Attention-Deficit / Hyperactivity Disorder
- 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).
- The DSM-5 has an extensive, but not exhaustive, list of criteria for ADHD. For these detailed criteria, please see the DSM-5 itself.
- 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.
- 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
- 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
- e.g., the Vanderbilt ADHD Diagnostic Parent Rating Scale, the SNAP Parent and Teacher Rating Scales, the Disruptive Behavior Disorder Parent and Teacher Rating Scales
- Broad-band measures of psychopathology
- 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
- Oppositional defiant disorder
- Conduct disorder
- Anxiety disorders
- Depressive/mood disorders
- Substance use disorders
- Developmental disorders (e.g., autism spectrum disorders)
- Learning disorders or intellectual limitations
- Sleep disorders
- Obsessive-compulsive disorder
- Epilepsy and other neurological disorders
- Elimination disorders (e.g., enuresis, encopresis)
- 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.
- 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.
- 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.
- 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
- 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.
- 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.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
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