Attention-deficit/hyperactivity disorder (ADHD) is a childhood onset neurodevelopmental disorder with a worldwide prevalence rate of 5.9% (Centers for Disease Control and Prevention [CDC], 2010). Its prevalence in the United States has increased significantly in the past decade (Xu, Strathearn, Liu, Yang, & Bao, 2018). The diagnosis of ADHD involves inattention, impulsivity, and distractibility and can include a hyperactive subtype (American Psychiatric Association, 2013). Diagnosis requires the presence of symptoms across more than one setting and impairment must occur across these settings (e.g., school, home, peer environments) and be first evident prior to age 12. A comprehensive diagnosis includes clinical interviews with the child and family, collateral information from teachers and other care providers, and diagnostic measures such as the Vanderbilt (National Institute for Children's Health Quality, 2002) or Conners' (2008) rating scales. A thorough evaluation for comorbid conditions must also be completed, as ADHD is the most common comorbid condition with other childhood disorders such as autism spectrum, mood, anxiety, learning, intellectual, and conduct disorders (Thapar, Cooper, Eyre, & Langley, 2013). Misdiagnosis can lead to a treatment plan that may worsen the child's symptoms, and careful consideration of primary and comorbid disorders will decrease the likelihood of such errors. Untreated ADHD in children and adolescents has been linked with higher risks of accidents, school failure, unwanted pregnancies, and sexually transmitted diseases, as well as increased risk for substance use disorders (Weed, 2016).
Environmental and genetic factors are believed to contribute to the pathogenesis of ADHD, with studies indicating that as many as one half of parents of children with ADHD have ADHD themselves (Starck, Grunwald, & Schlarb, 2016). In addition, racially and ethnically diverse families with children and adolescents with ADHD may have unique perceptions and attributions to the causes of ADHD, which, if not considered with care, can impact the therapeutic relationship and outcomes (Cummings, Ji, Allen, Lally, & Druss, 2017; Paidipati, Brawner, Eiraldi, & Deatrick, 2017).
Stimulant medications are considered to be the first line of treatment for the management of ADHD in children and adolescents, but they are only one part of a comprehensive plan. The National Institute of Mental Health (NIMH) completed a large treatment study called the Multi-modal Treatment Study (MTA) of Children with ADHD (MTA Cooperative Group, 1999, 2004). Data from this study compared therapy alone, therapy with stimulant treatment, and stimulant treatment alone and found the best response to be stimulant treatment alone or in combination with behavioral therapy. Other interventions include parent management training, parent education, social skills training, problem-solving skills training, and behavioral interventions in the classroom. In fact, in children younger than 6, behavioral therapy is indicated as a first-line treatment, with current guidelines indicating that school-aged children receive stimulant therapy with parent management and behavioral therapy as first-line treatment (Epstein et al., 2017; Jensen et al., 2001; MTA Cooperative Group, 1999). If therapy is not introduced along with medication treatment at the outset, families may be less likely to become engaged in therapy later. A strong therapeutic alliance with the family will aid in establishing a multimodal treatment plan that includes psychoeducation and behavioral, psychosocial, and pharmaco-therapies with collaboration across the child's school and other settings.
Psychostimulant medications such as methylphenidate, dexmethylphenidate, and amphetamine in various combinations are available in more than 20 various compounds and delivery systems. Stimulant agents act on dopamine and norepinephrine to stimulate the dorsolateral prefrontal cortex of the brain to help youth attend to their behavior, choices, and learning. Short-acting forms of stimulant medications provide 4 to 6 hours of symptom control and require several doses throughout the day, whereas extended-release formulas provide longer coverage. Clinical guidelines support starting with methylphenidateor amphetamine-based products and switching to the alternate compound if there are concerns with efficacy or tolerability. Stimulant medications are effective 70% of the time, with 90% efficacy achieved in symptom management if switching from methylphenidate to amphetamine (Faraone & Buitelaar, 2010; Vitiello et al., 2001).
Stimulant agents come in a wide array of delivery systems, including sprinkles, chewable tablets, liquids, and patches, which can aid in helping the child take the medications more easily. A nighttime-dosed stimulant (HLD200; Childress et al., 2018) with a slow release mechanism that starts working once the child wakes up in the morning is forthcoming.
The best formula for the patient depends on the child's needs across the day, his/her tolerability of medication effects and side effects, and the comfort of family members in incorporating treatment. Second-line treatments include non-stimulant medications, such as atomoxetine; long-acting guanfacine; and clonidine, which inhibit norepinephrine, dopamine, and serotonin reuptake or stimulate alpha-2 receptors (Stahl, 2013). These medications can be used as an adjunct to stimulant treatment or instead of a stimulant agent if the child or adolescent cannot tolerate stimulant therapies due to side effects or comorbid illnesses. These options take longer to work, but new non-stimulant medication options that show effects sooner are in development.
In addition, several drugs are used off-label for treatment of ADHD symptoms in children and adolescents. These drugs are not approved by the U.S. Food and Drug Administration (FDA) for use in treating ADHD in children, but show promise in managing ADHD symptoms. These drugs include bupropion, generic formulas of guanfacine and clonidine, and other alpha antagonists that may show promise in the future treatment of ADHD but do not have FDA approval for use to date.
The most common approach to addressing ADHD is to start with therapy and stimulant medications, moving toward non-stimulant medications if there are concerns with tolerability or efficacy. A large study of more than 1 million individuals with ADHD showed no evidence that current use of an ADHD drug was associated with increased risk of serious cardiovascular events (Cooper et al., 2011); however, a thorough assessment of patient and family risk for cardiovascular events and ongoing monitoring of cardiac status throughout treatment assures best care. Unless there are cardiac concerns within the family or for the child, a baseline electrocardiogram is not needed.
One of the most common side effects of stimulant medications is decreased appetite, which can occur across formulas and be dose related. Careful monitoring of eating habits throughout the day, taking medications after eating, and routine monitoring of growth will help health care providers determine risk versus benefit of a particular stimulant medication. If a child experiences tics or a tic disorder, stimulants across all types will typically worsen their incidence and severity. Careful use is also indicated in children with seizure disorders, as stimulant agents can lower the seizure threshold. Other common side effects include headaches, agitation and anxiety, and impaired sleep, with rare side effects such as priapism also possible.
Nonpharmacological approaches, such as sleep hygiene and cognitive-behavioral therapy–insomnia, can be discussed in anticipation of the effect on sleep, and when pharmacological intervention is necessary, it should be time-limited and in conjunction with nonpharmacological sleep interventions. Family members should also watch for a rebound effect children can experience when the stimulant medication wears off, which can look like worsening symptoms as the medication's peak concentration lowers. Using a different agent/formula with a smoother delivery system or offering an early booster dose can aid with managing rebound symptoms.
Recommendations to Improve Practice
Several clinical practice guidelines are presented.
- Explain to family members the symptoms of ADHD and how medication therapy, parent management, and behavioral therapy will aid in helping their child with his/her overall functioning.
- Understand that each child's family has its own understanding and attributions of medication use with children. Work with family members' understanding and follow their pace with pharmacological and nonpharmacological therapies.
- Discuss specific ways in which family members will see if treatments are effective, incorporating rating scales and specific behavioral goals, such as following directions, remembering more than three-step instructions, and being able to sit during dinner, as well as what the treatments should not affect, such as the child's personality or interests.
- Assure that the child has his/her own understanding of what to expect from the medications and a way to communicate this information (e.g., “my focus medication,” “my calmer pill”) with his/her parents as well as health care providers.
- Prescribe stimulant agents on the family's insurance formulary to aid with authorization requests. There is wide variation in the costs of stimulant medications, so assure the best option will be well covered.
- Do not be afraid of tapering dosing more rapidly than with other psychopharmacological agents, as effects on functioning (or not) can be seen quickly with stimulant medications.
- Be aware of patterns of tolerance, which can include acute tolerance, chronic tolerance, short-duration responders, and high-dose responders. Sometimes these patients are called “rapid metabolizers” due to atypical patterns of medication response (Weiss, Surman, & Elbe, 2018, p. 113).
- Discuss stimulant diversion potential and a plan for its occurrence with family members at the onset of prescribing this medication (Pham, Milanaik, Kaplan, Papaioannou, & Adesman, 2017).
- Explain how stimulants are believed to improve ADHD symptoms that may exacerbate anxious or aggressive symptoms (e.g., impulsiveness, fight-or-flight response), but also indicate that in comorbid conditions, these symptoms can worsen if the primary disorder is not well treated.
- Discuss with family members how the illness is year-round and help them determine the risks versus benefits of “taking breaks” from medication/therapy over holidays or the summer.
- Discuss alternative treatments and their modest effects in the management of ADHD, such as taking omega-3 supplements, eliminating dyes in the diet, and using mindfulness techniques and neurofeedback.
- Maintain frequent contact with family members, as in primary care settings it has been shown that this enhances best outcomes of treatment with stimulant medications (Epstein et al., 2017).
- Remember that 50% of parents of children and adolescents with ADHD also have the disorder, so help parents construct successful strategies for themselves and their child as part of a comprehensive plan to improve function.
ADHD is the most common psychiatric disorder in children and adolescents and has well-established effective treatments that have shown to improve patient and family functioning and decrease risks associated with untreated illness including, but not limited to, accidents, substance use disorders, and academic and sexual risks. Psychiatric–mental health nurses can make a difference in the recovery efforts of children, adolescents, and families by using a comprehensive and collaborative plan to assure best care.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
- Centers for Disease Control and Prevention. (2010). Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007. MMWR Morbidity and Mortality Weekly Report, 59, 1439–1443.
- Childress, A., Mehrotra, S., Gobburu, J., McLean, A., DeSousa, N.J. & Incledon, B. (2018). Single-dose pharmacokinetics of HLD200, a delayed-release and extended-release methylphenidate formulation, in healthy adults and in adolescents and children with attention-deficit/hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 28, 10–18. doi:10.1089/cap.2017.0044 [CrossRef]
- Conners, K.C. (2008). Conners3rd edition. Ontario, Canada: Multi-Health Systems.
- Cooper, W.O., Habel, L.A., Sox, C.L., Chan, K.A., Arbogast, P.G., Cheetham, T.C. & Ray, W.A. (2011). ADHD and serious cardiovascular events in children and young adults. New England Journal of Medicine, 365, 1896–1904. doi:10.1056/NEJMoa1110212 [CrossRef]
- Cummings, J.R., Ji, X., Allen, L., Lally, C. & Druss, B.G. (2017). Racial and ethnic differences in ADHD treatment quality among Medicaid-enrolled youth. Pediatrics, 139(6). doi:10.1542/peds.2016-2444 [CrossRef]
- Epstein, J.N., Kelleher, K.J., Baum, R., Brinkman, W.B., Peugh, J., Gardner, W. & Langberg, J.M. (2017). Specific components of pediatricians' medication-related care predict attention-deficit/hyperactivity disorder symptom improvement. Journal of the American Academy of Child and Adolescent Psychiatry, 56, 483–490. doi:10.1016/j.jaac.2017.03.014 [CrossRef]
- Faraone, S.V. & Buitelaar, J. (2010). Comparing the efficacy of stimulants for ADHD in children and adolescents using meta-analysis. European Child and Adolescent Psychiatry, 19, 353–364. doi:10.1007/s00787-009-0054-3 [CrossRef]
- Jensen, P.S., Hinshaw, S.P., Swanson, J.M., Greenhill, L.L., Conners, C.K., Arnold, L.E. & Wigal, T. (2001). Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): Implications and applications for primary care providers. Journal of Developmental and Behavioral Pediatrics, 22, 60–73. doi:10.1097/00004703-200102000-00008 [CrossRef]
- MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073–1086. doi:10.1001/archpsyc.56.12.1073 [CrossRef]
- MTA Cooperative Group. (2004). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder. Pediatrics, 113, 754–761. doi:10.1542/peds.113.4.754 [CrossRef]
- National Institute for Children's Health Quality. (2002). NICHQ Vanderbilt Assessment Scales. Retrieved from https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf
- Paidipati, C.P., Brawner, B., Eiraldi, R. & Deatrick, J.A. (2017). Parent and family processes related to ADHD management in ethnically diverse youth. Journal of the American Psychiatric Nurses Association, 23, 90–112. doi:10.1177/1078390316687023 [CrossRef]
- Pham, T., Milanaik, R., Kaplan, A., Papaioannou, H. & Adesman, A. (2017). Household diversion of prescription stimulants: Medication misuse by parents of children with attention-deficit/hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 27, 741–746. doi:10.1089/cap.2016.0058 [CrossRef]
- Stahl, S.M. (2013). Stahl's essential psychopharmacology (4th ed.). Cambridge, UK: Cambridge University Press.
- Starck, M., Grunwald, J. & Schlarb, A.A. (2016). Occurrence of ADHD in parents of ADHD children in a clinical sample. Neuropsychiatric Disease and Treatment, 12, 581–588. doi:10.2147/NDT.S100238 [CrossRef]
- Thapar, A. & Cooper, M. (2016). Attention deficit hyperactivity disorder. Lancet, 387, 1240–1250. doi:10.1016/S0140-6736(15)00238-X [CrossRef]
- Thapar, A., Cooper, M., Eyre, O. & Langley, K. (2013). Practitioner review: What have we learnt about the causes of ADHD?Journal of Child Psychology and Psychiatry, and Allied Disciplines, 54, 3–16. doi:10.1111/j.1469-7610.2012.02611.x [CrossRef]
- Vitiello, B., Severe, J.B., Greenhill, L.L., Arnold, L.E., Abikoff, H.B., Bukstein, O.G. & Cantwell, D.P. (2001). Methylphenidate dosage for children with ADHD over time under controlled conditions: Lessons from the MTA. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 188–196. doi:10.1097/00004583-200102000-00013 [CrossRef]
- Weed, E.D. (2016). ADHD in school-aged youth: Management and special treatment considerations in the primary care setting. International Journal of Psychiatry in Medicine, 51, 120–136. doi:10.1177/0091217416636561 [CrossRef]
- Weiss, M.D., Surman, C.B.H. & Elbe, D. (2018). Stimulant ‘rapid metabolizers’: Wrong label, real phenomena. Attention Deficit Hyperactivity Disorders, 10, 113–118. doi:10.1007/s12402-017-0242-9 [CrossRef]
- Xu, G., Strathearn, L., Liu, B., Yang, B. & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997–2016. JAMA Network Open, 1, e181471. doi:10.1001/jamanetworkopen.2018.1471 [CrossRef]