An 8 year old named Harry is accompanied by his mother to the primary care pediatric clinic. His mother relates that Harry's school wants him on a medication because he cannot sit still. He is always bothering other children in his classroom. There are 30 other children in his class. There is another boy Joel who has similar problems and is on methylphenidate (Ritalin), and is doing much better in not bothering others. Joel is now able to concentrate on his work. Harry's mother believes that Harry is quite bright but he is not learning well in his classroom. He is about to flunk math, reading and science - although he particularly likes science. His teacher says that he is well versed in identifying animals, which is part of the curriculum for his class, and he is much better than most of his classmates in doing so. However, he cannot work in a group, which is part of the science activities, without upsetting other members. He has impulsivity in working with materials and disrupts others who are trying to stay on task. Harry relates that he feels that everyone is out to get him, and that he gets teased about the teacher's frequent admonishments over his behavior. He often has to sit in a chair separated from other children. Harry's mother relates that his behavior was like this in earlier grade levels.
He is quite impulsive at home, often breaking things such as the computer and his toys. He also has broken his right tibia after riding his bicycle off the roof. He cannot sit still at meals. His mother relates that Harry's father has similar traits of being reckless, and inattentive. She relates that Harry's father is against medication for Harry. By his mother's report, Harry's father feels that he is quite successful, even after his own behavioral troubles in school during his childhood. His parents are happily married and his mother cannot think of any major social stressors other than Harry's behavior at this time.
His past medical history is unremarkable. His developmental milestones were all on time prior to age five.
Exam: VS T 37.2, P 105, R 16, BP 90/43. Height and weight are at the 20%ile. Head circumference is near the mean for age. He is happy and active, exploring the office, touching all medical instruments. He speaks coherently and in context, seems sad and then mad when talking about school. He draws a picture of three figures when asked to draw a picture of his family doing something. They are all swimming in the ocean. By Goodenough-Harris scoring, his figures in the drawing are at a 9 year old level. He has no dysmorphic features. His head, eyes, ears, mouth, dentition and neck are normal. His heart, lungs and abdomen are normal. No facial asymmetry or tics are observed. He moves all extremities well. He walks and runs well. He has good muscle tone and strength, without contractures or tremors. His DTRs are 2+/4 for knees, ankles and biceps. He has no rash and no neurocutaneous lesions. His hearing and vision screens were found to be normal.
Harry is evaluated using a variety of methods looking into several domains of his life. Behavioral rating scales (the 1997 revision of the Conners Rating Scale) shows Harry to be above two standard deviations in Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms for both the Teacher and the Parent scales. A school psychoeducational assessment shows Harry to be above average in both performance and verbal IQs, although the examiner did relate that it was difficult to keep him focused on the tasks presented. He is at the 2nd grade level for his reading and writing, but the 3rd grade level for his math and listening comprehension achievement tests.
A behavioral management program is started at his school. He is given preferential seating and he has a rewards/consequences system for keeping on task or if bothering others. He is tried on psychostimulant medication with some loss of appetite. With titrating of the dose, he is found to be much less distracted in school, and he pays much better attention to class activities. A counselor helps Harry learn how to maintain group activities without the other children becoming mad, and gives Harry insight into following rules on the playing field. He is eventually placed in a "gifted and talented" program at his school because of the excellence of his schoolwork and achievements. Medication holidays help maintain his growth.
Attention-Deficit/Hyperactivity Disorder (ADHD) and its treatment have been controversial areas in the US. Because of the number of children thought to have this condition and the number of prescriptions written for this diagnosis, alarmed families and civic groups have wondered if this condition is overdiagnosed. They also worry that medications are overly used and that medications for this condition will be abused or lead to future drug abuse.
However, without diagnosis and treatment, these children face school failure, poor self esteem, drug abuse (ironically), and multiple other problems. The astute clinician understands family and societal concerns, the natural history of the condition, diagnostic tools, and important treatment modalities in order to prevent or ameliorate major problems.
It has been estimated that 3% to 7% of school age children have ADHD (1). Currently, ADHD is the most common neurodevelopmental disorder of childhood (2). With such numbers of children affected, pediatricians and other primary care providers have an important role in assessing and managing many of these children. There are not enough neurologists, psychiatrists, psychologists or similar subspecialists for all children thought to be affected. Boys are diagnosed at least three times as often as girls (3).
Diagnostic criteria can be found in the DSM-IV-TR version of the Diagnostic and Statistical Manual of Mental Disorders (1). Unfortunately, labels and criteria have changed over the years, causing some confusion among practitioners and research groups (4). Previous diagnostic labels have included Minimal Brain Dysfunction (MBD) and Attention Deficit Disorder (ADD). Physicians in Europe and other countries use the term Hyperkinetic Disorder (HKD).
However, it is clear that whatever term is used, this is a clinical diagnosis based on a history of symptoms in multiple environmental contexts observed over time. The core areas that need to be delineated are inattention, hyperactivity and impulsivity. DSM-IV-TR relate three subtypes: 1) a predominantly inattentive type, 2) a predominantly hyperactive-impulsive type, and 3) a combined type. DSM-IV-TR criteria also include the stipulation that some symptoms that caused impairment were present before 7 years of age. Impairment has to be in two or more settings (for instance home AND school), and there must be clear evidence of significant impairment in functioning in interrelationships, schoolwork or in job performance (1). Interestingly, if impairment in school performance and behavioral functioning are not used as part of the criteria, the ADHD prevalence is much higher - 16.1% without impairment criteria versus 6.8% with this criteria (5).
There is also a category in DSM-IV-TR for ADHD, NOS (not otherwise specified) that can be used for children and adults that do not meet criteria for the above mentioned subtypes but have significant impairment from such symptoms. Primary care providers still need to help families and schools with children who do not meet full DSM-IV-TR criteria but have characteristics that cause impairment.
Usually the diagnosis is made in the school age years. High activity levels in toddlers do not invariably lead to ADHD in childhood. Many "hyperactive and inattentive" toddlers end up focusing and engaging in activities without impulsiveness and hyperactivity after maturing through their preschool and early school years. However, one study showed about 1/2 of children thought to have ADHD in their preschool years had a clear diagnosis by age 9 years. These children had more severe symptoms in their preschool years overall compared to peers (6). Therefore, a clinician needs to take great care to understand the ramifications of the child's age but still consider ADHD at these younger ages.
Much discussion has ensued on whether children with ADHD are just part of the normal continuum of children with varied levels of attention, activity and impulsivity. There is no firm evidence that shows a bimodal distribution where children with ADHD are clearly separate in a different part of the continuum. A recent National Institutes of Health report likens ADHD to essential hypertension or hyperlipidemia which are continuous throughout (and not bimodal) in a population, and where the importance of diagnosis and treatment has been shown (7).
The cause of ADHD is still being elucidated. Brain imaging studies (including MRI, PET and SPECT) show differences compared to healthy controls (8). There is a significant genetic inheritance component. Studies have started to implicate genes for dopamine in ADHD. This correlates with the fact that medications clinically helpful for ADHD involve dopamine transmission. Also, imaging studies have shown the frontostriatal regions of the brain to be important, which are rich in dopamine related neurons. Lastly, mice with impaired dopamine transport mechanisms, are hyperactive and resistant to medications (9).
Once diagnosed, ADHD appears to continue into the teen years for about 3/4 of the diagnosed pre-teen school aged children. Untreated, they often have more severe problems with their peers and family. Problems are worsened because of the multiple previous experiences of failing in endeavors, and also the bad relationship patterns that have been built up with family members (10). One half will have oppositional defiant disorder (ODD), conduct disorder (CD), or another psychiatric diagnosis in their teen years. Also, 1/4 will have comorbid learning disabilities (LD), which can be seen in a discrepancy between their scores in tests of learning ability as compared with achievement.
Interviewing the child and family is of utmost importance. Detailed history gathering will reveal the child's characteristics. Also the history should reveal whether the child's problem is in single vs. multiple settings, and how long symptoms have been noted over time. One needs to be careful not to use the child's appearance in the clinic visit as a measure of the child's problems. Children with (and without) ADHD often look different in structured, supervised, and/or novel settings such as a doctor's exam room. Although some children will show inattentiveness and hyperactivity in the clinic office, some children with severe ADHD may look fine in this setting (8).
Tools that can help in the diagnosis of ADHD include parent-child structured interviews which psychologists and psychiatrists are often familiar with, and ADHD behavioral rating scales which most child professionals have some familiarity with. Barkley, in his well known handbook for assessment and treatment of ADHD has detailed chapters regarding these (11). He finds that ADHD specific behavioral rating scales can be useful for a diagnostic assessment of a child or adolescent. Other reasons for using behavioral rating scales include evaluation of response to medication or child response to parent training in behavioral management. An analysis has shown the use of more global behavioral rating scales to not as effectively detect ADHD compared to ADHD specific scales (2).
After this careful information gathering, a clinician needs to decide if a particular child meets criteria for ADHD and whether an alternative diagnosis is primary. Other disorders that can affect attention include anxiety disorders, mood disorders, substance abuse, and schizophrenia. Head injury, seizure disorders, and brain infections can lead to symptoms of ADHD (8). Although hypothyroidism, fragile X syndrome, glucose-6-phosphate dehydrogenase deficiency and phenylketonuria have all been associated with ADHD, testing for these conditions have very low yields and are not suggested unless the history or physical suggests these in other ways (8). Also electroencephalograms (EEGs) and computerized Continuous Performance Tests (CPTs) have not shown sufficient consistent discrimination between children with and without ADHD (2). Children with lead toxicity as toddlers or preschoolers show normal lead levels by the time they are tested in the school age years. Therefore lead screening is also not recommended on a routine basis (2).
The conditions that are most commonly confused with ADHD are mood disorders and anxiety disorders (8). Both of these disorders are often episodic (and not continuous and unremitting like ADHD), with a later age onset compared to ADHD. Some clinicians like to treat the mood or anxiety disorder first, if one of these are suspected, and see if the symptoms of ADHD resolve.
Comorbid conditions that are often found in combination with ADHD include ODD, CD, LD, Tourette's disorder and speech/language disabilities. All of these may also be disorders that may mimic ADHD in some ways (for example a child who appears inattentive because of language processing disorders) but have substantial differences in criteria from ADHD.
Treatment of ADHD requires understanding of four aspects delineated in a recent American Academy of Pediatrics guideline (12):
1) ADHD is a chronic condition. Physicians should be working with families and schools over the long term to help support these children into adulthood. Follow-up over years is required. Initially the clinician needs to inform the family about ADHD. Then this provider will need to work with the family in coordinating other professionals as necessary, involve the family in treating the child and debriefing the situation, and connect the family to support groups as they desire.
2) Target symptoms need to be addressed. Physicians need to negotiate with the child's family and school over which target symptoms will be addressed at any particular time. These target symptoms should have the potential of being improved upon with appropriate support. These also need to be explicit and measurable. An example of a poor target would be to request the child to be a "good" child. More appropriate targets would include: a) Improvement of the relationships with people the child interacts with; b) Abating behaviors that interfere with the activities of others; c) Working on schoolwork being completed with improved accuracy and decreasing the time necessary for completion; d) Being able to work without supervision in schoolwork, homework and activities of daily living; e) Having better self esteem; and f) Improving safety skills.
3) Medication and behavior strategies are important. Many parents want to use only behavioral strategies rather than medication. Interestingly, the American Academy of Pediatrics' review that examined different treatments of ADHD rated medication as "good" and behavioral strategies as "fair" in strength of evidence. This was particularly affected by the Multimodal Treatment of children with ADHD (MTA) study (13). This study randomized 579 children with ADHD from ages 7 to almost 10 years of age to different groups: medication management alone, medication and behavior management, behavior management alone, and a standard community care group. Both groups that involved medication showed a substantial decrease in important ADHD symptoms over a 14 month period. The combined treatment group showed improved academic measures, measures of conduct, and some specific ADHD symptoms (although not on global ADHD symptom scales) compared to the single treatment groups. In reviewing most of the studies comparing behavior therapy with stimulants alone, there seems to be a much stronger effect from stimulants than with behavior therapy (9).
Medications used in ADHD include stimulants such as methylphenidate and dextroamphetamine; antidepressants such as imipramine and desipramine; and alpha-adrenergics such as clonidine. One of the stimulants, pemoline, was more widely used in the past but this has been advised against because of toxic hepatitis and acute hepatic failure (about 4 to 17 times the expected rate). Monitoring liver function tests usually does not alert the practitioner quickly enough to prevent the rapid progression of liver failure. The other more widely used stimulants have no such liver toxicity. Methylphenidate and dextroamphetamine have side effects such as appetite suppression (about 80%) and insomnia. Overall either of these two medications may cause short term slowing of weight gain and growth but long term effects are minimal. Tics may be precipitated in those predisposed to them, with improvement often seen while on drug holidays (9). A new non-stimulant medication, atomoxetine (Strattera) is now an available treatment option.
Stimulant medications show quick and often dramatic results in the ADHD characteristics of children. Unfortunately children without ADHD have similar behavioral responses so the response from medication should not be used as a diagnostic trial. Interestingly, good behavioral effects have been repeatedly shown but long term academic effects have not been shown in any long term trial yet. Antidepressants have also shown good initial efficacy but not sustained effects compared to stimulants. These medications are usually reserved for those with coexisting disorders (such as depression and tics) since they have a higher risk of sudden death which cannot be predicted with plasma drug levels or electrocardiography. Clonidine has also led to sudden death when used in combination with methylphenidate. This medication has a patch form that some families prefer. Serotonin-reuptake inhibitors have no evidence based effects that have been shown (9). Newer delivery systems for more sustained release of stimulant medication (such as Concerta, a time released form of methylphenidate) show great promise. They enable a dose prior to school that lasts 12 to 14 hours, rather than requiring the child to go to the school nurse to obtain another dose after the 4 to 5 hour duration of a short acting stimulant (14).
Behavioral Strategies for children with ADHD include: a) Positive reinforcement (providing desired reinforcers contingent on the child's behavior and activity); b) Time-out (using ignoring and isolation away from desired activity); c) Response cost (taking away rewards or privileges if undesired activity takes place); and d) Token economy (a form of positive reinforcement where the child obtains "tokens" such as stars that can be collected towards a even more strongly desired reward) (12).
4) Close follow-up of target symptoms and medication use. Reevaluation of whether the child has ADHD, a comorbid diagnosis, or another diagnosis altogether is important. Target symptoms should be measured by multiple methods if possible and treatment modified as necessary. These reevaluations and monitoring should be done periodically and consistently. The frequency of followup would depend of the severity of ADHD, other important comorbid conditions or factors, and the effects and complications of treatment.
In the past it was thought that most children with ADHD would have most of these symptoms abate when they become adults (after a rocky adolescence as mentioned above). It is known that many still have the characteristics for the criteria of ADHD in adulthood, and many have significant problems in work, school or other environments (3). Because of the genetic predisposition, many of the parents of the children seen for ADHD will also have ADHD. This complicates management since parents are essential for the child with ADHD to administer medication, and to ensure behavioral follow-through and academic planning.
Questions
1. True/False: A child psychiatrist is necessary to diagnose and manage children with ADHD
2. The different subtypes of ADHD in DSM-IV-TR relate to criteria around (select all that apply:)
. . . . a. Inattention
. . . . b. Particular learning disability
. . . . c. Impulsivity
. . . . d. Hyperactivity
. . . . e. Gender
3. Evidence is accumulating that shows ADHD to be connected to (select one):
. . . . a. Serotonin
. . . . b. Mast cells
. . . . c. Cortical sleep centers
. . . . d. Dopamine
. . . . e. Mental retardation
4. Which is the LEAST important concern in managing children with ADHD? (select one):
. . . . a. Parents of children with ADHD may have ADHD themselves.
. . . . b. Target symptoms need to be addressed.
. . . . c. The teen years.
. . . . d. Side effects from Pemoline use.
. . . . e. Growth problems from psychostimulant use.
5. Which should be used routinely in the evaluation of school aged children with ADHD? (select one):
. . . . a. Lead screening.
. . . . b. Electroencephalograms (EEGs).
. . . . c. ADHD specific behavioral rating scales.
. . . . d. Fragile X chromosomal testing.
. . . . e. Parent depression inventory.
6. Which is a common comorbid condition with ADHD?
. . . . a. Learning Disability
. . . . b. Autism
. . . . c. Obsessive Compulsive Disorder
. . . . d. Diarrhea
. . . . e. Seizure disorder
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 2000, Washington DC: American Psychiatric Association.
2. Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, American Academy of Pediatrics. Clinical practice guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics 2000;105(5):1158-1170.
3. Barkley RA. Attention-Deficit Hyperactivity Disorder. Scientific American September 1998;273:66-71.
4. Swanson JM, Sergeant JA, Taylor E, Sonuga-Barke EJS, Jensen PS, Cantwell DP. Attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet 1998;351:42933.
5. Agency for Health Care Policy and Research. Diagnosis of attention-deficit/hyperactivity disorder. AHCPR Technical Review 1999;3:1-114.
6. Cantwell DP. Attention deficit disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35(8):978-987.
7. National Institutes of Health. Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). NIH Consens Statement 1998;16(2):1-37.
8. Zametkin AJ and Ernst M. Problems in the management of attention-deficit-hyperactivity disorder. N Engl J Med 1999;340(1):40-46.
9. Elia JE, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med 1999;340(10):780-788.
10. Schubiner, HH and Robin AL. Attention-deficit/hyperactivity disorder in adolescence. Adolescent Health Update 1998;10(3):1-8.
11. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 1990, New York: Guilford Press.
12. Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, American Academy of Pediatrics. Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108(4):1033-1044.
13. Jensen P, Arnold L, Richters J, et al. 14-month randomized clinical trial of treatment strategies for attention deficit hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073-1086.
14. Wingert P. No more 'afternoon nasties': A new rival of Ritalin keeps kids out of the nurse's office. Time December 4, 2000;p 59.
Answers to questions
1. False, 2.a,c,d, 3.d, 4.e, 5.c, 6.a