ATTENTION DEFICIT/HYPERACTIVITY DISORDER

ATTENTION DEFICIT/HYPERACTIVITY DISORDER - Laura L. Novak, MD
BASICS
DESCRIPTION
• Behavior problem characterized by a short attention span, distractibility, low frustration tolerance, impulsivity, and hyperactivity. Attention deficit disorder (ADD) is ADHD without the impulsivity and hyperactivity.
• Can result in poor school performance, difficulty in peer relationships, and parent/child conflict
• System(s) Affected: Nervous
• Synonym(s): Attention deficit disorder; Hyperactivity
GENERAL PREVENTION
• Children are at risk for abuse, depression, and social isolation.
• Parents need regular support and advice.
• Establish contact with teacher each school year.
EPIDEMIOLOGY
• Predominant age
- Onset 7 years old
- Lasts into adolescence and adulthood
- 50% meet diagnostic criteria by age 4 years.
• Predominant sex: Male > Female (5:1); ADD without hyperactivity may be more common in girls
Incidence
5% of school-aged children
RISK FACTORS
• Family history
• Comorbid conditions (associated with, but not caused by)
- Learning disabilities
- Mood disorders
- Oppositional defiant disorder
- Conduct disorder
Genetics
Familial pattern
ETIOLOGY
Multifactorial
ASSOCIATED CONDITIONS
See "Risk Factors"

DIAGNOSIS
SIGNS AND SYMPTOMS
• The AAP guidelines recommend using the DSM-IV criteria to establish the diagnosis of ADHD.
• DSM-IV: 6 or more inattention criteria and/or 6 or more hyperactivity/impulsivity criteria. Symptoms must begin by age 7 years, be present for >6 months, and be noticed in 2 settings (e.g., home and school).
• Inattention
- Careless mistakes in tasks
- Difficulty sustaining attention
- Doesn't seem to listen
- Doesn't follow through or finish tasks
- Difficulty organizing tasks
- Avoids tasks that require sustained mental effort
- Loses things
- Easily distracted
- Forgetful
• Hyperactivity/Impulsivity
- Fidgets
- Difficulty remaining seated
- Runs or climbs excessively
- Difficulty playing quietly
- Acts as if "driven by a motor"
- Talks excessively
- Blurts out answers before question is complete
- Has difficulty awaiting turn
- Interrupts others
History
• Birth and development history
- Good psychosocial evaluation of home environment
• School performance history
TESTS
• Behavioral testing
- Behavior rating scales (Connors, others) should be completed by parents and teachers. They are repeated after therapy is started to gauge differences (DSM-IV criteria can be used).
- Testing for learning disability (e.g., dyslexia) through the school
Lab
Rarely needed, can check lead level
Diagnostic Procedures/Surgery
• Diagnosis is by DSM-IV criteria.
• Electroencephalogram not needed unless symptoms are highly suggestive of seizure disorder (e.g., absence seizures)
Pathological Findings
Motor tics can be present (e.g., cough, noises, twitching).
DIFFERENTIAL DIAGNOSIS
• Refer to DSM-IV (see References).
• Activity level appropriate for age
• Dysfunctional family situation
• Learning disability (e.g., dyslexia)
• Hearing/vision disorder
• Oppositional/defiant disorder (see DSM-IV)
• Conduct disorder (see DSM-IV)
• Lead poisoning
• Medication reaction (decongestant, antihistamine, theophylline, phenobarbital)
• Tourette syndromemotor tics and coprolalia
• Pervasive developmental delay (autism)
• Asberger syndromehigh functioning autism
• Absence seizures (attention deficit only)
TREATMENT
GENERAL MEASURES
• Parent/school/patient education
• Work closely with teacher.
• Avoid unproved therapies.
Diet
No dietary changes have been proven to help attention deficit/hyperactivity disorder.
MEDICATION (DRUGS)
First Line
The American Academy of Pediatrics has recommended in their guideline (1)[C] that stimulant medications should be the first line in treatment of ADHD. It also recommends that a second type of stimulant be tried if the first treatment fails. As of this writing, the FDA is considering applying a "black box" warning to stimulants based on some reported cases of sudden death seen in patients using stimulant medications.
• Stimulant
- Methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA, others): Ritalin 5-20 mg in the morning, at noon, and at 4 pm; maximum dose 60 mg/d (short-acting); Concerta 18, 36, 54 mg in the morning; Metadate CD 40 mg in the morning; Ritalin LA 20, 30, 40 mg in the morning (long-acting)
• Precautions
- If not responding, check compliance and consider another diagnosis. (1)[C]
- Some children experience withdrawal (tearfulness, agitation) after a missed dose.
- Methylphenidate has become a drug of abuse and should be monitored carefully: 20 mg nongeneric has highest street value
- Drug holidays should only be given if family/peer relationships are not harmed.
• Significant possible interactions
- Stimulants may increase levels of anticonvulsants, selective serotonin reuptake inhibitors, tricyclics, and warfarin.
ALERT
Pregnancy Considerations
Medications used in ADHD are category Ccaution in pregnancy
Second Line
• Amphetamine (stimulant)
• Adderall carries a "black box" warning for potential drug abuse
- Adderall: 2.5-20 mg q4-6h
- Adderall XR: 5-30 mg every morning;  6 years
• Nonstimulant
- Atomoxetine carries a "black box" warning regarding potential exacerbation of suicidality (similar to selective serotonin reuptake inhibitors). Because of this, the manufacturer recommends weekly visits for 4 weeks, then every other week visits for four sessions, then every 12 week visits. Atomoxetine has also been associated with hepatic injury in a small number of cases, and the manufacturer recommends checking liver enzymes if symptoms (jaundice, fatigue, malaise) develop,
- Atomoxetine (Strattera); selective norepinephrine reuptake inhibitor; 0.5-2 mg/kg/d every morning (10 mg, 18 mg, 25 mg, 40 mg, 60 mg). Maximum dose 1.4 mg/kg/d or 100 mg/d, whichever is less.
- Slower onset of efficacy; gastrointestinal side effects and sedation. Not addictive
- Atomoxetine interacts with paroxetine (Paxil), fluoxetine (Prozac), and quinidine
• Other nonstimulant drugs (e.g., clonidine, tricyclic antidepressants, selective serotonin reuptake inhibitors): Due to the mixed efficacy and high side effects of these drugs, they are not recommended for use without a consultant.
FOLLOW-UP
PROGNOSIS
• May last through school years and into adulthood
• May become easier to control with increasing age
• Encourage career choices that allow autonomy and mobility
• With treatment, there is no increased incidence of delinquency unless other comorbid features exist (e.g., conduct disorder).
• Encourage parents to subtract 2 years from their child's chronological age when allowing privileges (e.g., treat a 16-year-old like a 14-year-old, delay driving until age 18).
COMPLICATIONS
• Untreated attention deficit/hyperactivity disorder can lead to failing school, parental abuse, social isolation, and poor self-esteem.
• If appetite poor, offer food morning and evening
• Some children experience withdrawal (tearfulness, agitation) after a missed medication dose.
PATIENT MONITORING
• Parent/teacher rating scales initially, in 2 weeks, and regularly
• Office visits to monitor side effects and efficacy: End point is improved grades, improved rating scales, acceptable family interactions, and improved peer interactions.
- Monitor growth and blood pressure.
REFERENCES
1. American Academy of Pediatrics (AAP) Clinical Practice Guidelinestreatment of schoolafed children with ADHD. Pediatrics. 2001;108(4):1033-1044.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Revised. Washington, DC: American Psychiatric Association; 2000.
3. Rappley, MD. Attention Deficit-Hyperactivity Disorder. N Engl J Med. 2005;352(2):165-173.
4. Brown RT, Amler RW, Freeman WS, et al. Treatment of Attention Deficit/Hyperactivity Disorder: Overview of the evidence. Pediatrics. 2005;115(6):e749-e757.
ADDITIONAL READING
Barkley RA. ADHD: A Handbook for Diagnosis and Treatment. 2nd ed. New York: Guilford Press; 1998.