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Attention-Deficit/Hyperactivity Disorders

Margaret T. Johnson, MD

Attention-deficit/hyperactivity disorder (AD/HD) affects about 5% of girls and 10% of boys of elementary age. AD/HD can interfere with an individual's ability to inhibit behavior (impulsivity) and/or function efficiently in goal-oriented activities (inattention). Symptoms of AD/HD emerge in early childhood and continue to be present into adulthood in up to 70% of cases.

Clinical evaluation

Three behavioral subtypes of ADHDs are defined: predominantly inattentive, predominantly hyperactive/impulsive, and combined. The symptoms must be chronic and have persisted for more than 6 months. Some symptoms should be present before age 7.

A comprehensive, developmentally oriented evaluation should assess the child's functioning within academic and psychosocial contexts.

Findings on sensory, physical, and neurologic examinations are usually normal. Motor coordination, language skills, and social style should be assessed. Behavioral observations should be interpreted cautiously because children may show few symptoms of AD/HD in the office setting.

Laboratory studies, such as a thyroid screen or electroencephalography, should be based on clinical indications. Lead levels and hematocrit should be considered in preschool children.

DSM-IV Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder

At least six of the following symptoms of inattention or hyperactivity-impulsivity must be evident:

Inattention

Lack of attention to details or careless mistakes in schoolwork or other activities

Difficulty sustaining attention in tasks or play activities

Impression of not listening when spoken to directly

Failure to follow through on instructions or finish schoolwork or duties

Difficulty organizing tasks and activities

Avoidance or dislike of tasks that require sustained mental effort (eg, schoolwork or homework)

Tendency to lose things necessary for tasks or activities (eg, toys, school assignments, pencils, books)

Distractions by extraneous stimuli

Forgetfulness in daily activities

Hyperactivity

Fidgeting with hands or feet or squirming in seat

Not remaining seated when expected

Running about or climbing excessively

Difficulty engaging in leisure activities quietly

Often "on the go" or "driven by a motor"

Excessive talking

And/Or

Impulsivity

Tendency to blurt out answers before questions have been completed

Difficulty awaiting turn

Tendency to interrupt or intrude on others (eg, butting into conversations or games)

Exclusionary Criteria

A. Some hyperactive-impulsive or inattentive symptoms that caused impairment must have been present before age 7.

B. Some impairment from the symptoms must be present in two or more settings (eg, at school and at home).

C. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.

D. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder.

Management

Behavioral interventions. Parents may need training in basic management or behavior modification. The child may benefit from social skills training or cognitive-behavioral therapies.

Behavior modification strategies can be used to decrease less desirable behaviors (eg, hitting), increase more desirable behaviors (eg, using words instead of actions), or teach a new skill (eg, negotiating). Strategies used to modify the behaviors include increased positive attention (eg, "time-in"), punishment (eg, "time-out"), and "selective ignoring." Charts or point systems that track specific behaviors are useful.

Stimulant medications

Methylphenidate is the most commonly used stimulant. Other stimulants include dextro-amphetamine pemoline, and a combination of amphetamine salts (Adderall).

Effects of stimulants. Stimulants have significant short-term benefits in at least 70% to 80% of children who have AD/HDs.

Stimulant side effects

Behavioral rebound, characterized by increased irritability and activity, may occur as the last dose is wearing off. A small additional dose may be beneficial in the afternoon.

Tics or dyskinesias are an infrequent side effect of stimulants. There is no evidence that stimulants cause permanent tic disorders. About 50% to 60% of children who have Tourette syndrome (TS) also have AD/HD, which often presents 2 to 3 years before the onset of tics.

Appetite suppression is common with stimulant use and may result in transitory effects on weight and decreases in height velocity. There is no evidence of any effect on adolescent growth or ultimate adult height. Appetite suppression often diminishes over time.

Stimulant Medications for AD/HDs
Medication	Dose schedule	Dose range	Potential side effects/cautions
Methylphenidate (Ritalin or generic) 5-, 10-, 20-mg tablets	Initial: 5 mg or 0.3 mg/kg per dose Increase: 2.5 mg to 5 mg weekly Frequency: 2 to 3 doses/d	5 to 80 mg/d 0.3 to 0.8 mg/kg per dose	Anorexia, insomnia, stomach aches, headaches, irritability, "rebound," flattened affect, social withdrawal, weepiness, tics, weight loss, reduced growth velocity Avoid decongestants Monitor height, weight, blood pressure, pulse
Ritalin SR or generic20-mg sustained-release tablets only	Initial: 20 mg Increase: 20 mg Frequency: 1 or 2 doses/d	20 to 80 mg/d 0.6 to 2 mg/kg per dose	Same as regular MPH. May release unevenly Do not chew or cut in half 20 mg SR may be equivalent to 12 to 15 mg regular released over 5 to 8 h
Dextroamphetamine (Dexedrine) 5-mg tablets (Dextrostat) 5-, 10-mg tablets	Initial: 2.5 to 5 mg (0.15 mg/kg per dose) Increase: 2.5 mg to 5 mg weekly Frequency: 2 to 3 doses/d	2.5 to 40 mg/d 0.15 to 0.4 mg/kg per dose	Anorexia, insomnia, stomach aches, headaches, irritability, "rebound," tics, stereotypy, weight loss/reduced growth velocity Avoid decongestants Monitor height, weight, blood pressure, pulse
Dexedrine Spansules 5-, 10-, 15-mg capsules	Initial: 5 mg in AM (0.3 mg/kg per dose) Increase: 5 mg weekly Frequency: 1 to 2 doses/d	5 to 40 mg/d 0.3 to 0.8 mg/kg per dose	Anorexia, insomnia, stomach aches, headaches, irritability, social withdrawal, weepiness, stereotypy, tics, weight loss, reduced growth velocity Avoid decongestants Monitor height, weight, blood pressure, pulse
Mixed Amphetamine Salts (Adderall) 5, 10, 20, 30 mg	Initial: 2.5 to 5 mg in AM Increase: 2.5 to 5 mg weekly Frequency: 1 to 2 doses/d	2.5 to 40 mg/d	Similar to dextroamphetamine Well tolerated
Pemoline (Cylert) 18.75-, 37.5-, 75-mg tablets 37.5-mg chewable tablets	Initial: 37.5 mg in AM Increase: 18.25 mg weekly Frequency: 1 to 2 doses/d Must be taken daily	18.75 to 112.5 mg/d 2 mg/kg per day	Insomnia, anorexia, stomach aches, irritability, headaches, choreoathetoid movements, liver dysfunction, rare fulminant liver failure Monitor height, weight, blood pressure, pulse Obtain liver function tests at baseline and 2 to 3 times per year

Nonstimulant medications

Nonstimulant medications may be beneficial in children who respond poorly to an adequate trial of stimulants, experience unacceptable stimulant side effects, or have comorbid conditions (tics, anxiety, mood disorder).

Nonstimulant Medications for AD/HDs
Medication	Indications	Dose schedule
Imipramine ( Tofranil or generic) 10-, 25-, 50-mg tablets	Alternative to stimulant AD/HD + tics Enuresis Anxiety	Initial: 10 to 25 mg or 0.5 mg/kg bedtime Increase: 10 to 25 mg every 5 to 7 d up to 3 mg/kg per day Frequency: 2 to 3 doses/d Must be taken daily. Stop slowly
Desipramine ( Norpramin or generic) 10-, 25-, 50-, 75-mg tablets	Alternative to stimulant AD/HD + tics Anxiety	Initial: 25 mg in morning Increase: 25 mg every 5 to 7 d Frequency: 2 to 3 doses/d Must be taken daily. Stop slowly
Nortriptyline ( Pamelor or generic) 10-, 25-, 50-, 75-mg tablets 10 mg/5 mL liquid	Alternative to stimulant AD/HD + tics Anxiety	Initial: 10 to 25 mg at bedtime Increase: Up to 2 mg/kg per day Frequency: Once or twice a day
Bupropion ( Wellbutrin) 75, 100 mg (Wellbutrin SR) 100, 150 mg	Alternative to stimulant Mood lability Depression Aggression	Initial: 100 SR QD Increase: 50 mg every 1 to 2 wkFrequency: 2 doses/d Must be taken daily.
Clonidine ( Catapres or generic) 0.1-, 0.2-, 0.3-mg tablets	Alternative to stimulant AD/HD + tics Insomnia Oppositionality Hyperarousal Aggression	Initial: 0.05 mg HS Increase: 0.05 mg every 3 to 7 d Frequency: 2 to 4 doses/d for AD/HD Start and stop slowly
Catapres TTS 1, 2, 3 (transdermal patches)	Same as clonidine Sustained delivery avoids multiple dosing Less sedating	Initial: TTS 1 patch (0.1 mg/d) Increase: 0.1 mg in 2 wk Frequency: Change every 5 d Beclomethasone nonaqueous nasal spray applied to site decreases irritation
Guanfacine ( Tenex or generic) 1-, 2-mg tablets	Same as clonidine Longer half-life and much less sedation than clonidine	Initial dose: 0.5 mg HS Increase: 0.5 mg/wk Give as one to two doses/d Takes several days to weeks to take effect

Tricyclic antidepressants (TCAs) are efficacious in 60% to 70% of children who have AD/HDs. Those who have AD/HDs and comorbid anxiety, depression, or tic disorders may respond better to TCAs than to stimulants.

Antihypertensives. A positive behavioral response to clonidine occurs in up to 50% of patients. The best responders tend to be those who are overaroused, easily frustrated, extremely hyperactive, or aggressive. Clonidine has been used as a first-line treatment in children who have comorbid tics or Tourette’s syndrome or as an alternative to stimulants when there are severe side effects. Clonidine is not as effective as stimulants.