Attention-Deficit/Hyperactivity Disorder (ADHD)
What are second-line medications for ADHD?
Nonstimulant medications, including atomoxetine (norepinephrine-reuptake inhibitor), guanfacine, or clonidine (α-agonists), may be helpful in children that do not respond to stimulant medication, or for family preference, concerns about medication abuse or diversion, and contraindications to stimulant use.
How is ADHD managed pharmacologically?
1st line meds - caution: wt. loss & ↓ growth with stimulants! -Methylphenidate (Ritalin, Concerta, Daytrana) -Dexmethylphenidate (Focalin) -Amphetamine/dextroamphetamine (Adderall, Dexedrine) -Atomoxetine (Strattera) selective norepinephrine -Atomoxetine (Strattera) selective norepinephrine reuptake inhibitor (non-stimulant) 2nd line/adjuncts -Antidepressants (guanfacine, clonidine (alpha agonist), imipramine, bupropion, venlafaxine) Behavior modification (structure, routine & appropriate goals), family, educational mgmt.
What are the DSM-5 diagnostic criteria for ADHD?
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: -Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. -Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). -Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). -Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). -Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). -Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). -Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). -Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). -Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). -Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: -Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. -Often fidgets with or taps hands or feet or squirms in seat. -Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). -Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) -Often unable to play or engage in leisure activities quietly. -Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). -Often talks excessively. -Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation). -Often has difficulty waiting his or her turn (e.g., while waiting in line). -Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
Which of the following statements is correct about ADHD? A. ADHD is one of the most heritable psychiatric disorders B. ADHD is more common in girls than boys C. ADHD is rarely associated with other clinical diagnoses D. ADHD is largely caused by environmental exposure
A. ADHD is one of the most heritable psychiatric disorders Studies estimate the mean heritability of ADHD to be 76%, indicating that ADHD is one of the most heritable psychiatric disorders. Hypotheses exist that include in utero exposures to toxic substances, food additives or colorings, or allergic causes. However, diet, especially sugar, is not a cause of ADHD. How much of a role family environment has in the pathogenesis of ADHD is unclear, but it certainly may exacerbate symptoms. ADHD is associated with a number of other clinical diagnoses. Studies have demonstrated that many individuals have both ADHD and antisocial personality disorder. These individuals are at higher risk for self-injurious behaviors. ADHD is also linked to addictive behavior. In children, ADHD is three to five times more common in boys than in girls. Some studies report an incidence ratio of as high as 5:1. The predominantly inattentive type of ADHD is found more commonly in girls than in boys.
Which of the following is an evidence-supported concern in children with ADHD? A. Comorbid bipolar disorder B. Increased risk for cardiac conditions C. An associated underlying immunodeficiency disease D. Foods that contain food coloring or that are high in simple sugars, which exacerbate symptoms
A. Comorbid bipolar disorder ADHD can be comorbid with the following conditions: -Other developmental learning disorders -Conduct disorder or oppositional defiant disorder -Bipolar disorder (Studies in the United States have shown a comorbidity prevalence that ranges from 2% to 23%.) -Tourette syndrome -Pervasive developmental disorder -Mental retardation For decades, speculation and folklore have suggested that foods containing preservatives or food coloring, or foods high in simple sugars, may exacerbate ADHD. Many controlled studies have examined this question. To date, no adequate dataset has confirmed the speculation.
How is ADHD diagnosed?
ADHD is diagnosed clinically by history. The reports of parents, teachers, and others, including teenage self-report, are core to its diagnosis. The history should rely on open-ended questions as much as possible to explore specific behaviors and their impact on academic performance, family and peer relationships, safety, self-esteem, and daily activities. However, ultimately, a diagnosis of ADHD requires that the symptoms be measured with validated rating scales to establish the diagnosis.
What is the etiology of ADHD?
ADHD is multifactorial in origin with genetic, neural, and environmental contributions. There are many studies that suggest variable degrees of genetic associations with ADHD, yet overall, clear and definitive associations are not well defined. Twin and family studies demonstrate high heritability (0.8) and greater risk of developing ADHD in first-degree relatives, especially those where ADHD persists into adolescence and adulthood. Candidate genes include those involving the dopaminergic and noradrenergic neurotransmitter systems. Neuroimaging studies (functional magnetic resonance imaging and positron emission tomography) have shown structural and functional differences, particularly of the frontal lobes, inferior parietal cortex, basal ganglia, corpus callus, and cerebellar vermis. Neuroimaging studies have demonstrated delay in cortical maturation and suggest that the pathophysiological features include large-scale neuronal networks including frontal to parietal cortical connections. Environmental links have been described with prenatal exposure to a variety of substances including nicotine, alcohol, prescription medications, and illicit substances. Environmental exposure to lead, organophosphate pesticides, or polychlorinated biphenyls has also been shown to be a risk factor.
What are complications of ADHD?
ADHD may be associated with academic underachievement, difficulties in interpersonal relationships, and poor self-esteem. These complications may have long-reaching effects including lower levels of educational and employment attainment. Adolescents with ADHD, particularly those who are untreated, are at increased risk for high-risk behaviors. Despite parental concerns of illicit drug use and addiction from stimulant medication, there is actually decreased risk of drug abuse in children and adolescents with ADHD who are appropriately medically managed.
What is ADHD?
Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder characterized by symptoms of inattention, hyperactivity, impulsivity, or a combination of these symptoms. It is typically diagnosed in childhood but frequently has long-term implications, including decreased likelihood of high school and postsecondary graduation as well as poor peer relations.
Which of the following is recognized as a symptom of the predominantly inattentive type of ADHD? A. Fidgeting with or tapping hands or feet B. Often loses things necessary for tasks or activities C. Excessive talking D. Interrupting others
B. Often loses things necessary for tasks or activities
What is the behavioral management for ADHD?
Behavioral therapy is central to children of all ages with ADHD and must be the core of overall treatment. Behavioral management includes establishment of structure, routine, consistency in adult responses to behaviors, and appropriate behavioral goals. Children also benefit when parents and clinicians work with teachers to address the child's needs. Regular behavior report cards and other "check-in" aids may be helpful to the child in their respective environments such as for a classroom and the overall school day.
A mother brings her 6-year-old son to the office for a complete assessment. She states that "there is something very wrong with him." He just sprinkled baby powder all over the house, and last night he opened a bottle of ink and threw it on the floor. He is unable to sit still at school, is easily distracted, has difficulty waiting his turn in games, has difficulty in sustaining attention in play situations, talks all the time, always interrupts others, does not listen when talked to, and is constantly shifting from one activity to another. As you enter the examining room, the child is in the process of destroying it. On examination (what examination you can manage), you discover that there are no physical abnormalities demonstrated. What is the most likely diagnosis in this patient? A. Mental retardation B. Childhood depression C. Attention-deficit/hyperactivity disorder (ADHD) D. Maternal deprivation E. Childhood schizophrenia
C. Attention-deficit/hyperactivity disorder (ADHD) ADHD is characterized by a pattern of behavior, present in multiple settings (e.g., school and home), that can result in performance issues in social, educational, or work settings. As in DSM-V, symptoms will be divided into two categories of inattention and hyperactivity and impulsivity that include behaviors like failure to pay close attention to details, difficulty organizing tasks and activities, excessive talking, fidgeting, or an inability to remain seated in appropriate situations. Children must have at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while older adolescents and adults (over age 17 years) must present with five.
Which of the following is generally accepted as the most effective first-line therapeutic option in children with ADHD? A. Norepinephrine reuptake inhibitors B. Behavioral psychotherapy alone C. Stimulants and cognitive therapy D. Cognitive therapy alone
C. Stimulants and cognitive therapy In children with ADHD, stimulant therapy is more effective than behavioral therapy or regular community care (medication management by primary care provider). This finding has been borne out for the treatment of adults with ADHD as well. Atomoxetine (Strattera®) has become a second-line—and in some cases, first-line—treatment in children and adults with ADHD because of its efficacy and classification as a nonstimulant. However, studies have reported that the overall effect of atomoxetine has not been as extensive as that reported for stimulants. Behavioral psychotherapy is often effective when used in combination with an effective medication regimen. Behavioral therapy or modification programs can help diminish uncertain expectations and increase organization. Metacognitive therapy in adults involves the principles and techniques of cognitive and behavioral therapies to enhance time management. In doing so, these have made adult patients with ADHD better able to counter the anxiety and depressive symptoms they experience in task performance.
What anticipatory guidance should be provided for parents of children with ADHD?
Child-rearing practices, including promoting calm environments and opportunities for age-appropriate activities that require increasing levels of focus, may be helpful in terms of behavioral modifications. Limiting time spent watching television and playing rapid-response video games also may be prudent as these activities may reinforce short attention span. Early implementation of behavior management techniques may assist in curtailing problematic behaviors before they result in significant impairment and can help with the child's self-esteem and school performance concerns. Education of medical professionals and teachers about the signs and symptoms of ADHD and the most appropriate and timing behavioral and pharmaceutical interventions is helpful to the overall management of ADHD. Collaboration between health care providers, educational professionals, mental health clinicians, and families will enhance the early identification of, treatment, and provision of services to children with ADHD.
What are diagnostic criteria for ADHD?
Clinical guidelines emphasize the use of the Diagnostic and Statistical Manual of Mental Health Disorders, fifth edition, with specific criteria to diagnose ADHD. Symptoms must have been present prior to 12 years of age; evidence of significant impairment in social, academic, or work settings must occur; and other mental disorders must be excluded. Changes incorporated into the fifth edition include the age prior to which symptoms must occur (to identify the subset of older children (frequently female) who exhibit predominantly inattentive symptoms and who may not present with significant functional impairment early in childhood), the need for symptoms to occur in at least two settings, and the decrease in number of symptoms to five for adolescents 17 years of age or older.
What comorbidities are associated with ADHD?
Co-morbidities are present in up to 60% of children with ADHD such as anxiety, learning disabilities, language disorders, tic disorders, mood disorders, coordination problems, oppositional defiant disorder, and other conduct disorder. Tourette syndrome and fragile X syndrome, in particular, are known conditions with associated ADHD. It is important to discern if the symptoms are due to the co-morbidities independently or as a co-morbidity with ADHD.
Which of the following is (are) true regarding the prevalence of the disorder? A. Prevalence rates are higher in preschool children than in school-age children B. Affected boys outnumber girls in surveys of school-age children C. Prevalence rates decline as a cohort of children ages into adulthood D. A, B and C E. None of the above
D. A, B and C Some studies suggest that between 14% and 20% of preschool and kindergarten boys and approximately one third as many girls have ADHD. In elementary school studies, 3% to 10% of students have ADHD symptoms. Affected boys outnumber girls until young adulthood, when women predominate.
Which of the following is required for a diagnosis of ADHD? A. Prolonged lethargy lasting at least 3 months B. Presence of a comorbid psychiatric disorder C. Positive findings on brain imaging (such as functional MRI or single-photon emission CT [SPECT]) D. At least six symptoms of inattention or hyperactivity-impulsivity (or both) that have persisted for at least 6 months
D. At least six symptoms of inattention or hyperactivity-impulsivity (or both) that have persisted for at least 6 months The specific criteria for diagnosis require at least six symptoms of inattention or hyperactivity-impulsivity (or both) that have persisted for at least 6 months. In addition, ADHD is specified by the severity based on social or occupational functional impairment: mild (minor impairment), moderate (impairment between "mild" and "severe"), or severe (symptoms in excess of those required to meet diagnosis; marked impairment). Brain imaging, such as functional MRI or SPECT scans, has been useful for research, but no clinical indication exists for these procedures because the diagnosis is clinical.
Who is the person who usually makes this diagnosis? A. The child psychiatrist B. The family physician C. The mother or father D. The schoolteacher E. The grandparents
D. The schoolteacher The most common person to make the diagnosis of ADHD is the schoolteacher. There is considerable controversy concerning the fact that many children who are hyperactive take medication because of the remarks or diagnosis of the schoolteacher. There may be some truth to this statement. Inexperienced or overly critical teachers may in fact confuse normal age-appropriate overactivity with ADHD. However, on the basis of a study by the Centers for Disease Control and Prevention, the rate of parent-reported ADHD among children between the ages of 4 and 17 years is increasing. Between 2003 and 2007, there was a 22% increase in parent reporting from 7.8% to 9.5%.
Which of the following are pharmacologic treatment options in the disorder described? A. Methylphenidate or its derivatives B. Dextroamphetamine or amphetamine derivatives C. Magnesium pemoline D. Modafinil E. A or B
E. A or B The pharmacologic agents of choice for the management of ADHD are the stimulant medications (1) methylphenidate or derivatives and (2) dextroamphetamine or amphetamine derivatives. As many as 96% of children with ADHD have at least some positive behavioral response to stimulants, of which methylphenidate and dextroamphetamine are the two tried and true medications. Both are available in various formulations, including longer acting derivatives. Methylphenidate is available in short-acting (Ritalin), intermediate-acting (Ritalin-SR), and long-acting (Concerta) preparations. Dextroamphetamine is also available as short-acting (6 to 8 hours; Dexedrine and Adderall) and long-acting (Dexedrine spansules and Adderall XR) formulations. Unfortunately, side effects may limit efficacy or require discontinuation of medication in some children. Lower weight-adjusted doses may be required for both preschool children and adolescents than for school-age children, with a greater likelihood of side effects and somewhat lower therapeutic efficacy. Pemoline was removed from the market because of liver toxicity and should not be used. Atomoxetine, an inhibitor of presynaptic norepinephrine, is also less effective than stimulants but is an option for some patients.
The differential diagnosis of this disorder includes which of the following? A. Adjustment disorder B. Bipolar disorder C. Anxiety disorder D. Childhood schizophrenia E. A, B and C
E. A, B and C The differential diagnosis of ADHD includes the following: (1) adjustment disorder (an identifiable stressor is identified at home and the duration of symptoms is less than 6 months); (2) anxiety disorder (instead of or in addition to the diagnosis of ADHD); (3) bipolar disorder (bipolar disorder in children may be manifested as a chronic mixed affective state marked by irritability, overactivity, and difficulty concentrating); (4) mental retardation; (5) a specific developmental disorder; (6) drugs (phenobarbital prescribed for children as an anticonvulsant and theophylline prescribed for asthma); (7) systemic disorders (hyperthyroidism); and (8) other disruptive behavioral disorders, including oppositional defiant disorder (ODD) and conduct disorder. The differential diagnosis of ADHD does not include childhood schizophrenia.
Which of the following is (are) associated with the disorder described? A. Feelings of low self-esteem B. Feelings of depression C. Impaired interpersonal relationships D. A reduction in life successes E. All of the above
E. All of the above Commonly associated features of ADHD are low self-esteem, feelings of depression, feelings of demoralization, and lack of ability to take responsibility for one's actions. In social situations, these young children are immature, bossy, intrusive, loud, uncooperative, out of synchrony with situational expectations, and irritating to both adults and peers. Children with ADHD are more likely to sustain severe injuries than are those without ADHD.
When are laboratory and imaging studies useful in the diagnosis of ADHD?
Laboratory and imaging studies should be considered with the aim to exclude other conditions. Consider thyroid function studies, blood lead levels, genetic studies, anemia screening, and brain imaging studies if clearly indicated by medical history, environmental history, or physical examination.
How is ADHD managed?
Management begins with recognizing ADHD as a chronic condition and educating affected children and their parents about the diagnosis, treatment options, and prognosis. With appropriate management, including behavioral and academic interventions in conjunction with medication, up to 80% of children have significant response to treatment. Anticipatory guidance is important and includes providing proactive strategies to mediate adverse effects on learning, school functioning, social relationships, family life, and self-esteem.
How does ADHD present clinically?
Many of the symptoms of ADHD mimic typical findings of normal development; thus it is important to consider whether the child's symptoms are out of proportion to what would be expected for stage of development. Symptoms of inattention (e.g. failing to pay close attention to details, appearing to not listen when spoken to directly), hyperactivity (e.g. being fidgety or restless, leaving a seat when expected to remain seated), or impulsivity (e.g. blurting out answers before a question has been completed) may indicate a diagnosis of ADHD.
What are adverse effects of medications for ADHD?
Medication side effects are common, occurring in about one third of patients and severe enough to indicate changing or discontinuing the medication in 15% of patients. The most common side effects include appetite suppression and sleep disturbance with stimulant medications, gastrointestinal tract symptoms with atomoxetine, and sedation with α-agonists. Side effects must be assessed while children are undergoing treatment, including careful monitoring of the child's height and weight at regular follow-up appointments. In general, providers should titrate medication dosages and timing to minimize side effects and optimize treatment response. Screening for cardiac disease by history, family history, and physical exam, as well as monitoring the cardiac status of children on stimulant medication is prudent.
What are first-line medications for ADHD?
Stimulant medications (methylphenidate or amphetamine compounds) are the first-line agents for pharmacologic treatment of ADHD due to extensive evidence of efficacy and safety. Short-term studies have shown a significant clinical benefit of stimulant medications in reducing inattention, hyperactivity, and impulsivity. Stimulant medications are available in short-acting, intermediate-acting, and long-acting forms. Sustained and long-acting forms are often preferred, yet there are no definitive studies to establish the benefit of long-acting stimulants over short-acting stimulant medication. Preparations include liquid, chewables, tablets, capsules, and a transdermal patch, allowing the clinician to tailor the choice of medication to the child's needs. While stimulants have been shown to provide some benefit in short-term studies in preschool-aged children, behavioral management is still considered the standard of care for this age group.
According to the DSM-5, symptoms of attention-deficit hyperactivity disorder must be present before what age?
The DSM-V describes criteria for ADHD that must be present before the age of 12 years old. This is a change from age 7, as was in the DSMIV-TR.
What differential diagnoses should be considered when evaluating a patient for ADHD?
The differential diagnosis can be challenging given that co-morbidities of ADHD overlap and intertwine with the differential diagnoses. The diagnostic process should evaluate for other conditions such as sleep disorders, seizure disorders, substance use, hyperthyroidism, lead intoxication, sensory processing issues, and vision or auditory deficits as possible causes for a child's hyperactivity and distractibility. Inattention and hyperactivity may be present as features of genetic disorders such as fragile X, 22q11.2 deletion syndrome, and neurofibromatosis 1. Psychological stress (e.g., bullying, abuse) and disruptive surroundings can also lead to symptoms of hyperactivity, impulsivity, and inattention and mimic indeed the symptoms of ADHD. Children who have symptoms of ADHD in only one setting may be having problems due to cognitive disability, level of emotional maturity, or feelings of inadequate well-being in that setting. Overall, it is prudent to investigate and ensure overall well-being including sleep and nutritional hygiene before embarking on an extensive evaluation of ADHD.
What is the educational management for ADHD?
The pediatrician should advocate for optimal educational settings in the school. Children may qualify for individual education plans where school psychologists can establish organizational plans and charts for the individual child as part of a management plan. Social skills training or additional mental health interventions may assist some children with behavior change or preservation of self-esteem, particularly when they have coexisting developmental or mental health conditions also requiring treatment.
What is the epidemiology of ADHD?
US prevalence rates for ADHD vary depending on criteria used and population studied, with approximately 11% of US children diagnosed with ADHD today. The male to female ratio is 2-6:1, with greater male predominance for the hyperactive/impulse and combined types. Girls often present with inattentive symptoms and are more likely to be underdiagnosed or to receive later diagnoses. Symptoms of ADHD, particularly impulsivity and inattention, frequently persist past childhood, with up to 80% of those affected having symptoms into adolescence, and 40% into adulthood.
