Medical Management Considerations
Attention Deficit Hyperactivity Disorder is a disorder characterized by inattention, hyperactivity and impulsivity. Even though the symptoms of ADHD may not impair an individual until adulthood, some of the symptoms of the disorder must be present during early childhood in order to make a positive diagnosis. The cause of ADHD is unknown; however, research suggests an interaction of genetic, biologic and environmental factors. Certain conditions occurring prenatally, perinatally or postnatally may predispose a child to developing this disorder. These include the following: prenatal exposure to alcohol, tobacco or cocaine; prematurity; low birth weight at term; brain infections; inborn errors of metabolism such as Reye’s syndrome; traumatic brain injury; lead exposure; sex chromosome abnormalities, such as Kleinfelter, Turner and Fragile X syndromes, and other genetic syndromes such as neurofibromatosis and Tourette syndrome.
ADHD affects an estimated two million American children, or approximately 3-5% of school age children (an average of 1 child in every classroom). Boys with ADHD outnumber girls with the disorder by a 5:1 ratio. While ADHD is sometimes present from birth, it may present clinically anytime during an individual’s life span. It requires a six-month duration and presence that is problematic in at least two settings to make a diagnosis. Symptoms may not become problematic until the individual begins to struggle at school, work or other activities. Half of the children with ADHD retain symptoms of the disorder throughout their adult lives. Rates of ADHD in adults are not known.
The individual must present 6 or more of the following:
Because the symptoms of ADHD are also attributable to other disorders, a differential diagnosis is necessary. Alternative causes for symptomatic behaviors may include learning disabilities, seizure disorders, hearing or visual impairments and certain psychiatric disorders. Moreover, ADHD often exists concurrently with other disorders. Studies show that 50 percent of youth with ADHD also have conduct disorder or oppositional defiant disorder, while 20 to 40 percent of adolescents and adults with ADHD engage in criminal behavior, substance abuse, risk-taking or impulsive behavior. Approximately 65 percent of ADHD patients have at least one comorbid disorder. These may include:
Specific syndromes that can cause and be comorbid with ADHD include:
Note: These considerations are in addition to the normal medical care provided to an individual without ADHD. There is no cure for ADHD; however treatment can help manage symptoms. Multi-modal treatment plans that combine parent education, behavior management, appropriate education, medication and family support services are most effective. Individual and family counseling should be provided when appropriate; this type of intervention is primarily recommended for patients with associated mental health problems.
An experienced primary care physician and office staff can address the special care needs of children with ADHD, starting with an initial evaluation. This involves conducting parent, child and teacher interviews, performing a complete medical examination, reviewing behavior rating scales and counseling the child and parents about the diagnosis and recommended treatment. Some children with ADHD and their families are referred to a child development team headed by a developmental pediatrician. Other members typically include a psychologist, a speech-language pathologist, an occupational therapist, an audiologist and a medical social worker. Other appropriate referrals may include a child neurologist and/or mental health professional.
*Note: Contraindications to the use of stimulants include substance abuse, agitated behavior, cardiac disorders, glaucoma, thought disorder and marked anxiety.
**Note: Childhood exposure to stimulant medications does not increase the likelihood of drug experimentation or drug addiction in teenage and adult years. On the contrary, studies clearly show that the ADHD child not adequately treated with high enough (i.e., therapeutic) levels of Ritalin or Adderall are more likely (due to decreased learning-socialization) to become drug addicted.
Tricyclic Antidepressants – An EKG should be preformed before initiation of treatment with these medications if an individual is at risk for heart disease.
*Treatment for ADHD remains controversial, as there is potential for inappropriate prescribing and abuse of medication. Unproven or controversial treatments include dietary management, megavitamin or orthomolecular therapies, sensory integration therapy, chiropractic manipulations, ocular motor exercises or optometrics, tradition play therapy, relaxation training or electromyogram (EMG) biofeedback and EEG biofeedback.
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Retrieved January 25, 2006 from http://www.ahcpr.gov/clinic/epcsums/adhdsum.htm
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American Academy of Pediatrics, 800-433-9016,
A.D.D. Warehouse, 800-233-9273,
C.H.A.D.D. (Children and Adults with Attention Deficit Hyperactivity Disorder), 800-233-4050,
Division of Birth Defects, Child Development, and Disability and Health, Center for Disease Control and Prevention, 770-488-7360,
National Attention Deficit Disorder Association (ADDA), 847-432-ADDA,
National Alliance for the Mentally Ill (NAMI), 800-950-NAMI (6264),
The Attention Deficit Information Network, Inc. 781-455-9895,
Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
James R. Popplewell, M.D.
Leonard Magnani, M.D., Ph.D.
Patricia Samuelson, M.D.
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This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.