Attention Deficit Hyperactivity Disorder

BACKGROUND

Description and Cause

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.

Occurrence

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.

Characteristic Features

Diagnostic and Statistical Manual of Mental Disorders, Ed. IV (DSM-IV) Criteria: Either 1 (Inattention) or 2 (Hyperactivity-Impulsivity)

The individual must present 6 or more of the following:

Inattention

Often fails to pay close attention to details, or makes careless mistakes in schoolwork, work or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when addressed directly
Often does not follow through on instructions; fails to finish schoolwork, chores or duties in the workplace
Often has difficulty in organizing tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Often is easily distracted by extraneous stimuli
Often is forgetful in daily activities

Hyperactivity-Impulsivity

Often fidgets or squirms in seat
Often leaves seat in situations where remaining seated is expected
Often moves excessively in inappropriate situations
Often has difficulty in quietly engaging in leisure activities
Often is “on the go” or acts as if “driven by a motor”
Often talks excessively
Often blurts out answers before questions have been completed
Has difficulty waiting for a turn
Often interrupts or intrudes on others

Results

In Children

Poor social skills
Problems with parents
Low academic functioning
Learning difficulties
Behavioral problems
Lack of peer acceptance
Low self-esteem

In Adults

High rates of comorbid psychiatric disorder
Significant relationship disfunction
Educational failure

Common Associations

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:

Depressive and Bipolar Disorders
Anxiety Disorders
Chemical and Behavioral Addictions
Oppositional Defiant and Conduct Disorders
Learning Disorders
Psychotic Disorders and Pervasive Developmental Disorders
Personality Disorders
Tic Disorders
Sleep Disturbances
Brain Trauma

Specific syndromes that can cause and be comorbid with ADHD include:

Tourette syndrome
Turner syndrome
Klinefelter syndrome
Homocystinuria
Hypo and Hyperthyroidism

MEDICAL MANAGEMENT CONSIDERATIONS

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.

Management by Age

Ongoing (all ages)

Reevaluate the management plan for children and their families at least twice yearly, and update as appropriate. More frequent evaluation may be needed for a younger child.
If patient displays ongoing or worsening behavior problems, fails to make expected progress at school, fails to respond to stimulants, experiences severe side effects from medication, experiences onset or worsening of tics, develops symptoms of anxiety or depression, exhibits skill regression, experiences developmental delay or is suspected of having autism spectrum disorder (ASD), refer patient to a specialist.

Pre-school Age (Birth to 5 years)

Evaluate growth and diet history
Refer child for hearing and vision tests as needed
Perform EEG when indicated for services
Review oral hygiene and refer as needed
Conduct parent and teacher interviews
Administer behavior rating scales, and collect preschool information at least twice yearly, more frequently if on medication
Recommend behavioral therapy consultation and provide ongoing therapy as needed
Refer child for screening surveillance for associated developmental or learning problems
Recommend counseling for both the child and the family
Educate parents about realistic expectations for their child
Refer family to advocacy and support groups specifically for children with ADHD

Childhood (6 to 12 years)

Establish contact with teacher each school year and send teacher report at least twice yearly
Conduct parent and teacher interviews and administer behavior rating scales to parents and teachers
Monitor feedback from teacher to determine if medication changes are needed and if changes are effective
Collaborate with school staff and refer child to school-based social skills program or community services as needed
Recommend special education classrooms and/or tutoring if needed
Check growth, blood pressure, heart rate and tics at least twice yearly if child is stable and doing well
Review medication management
Monitor side effects of medication, which may include: reduction in appetite, difficulty sleeping, height and weight in child that seem to be lagging behind his or her peers, latent tics.
Monitor for associated risk factors: abuse, depression and social isolation
Perform EKG and lab work as needed
Refer child for intellectual and achievement testing as needed

Adolescence (13-21 years)

Review medication management
Monitor associated risk factors: abuse, depression and social isolation

Adulthood (22 years and over)

Review medication management
Encourage career choices that maximize patient autonomy

Medication Management

Medical Considerations for Treating ADHD:

The more severe the child’s ADHD behavior, the greater the probability of showing a positive response to stimulants.
Treatment of preschool-age children should begin with behavior management, as this age level responds less well to stimulants and tends to experience more side effects.
Children with a comorbid disorder will respond less positively to stimulant medication than children expressing only ADHD.
Use standardized instruments for evaluating the effectiveness of medications at varying dosages.

Stimulant Medications

Methylphenidate (Ritalin)
Dextroamphetamine-amphetamine (Adderall)
Pemoline (Cylert) – monitor liver function when giving this medication (Please be advised that the risks associated with this medication warrant further investigation)
Dextroamphetamine (Dexedrine)
Atomextine (Strattera) – monitor liver function when giving this medication (Please be advised that the risks associated with this medication warrant further investigation)

*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.

Imipramine (Tofranil)
Desipramine (Norpramine)
Amitryptyline (Elavil)
Nortriptyline (Pamelor)

Adrenergic Blockers

Clonidine (Catapres) – helpful for motor tics; the combination of clonidine and methylphenidate should be used cautiously. May cause sedation;may cause hypertension if abruptly discontinued.
Guanfacine (Tenex)– may decrease hyperactivity, aggression and oppositionality. May cause sedation; may cause hypertension if abruptly discontinued.

*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.

REFERENCES

Peer-reviewed Journal Articles/Academies

American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention – Deficit/Hyperactivity Disorder. (2000). Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder. Pediatrics 105(5), 1158-1170.

Goldman, Larry S. et al. (1998). Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder in Children and Adolescents. Journal of the American Medical Association. 279(14), 1100-1107.

Shaywitz, BA. et al. (1997). Attention Deficit Hyperactivity Disorder. Advances in Pediatrics 44, 331-367.

Spencer, T. et al. (1999). Attention Deficit Hyperactivity Disorder and comorbidity. Pediatric Clinic of North America 46(5), 915-927.

Spencer, T. et al. (2000). Pharmacotherapy of attention deficit hyperactivity disorder. Child and Adolescent Psychiatric Clinics of North America 9(1), 77-97.

Spencer, T. et al. (1996). Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. Journal of the American Academy of Child and Adolescent Psychiatry 35(4), 409-432.

Trollor, J.N. (1999). Attention deficit hyperactivity disorder in adults: conceptual and clinical issues. Medical Journal of Australia 171(8), 421-425.

Brown, R.T. et al. (2005).American Academy of Pediatrics Committee on Quality Improvement; American Academy of Pediatrics Subcommittee on Attention-Deficit/Hyperactivity Disorder. Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the Evidence. Pediatrics, 115(6),749-757.

Rappley, M.D. (2005). Clinical Practice. Attention Deficit-Hyperactivity Disorder.

New England Journal of Medicine, 352(2),165-73.

Rushton J.L., Fant, K.E, Clark, S.J. (2004). Use of Practice Guidelines in the Primary Care of Children with Attention-Deficit/Hyperactivity Disorder. Pediatrics, 114(1), 23-28.

Leslie, L.K., Weckerly, J., Plemmons, D., Landsverk, J., Eastman, S. (2004). Implementing the American Academy of Pediatrics Attention-Deficit/Hyperactivity Disorder Diagnostic Guidelines in Primary Care Settings. Pediatrics, 114(1), 129-140.

Kutcher S, et al. (2004). International Consensus Statement on Attention-Deficit/Hyperactivity Disorder (ADHD) and Disruptive Behaviour Disorders (DBDs): Clinical Implications and Treatment Practice Suggestions. European Neuropsychopharmacology, 14(1),11-28.

Reiff, M.I., Stein, M.T. (2003). Attention-Deficit/Hyperactivity Disorder Evaluation and Diagnosis: a Practical Approach in Office Practice. Pediatric Clinics of North America, 50(5), 1019-1048.

Greenhill L, et al (2002). Guidelines and Algorithms for the Use of Methylphenidate in Children with Attention-Deficit/Hyperactivity Disorder. Journal of Attention Disorders, 6(1), 89-100.

American Academy of Pediatrics.(2001). Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. Clinical practice guideline: Treatment of the School-Aged Child with Attention-Deficit/Hyperactivity Disorder. Pediatrics, 108(4),1033-1044.

Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder. American Academy of Pediatrics.

Pediatrics,105(5),1158-1170.

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD) (1998).

NIH Consensus Statement, 16(2), 1-37.

Dulcan M. (1997). Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention-Deficit/Hyperactivity Disorder. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 36(10), 85-121.

Special Interest Groups/Other Publications

Agency for Health Care Policy and Research (AHCPR). Treatment of Attention Deficit Hyperactivity Disorder.

Retrieved January 25, 2006 from http://www.ahcpr.gov/clinic/epcsums/adhdsum.htm

Attention Deficit Disorder Association (ADDA). Guiding Principles for the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. Retrieved January 25, 2006 from http://www.add.org/articles/coachingguide.html

Blum, N. J. & Mercugliano, M. (1997). Attention Deficit Hyperactivity Disorder. In, M.L. Batshaw (Ed.), Children with Disabilities (449-470). Baltimore: Paul H. Brookes Publishing Co.

Center for Disease Control and Prevention (CDC). Attention Deficit Hyperactivity Disorder: Symptom Checklist for ADHD. Retrieved January 25, 2006, from http://www.cdc.gov/ncbddd/autism/actearly/pdf/parents_pdfs/ADHDFactSheet.pdf

Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD). ADHD Fact Sheets. Retrieved January 25, 2006 from http://www.chadd.org/webpage.cfm?cat_id=24

National Alliance for the Mentally Ill. Attention Deficit Hyperactivity Disorder. Retrieved January 25, 2006 from http://www.nami.org/helpline/adhd.htm.

Nickel, R. E. (2000). Attention Deficit Hyperactivity Disorder and Related Disorders. In R.E. Nickel & L.W. Desch (Eds.) The Physician’s Guide to Caring for Children with Disabilities and Chronic Conditions(185-221). Baltimore: Paul H. Brookes Publishing Co.

Novak, L. L. (1999). Attention deficit hyperactivity disorder. In M.R. Dambro, (Ed.) Griffith’s 5 Minute Clinical Consult.(110-111). Baltimore: Lippincott Williams & Wilkins.

RESOURCES FOR FAMILIES

American Academy of Pediatrics, 800-433-9016,

http://www.aap.org

A.D.D. Warehouse, 800-233-9273,

http://www.addwarehouse.com

C.H.A.D.D. (Children and Adults with Attention Deficit Hyperactivity Disorder), 800-233-4050,

http://www.chadd.org

Division of Birth Defects, Child Development, and Disability and Health, Center for Disease Control and Prevention, 770-488-7360,

http://www.cdc.gov/ncbddd/default.htm

National Attention Deficit Disorder Association (ADDA), 847-432-ADDA,

http://www.add.org

National Alliance for the Mentally Ill (NAMI), 800-950-NAMI (6264),

http://www.nami.org

The Attention Deficit Information Network, Inc. 781-455-9895,

http://www.addinfonetwork.com/

ADVISORY COMMITTEE

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.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental, , S, ervices

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

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.