In Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD) (J Am Acad Child Adolesc Psychiatry. 2007;46:894-921), the American Academy of Child and Adolescent Psychiatry addresses one of the most common childhood psychiatric conditions: in the United States, the prevalence of ADHD is generally reported in the 7%-8% range, with estimates ranging as high as 10%.
“The majority of children with ADHD can be cared for in primary care, particularly those without significant comorbidity,” says Steven R. Pliszka, MD, professor and chief of the division of child and adolescent psychiatry at the University of Texas Health Sciences Center at San Antonio, and principal author of the practice parameter.
The single most important aspect of the document, according to Dr. Pliszka, is its endorsement of medication—particularly psychostimulants—as first-line treatment for ADHD. This is not to deny that psychosocial treatments have their place, however. For example, “We very much endorse behavioral therapy as a supplement to medication, particularly when comorbidity is present,” Dr. Pliszka says.
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Evaluation for ADHD
The diagnosis of ADHD is based on a detailed interview with the parents and the young patient to assess symptoms, preferably with reference to a standardized rating scale.
The patient’s academic and intellectual progress merit particular attention as a reflection of both ADHD-linked impairment and possible learning disorders, the parameter states.
Consider family history: ADHD has a strong genetic component, and psychiatric disorders in close relatives can also help clarify comorbidity.
An understanding of family function should inform treatment. “Families need to provide a structured environment. While a chaotic environment does not cause ADHD, it can complicate its course,” explains Dr. Pliszka.
According to the parameter, “Clinicians should be prepared to encounter a wide range of psychiatric symptoms in the course of managing patients with ADHD”: 54%-84% may meet criteria for oppositional defiant disorder (ODD); 25%-35% will have a language or learning problem; up to a third have an anxiety disorder, and some reports indicate that a third meet the criteria for a depressive disorder.
While most primary-care practitioners (PCPs) feel comfortable dealing with such simpler comorbidities as ODD, such problems as explosive aggression or significant mood disorders indicate the need for referral, says Dr. Pliszka.
Laboratory and neurologic tests should not be performed routinely but reserved for specific circumstances (e.g., known or suspected exposure to lead; symptoms of hyperthyroidism besides hyperactivity). Similarly, intelligence and neuropsychologic tests are only indicated when the history suggests low cognitive ability or when focal impairment (e.g., in language or mathematics) suggests a learning disorder.
Initial treatment
The patient and parents should be fully informed about the nature of the disorder, its probable course, and developmental challenges to anticipate. “Psychoeducation includes explaining how ADHD influences impulse control; that [behavior problems] may not be deliberate, but that the child must make an effort to control behavior,” Dr Pliszka comments.
The parameter suggests that books, videos, and noncommercial Web sites may be useful adjuncts to psychoeducation.
The choice between medication and psychosocial treatment ultimately belongs to the patient and/or parents, but they should be aware that a strong evidence base makes pharmacotherapy the logical first-line approach in most cases. Behavior therapy is the only psychosocial treatment with proven efficacy and has a significantly smaller effect than medication.
According to the parameter, behavior therapy might be recommended as initial treatment if symptoms are mild and impairment is minimal, the diagnosis is uncertain or a matter of disagreement between parents and teachers, or the family rejects medication.
Pharmacotherapy should start with an FDA-approved agent. These include various formulations of the psychostimulants amphetamine and methylphenidate (Ritalin, Methylin), the noradrenergic reuptake inhibitor atomoxetine (Strattera), and (approved after publication of the parameter) a long-acting formulation of the alpha-agonist guanfacine (Tenex, Intuniv) for ADHD.
The authors do not recommend one drug over another but note that efficacy data are strongest for psychostimulants and suggest that atomoxetine might be a first-line choice for patients with an active substance problem, comorbid anxiety, or tics.
Adverse effects
The most common side effects of ADHD drugs are insomnia, weight loss, reduced appetite, and headaches. Tics and emotional lability are also not rare. If they do not compromise the patient’s health or functioning and the clinical response has been robust, such problems need not be addressed immediately; they may resolve without treatment. Otherwise, dose reduction or a trial of a different medication may be in order.
Pronounced psychiatric side effects are rare, but when aggression or emotional lability increases to a distressing level or psychotic symptoms emerge, the medication should be discontinued and another agent considered, the practice parameter advises.
A small but significant increase in suicidal thinking with atomoxetine (4/1,000 patients) has resulted in a boxed warning. Discuss this issue with patients and family, and monitor for suicidal thinking, particularly early in treatment.
Concern about the risk of sudden cardiac death with stimulant therapy led the FDA to consider (and reject) the possibility of a boxed warning. The authors note that cardiac mortality in ADHD-treated children does not exceed the base rate in the general population. Consequently, routine cardiac screening is not needed, but a young patient with known heart disease or suggestive symptoms (e.g., fainting, severe palpitations) should be referred for a cardiology consultation before pharmacotherapy is initiated.
While significant decrements in adult height attributable to medication or the disease itself are unusual, the tempo of growth is not infrequently reduced. The parameter recommends monitoring weight and height once or twice yearly and a temporary discontinuation of medication or switch to another drug if growth indices decline markedly.
Suboptimal response
Patients who fail to respond adequately to first-line drugs may benefit from behavior therapy or a trial of such non-FDA-approved medications as bupropion (Wellbutrin, Zyban), imipramine (Tofranil), or clonidine (Catapres). Particularly in the context of psychiatric comorbidity or a stressful family situation, combined pharmacotherapy and behavior therapy are often beneficial.
It is at this point, Dr. Pliszka says, that most PCPs might well consider referral to a specialist.
Follow-up care
The natural history of ADHD is variable: “Many children have difficulties all through high school and young adulthood, but in others, symptoms improve to the extent that treatment is no longer needed,” says Dr. Pliszka.
Follow-up visits should be scheduled at least two to four times yearly to re-evaluate treatment response and symptom severity. Consider a trial off medication when the patient has been symptom-free for at least one year, the parameter authors write. “Low-stress times such as vacation are a good time to attempt [this].”
