Paying Attention to ADHD

Background

ADHD is one of the most common neurobehavior disorders of childhood

• Prevalence estimates: 7-15 %
• Twice as common in boys than girls
• Majority of boys and girls also meet criteria for another disorder
• Most common comorbid conditions are language and learning disorders
  • Boys are more likely to exhibit externalizing conditions like ODD or conduct disorder
  • Girls are more likely to have internalizing conditions such as anxiety and depression

Providers should initiate ADHD evaluation for children presenting with academic or behavior problems and symptoms of inattention, hyperactivity, or impulsivity

Diagnosis

DSM-5 criteria define 4 dimensions of ADHD:

• ADHD/I (primarily inattentive presentation)
• ADHD/H (primarily hyperactive-impulsive presentation)
• ADHD/C (combined presentation)
  • meets criteria for both ADHD/I and ADHD/H
• ADHD other specified and unspecified

Diagnosis is made across more than one setting by gathering rating scales from parents, teachers, other school personnel, and mental health clinicians.

Always consider alternative causes!

Majority of boys and girls with ADHD also meet criteria for another mental disorder including a variety of other behavioral, development and physical conditions (learning disabilities, language disorders, disruptive behavior, anxiety, depression, tic disorder, seizures, ASD, sleep disorders, etc)

ADHD/I

• ≥6 symptoms of inattention for children up to 16yo; ≥5 if ≥17yo (including adults)
• Symptoms present for ≥6 months, and inappropriate for developmental level
• Symptoms present before age 12yo
• Symptoms are present in ≥2 settings
• Symptoms interfere with or reduce quality of social, school or work funtioning
• Not better explained by another mental disorder

9 possible symptoms: makes careless mistakes, has difficulty keeping attention on what needs to be done, does not listen, does not follow through on instructions, has difficulty organizing tasks and activities, avoids mental effort, loses things necessary for tasks and activities, easily distracted, forgetful in daily activities

ADHD/H

• ≥6 symptoms of hyperactivity-impulsivity for children up to 16yo; ≥5 if ≥17yo
• Present for ≥6 months and inappropriate for developmental level
• Symptoms present before age 12yo
• Symptoms are present in ≥2 settings
• Symptoms interfere with or reduce quality of social, school or work functioning
• Not better explained by another mental disorder

9 possible symptoms: Figdets/taps/squirms, leaves seat, runs or climb too much, difficulty playing quiet games, on the go/driven by motor, talks too much, blurts out answer, difficulty waiting turn, interrupts/intrudes

Treatment

• Children <4yo: insufficient evidence to recommend diagnosis or treatment other than parent training in behavior management (PTBM)
• Children age 4-6yo: treatment should include PTBM as first line and school supports (Grade A recommendation)
• Children 6-12yo: PTBM, school supports, and medications (Grade A recommendation for stimulants)
• Children >12yo: school supports, medication, and transition supports. Teens should also be screened for substance use

PTBM does not require a diagnosis to be applied, and is most effective in young children when delivered by parents. When parents become trained in behavior therapy they learn skills and strategies to help their child succeed at school home and with peers. School supports should include classroom modification and accommodations. 

Medications

Medications for ADHD include stimulants (methylphenidate derivatives and ampethamine derivatives) and non-stimulants (atomoxeinte, guanfacine, and clonidine.)

Preschool children may experience mood lability/dysphoria with stimulants. None of the non-stimulants are approved in this group. 

Elementary school children and adolescents:

• Strong evidence for stimulant medications
• Evidence less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order)
• Response to methylphenidate vs amphetamine is idiosyncratic: 40% respond to both, and 40% to only 1

List of FDA-approved meds for ADHD:

ADE: Stimulants

• Appetite loss, abdominal pain, headaches and sleep disturbance.
• Diminished growth rate in the 1-2cm range from predicted adult height, which is dose-dependent.
• Increased HR and BP are mild and often clinically insignificant, but may be linked to substantial increases in 5-15% individuals so should at least be monitored.
• Sudden cardiac death concerns, but this is extremely rare occurrence and stimulants have not been shown to increase the risk of sudden death.
• Clinicians should obtain cardiac history/symptoms and FHx before initiating

ADE: Non-stimulants

• Atomoxetine: increased HR and BP, somnolence, GI symptoms, decreased appetite
  • Less commonly increase suicide thoughts (black box), rare hepatitis, growth delays
• Guanfacine and clonidine: decreased HR and BP, dry mouth, somnolence, dizziness, irritability, bradycardia, hypotension.
  • Rebound hypertension with abrupt termination

Take-home points!

• Providers should initiate ADHD evaluation for children presenting with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity
• Diagnosis should be based on DSM-5 criteria. 6/9 criteria if ≤16yo, 5/9 if ≥17yo. Symptoms should be present for >6 months, have started before age 12yo, be maladaptive, and present in 2 or more settings
• Providers should screen for comorbid conditions. ADHD should be managed as a chronic care condition
• PTBM is first line for children 4-6yo, medications if >6yo. Teens should be screened for substance use and monitored for signs of diversion
• Medications include stimulants and non-stimulants. 40% respond to both methylphenidate derivates and ampethamines; 40% respond to 1 only. If no response to one type of stimulant, try the other.

Further reading and listening!

• American Academy of Pediatrics’ 2019 Clinical practice guideline for the diagnosis, evaluation, and treatment of children and adolescents with attention‐deficit/hyperactivity disorder
• CDC’s Review of ADHD: Symptoms and Diagnosis
• American Academy of Pediatrics’ ADHD Toolkit (3rd edition)
• The Cribsiders episode on ADHD

Blog post based on Med-Peds Forum talk by Sybil Cineas, MP Core Faculty