Current
Concepts in ADHD
Ross Finesmith MD
The Center for Disease Control (CDC) states that ADHD
affects approximately 5% of children1 and 4% of adults2
in the U.S. Recent CDC monitoring suggests these numbers continue to increase
as awareness and public education have become more widespread.3 The
symptoms of Attention Deficit Hyperactivity Disorder include high activity
level, impulsivity, low frustration tolerance, difficulty remaining focused on
a task, forgetfulness and easy distractibility. These are all personality
traits that we all, to some degree, manifest. These traits must occur at a high
enough level to interfere with learning and daily activities to meet criteria
for ADHD.
Approximately one-quarter of those with ADHD symptoms
display primarily high activity, low frustration and intolerance. There persons
are diagnosed with ADHD-Impulsive/Hyperactive type. Individuals with primary
symptoms of inattention, easy distractibility and forgetfulness are considered
to have ADHD-Inattentive type. Is seems to be a misnomer that the inattentive
individuals are still under the heading of ADHD, with the “H” standing for
hyperactivity. This is simply the nomenclature of the medical literature.
Approximately one-half manifest a combination of both hyperactive and
inattentive behaviors and are considered to have the combined type.4,5
Assessment and diagnosis of ADHD is dependent on age.5,6
Young children naturally have higher activity levels and shorter attention
spans than older children, and certainly adults. Therefore there cannot be
strict measurements of an ability or length of time a child should remain on a given
task. The various assessments are designed to determine if the limitations of a
child’s ability to remain focused interferes with age appropriate tasks. For
example, a second grader should be able to remain focused and complete 5 basic
mathematics problems without getting distracted. A forth grader should be able to accomplish
more with increasing distractions that are typical in an higher grade classroom
or during homework time at home.
The assessment of these “age appropriate” abilities must be
carried out by a professional trained, skilled and experienced in this type of
assessment. The actual “testing” or assessment can be carried out by a number
of professionals, but since the final diagnosis is of a medical condition, a
physician should make this diagnosis. This includes developmental
pediatricians, pediatric neurologists and child psychiatrists. Some general
pediatricians that take the time to perform some testing and review educational
reports can appropriately make the diagnosis as well. The assessment and
diagnosis in adults is almost exclusively performed by adult psychiatrist,
since internist’s and adult neurologist have traditional not been educate and
trained in this diagnosis.
The corner stone in the treatment of ADHD, at any age, is
education and lifestyle and behavioral changes. Individuals with ADHD should
learn strategies to compensate for their weaknesses of limited attention span,
easy distractibility and high activity levels.7 For young children,
frequent breaks with the opportunity for physical activity can help them be
more productive when returning to a complicated or “boring” task such as
homework. Those children with a high activity level and impulsively often
respond well to behavioral management programs that “reward” accomplishable
time periods that the child can remain on task or complete assignments. Quit
environments or headphones help prevent those with easy distractibility. Many
children and most adults with ADHD have poor organizational abilities and
frequent forgetfulness. There are an abundance of strategies and professionals,
primarily psychologists that can provide guidance in theses areas.
If lifestyle and behavioral interventions do not completely
allow an individual to perform age appropriate tasks, then medication should be
considered. Many parents are initially opposed to “medicating” their children.
Parents should be counseled that the goal of any treatment is to allow their
children to be more successfully both academically and socially. A cognitively
average, or even about average, can have significant academic and social problems
solely related to their concentration and distractibility weaknesses. These
weaknesses become more prevalent and problematic as children are presented with
more complicated academic challenges as they progress in school.
Medications administered in the treatment are primarily
stimulants, but there are several “non-stimulants” that are also used. Methylphenidate
(Ritalin, etc.) has been used safely in several different formulations for over
50 years. Other methylphenidate formulations include: Concerta, Metadate,
Methylin, Focalin, Methylin and Quilivant. A second class of amphetamine
stimulants include: Adderall, Vyvanse, Dexedrine and Dextrostat.8 Despite
frequent reports in the popular press and internet, methylphenidate has been
found to be safe and effective in the treatment of children and adults with
ADHD. Over the years there have been additional formulations of methylphenidate
and other stimulant medications. Some individual’s react better to one
formulation compare to another, but there has been no “superior” stimulant ADHD
medication compared to the others.
Non-stimulant medications FDA approved for ADHD treatment
include atomoxetine (Strattera), guanficine (Intuiv) and clonidine (Kapvay).8
These medications do not have the long safety history of the stimulant
medications, but are a good alternative for those that do not tolerate
stimulant medications. There are other medications used by doctors that are not
FDA approved for the treatment of ADHD including several antidepressants.
The outlook for most individuals with ADHD is good with a
“normal” life. A recent meta-analysis, that included 1,057 children with ADHD,
reported that combined behavioral and medication interventions are effective in
“managing” core ADHD symptoms and academic performance. However, this is dependent on early
institution of lifestyle and behavioral interventions and the appropriate
medical interventions when required.9 In addition, the presence of
coexisting conditions can impact success as well. Individuals with ADHD have a
higher incidence of also having a learning disability, mood disorder and other
behavioral conditions. Early and effective treatment of ADHD in those with
these “co-morbid” conditions increases the successful outcome of both.
Continuing education of parents, children and adults with
ADHD is essential to the successful intervention on the affected persons
dealing with the symptoms of ADHD. Ongoing professional management of
behavioral and medication may be necessary for long-term success.
1.
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders: DSM-IV-TR. Washington: American
Psychiatric Association, 2000. http://www.cdc.gov/ncbddd/adhd/data.html#1
2.
Kessler RC, Adler L, Barkley R, Biederman J,
Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T,
Ustun TB, Walters EE, Zaslavsky AM. The Prevalence and Correlates of Adult ADHD
in the United States: Results from the National Comorbidity Survey Replication.
American Journal of Psychiatry. 2006. 163: 724-732. http://www.nimh.nih.gov/news/science-news/2006/harvard-study-suggests-significant-prevalence-of-adhd-symptoms-among-adults.shtml
5.
Attention-deficit/hyperactivity disorder. In:
Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed.
Arlington, Va.: American Psychiatric Association; 2000. http://www.psychiatryonline.com.
6.
Attention deficit/hyperactivity disorder.
National Institute of Mental Health. http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml
7.
Bader
A, et al. Complementary and alternative therapies for children and adolescents
with ADHD. Current Opinion in Pediatrics. 2012;24:760. http://www.mayoclinic.com/health/adhd/DS00275/DSECTION=treatments-and-drugs
9.
Parker J,
Wales G,
Chalhoub N,
Harpin V.
The long-term outcomes of interventions
for the management of attention-deficit hyperactivity disorder in children and
adolescents: a systematic review of randomized controlled trials. Psychol Res
Behav Manag. 2013 Sep
17;6:87-99. www.ncbi.nlm.nih.gov/pubmed/24082796
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