Johns Hopkins Psychiatry Guide

Attention-Deficit / Hyperactivity Disorder

Matthew Burkey, M.D., Carisa Perry-Parrish, Ph.D.

DEFINITION

  • Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental, chronic disorder involving a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development.
  • ADHD is classified under the Neurodevelopmental Disorders section of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [1].
    • The DSM-5 has an extensive, but not exhaustive, list of criteria for ADHD. For these detailed criteria, please see the DSM-5 itself [1].
    • The criteria-based diagnosis requires meeting of inattention and/or hyperactivity-impulsivity criteria, onset before age 12, occurrence in two or more settings, and resulting impairment in functioning.

EPIDEMIOLOGY

  • Population studies suggest that ADHD occurs in most cultures in 5% of children and 4.4% of adults.
  • More frequent in males than females, with ratio of 2:1 in children and 1.6:1 in adults
    • Females may be more likely to present primarily with inattentive features.
  • Risk factors:
    • Temperament (e.g., reduced behavioral inhibition and effortful control, increased negative emotionality and novelty-seeking)
    • Environmental (e.g., very low birth weight: < 1500g, in utero exposures)
    • Genetic: substantial heritability

DIAGNOSIS

Clinical Presentation

  • ADHD is a multifaceted disorder which varies greatly in symptom type and severity.
  • Along with inattention, hyperactivity, and impulsivity, difficulties with emotion regulation, cognitive deficits, and multiple comorbidities are common (e.g., learning disorders, oppositional defiant disorder).
  • ADHD is often a lifelong disorder, with 85% of adolescents and 50% of adults exhibiting residual symptoms.
  • Poor social/interpersonal functioning and negative self-attitude are common, along with poor frustration tolerance and irritability.
  • ADHD is associated with increased risk for later depression and suicide attempts.

Tests and Procedures

  • ADHD is a clinical diagnosis based on developmental history, clinical interview regarding symptoms/impairment, and objective ratings of inattention and/or hyperactivity/impulsivity across multiple settings, with multiple informants (e.g., parents, teachers).
  • When assessing adults, collateral and developmental data is needed to document developmental onset.
  • There is no diagnostic laboratory test or imaging modality to diagnose ADHD.
    • However, etiology-specific tests, such as TSH or serum lead levels may be helpful when hyperthyroidism or lead poisoning are suspected by history or examination.
  • In the pediatric population, common ADHD screening measures include:
    • Broad-band measures of psychopathology
      • e.g., the Child Behavior Checklist, the Behavior Assessment Scale for Children
    • Narrow-band measures that are specific to ADHD and common comorbidities
  • For the adult population, there are a few ADHD-specific screening tools available for self and informant ratings:
    • e.g., the Barkley Adult ADHD Rating Scale–IV, the Adult ADHD Self-Report Scale, the Conners Adult ADHD Rating Scale (CAARS)
    • Some measures focus on assessment of childhood ADHD symptoms in patients who present as adults.
      • e.g., the Wender Utah Rating Scale
  • Some patients may benefit from psychological testing to clarify whether cognitive deficits should be addressed in treatment.
    • e.g., to assess for low intelligence, executive dysfunction, and learning disabilities
  • Computerized tests show modest correlations with parent and teacher ratings and do not detect inattention unique to ADHD.
    • e.g., the CPT-II

Differential Diagnosis

TREATMENT

General

  • A combination of stimulant medication and behavior therapy is first-line treatment.
  • Treatment may involve home-, clinic-, and school-based efforts.
  • Psychoeducation is useful to increase parent, teacher, and self-knowledge about ADHD symptoms and effects on behavior and emotions.
  • Family involvement and control of behaviors (e.g. noncompliance, oppositionality, rule-breaking) are beneficial.

Pharmacotherapy

  • Most youths and adults with ADHD respond favorably to psychostimulants (e.g., derivatives of methyphenidate and amphetamine).
    • Efficacy in preschoolers is more modest.
    • Common adverse effects include appetite decrease, weight loss, insomnia, and headache.
      • These may improve with dose adjustment or switching to another stimulant.
    • Coexisting substance use disorders may increase the risk for diversion of stimulants.
      • Osmotic delivery systems (e.g., Concerta) may reduce inappropriate use.
    • For young patients and any patients with difficulties swallowing pills, liquid preparations are available.
      • e.g., dextroamphetamine, ProCentra, methylphenidate HCl, Quillivant
  • Nonstimulant medications have more modest effects and typically take longer to produce therapeutic responses.
    • e.g., atomoxetine, guanfacine, and bupropion
    • These may be useful when stimulants side effects are intolerable, or as adjunctive treatment.
  • To optimize medication treatment, pre- and post-treatment parent and teacher ratings are recommended until adequate dosing is achieved with minimal adverse effects.

Psychotherapy

  • Behavior therapy (i.e., parent management training) is effective as front-line treatment for mild ADHD and recommended as an adjunctive treatment for moderate-to-severe ADHD.
  • Comorbid disruptive behavior (e.g., ODD) is also an indication for behavior therapy.
  • Cognitive behavioral therapy (CBT) may be appropriate in older children, adolescents, and adults with comorbid internalizing symptoms (e.g., anxiety, depression).
  • CBT in older adolescents and adults on stable stimulant doses may help manage residual symptoms of ADHD (e.g., disorganization, time management).
  • Consulting with schools about behavior management and supports is recommended.

Other

  • ADHD is a chronic disease with early onset and frequent progression into adulthood.
  • Engagement in prosocial, healthy activities is recommended (e.g., sports, social activities, exercise).
  • Vitamins, dietary supplements, and other alternative/complementary approaches lack scientific evidence of effectiveness.

WHEN TO REFER

  • Pediatricians and other primary care physicians manage the majority of patients with ADHD.
    • Pediatricians are well-positioned to diagnose and treat uncomplicated ADHD.
  • ADHD without hyperactivity/impulsivity may be more difficult to detect.
  • ADHD over diagnosis and over treatment may be common in some community settings.
  • Seek psychiatrist consultation if the patient exhibits unusual reactions to stimulants or fails three trials of stimulant medications.
    • Patients with preexisting cardiac disease should undergo cardiologic evaluation prior to initiating a stimulant medication.
  • Consider referring to a child psychologist or psychiatrist when multiple comorbid conditions.
    • e.g., learning issues, social problems, internalizing/externalizing disorders

FOLLOW UP

  • The need for ongoing behavior therapy can be determined by a child’s level of functional impairment and co-occurring behavioral difficulties.
  • Annual medication-free periods are recommended to reassess the need for medication and optimize dosing.

COMMENTS

  • ADHD is associated with other psychiatric disorders, notably disruptive behavior problems, internalizing disorders, and later substance use problems.
    • These will need to be addressed during treatment.
  • All ADHD subtypes in childhood predict adolescent depression/dysthymia and suicide attempts, underlining the need for ongoing treatment across development.
  • Attention and impulsivity/hyperactivity are dimensional in nature.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. Adler LA et al: Self-Reported quality of life in adults with attention-deficit/hyperactivity disorder and executive function impairment treated with lisdexamfetamine dimesylate: a randomized, double-blind, multicenter, placebo-controlled, parallel-group study. BMC Psychiatry 13:, 2013  [PMID:24106804]
  3. Amador-Campos JA, Gómez-Benito J, Ramos-Quiroga JA: The Conners' Adult ADHD Rating Scales--Short Self-Report and Observer Forms: Psychometric Properties of the Catalan Version. J Atten Disord Jul 6  [PMID:22771453]
  4. Becker SP et al: Sluggish Cognitive Tempo is Associated With Academic Functioning and Internalizing Symptoms in College Students With and Without Attention-Deficit/Hyperactivity Disorder. J Clin Psychol Sep 24  [PMID:24114716]
  5. Chronis-Tuscano A et al: Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 67:1044, 2010  [PMID:20921120]
  6. Greenhill LL et al: Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 41:26S, 2002  [PMID:11833633]
  7. Kessler RC et al: The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 163:716, 2006  [PMID:16585449]
  8. Lara C et al: Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative. Biol Psychiatry 65:46, 2009  [PMID:19006789]
  9. McGee RA, Clark SE, Symons DK: Does the Conners' Continuous Performance Test aid in ADHD diagnosis? J Abnorm Child Psychol 28:415, 2000  [PMID:11100916]
  10. Riccio CA, Reynolds CR: Continuous performance tests are sensitive to ADHD in adults but lack specificity. A review and critique for differential diagnosis. Ann N Y Acad Sci 931:113, 2001  [PMID:11462737]
  11. Ward MF, Wender PH, Reimherr FW: The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 150:885, 1993  [PMID:8494063]
  12. Wilens TE, Spencer TJ, Biederman J: A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord 5:189, 2002  [PMID:11967475]
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Last updated: November 6, 2014