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ARTICLE IN PRESS

Attention Deficit/Hyperactivity Disorder:


A Review and Update

Eileen Cormier, PhD, RN

Attention deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and pervasive childhood disorder characterized by
developmentally inappropriate activity level, impulsivity, and inability to sustain attention and concentration. Core symptoms of
the disorder are associated with impairment in multiple domains of functioning and often coexist with other psychiatric
disorders, the most prevalent being oppositional defiant disorder, conduct disorder, depression, and anxiety disorders. Concerns
have been expressed about the overdiagnosis of ADHD, an upsurge in prescription of stimulant medication, and wide variations
in practice patterns related to diagnosis and treatment of children with ADHD among primary care providers. Clinical research
and expert consensus guidelines over the past decade have increasingly clarified the most effective approaches to diagnosis and
treatment of the disorder. Hence, the purpose of this article was to provide primary care providers with the most current,
evidence-based information on the assessment and treatment of children with ADHD.
2008 Published by Elsevier Inc.

Key words: Attention deficit/hyperactivity disorder; Diagnosis; Treatment

A TTENTION DEFICIT/HYPERACTIVITY
disorder (ADHD) is a chronic, pervasive
childhood disorder characterized by developmen-
effective treatments. Public interest in the disorder
has increased, including debate in the public media
concerning the diagnostic process and treatment
tally inappropriate activity level, low frustration choices (Timimi, 2006). Concerns have been
tolerance, impulsivity, poor organization of beha- expressed about the overdiagnosis of ADHD,
vior, distractibility, and inability to sustain attention including the increasing numbers of preschoolers
and concentration (American Psychiatric Associa- who are diagnosed, the severalfold increase in
tion, [APA], 2000). It is one of the more common prescription of stimulant medication, and wide
childhood disorders, occurring in 3% to 7% of variations in practice patterns related to diagnosis
school-age children and representing one third to and treatment of children with ADHD among
one half of referrals to child mental health services primary care providers (Goldman, Genel, Bezman,
(Argold, Erkanli, Egger, & Costello, 2000; Faraone, & Slanetz, 1998; Robison, Sclar, Skaer, & Galin,
Sergeant, Gillberg, & Biederman, 2003). The core 1999; Stevens, 2005; Wilens et al., 2002; Zito
symptoms of ADHD are associated with impair- et al., 1999).
ments in several domains of functioning, including Although controversies in the medical literature
academic achievement and deportment at school, and popular media persist, there has been a
interactions with parents and siblings, and peer concerted effort on the part of the scientific
relationships (Barkley, 2006; Root & Resnick, community to identify the most appropriate and
2003). Children diagnosed with ADHD also have empirically supported diagnostic and treatment
a higher likelihood of coexisting psychiatric dis- approaches to children with ADHD. Furthermore,
orders and usually continue to have problems clinical practice guidelines have been developed
attributable to ADHD as adults that require treat-
ment (Brassett-Harknett & Butler, 2007; Gillberg From the Florida State University
et al., 2004; Resnick, 2000; Wender, 1995). Corresponding author: Eileen Cormier, PhD, Florida State
The core symptoms of ADHD, the associated University College of Nursing, 421 Vivian M. Duxbury Hall,
functional deficits and comorbid disorders, and the Tallahassee, FL 32306-4310.
E-mail: eCormier@nursing.fsu.edu
risk for ongoing problems as adults underscore the 0882-5963/$ - see front matter
seriousness of ADHD as a childhood condition © 2008 Published by Elsevier Inc.
and the importance of appropriate diagnosis and doi:10.1016/j.pedn.2008.01.003

Journal of Pediatric Nursing, Vol 00, No 00 (June), 2008 1


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2 EILEEN CORMIER

that provide evidence-based recommendations for Table 1. Diagnostic Criteria for ADHD
assessment and treatment of ADHD by primary A. Either 1 or 2:
care providers (American Academy of Child and 1. Six (or more) of the following symptoms of inattention have persisted
Adolescent Psychiatry [AACAP], 1997, 2002; for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level:
American Academy of Pediatrics [AAP], 2000, Inattention
2001). Based on a review of pertinent research and (a) Often fails to give close attention to details or makes careless
practice guidelines, the purpose of this article was mistakes in schoolwork, work, or other activities
to provide primary care providers with the most (b) Often has difficulty sustaining attention in tasks or play activities
(c) Often does not seem to listen when spoken to directly
comprehensive, current information to date on the
(d) Often does not follow through on instructions and fails to finish
assessment and treatment of children with ADHD. 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
HISTORICAL CONTEXT OF ADHD (f) Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
Hyperactivity in children was first described
(g) Often loses things necessary for tasks or activities (e.g., toys, school
clinically in 1902, and the first report of stimulant assignments, pencils, books, or tools)
use to treat hyperactivity in that condition was in (h) Is often easily distracted by extraneous stimuli
1937 (Bradley, 1937). Initially, the condition was (i) Is often forgetful in daily activities
called minimal brain dysfunction due to the high 2. Six (or more) of the following symptoms of hyperactivity/impulsivity
frequency of “soft” neurological findings and the have persisted for at least 6 months to a degree that is maladaptive
and inconsistent with developmental level:
expectation that consistent neurological legions Hyperactivity
would eventually be found (Clements, 1966). As (a) Often fidgets with hands or feet or squirms in seat
the association of brain damage became less (b) Often leaves seat in classroom or in other situations in which
certain, the nomenclature changed to reflect an remaining seated is expected
(c) Often runs about or climbs excessively in situations in which it is
emphasis on hyperactivity as the primary beha-
inappropriate (in adolescents or adults, may be limited to
vioral deficit. Subsequently, in the Diagnostic and subjective feelings of restlessness)
Statistical Manual of Mental Disorders, Second (d) Often has difficulty playing or engaging in leisure activities quietly
Edition (DSM-II), it was called hyperkinetic reac- (e) Is often “on the go” or often acts as if “driven by a motor”
tion of childhood disorder (APA, 1967). (f) Often talks excessively
In 1980, the DSM-III publicized a new name, Impulsivity
(g)Often blurts out answers before questions have been completed
attention deficit disorder, and delineated the first (h) Often has difficulty awaiting turn
empirically based set of diagnostic criteria. Again, (i) Often interrupts or intrudes on others (e.g., butts into conversations
the focus on hyperactivity as the primary deficit or games)
shifted to inattention but was amended in the 1987 B. Some hyperactive/impulsive or inattentive symptoms that caused
revision of DSM-III to give equal weight to impairment were present before age 7
C. Some impairment from the symptoms is present in two or more
inattention and hyperactivity problems (APA, settings (e.g., at school [or work] and at home)
1980, 1987). The currently accepted criteria D. There must be clear evidence of clinically significant impairment in
for making an ADHD diagnosis appears in the social, academic, or occupational functioning
fourth edition of the DSM (APA, 1994), which E. The symptoms do not occur exclusively during the course of a
pervasive
enumerates three subtypes for ADHD: (a) pre-
disorder, schizophrenia, or other psychotic disorder and are not better
dominantly inattentive type, (b) predominantly accounted for by another mental disorder (e.g., mood disorder,
hyperactive/impulsive type, and (c) combined anxiety disorder, dissociative disorder, or a personality disorder).
type (this includes inattention and hyperactivity/
Note. Reprinted with permission from the Diagnostic and Statisti-
impulsivity symptoms). cal Manual of Mental Disorders, Copyright 2000. American
Psychiatric Association.

DIAGNOSTIC CRITERIA FOR ADHD


In DSM-IV-TR (APA, 2000), diagnostic deci-
sion-making centers on two 9-item symptom of predominantly inattentive type or hyperactive/
listings––one related to inattention symptoms and impulsive type. For a diagnosis of ADHD com-
the other to hyperactivity-impulsivity concerns bined type, more than six symptoms must be
(Table 1). Parents and/or teachers must report the present from both lists. Such behaviors have an
presence of at least six of nine behaviors from either onset prior to 7 years of age, duration of at least
list to warrant consideration of an ADHD diagnosis 6 months, and a frequency above and beyond that
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ADHD REVIEW AND UPDATE 3

expected in children of a comparable level of report and receive treatment for ADHD, regardless
development. Furthermore, they must be evident in of socioeconomic status (Pastor & Reuben, 2005).
two or more settings, have a clear impact on
psychosocial functioning, and not be due to other
types of mental health or learning disorders that DEVELOPMENTAL COURSE AND
might better explain their presence (APA, 2000). OUTCOME
Clinical research has been supportive of the Many parents of children with ADHD recall that
validity of the DSM-IV subtypes of ADHD, their child was excessively active, intense, and
although there remain unresolved issues, such as demanding as an infant and toddler (Bussing,
developmental variations in behavior, the influence Lebninger, & Eyberg, 2006). Most, however, first
of comorbid learning disabilities, gender differ- display clear signs of developmentally inappropri-
ences, and racial disparities (Hillemeier, Foster, ate inattentive and overactive behavior suggestive
Heinrichs, & Brigitt, 2007; Lahey et al., 1998; of ADHD between 3 and 4 years of age (Barkley,
Morgan, Hynd, Riccio, & Hall, 1996). The 2006). For a smaller number of children, ADHD
extensive review by Egger, Kondo, and Angold symptoms may not be evident until 5 or 6 years of
(2006) suggests that ADHD can be reliably age, corresponding with school entry. The ability to
diagnosed using DSM-IV-TR criteria in preschool sit still, sustain attention, inhibit impulsive beha-
children. Younger children are more likely to be vior, organize actions, and follow through on
diagnosed as predominantly hyperactive/impulsive. instructions, as well as interact appropriately with
Children with either the predominantly hyperactive/ other children is essential to a successful school
impulsive or combined subtypes often as they experience (Cohen, 1993). In view of the expanding
mature change in their presentation to meet the number of children participating in preschool
diagnostic criteria for predominantly inattentive programs that incorporate school readiness curri-
type, as hyperactive and impulsive symptoms are cula, it is not surprising that referrals of preschoo-
reduced or better controlled (Biederman, Mick, & lers for ADHD evaluations have increased so
Faraone, 2000; Goldstein & Goldstein, 1998). dramatically (Wolraich, 2006).
Many support a progression of the disorder from Psychosocial impairment in relationships and
predominantly hyperactive/impulsive as children to functioning across multiple settings becomes more
predominantly inattentive as adolescents and adults apparent in middle childhood (Barkley, 2006; Trott,
(Resnick, 2000; Trott, 2006). 2006). At home, parents must contend with
ongoing behavior problems around chores, self-
help activities (e.g., dressing, bathing, etc.), and
PREVALENCE interactions with siblings. At school, academic
Estimates of the incidence of ADHD vary performance and classroom behavior are often
considerably, ranging 2% to 16%, depending on erratic over time, contributing to underachievement
the diagnostic criteria and assessment tools relative to ability and impaired relationships with
employed (Brown et al., 2001; Faraone et al., teachers and peers. Poor social skills characterized
2003). Using the criteria specified by DSM-IV-TR, by high behavior rate and intensity, vocal noisiness,
approximately 3% to 7% of school-age children intrusiveness, and inability to read and respond to
meet requirements for some type of ADHD social cues eventually creates a pattern of social
diagnosis (Sciutto & Eisenberg, 2007). Predomi- rejection. By late childhood and preadolescence,
nantly hyperactive/impulsive and combined sub- these patterns of academic, familial, and social
types are more common than the inattentive impairment have become well established, and
subtypes among younger children (Egger et al., secondary comorbid problems have emerged
2006). ADHD also occurs more often in boys than (Spencer, Biederman, & Mick, 2007).
in girls, although estimates of the ratio of boys to Historically, it was believed that ADHD symp-
girls vary considerably, with ratios in clinic-based toms were remitted before or during adolescence
samples reported to be as high as 6:1 and as low as (Resnick, 2000). It is currently estimated that as
1:1 in community-based samples (Barkley, 2006). many as 70% of children diagnosed with ADHD in
Although prevalence rates have not been found to childhood continue to exhibit developmentally
vary by race in the United States (Centers for inappropriate levels of inattention and, to a lesser
Disease Control and Prevention, 2005), African extent, symptoms of impulsivity-hyperactivity dur-
American and Hispanic children are less likely to ing adolescence and adulthood (Biederman et al.,
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4 EILEEN CORMIER

1998; Faraone, Biederman, & Monuteaux, 2002). 2003). Propositions that ADHD may be a childhood
Many learn to compensate for these problems and precursor of bipolar disorder, or that bipolar
subsequently make a satisfactory adult adjustment disorder with childhood onset may represent a
(Spenser et al., 2007). For those who do not, mistaken diagnosis of ADHD, have drawn con-
comorbid problems such as depression, substance siderable controversy but remain unresolved (Gill-
abuse, and antisocial pathology are of greater berg et al., 2004).
clinical concern than their ADHD symptoms Developmental disorders are also commonly
(Goodman, 2007; Sobanski, 2006; Weiss & Mur- associated with an ADHD diagnosis. Many chil-
ray, 2003). dren with ADHD experience developmental coor-
dination disorder symptoms and perceptual motor
problems regardless of whether there is an asso-
COMORBIDITY WITH ADHD ciated learning disability, although clumsiness
It is now well established that ADHD is usually becomes less problematic over time (Dewey,
associated with the presence of one or more major Kaplan, Crawford, & Wilson, 2002; Pitcher, Piek,
psychiatric disorders and that these problems are at & Hay, 2003; Raggio, 1999). Asperger's syndrome
least as important as ADHD in predicting the long- has a highest rate of comorbidity with ADHD of the
term outcome of the individual child. It is estimated ASDs (Brassett-Harknett & Butler, 2007; Ehlers &
that as many as two in three children with ADHD in Gillberg, 1993; Ke et al., 2007).
the general population meet criteria for one or more
DSM-IV-TR diagnoses (Gillberg et al., 2004; Jensen
et al., 2001; Jensen, Martin, & Cantwell, 1997; ETIOLOGY
Kadesjo & Gillberg, 2001). The most common Over the past 15 years, significant progress has
coexisting disorders in ADHD are developmental been made in understanding the etiology of child-
coordination disorder, oppositional defiant disorder hood ADHD, largely due to the publication of
(ODD), conduct disorder (CD), depression and family, twin, and adoption studies, which are
anxiety disorder, bipolar disorder, tic disorders, consistent in suggesting genetic and neurological
obsessive compulsive disorder, and autism spec- influences (Brassett-Harknett & Butler, 2007;
trum disorder (ASD; Banascheski, Neale, Rothen- Waldman & Gizer, 2006). About one fourth to
berger, & Roessner, 2007; Steinhausen et al., 2006). one third of biological parents with an ADHD child
Learning disabilities are also common, including are affected by ADHD themselves. A dopamine
central auditory processing disorder, reading dis- transmitter gene (DAT-1) and dopamine receptor
order, disorder of written expression, dysgraphia, gene (DAT-4) have been linked to children with
mathematics disorder, and mental retardation ADHD, and neuroimaging studies have identified
(Gomez & Condon, 1999; Luca et al., 2007; abnormalities of brain structure and function
Maria, Martina, & Cornoldi, 2007; Plizka, 2000). (Faraone, 2006; Valera & Siedman, 2006).
All of these disorders need to be considered in any Traumatic injuries to the brain have also been
child diagnosed with ADHD. associated with behaviors characteristic of ADHD
ODD and CD are the most common comorbid (Levin et al., 2007). Similarly, prenatal exposure to
disorders, with 50% to 60% of children with ADHD alcohol and/or cocaine, birth trauma, and exposure
meeting criteria for ODD and 25% meeting criteria to lead or infections such as meningitis as a young
for CD (Kadesjo & Gillberg, 2001; Lalonde, child have been linked to the later development of
Turgay, & Hudson, 1998). Although many clin- ADHD Brassett-Harknett & Butler, 2007). Con-
icians (and researchers) believe that ADHD pre- siderable attention has also focused on the role of
cedes ODD, which in turn precedes CD, which in food components, in particular, food additives/
turn precedes adult antisocial personality disorder, artificial colors, food allergies, and refined sugar,
this developmental pathway has not been thor- suggesting a causal link to ADHD (Rojas & Chan,
oughly examined in empirical studies (Lavigne 2005; Schnoll, Bursheteyn, & Cea-Aravena, 2003).
et al., 2001; Loeber, Burke, Lahey, Winters, & Zera, Overall, scientific evidence has not supported these
2000). Depression and anxiety disorders are also hypotheses, although a small subset of children has
more common, seen in about one fourth of children been identified who are sensitive to specific
with ADHD (Root & Resnick, 2003). Comorbid artificial flavors, preservatives, and colors (Bate-
bipolar disorder has also been identified in a man et al., 2004; Dengate & Ruben, 2002; Schab &
number of children with ADHD (Kent & Craddock, Trinh 2004). Food sensitivities or allergies can also
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ADHD REVIEW AND UPDATE 5

be involved in provoking behavior problems in degree of functional impairment can be obtained


certain children but do not cause ADHD (Schmidt from parents or caregivers using open-ended
et al., 1997). questions (e.g., What are your concerns about
your child's behavior at school?), focused questions
about specific behaviors, semistructured interview
ASSESSMENT OF ADHD schedules, questionnaires, and rating scales (AAP,
Primary care providers see a variety of school- 2000). Questionnaires and rating scales have been
age children with developmental and behavioral developed that are specific for and quantify
concerns. Based on the high prevalence of ADHD behavioral characteristics of ADHD, such as the
in this population, AAP (2000) recommends asking Connors ADHD Index or the DSM-IV Symptoms
parents about behavioral and/or learning problems scales (both teacher and parent versions), have been
at school during routine visits. In many cases, shown to discriminate adequately between children
requests for evaluation of the child for ADHD with ADHD and those without it (Connors, 1997;
derive from parents, teachers, other professionals, Green, Wong, Atkins, Taylor, & Feinleib, 1999;
or nonparental caregivers, who have identified Tripp, Schaughency, & Clarke, 2006). The AAP
problems in the school setting such as inattentive- (2000) guidelines recommend the use of these
ness, disruptive classroom behavior, academic scales and discourage the use of broadband scales
underachievement, difficulty establishing and that assess a variety of behavioral conditions
maintaining peer relationships, or poor self-esteem. because they have not been shown to distinguish
The overall goals of the assessment are to determine children with and without ADHD. If the child
whether the child meets diagnostic criteria for spends considerable time in other structured
ADHD and rule out other conditions that might environments such as after-school programs,
simulate it (Liu & Leslie, 2003). Thus, a complete ADHD-specific questionnaires can also be used to
physical examination is recommended if one has evaluate the child's behavior in these settings.
not been conducted in the past year. Establishing a Discrepancies between parent and teacher ratings
diagnosis of ADHD involves a synthesis of of child behavior are not unusual and may be in
information from multiple sources with parents as either direction (Swanson, Lerner, March, &
key partners in the assessment process. Gresham, 1999; Wolraich et al., 2004). These
A primary diagnosis of ADHD is contingent on discrepancies may be due to differences between
the presence of developmentally inappropriate the home and school in terms of expectations, level
levels of inattention and/or hyperactivity/impul- of structure, behavioral management strategies,
sivity that are not better explained by other and/or environmental factors. Finding a discre-
medical, psychiatric, or developmental disorders pancy between parents and teachers does not
(AAP, 2000). The child's behavioral symptoms preclude a diagnosis of ADHD, but there should
must also demonstrate a pattern that is enduring, be further information seeking from informants
present across multiple settings (e.g., at home, in such as former teachers, coaches, or religious
school, and with peers), and is causing functional leaders. The situational variability of ADHD
impairment. To make this appraisal, the clinician symptoms makes it essential that the clinician
must be familiar with normal variations in obtain information from any individuals who
development and behavior, solicit data from observe the child across multiple settings. The
multiple sources to evaluate the child's symptoms ways that significant persons in the child's life
in different contexts, and construct an appropriate perceive and respond to the child's behavioral
differential diagnosis for the presenting complaints symptoms are critical influences in the plan of care
(AAP, 2000; Liu & Leslie, 2003). Information (Magyary & Brandt, 2002).
regarding behavioral symptoms is obtained Behavioral observations of the child's behavior
through parental or caregiver and child interview, and parent–child interactions in the clinic waiting
behavioral observation, child behavior rating area and during the interview can also be useful in
scales (parent and teachers versions), school evaluating the child's ADHD symptoms, as well
reports, and other adjunctive evaluations that as comorbid ODD or CD symptoms (Root &
might be relevant (achievement testing, psychoe- Resnick, 2003). Assessment information regarding
ducational assessment, speech, and language). parental, marital, and family functioning may not
Information pertaining to core symptoms of clarify whether or not ADHD is present but
ADHD, onset, duration, situational variability, and provide a context for understanding how problem
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6 EILEEN CORMIER

child behaviors are being maintained. It may As is the case with common chronic conditions, a
also help to determine how likely it is that broad variety of treatments have been tried and
parents will implement recommended parent continue to be employed with ADHD, many of
training and other treatment strategies on behalf them controversial, including traditional individual
of the child (Chronis, Chacko, Fabiano, Wymbs, therapy, restrictive diets (e.g., Feingold/additive
& Pelham, 2004). free, sugar elimination, and oligoantigenic), fatty
Another important consideration in the diagnosis acid supplementation, chiropractics, electroence-
and evaluation of the child with ADHD is race and phalogram biofeedback, and perceptual–motor
ethnicity. Primary care providers should be aware training, among others (Pelham, Wheeler, &
of differences in cultural norms, expectations of Chronis, 1998; Rojas & Chan, 2005). However,
children and parenting, and attitudes about mental none of these interventions have strong empirical
health that may influence treatment-seeking beha- evidence to support their effectiveness in treating
vior (Chronis, Jones, & Raggi, 2006). National ADHD. The current consensus based on extensive
health survey data suggest that parents of Hispanic empirical research and reflected in clinical practice
and African American children are less likely to guidelines developed by the AACAP (1997) and
report a diagnosis of ADHD or use medication to the AAP (2000) is that only three treatments have
treat it (Kendall & Hatton, 2002; Pastor & Reuben, been validated as effective short-term treatments:
2005). Parents of African American children, in behavior intervention, central nervous stimulants,
particular, report that they are less knowledgeable and a combination of these (Abikoff et al., 2004;
about ADHD and are less likely to endorse Brown et al., 2008; Multimodal treatment study of
hyperactivity items on parental report screening ADHD [MTA] Cooperative Group, 1999, 2004;
instruments than their Caucasian counterparts Pelham et al., 1998; Valente, 2001; Wells et al.,
(Bussing, Gary, Mills, & Garvan, 2007; Hillemeier 2006; Wolraich, 2003).
et al., 2007). Hence, parental knowledge and Current intervention guidelines for treatment of
perceptions of ADHD, including attributions ADHD have been significantly influenced by one
about child ADHD behavior should be addressed large randomized 5-year treatment study, the MTA
in a culturally sensitive manner. (Arnold et al., 1997; Hinshaw et al., 2000; Jensen et
al., 2001; MTA Cooperative Group, 1999, 2004).
The primary goal of the MTA study was to compare
TREATMENT the efficacy of medication management, beha-
Factors that complicate the assessment process vioral–psychosocial treatment (this included parent
such as the situational variability of primary ADHD training, an intensive 8-week summer treatment
symptoms, the likelihood of comorbid conditions, program, and school-based interventions), and a
and race/ethnicity, also affect the treatment process. combination of both against routine community-
These issues make it improbable that any one based care (Richters et al., 1995). As reported by
primary care provider or treatment approach can the MTA Cooperative Group (1999), initial out-
respond to all of the clinical management needs of come data revealed that the medication alone and
the child with ADHD. Parents are key partners in combined treatment (medication and behavioral
the treatment plan, and ongoing communication intervention) groups showed greater improvements
among parents, teachers, and other school-based on multiple measures of domains of child function-
professionals is essential in monitoring the progress ing. Subsequent reports using different approaches
and effectiveness of specific interventions (Magy- to analysis of outcomes, however, found that a
ary & Brandt, 2002). Integration of services with a combination of medication management and psy-
child psychiatrist, psychologist, behavioral and/or chosocial treatment to be superior to either treat-
educational specialist, and/or other mental health ment alone (Connors, Eptstein, & Marsh, 2001;
professionals may be indicated, especially if the Swanson, Kraemer, & Hinshaw, 2001). Further-
child with ADHD is affected by coexisting more, improvements in core symptoms of ADHD
conditions and continues to experience difficulties were achieved using significantly lower medication
despite treatment. National, grassroots, and parent- doses in the combination treatment group than were
led associations such as children and adults used in the medication management group.
with ADHD are also important sources of support Expert consensus guidelines indicate that a
and education to families (DeMarle, Denke, & combination of stimulant medication and beha-
Ernsthausen, 2003). vioral treatment is favored in the treatment of
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ADHD REVIEW AND UPDATE 7

ADHD, in particular, children with significant dextroamphetamine have been found to be equally
comorbid behavioral difficulties that are adversely effective in treating core symptoms of ADHD
affecting family and school functioning (AAP, (Jahad et al., 1999). AAP guidelines recommend a
2001; Connors, Marsh, Frances, Wells, & Ross, trial of three types or formulations of stimulant
2001). Numerous studies in addition to the MTA medication before considering alternative agents.
study have demonstrated the short-term efficacy of At present, only one nonstimulant, atomoxetine, a
stimulant medication in reducing the core symp- selective norepinephrine reuptake inhibitor, has
toms of ADHD as well as improving the child's received approval by the Food and Drug Admin-
ability to follow rules and decrease emotional istration (FDA) to treat ADHD in children (Lopez,
reactivity, thereby leading to improved relation- 2006). Although current evidence also supports the
ships with parents, teachers, and peers (Chacko efficacy of two tricyclic antidepressants and
et al., 2005; Greenhill et al., 2002). The MTA study buproprion for ADHD treatment, these agents are
extended the demonstrated efficacy to 14 months, not approved for use in pediatric ADHD (Spencer
but the long-term effects of stimulants on prognosis et al., 2002; Wood, Crager, Delap, & Heiskell,
remain unclear (MTA Cooperative Group, 1999). 2007). Similarly, clonidine and guanfacine, both
Two classes of stimulants are currently available, antihypertensive medications, are occasionally used
including methylphenidate and dextroampheta- in the treatment of ADHD but are not FDA
mine; both are available in short-, intermediate-, approved (Rains & Scahill, 2006).
and long-acting forms. When administered and The FDA-approved medications used to treat
dosed appropriately, at least 90% of children with ADHD are listed in Table 2, including available
ADHD will have a positive response to at least one formulations, dosage, side effects with higher risk
stimulant without a major adverse event (AAP, potential, and implications for care providers. In
2001; AACAP, 2002). Although individual chil- general, both stimulants and nonstimulants should
dren may respond to and tolerate one stimulant be initiated at low doses and titrated upward to a
better than another, both methylphenidate and maximally effective level. Adverse effects from

Table 2. FDA-Approved Medications of the Treatment of ADHD


Medication Dosage Side effects/Risks Implications

Stimulants
Methylphenidate (MPH)
• Short acting (Ritalin and Methylin) 5-20 mg BID-TID Tachycardia, arrhythmia, Monitor heart rate and blood pressure; baseline
sudden death. ECG or echocardiogram in high-risk cases only
• Intermediate acting (Ritalin SR, 20-40 mg QD or Growth suppression Baseline height, weight, and periodic monitoring;
Metadate ER, and Methylin ER) 40 mg AM, dietary consultation and/or nutritional supplementation
20 mg PM
• Long acting (Concerta, 18-72 mg QD Tics Monitor for appearance and/or exacerbation of tics;
Metadate CD, and Ritalin LA) decrease anxiety; adjust dose; change medication
Potential for abuse Counsel; nonstimulants; extended release
& diversion form of stimulants
• Transdermal system 5-15 mg BID-TID Skin erythema; possible Monitor; topical skin cream; rotate sites
reduced risk for
abuse/diversion
Amphetamine
• Short acting (Dexedrine 5-30 mg QD-BID Side effects/risks similar See recommendations for MPH
and Dextrostat) to MPH with some
individual variations
• Intermediate acing (Adderall and 5-15 mg BID
Dexedrine spansule)
• Long acting (Adderall XR) 10-30 mg QD
Nonstimulants
Atomoxetine (Strattera) N70 kg: Hepatoxicity Baseline history; monitor for abdominal pain/jaundice
40-100 mg
≤70 kg: Suicidal ideation Monitor weekly when beginning treatment or
0.5-1.4/kg changing dose
Sedation Give BID; bedtime dosing
Tachycardia, arrhythmia, Same as MPH
and sudden death
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8 EILEEN CORMIER

stimulants are generally transient and mild, usually cardiovascular function. Baseline electrocardio-
managed by adjusting dose and time of adminis- gram (ECG) is not considered essential, except in
tration. The most common adverse effects include high-risk cases, because it is unlikely to detect
decreased appetite, headache or stomachache, structural cardiac defects.
delayed sleep onset, edginess, and social with- Another concern raised by practitioners and
drawal (AAP, 2001). A small percentage of children parents is the possibility of substance abuse or
experience motor tics, most of which are transient diversion to others among children and adolescents
(Roessner, Robatzek, Knapp, Banaschewski, & treated with stimulants. The results of a recent
Rothenberger, 2006). Modest increases in pulse meta-analytic review published by Wilens et al.
and blood pressure may occur but are rarely a (2003) suggest that stimulant therapy for youths
problem. Nonetheless, expert guidelines on stimu- with ADHD is actually associated with a decrease
lants recommend a complete physical examination in risk of subsequent drug and alcohol disorders. On
before initiating medication and monitoring vital the other hand, studies indicate that a subgroup of
signs at routine follow-ups visits (AACAP, 2002). young people does engage in abuse and/or diver-
The child should be also be evaluated frequently sion of their prescription stimulants in the public
early in treatment for acute, undesirable emotional, school system (McCabe, Teter, & Boyd, 2004;
or behavioral changes as a result of medication. Wilens, Gignac, Swezey, Monuteaux, & Bieder-
Although stimulants may contribute to appetite man, 2006). The recent availability of extended
reduction and weight loss, tolerance to these effects release forms of stimulants provides continuous
generally develops in the first few weeks of coverage for controlling ADHD symptoms
treatment. The effects of long-term stimulant throughout the school day and has eliminated the
treatment on growth remain controversial with need for in-school dosing in most cases. Further-
controlled studies reporting conflicting data more, the recently FDA-approved transdermal
(Lopez, 2006). The consensus at this time is that system minimizes the potential for diversion
stimulant use is not associated with significant because once the patch is applied, it cannot be
impairment in height, with any decrease in growth reapplied to another individual.
early in treatment compensated for later on (AAP, Atomoxetine represents an alternative when
2001). However, careful and accurate monitoring of children are not responsive to or experience
growth for all children using measurements of intolerable adverse effects from stimulants. Ato-
height and weight is recommended throughout the moxetine is FDA approved for use with children
course of treatment. and has demonstrated efficacy in managing the
The risk of adverse cardiovascular events in symptoms of ADHD, although the response is
children taking stimulants has received consider- generally lower than that of stimulants (Michelson
able recent attention, based on reports of 12 cases of et al., 2002). The most common adverse effects
sudden cardiac death in children receiving amphe- include upset stomach, decreased appetite, seda-
tamines (Nissen, 2006). Subsequent review tion, dizziness, tachycardia, and mood swings. Risk
revealed the presence of underlying structural for adverse cardiac events is similar to stimulants.
heart defects or other problems complicating the Although rare, the FDA requires that atomoxetine
assessment of medication-related risk, for example, carry a warning regarding the potential for liver
family history of ventricular tachycardia, heat toxicity and suicidal ideation. Liver function tests
exhaustion, dehydration, very rigorous exercise, are not routinely obtained but should be conducted
and so forth. The most recent information indicates if the child develops abdominal pain or jaundice
that the risk for sudden cardiac death does not associated with treatment. The potential for suicidal
exceed the base rate for the general population thoughts and/or behavior should be thoroughly be
and is usually associated with preexisting risk discussed with the family prior to initiating
factors (Wilens, Prince, Spenser, & Biederman, treatment and monitored carefully by parents and
2006). However, these occurrences highlight care provider.
the importance of verifying underlying cardiovas- Empirically validated behavioral treatments for
cular problems, specifically structural cardiac ADHD include behavioral parent training and
abnormalities as well as obtaining detailed family classroom interventions with the common goal of
histories regarding unexplained cardiac deaths modifying physical and social environment factors
(especially under 30 years), in children prior to that may be maintaining problem child behavior.
beginning treatment and continuing to monitor Behavior therapy involves training parents and
ARTICLE IN PRESS
ADHD REVIEW AND UPDATE 9

teachers in the use of specific techniques (e.g., review of ADHD, which they could use to educate
positive reinforcement, time-out, and response cost) families and involve them in treatment decisions.
to reward desirable behavior and applying con- Primary care clinicians routinely encounter ADHD,
sequences for noncompliance or disruptive beha- yet approaches to diagnosis and treatment of the
vior. Behavior therapy should be distinguished disorder vary considerably in primary care settings
from psychological interventions directed at the (Connors, Marsh, et al., 2001; Magyary & Brandt,
child's emotional status (e.g., play therapy) or 2002; Rushton, Fant, & Clark, 2004). The guide-
thought patterns (e.g., cognitive therapy), which lines provided by the AAP (2000) recommend
have little documented efficacy (AAP, 2001). applying DSM-IV diagnostic criteria, soliciting
Parent training typically involves 8 to 12 weekly information from parents and teachers, and using
sessions with a trained therapist with the aim of rating scales to establish the developmental inap-
improving parents' or caregivers' understanding of propriateness of ADHD symptoms. Evidence
the child's behavior and teaching them skills to deal regarding core symptoms should encompass age
with behavioral difficulties related to ADHD of onset, duration of symptoms, and degree of
(Breismeister & Shaefer, 1998; Daly, Creed, functional impairment across multiple settings.
Xanthopoulos, & Brown, 2007; Danforth, Harvey, Assessment for coexisting conditions, in particular,
Ulaszek, & McKee, 2006). Current best practice conduct and oppositional defiant disorder, mood
emphasizes a collaborative approach in both group and anxiety disorders, and learning disabilities, is
and individual formats (Chronis et al., 2004). A essential as a basis for intervention planning. Thus,
collaborative approach consists of actively invol- primary care providers should have some knowl-
ving parents in the therapeutic process by soliciting edge of the various possible coexisting disorders
their ideas and viewpoints, mutually setting treat- and be prepared to either diagnose and treat them or
ment goals that are realistic and meaningful to the facilitate referrals.
family, and teaching and suggesting, as opposed to The treatment guidelines of AAP (2001) empha-
dictating alternative responses to behavior pro- size the chronic nature of ADHD, necessitating
blems. Similar to parent training, classroom inter- child-specific treatment plans and mechanisms for
ventions that can be implemented by the child's monitoring target outcomes over the long term.
teacher are developed through a series of consulta- Primary care clinicians have important roles in
tion sessions at school, including daily report cards establishing a therapeutic alliance with families,
to provide feedback to parents on the child's school educating them about the disorder, and involving
performance, for which parents can provide them in developing and monitoring interventions.
rewards or consequences at home (Chronis et al., Parents first need to understand the ways in which
2006; Pelham et al., 1998). core symptoms of ADHD can affect child behavior,
A wide range of clinicians with specialized learning, social skills, self-esteem, and family
training can implement behavior therapy directly functioning. They also need accurate, current
or train parents or school personnel in behavioral information on the etiology of ADHD, factors that
techniques. Many primary care providers favor may influence the course of the disorder, the
referral of families to community resources that relative benefits of medication and/or psychosocial
offer this service because behavior therapy with treatment options, and community resources that
parents is time consuming and often inconsistent provide support and/or services to individuals and
with the structure and schedule of the primary care families with ADHD. Information provided by
office. Schools may offer behavioral consultation primary care providers should be evidence based,
and training to school personnel in the context of practical, and reinforce the central role of parents
the section 504 of the 1973 Rehabilitation Act that in the child's treatment, including ongoing colla-
requires schools to make accommodations to help boration among clinicians, parents, teachers, and
children with ADHD function in that setting the child.
(AAP, 2001). Expert consensus guidelines emphasize a com-
prehensive management plan that focuses on key
target outcomes and desired outcomes. Families
IMPLICATIONS FOR PRIMARY should be told that a combined medication and
CARE PROVIDERS behavioral–psychosocial approach is likely to be
The aim of this paper was to provide primary more effective for addressing the comorbid pro-
care clinicians with a current and evidence-based blems that a large proportion of children with
ARTICLE IN PRESS
10 EILEEN CORMIER

ADHD have, but a medication-only approach, if monitor medication response, and minimize anxiety
this is their preference, also has empirical support. should adverse effects develop. If parents are
When medication is prescribed, attention to safety motivated to participate in behavioral treatment,
issues, including adverse events and/or risks (Table clinicians should have access to information
2), is critical. It is important to counsel the child and regarding community resources that are available
parents regarding potential benefits and adverse to provide parent training in behavior therapy and
effects of pharmacological treatments to help them classroom behavior interventions and facilitate
develop realistic expectations regarding treatment, appropriate referral.
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