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November 12, 2004
Treatment of Attention-Deficit/Hyperactivity Disorder

Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common disorders diagnosed in children and adolescents. The American Psychiatric Association (APA) describes the essential feature as "a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development." According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), the prevalence of ADHD in school-age children is 3 to 5 percent. ADHD has been associated with impaired academic achievement, rejection by peers, and family resentment and antagonism. The rich terminology may reflect the broad spectrum and the high frequency with which it is described with other comorbid conditions.

Questions: What is the treatment of Attention-Deficit/Hyperactivity Disorder?


Discussion: Attention-deficit/hyperactivity disorder is one of the more common chronic conditions of childhood. Studies using parent reports indicate persistence of ADHD of 60% to 80% into adolescence.  Given the high prevalence of ADHD among school-aged children (4% to 12%), primary care clinicians will encounter children with ADHD in their practices regularly and should have a strategy for diagnosis and long-term management of this condition. The primary care of children with ADHD includes attention to the main principles of care for children with any chronic condition, such as

  • Providing information about the condition
  • Updating and monitoring family knowledge and understanding on a periodic basis
  • Counseling about family response to the condition
  • Developmentally appropriate education of the child about ADHD, with updates as the child grows
  • Availability to answer family questions
  • Ensuring coordination of health and other services
  • Helping families set specific goals in areas related to the child's condition and its effects on daily activities
  • Linking families with other families with children who have similar chronic conditions as needed and available
The core symptoms of ADHD (ie, inattention, impulsivity, hyperactivity) can result in multiple areas of dysfunction relating to a child's performance in the home, school, or community. The primary goal of treatment should be to maximize function. Desired results include
  • improvements in relationships with parents, siblings, teachers, and peers
  • decreased disruptive behaviors
  • improved academic performance, particularly in volume of work, efficiency, completion, and accuracy
  • increased independence in self-care or homework
  • improved self-esteem
  • enhanced safety in the community, such as in crossing streets or riding bicycles. Target outcomes should follow from the key symptoms the child manifests and the specific impairments these symptoms cause.
The process of developing target outcomes requires input from parents, children, and teachers, as well as other school personnel where available and appropriate.  They should agree on at least 3 to 6 key targets and desired changes as prerequisites to constructing the treatment plan. The goals should be realistic, attainable, and measurable. The methods of treatment and of monitoring change will vary as a function of the target outcomes.
The clinician should develop a comprehensive management plan focused on the target outcomes. For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances. The most powerful effects are found on measures of observable social and classroom behaviors and on core symptoms of attention, hyperactivity, and impulsivity. The effects on intelligence and achievement tests are more modest.
Medications Used in the Treatment of Attention-Deficit/Hyperactivity Disorder
Generic Class (Brand Name)
Daily Dosage Schedule
Duration
Prescribing Schedule
Stimulants (First-Line Treatment)
   
    Methylphenidate
   
        Short-acting (Ritalin, Methylin)
Twice a day (BID) to 3 times a day (TID)
3-5 hr
5-20 mg BID to TID
        Intermediate-acting (Ritalin SR,
    Metadate ER, Methylin ER)
Once a day (QD) to BID
3-8 hr
20-40 mg QD or 40 mg in the morning and 20 early afternoon
        Long-acting (Concerta, Metadate
    CD, Ritalin LA*)
QD
8-12 hr
18-72 mg QD
    Amphetamine
   
        Short-acting (Dexedrine, Dextrostat)
BID to TID
4-6 hr
5-15 mg BID or 5-10 mg TID
        Intermediate-acting (Adderall,
    Dexedrine spansule)
QD to BID
6-8 hr
5-30 mg QD or 5-15 mg BID
        Long-acting (Adderall-XR*)
QD
 10-30 mg QD
Antidepressants (Second-Line Treatment)
   
    Tricyclics (TCAs)
BID to TID
 2-5 mg/kg/day†
        Imipramine, Desipramine
   
    Bupropion
   
        (Wellbutrin)
QD to TID
 50-100 mg TID
        (Wellbutrin SR)
BID
 100-150 mg BID
Effective Behavioral Techniques for Children With Attention-Deficit/Hyperactivity Disorder
Technique
Description
Example
Positive reinforcement
Providing rewards or privileges contingent on the child's performance.
Child completes an assignment and is permitted to play on the computer.
Time-out
Removing access to positive reinforcement contingent on performance of unwanted or problem behavior.
Child hits sibling impulsively and is required to sit for 5 minutes in the corner of the room.
Response cost
Withdrawing rewards or privileges contingent on the performance of unwanted or problem behavior.
Child loses free time privileges for not completing homework.
Token economy
Combining positive reinforcement and response cost. The child earns rewards and privileges contingent on performing desired behaviors and loses the rewards and privileges based on undesirable behavior.
Child earns stars for completing assignments and loses stars for getting out of seat. The child cashes in the sum of stars at the end of the week for a prize.
Conclusion: Families must manage the treatment of ADHD on an ongoing basis. Treatment need to include long-term management plan. It is important to set behavior goals, improvement in school work. Establish follow-up to adjust the medication, that would make changes that affect behavior at school and at home. At every visit check the child's progress with the target outcomes. For most children, stimulant medications are a safe and effective way to relieve ADHD symptoms. Behavior therapy should focuse on changing the child's environment to help improve behavior. Educating the parents about the disease and how to deal with the child behavior can give parents specific skills to deal with ADHD behaviors in a positive way. All involved need to understand what ADHD is. Treatment works best when doctors, parents, teachers, caregivers, other health care professionals, and the child work together.
Posted At : 7:18 PM. | Link | Rotation 2 04-05 | Comments (6)

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Comments

Thank you so much for this great information on how to treat ADHD children. The tables are very useful. I was not aware of the number of drugs that can be used in the management of ADHD. Thanks again. Great job.

Posted By Gazelle Aram / Posted At 11/12/04 7:49 PM

Nice job denis and great information but it was a little long. Can we try to cut down on the length next time? But VERY good information on the behavioral therapy and ADHD...it's something that gets overlooked by many I feel.

Posted By John Mastrangelo / Posted At 11/14/04 7:56 AM

thanks for the info, but i agree that it was a little long so i just skimmed it. the tables were helpful though.

Posted By Rajanya Shah / Posted At 11/14/04 1:55 PM

I enjoyed the review, Dennis. What did you find about non-stimulant drugs like stratera that aren't anti-depressants? Great job, very thorough.

Posted By Michael Paul / Posted At 11/14/04 5:12 PM

I would agree with JOhn. There is too much information here. YOu need to work more on building a focus. What's really important and what is not. Hone it down for the poor reader.

Posted By Jacob Reider / Posted At 11/14/04 8:28 PM

nice disseration Denis!!! But now I can save money on Ambien and just read this intead! heehee, just kidding, it was a bit long, but at the same time very thorough.

Posted By Furkan Shinaishin / Posted At 11/18/04 12:53 PM