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General Considerations
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Up to 20% of school-aged children in the United States have behavioral problems, at least half of which involve attention and/or hyperactivity difficulties. Attention Deficit Hyperactivity Disorder (ADHD) is the most common and well-studied of the childhood behavioral disorders.
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Individuals diagnosed with ADHD are likely to experience significant difficulties with executive functioning, which impairs academic performance, social relationships, self-control, and memory. Brown (2005) outlines six executive function deficits that are observed in individuals diagnosed with ADHD: (1) organizing and prioritizing (difficulty getting started on tasks); (2) focusing and sustaining attention (easily distracted); (3) regulating alertness, sustaining effort (drowsiness); (4) managing frustration (low frustration tolerance or disproportionate emotional reactions); (5) working memory (difficulty retrieving information); and (6) self-regulation (difficulty inhibiting verbal and behavior responses).
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Brown
TE Attention Deficit Disorder: The Unfocused Mind in Children and Adults. New Haven, CT: Yale University Press; 2005.
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There is no single diagnostic test or tool for ADHD. The diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) are the current basis for the identification of individuals with ADHD. There is rarely a need for extensive laboratory analysis, but screening for iron deficiency and thyroid dysfunction is reasonable.
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The American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics (AAP), with input from members of the American Academy of Family Physicians, have formulated evidence-based practice guidelines to aid in the improvement of current diagnostic and treatment practices.
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American Academy of Child and Adolescent Psychiatry.
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American Academy of Pediatrics website.
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Differential Diagnosis
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The diagnosis is made by parent interview, direct observation, and the use of standardized and scored behavioral checklists such as the Connors Parent and Teacher Rating Scales, Child Behavior Checklist (CBCL), Vanderbilt ADHD Diagnostic Parent and Teacher Scales, Achenbach, along with computerized tests (Gordon Diagnostic Testing, Connors Continuous Performance Task, and Test of Variables of Attention) measuring impulsivity and inattention that are specific for ADHD and should include input from both parents and teachers.
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Attention deficit–hyperactivity disorder is often associated with other Axis I diagnoses. From 35% to 60% of referred ADHD children have oppositional defiant disorder (ODD), and 25-50% will develop conduct disorder (CD). Of these, 15–25% progress to antisocial personality disorder in adulthood. Of all referred ADHD children, 25–40% have a concurrent anxiety disorder. As many as 50% of referred children with ADHD eventually develop a mood disorder—most commonly depression, diagnosed in adolescence. The diagnosis of bipolar disease in childhood increases the risk of concurrent label of ADHD because of the overlap of behaviors. About half the children with Tourette syndrome have ADHD.
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There is a definite association among ADHD, academic problems, and learning disabilities. Between 20% and 50% of children with ADHD have at least one type of learning disorder.
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Stimulant medications are the most frequently researched and the safest and most effective treatments for the symptoms of ADHD, but they are not a “cure.” The fact that stimulants are controlled substances (schedule II) with an abuse potential justifies the close scrutiny of their use. About 65% of children with ADHD show improvement in the core symptoms of hyperactivity, inattention, and impulsivity with their first trial of a stimulant, and ≤95% will respond when given appropriate trials of various stimulants. The management of these medications can be complex, and treatment failures may more often be the result of improper treatment strategies than effective medication.
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Perhaps the most important step is the choice of medications. Stimulants most commonly used include methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA, Methylphenidate ER, Daytrana), dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine, Vyvanse), and mixed amphetamine salts (Adderall). In more recent years, novel drug delivery systems have been developed for stimulants and these formulations have become routine in clinical practice.
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Absolute contraindications to the use of stimulants include concomitant use of monoamine oxidase (MAO) inhibitors, psychosis, glaucoma, underlying cardiac conditions, existing liver disorders, and a history of stimulant drug dependence. Adverse cardiovascular effects of stimulants have consistently documented mild increases in pulse and blood pressure of unclear clinical significance. Caution should be used in treating patients who have a family history of early cardiac death of arrhythmias or a personal history of structural abnormalities, palpitations, chest pain, and shortness of breath or syncope of unclear origin either before or during treatment with stimulants.
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Because stimulants are Schedule II controlled substances, prescriptions with no refills are usually written monthly; however, several states allow 3-month prescriptions. Growth and vital signs should be checked and documented, and it is vital to monitor the medication effects and the child’s progress. Issues to address include: (1) adequacy and timing of the dosage, (2) compliance with the regimen, (3) changes in school or non-school-related activities that may affect medical therapy, and (4) maintenance of appropriate growth. An initial dropoff in weight gain may occur during titration phase, but over 2 years this reverses, resulting in no long-term sustained growth suppression from stimulant use. Drug holidays are no longer standard procedure, but parents may opt for their children to have periods off the medications to minimize potential unknown drug effects or to assess the continuing need for the medication.
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Many nonstimulant medications are being used for ADHD, alone and in combination with neurostimulants. Nonstimulant agents are less widely studied and are summarized here to inform the physician about their use. They vary from the tricyclic antidepressants to α-agonists (Tenex, Intuniv and Clonidine, Kapvay) to the highly selective catecholamine reuptake inhibitor atomoxetine (Strattera). Nonstimulants are often used to treat both ADHD and comorbid states, and their effectiveness alone is generally less than that of the neurostimulants. Fear and misunderstanding about the effects of neurostimulants make these nonstimulant agents attractive to parents.
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B. Psychotherapeutic Interventions
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1. Behavioral modification
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Behavioral modifications are designed to improve specific behaviors, social skills, and performance in specific settings. Behavioral approaches require detailed assessment of the child’s responses and the conditions that elicited them. Strategies are then developed to change the environment and the behaviors while maintaining and generalizing the behavioral changes. The most prudent approach to the treatment of ADHD is multimodal. The combination of psychosocial interventions and medications produces the best results.
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2. Educational interventions
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The education of children with ADHD is covered by three federal statutes: the Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990. The diagnosis of ADHD alone does not suffice to qualify for special education services. The ADHD must impair the child’s ability to learn. A 1991 Department of Education Policy Clarification Memorandum specifies three categories by which ADHD children may be eligible for special education: (1) health impaired (other documented condition such as Tourette syndrome), (2) specific learning disability (could be ADHD alone if there is a significant discrepancy between a child’s cognitive ability or intelligence and his or her academic performance), and (3) seriously emotionally disturbed. It is therefore vital to document all comorbid conditions in these children.
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3. Parent education and training
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Parental understanding of ADHD is vital to successful treatment. Parents must know the difference between nonadherence and inability to perform. They need to understand that ADHD is not a choice but a result of nature. Many parents respond well to referral to local and national support groups such as Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) or the Attention Deficit Disorder Association (ADDA).
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Parent training programs such as developed by Russell Barkley and others provide confused and overwhelmed parents with specific management strategies shown to be effective in reducing noncompliance. In these group training sessions, parents are taught skills in how to more effectively communicate with their children, learn how to consequate noncompliance, and enhance school performance.
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Follow-up studies of children with ADHD show that adult outcomes vary greatly. There are three general outcome groups. The largest group is the 50–60% of affected children who continue to have concentration, impulsivity, and social problems in adulthood. About 30% of affected children function well in adulthood and have no more difficulty than controlled normal children. The final group represents about 10–15% who, in adulthood, have significant psychiatric or antisocial problems. Predictors for bad outcomes include comorbid CD, low IQ, and concurrent parental pathology.