Evaluation and management of attention-deficit hyperactivity disorder - includes patient information

Author: Michael A. Taylor
Date: Feb 15, 1997

Attention-deficit hyperactivity disorder is the most common pediatric psychiatric disorder, involving one of every 20 children. It is often a disabling condition and is frequently accompanied by high levels of frustration and comorbidity. Diagnosis of attention-deficit hyperactivity disorder requires a detailed history from the family and use of rating scales to collect observations from two or more settings. Effective treatment, including behavior management, appropriate educational placement and stimulant medication, will improve academic performance and behavior in most patients. Armed with an organized approach and a broad general knowledge of stimulant therapy, the family physician can effectively evaluate and coordinate the initial therapy for many of these troubled children within the office setting. Children in whom initial management fails or for whom the diagnosis is unclear or complicated should be referred to appropriate mental health professionals.

Attention-deficit hyperactivity disorder (ADHD) is the name given to a cluster of behavior characteristics that cause problematic behaviors in a substantial number of children and adults. The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than that typically observed in persons at a comparable level of development.[1]

The severity of ADHD symptoms vary widely in affected children and adults as a result of several pathologic processes affecting similar areas of the brain.[2] A number of unsubstantiated etiologic theories have been proposed, including dietary factors such as food additives and refined sugar, but none have been validated by properly conducted research studies. ADHD is not the result of poor parenting practices, although ineffective behavior management will adversely affect the performance and maturation of children with ADHD. Although certain brain injuries such as lead poisoning and encephalitis may cause an increased incidence of ADHD-type symptoms, most cases are the result of a multifactorial pattern of inheritance.[3]

ADHD is a common disorder in children, with an estimated frequency of 5 percent (range: 2 to 9 percent).[2] Males are diagnosed three to seven times more often than females, depending on whether they present to a referral clinic or a primary care office. There is a familial pattern of occurrence, with 30 percent of first-degree relatives of children with ADHD also being affected.[3] Siblings are at particularly increased risk, three-fold higher for sisters and five-fold higher for brothers. ADHD occurs in persons of all races and socioeconomic classes.

Diagnosis

Table 1 lists the current diagnostic criteria for ADHD from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).[1] The diagnostic criteria include two categories with nine symptoms listed in each. The categories are inattention and hyperactivity-impulsivity. Six of the nine symptoms should be present in each category for diagnosis. Depending on the symptom cluster, the diagnosis can be categorized as follows: (1) ADHD, combined type, if criteria of both categories are met; (2) ADHD, predominately inattentive type, if only criteria for inattention category are met, and (3) ADHD, predominately hyperactive-impulsive type, if criteria for hyperactivity-impulsivity category are met.

TABLE 1Diagnostic Criteria for ADHDA. 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 (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities (b) Often has difficulty sustaining attention in tasks or play activities (c) Often does not seem to listen when spoken to directly (d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) Often has difficulty organizing tasks and activities (f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools) (h) Is often easily distracted by extraneous stimuli (i) Is often 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 (a) Often fidgets with hands or feet or squirms in seat (b) Often leaves seat in classroom or in other situations in which remaining seated is expected (c) 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) (c) Often has difficulty playing or engaging in leisure activities quietly (e) Is often "on the go" or often acts as if "driven by a motor" (f) Often talks excessively Impulsivity (g) Often blurts out answers before questions have been completed (h) Often has difficulty awaiting turn (i) Often interrupts or intrudes on others (e.g., butts into conversations or games)B. Some hyperactive-impulsive or inattentive symptoms that causedimpairment were present before age 7 years.C. Some impairment from the symptoms is present in two or moresettings (e.g., at school [or work] and at home).D. There must be clear evidence of clinically significantimpairment in social, academic or occupational functioning.E. The symptoms do not occur exclusively during the course of apervasive developmental disorder, schizophrenia or other psychoticdisorder and are not better accounted for by another mental disorder(e.g., mood disorder, anxiety disorder, dissociative disorder or apersonality disorder).From American Psychiatric Association. Diagnostic and statisticalmanual of mental disorders. 4th ed. Washington, D.C.: AmericanPsychiatric Association, 1994.

From American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.

Several observers from at least two different settings should be asked for information about the child's behavior and academic performance. It is also important to interview school-age children separately from their parents. Use of standardized history forms and rating scales reduces otherwise burdensome time commitments while adding to the completeness and consistency of historical information obtained.

The history should focus on the following information: (1) Are there significant ADHD symptoms in at least two settings? (2) Is there a family history of similar problems? (3) Has the child developed normally? (Slow development increases the possibility of learning disorders or mental retardation.) (4) Is the child taking medications that may mimic or worsen symptoms? (Such medications include prednisone, theophylline and phenobarbital.) (5) Does the child have adequate supervision?

The physical examination should be thorough, including development, vision and hearing screening tests. The majority of children with ADHD have normal examinations and do not appear hyperactive or inattentive in the physician's office, where they may be intimidated. Careful evaluation should be conducted to detect hearing deficits, since hearing problems may cause children to appear inattentive and hyperactive as a result of an inability to understand in a classroom setting. The only routine laboratory tests are those that are recommended for periodic health assessments for all children.[4]

RATING SCALES

A number of rating scales that have undergone thorough reviews are available[2,3] When choosing among the scales, considerations include whether the rating scale yields understandable information and can be completed and scored in a reasonable amount of time. A fifth-grade reading level is required to complete these scales, and up to 30 percent of American adults read below this level.[2] Despite the drawbacks, rating scales allow the clinician to gather information from several sources. However, they should be used to complement rather than to replace other historic information. One approach for using rating scales is shown in Table 2. If parental assessments show significant discrepancies, more credence is given to the assessment completed by the primary caregiver. If teacher ratings are discrepant, it may be necessary to obtain additional opinions and/or teacher telephone interviews.

The next visit is usually scheduled at three months with fine tuning of the doses and timing of the medication. If the first dose is wearing off during school hours, a trial of a sustained-release product (Ritalin SR, Dexedrine Spansule, Desoxyn Gradumet) at an equivalent dose can be considered. Beginning alterations in dosages on weekends is preferable. After this visit, most patients with ADHD can be followed two or three times a year to monitor medication effects and dosages as well as blood pressure, heart rate, weight and height.[15-17]

For patients undergoing therapy with pemoline, the timing of the return visits is the same, but the initial dosing is once daily at breakfast, starting with 37.5 mg and increasing weekly by 18.75-mg increments until either favorable response, side effects or the maximum dose of 112.5 mg (3 mg per kg) is achieved. Follow-up recommendations include measurements of weight, height, blood pressure, complete blood cell count and liver function screen at baseline, one month later, then regularly thereafter.[18]

DURATION OF THERAPY

The decision to discontinue therapy should be considered on a case-by-case basis. Periodic drug "holidays" enable the family to compare the treated and untreated states. Stopping the stimulant medication for a couple of weekends during the summer vacation from school minimizes potential disruptions. If no appreciable difference is observed without medication, then a trial period without medication during school hours is warranted. Parents and children can expect to continue the medication as long as there is a clear benefit noted without significant side effects. It has been estimated that one-half of the children who respond to stimulants will continue to benefit from therapy as adults.[19]

BREAKING THE MOLD

Three common prescribing practices in the management of patients with ADHD merit specific discussion.

(1) Treating the school, not the child. Medicating only during school hours seems to be a phenomenon unique to ADHD therapy. Imagine treating depressed or anxious patients only during business hours. ADHD is a life disorder, not a school disorder, and a child's self-esteem is influenced by interactions with peers and adults in all aspects of life (church, day care, sports, etc.). Furthermore, as the child grows older, homework becomes increasingly more important to successful school performance. Since the additional dosages needed to cover nights, weekends and holidays do not significantly increase the side effects for most children,[7] physicians should inquire about each aspect of the child's life and individualize therapy accordingly.

(2) The "Ritalin Doc." Methylphenidate has an excellent track record, but to use it exclusively could be compared with managing all hypertensive patients with hydrochlorothiazide or all seizure patients with phenobarbital. Familiarity with all of the stimulants will enable physicians to assist a greater number of these children.

(3) The "breakfast and lunch" plan. Methylphenidate is frequently administered at breakfast and lunch without consideration for the individual circumstances. School lunch times vary from 10:30 a.m. to 1:00 p.m. If the first dose is taken at a 6:30 a.m. breakfast and the second dose is taken at a 1:00 p.m. school lunch time, the child may spend one-half of the school day (from 10:00 a.m. to 1:30 p.m.) without benefit of medication. In addition, lunch time usually changes each year. Dosing intervals should meet the child's needs, but "school doses" should be avoided whenever possible by using longer-acting medications.

Final Comment

ADHD is a common and difficult problem for affected children and their families, as well as day care and school staff. It is a life problem, not just a school problem, and it is a lifetime problem for most patients. The primary care physician should exercise patience and thoroughness during the initial assessment. With an organized approach, many children with ADHD can be effectively and efficiently managed without sacrificing quality of care or professional satisfaction. Special resources that may help parents and children are given in Table 7.

TABLE 7Resources for Parents and ChildrenBooksBaren M. Hyperactivity and attention disorders in children. San Ramon, Calif.: Health Information Network, 1994. (Telephone: 800-446-1947. Booklets come in sets of 25 for office use.)Clark L. SOS help for parents. Bowling Green, Ky: Parents Press, 1996.Fowler MC. Maybe you know my kid: a parents' guide to identifying, understanding, and helping your child with attention-deficit/ hyperactivity disorder. New York: Carol Publishing Group, 1995.Goldstein S, Goldstein M. Hyperactivity: why won't my child pay attention? New York: Wiley, 1992.Ingersoll BD. Your hyperactive child: a parent's guide to coping with attention deficit disorder. New York: Doubleday, 1988.Parker HC. The ADD hyperactivity workbook for parents, teachers, and kids. Plantation, Fla.: Specialty Press, 1994.Silver LB. Dr. Larry Silver's advice to parents on attention-deficit hyperactivity disorder. Washington, D.C.: American Psychiatric Press, 1993.Taylor JE Helping your hyperactive/attention deficit child. Rocklin, Calif.: Prima Publishing, 1994.Wender PH. The hyperactive child, adolescent, and adult: attention deficit disorder through the lifespan. New York: Oxford University Press, 1987.VideotapesBarkley RA. ADHD: what do we know? New York: Guilford Press, 1992. (Telephone: 800-365-7006)Copeland ED. Understanding attention disorders (ADD) with and without hyperactivity, preschool through adulthood. Atlanta, Gal: 3 C's of Childhood, Inc., 1989.Garfinkel BD. Creative approaches to ADHD: active partnerships. Minneapolis: University of Minnesota, 1991.Goldstein S. Why won't my child pay attention? Salt Lake City: Neurology Learning and Behavior Center, 1989.Books for childrenGalvin M. Otto learns about his medicine: a story about medication for hyperactive children. New York: Magination Press, 1995.Moss DM. Shelley, the hyperactive turtle. Kensington, Md.: Woodbine House, 1989.Gehret J. Eagle eyes: a child's guide to paying attention. Fairport, N.Y: Verbal Images Press, 1996.Quinn PO, Stern MA. Putting on the brakes: young people's guide to understanding attention deficit hyperactivity disorder. New York: Magination Press, 1991.Quinn PO. ADD and the college student: a guide for high school and college students with attention deficit disorder. New York: Magination Press, 1994.Quinn PO, Stern JM. Brakes: the interactive newsletter for kids with ADHD. New York: Magination Press.Nadeau KG. Survival guide for college students with ADD or LD. New York: Magination Press, 1994.Parent support groupsChildren and Adults with Attention Deficit Disorder (CH.A.D.D.), 499 NW 70th Avenue Suite 101, Plantation, FL 33317. Telephone: 305-587-3700.Attention Deficit Disorder Association (ADDA), 4300 West Park Blvd., Plano, TX 75093. Telephone: 800-487-2282.Attention Deficit Disorder Advocacy Group (ADDAG), 8091 South Ireland Way, Aurora, CO 80016. Telephone: 303-690-7548.Learning Disabilities Association of America. National Headquarters, 4156 Library Rd, Pittsburgh, PA 15234. Telephone: 412-341-1515. Newsletter produced six fumes yearly.The National Center for Children with Learning Disabilities, 99 Park Ave, New York, NY 10016.The Neurology, Learning and Behavior Center, 230 South 500 E, Suite 100, Salt Lake City, UT 84102. Telephone: 801-532-1484.Tourette's Syndrome Association, 42-40 Bell Blvd., Bayside, NY 11361. Telephone: 718-224-2999.

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