CE/CME

ADHD: Putting the Pieces Together

Clinician Reviews. 2015 January;25(1):28-36

References

1. Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.

2. Merikangas KR, He JP, Brody D, et al. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010;125(1):75-81.

3. Post RE, Kurlansik SL. Diagnosis and management of attention-deficit/hyperactivity disorder in adults. Am Fam Physician. 2012;85(9):890-896.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

5. Krull KR. Attention deficit hyperactivity disorder in children and adolescents: clinical features and evaluation. www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-evaluation?source=see_link. Accessed December 15, 2014.

6. Wilens TE, Spencer TJ. Understanding attention-deficit/hyperactivity disorder from childhood to adulthood. Postgrad Med. 2010;122(5): 97-109.

7. Danckaerts M, Sonuga-Barke E, Coghill D, et al. The quality of life of children with attention deficit/hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry. 2010;19(2):83-105.

8. Pelham WE, Foster EM, Robb JA. The economic impact of attention-deficit/hyperactivity disorder in children and adolescents. Ambul Pediatr. 2007;7(1 suppl):121-131.

9. Deault LC. A systematic review of parenting in relation to the development of comorbidities and functional impairments in children with attention-deficit/hyperactivity disorder (ADHD). Child Psychiatry Hum Dev. 2010;41(2):168-192.

10. Krull KR. Attention deficit hyperactivity disorder in children and adolescents: epidemiology and pathogenesis. www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-epidemiology-and-pathogenesis?source=see_link. Accessed December 15, 2014.

11. Marcdante KJ, Kliegman RM, Jenson HB, Behrman RE. Attention-deficit/hyperactivity disorder. In: Merrit J, Cicalese B, eds. Nelson Essentials of Pediatrics. 6th ed. Philadelphia, PA: Saunders Elsevier; 2011:50-52.

12. Bush G. Cingulate, frontal, and parietal cortical dysfunction in attention-deficit/hyperactivity disorder. Biol Psychiatry. 2011;69(12):1160-1167.

13. CDC. Facts about ADHD. www.cdc.gov/NCBDDD/adhd/facts.html. Accessed December 15, 2014.

14. Rajwan E, Chacko A, Moeller M. Nonpharmacological interventions for preschool ADHD: state of the evidence and implications for practice. Prof Psychol Res Pr. 2012;43(5):520-526.

15. Daley D. Attention deficit hyperactivity disorder: a review of the essential facts. Child Care Health Dev. 2006;32(2):193-204.

16. van der Oord S, Bögels S, Peijnenburg D. The effectiveness of mindfulness training for children with ADHD and mindful parenting for their parents. J Child Fam Stud. 2012;21(1):139-147.

17. Zisser AR, Eyberg SM. Maternal ADHD: parent-child interactions and relations with child disruptive behavior. Child Fam Behavior Ther. 2012;34(1):33-52.

18. Daley D, Jones K, Hutchings J, Thompson M. Attention deficit hyperactivity disorder in pre-school children: current findings, recommended interventions and future directions. Child Care Health Dev. 2009;35(6):754-766.

19. Bruchmüller K, Margraf J, Schneider S. Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. J Consult Clin Psychol. 2012;80(1):128-138.

20. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.

21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

22. American Psychiatric Association. Highlights of Changes from DSM-IV-TR to DSM-5. www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf. Accessed December 15, 2014.

23. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1007-1022.

24. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder. Supplemental information. Implementing the key action statements: an algorithm and explanation for process of care for the evaluation, diagnosis, treatment, and monitoring of ADHD in children and adolescents. http://pediatrics.aappublications.org/content/suppl/2011/10/11/peds.2011-2654.DC1/zpe611117822p.pdf. Accessed December 15, 2014.

25. Olfson M, Huang C, Gerhard T, et al. Stimulants and cardiovascular events in youth with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(2):147-156.

26. Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117(18):2407-2423.

27. Perrin JM, Friedman RA, Knilans TK, et al. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics. 2008;122:451-453.

28. Berger S. Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder. www.uptodate.com/contents/cardiac-evaluation-of-patients-receiving-pharmacotherapy-for-attention-deficit-hyperactivity-disorder?source=see_link. Accessed December 15, 2014.

29. Ho SC, Chien WT, Wang L. Parents’ perceptions of care-giving to a child with attention deficit hyperactivity disorder: an exploratory study. Contemp Nurse. 2011;40(1):41-56.

30. Moen ØL, Hall-Lord ML, Hedelin B. Contending and adapting every day: Norwegian parents’ lived experience of having a child with ADHD. J Fam Nursing. 2011;17(4):441-462.

31. Theule J, Wiener J, Rogers M, Marton I. Predicting parenting stress in families of children with ADHD: parent and contextual factors. J Child Fam Stud. 2011;20(5):640-647.

32. Brown RP, Gerbarg PL. Non-Drug Treatments for ADHD. New York, NY: Norton & Company; 2012:5-26.

33. Jones K, Daley D, Hutchings J, et al. Efficacy of the Incredible Years Basic parent training programme as an early intervention for children with conduct problems and ADHD. Child Care Health Dev. 2007;33(6):749-756.

34. Krull KR. Attention deficit hyperactivity disorder in children and adolescents: overview of treatment and prognosis. www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-overview-of-treatment-and-prognosis?source=see_link. Accessed December 15, 2014.

35. Fabiano GA, Vujnovic RK, Pelham WE, et al. Enhancing the effectiveness of special education programming for children with attention deficit hyperactivity disorder using a daily report card. School Psychol Rev. 2010;39(2):219-239.

36. Wilens TE, Faraone SV, Biederman J, Gunawardene, S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. 2003; 111(1):179-185.

37. Krull KR. Attention deficit hyperactivity disorder in children and adolescents: treatment with medications. www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-treatment-with-medications?source=see_link. Accessed November 10, 2014.

38. Swanson JM, Elliott GR, Greenhill LL, et al. Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 2007;46(8):1014–1026.

39. Krull KR. Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. www.uptodate.com/contents/pharmacology-of-drugs-used-to-treat-attention-deficit-hyperactivity-disorder-in-children-and-adolescents?source=see_link. Accessed December 15, 2014.

40. Scahill L. Alpha-2 adrenergic agonists in children with inattention, hyperactivity and impulsiveness. CNS Drugs. 2009;23(suppl 1):43-49.

41. Krull KR. Patient information: treatment of attention deficit hyperactivity disorder in children (beyond the basics). www.uptodate.com/contents/treatment-of-attention-deficit-hyperactivity-disorder-in-children-beyond-the-basics?source=related_link. Accessed December 15, 2014.

42. Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disorder: update and clinical recommendations. J Am Acad Child Adolesc Psychiatry. 2011;50(10):978-990.

MAKING THE DIAGNOSIS
Presenting behaviors
Symptoms of ADHD typically manifest in academic settings. The greater frequency of ADHD diagnosis and treatment in boys may derive from differences in how the genders externalize behaviors.¹⁹ While boys often exhibit more impulsive and aggressive behavior, girls internalize symptoms and are more likely to be inattentive. As a result, girls are less likely to be disruptive in the classroom and may not be referred for evaluation. Boys, on the other hand, may be overdiagnosed due to their disruptive behaviors.¹⁹ Daley indicates that inattention (eg, daydreaming) and hyperactivity (eg, fidgeting) symptoms become more apparent in structured settings, such as a classroom.¹⁵

Any child who requires a mental health assessment should also be screened for ADHD; if the results of the screening suggest ADHD, a full evaluation is warranted.²⁰

Diagnostic criteria
According to the American Psychiatric Association’s criteria—outlined in the Diagnostic and Statistical Manual of Mental Disorders–IV (Text Revision) (DSM-IV-TR) and the subsequent DSM-5—the diagnosis of ADHD requires that the patient have at least six symptoms of inattention, hyperactivity, and/or impulsivity.^4,21,22 For patients ages 17 or older, the DSM-5 requires five symptoms of inattention or hyperactivity-impulsivity.²¹

Children are usually unable to complete one task prior to starting another and are easily distracted by noises otherwise ignored by others (eg, lawnmowing, background conversation).⁴ They may also exhibit excessive fidgeting and interrupt formal conversations or lectures.⁴ Inappropriate behavior relative to the child’s developmental level must have been present for at least six months prior to age 7 (according to DSM-IV-TR)⁴ or age 12 (DSM-5).²¹

In addition to exhibiting the above symptoms for a minimum of six months, impairment must be observed in at least two settings (home, school, or work), with obvious clinical impairment in social, academic, or occupational functioning.⁴ ADHD symptoms can vary depending on the setting; the child may have more difficulty paying attention and following directions in a classroom filled with children than in an environment with less stimuli (eg, one-on-one home situations).¹¹

Children who exhibit ADHD symptoms in only one setting may actually have problems secondary to cognition, emotional maturity, or feelings of well-being in a particular setting.¹¹ Therefore, the clinician must rely on multiple sources of information (eg, parents, teachers, other caregivers) in order to make the diagnosis of ADHD.²³ A teacher should have had regular contact with the child for at least four to six months in order to provide an accurate evaluation of symptoms and their persistence.⁵

Assessment scales
Validated parent and teacher instruments, along with the DSM-IV-TR criteria, can be used to obtain data to support a diagnosis of ADHD.^5,24

The Conners Comprehensive Behavior Rating Scales and the ADHD Rating Scale IV (DSM-IV) can be used by teachers and parents to document behaviors of preschool-aged children.⁵

The Vanderbilt Assessment Scales, which have been validated in both primary care and referral settings, may be used for children older than 4.⁵

More information about rating scales is available at the National Resource Center on ADHD website (www.help4adhd.org/en/treatment/scales).

In addition to parent- or teacher-reported data, further evidence of functional impairment may be gleaned through a review of report cards, standardized testing, and school records (eg, attendance or disciplinary actions).²⁴

Differential diagnosis
The differential diagnosis should include other mental health conditions, sleep disorders, and any possible underlying medical or developmental problems.²⁴ Hyperthyroidism and lead toxicity, as examples, could elicit symptoms consistent with ADHD.¹¹ When the diagnosis is in doubt, coexisting conditions are present, or treatment options are in question, the primary care clinician should refer the patient to a pediatric or mental health specialist for further evaluation.²³

BEFORE TREATMENT
After the diagnosis is made but before treatment commences, a complete review of systems, physical and psychologic evaluation, cardiac and sleep history, thorough family history pertaining to mental health and medical conditions, and an age-appropriate interview are required.²⁴ The exam results assist in identifying other concerns that would indicate the need for appropriate diagnostic testing and/or referral (see Table 1).

Although stimulant treatment for ADHD has not been shown to increase cardiovascular events in otherwise healthy young people,²⁵ experts differ in their opinions about the need for screening ECG prior to treatment initiation. The American Heart Association recommends a screening ECG before stimulant therapy is initiated,²⁶ while the American Academy of Pediatrics (AAP) does not, as long as the history and exam results yield no cardiac findings.²⁷ Since the Prescribing Information for most ADHD medications cautions against use in patients with known serious cardiac abnormalities, if exam findings suggest the possibility of cardiovascular disease, further evaluation with ECG and referral to a pediatric cardiologist are indicated.^26,28

In the interview, the clinician should explore the patient’s perception of his or her behavior in response to family and social relationships and academic performance (eg, parent-teacher communication, report cards, detentions, suspensions). The psychosocial history may provide an explanation for acute onset of symptoms or coexisting disorders. Family history provides valuable insight regarding the health and cognitive abilities of family members, as well as the possibility of genetic influences on the child.²⁴

Parents should be advised that ADHD is a chronic condition that requires a long-term treatment approach for symptoms that may last into adulthood. Identification of goals and treatment success depend on collaborative efforts with parents, teachers, clinicians, caregivers, and mental health clinicians.²⁴

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