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Attention-Deficit/Hyperactivity Disorder

Anna Maria Wilms Floet, Cathy Scheiner and Linda Grossman


Pediatr. Rev. 2010;31;56-69
DOI: 10.1542/pir.31-2-56

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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Article behavioral & mental health

Attention-Deficit/Hyperactivity Disorder
Anna Maria Wilms Floet, Introduction
MD,* Cathy Scheiner, MD,† Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiologic disorder
Linda Grossman, MD § characterized by developmentally inappropriate levels of inattention, hyperactivity, and
impulsivity. ADHD also is one of the most prevalent chronic health conditions affecting
school-age children. Consequently, physicians frequently are asked to evaluate children for
Author Disclosure a possible diagnosis of ADHD. The importance of an appropriate and timely diagnosis is
based on the knowledge that children who have ADHD may experience difficulty in social,
Drs Wilms Floet,
emotional, and academic domains and that treatment can improve outcomes for these
Scheiner, and
children.
Grossman have
disclosed no financial Prevalence
relationships relevant ADHD is a behavioral disorder, making it difficult to quantify. Epidemiologic studies
to this article. This indicate that at least 3% of children in the United States are affected by ADHD, with usual
quoted rates of 5% and 8%. (1) Prevalence rates for ADHD vary, depending on the patient
commentary does not
sample, geography, and diagnostic criteria (Table 1). The diagnosis is reported 2.5 times
contain a discussion
more frequently in boys than in girls, with 9.2% of males and 2.9% of females found to have
of an unapproved/ behaviors that are consistent with ADHD. ADHD is considered a lifelong condition.
investigative use of a Among adolescents who receive ADHD diagnoses as children, 60% to 80% continue to
commercial product/ meet criteria for ADHD during their teenage years and adulthood.
device. Prevalence rates for ADHD vary by age. Studies indicate that school-age children are
more likely to be diagnosed compared with preschool-age children and adolescents.
Approximately 50% of children who receive the diagnosis are treated with medication.
According to a 2003 National Survey of Children’s Health, 56.3% of children who had
reported ADHD were being treated with medication at the time of the survey, and
school-age children were most likely to be receiving medication for ADHD. (2)
Studies have not demonstrated a consistent association among ADHD prevalence and
race, ethnicity, or socioeconomic status. However, environmental and biologic factors may
increase the risk of ADHD. Environmental factors include early lead exposure and prenatal
exposure to cigarette smoking and alcohol. Biologic factors such as low birthweight,
prematurity, and intrauterine growth restriction also increase the risk for ADHD.

Causes
Research in the fields of neurobiology, genetics, and neuropsychology support a biologic
basis for ADHD. Many studies show an association between ADHD and biologic systems
that are believed to control attention and regulate inhibition. However, no single cause of
ADHD has been identified
Neuroimaging studies have shown structural and functional differences in areas of the
brains in patients who have ADHD compared with patients who have no ADHD. Certain
regions of the brain, rich in dopaminergic and noradrenergic pathways and associated with
executive function, seem to be particularly affected, including the prefrontal cortex,
striatum, and cerebellum. Functional magnetic resonance imaging (MRI) studies suggest
that these particular regions of the brain are less activated in children who have ADHD
compared with those of age-matched controls during activities that measure executive
function, a cognitive process of the frontal lobe that is used to solve problems or achieve a
goal. Other studies, using brain MRI, have found reductions in prefrontal, frontal, and
hemispheric volumes in individuals who have ADHD compared with controls. The clinical
significance of these differences is not clear.

*Kennedy Krieger Institute, Center for Development and Learning, Center for Autism and Related Disorders, Baltimore, Md.

Children’s National Medical Center, Washington, DC.
§
Baltimore County Department of Health, Baltimore, Md.

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behavioral & mental health attention-deficit/hyperactivity disorder

Table 1. Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder


A. Either 1 or 2
1. Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level
Inattention
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. Often has difficulty sustaining attention in tasks or play activities
3. Often does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not
due to oppositional behavior or failure to understand instructions)
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or
homework)
7. Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, tools)
8. Often is easily distracted by extraneous stimuli
9. Often is forgetful in daily activities
2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree
that is maladaptive and inconsistent with developmental level
Hyperactivity
1. Often fidgets with hands or feet or squirms in seat
2. Often leaves seat in classroom or in other situations in which remaining seated is expected
3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be
limited to subjective feelings of restlessness)
4. Often has difficulty quietly playing or engaging in leisure activities
5. Often is “on the go” or acts as if “driven by a motor”
6. Often talks excessively
Impulsivity
7. Often blurts out answers before the questions have been completed
8. Often has difficulty awaiting turn
9. Often interrupts or intrudes on others (eg, butts into conversations or games)
B. Some hyperactive-impulsive symptoms or inattentive symptoms that caused impairment were present before 7 years of
age
C. Some impairment from the symptoms is present in two or more settings (eg, at school or at home)
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other
psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder,
dissociative disorder, or personality disorder)
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (DSM IV). Copyright 1994, American Psychiatric
Association.

Several studies support the hypothesis that ADHD is logical tests, such as continuous performance testing,
associated with deficits in executive functioning. Studies should not be used alone to diagnose ADHD. (3)
based on results from neuropsychological tests of execu- Genetic studies suggest that ADHD is an inherited
tive function in children who have ADHD showed that disorder. ADHD is more likely if a parent or sibling has
these children performed poorly compared with age- been diagnosed with the disorder. This conclusion is
matched controls on specific tasks. Although these re- supported by the high concordance for ADHD in iden-
sults improve understanding of the cognitive problems tical twins as well as by family studies. Multiple genes
that some children who have ADHD may face, the contribute to the ADHD phenotype, including those
results do not provide adequate evidence to conclude related to monoaminergic (dopaminergic, serotonergic,
that problems with executive function are specific to and noradrenergic) neurotransmission. These genes in-
ADHD. However, executive function deficits may be a clude dopamine receptor genes (DRD4 and DRD5) and
comorbid problem among children who have ADHD. a dopamine transporter gene (DAT1). The basis for these
Tests of executive function, such as set shifting, working studies emerged from evidence indicating that these
memory, or processing speed, and other neuropsycho- neurotransmitters are involved in the modulation of at-

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behavioral & mental health attention-deficit/hyperactivity disorder

tention and behavioral regulation in the frontal cortex. of ADHD, behavior problems or academic difficulties.”
Despite the increased prevalence in male children, no In addition, the guideline specifies that:
study has shown that ADHD is attributable to an 1. The child’s symptoms meet the DSM IV criteria for
X-linked effect. ADHD.
2. Information be collected from the parents or care-
Defining ADHD givers regarding the core symptoms of ADHD, the age of
ADHD is defined as a mental health disorder in the onset, the duration of symptoms, and the degree of
Diagnostic and Statistical Manual 4th Edition (DSM functional impairment.
IV). (4) Over the years, the diagnostic criteria have been 3. Information be obtained from another source such
revised as clinical impressions of what constitutes this as the classroom teacher regarding the core symptoms of
disorder have shifted. The most current definition of ADHD, the duration of symptoms, and the degree of
ADHD is listed under DSM IV criteria as “a persistent impairment.
pattern of inattention and/or hyperactivity-impulsivity 4. An assessment of potential coexisting conditions,
that is more frequent and severe than is typically observed such as mood disorders or learning disabilities, be per-
in individuals of comparable levels of development.” The formed.
DSM IV criteria were developed by a committee and
were based on a review of the literature and an analysis of Initiating an Evaluation
field trials to determine whether the symptoms of The initial evaluation for suspected ADHD may be
ADHD had diagnostic utility. This effort led to the prompted by a variety of clinical circumstances. A clini-
development of the two broad categories of symptoms cian may become concerned about ADHD during a
(inattention and hyperactivity/impulsivity) and the dis- routine health supervision visit after screening for behav-
tinction of three subtypes of ADHD (predominantly ior and emotional problems. More frequently, parents,
inattentive, predominantly hyperactive/impulsive, and teachers, caregivers, or other professionals may raise con-
combined type) (Table 1). To meet criteria for the cerns independent of any health-care screening effort.
predominantly inattentive subtype, the child must ex- For example, parents may be concerned about their
hibit six of nine symptoms from A1. To meet criteria for child’s declining academic performance, relationship dif-
the predominantly hyperactive subtype, the child must ficulties with peers or family members, or symptoms of
exhibit six of nine symptoms from category A2. To meet emotional problems.
criteria for the combined type, the child must exhibit six Once a concern is identified, an initial screening be-
of nine symptoms from both categories. gins by obtaining a description of the child’s behavior
and its impact on his or her ability to function in school,
Diagnosing ADHD at home, and with peers. During the screening process, it
Overview should be determined if evidence is sufficient to proceed
ADHD is a behavioral disorder. Diagnosis requires a with an additional evaluation for ADHD. Useful ques-
comprehensive clinical evaluation based on identifying tions at this point should address the child’s academic
children who have the core symptoms of inattention, performance, homework completion, behavioral or
hyperactivity, and impulsivity and whose behavior is suf- mood problems, and peer relationships.
ficiently severe and persistent to cause functional impair- While gathering information, the clinician should be
ment. No single test is available to establish the diagno- aware that the presenting symptoms of ADHD vary with
sis. Although many children may be inattentive, the age and developmental level of the child. For exam-
hyperactive, or impulsive, the level of severity and degree ple, during the preschool years, many children are inat-
of functional impairment, as well as considerations of tentive, hyperactive, or impulsive. It may be difficult to
what else might be causing the symptoms, determine distinguish age-appropriate levels of physical activity and
which children meet the diagnosis and are treated for short attention span from those activity levels and atten-
ADHD. tion spans in children who have ADHD. Although the
To assist clinicians with the accurate identification of AAP guideline does not include specific recommenda-
children who have ADHD, the American Academy of tions regarding the diagnosis of ADHD in this popula-
Pediatrics (AAP) published a clinical practice guideline in tion, studies show that preschool-age children may have
2000. (5) This guideline specifically urges primary care significant attention or behavioral problems consistent
physicians to initiate an evaluation for ADHD in “any with a diagnosis of ADHD. However, among preschool-
child, ages 6 to 12, who presents with the core symptoms age children who receive the diagnosis of ADHD, fewer

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behavioral & mental health attention-deficit/hyperactivity disorder

than 50% continue to have the diagnosis during child- and Statistical Manual for Primary Care (DSM-PC) (6)
hood. The degree, duration, and pervasiveness of to document the child’s behavior in the medical record
ADHD symptoms help to distinguish those children and to develop an intervention plan.
who are most likely to develop a persistent pattern of The medical record should contain specific descrip-
behavior that is consistent with ADHD. tions of the child’s symptoms and not simply state that
As children enter elementary school, activity levels the child is inattentive, hyperactive, or impulsive. For
decline and children are expected to sustain attention for example, the description of a hyperactive middle school
longer periods of time, to complete tasks independently, child may indicate that the child leaves his seat during
and to work cooperatively with their peers. At this age, class, runs out of the classroom, fidgets endlessly, or has
children typically are able to focus for longer periods of difficulty sitting still during any activity that requires
concentration.
time but may be impulsive at times. Teachers and parents
Because the DSM-IV symptoms were not selected
of children who have underlying ADHD may express
scientifically and because there is substantial overlap
concerns about the child’s safety or his or her ability to
among the symptoms, it is harder to establish a rating
remain focused in class or to follow school routines.
scale or a scientific scoring to determine whether a spe-
During adolescence, demands are greater for organi-
cific child has ADHD. Therefore, ADHD-specific rating
zational skills, time management, and the mastering of scales are not diagnostic. However, they may be used to
large amounts of material. Some adolescents who have gather information about the child’s behaviors from the
ADHD, especially the predominately inattentive type, parent, teacher, or both. In general, these rating scales
may not receive a diagnosis until middle school or high assess the core symptoms of ADHD, as specified in the
school. If there are not signs of significant impairment in DSM IV, and they are relatively easy to administer (Table
functioning, a diagnosis of ADHD cannot be made. 2). The strength of the rating scales lies in their link to
However, a diagnosis of ADHD still should be consid- DSM IV symptoms. Rating scales probably are most
ered if an undiagnosed adolescent manifesting previous useful in documenting whether the rater sees the core
symptoms becomes more disruptive in class, exhibits symptoms as being present for a specific child compared
increased academic problems, engages in increased risk- with his or her same-age peers. Broad-band rating scales
taking behavior, or becomes oppositional as the aca- that are not ADHD-specific have not been shown to
demic and maturational challenges increase. provide sufficient evidence to support their use in the
assessment of ADHD. (5)(16)
When choosing a rating scale, it is important to realize
Confirming the Symptoms their limitations. Two different clinical situations illus-
If the history indicates that a child’s behavior is contrib- trate this problem. First, although most of the ADHD-
uting to significant impairment in more than one setting, specific rating scales demonstrate good concurrent valid-
the clinician may proceed with the diagnostic process. ity with other established instruments that are used to
Specific information about the child’s symptoms to de- measure similar behaviors, they may not be good mea-
termine if they meet DSM IV criteria for ADHD must be sures of developmental variations in the expression of
obtained and whether another cause might better explain ADHD. Second, when a child’s behaviors do not con-
form to DSM IV criteria, such as ADHD complicated by
the symptoms must be determined. Both the parent and
oppositional behaviors, the diagnosis may be missed if
child should be interviewed to determine information
the clinician only uses the DSM IV criteria to establish a
about the child’s behavior as well as the onset, duration,
diagnosis of ADHD.
and severity of symptoms and the context in which the
The clinician also should recognize that ADHD-
symptoms occur. For example, the clinician may inquire
specific rating scales differ in their normative data. For
about the child’s behavior in various situations: complet- example, normative data for the Connors Scales and the
ing homework assignments and long-term school Attention Deficit Disorder Evaluation Scale (ADDES-
projects, getting ready for school in the morning, relat- 3) were formulated based on discrete age ranges (eg,
ing to peers, sitting in class, or following instructions. In comparing ages 3 to 5, 6 to 8); other scales, such as the
cases where the presenting symptoms of inattention, ADHD-Symptoms Rating Scale (ADHD-SRS), estab-
hyperactivity, or impulsivity do not meet criteria for lished normative data based on broader age ranges (eg,
ADHD but warrant additional behavioral interventions 5 to 12 years, 13 to 18 years). Only the Connors Scales
or parent education, the clinician can use the Diagnostic have normative data for preschool-age children. Norma-

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behavioral & mental health attention-deficit/hyperactivity disorder

tive data also may differ by race, sex, and geographic area. Differential Diagnosis and Coexisting
Therefore, when using a rating scale, it may be difficult to Conditions
interpret the results if the clinician’s particular patient The evaluation of a child for ADHD should include
sample is not represented in the scale’s normative data. careful consideration of other possible explanations for
Rating scales also may be used to measure behavioral the symptoms as well as an assessment of possible coex-
changes that occur over time or in response to treatment. isting conditions and disorders (Table 3). It is important
However, few studies have been published that describe to consider whether family stressors (including domestic
their diagnostic utility in this context. When using a violence), lack of sleep (from organic disorders such as
rating scale for these purposes, it is best to select one that sleep apnea or nonorganic conditions such as poor sleep
has sufficient test-retest reliability and good sensitivity to hygiene), sensory impairments, a seizure disorder, inap-
treatment effects. propriate school placement, or unrealistic expectations is
Many of the ADHD rating scales also provide screen- the cause of the symptoms. In addition, psychiatric dis-
ing questions for comorbid conditions. In many cases, orders such as autism, anxiety problems, mood disorders,
the validity and psychometric properties of these sub- specific learning disabilities, or intellectual disability may
scales have not been determined. present with symptoms that mimic ADHD. Skillful in-
In summary, ADHD-specific rating scales are useful terviewing may help determine whether another disorder
but must be interpreted within the clinical context of the is the sole explanation for the symptoms or represents a
child being evaluated. Rating scales should be used to coexisting disorder.
supplement information obtained from a clinical history Studies show that as many as 67% of children who
as well as to assess the functional consequences of the have ADHD may have a coexisting condition such as a
behaviors. Despite the benefits of using rating scales, psychiatric problem, learning disorder, or social immatu-
their scores alone do not establish a diagnosis. Clinical rity. The more common comorbid psychiatric conditions
judgment is needed to integrate the results of these scales that have been described include oppositional defiant
into the clinical assessment. disorder (prevalence of 35%), conduct disorder (preva-

Table 2. Attention-Deficit/Hyperactivity Disorder-specific Rating Scales


Scale Normative Data (ages) Benefits Limitations
Conners-3 6 to 18 years Adolescent self-report Multiple versions available;
Conners-EC (Early Childhood) 2 to 6 years available may be confusing
Conners (7,8)
Swanson, Nolan, and Pelham IV 5 to 11 years Scoring available on the Limited normative data
Questionnaire (SNAP IV) Internet
Swanson 1992 (9)
ADHD Rating Scale IV (ADHD RS IV) 5 to 18 years Only asks about DSM-IV
DuPaul et al 1998 (10) ADHD symptoms
Vanderbilt ADHD Rating Scale (VARS) Elementary school Includes rating of No normative data on
Wolraich 2003 (11) impairment; asks adolescents
about comorbid
symptoms
ADHD Symptoms Rating Scale 5 to 18 years Lengthy
(ADHD-SRS)
Holland et al 2001 (12)
Attention Deficit Disorder 4 to 18 years Lengthy
Evaluation Scale-3rd Edition
(ADDES-3)
McCarney 2004 (13)(14)
ACTeRS-2nd Edition Kindergarten to 8th grade Adolescent self-report Normative data on parent
Ullman et al 2000 (15) for teacher version available and adolescent version
not published
Each scale has a parent and teacher version except the SNAP IV.

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behavioral & mental health attention-deficit/hyperactivity disorder

disorder. Because most children who have ADHD expe-


Coexisting Disorders and
Table 3. rience academic underachievement, it is important to
distinguish whether a learning disability also is present.
Differential Diagnosis of The patient’s history may provide clues to the underlying
Attention-Deficit/ reasons for academic problems. For example, if a child’s
Hyperactivity Disorder ADHD symptoms are more likely to occur during a
particular activity or setting, a learning disorder may be
Developmental Disorders present. Psychological testing combined with achieve-
Language disorder ment testing may help to identify a learning disorder.
Learning disability Learning problems are more likely to occur in children
Intellectual disability who have the predominantly inattentive or combined
Autism spectrum disorders subtypes of ADHD.
Developmental coordination disorder
The differential diagnosis of ADHD also includes
Medical Disorders medical conditions, genetic disorders, neurologic disor-
Lead intoxication ders, and developmental disorders that may contribute to
Anemia a child’s symptoms of inattention, impulsivity, or hyper-
Medication adverse effects activity. Although the DSM IV criteria for ADHD spe-
Seizure disorder cifically exclude developmental disorders such as intellec-
Substance abuse
Sensory deficits tual disability and pervasive developmental disorders
Prematurity such as autism, children who have these disorders may
Fetal alcohol syndrome present with symptoms of inattention, hyperactivity, or
Tourette syndrome impulsivity that are consistent with ADHD and treatable
Sleep apnea according to accepted standards for ADHD treatment.
Genetic Disorders
Klinefelter syndrome Treatment
Fragile X syndrome In 2001, after extensive review of the scientific literature,
Turner syndrome the AAP published an evidence-based clinical practice
22q11.2 deletion syndrome guideline for the treatment of the school-age child who
Williams syndrome
Neurofibromatosis I has ADHD. (17) A key study considered in developing
Inborn errors of metabolism this guideline was the National Institute of Mental
Health Collaborative multi-site multimodal treatment
Psychiatric Disorders
study of children with attention deficit/hyperactivity
Adjustment disorder disorder (MTA study). (18) In the MTA study, children
Anxiety disorder
Attachment disorder were randomized to four groups: medication treatment
Mood disorder alone (these children also had monthly 30-minute
Oppositional defiant disorder follow-up appointments, during which some brief coun-
Posttraumatic stress disorder seling was included), intensive behavioral treatment
Adapted from Lock TM, Worley KA, Wolraich ML. Attention deficit/ alone, a combination of medication management and
hyperactivity disorder. In: Wolraich ML, Drotar DD, Dworkin PH, behavioral treatment, and community treatment as the
Perrin EC, eds. Developmental-Behavioral Pediatrics: Evidence and
Practice. Philadelphia, Pa: Mosby, Inc; 2008: 579 – 601. control group.
The MTA study showed that pharmacologic interven-
tion for ADHD was more effective than behavioral treat-
lence of 30%), anxiety disorder (prevalence of 25%), and ment alone. Combination treatment was no better than
mood disorder (prevalence of ⬃18%). (4) These coexist- medication alone, except when the children studied also
ing conditions also need to be addressed. Although some had a comorbid anxiety or oppositional defiant disorder.
of these coexisting conditions may improve as the When those comorbid conditions were present, combi-
ADHD is treated, most require separate intervention. nation treatment was more effective than medication
Depending on the specific definition and treatment alone. Satisfaction with treatment reported by teachers
setting, 12% to 60% of children who have ADHD may and parents was highest in the combination treatment
have a coexisting learning or language problem. The group.
most common learning disorder is a written language The AAP guideline includes five recommendations

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behavioral & mental health attention-deficit/hyperactivity disorder

regarding treatment of ADHD: 1) Approach and treat accommodations, explain the process of requesting and
ADHD as a chronic health condition, 2) Collaborate implementing a 504 plan, and make suggestions regard-
with partners in designing and evaluating treatment ing the specific accommodations
plans and outcomes, 3) Provide medication manage- When children diagnosed as having ADHD need
ment, 4) Provide periodic systematic follow-up, and special education services for a comorbid learning dis-
5) Evaluate treatment failure as needed. ability or because of the functional impact of their
ADHD symptoms, parents may request an Individual-
Treat ADHD as a Chronic Health Condition ized Education Plan (IEP) according to the provisions of
The 2001 AAP practice guideline emphasizes that the Individuals with Disabilities Education Act (IDEA).
ADHD is a chronic health condition. This chronic care An IEP also may include counseling and a behavior
model, originally designed for adults, was adapted for use management program. A yearly review of treatment
in children by the National Initiative for Children’s goals and the child’s progress is mandatory under IDEA.
Healthcare Quality. This model emphasizes ongoing A clinician may participate in this process by making
parental and child education about ADHD and its treat- recommendations regarding these goals and treatments
ments. The treatment of ADHD as a chronic care con- (Table 4).
dition involves engaging the family, the child, and pro- The use of a daily report card provides parents and
fessionals in the schools (teachers, nurses, psychologists, teachers with a communication tool that records a child’s
counselors) in the assessment and long-term treatment progress in achieving treatment goals and provides op-
of this disorder. portunities for rewards and consequences.

Collaborate With Partners Regarding Medication Management


Treatment Goals For most children, stimulant medication is highly effec-
The primary goal of ADHD treatment is to maximize the tive in treating the core symptoms of ADHD. Therefore,
child’s functioning in the home and school. The clini- initiation of medication often is recommended in the
cian’s role is to design and implement an individual treatment for school-age children who have ADHD.
treatment plan for the child in partnership with the family General guidelines for medication management include:
that sets treatment goals and priorities. The clinician also 1. Initiate treatment with a stimulant medication from
collaborates with the educational system to address the the amphetamine or methylphenidate group. If one
child’s symptoms and monitor the response to medica- stimulant group does not work, switch to the other.
tion within the school. The process of developing target 2. Dosing of stimulant medication is not weight-
outcomes requires input from the parents, teachers, and dependent. Start with a low dose and titrate until ADHD
other professionals involved with the child. symptoms are manageable, maximum dose is reached, or
Although some children who have ADHD respond to adverse effects prevent additional titration. Generally,
medication intervention and no longer need special ac- the relationship between dose and clinical response is
commodations at school, others may need significant
support to participate fully in their educational programs.
Thus, school-based interventions become an integral
aspect of behavioral treatment and educational support
Table 4. Examples of Treatment
for children who have ADHD. Goals
The Rehabilitation Act of 1973 provides the legal
basis for school-based accommodations once a disability ● Improve academic performance: work completion,
accuracy, efficiency
such as ADHD is identified. According to Section 504 of
● Improve independence in self-care and school work
the Rehabilitation Act, parents may request accommoda- ● Improve relationships with parents, siblings, peers,
tions within the regular classroom based on the child’s and teachers
individual needs. Examples of accommodations include ● Decrease frequency of disruptive behavior
preferential seating, modified assignments and home- ● Improve self-control
● Improve self-esteem
work load (such as dividing longer assignments into
● Improve safety in the community; reduce
shorter manageable parts), use of visual cues and remind- inappropriate risk-taking behavior
ers to help children stay on task, and frequent motor
Adapted from AAP Clinical Practice Guideline. Treatment of the
breaks from the classroom routine. The clinician may school-aged child with ADHD. Pediatrics. 2001;108:1033–1044.
help parents understand the value of these educational

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linear, with a greater reduction in symptoms achieved at be longer, especially with methylphenidate hydrochlo-
higher doses of stimulant medication. ride or with methylphenidate transdermal. Stimulant
3. Initiation of treatment with an extended-release medications are classified as category II controlled sub-
preparation of medication often is preferred, especially stances because they have the potential for abuse or
for older children who need medication coverage for dependence. However, multiple studies indicate that
extended periods of time (there is no need to start with children taking stimulants to treat ADHD do not de-
short-acting medications). velop dependence or signs of addiction, they do not need
4. Use of parent and teacher ADHD rating scales is escalating doses beyond that expected from their growth,
helpful during the titration phase and periodically there- and they do not suffer withdrawal symptoms when they
after to determine response to medication and to moni- stop taking their stimulant medications. Multiple studies
tor adverse effects. of children taking stimulants to treat their ADHD also
5. At each visit, monitor for growth impairment by suggest that taking such medications decreases, rather
measuring height and weight; monitor for potential car- than increases, the child’s risk for addiction to illicit
diac effects of the medication (such as elevated blood drugs.
pressure or tachycardia) by measuring blood pressure Children who have ADHD and are treated with stim-
and pulse. ulants show improvement in attention to task and de-
6. A 1-month follow-up visit is recommended after crease in impulsivity and hyperactivity. Stimulants also
starting the medication. Additional follow-up visits are may improve parent-child interactions, reduce aggressive
based on treatment response but should occur at least behavior, and improve a child’s academic productivity
twice a year. Treatment of ADHD should continue as and accuracy. The effect on academic performance is less
long as symptoms remain present and cause impairment. strong.
7. If a child who has ADHD shows full remission of Stimulants generally are well tolerated. However, ap-
symptoms and normative functioning, behavior therapy propriate medication management requires interviewing
may not need to be added to the regimen. both the parent and child regarding possible adverse
8. Additional laboratory investigation or electrocardi- effects. The most common adverse effects of stimulants
ography is not recommended unless clinically indicated. are decreased appetite, abdominal pain, headaches, irri-
(19) tability, and sleep problems. Gastrointestinal effects and
headaches may be lessened if the medication is taken with
First-line Agents: Stimulant Medications food. Less common adverse effects include weight loss,
Stimulant medications are considered the first line of “rebound” effects, tics, social withdrawal, and affective
treatment for ADHD because they are highly efficacious changes. Rebound refers to temporary worsening of
in reducing symptoms. More than 80% of children who symptoms (irritability, increased activity, or mood
have ADHD respond to stimulants (although a few swings) when the medication wears off. Administering a
medication trials may be needed before finding the agent low dose of an immediate-release (short-acting) stimu-
that elicits the best response). Two categories of stimu- lant at this time may be helpful. Social withdrawal, leth-
lants are available: methylphenidate and amphetamine argy, or restricted affect may be a result of overdosing.
compounds. Studies indicate that each of these groups of Rare adverse effects include psychotic behavior that may
stimulants has equal efficacy. Their primary mode of present as hallucinations or mania.
action is to enhance central nervous system catechol- Tics are reported with varying frequency after the start
amine action, probably by increasing the availability of of stimulant medication. Stimulant medication may
dopamine and norepinephrine at the synaptic cleft level lower the threshold for the development of tics, but such
in the frontal cortical-striatal circuits that regulate atten- medications are not believed to “cause” tics. The pres-
tion, arousal, and impulse control. When converting ence of tics is not a contraindication to stimulant use.
between dextroamphetamine and methylphenidate The decision to modify drug treatment based on the
products, the equivalent dose of a dextroamphetamine presence or development of tics should be individualized
product generally is half that of a methylphenidate prod- for each patient. The clinician and the family may con-
uct (except for dexmethylphenidate, which has the same sider factors such as the improvement in symptoms ver-
dose). sus the impairment caused by the tics when trying to
Both categories of stimulant medications are available make such a decision.
as short-, intermediate-, and long-acting formulations. The effect of stimulants on long-term growth contin-
The onset of action usually is within 30 minutes but may ues to be studied. Short-term use of stimulants (studies

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behavioral & mental health attention-deficit/hyperactivity disorder

evaluating up to 3 years of treatment) can cause a tran- Most common adverse effects of atomoxetine include
sient lag in growth, with most growth deficits occurring decreased appetite, abdominal pain, nausea, and somno-
in the first year. Fewer data are available concerning lence. Among the less common adverse effects are head-
long-term treatment and its impact on final adult height aches, fatigue, dyspepsia, vomiting, and diarrhea. Rare
with long-term stimulant use. (20) cases of hepatitis (reversible) have been related to this
Recent attention has focused on the risk of sudden medication. Some studies show that tics are less likely to
cardiac death in pediatric patients who are treated with develop with atomoxetine treatment. In 2005, a “black
stimulant drugs. After careful consideration of the avail- box” warning was added regarding an increased risk for
able data, the AAP published a policy statement in 2008 suicidal ideation or suicidal behavior, similar to that
regarding cardiovascular monitoring and stimulant drugs found with selective serotonin reuptake inhibitors.
for ADHD. (19) The statement recommends assessing FDA-approved medications for treating ADHD are
all children, including those in whom stimulant medica- listed in Table 5. Contraindications to medications for
tion is being considered, using a targeted cardiac history treating ADHD are listed in Table 6. Patient medication
(patient history of previously detected cardiovascular guidelines, required by the FDA in 2006 and published
disease, palpitations, syncope, or seizures; family history by the individual drug manufacturers, can be accessed on
of sudden death in children or young adults; hypertro- the FDA Center for Drug Evaluation and Research web
phic cardiomyopathy, long QT syndrome) and a physical page. (21) These guides inform parents about possible
examination (including a cardiac examination). Routine cardiovascular risks, psychiatric effects, and contraindica-
electrocardiography is not indicated before starting a tions of the medications.
child on stimulant medication. Special caution is recom- Second-line agents not approved by the FDA may be
mended before using stimulant medications in children used to treat ADHD. These medications include antide-
or adolescents who have pre-existing cardiovascular dis- pressants (tricyclic antidepressants, bupropion) and
ease or symptoms suggesting cardiovascular disease. In alpha-2-adrenergic agonists (clonidine, guanfacine).
these cases, consultation with a pediatric cardiologist is A review of these medications is beyond the scope of this
recommended. article.
All children who are prescribed stimulant medications
require regular monitoring of pulse and blood pressure.
Small elevations in pulse or blood pressure may not be Nonpharmacologic Interventions
clinically significant. If significant elevations occur, eval- Behavioral Therapy
uation for an underlying medical problem should be Behavioral interventions (Table 7) are directed at manip-
initiated. ulating the physical and social environment to modify
behavior. These interventions can be used in the home
Second-line Agents: Nonstimulant and school. Behavior therapy may be recommended as an
Medications initial treatment when ADHD symptoms are mild and
Atomoxetine is considered a second-line drug for the cause minimal impairment, when the diagnosis is uncer-
treatment of ADHD because it has been shown to be less tain, when the family chooses not to use medication for
effective in treating ADHD symptoms when compared the child, or as an adjunct to medication treatment.
with stimulants. Atomoxetine is a selective inhibitor of Behavior management in the home is most effective
the presynaptic norepinephrine transporter in the central when parents understand the principles of the approach.
nervous system. It increases norepinephrine and dopa- The clinician may help the parent better understand
mine concentrations, especially in the prefrontal cortex. behavior management, and parent training programs are
This medication has been approved by the United States available in many communities. These programs help
Food and Drug Administration (FDA) for treatment of parents understand their child’s behavior and provide
children ages 6 years and older who have ADHD. tools to deal with behavioral difficulties. Behavioral ther-
Atomoxetine has a longer half-life compared with that apies have proven effective when consistently imple-
of stimulants. Therefore, treatment effects may not be mented and maintained. Additional forms of therapy,
noted for several days and a steady state not be reached such as cognitive-behavioral therapy or family therapy,
for up to 6 weeks. Some data show efficacy in treatment although not proven to be effective in the management
of ADHD with comorbid anxiety disorder. Atomoxetine of core ADHD symptoms, may be appropriate in the
also may be used in situations where substance abuse is a treatment of comorbid problems or family interaction
concern because this medication is not a class II drug. difficulties.

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Approved Medications for the Treatment of Attention-Deficit/


Table 5.

Hyperactivity Disorder in Children 6 Years of Age and Older


Brand/Generic Form/Units Available Starting Dose MRD Comment
Methylphenidate (MPH)
Ritalin姞*/MPH (Novartis, 5-, 10-, 20-mg tab 5 mg bid to tid 60 mg Rapid onset (within 15
East Hanover, NJ) (scored) to 20 min), rapid
termination of action.
Lasts 3.5 to 4 h**
Ritalin SR姞*/MPH (Novartis, 20-mg tab (sustained 20 mg q AM 60 mg Effect usually lasts about
East Hanover, NJ) release: half released 8 h.** Must be
immediately, half swallowed whole;
released 4 h later) cannot be crushed or
chewed.
Ritalin LA姞/MPH (Novartis, 10-, 20-, 30-, 40-mg 10 mg q am; increase 60 mg May sprinkle contents on
East Hanover, NJ) caps, extended-release by 10 mg each applesauce and swallow
(50% immediate week until good without chewing beads
release beads; 50% control is achieved (contents should not be
modified release crushed, chewed, or
beads; bimodal release divided). Lasts 8 to
profile) 10 h.**
Concerta姞/MPH (ALZA, 18-, 27-, 36-, 54-mg 18 mg q AM; increase 72 mg Noncrushable; must be
Mountain View, CA tabs (immediate- weekly by 18 mg swallowed whole.
[marketed by Mc Neil]) release outer coating; each week until Lasts 12 h.** Note:
osmotic pressure good control is nonabsorbable outer
system delivers drug achieved. shell may be seen in
gradually) stool; avoid with
gastrointestinal
narrowing.
Metadate CD姞/MPH (UCB, 10-, 20-, 30-, 40-, 50-, 20 mg q AM and 60 mg Note: may sprinkle
Rochester, NY) 60-mg cap extended- increase by 10 mg contents on applesauce.
release (30% each week
immediate release,
70% gradually;
bimodal peaks at 11⁄2
and 41⁄2 h)
Methylin姞/MPH (AlliantPhr, 2.5-, 5-, 10-mg tab 5 mg bid with 60 mg
Alpharetta, GA) (chewable); 5 mg/ increments of 5 to
5 mL,10 mg/5 mL 10 mg weekly
(oral solution)
Focalin姞/dexMPH (Novartis, 2.5-, 5-, 10-mg tabs 2.5 mg bid; increase 20 mg
East Hanover, NJ) in 2.5- to 5-mg
increments
Focalin XR姞/dexMPH 5-, 10-, 15-, 20-mg 5 mg q AM; increase 20 mg May sprinkle contents on
(Novartis, East Hanover, caps extended-release weekly by 5 mg applesauce and swallow
NJ) (bimodal peaks 4 h without chewing beads.
apart)
Daytrana姞/MPH (Shire US, 10-, 15-, 20-, 30-mg Apply 2 h before 30 mg Hypersensitivity to
Wayne, PA) transdermal patch desired effect; methylphenidate,
remove after 9 h especially when patch
(may remove not removed after 9 h.
earlier) MRD 30 mg/day.
(Continued)

Complementary and Alternative Therapies the scope of this article. Common dietary interventions
Numerous complementary and alternative treatments include elimination of foods (such as sugar) or food
exist for ADHD, but a comprehensive review is beyond additives (such as dyes) or addition of dietary supple-

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behavioral & mental health attention-deficit/hyperactivity disorder

Approved Medications for the Treatment of Attention-Deficit/


Table 5.

Hyperactivity Disorder in Children 6 Years of Age and Older— continued


Brand/Generic Form/Units Available Starting Dose MRD Comment
Amphetamines (AMP)
Dexedrine姞*†/dextroAMP 5-mgtab 5 mg q day or bid 40 mg For 3 to 5 year olds,
(GlaxoSmithKline, and increase of 2.5 mg daily and
Research Triangle Park, 5 mg weekly weekly increases of
NC) 2.5 mg.
Dexedrine Spansules姞/ 5-, 10-, 15-mg spansule 5 mg q AM and 40 mg May sprinkle contents on
dextroAMP sulfate sustained-release caps increase by 5 mg applesauce and swallow
(GlaxoSmithKline, Research weekly without chewing beads.
Triangle Park, NC)
Adderall姞*/mixed AMP salts 5-, 7.5-, 10-, 12.5-, 5 mg 1 to 2 times/ 40 mg
(DSM Pharm, Greenville, 15-, 20-, 30-mg all day and increase by
NC) scored 2.5 mg weekly
Adderall XR姞*/mixed 5-, 10-, 15-, 20-, 25-, 10 mg q AM and 40 mg May sprinkle contents on
dextroAMP/AMP salts 30-mg caps extended- increase by 10 mg applesauce and swallow
(Shire US, Wayne, PA) release (50% weekly without chewing beads.
immediate release
bead; 50% beads
release 4 h later;
biphasic model)
Desoxyn姞/Met AMP HCl 5-mg tab 5 mg 1 to 2 times 20 to 25 mg
(Abbott Pharmaceuticals, per day, increase by
Deerfield, IL) 5 mg weekly
Vyvanse姞 Lisdex AMP 20-, 30-, 40-, 50-, 60-, 20 mg q AM 70 mg May sprinkle contents in
dimesylate (Shire US, 70-mg caps a glass of water; needs
Wayne, PA) to be consumed
immediately.
Nonstimulant
Strattera姞/Atomoxetine (Eli 10-, 18-, 25-, 40-, 60-, <70 kg: Start 1.4 mg/kg
Lilly, Indianapolis, IN) 80-, 100-mg caps 0.50 mg/kg q per day or
(cannot be opened) AMⴛ4 days; 100 mg
increase to 1 mg/kg
po q AMⴛ4 days,
then to 1.2 mg/kg
per day in single or
bid dose; assess
response in 2 wk.
>70 kg: Start 40 mg
po q AMⴛ4 days;
increase to 80 mg
po q AM (or 40 mg
po bid); assess
response in 2 wk.
MRD: maximum recommended daily dose
*Generic forms available.
**Note: durations of action are estimates; duration may vary with individual child.

Dexedrine is approved in children 3 to 5 years of age.
Note: drugs listed do not appear in order of importance. Pediatrics in Review does not imply endorsement of any product. Recommendation does not serve
as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Resource: Accessed October 2009 at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm107918.htm

ments (egs, vitamins, minerals, herbs). Elimination of more evidence-based research needs to be conducted
sugar has not proven to have an observable effect. Al- before complementary and alternative therapies can be
though new treatments for ADHD would be a welcome recommended for the daily management of children who
addition to pharmacologic and behavioral intervention, have ADHD.

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behavioral & mental health attention-deficit/hyperactivity disorder

Contraindications to Medications Used for Treatment of


Table 6.

Attention-Deficit/Hyperactive Disorder
Active Ingredient Contraindication
Mixed salts of amphetamine Monoamine oxidase (MAO) inhibitors within 14 days, glaucoma, symptomatic
cardiovascular disease, hyperthyroidism, moderate-to-severe hypertension
Dextroamphetamine MAO inhibitors within 14 days, glaucoma, symptomatic cardiovascular disease,
hyperthyroidism, moderate-to-severe hypertension
Methylphenidate MAO inhibitors within 14 days, glaucoma, symptomatic cardiovascular disease,
hyperthyroidism, moderate-to-severe hypertension, pre-existing severe gastrointestinal
narrowing; use caution when prescribing concomitantly with anticoagulants,
anticonvulsants, phenylbutazone, and tricyclic antidepressants
Atomoxetine MAO inhibitors within 14 days, glaucoma; may interfere with selective serotonin reuptake
inhibitor metabolism (uses CYP2D6 system); drug interaction with albuterol; jaundice or
laboratory evidence of liver injury
Adapted from Caring for Children with ADHD: A Resource Toolkit for Clinicians. 2002.

Follow-up and Long-term Management specially trained in assessing and managing such condi-
Children who receive ADHD diagnoses require long- tions.
term follow-up because evidence is increasing that In general, stimulants are effective for treating ADHD
ADHD does not resolve as children get older. Long- symptoms in children who present with comorbid anxi-
term management includes adhering to the principles of ety or depressive disorder, although additional treat-
treatment discussed previously. ments (psychotherapy or medication treatment) often
The clinician, family, and school professionals are are needed. Children who have intellectual disability
responsible for joint assessment and treatment of the receive the diagnosis of ADHD if their symptoms are
comorbid conditions associated with ADHD. For exam- inconsistent with their developmental level and cause
ple, if academic performance is an ongoing concern additional functional impairments.
despite treatment for ADHD, the clinician may want to The evaluation of a lack of response to treatment
empower the family to request that the school evaluate should include determining whether the set target goals
the child for a possible learning disorder. Screening for are realistic and target behaviors clearly defined, re-
comorbid mental health conditions may prompt the evaluating the original diagnosis of ADHD, and screen-
primary care clinician to refer the child to clinicians ing for and treating any comorbid conditions. Lack of

Effective Behavioral Techniques for Attention-Deficit/


Table 7.

Hyperactivity Disorder
Technique Description Example
Positive reinforcement Providing rewards or privileges contingent on Child completes assignment and is allowed
the child’s performance to play on the computer
Time out Removing access to enjoyable activities because Child hits sibling impulsively and is required
of unwanted or problem behavior to sit for 5 minutes in time out
Response cost Withdrawing rewards or privileges contingent Child loses free time privileges for not
on performance of unwanted or problem completing homework
behavior
Token economy Combining positive reinforcement and response Child earns stars for completing
cost assignments and loses stars for getting
out of seat. The child cashes in the sum
of stars at the end of the week for a
prize
Adapted from AAP Clinical Practice Guideline. Treatment of the school-aged child with ADHD. Pediatrics. 2001;108:1033–1044.

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behavioral & mental health attention-deficit/hyperactivity disorder

adherence to treatment also may be a factor or a change


in medication may be warranted. Medication failure may Summary
prompt use of a second-line medication or referral to
specialists for consultation and treatment when adequate • Based on strong research evidence, school-age
children who present with behavior problems or
trials of both groups of stimulants have failed. academic underachievement should receive an
evaluation for ADHD. (2)(5)
Prognosis/Long-term Outcome • Based on consensus and strong research evidence,
As children age, their hyperactive and impulsive symp- ADHD-specific rating scales may be used to evaluate
toms tend to decrease. Despite these changes in symp- a child for symptoms of ADHD, but they are not
toms, most children continue to meet criteria for ADHD diagnostic of ADHD. (5)(16)
• Based on strong research evidence, approximately
as adolescents and adults. However, the treatment goals 67% of patients diagnosed as having ADHD have
and objectives need to be modified over time. Academic comorbid mood disorder or learning disorder.
problems may become more obvious and require addi- (5)(22)(23)
tional interventions as children grow older. Children • Based on strong research evidence, the primary care
clinician should establish a treatment program that
whose ADHD is untreated also are at increased risk for recognizes ADHD as a chronic condition that
developing substance abuse problems and other high- requires ongoing management and monitoring.
risk behaviors. Comorbid conditions remain present and (17)
require ongoing monitoring. • Based on strong research evidence, the clinician
initially should recommend stimulant medication for
the treatment of ADHD, with stimulant drugs from
To view References, a Suggested Reading list, and either class (amphetamines, methylphenidate) being
books and resources for families for this article, visit equally effective. (17)
http://pedsinreview.aappublications.org and click on
the article title.

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behavioral & mental health attention-deficit/hyperactivity disorder

PIR Quiz
Quiz also available online at http://pedsinreview.aappublications.org.

5. An association has been found between ADHD and:


A. Ethnicity.
B. High birthweight.
C. Lead exposure.
D. Race.
E. Socioeconomic status.

6. According to Section 504 of the Rehabilitation Act of 1973, an educational modification that is not
allowed is:
A. Modified homework assignments.
B. Motor breaks from classroom routine.
C. Preferential classroom seating.
D. Reminders to stay on task.
E. Special education services.

7. Of the following, the statement about medication management for ADHD that is not correct is that:
A. Dosing of medication is not weight-dependent.
B. Extended-release preparations are preferred for older children.
C. Medication effects are dose-dependent.
D. Medication should be initiated after behavioral management fails.
E. Teacher rating scales are useful during the titration phase.

8. Of the following, the least common adverse effect of stimulant medication is:
A. Abdominal pain.
B. Headache.
C. Irritability.
D. Sleep disturbances.
E. Weight gain.

9. A true statement about tics that occur after the start of stimulant medication is that:
A. Improvement in symptoms may outweigh the impairment caused by the tics.
B. Stimulant medication is a well-established cause of tics.
C. The drug dose should be decreased as soon as tics appear.
D. The onset of tics and the use of stimulant medication are unrelated.
E. The presence of tics is a contraindication to stimulant use.

Pediatrics in Review Vol.31 No.2 February 2010 69


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Attention-Deficit/Hyperactivity Disorder
Anna Maria Wilms Floet, Cathy Scheiner and Linda Grossman
Pediatr. Rev. 2010;31;56-69
DOI: 10.1542/pir.31-2-56

Updated Information including high-resolution figures, can be found at:


& Services http://pedsinreview.aappublications.org/cgi/content/full/31/2/56
Supplementary Material Supplementary material can be found at:
http://pedsinreview.aappublications.org/cgi/content/full/31/2/56/
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