Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents

Background

• Attention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder consisting of a pattern of inattention and/or hyperactivity-impulsivity more frequent and severe than typically observed in individuals of comparable developmental level.
• Depending on diagnostic criteria, methodology used to evaluate, and population studied it may affect 2%-9.5% of school-aged children and adolescents.
• The underlying cause may be an abnormality in the central dopaminergic and noradrenergic pathways. Significant risk factors include family history of ADHD, prematurity, low birth weight, intrauterine growth restriction, history of brain injury, and certain genetic syndromes.
• Comorbid conditions are common and may include learning or language disorders, neurodevelopmental disorders, psychological and behavioral conditions, sleep disorders, and autism spectrum disorder.

Evaluation

• Children will usually present with a number of behavioral, social, and academic concerns. Physical examination may be normal or show subtle neurologic findings such as imprecise movements.
• Evaluate all children and adolescents aged 4-18 years presenting with academic and/or behavioral problems plus symptoms of inattention, hyperactivity, or impulsivity for attention deficit hyperactivity disorder (ADHD) (Strong recommendation). Evaluation should include assessment for coexisting conditions (Strong recommendation).
  • Evaluation usually involves using rating scales to gather information about the child's behavioral, social, and academic concerns. This is scored and compared to diagnostic criteria from Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or ICD-10. These will also help to identify any psychiatric symptoms associated with comorbid conditions or an alternative diagnosis.
  • Commonly used validated rating scales include the Vanderbilt ADHD Rating Scales (ages 6-12 years), Conners Rating Scales, ADD-H Comprehensive Teacher's Rating Scale (kindergarten to eighth grade), Attention Deficit Disorder Evaluation Scale (ages 4-18 years), Brown Rating scales (ages 3 to adulthood), Child Behavior Checklist (ages 18 months to 18 years), ADHD Rating Scale IV (ages 5-18 years), and Swanson, Nolan, and Pelham IV Questionnaire (ages 5-11 years).
• Consider referral for neuropsychological testing in children presenting with inattentiveness and/or hyperactivity in home or school environment and history of low general cognitive ability or low achievement in language or mathematics relative to intellectual ability since the prevalence of learning disabilities may be as high as 46%.
• The DSM-5 diagnostic criteria are one method for making the diagnosis of ADHD. Diagnosis can be made when:
  • symptoms are present for ≥ 6 months, begin before 12 years old, clearly interfere with function, are inappropriate for developmental level with several symptoms being present in ≥ 2 settings, and not better explained by an alternative disorder
  • children and adolescents < 17 years old have ≥ 6 symptoms from the specific subtype category to diagnose ADHD inattention or hyperactivity/impulsivity subtypes and ≥ 6 symptoms from each category to diagnosis ADHD combined type, and adolescents aged ≥ 17 years require ≥ 5 symptoms
• A screening electrocardiogram before starting stimulant medications has been suggested by the American Heart Association (AHA), but not the American Academy of Pediatrics (AAP).
• Neurologic imaging and blood tests are only indicated if there is strong evidence for neurologic pathology or other conditions.

Management

• American Academy of Pediatrics (AAP) recommendations for children aged 4-5 years:
  • initial treatment is parent- and/or teacher-administered behavioral therapy (Strong recommendation)
  • consider methylphenidate only if the behavioral interventions do not lead to improvement and if there is moderate-to-severe functional disturbance (Weak recommendation)
• AAP recommendations for children aged 6-11 years include:
  • treatment with short- and long-acting methylphenidate, extended-release dexmethylphenidate, short- and long-acting amphetamines, lisdexamfetamine, or modafinil (Strong recommendation)
  • parent- and/or teacher-based behavioral therapy (Strong recommendation)
  • preferably, combined management of therapy and medication (Strong recommendation)
• AAP recommendations for adolescents aged 12-18 years include:
  • treatment with long-acting methylphenidate, extended-release dexmethylphenidate, or lisdexamfetamine (Strong recommendation)
  • behavioral therapy (Weak recommendation)
  • preferably, combined management
• Nonstimulant medications may be used as a second-line treatment or in addition to other ADHD medication.
  • Consider atomoxetine or alpha-2 adrenergic agonists (clonidine or guanfacine) if stimulant medication is ineffective or poorly tolerated. Additional options include carbamazepine or antidepressants.
  • Consider adding alpha-2 adrenergic agonists if hyperactivity and impulsivity are poorly controlled.
• Consider follow-up every 1-3 weeks for initial dose titration, then every 3-6 months.
• Other measures to consider include neurofeedback and zinc supplementation.