Your Family Physician

Diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in the primary care setting are reviewed in an article published in the April 15 issue of the American Family Physician.

"...ADHD is a chronic, neurobiologic, behavioral disorder that affects 2 to 16 percent of school-aged children, depending on the diagnostic criteria and population studied (e.g., primary care versus referral)," write Robert Rader, MD, DPh, from Saint Anthony Family Medicine Residency in Oklahoma City, Oklahoma, and colleagues. "The symptoms of ADHD affect cognitive, academic, behavioral, emotional, social, and developmental functioning....Although there are many theories, no single etiology for ADHD has been substantiated."

ADHD is the most frequently diagnosed neurodevelopmental disorder in children and adolescents. Although the pathogenesis of ADHD is still poorly understood, most recent studies have attempted to clarify the role of neurotransmitters including dopamine, norepinephrine, and, most recently, serotonin.

Three general subtypes of ADHD have been identified for purposes of classification: predominantly hyperactive-impulsive, predominantly inattentive, and combined. To facilitate diagnosis and management, screening tools and rating scales have been developed. These include broadband assessments, narrowband assessments, and evaluation of medication adverse effects.

The functioning of the child with ADHD and the quality of life of the patient and family can be dramatically improved with appropriate treatment. A combination of pharmacotherapy and behavioral management is usually recommended.

Pharmacologic treatment includes methylphenidate, mixed amphetamine salts, or other stimulants, and/or nonstimulants such as atomoxetine. There is no evidence supporting the use of 1 stimulant vs another, and short-acting, intermediate-acting, and long-acting preparations have similar effectiveness. Short-acting preparations timed appropriately may facilitate certain activities, whereas long-acting formulations eliminate the need to give medication during school, improve compliance, and decrease opportunity for abuse.

"Treatment should be initiated at low dosages and then titrated over two to four weeks until an adequate response is achieved or unacceptable adverse effects occur," the study authors write. "If one stimulant is not effective, another should be attempted before second-line medications are considered. Although some children benefit from daily psychostimulant therapy, weekend and summer 'drug holidays' are suggested for children whose ADHD symptoms predominantly affect schoolwork or to limit adverse effects (e.g., appetite suppression, abdominal pain, headache, insomnia, irritability, tics)."

Behavioral approaches are also effective, especially those that immediately reward desirable behavior with tokens or points. The efficacy of psychotherapy and cognitive behavioral therapy for the treatment of ADHD has not been tested in high-quality studies.

Key clinical recommendations for practice, and their accompanying level of evidence, are as follows:

• Obtaining information from teachers, family members, and non–family members who are familiar with the child's behavior is essential to properly diagnose ADHD (level of evidence, C).

• The first-line treatment for most patients with ADHD is pharmacologic treatment with stimulant medication (level of evidence, A).

• Compared with intensive behavioral treatment alone, carefully monitored pharmacotherapy is typically more effective for ADHD (level of evidence, B).

• Support groups for parents of children with ADHD facilitate networking with others who have children with similar problems (level of evidence, B).

Combined recommendations from the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry (AACAP) for the evaluation of children with suspected ADHD are as follows:

• A child aged 6 to 12 years presenting with inattention, hyperactivity, impulsivity, academic underachievement, or behavioral problems should be evaluated for ADHD by the primary care physician. This evaluation should include the following:

o Standard history and physical examination. The AACAP also recommends evaluating the patient's developmental history, hearing and vision, history of learning difficulties or psychiatric disease illness, and family history of ADHD.

o Neurologic examination

o Family evaluation. The AACAP also recommends assessment of family stressors and family coping style.

o School evaluation.

• Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV) diagnostic criteria for ADHD must be met to diagnose this condition.

• Information obtained directly from parents or caregivers is needed for accurate diagnosis of ADHD. This should include a description of the main symptoms of ADHD in different settings, age at onset of symptoms, duration of symptoms, and severity of functional impairment.

• Information obtained directly from the classroom teacher, or other school-based professional, should be an important part of the evaluation for ADHD. This should highlight information regarding the core symptoms of ADHD, duration of symptoms, severity of functional impairment, and comorbid conditions. The physician should review all available reports from a school-based multidisciplinary evaluation, including evaluations from the child's teacher or other school-based professional.

• Assessment of a child with ADHD should include workup for comorbid conditions including learning and language disabilities, oppositional defiant disorder, conduct disorder, anxiety, and depression.

• Diagnostic testing in the absence of specific indications is not routinely recommended. Tests that might be appropriate in certain clinical settings include measurement of lead and thyroid hormone levels, neuroimaging, and/or electroencephalography.

In an editor's note, Caroline Wellbery, MD, writes: "As this article was going to press, a study by Molina and colleagues [J Am Acad Child Adolesc Psychiatry. 2009 Epub ahead of print.] was released questioning the long-term effectiveness of ADHD drug therapy. The study showed that there were no significant differences among pharmacologic, behavioral, and combined therapy groups after six to eight years, and that all children in the study had significant impairment compared with unaffected peers."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;79:657-665.
Clinical Context

ADHD is a chronic, biologic behavioral disorder that affects 2% to 16% of school-aged children. There is no single cause, but neurotransmitters such as dopamine, norepinephrine, and serotonin have been implicated. Recent studies suggest no association between a child's sex and the disorder.

This is a review of the diagnostic criteria for ADHD and management strategies in children.
Study Highlights

* DSM-IV criteria require that at least 6 of 9 symptoms of either inattention or hyperactivity-impulsivity be met, in discrete settings, and that they be present for more than 6 months, with onset before age 7 years.
* The DSM-IV criteria recognize 3 subtypes: predominantly hyperactive-impulsive, predominantly impulsive, and combined.
* The hyperactive-impulsive subtype is fidgety and restless, on the go, and has difficulty waiting and sitting still.
* The inattentive subtype is easily distracted, forgetful, disorganized with poor concentration, and has difficulty completing tasks.
* The combination subtype exhibits in both types of traits.
* Consequences of ADHD in adolescence include antisocial behavior, cognitive fatigue, legal problems, ineffective self-monitoring, low self-esteem, risk taking, and substance abuse.
* The American Academy of Pediatrics and the AACAP provide 6 recommendations for the evaluation of children suspected of having ADHD.
* The initial evaluation should include history and physical examination, neurologic examination, and family and school assessment.
* Diagnostic testing such as neuroimaging is not routinely recommended.
* DSM-IV criteria should be met before a diagnosis is made.
* Evidence on the core symptoms of ADHD should be obtained directly from parents or caregivers.
* Reports from schools and multidisciplinary reports should be assessed.
* Coexisting conditions such as learning disabilities and conduct disorders should be considered.
* Key recommendations are family and teacher input into assessment, use of stimulant medications as first-line treatment, use of monitored pharmacotherapy, and provision of support groups for parents.
* ADHD is considered a clinical diagnosis and coexists with other conditions.
* Estimated comorbidity rates are 10% to 90% for developmental disorder, 15% to 75% for mood disorder, 35% to 65% for oppositional defiant disorder, 20% to 40% for substance abuse, and 25% for anxiety.
* Stimulants used as first-line treatment include methylphenidate and mixed amphetamine salts with no good evidence to support 1 stimulant vs another.
* Long-acting formulations improve compliance and decrease abuse potential.
* Treatment should be initiated at low doses and titrated during 2 to 4 weeks.
* Weekend and summer drug holidays are suggested to limit adverse effects such as appetite suppression, headache, irritability and tics.
* Serious effects include delays in growth, sudden death, and cardiovascular problems, but these effects are rare.
* Atomoxetine is the first nonstimulant medication approved by the US Food and Drug Administration for ADHD and should be considered if the child does not respond to stimulants or if there is a concern about stimulant abuse.
* Atomoxetine should be discontinued if liver problems or jaundice occurs, and there is a black box warning about suicidal ideation.
* Bupropion is an alternative treatment especially in the presence of mood disorder, but a history of seizure disorder is a contraindication.
* The tricyclic antidepressants imipramine and desipramine can effectively control core ADHD symptoms and should be titrated up.
* Clonidine can be used as a single-dose agent, titrated slowly for 2 to 4 weeks at bedtime.
* Behavioral interventions that have been shown to be useful include rewards for good behavior and consequences for poor behavior, and parental support and training.
* Psychotherapy and cognitive behavioral therapy have no documented efficacy for ADHD.
* Combination pharmacotherapy and behavioral therapy is as effective as pharmacotherapy alone and is more effective than behavioral therapy alone.

Clinical Implications

* The DSM-IV criteria require at least 6 of 9 symptoms to be met for hyperactivity-impulsivity or inattention, duration of more than 6 months, and onset before age 7 years.
* First-line treatment of ADHD is stimulant medications, followed by atomoxetine or antidepressants, and reward and consequences and parental support are used for behavior modification.

Source : http://cme.medscape.com/viewarticle/701882?src=cmemp