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.

MEDICATION RECOMMENDATIONS
AAP medication recommendations are age-specific and should be used only if the patient meets DSM-IV-TR criteria.²⁴ An overview of both stimulant and nonstimulant treatment options for ADHD is provided in the Figure.

When an ADHD treatment regimen does not result in improved symptoms and functioning, the clinician should revisit the treatment plan and differential diagnosis. After reevaluation, the clinician may choose to add or change medication type or dose, adjust behavioral therapy, or consider the possibility of language or learning disabilities, mental health disorders, other psychosocial stressors, or poor adherence to the treatment plan.²⁴

Parents may refuse stimulant therapy for their child, fearing future drug use (or abuse) in adolescence.²⁴ Clinicians should respect parents’ decisions to defer stimulant therapy, while at the same time clarifying concerns or misunderstandings in order to provide optimal care for the child.²⁴ Studies have demonstrated that stimulant treatment for ADHD has a protective effect, with outcomes suggesting significantly decreased risk for drug or alcohol dependence.³⁶

Clinician-provided anticipatory education about dose titration, expected treatment results, and potential adverse effects will help prepare parents for the ADHD medication management process.²³ The length of time needed for dose titration varies by class of ADHD medication (see Table 2). For stimulants, effects on core symptoms may be seen within the first week. Nonstimulants take longer: up to six weeks for atomoxetine and up to four weeks for the a₂-adrenergic agonists.²⁴

Stimulants
Evidence strongly supports stimulants as first-line treatment for ADHD in children ages 6 and older.²³ Stimulants are safe and efficacious in reducing the core symptoms of inattention, hyperactivity, and impulsivity.²³ The initial choice of stimulant depends on the individual child’s needs. It should be noted that, although decreased growth rates have been observed in children taking stimulants, this effect ends by the third year of treatment.³⁸ If maximum doses are reached and desired effects are not achieved with the first stimulant, choosing an alternate drug in the stimulant class may be an effective option.²⁴ Clinicians may also consider other drug classes based on the comprehensive exam, adverse effects profile, contraindications, and individual responses.

Nonstimulants
Nonstimulant medications include atomoxetine and the a₂-adrenergic agonists extended-release clonidine and extended-release guanfacine.²⁴

Atomoxetine. Atomoxetine is a selective norepinephrine-reuptake inhibitor that may be prescribed if substance abuse or diversion is suspected or if stimulant therapy is contraindicated, undesirable, or unsuccessful.^24,39 Using weight-based dosing for titration,³⁷ the first week of therapy should begin with a half-dose to minimize sedation or gastrointestinal symptoms.²⁴ While atomoxetine can be quite effective, caution should be used when prescribing this agent, as it carries a black box warning for suicidal ideation.²⁴

α₂-Adrenergic agonists. Both extended-release clonidine and extended-release guanfacine are α₂-adrenergic agonists that may be beneficial when stimulants and atomoxetine have failed or when there are coexisting conditions.³⁷ Either clonidine or guanfacine can be given in combination with a stimulant, if stimulant or atomoxetine treatment alone is unsuccessful or if adverse effects are unacceptable.^24,39 Sedative effects and withdrawal irritability are more common with clonidine than with guanfacine, and when discontinued, these medications should be tapered to avoid blood pressure changes.^24,40

Age-specific recommendations
Medications should be selected based on age ranges. In preschool-age children (ages 4 to 5), methylphenidate is recommended when target behaviors and impaired functioning persist for nine months in both home and day care/school settings, despite behavioral therapy.^23,24 As examples, medication may be warranted if the child poses a significant risk of injury to other children or caregivers and/or faces expulsion from preschool or day care because of his or her behaviors.³⁴

Risks and benefits should be considered carefully before medical therapy is initiated in this group. Further, the lowest possible starting dose of methylphenidate is preferred for preschoolers due to their slower metabolism.²⁴ While dextroamphetamine is FDA approved for children younger than 6, efficacy and safety have not been proven in this age group and the AAP does not recommend it.²³

For children ages 6 to 18, the AAP recommends combined treatment with medication and evidence-based behavioral training for the patient, parent, and teacher. In the adolescent population, evidence supports use of stimulants as first-line therapy, but with close monitoring for medication misuse.²³ Misuse may become apparent through increased prescription refills; if identified, ADHD medication should be discontinued and substance abuse treatment initiated before ADHD therapy recommences.²⁴

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