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ATTENTION-DEFICIT DISORDER

Attention-deficit hyperactivity disorder is the most common behavioral disorder diagnosed during childhood and adolescence, with 2.8% of all youths 5 to 18 in the United States receiving methylphenidate in 1995. The conventional cardinal symptoms of ADD include age-excessive inattentiveness, usually in association with overactivity and impulsivity. Newer data and recommendations now support that a distinct subgroup of patients have ADD without hyperactivity or impulsivity. ADD has been classically associated with

To diagnose ADD, clinicians must judge the duration, frequency, intensity, pervasiveness, and maladaptive nature of these behaviors while excluding a myriad of other possible causes. Furthermore, these behaviors must be differentiated from normal age-related variations, mood disorders, and

Teachers or parents frequently comment that untreated children manifest no problems on some "good days" or while watching television or playing video games. They assume that if the behavior can be modulated some of the time, then the child is not hyperactive. Even after the patient has shown dramatic improvement with medication, adults may still complain that some days the child's behavior is worse than at baseline attention deficit disorder, ADD, atention, defacit, attenshun

Most medication for ADD is prescribed by physicians in general practice, not neurologists or psychiatrists, with more than half of stimulant prescriptions written by pediatricians. More than 80% of these prescriptions are written for school-aged children. Because of the inherent complexity and difficulty incorporating

CLASSIFICATION OF ATTENTION-DEFICIT DISORDERS

In the past, pediatricians have generally considered the diagnosis of ADD only in those children who displayed overt overactivity, aggressiveness, or behavioral problems. Another misconception has been that, as children progress into adolescence and adulthood, ADD is outgrown primarily because the "cardinal symptom," overactivity, subsides. Instead, inattentiveness, restlessness, and

Hyperactive-Impulsive Attention-Deficit

Disorder

Most children with ADD-H present during preschool and elementary school years with behavioral problems. Usually, parents bring the child to the office complaining of either their child's hyperactivity,

Inattentive Attention-Deficit Disorder

In contrast, patients with ADD-I usually present in middle or high school years, predominantly with academic problems. August and Garfinkel coined ADD-I as the "cognitive deficit" form of ADD as

Comorbid Disorders

Comorbid disorders may be observed in as many as two thirds of children referred to a tertiary-care clinic for ADD. Patients with ADD-H are more frequently affected by comorbid conduct disorders (36%-50%) and oppositional defiant disorder (59%). Among a tertiary-care hospitalized referral population with ADD-H and ADD-I, Eiraldi and colleagues observed conduct disorders in 44% and 0% of patients, respectively, and oppositional defiant disorder in

Prognosis

Schachar and colleagues reported a worse prognosis and lower cognitive functioning among pervasively versus situationally hyperactive children. Early age of ADD onset is associated with higher cognitive deficits, poor reading skills, comorbidity at age 11 years, and worse outcome at age 15 years. Clinical course and outcomes are significantly worse in those with ADD-H comorbid with conduct disorders, aggression, or

ASSESSMENT FOR ATTENTION-DEFICIT DISORDER

The Behavioral Checklist

No chemical, serologic, or imaging tests are available to diagnose ADD. In addition, pediatricians have limited observation of the patient's behavior. Thus, to diagnose ADD, pediatricians must rely on the "foundation," the subjective parental, patient, and social history; the "cornerstone," the objective behavioral checklist from the teacher(s); and the "mortar," the physician gestalt regarding the patient and family dynamics.

A single checklist for both age groups-adolescents and children-should be selected and uniformly used within an office. To diagnose ADD, the checklist should be obtained from both the parents/caregivers and teachers. Using both sources improves the accuracy of the diagnosis by providing information regarding behavior from two different vantage points: parents have a long-term (and biased) view of their child in multiple milieus; teachers have a short-term, more objective, and reliable viewpoint and are able to compare the patient with 30 other students (control subjects) in the classroom. The school setting singularly places the most intense demands on concentration. Each assessed environment has its own set of diverse requirements of both attention and social behavior. By elucidating behavioral or discipline problems that

Diagnostic Criteria

The current criteria for diagnosing ADD are listed in DSM-IV. Furthermore, according to DSM-IV in order to diagnose ADD, the clinician must also ascertain the following:

  1. Onset before age 7 years
  2. Pervasive rather than situational behavioral disorder (the problem must manifest and interfere in


TABLE 2 -- SPECIFIC MEDICATIONS FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER
Medication Dose Duration Titration Advantages Disadvantages
Methylphenidate
(Ritalin)
5, 10, 20 mg
0.3 to 0.6 mg/kg/dose b.i.d. or t.i.d. 2 to 4 hours Pills can be cut in half, but difficult Most popular stimulant; least negative effects on appetite and mood. Not labelled as "speed" or diet pill. Some differences between brand-name and generic, too short-acting, requires multiple dosing. Worse peaks and troughs. Recent negative press. Not approved for children < 6 years of age.
Methylphenidate SR
(Ritalin SR)
0.5 to 0.7 mg/kg/dose q.d. or b.i.d. 2 to 6 hours
Erratic
None Lowest rate of AEs among long-acting formulations Erratic, unreliable pharmacokinetics, occasional differences between brand-name and generic.
Dextroamphetamine sustained release capsules
(Dexedrine Spansule)
5, 10, 15 mg
0.15 to 0.3 mg/kg/ dose q.d. or b.i.d. 5 to 7 hours Capsules can be split in half (2.5 mg increments). See text. May be sprinkled for children unable to swallow pills. Less abuse potential than tablets. Appetite suppression and moodiness somewhat more common than with methylphenidate; avoid vitamin C simultaneously. Administer prebreakfast. Higher abuse potential.
Dextroamphetamine tablets
(Dexedrine)
5 mg tablets
0.15 to 0.3 mg/kg/ dose b.i.d. 3 to 5 hours Easy to cut in half Longer duration than short-acting methylphenidate (Same as spansules). Requires more frequent administration. Common form of "speed" on the street. Higher abuse potential.
Mixture of amphetamine salts
(Adderall)
5, 10, 20, 30 mg
0.15 to 0.3 mg/kg/ dose q.d. or b.i.d. 5 to 7 hours Easy to cut in half (2.5 mg increments). Reliable long-acting preparation, easiest of all medications to titrate, approved for 3 years and older. No recent published clinical trials. Otherwise apparently similar to dextroamphetamine spansules. Higher abuse potential.
Pemoline
(Cylert)
18.75, 37.5, 75.0 mg tablets and 37.5 mg chewables
1-2 mg/kg/day qd (once a day) 12 to 24 hours
Longest acting of all
Easy. Half-doses may be administered. Effects may not be apparent for several weeks. Longest-acting preparation, usually single daily dose. No abuse potential. Not considered a potential "street" drug. Alternative for adolescents or for patients with frequent homework. Lower rates of efficacy compared with other stimulants. Requires informed consent before prescribing and frequent serologic monitoring of LFTs. Onset of action may be from 3 days to 3 weeks.
Clonidine
(Catapres)
Transdermal patches
[TTS (1, 2, or 3)]
Start with 0.05 mg or tid or qid oral form. Increase by 0.05 mg tid weekly. Try transdermal patches replaced every 3 to 5 days in stable patients. Pills 4 to 6 hours Patches 3 to 5 days Half-doses can be used for pills or patches. Weekly increased dosing usually necessary. Most helpful in children with aggression, extreme overactivity, or conduct disorders. Use concomitantly with psychostimulants. Preferred therapy for children with concomitant tic disorder. Significant or severe problems with sedation. Not effective for inattention. Brand-name may be preferred over generic. Not FDA approved for behavioral pharmacotherapy. Discontinue gradually to prevent rebound hypertension.
AEs, adverse effects; LFTs, liver function tests; TTS, transdermal therapeutic system.

SELECTION OF MEDICATIONS BY AGE GROUP

Psychostimulants

Initial Therapy

Initial therapy in children diagnosed with uncomplicated ADD always consists of one the psychostimulants: methylphenidate, dextroamphetamine, or a combination of dextroamphetamine and levoamphetamine (Adderall). These medications are extremely safe and require no serologic or hematologic monitoring. Patients may respond better to one or the other of these psychostimulants, and patients who do not respond to the initial choice can be treated with either remaining alternative. Interestingly, parent-rating scales favored dextroamphetamine over methylphenidate, probably secondary to the longer half-life of dextroamphetamine so that effects were observed at home and school. Barkley reviewed 15 studies using dextroamphetamine and 14 using methylphenidate and observed a mean improvement of 75% for both

Children 5 to 14 Years of Age

Although selecting with which medication to initiate therapy may be somewhat arbitrary, in children 5 to 14 years old, either Dextroamphetamine Spansules or Adderall (mixture of amphetamine salts) may be preferred because of the longer, smoother duration of effects, reduced likelihood of midday school dosing with its subsequent stigmatization and teasing by classmates, ease of titration, and relatively lower costs. According to Pelham, Dextroamphetamine Spansules may be the preferred medication for children with

Compared with methylphenidate, sustained-release Dextroamphetamine Spansules (and possibly Adderall) is a significantly more reliable and effective long-acting form of amphetamines. Furthermore, sustained-release preparations are preferred by the children themselves and are less likely to be a factor in nonadherence. As shown in, the spansules and Adderall allow for easier titration in 2.5-mg (half-dose) increments. Adderall tablets may be cut in half. Pediatricians should consider demonstrating to the parents

Two Problematic Populations
Children 3 to 4 Years of Age.

Stimulant therapy is often avoided in children aged 3 to 4 years because of lower efficacy; the increased rate of problematic AEs, especially moodiness, irritability, and appetite suppression; and because of the lack of availability of a liquid formulation. Only highly aggressive and pervasively, behaviorally disruptive or

Adolescents.

Prescribing psychostimulants for the adolescent population creates a significant dilemma for pediatricians, who must now choose between the standard stimulants, which demonstrate no evidence of lethality when

In adolescents who may abuse or sell the medicine, the number of pills dispensed and purportedly taken when using either amphetamines or methylphenidate should be monitored carefully. Consequently, pediatricians may want to consider pemoline therapy for male adolescents initially, unless the family and adolescent are deemed trustworthy and reliable (which is possible with established patients). Patients previously managed with the other psychostimulants who are approaching age 13 or 14 years, particularly male adolescents who are impulsive, defiant, or have conduct problems,

Adolescents and their parents may prefer pemoline for any of five reasons: (1) it usually requires only a single daily dose, removing in-school dosing, a significant source of embarrassment for self-conscious teens; (2) it sustains positive effects into the evening, improving homework productivity; (3) it reduces

Tics.

Less than 1% of children with ADD develop tics. Previously, stimulants were believed to be contraindicated in children with Tourette's syndrome; however, current literature suggests that tics are not caused by stimulants but rather that stimulants exacerbate the underlying propensity for a tic disorder. Among children with Tourette's syndrome, approximately 40% to 50% have comorbid ADD. Clonidine, which has