> Table of Contents > Attention Deficit/Hyperactivity Disorder, Pediatric
Attention Deficit/Hyperactivity Disorder, Pediatric
Laura Novak, MD
Christina Emanuel, MD
image BASICS
DESCRIPTION
  • Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental problem that manifests in early childhood characterized by distractibility, impulsivity, hyperactivity, and/or inattention.
  • Three subsets: predominantly hyperactivity impulsive (ADHD-HI), predominantly inattentive (ADHD-I), or combined (ADHD-C)
  • System(s) affected: nervous
  • Synonym(s): attention deficit disorder; hyperactivity
EPIDEMIOLOGY
  • Predominant age: onset <12 years; lasts into adolescence and adulthood; 50% meet diagnostic criteria by age 4 years
  • Predominant sex: male > female (2:1); inattentive type (ADHD-I) may be more common in girls
Prevalence
11% of children 4 to 17 years old were diagnosed with ADHD as of 2011. Of those, 6.1% are receiving a medication for ADHD.
ETIOLOGY
Not definitive
Genetics
Familial pattern
RISK FACTORS
  • Family history
  • Medical causes (affecting brain development)
  • Environmental causes (toxins such as lead, fetal alcohol, and nutritional deficiencies)
GENERAL PREVENTION
  • Children are at risk for abuse, depression, and isolation.
  • Parents need regular support and advice.
COMMONLY ASSOCIATED CONDITIONS
  • Depression (in up to 1/3 of cases)
  • Oppositional defiant disorder
  • Conduct disorder
  • Anxiety disorder
  • Learning disabilities
image DIAGNOSIS
  • American Academy of Pediatrics (AAP) guidelines recommend DSM-5 criteria to establish diagnosis.
  • DSM-5 criteria for children < 17 years: ≥6 inattention criteria and/or ≥6 hyperactivity/impulsivity criteria. Symptoms must occur often, be present before age of 12 years, for >6 months, be noticed in ≥2 settings (e.g., home, school), reduce quality of social or scholastic functioning, be excessive for development level of child, and are not better explained by or occur with another mental disorder (e.g., mood, anxiety, or personality disorder) (1)[A].
  • Inattention
    • Careless mistakes in tasks; difficulty sustaining attention or in organizing tasks; does not seem to listen, follow through, or finish tasks; avoids tasks that require sustained mental effort; loses things; forgetful in daily activities
  • Hyperactivity/impulsivity
    • Fidgets; difficulty remaining seated; runs/climbs excessively or inappropriately; difficulty playing quietly; acts as if “driven by a motor” or seeming to always be “on the go”; talks excessively; blurts out answers before question is complete; has difficulty waiting turn; interrupts others
  • Children undergoing extreme stress (parent's divorce, illness, homelessness, abuse) may demonstrate ADHD behaviors secondary to stress (1). This can be assessed using the American Academy of Child and Adolescent Psychiatry (AACAP) screening tool.
  • If diagnostic behaviors are noted in only one setting, explore the stressors in that setting.
  • The diagnostic behaviors are more noticeable in tasks that require concentration or boredom tolerance than in free play or office situations.
PHYSICAL EXAM
  • Baseline weight for future monitoring
  • Note any soft neurologic signs, such as tics, clumsiness, mixed handedness
  • Assess hearing and vision.
DIFFERENTIAL DIAGNOSIS
  • Activity level appropriate for age
  • Language or communication disorders
  • Hearing/vision disorder
  • Dysfunctional family situation
  • Learning disability (e.g., dyslexia)
  • Autism spectrum disorders
  • Oppositional/defiant disorder or conduct disorder
  • Tourette syndrome: motor and verbal tics
  • Absence seizures (inattentive type ADHD only)
  • Lead poisoning
  • Sequelae of central nervous system infection/trauma
  • Medication (decongestant, antihistamine, theophylline, phenobarbital)
  • Sleep disorder (e.g., obstructive sleep apnea [OSA]) leading to daytime behavioral problems
DIAGNOSTIC TESTS & INTERPRETATION
  • Behavior rating scales must be completed by parents, caregivers, and teachers prior to initiation of therapy and then repeated after therapy is started to gauge treatment efficacy.
  • Forms are available from the ADHD toolkit at http://www.nichq.org/adhd.html (Vanderbilt Assessment Scales)
  • Testing for learning disability (e.g., dyslexia) through the school may be needed.
Initial Tests (lab, imaging)
Lead level if high risk
Diagnostic Procedures/Other
  • EEG if symptoms are highly suggestive of absence seizure disorder
  • EKG if high risk
image TREATMENT
GENERAL MEASURES
  • Parent/school/patient education
  • Work closely with teacher.
  • Behavioral therapy/environmental changes
MEDICATION
  • 2011 AAP guideline recommends behavioral interventions for age 4 to 5, and behavioral interventions plus stimulant medications as first-line treatment for age 6 to 17 (2,3)[A].
  • Stimulant choice should be based on cost, formulary, convenience, and duration. A second type of stimulant should be tried if the first treatment fails. All stimulant capsules can be opened and sprinkled (note Concerta is a pill)
First Line
Stimulant:
  • Dexmethylphenidate
    • Focalin: initial: 2.5 mg BID; increase total daily by 2.5 to 5 mg weekly up to maximum dose of 20 mg/day
    • Focalin XR: initial: 5 mg in AM; increase daily dose by 5 mg weekly up to maximum dose of 30 mg/day
  • Methylphenidate
    • SHORT-ACTING
      • Ritalin, Methylin: initial 5 mg BID before breakfast and lunch; increase by 5 to 10 mg weekly to maximum dose of 60 mg/day (2 or 3 divided doses)
    • INTERMEDIATE-ACTING
      • Ritalin SR: 20 mg once in AM; increase by 10 mg weekly up to 40 to 60 mg
      • Metadate ER: 10 mg BID; increase by 10 mg weekly to 40 to 60 mg
    • LONG-ACTING
      • Metadate CD: 20 mg in AM; increase by 10 to 20 mg weekly to 40 to 60 mg
      • Quillivant XR: 20 mg in AM; increase 10 to 20 mg weekly until 40 to 60 mg
      • Ritalin LA: 10 to 20 mg in AM; increase 10 mg weekly until 40 to 60 mg
      • Concerta: 18 to 36 mg in AM; increase by 18 mg weekly until 54 to 72 mg
      • Daytrana transdermal patch: 10 mg patch on (hip area) 2 hours before effect is needed; patch removed 9 hours after application; increase to next higher patch weekly until 30 mg patch if needed
  • Dextroamphetamine
    • Dexedrine spansule (long-acting): 5 mg BID; increase by 5 mg weekly to maximum dose of 40 mg daily
  • Dextroamphetamine and amphetamine
    • SHORT-ACTING
      • Adderall: 5 mg daily or BID; increase by 5 to 10 mg weekly to a maximum dose of 40 mg daily divided into 1 to 3 doses
    • LONG-ACTING
      • Adderall XR: 5 to 10 mg in AM; increase by 5 to 10 mg weekly until maximum dose of 30 mg/day
  • Lisdexamfetamine
    • Vyvanse: 30 mg in AM; increase by 10 to 20 mg weekly up to a maximum of 70 mg/day
P.97

  • Precautions:
    • If not responding, check compliance and consider another diagnosis.
    • Some children experience withdrawal (tearfulness, agitation) after a missed dose or when medication wears off. A small, short-acting dose at 4 PM may help to prevent this.
    • Stimulants are drugs of abuse and should be monitored carefully.
    • Drug holidays are not recommended.
  • Common adverse effects:
    • Anorexia, insomnia, GI effects, and headache
  • Significant possible interactions: may increase levels of anticonvulsants, SSRIs, tricyclics, and warfarin
  • High caffeine energy drinks, albuterol inhalers and decongestants may increase side effects.
  • The FDA reports permanent skin discoloration with Daytrana patches.
Pregnancy Considerations
Medications are Category C: caution in pregnancy
Second Line
Nonstimulant:
  • SNRI
    • Atomoxetine (Strattera):
      • ≤70 kg: 0.5 mg/kg/day initial; increase after a minimum of 3 days to target dose of 1.2 mg/kg/day; maximum of 1.4 mg/kg/day
      • >70 kg: 40 mg daily; increase after minimum of 3 days to target dose of 80 mg/day; dose may be increased to maximum of 100 mg/day after additional 2 to 4 weeks
  • α2-Agonist
    • Modest efficacy, high side effects. Consider consultation before use.
      • Clonidine XR (Kapvay): 0.1 mg once daily at bedtime; increase by 0.1 mg weekly; doses should be taken twice daily with equal or higher split dosage given at HS; maximum of 0.4 mg/day; taper when discontinued
      • Guanfacine XR (Intuniv): 1 mg daily; increase by 1 mg weekly until 1 to 4 mg daily; taper when discontinued
ISSUES FOR REFERRAL
Should be considered for children <6 years old for psychological or medical complications, developmental disorder or intellectual disability, or poor response to medication
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Surveys have shown that parents of children with ADHD use herbals and complementary treatments frequently (20-60%).
  • Omega-3 fatty acids (found in fish oil and some supplements) showed improvement in rating scales in two double-blind, placebo-controlled studies of 116 and 130 patients (4).
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Parent/teacher rating scales
  • Office visits to monitor side effects and efficacy: End points are improved grades, rating scales, family interactions, and peer interactions.
  • Monitor growth (especially weight) and BP.
DIET
  • “Insufficient evidence to suggest that dietary interventions reduce the symptoms of ADHD” (4).
  • The AAP recommends that “For a child without a medical, emotional, or environmental etiology of ADHD behaviors, a trial of a preservative-free food coloring-free diet is a reasonable intervention” (4).
PATIENT EDUCATION
  • Excellent reference: http://www.parentsmedguide.org
  • Key points for parents:
    • Find things the child is good at and emphasize these; reinforce good behavior; give one task at a time; stop behavior with quiet discipline; coordinate homework with teachers; have external organization tools—charts, schedules, tokens
    • Develop an individualized education plan (IEP) with the school.
  • Support groups:
    • Children and Adults with Attention Deficit Disorder (CHADD): http://www.chadd.org
    • Attention Deficit Disorder Warehouse: http://www.addwarehouse.com
    • National Information Center for Children and Youth with Disabilities: http://www.nichcy.org
PROGNOSIS
  • May last into adulthood; plan for a transition at age 17 years
  • Relative deficits in academic and social functioning may persist into late adolescence/adulthood.
  • Encourage career choices that allow autonomy and mobility.
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Rader R, McCauley L, Callen EC. Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 2009;79(8):657-665.
3. Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.
4. Sinn N. Nutritional and dietary influences on attention deficit hyperactivity disorder. Nutr Rev. 2008;66(10):558-568.
Additional Reading
  • Laforett DR, Murray DW, Kollins SH. Psychosocial treatments for preschool-aged children with attention-deficit hyperactivity disorder. Dev Disabil Res Rev. 2008;14(4):300-310.
  • Larson K, Russ SA, Kahn RS, et al. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics. 2011;127(3):462-470.
  • Millichap JG, Yee MM. The diet factor in attention-deficit/hyperactivity disorder. Pediatrics. 2012;129(2):330-337.
Codes
ICD10
  • F90.9 Attention-deficit hyperactivity disorder, unspecified type
  • F90.0 Attn-defct hyperactivity disorder, predom inattentive type
  • F90.1 Attn-defct hyperactivity disorder, predom hyperactive type
Clinical Pearls
  • AAP recommends the use of stimulant medications as the first-line treatment.
  • Children undergoing extreme stress (parent's divorce, illness, homelessness, abuse) may demonstrate ADHD behaviors secondary to stress.
  • ADHD is 2 to 8 times more common in persons who have a first-degree relative with the condition.