ADHD Symptoms and Treatment

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurobehavioral disorder in the United States,¹with about 9.4% of children aged 2 to 17 years having received a diagnosis, according to the CDC.²

ADHD prevalence increased by 57% from 2007-2008 to 2011-2012, according to the results of a recent study in theJournal of Developmental & Behavioral Pediatrics.³ADHD left untreated can negatively affect patients both academically and socially. Primary care providers (PCPs) should take note of this astounding increase in prevalence and aid with early recognition of symptoms to provide a concise management plan for these patients.

ADHD is marked by 3 key behaviors: hyperactivity, impulsivity, and inattention.^4,5

Hyperactivity is when a patient moves about constantly, including in situations when it is not appropriate. A patient may even excessively fidget, talk, or tap. For preschool-aged children, hyperactivity is the most common symptom of ADHD.

Impulsivity in patients may cause them to act in the moment without first thinking. This may have a potential for harm. A patient with impulsivity may have a desire for instant gratification. Sometimes an impulsive patient may make important decisions without considering the long-term consequences or interrupt others.⁵

Inattention can mean that the patient is disorganized, has difficulty sustaining focus, lacks persistence, and wanders off task. In elementary grades, patients may be described as lazy.⁶In young children with ADHD, hyperactivity and impulsivity are the most prevalent presenting behaviors. TheDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-5) criteria can support PCPs in making a diagnosis of ADHD. Diagnosis can be made using only these DSM-5 criteria, based on patients’ exhibiting a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with development and functioning.^2,7Management can be determined by referencing the American Academy of Pediatrics (AAP) clinical practice guideline for ADHD, which provides detailed, evidence-based information regarding managing patients aged 4 to 18 years and treatment recommendations.^1,8

Experts are unsure of what causes ADHD but have concluded that many factors should be considered, such as brain injuries, cigarette smoking and/ or drug use during pregnancy, exposure to environmental toxins, genes, and low birth weight.⁵Study results have shown that ADHD is diagnosed more in men than in women. In addition, non-Latino white patients have a higher prevalence of ADHD than other ethnic and racial groups. Most patients receive a diagnosis between 3 and 6 years of age, with a median age of onset at 6 years old.⁵

Children with ADHD symptoms should be comprehensively evaluated as early as 4 years old by a licensed pediatrician, psychiatrist, or psychologist with expertise in the condition. Professionals should gather information from at least 2 different environments (home and school) and perform a comprehensive developmental, educational, family, and medical history.⁶

ADHD can be successfully managed with the appropriate plan provided by the PCP. ADHD management consists of behavioral therapy (BT) and medications. For children older than 6 years, the AAP recommends BT and medication as part of the management plan. In children younger than 6 years, BT is indicated as the first line of treatment.²BT is a treatment option that can reduce the behaviors prominent in patients with ADHD.

There are 2 types of BT: BT with children and parent training in BT. Having a child with disruptive behaviors can create stress for the entire family.⁷The child—parent relationship is affected by ADHD because of the disruptive behaviors. It is important for not only the child to be involved in BT but the parents as well.

In BT with children, the therapist helps the child convey improved behaviors to replace unfavorable behaviors.²In parent training in BT, parents learn skills to guide and teach their children to better control their behavior.²

Four programs for parents of young children with ADHD that have been shown to significantly help behavior and symptoms include the Forest Parenting Programme, the Incredible Years parenting programs, the Parent-Child Interaction Therapy, and the Triple P (Positive Parenting Program).²Medications can be used in combination with BT or initiated alone in children older than 6 years. ADHD medications include stimulants and nonstimulant medications.

Stimulants are the first-line treatment for ADHD, with 75% to 90% of children taking them.⁴Stimulants improve focus because they increase dopamine and norepinephrine, which play an essential role in attention and thinking. Stimulants commonly prescribed include dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine, Dextrostat, ProCentra, and Zenzedi), dextroamphetamine/amphetamine (Adderall), methamphetamine (Desoxyn), and methylphenidate (Methylin and Ritalin). Methylphenidate (Ritalin) is the cheapest stimulant medication, costing about $33.55 for 60 days’ worth of 5-mg tablets. Dextroamphetamine/ amphetamine (Adderall) is approved by the FDA for children 3 years and older.⁴Stimulants come in several different preparations (short acting, intermediate acting, and long acting) to treat ADHD. There are no clear benefits of one preparation over another. The choice depends on how the child responds to each individually.

Nonstimulants take longer to work than stimulants. They can be effective when used alone or in combination with a stimulant. PCPs may prescribe a nonstimulant because of possible adverse effects or contraindications of stimulants or use one in combination with a stimulant for increased effectiveness. Nonstimulants include atomoxetine (Strattera), clonidine extended release (Kapvay), and guanfacine (Intuniv).^2,4PCPs must determine what is best for the patient: BT, medication, or both.

CONCLUSION

PCPs provide a fundamental role in assessing key behaviors to lead to a diagnosis of ADHD. Through early recognition of these behaviors, PCPs can provide appropriate management for children with BT and/or medications. Ultimately, the goal of management is to improve these behaviors to help children progress academically, developmentally, and socially.

References

1. Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management; Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.Pediatrics. 2011;128(5):1007- 1022. doi: 10.1542/peds.2011-2654.
2. CDC. Attention-deficit/hyperactivity disorder (ADHD). cdc.gov/ncbddd/adhd/. Updated February 14, 2018. Accessed April 11, 2018.
3. Danielson ML, Visser SN, Gleason MM, Peacock G, Claussen AH, Blumberg SJ. A national profile of atten- tion-deficit hyperactivity disorder diagnosis and treatment among US children aged 2 to 5 years.J Dev Behav Pediatr. 2017;38(7):455-464. doi: 10.1097/DBP.0000000000000477.
4. Luthy K, David R, Macintosh J, et al. Attention-deficit hyperactivity disorder: comparison of medication efficacy and cost.J Nurse Pract.2015;11(2):226-232. doi: 10.1016/j.nurpra.2014.07.026.
5. Attention deficit hyperactivity disorder. National Institute of Mental Health website. nimh.nih.gov/health/topics/ attention-deficit-hyperactivity-disorder-adhd/index.shtml. Updated March 2016. Accessed April 11, 2018.
6. Pericak A. Diagnosing attention-deficit hyperactivity disorder using the DSM-5 criteria.J Nurse Pract.2015;11(2):274-275. doi: 10.1016/j.nurpra.2014.10.001.
7. Witherington T, Trotter, S. New primary care guidelines for pediatric attention-deficit/hyperactivity disorder. J Nurse Pract. 2012;8(7):573-574. doi: 10.1016/j.nurpra.2012.05.012. 8. Ryan-Krause P. Preschoolers with ADHD and disruptive behavior disorder.J Nurse Pract. 2017;13(4):284-290. doi: 10.1016/j.nurpra.2016.11.010.