Review of Pediatric Attention Deficit/Hyperactivity Disorder for the General Psychiatrist

doi:10.1016/j.psc.2008.10.001

Psychiatric Clinics of North America

Volume 32, Issue 1, March 2009, Pages 39-56

https://doi.org/10.1016/j.psc.2008.10.001 Get rights and content

Attention deficit/hyperactivity disorder (ADHD) is a common and impairing psychiatric condition, affecting significant numbers of children and adolescents. General psychiatrists serve, both by choice and out of necessity, in the assessment and treatment of children and adolescents who have ADHD and in the education of patients and their families. For many clinicians, however, there are numerous unanswered questions regarding the diagnosis and therapeutic interventions for ADHD. This article provides general psychiatrists with a practical overview and update on the assessment, diagnosis, and treatment of pediatric ADHD. Background information, recent relevant research, current evidence-based practice guidelines, and tips for clinical practice are reviewed in this article. The information is presented in a question-answer format.

Section snippets

How common is attention deficit/hyperactivity disorder?

ADHD is one of the most common psychiatric disorders in pediatrics. Conservative estimates report ADHD prevalence rates of 3% to 7% in children,¹ with other estimates as high as 7% to 12%.2, 3 Even if the conservative reports are the most accurate, ADHD is clearly a significant public health issue. Additionally, as many as 60% to 85% of children diagnosed with ADHD continue to meet criteria for the disorder as teenagers, and up to 60% continue to experience symptoms as adults.4, 5, 6, 7 It is

Why is it important to treat attention deficit/hyperactivity disorder early and effectively?

One of the crucial elements for making a diagnosis of ADHD is identifying significant impairment in functioning in at least two settings. Three- to 5-year-old children who have ADHD have been shown to be at increased risk for academic, social, behavioral, and family dysfunction.¹¹ Affected preschoolers are more likely to need special education services and have increased academic difficulties.12, 13 These young children are also at higher risk for accidents and injuries,¹³ aggression,¹⁴ and

What causes attention deficit/hyperactivity disorder?

ADHD is a disorder with strong neurobiological underpinnings. In a meta-analysis, Faraone and colleagues¹⁷ estimated the heritability of ADHD to be approximately 76%. Although genetics play a significant role,17, 18 nongenetic factors and environmental exposures, such as prenatal smoking and alcohol use, pre- and neonatal hypoxia, lead exposure, and traumatic brain injury have also been associated with the development of ADHD.19, 20, 21, 22 Additionally, neuroimaging studies have reinforced the

How does attention deficit/hyperactivity disorder typically present in the pediatric population?

Hyperactivity is the most common presenting symptom for preschool children who have ADHD.²⁵ Inattention becomes more apparent during the school-aged years because of increased academic demands, although hyperactive and impulsive behaviors frequently persist. Overt physical hyperactivity and impulsivity are often less prominent after puberty.²⁶ These symptoms may change over time in presentation, in fact persisting as excessive talking, avoidance of situations requiring sitting quietly,

How is attention deficit/hyperactivity disorder diagnosed?

Increased awareness and improved detection of ADHD has resulted in an increased number of children being identified with the disorder. Although estimates of the prevalence of ADHD vary, it is clear that it is a common and impairing condition with the potential for negative sequela if left undiagnosed and untreated. Currently there are no blood tests or neuroimaging studies available to diagnose ADHD. A careful systematic assessment by a trained clinician is required. The diagnostic process

What other disorders should be considered in the differential diagnosis of a child who has suspected attention deficit/hyperactivity disorder?

Various other disorders and conditions might masquerade as ADHD. A child who has developmental disabilities, learning disorders, or cognitive limitations may be unable to complete certain academic tasks, be unable to focus because he or she may not understand the task, and may become disruptive out of frustration. A child who has poor vision or poor hearing might present with symptoms overlapping those of ADHD, and so these impairments should be ruled out. Depressive and anxiety disorders

How frequently is attention deficit/hyperactivity disorder comorbid with other psychiatric disorders?

Perhaps one of the most compelling reasons for a comprehensive psychiatric evaluation is the frequency of comorbidity with ADHD. Even when a diagnosis of ADHD is certain, the examination is only partially complete, because nearly two thirds of children diagnosed with ADHD have at least one comorbid psychiatric diagnosis. The MTA study included the largest and best characterized ADHD population to date, and demonstrated that only 31% of participants had ADHD alone, whereas 40% also met criteria

Educating the Patient and Family

The National Initiative for Children's Healthcare Quality (NICHQ) recommends that children who have ADHD and their families receive ongoing support and education as a foundation to individualized treatment planning.37, 38 A multitude of reliable educational resources are available for patients, parents, and teachers to facilitate the educational component of the treatment plan (Box 2).

Behavioral Interventions

Behavioral therapies for ADHD (such as parent training), child-focused treatments (such as behavioral

Stimulants

Although there are more than a dozen US Food and Drug Administration (FDA)–approved stimulant medications that are currently available, all are derivatives of either methylphenidate or amphetamine. The stimulants act by enhancing the neurotransmission of dopamine, and to a lesser extent, norepinephrine.³⁹ The stimulants have one of the highest response rates in all of psychopharmacology, with approximately two of every three patients treated with either methylphenidate or amphetamine responding.

Stimulants

Adverse event profiles are comparable for all formulations of the stimulant medications.⁴¹ Delayed sleep onset, decreased appetite, weight loss, headache, stomach upset, and increased heart rate and blood pressure are common. Emotional outbursts and irritability have also been reported in younger children.⁴⁷ Many of these problems can be managed by selecting alternate formulations with shorter durations of action to minimize effects on sleep and evening appetite, modifying administration

What is important to know about the treatment of preschool children who have attention deficit/hyperactivity disorder?

Apart from obtaining a detailed history and thorough examination, assessment of developmental milestones is particularly important in the evaluation of the preschooler, because many developmental disorders are associated with attentional problems and hyperactivity.³³ In addition, temperament difficulties, learned behavioral responses, parent–child relationship problems, and anxiety may all present with ADHD-like symptoms. Although pharmacotherapy in this population has been increasing, growing

What is important to know about the treatment of adolescents who have attention deficit/hyperactivity disorder?

In a longitudinal study of 358 clinically referred subjects who had ADHD, 27.9% of those who were on medication at some point in their lives, usually starting treatment by age 10, had stopped taking medication by age 11, and 67.9% had discontinued pharmacotherapy by age 15.⁶¹ Treatment adherence frequently decreases in adolescence, although the consequences of untreated ADHD can be just as significant, if not more so, as those in younger children (ie, motor vehicle accidents, unplanned

Summary

ADHD is well known to be a common condition in children, with increasing awareness of its presence in preschoolers and adolescents. Given the potential for functional impairment over time, it is important for psychiatrists to be able to identify and accurately diagnose ADHD, make appropriate decisions regarding treatment, educate those involved, and carefully monitor the safety and effectiveness of the treatment. By partnering with the patient, the family, and the school, ADHD can be

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Cited by (18)

Attention-Deficit/Hyperactivity Disorder Medication Treatment Impact on Response to Growth Hormone Therapy: Results from the ANSWER Program, a Non-Interventional Study
2015, Journal of Pediatrics
To examine whether attention-deficit/hyperactivity disorder (ADHD) stimulant medication modified the linear growth response to growth hormone (GH) treatment in children enrolled in the American Norditropin Studies: Web-Enabled Research Program.
Short, GH treatment-naive children with or without GH deficiency (GHD) received GH therapy. A subset also received ADHD stimulant medication (n = 1190), and others did not (n = 7230). Linear mixed models (adjusted means) examined height SDS (HSDS) and body mass index (BMI) SDS from baseline through year 4. Analyses were repeated with ADHD groups matched for baseline age, height, weight, BMI, and sex. Groups with and without GHD were compared between ADHD groups.
Adjusted change in HSDS for the group receiving ADHD stimulant medication was slightly lower than that for patients not receiving stimulant medication at years 1 to 4 (P < .05). However, adjusted change in HSDS was similar between children receiving and not receiving ADHD stimulant medication when matched for baseline measurements. At year 4, 86.7% of patients receiving ADHD stimulant medication, 86.8% of total patients not receiving ADHD stimulant medication, and 84.6% of matched group patients not receiving ADHD stimulant medication achieved HSDS >−2. Year 4 adjusted change in BMI SDS was greater in the patients receiving ADHD stimulant medication compared with both groups not receiving ADHD stimulant medication (P < .05). Patients with GHD showed comparable differences in adjusted change in BMI SDS among the ADHD groups at year 4, whereas patients without GHD showed no significant differences.
ADHD medication did not affect the linear growth response of children treated with GH when those receiving or not receiving ADHD stimulant medication were matched for baseline measurements. Underlying reasons for the observed greater increase in BMI in patients with GHD concomitantly treated with ADHD medication remain to be elucidated.
ClinicalTrials.gov: NCT01009905.
Sociodemographic characteristics and mental disorders in children and adolescents psychiatric outpatient clinic children of Medellin
2015, Revista Colombiana de Psiquiatria
Los trastornos mentales en el mundo afectan a un 15-30% de los niños y adolescentes, lo que compromete el funcionamiento y el desarrollo emocional, cognitivo y social, afectan a las relaciones interpersonales y el rendimiento escolar y aumentan el riesgo de consumo de sustancias y de suicidio.
Describir las características sociodemográficas y los trastornos mentales de niños y adolescentes de consulta psiquiátrica.
Estudio descriptivo retrospectivo que analizó la totalidad de las historias clínicas de niños y adolescentes de ambos sexos de 5-16 años que asistieron por primera vez a consulta externa de psiquiatría en una clínica universitaria de Medellín, desde julio de 2010 a julio de 2012.
Se estudió a 197 pacientes; la media de edad era 11 ± 3,5 años; el sexo más frecuente fue el masculino (69%); el 46,2% pertenecía a familia nuclear. Los trastornos psiquiátricos más prevalentes fueron el déficit de atención e hiperactividad (44,2%), los depresivos (9,1%) y el obsesivo-compulsivo (8,1%). Un 61% tenía comorbilidad psiquiátrica; la más frecuente fue el trastorno oposicional desafiante con déficit de atención e hiperactividad (35,6%).
La frecuencia de trastornos mentales y comorbilidades encontradas en este estudio es similar a la reportada por otros investigadores.
Mental disorders in the world affecting 15% to 30% in children and adolescents, altering its function and emotional, cognitive and social. Affect interpersonal relationships, school performance and increased substance use and the risk of suicide.
describe the social-demographic characteristics and mental disorders of children and adolescents of psychiatric consultation.
Retrospective descriptive study that analyzed all the histories of children and adolescents of both sexes from 5 to 16 years who attended for the first time outpatient psychiatry university clinic of Medellin, from July 2010 to July 2012.
We studied 197 patients, the average age was 11 ± 3.5 years, male sex was the most common 69%, 46.2% belonged to nuclear family. The most prevalent psychiatric disorders were 44.2% ADHD, depressive disorders 9.1% and 8.1% TOC. 61% had psychiatric comorbidity, the most frequent was oppositional defiant disorder with ADHD 35.6%.
The frequency of mental disorders and comorbidities found in this study were similar to those reported by other researchers.
Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Task Force 11: Drugs and Performance-Enhancing Substances: A Scientific Statement from the American Heart Association and American College of Cardiology
2015, Journal of the American College of Cardiology
A Framework for the Assessment and Treatment of Sleep Problems in Children with Attention-Deficit/Hyperactivity Disorder
2011, Pediatric Clinics of North America
Citation Excerpt :
If changing the dose and/or timing of the stimulant medication is ineffective, a different stimulant or a nonstimulant medication could be considered for the treatment of ADHD.57 For a review of ADHD medications and their properties, see Kratochvil and colleagues58 or the following Web sites: http://www.addwarehouse.com/shopsite_sc/store/html/article3.htm; http://www.caddra.ca/cms4/pdfs/medication-adhd-canada_April2010.pdf. Some pediatricians recommend an additional dose of stimulant medication in the evening, as it is believed that difficulties falling asleep are the result of “rebound effects” (ie, increased irritability, agitation, and emotional liability) as the child’s daytime medication wanes.
Case-control genome-wide association study of attention-deficit/ hyperactivity disorder
2010, Journal of the American Academy of Child and Adolescent Psychiatry
Although twin and family studies have shown attention-deficit/hyperactivity disorder (ADHD) to be highly heritable, genetic variants influencing the trait at a genome-wide significant level have yet to be identified. Thus additional genomewide association studies (GWAS) are needed.
We used case-control analyses of 896 cases with DSM-IV ADHD genotyped using the Affymetrix 5.0 array and 2,455 repository controls screened for psychotic and bipolar symptoms genotyped using Affymetrix 6.0 arrays. A consensus SNP set was imputed using BEAGLE 3.0, resulting in an analysis dataset of 1,033,244 SNPs. Data were analyzed using a generalized linear model.
No genome-wide significant associations were found. The most significant results implicated the following genes: PRKG1, FLNC, TCERG1L, PPM1H, NXPH1, PPM1H, CDH13, HK1, and HKDC1.
The current analyses are a useful addition to the present literature and will make a valuable contribution to future meta-analyses. The candidate gene findings are consistent with a prior meta-analysis in suggesting that the effects of ADHD risk variants must, individually, be very small and/or include multiple rare alleles.
Prospective follow-up studies found no chromosomal mutagenicity of methylphenidate therapy in ADHD affected children
2010, Toxicology Letters
Five to ten percent of all children suffer from attention-deficit/hyperactivity disorder (ADHD), which is often treated with the central nervous stimulant methylphenidate (MPH). In 2005 controversy arose due to a report of enhanced cytogenetic effects in 12 children after 3 months of MPH treatment. Since then, several prospective studies have been performed and published, which are summarized here. A table comparing the micronucleus frequencies, a marker investigated in all of these studies, is presented. An induction of cytogenetic effects by MPH was only reported in one, the 2005 study by El-Zein et al., while all other studies, with now altogether 110 MPH-exposed individuals, showed no elevation. To address the question of long-term use of MPH, we published the data of 30 chronically treated children and also saw no difference compared to untreated children. Here, we report as new follow-up data that an additional 12 months time point in a small group of 12 children who had begun MPH therapy within our published study also did not reveal elevated cytogenetic damage. Furthermore, a previously unpublished analysis of urinary 8-oxo-7,8-dihydro-2′-deoxyguanosine (8-oxodG; a non-invasive biomarker for DNA-base oxidation and its repair) in 11 children before and after 3 months of MPH exposure yielded no significant difference. Since gene mutations may not necessarily manifest as chromosomal aberrations, micronuclei or SCEs, we discuss the available data from animal models, which also do not reveal a mutagenic potential of MPH. Although the only two available epidemiological studies do not report elevated risk for MPH exposure, the results are not conclusive yet, and further monitoring of exposed populations is suggested.

View all citing articles on Scopus

: Dr. Kratochvil is supported by NIMH Grant 5K23MH06612701A1; receives grant support from Eli Lilly, McNeil, Shire, Abbott, and Somerset; is a consultant for Eli Lilly, AstraZeneca, Abbott, and Pfizer; and receives study drugs for an NIMH-funded study from Eli Lilly.

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Review of Pediatric Attention Deficit/Hyperactivity Disorder for the General Psychiatrist

Section snippets

How common is attention deficit/hyperactivity disorder?

Why is it important to treat attention deficit/hyperactivity disorder early and effectively?

What causes attention deficit/hyperactivity disorder?

How does attention deficit/hyperactivity disorder typically present in the pediatric population?

How is attention deficit/hyperactivity disorder diagnosed?

What other disorders should be considered in the differential diagnosis of a child who has suspected attention deficit/hyperactivity disorder?

How frequently is attention deficit/hyperactivity disorder comorbid with other psychiatric disorders?

Educating the Patient and Family

Behavioral Interventions

Stimulants

Stimulants

What is important to know about the treatment of preschool children who have attention deficit/hyperactivity disorder?

What is important to know about the treatment of adolescents who have attention deficit/hyperactivity disorder?

Summary

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Biol Psychiatry

Biol Psychiatry

Biol Psychiatry

Lancet

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Child Adolesc Psychiatr Clin N Am

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

J Pediatri

J Am Acad Child Adolesc Psychiatry

Psychiatr Clin North Am

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Pediatr

American Psychiatric Association: diagnostic and statistical manual of mental disorders fourth edition text revision

Mental health in the United States. Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder—United States

MMWR Morb Mortal Wkly Rep

Trends in environmentally related childhood illnesses

Pediatrics

The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study

J Am Acad Child Adolesc Psychiatry

The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder

J Abnorm Psychol

A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders

Arch Gen Psychiatry

Absence of gender effects on attention deficit hyperactivity disorder: findings in nonreferred subjects

Am J Psychiatry

Three-year predictive validity of DSM-IV attention deficit hyperactivity disorder in children diagnosed at 4–6 years of age

Am J Psychiatry