Side f/x include headache, decreased appetite, restlessness, insomnia, abdominal pain, tachycardia, and hypertension.
  3. Take family and personal cardiac history before starting
  4. Avoid in pts with known structural cardiac abnormlaities, cardiomyopathy, dysrhythmias, coronary disease, or other cardiac problems.
  5. In a case-control study of 564 children 7-19yo with no h/o cardiac or other chronic illness who sustained sudden death, with 564 children who died as passengers in MVAs, , sudden-death group had sig. higher likelihood (OR 7.4) of being on stimulant medication.  (Am. J. Psychiat. 6/15/09; ePublication ahead of print-JW)  JW editor advises precautions for children on stimulants of "a cardiac history and physical examination for previously undetected cardiac abnormalities, including congenital heart disease, conduction abnormalities, and cardiomyopathy".
  6. Dextroamphetamine
    1. Start at 2.5mg for 3-5yo; 5mg 1-2x/d for > 6yo
    2. Take in am and noon; add 4pm dose if needed
    3. Can increase weekly in increments of 2.5-5mg/dose
    4. Long-acting formulation avaiable?
  7. Amphetamine/dextroamphetamine salts (Adderall, Adderall XR)
    1. For Adderall, start at 2.5-5mg Qam; Can increase in increments of 2.mg at weekly intervals to max 40mg/d (?); can add 2nd dose 6-7h after am dose; usually lower dose needed in afternoon than am
    2. For XR, start 10mg Qam for >6y and can increase dose weekly by 5-10mg/d to max 30mg/d at 6-12yo or 20mg/d in adolescents
  8. Lisdexamfetamine (Vyvanse)
    1. Dosing: For kids > 6yo, 30mg Qam, increase weekly in increments of 10-20mg/d to max 70mg/d.
  9. Methylphenidate (See brand names below)
    1. Ritalin immediate-release: Start at 5mg BID if < 8yo and 10mg BID if > 8yo; Increase each dose by 2.5-5mg Q1-2wks; Take in am and noon; can add 4pm dose if needed
    2. Ritalin LA: For kids > 6yo, 20mg Qam; can increase Qwk at 10mg increments
    3. Ritalin SR: 20mg Qam; can add 5-10mg immediate-release in am and/or 4pm
    4. Concerta: For kids > 6yo, 18mg Qam; can increase weekly in 18mg increments to max 72mg/d in adolescents
    5. Daytrana (transdermal patch): Kids 6-12yo: 10mg patch QD to hip (alternate hips QOD; can remove 9h after application; do not cut patch); can increase to next size up to Qwk
    6. Metadate CD: For kids > 6yo, 20mg Qam, can increase weekly in 10-20mg increments
    7. Metadate ER: 30mg Qam, can add 5- of 10-mg tablet Qam and/or at 4pm
    8. Methylin ER: 30mg Qam, can add 5- of 10-mg tablet Qam and/or at 4pm
  10. Dexmethylphenidate (Focalin, Focalin XR)
    1. For children > 6yo
    2. Do not combine with methylphenidate
    3. Focalin dose: start 2.5mg BID at least 4h apart; increase weekly in increments of 2.5-5mg, max 20mg/d
    4. Focalin XR dose: Start at 5mg/d and increase weekly at 5mg increments to max 20mg/d; dosing is different in pts switching from methylphenidate
  1. Atomoxetine (Strattera)
    1. A selective inhibitor of the presynaptic norepinephrine transporter
    2. Increases both norepinephrine and dopamine levels, especially in the prefrontal cortex
    3. Dosing: Start at 0.5 mg/kg (if > 70kg, 40mg) per day and increase after 3-5d to 1.2-1.4 mg/kg/d (max 100mg/d). Can be given at bedtime or in divided dosages BID if causes somnolence.
    4. May not reach full effect for up to 4wks
    5. Studies of efficacy:
      1. 297 pts 8-18yo with mod-severe ADHD randomized to atomoxetine (at one of 3 doses; 0.5-1.8mg/kg/d divided BID) vs. placebo; active-tx groups had sig. better improvement in ADHD sx at 8wks; 1.2mg/kg/d was as good as 1.8mg/kg/d (Peds. 108:E83, 2001--JW)
      2. 228 children w/ADHD randomized to atomoxetine vs. methylphenidate (open-label); at 10wks, parent- and clinician-rated ADHD sx were similar in both groups (Am. J. Psychiat. 159:1896, 2002--JW)
    6. Adverse effects:
      1. Reported: nausea/vomiting, abdominal pain, anorexia, dizziness, somnolence, skin rash, pruritis, tachycardia, hypertension, urinary retention
      2. Two cases of severe hepatotoxicity reported early 2005; incidence of that adverse effect unknown at that time
    7. Contraindications:
      1. MAO inhibitors within 15 days
      2. Narrow-angle glaucoma
      3. Use w/caution in presence of hypertension, tachycardia, or urinary retention
  2. Guanfacine (Intuniv-not interchangeable wiht regular-release guanfacine)

    1. For treatment of ADHD in pts > 6yo as monotherapy or as adjunct to stimulants

    2. Start at 1mg QD; can increase weekly by 1mg increments

    3. A selective alpha-2A adrenergic agonist

    4. Also used for hypertension

    5. Adverse effects reported: somnolence (up to 38% of pts), headache, abdominal pain, nausea, dizziness, decreased appetite hypotension, bradycardia, syncope

    6. Do not discontinue therapy abruptly

    7. No safety data beyond 2y as of 2011.

  3. Other medications used (limited data): bupropion, clonidine, desipramine, imipramine

VI. Non-pharmacologic management approaches

  1. There appears to be little literature on behavioral approaches to ADHD
  2. Support groups and parenting skills training can help
  3. Parents can be advised on providing a structured home environment, clear and consistent expectations, and appropriate positive and negative behavioral reinforcement.
  4. Social skills training for the child may help overcome peer relationship issues affected by ADHD symptoms
  5. School-based interventions may help, e.g. seating child near the teacher to minimize distractions, providing a  notebook to keep track of assignments, etc., lists of targeted behaviors, daily reports to parents, positive reinforcement, etc.
  6. Cognitive-behavioral therapy can be effective but less so than stimulant medications
  7. Adequate physical exercise may help.
  8. Supplementation with omega-3 and -6 fatty acids
    1. Some evidence of benefit in short-term randomized controlled trials
  9. "Feingold diet"-Eliminates food additives and foods high in salicylates-Little evidence of benefit

Sources include: American Academy of Child and Adolescent Psychiatry guidelines: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7); also Core Content Review of Family Medicine, 2012.