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 &/or hyperactivity-impulsivity.
Symptoms that suggest ADHD includes hyperactivity, acting without thinking, inattention/daydreaming, fidgety, restless, excessive talking, aggressive behavior, academic underachievement, disorganized and has difficulty in completing task.

Principles of Therapy

  • 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
  • Prior to starting pharmacotherapy in adolescents, it is important to assess them for symptoms of substance abuse
  • Treatment failure may be a sign of incorrect or incomplete diagnosis. It is recommended to repeat diagnostic evaluation
    • Check for adherence to treatment plan
Consider the following when choosing a medication:
  • Presence of comorbid conditions
    • Treatment of attention-deficit/hyperactivity disorder may sometimes resolve the coexisting condition; however, there are also cases that comorbid conditions should be treated in addition to attention-deficit/hyperactivity disorder management
    • 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
  • Adverse effects of drugs
  • Potential for drug diversion (where the drug is forwarded on to others for non-prescription uses)
  • Cost of medication

Pharmacotherapy

Stimulant Medications
  • Considered 1st-line therapy
    • Should be combined with behavioral training
  • Only preschool-aged patients who have moderate-severe attention deficit/hyperactivity disorder 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
  • Although Dextroamphetamine is the only drug approved by United States Food and Drug Administration 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
  • Lisdexamfetamine is a prodrug of Dextroamphetamine
    • Therapeutically inactive until metabolized in the body
  • 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 attention deficit/hyperactivity disorder (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
  • Individual patient may respond to one type/form but not 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 to a cardiologist
Alternative Agents
  • Clinicians should seek specialist referral if unfamiliar with use of the following agents
  • 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, 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
  • A United States Food and Drug Administration-approved nonstimulant agent for use in attention deficit/hyperactivity disorder
  • Not yet approved for use in preschool-aged patients
  • Not recommended by the United States Food and Drug Administration 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
  • Have 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
  • Have 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
  • Not yet approved for use in preschool-aged patients
Tricyclic Antidepressants
  • 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 attention deficit/hyperactivity disorder
  • 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 should be reviewed with all involved eg parent, 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
  • 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 medication 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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