Pediatric Annals

Healthy Baby/Healthy Child 

Focusing on ADHD Management

Amy Liu, MD, MPH

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children, and it affects academic performance, personal relationships, and future well-being. Given the prevalence of ADHD, many pediatricians should feel comfortable with the diagnosis and management of this condition. This article aims to improve understanding of ADHD, treatment options including both medication and behavioral interventions, as well as the laws in place to help these patients. [Pediatr Ann. 2020;49(12):e501–e505.]

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children, and it affects academic performance, personal relationships, and future well-being. Given the prevalence of ADHD, many pediatricians should feel comfortable with the diagnosis and management of this condition. This article aims to improve understanding of ADHD, treatment options including both medication and behavioral interventions, as well as the laws in place to help these patients. [Pediatr Ann. 2020;49(12):e501–e505.]

Globally, the prevalence of attention-deficit/hyperactivity disorder (ADHD) in children is approximately 7.2%, although estimates of prevalence in the US range from 9.4% to 14%.1–4 The prevalence of ADHD or a learning disability varies by race, gender, age, family income level, and parental educational attainment.2,4 Non-Hispanic Black children are more likely to be diagnosed with ADHD or a learning disability.4 Boys are twice as likely as girls to be diagnosed with ADHD.4 Children living with families at less than 100% of the federal poverty level or whose parents have a high school education or less were more likely to be diagnosed with ADHD.4

Children with ADHD are almost 2 times more likely to have chronic absenteeism than children without this condition.5 The effects of ADHD can continue into adulthood are significant, as is has been associated with increased risks for suicide, depression, and substance use disorders.1,6 Adults with ADHD experience higher rates of divorce and achieve lower educational and occupational attainment, with one study demonstrating as much as a $40,000 difference in median annual salary.7

Diagnosis

Although the median age that children are diagnosed with ADHD is around 7 years, one-third are diagnosed before age 6 years.8,9 For some children, presentation may occur later as schoolwork becomes more difficult. Primary care physicians diagnose more than 50% of children with ADHD, which emphasizes the important role that pediatricians play in identifying children early so that they may receive needed services and support. ADHD is diagnosed using guidelines outlined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition.10 Criteria for children up to age 16 years include six or more symptoms of inattention and/or hyperactivity-impulsivity, whereas adolescents age 17 years and older require at least five. Impairments in these categories must be present for at least 6 months, noted in more than one setting (ie, school, home, work), and affect performance in those settings.10 For adolescents who have never received a prior diagnosis, symptoms of inattention or hyperactivity/impulsivity must have been reported or documented prior to age 12 years.1 Neuropsychological testing may be helpful as a supplement in identifying a child's learning abilities; however, it may not aid in the diagnosis of ADHD.

There are many validated tools available to evaluate ADHD as well as other coexisting conditions (Table 1). The frequency of other medical problems highlights the importance of screening for other conditions during an evaluation for ADHD. Additionally, comorbid conditions can make it more difficult to diagnosis and treat ADHD. Approximately 64% of children diagnosed with ADHD had at least one additional co-existing condition.11 Behavior or conduct problems are the most common (51.5%), followed by anxiety (32.7%), depression (16.8%), autism spectrum disorder (13.7%), Tourette syndrome (1%), and substance use disorder (1%).11

Comparison of ADHD Rating Scales

Table 1.

Comparison of ADHD Rating Scales

Behavioral Management

For preschool children who are diagnosed with ADHD, first-line treatment is parent training in behavior management (PTBM).1 Physicians may help parents by identifying therapists in the area who work with parents on skills and strategies to help their child succeed. Parent training may include different approaches to dealing with problem behavior (eg, positive reinforcement, consistency) or strengthening parent-child relationships (eg, improving communication). Other studies have demonstrated benefits of a daily report card or classroom management with teachers outlining rules and expectations and providing students with individual attention and praise.12 For older children, behavioral interventions as well as training programs that help with school functioning skills (eg, time management, organizational skills) may also prove to be beneficial.

School Support

Children with ADHD between the ages of 3 and 21 years may be eligible to receive special education services through federal funding under the Individuals with Disabilities Education Act (IDEA).13 There are 13 disabilities (Table 2) defined by the IDEA, and ADHD falls under the category “other health impairment.”14 In order for children to receive these services, they must undergo a formal evaluation to determine if there is a disability. Parents or school professionals may make this request or referral and the school district will decide if further evaluation is necessary. The evaluation will not move forward without parental consent, and it is conducted at no cost to the parents. IDEA 2004 requires that the evaluation be conducted within 60 calendar days after receiving parental consent, although each state may have a different timeline or exceptions for completing the evaluation.15 In addition to being identified as having one or more disabilities defined by IDEA, the student must demonstrate adverse effects on academic performance for which special education will benefit the child. The next steps involve creating an Individualized Education Program (IEP) for the student.

Disabilities Defined by the Individuals with Disabilities Education Act

Table 2.

Disabilities Defined by the Individuals with Disabilities Education Act

For those students who do not qualify for special education services, education assistance may still be provided under Section 504 of the Rehabilitation Act. Section 504 defines a person with disability as anyone with “a physical or mental impairment which substantially limits one or more major life activities,” and learning qualifies as a life activity.16 Examples of ways in which student's needs may be addressed include accommodations such as modified test arrangements or class schedules, or having someone take notes for them.

Pharmacologic Management

Among children with a current diagnosis of ADHD, almost two-thirds receive pharmacological management and almost one-half receive behavioral treatment, but nearly one-fourth receive neither treatment.11 Although behavioral interventions are the first line of treatment, methylphenidate may be an option for childen age 4 and 5 years who continue to have significant effects on performance using only behavioral therapy. For children between the ages of 6 and 12 years with ADHD, the American Academy of Pediatrics recommends medications, PTBM, and/or behavioral classroom intervention.1 Medication should be prescribed to adolescents with their consent, and they should also have interventions that include skills for better school functioning.

Stimulant medications, including methylphenidate and amphetamine, continue to be first-line pharmacologic treatment for ADHD, as these have been shown to cause significant reductions in the core symptoms of ADHD.17,18 Although the exact mechanism of action is unknown, it is believed that methylphenidate and amphetamine block dopamine and norepinephrine uptake.19,20 In comparing effectiveness between the two stimulants, approximately 40% of patients will respond to both medications and 40% will respond to only one.1 One meta-analysis found that amphetamines were superior to methylphenidate as rated by clinicians at 12 weeks; however, only methylphenidate was more efficacious based on teachers' ratings.21 The same study found that children and adolescents felt that amphetamines, specifically lisdexamfetamine, were less tolerable.21

Determining which stimulant to prescribe will depend in large part on the duration, cost, side effect profile, and formulation availability (eg, liquid or chewable for a younger patient who cannot swallow pills). Typically, the effectiveness of a stimulant will be noted within 4 weeks of initiating and titrating to the appropriate dose. If no significant improvement in symptoms are noted, the next step would be to consider another formulation within the same or other subclass of stimulants before deciding that the medication is ineffective or intolerable to the child. Choosing a once-daily, long-acting stimulant is preferable as it can improve medication adherence. Medications should be taken with breakfast rather than afterwards, as they can cause appetite suppression, which is a common side effect for all stimulants. Ideally, the medication should wear off by nighttime and not affect dinner or subsequent nighttime sleep.

There are three nonstimulant medications approved by the US Food and Drug Administration for the treatment of ADHD: atomoxetine, extended-release guanfacine, and extended-release clonidine (Table 3). All three are efficacious in reducing core symptoms of ADHD; however, they all are secondary to stimulants in terms of response.1,12 For children who have both ADHD and anxiety, atomoxetine may be preferable to stimulants because they may make their anxiety worse.12 Youth who are taking certain antidepressants, such as fluoxetine or paroxetine, may require lower doses of atomoxetine because these medications can raise atomoxetine levels in the bloodstream.

Nonstimulant ADHD Medications Approved by the FDA

Table 3.

Nonstimulant ADHD Medications Approved by the FDA

Extended-release guanfacine would be a good option to consider for patients with ADHD and sleep problems, tics, or oppositional symptoms like aggression. Extended-release clonidine may be helpful in patients with ADHD and tics. One difference between the two medications is that guanfacine is dosed once daily whereas clonidine is dosed twice daily. Another consideration when choosing either alpha agonist is that both medications must be swallowed whole. This class of drugs can take up to 4 weeks and potentially longer to see a clinical benefit. Parents should be counseled not to discontinue clonidine or guanfacine without a physician's guidance as it can cause rebound hypertension. When discontinuing, both medications require a taper of no more than 1 mg every 3 to 7 days.

Side effects such as weight loss and increases in systolic blood pressure are most significant for amphetamines, methylphenidate, and atomoxetine.21,22 Only amphetamines and atomoxetine are noted to also have statistically significant increases in diastolic blood pressure and heart rate.22 Because increased blood pressure and heart rate in general are risk factors for cardiovascular morbidity and mortality during adult life, primary care physicians should continue to monitor heart rate and blood pressures at regular intervals, especially in those with hypertension. Growth parameters are also important to follow given the weight loss and suppression of adult height by 1 to 2 cm noted in the Multimodal Treatment Study of Children with ADHD study.1,18,23 Other side effects noted in nonstimulants can be found in Table 3.

Prior to the start of any medication, it is important to document any baseline symptoms, medical problems, or cardiac risk factors as it can be difficult to assess if symptoms after medication initiation are secondary to the medication or present prior to medication onset. For those with an abnormal cardiac examination or a personal/family history of cardiac conditions, electrocardiogram testing or pediatric cardiology referral would be indicated prior to stimulant initiation. Primary care physicians should continue to monitor blood pressure (especially in those with hypertension) and growth parameters.

Nonpharmacologic Management

Some parents will ask about nonpharmacologic management given concerns related to the side effects of medication. The importance of general health such as exercise, which improves ADHD core symptoms and cognitive function, should be discussed with parents and patients.12 No conclusive recommendations for mindfulness, cognitive training, neurofeedback, cannabidiol oil, or diet modifications can be provided at this time given that there have not been enough robust studies on these interventions. One study that did examine restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation noted that free fatty acid supplementation resulted in a small but significant reduction in ADHD symptoms, although the clinical significance of this result is unclear.24 External trigeminal nerve stimulation has been approved by the United States Food and Drug Administration, but the evidence for this treatment is weak and requires further research examining safety and efficacy.1

Conclusion

As the prevalence of ADHD rises, more patients will rely on pediatric providers to diagnose and manage this common condition. The importance of understanding the resources available at school for parents may prove useful as many are not versed in the process for IEP or 504 plans. Although behavioral interventions are important in children with ADHD, medications may be a fundamental component of a successful treatment plan. Stimulants are typically the first-line choice; however, additional nonstimulant alternatives are available for those who are unable to tolerate, respond, or opt against stimulants.

References

  1. Wolraich ML, Hagan JF Jr, Allan C, et al. Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528. doi:10.1542/peds.2019-2528 [CrossRef] PMID:31570648
  2. Centers for Disease Control and Prevention. National Center for Health Statistics. Attention deficit hyperactivity disorder. Accessed November 14, 2020. https://www.cdc.gov/nchs/fastats/adhd.htm
  3. Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. J Am Acad Child Adolesc Psychiatry. 2014;53(1):34–46.e2. doi:10.1016/j.jaac.2013.09.001 [CrossRef] PMID:24342384
  4. Zablotsky BA, Josephine M. Racial and ethnic differences in the prevalence of attention-deficit/hyperactivity disorder and learning disabilities among u.s. children aged 3–17 years. NCHS Data Brief. 2020;(358):1–8. PMID:32487288
  5. Lindsey I, Black BZ. Chronic school absenteeism among children with selected developmental disabilities: national health interview survey, 2014–2016. National Center for Health Statistics. Accessed November 16, 2020. https://www.cdc.gov/nchs/data/nhsr/nhsr118.pdf
  6. Harty SC, Ivanov I, Newcorn JH, Halperin JM. The impact of conduct disorder and stimulant medication on later substance use in an ethnically diverse sample of individuals with attention-deficit/hyperactivity disorder in childhood. J Child Adolesc Psychopharmacol. 2011;21(4):331–339. doi:10.1089/cap.2010.0074 [CrossRef] PMID:21823914
  7. Klein RG, Mannuzza S, Olazagasti MA, et al. Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Arch Gen Psychiatry.2012;69(12):1295–1303. doi:10.1001/archgenpsychiatry.2012.271 [CrossRef] PMID:23070149
  8. Visser SN, Zablotsky B, Holbrook JR, Danielson ML. RH B. Diagnostic experiences of children with attention-deficit/hyperactivy disorder. National Health Statistic Reports. Accessed November16, 2020. https://www.cdc.gov/nchs/data/nhsr/nhsr081.pdf
  9. Visser SN, Danielson ML, Wolraich ML, et al. vital signs: national and state-specific patterns of attention deficit/hyperactivity disorder treatment among insured children aged 2–5 years - United States, 2008–2014. MMWR Morb Mortal Wkly Rep. 2016;65(17):443–450. doi:10.15585/mmwr.mm6517e1 [CrossRef]
  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.
  11. Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47(2):199–212. doi:10.1080/15374416.2017.1417860 [CrossRef] PMID:29363986
  12. Feldman ME, Charach A, Bélanger SA. ADHD in children and youth: part 2-treatment. Paediatr Child Health. 2018;23(7):462–472. doi:10.1093/pch/pxy113 [CrossRef] PMID:30681665
  13. US Department of Education. About. IDEA. Accessed November 14, 2020. https://sites.ed.gov/idea/about-idea/
  14. US Department of Education. Sec. 300.8 Child with a disability. Individuals with Disabilities Education Act. Accessed November 14, 2020. https://sites.ed.gov/idea/regs/b/a/300.8
  15. National Center for Learning Disabilities. IDEA Parent Guide: A comprehensive guide to your rights and responsibilities under the Individuals with Disabilities Education Act (IDEA 2004). Accessed November 14, 2020. https://www.ncld.org/wp-content/uploads/2014/11/IDEA-Parent-Guide.pdf#:∼:text=At%20any%20point%20in%20an,formal%20evaluation%20for%20special%20education.
  16. US Department of Education. The Civil Rights of Students with Hidden Disabilities Under Section 504 of the Rehabilitation Act of 1973. Accessed November 14, 2020. https://www2.ed.gov/about/offices/list/ocr/docs/hq5269.html
  17. Molina BSG, Hinshaw SP, Swanson JM, et al. MTA Cooperative Group. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):484–500. doi:10.1097/CHI.0b013e31819c23d0 [CrossRef] PMID:19318991
  18. The MTA Cooperative Group. Multimodal treatment study of children with ADHD. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073–1086. doi:10.1001/archpsyc.56.12.1073 [CrossRef] PMID:10591283
  19. US Food and Drug Administration. Label for Concerta (methylphenidate) extended-release tablets. Accessed November 14, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021121s038lbl.pdf
  20. US Food and Drug Administration. Label for Adderall. Accessed November 14, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/011522s043lbl.pdf
  21. Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2018;5(9):727–738. doi:10.1016/S2215-0366(18)30269-4 [CrossRef] PMID:30097390
  22. Hennissen L, Bakker MJ, Banaschewski T, et al. ADDUCE Consortium. Cardiovascular effects of stimulant and non-stimulant medication for children and adolescents with adhd: a systematic review and meta-analysis of trials of methylphenidate, amphetamines and atomoxetine. CNS Drugs.2017;31(3):199–215. doi:10.1007/s40263-017-0410-7 [CrossRef] PMID:28236285
  23. Murray DW, Arnold LE, Swanson J, et al. A clinical review of outcomes of the multimodal treatment study of children with attention-deficit/hyperactivity disorder (MTA). Curr Psychiatry Rep. 2008;10(5):424–431. doi:10.1007/s11920-008-0068-4 [CrossRef] PMID:18803917
  24. Sonuga-Barke EJ, Brandeis D, Cortese S, et al. European ADHD Guidelines Group. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry. 2013;170(3):275–289. doi:10.1176/appi.ajp.2012.12070991 [CrossRef] PMID:23360949
  25. Gaba P, Giordanengo M. Attention deficit/hyperactivity disorder: screening and evaluation. Am Fam Physician. 2019;99(11):712. PMID:31150173
  26. Green M, Wong M, Atkins D, et al. Diagnosis of Attention-Deficit/Hyperactive Disorder. Agency of Health Care Policy and Research. Accessed November 16, 2020. https://www.ncbi.nlm.nih.gov/books/NBK44173/pdf/Bookshelf_NBK44173.pdf
  27. US Food and Drug Administration. Label for Strattera (atomoxetine capsule). Accessed November 14, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021411s029s030lbl.pdf
  28. US Food and Drug Administration. Label for Intuniv (guanfacine extended-release tablets). Accessed November 14, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/022037s009lbl.pdf
  29. US Food and Drug Administration. Label for Kapvay (clonidine extended release tablets.) Accessed November 14, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022331s001s002lbl.pdf

Comparison of ADHD Rating Scales

ADHD rating scale Free Informants Age, years Sensitivity, % Specificity, % Screens for comorbid conditions
Vanderbilt Parent Rating Scale Vanderbilt Teacher Rating Scale Yesa Parent, teacher 6–12 80 69 75 84 Yes
Conners Parent Rating Scale (R-S) Conners Teacher Rating Scale (R-S) Conners ASQ No Parent, teacher, selfb 3–17 75 72 83 75 84 84 Yes
Child Behavior Checklist No Parent, teacher 2–18 77 73 Yes

Disabilities Defined by the Individuals with Disabilities Education Act

<list-item>

Autism

</list-item> <list-item>

Deaf-blindness

</list-item> <list-item>

Deafness

</list-item> <list-item>

Emotional disturbance

</list-item> <list-item>

Hearing impairment (permanent or fluctuating)

</list-item> <list-item>

Intellectual disability

</list-item> <list-item>

Multiple disabilities

</list-item> <list-item>

Orthopedic impairment

</list-item> <list-item>

Other health impairmenta

</list-item> <list-item>

Specific learning disability

</list-item> <list-item>

Speech or language impairment

</list-item> <list-item>

Traumatic brain injury

</list-item> <list-item>

Visual impairment, including blindness

</list-item>

Nonstimulant ADHD Medications Approved by the FDA

Medication Mechanism of action Dosage Prescribing schedule Side effects
Atomoxetine Selective norepinephrine reuptake inhibitor Qnce or twice daily Start at 0.5 mg/kg/day and increase to 1.4 mg/kg/day Potential for suicidal thoughts in first few weeks of treatment, decreased appetite, upset stomach, nausea, vomiting, fatigue, problems sleeping, dizziness
Guanfacinea Alpha agonist 1–4 mg once daily Start at lower dose of 1 mg/day Sleepiness, fatigue, nausea, lethargy, dizziness, hypotension, abdominal pain, constipation
Clonidinea Alpha agonist 0.1–0.2 mg twice daily Start at lower dose of 0.1 mg/day Sleepiness, headache, upper abdominal pain, fatigue, upper respiratory tract infection, irritability, nausea, nightmare, throat pain, constipation
Authors
Amy Liu, MD, MPH

Amy Liu, MD, MPH, is an Assistant Professor and General Pediatrician, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine.

Address correspondence to Amy Liu, MD, MPH, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, 333 S. Columbia Street, Room 231 MacNider Hall, CB 7225, Chapel Hill, NC 27599-7225; email: amy.liu@med.unc.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20201112-01

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