attention%20deficit_hyperactivity%20disorder
ATTENTION DEFICIT/HYPERACTIVITY DISORDER
Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by the presence of impairing levels of inattention, disorganization and/or hyperactivity-impulsivity.
Symptoms that suggest ADHD include hyperactivity, acting without thinking, inattention/daydreaming, fidgety, restless, excessive talking, aggressive behavior, academic underachievement, disorganized and has difficulty in completing tasks.

Principles of Therapy

  • Medications should only be started by an ADHD specialist  
    • Pharmacotherapy for children <5 years old may be started only when advised by an ADHD specialist
    • Pharmacotherapy for children >5 years old may be started only when a baseline assessment had been done and there is persistent significant impairment in at least 1 area of function after the implementation and review of environmental changes  
  • Prior to starting pharmacotherapy in adolescents, it is important to assess them for symptoms of substance abuse 
  • Inform the parents on the initial titration process and the usual duration of the process 
    • Medications should be titrated to maximum doses that control the symptoms with minimum or no adverse effects  
    • Slower dose titration and more frequent treatment monitoring are indicated in children with ADHD with mental or physical health conditions (eg acquired brain injury, epilepsy, or cardiac disease), or neurodevelopmental disorders 
  • Treatment failure may be a sign of incorrect or incomplete diagnosis, thus the following are recommended:
    • Repeat diagnostic evaluation
    • Check for adherence to treatment plan 
    • Children aged ≥5 years should be referred to an ADHD specialist if unresponsive to treatment with ≥1 stimulant and 1 non-stimulant agents
Consider the following when choosing a medication:
  • Presence of comorbid conditions
    • Treatment of ADHD may sometimes resolve the coexisting condition; however, there are also cases that comorbid conditions should be treated in addition to ADHD management
    • Coexisting medical conditions may have contraindications for other specific medications  
    • Perform a cardiovascular evaluation
      • Patients with known structural heart problems should be seen by a cardiologist before being given stimulants and/or Atomoxetine
  • Preferences of the child and/or his or her parent or guardian
  • Potential issues regarding adherence to medication regimen, ie mental health or social circumstances
  • Current medications or adverse effects of drugs
  • Potential for drug diversion (where the drug is forwarded on to others for non-prescription uses) or misuse
  • Cost of medication

Pharmacotherapy

Stimulant Medications
  • Considered 1st-line therapy
    • Should be combined with behavioral training
  • Methylphenidate is the 1st-line agent for children aged ≥5 years 
  • Only preschool-aged patients who have moderate-severe ADHD are considered for pharmacotherapy
    • Methylphenidate may be used if behavior interventions do not provide significant improvement
    • There is moderate evidence to support the efficacy and safety of Methylphenidate in this age group
  • For patients 6-11 years of age, stimulants and/or behavioral training is recommended
  • Lisdexamfetamine is a prodrug of Dextroamphetamine
    • Therapeutically inactive until metabolized in the body
    • Considered in children aged ≥5 years unresponsive to a 6-week optimum Methylphenidate therapy
  • Although Dextroamphetamine is the only drug approved by United States Food and Drug Administration (US FDA) for patients <6 years of age, there is insufficient evidence to support its safety and efficacy in this age group; hence, it is not recommended by American Academy of Pediatrics (AAP) at this time in children age 3-5 years  
    • Considered in children aged ≥5 years who are responsive to Lisdexamfetamine therapy but are intolerant of its prolonged effect
  • Predominantly attributed to binding with the dopamine transporter and subsequent inhibition of dopamine reuptake resulting in increased levels of extracellular dopamine
  • Studies have documented the efficacy of reducing the core symptoms of ADHD (hyperactivity, inattention and impulsivity)
    • Also improve the child’s ability to follow rules, decrease over-reactivity of emotions and eventually lead to improved relationships
    • Most patients though improved do not show fully normal behavior
  • Most controlled studies have been based on short-term use
    • Efficacy has been proven at least up to 14 months of use
  • Careful and systematic dosing titration should be done to determine the optimal dosing for an individual
    • Titration can be done on a 3- to 7-day basis
  • All types and dosage forms have been shown to have equal efficacy but may try considering immediate- and modified-release stimulant preparations for optimal effect
  • Individual patient may respond to one type/form but not to another; effects vary from one person to another
  • Consider another stimulant if one stimulant does not achieve desired results
  • Consider alternative agents when ≥2 stimulants have been tried without success
    • Specialist referral may be needed
  • Any history or physical examination changes during treatment should warrant consultation with a cardiologist
Alternative Agents
  • Clinicians should seek specialist referral if unfamiliar with the use of Atomoxetine, Clonidine, Guanfacine and tricyclic antidepressants
  • Atomoxetine, extended-release Guanfacine and extended-release Clonidine are administered instead of stimulants if there is an issue on possible abuse or diversion of the drug, if stimulant-related tics developed, and if preferred by parents
  • Extended-release Guanfacine and extended-release Clonidine may be given as an adjunctive therapy in patients who partially respond to stimulants
  • Atomoxetine or Guanfacine may be given to children aged ≥5 years if they are intolerant of Methylphenidate or Lisdexamfetamine, or are unresponsive to separate Methylphenidate and Lisdexamfetamine 6-week trial therapies
Atomoxetine
  • A US FDA-approved non-stimulant agent for use in ADHD
  • Not yet approved for use in preschool-aged patients
  • Not recommended by the US FDA in patients with serious heart problems
  • Has shown to be more effective than placebo, in short and longer term (at least 2 years)
    • May be as effective as stimulant medications but more studies are needed
    • Have demonstrated efficacy in reducing core symptoms
  • Long-term safety is yet to be determined
Clonidine
  • May be used in patients 6-11 years of age, either alone or combined with behavioral training
  • Not yet approved for use in preschool-aged patients
  • Has been shown to reduce core symptoms
  • May be more effective for extensive impulsivity/aggression or for tics
    • May take 6-8 weeks to see effect
Guanfacine
  • Has demonstrated efficacy in reducing core symptoms
  • Less sedating than Clonidine and may be an alternative for children with tics
    • May take 6-8 weeks to see effect
  • Decrease dose or change to another ADHD medication if patient is experiencing orthostatic hypotension on Guanfacine 
  • Not yet approved for use in preschool-aged patients
Tricyclic Antidepressants (TCAs)
  • Only Desipramine and Imipramine have been studied extensively; others include Amitriptyline, Nortriptyline and Clomipramine
  • May only be administered when patients have not responded to licensed drugs for ADHD
  • Have larger potential effect on behavior compared to attention or concentration deficits
    • Narrower margin of safety than stimulants
    • More potential adverse reactions than stimulants

Non-Pharmacological Therapy

Develop Management Plan

  • Specific target outcomes should be defined to guide management
    • Primary goal is to maximize function
    • Examples of target outcome include: Improvements in relationships, decrease in disruptive behaviors, improve academic performance, etc
  • Goals, treatment planning and decision making should be reviewed with all involved eg parent/caregiver, patient, school
Behavioral Training
  • Parent and/or teacher-administered behavioral training is the 1st-line treatment in preschool-aged children (ie 4-5 years of age)
  • In patients 6-11 years of age, behavioral training  may be used in combination with stimulants, Atomoxetine, Guanfacine and Clonidine
  • In patients 12-18 years of age, behavioral training  may be suggested as part of pharmacotherapy
  • Provide management strategies to modify the physical and social environment to help modify behavior
  • Cognitive behavioral training - problem-solving strategies that help patients stop and think before acting; used to treat impulsive patients with non-self-controlled behavior and problem solving deficits
    • Consider giving cognitive behavioral therapy to young patients in whom there is still significant impairment in at least 1 area of function despite benefiting from medical therapy
  • Train parents/caregivers and teachers with specific techniques for improving behavior
    • Positive reinforcement
    • Time-out
    • Response cost
    • Token economy
  • Group-based behavioral interventions are focused on peer relationships or interactions
  • Evidence of effectiveness of behavioral training comes from varied studies
    • Long-term positive effects of behavioral training is still to be determined
    • The large variety in behavioral therapy and outcome measures make meta-analysis difficult
    • Majority of studies comparing behavioral training alone vs stimulant medications show stimulants to be more effective
    • Based on a study, combining behavioral training with medication showed no more efficacy in reducing core symptoms than medication alone
    • Combination therapy also allowed the use of lower drug dosages; hence, reducing the risk of adverse effects
    • Most patients, though improved, do not show fully normal behavior
    • For families who refuse pharmacological therapy, behavioral training alone has been found to be more effective than no treatment
Social Skills Training
  • Used to teach children practical interpersonal skills in a safe setting
  • Skills taught include maintaining eye contact, strategies for initiating and maintaining conversations, remembering to share and cooperate
Psychological Interventions
  • Different from behavioral interventions
  • Directed at child
    • Psychological interventions are designed to change child’s emotional status or thought patterns
    • Effects: Documented efficacy of psychological treatment of children is lacking
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