Attention deficit hyperactivity disorder (ADHD) – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Attention deficit hyperactivity disorder (ADHD) is a behavior problem characterized by a short attention span, distractibility, low frustration tolerance, impulsivity, and hyperactivity.
  • ADHD is divided into 3 subsets: predominantly hyperactivity-impulsive, predominantly inattentive, or both.
  • System affected: Nervous
  • Synonym(s): Attention deficit disorder; Hyperactivity

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); predominantly inattentive type 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

General Prevention

  • Children are at risk for abuse, depression, and social isolation.
  • Parents need regular support and advice.
  • Parents should establish contact with teacher each school year.

Commonly Associated Conditions

See Risk Factors

Oppositional defiant disorder, ADHD, ADHD In Teenagers, Adderall, child and adolescent psychiatry, attention deficit hyperactivity disorder adhd,

Diagnosis

  • American Academy of Pediatrics (AAP) guidelines recommend using the DSM-IV criteria to establish the diagnosis.
  • Children undergoing extreme stress (divorce, illness, homelessness, abuse) may demonstrate ADHD behaviors secondary to stress. This can be assessed using the American Academy of Child and Adolescent Psychiatry (AACAP) screening tool, if needed.
  • If diagnostic behaviors are noted in only one setting, explore the stressors in that setting.
  • The diagnostic behaviors are more noticeable in tasks that require concentration or boredom tolerance than in free play or office situations.
  • DSM-IV criteria: 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). Teachers and caretakers should fill out assessments in addition to parents.
  • Inattention:
    • Careless mistakes in tasks
    • Difficulty in sustaining attention
    • Does not seem to listen
    • Does not follow through or finish tasks
    • Difficulty in organizing tasks
    • Avoids tasks that require sustained mental effort
    • Loses things
    • Easily distracted
    • Forgetful
  • Hyperactivity/impulsivity:
    • Fidgets
    • Difficulty in remaining seated
    • Runs or climbs excessively
    • Difficulty in playing quietly
    • Acts as if “driven by a motor”
    • Talks excessively
    • Blurts out answers before question is complete
    • Has difficulty in awaiting turn
    • Interrupts others

History

  • Birth and development history
  • Comprehensive psychosocial evaluation of home environment
  • School performance history

Diagnostic Tests & Interpretation

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).
  • An ADHD toolkit with forms is available from www.nichq.org/adhd.html
  • Testing for learning disability (e.g., dyslexia) through the school

Lab

Rarely needed; check lead level if high risk

Diagnostic Procedures/Surgery

  • Electroencephalogram not needed unless symptoms are highly suggestive of seizure disorder (e.g., absence seizures).
  • Patients with a personal or family history of congenital heart disease or sudden death should be screened with an electrocardiogram (EKG) and possible cardiology consultation before beginning stimulant medication (1).

Pathological Findings

Motor tics can be present (e.g., cough, noises, twitching).

Differential Diagnosis

  • Activity level appropriate for age
  • Hearing or vision disorder
  • Lead poisoning
  • Medication reaction (decongestant, antihistamine, theophylline, phenobarbital)
  • Dysfunctional family situation
  • Learning disability (e.g., dyslexia)
  • Pervasive developmental delay (autism)
  • Asperger syndrome: High-functioning autism
  • Oppositional/defiant disorder (see DSM-IV)
  • Conduct disorder (see DSM-IV)
  • Tourette syndrome: Motor and verbal tics
  • Absence seizures (attention deficit only)

Treatment

Medication

First Line

The 2001 AAP guideline recommends (1)[C] the use of stimulant medications as 1st-line in treatment. A 2nd type of stimulant should be tried if the 1st treatment fails.

Alert

The Food and Drug Administration (FDA) has considered applying a “black box” warning to stimulants based on some reported cases of sudden death seen in patients using stimulant medications. It recommends that patients with a personal or family history of congenital heart disease or sudden death be screened with an EKG and possible cardiology consultation before beginning stimulant medication.

  • Stimulant:
    • Methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA, others):
      • Short-acting: Ritalin 5–20 mg in the morning, at noon, and at 4 p.m.; maximum dose, 60 mg/d
      • Long-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
      • Methylphenidate patch (Daytrana): Apply to hip for up to 9 hours daily. Begin at 10 mg and titrate upward weekly as needed. Available as 10, 15, 20, and 30 mg.
    • Amphetamines:
      • Adderall: 2.5–20 mg q4–6h
      • Adderall XR: 5–30 mg every morning; ≥6 years
  • Precautions:
    • If not responding, check compliance and consider another diagnosis (1)[C].
    • Some children experience withdrawal (tearfulness, agitation) after a missed dose or when medication wears off.
    • Stimulants are drugs of abuse and should be monitored carefully.
    • Drug holidays should be given only if family/peer relationships are not harmed.
  • Significant possible interactions:
    • Stimulants may increase levels of anticonvulsants, selective serotonin reuptake inhibitors (SSRIs), tricyclics, and warfarin.

Pregnancy Considerations

Medications used in ADHD are Category C: Caution in pregnancy.

Second Line

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  • 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 sessions, then every-other-week visits for 4 sessions, then every-12-weeks 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, SSRIs): Owing to the mixed efficacy and high side effects of these drugs, they are not recommended for use without a consultant.

Additional Treatment

  • Medication alone or combined with behavioral therapy produced better results than behavioral therapy alone.
  • Behavioral therapy may be useful in cases where parents object to medication (2).

General Measures

  • Parent/school/patient education (2)
  • Work closely with teacher.
  • Avoid unproven therapies.

Complementary and Alternative Medicine

  • Surveys have shown that parents of children with ADHD use herbals and complementary treatments frequently (20–60%) (3,4).
  • Many herbals have been assessed for efficacy, but studies are small and brief and, therefore, difficult to translate into clinical recommendations.
  • Dietary and nutritional supplements have also been assessed:
    • Omega-3 fatty acids (found in fish oil and some supplements) showed improvement in rating scales in 2 double-blind, placebo-controlled studies of 116 and 130 patients.
  • Rapid eye training and biofeedback have contradictory results and can be costly.

Ongoing Care

The “toolkit for physicians” may be useful: http://www.nichq.org/adhd.html

Follow-Up Recommendations

Patient Monitoring

  • Parent/teacher rating scales initially, 2 weeks after an intervention such as starting medication, and regularly
  • Office visits to monitor side effects and efficacy: Endpoints are improved grades, improved rating scales, acceptable family interactions, and improved peer interactions.
  • Monitor growth (especially weight gain) and blood pressure.

Diet

“Insufficient evidence exists to suggest that dietary interventions improve the symptoms of ADHD in children” (5).

Patient Education

  • Key points for parents:
    • 50% of children with ADHD have 1 parent with ADHD; modify education sessions with parents accordingly.
    • Behavioral interventions such as token systems may be helpful (1)[A].
    • Find things child is good at and emphasize these.
    • Reinforce good behavior (with rewards and attention).
    • Make eye contact with each request.
    • Give one task at a time.
    • Stop behavior before it escalates.
    • Some families benefit from “parent training” and family therapy.
    • Coordinate homework with teachers using daily assignment notebook.
    • Refer to advocacy and support groups.
  • Schools are required by law to provide necessary testing and Individualized Educational Plans (IEPs) or 504 plans to accommodate the child’s educational needs
  • Support groups:
    • Children and Adults with Attention Deficit Disorder (CHADD): chadd.org; 800-233-4050
    • Attention Deficit Disorder Warehouse: addwarehouse.com; 800-233-9273
    • Learning Disabilities Association (LDA): LDAlearning.com
    • National Information Center for Children and Youth with Disabilities: www.nichcy.org

Prognosis

  • May last into adulthood
  • The hyperactivity component 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 ADHD can lead to failing school, parental abuse, social isolation, and poor self-esteem.
  • Some children experience withdrawal (tearfulness, agitation) after a missed medication dose or when medication wears off.
  • If appetite is poor as a side effect of stimulant medication, offer small frequent meals.

References

1. American Academy of Pediatrics. 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. 2001;108:1033–44.

2. Laforett DR, Murray DW, Kollins SH. Psychosocial treatments for preschool-aged children with Attention-Deficit Hyperactivity Disorder. Dev Disabil Res Rev. 2008;14:300–10.

3. Sawni A. Attention-deficit/hyperactivity disorder and complementary/alternative medicine. Adolesc Med State Art Rev. 2008;19:313–26, xi.

4. Weber W, Newmark S. Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatr Clin North Am. 2007;54:983–1006; xii.

5. Sinn N. Nutritional and dietary influences on attention deficit hyperactivity disorder. Nutr Rev. 2008;66:558–68.

Additional Reading

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Revised. Washington, DC: American Psychiatric Association, 2000.

Barkley RA. ADHD: A Handbook for Diagnosis and Treatment. 2nd ed. New York: Guilford Press, 1998.

Brown RT, Amler RW, Freeman WS, et al. Treatment of attention deficit/hyperactivity disorder: Overview of the evidence. Pediatrics. 2005;115(6):e749–e757.

Ghuman JK, Arnold LE, Anthony BJ. Psychopharmacological and other treatments in preschool children with attention-deficit/hyperactivity disorder: Current Evidence and Practice. J Child Adolesc Psychopharmacol. 2008.

Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:894–921.

Rader R, McCauley L, Callen EC. Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 2009;79:657–65.

Rappley, MD. attention deficit-hyperactivity disorder. N Engl J Med. 2005;352(2):165–73.

Rostain AL. Attention-deficit/hyperactivity disorder in adults: evidence-based recommendations for management. Postgrad Med. 2008;120:27–38.

Soileau EJ. Medications for adolescents with attention-deficit/hyperactivity disorder. Adolesc Med State Art Rev. 2008;19:254–67, viii–ix.

Codes

ICD9

  • 314.00 Attention deficit disorder of childhood without mention of hyperactivity
  • 314.01 Attention deficit disorder of childhood with hyperactivity

Snomed

  • 406506008 Attention deficit hyperactivity disorder (disorder)
  • 35253001 Attention deficit hyperactivity disorder, predominantly inattentive type (disorder)

Clinical Pearls

  • Children undergoing extreme stress (divorce, illness, homelessness, abuse) may demonstrate ADHD behaviors secondary to stress.
  • 50% of ADHD children have a parent with ADHD.
  • AAP recommends the use of stimulant medications as the 1st-line treatment.

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