Treatment of ADHD: A Developmental Approach

Attention deficit hyperactivity disorder (ADHD) is very common. In the United States, between 6% and 10% of children and adolescents are affected, as are 4% of adults.¹ Children in other countries also have ADHD, although rates of comorbid disorders may vary from those found in the United States.²

The pediatrician is often the first physician many families contact when they suspect their child has ADHD. Also, the pediatrician is often responsible for overseeing treatment of ADHD over many years. Often, this involves changing formulations, strengths, or types of medication and providing non-medical interventions for a child as he or she matures. Thus, it is vital that pediatricians have a good understanding of the symptoms and treatment of ADHD at all stages of a child's development.

Here I discuss the diagnosis and treatment of ADHD in toddlers, in school-aged children, and in adolescents. I discuss an age-specific differential diagnosis, describe appropriate treatment options (including some off-label and soon-to-be-approved agents), and address common management issues for patients and their families. Case vignettes illustrate some of the typical issues likely to be seen in patients of each age group when they first present for an ADHD evaluation.

Both the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Academy of Pediatrics (AAP) have published treatment guidelines within the last 10 years regarding the diagnosis, treatment, and long-term management of ADHD. Both sets of guidelines came out before the FDA approval of atomoxetine(Drug information on atomoxetine); consequently, neither includes that medication as a treatment option.

The AACAP guidelines, which were published first, provide several recommendations for the general assessment of youth with ADHD.³ They recommend a thorough assessment that includes a developmental, medical, psychiatric, and family history.

The AAP guidelines were published in 2001.⁴ These guidelines also call for a complete assessment, followed by the least restrictive and invasive interventions with ongoing evaluation of treatment, education plans, and support for the family and child. The AAP guidelines offer 5 general recommendations:

•Treat ADHD as a chronic condition.

•To maximize functioning, identify target outcomes for each patient.

•Treat with a stimulant and/or behavior therapy.

•If treatment is not effective or the target outcome cannot be achieved, reevaluate both the diagnosis and therapy.

•See children with ADHD every 3 to 6 months for ongoing monitoring and assessment, including achievement of both target outcomes and growth parameters.

A third set of recommendations--and the one most recently revised--is the Texas Children's Medical Algorithm.⁵ The updated guidelines incorporate changes in treatment recommendations, including the use of atomoxetine and the treatment of ADHD in patients with comorbid psychiatric diagnoses.

It is important to review the core set of ADHD symptoms listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which appears in Table 1 on page 9 of this issue.⁶ Look for symptom onset before age 7 years, presence in more than one setting (school, home, peers), and functional impairment. The mental status examination should include evaluation of speech and language skills, tests for hearing impairment, and an estimation of cognitive ability.⁶ In addition, screen for lead toxicity and possible abuse. Referrals to rule out comorbid medical disorders and assessment for other psychiatric disorders as primary or a comorbid cause of symptoms should be completed before therapy is initiated.

Treatment is usually multimodal and can include parent training, psychotherapy, educational interventions, and pharmacotherapy.

JT, a 4-year-old African American boy, is brought in for evaluation by his mother after combined type ADHD had been diagnosed in his older sister. The sister's symptoms had been stabilized with a stimulant.

The mother reports that the boy was about to be expelled from preschool because he refused to hold the teacher's hand and would run into busy streets. The mother could not go to the grocery store without another adult, because her son would escape from the grocery cart and run away if she turned to remove an item from the shelf. She was afraid to sleep at night because he would try to leave the house. She worried that her son would be injured or killed because he could not stay or sit still and did not follow any rules.

As any busy pediatrician knows, all toddlers suffer from a deficit of attention and an excess of energy. Attention spans and the ability to sit still increase with age. How do you decide which toddler is just a normal 3-year-old, and which is seriously out of control and in need of treatment for ADHD?

The first step is a thorough history of the child's developmental trajectory--including speech, gross and fine motor milestones, birth trauma, and family history. Perform a neurologic examination, and assess vision and hearing. For a disruptive toddler, referral to a local child-screening center for a more complete speech and language assessment and cognitive assessment is crucial.

Diagnosis. The differential diagnosis of ADHD in toddlers includes:

•Speech and language disorders.

•Hearing or vision impairment.

•Mental retardation, including fragile X syndrome.

•Fetal alcohol(Drug information on alcohol) syndrome.

•Pervasive developmental disorder (PDD).

•Lead toxicity.

•Physical or sexual abuse.

•Other neurodevelopmental disorders, such as neurofibromatosis, that are highly comorbid with ADHD.

In addition, several psychiatric disorders can present with symptoms that overlap with those of ADHD. These include adjustment disorders, separation anxiety, obsessive-compulsive disorder, reactive attachment disorder (seen in children who have been in foster care and are adopted at a more advanced age after severe deprivation), and depression.

Assessment. Laboratory testing for lead poisoning and genetic disorders (such as fragile X syndrome or neurofibromatosis) is performed if indicated by the history and physical examination findings.

If the comprehensive assessment determines that a child has speech and language deficits, PDD, or mental retardation, address those issues first, before adding specific therapies for ADHD. Interventions for children with mental retardation, PDD, or speech and language delays include speech therapy, physical and occupational therapy (if needed), and a structured special education preschool with interventions geared toward helping the child reach appropriate speech and academic milestones with same-age peers.

Treatment. If the toddler does not have a developmental delay or another psychiatric disorder, the next step is to design an intervention tailored to his or her specific needs and those of the family. Most experts who treat toddlers with ADHD recommend beginning with parent training and a structured preschool or daycare setting to modify the child's environment. Should those therapies fail to minimize symptoms, the next step is pharmacologic intervention.

Dextroamphetamine is the only medication that is FDA-approved for the treatment of ADHD in children aged 3 to 5 years. However, more controlled data exist on the non- FDA-approved medication, methylphenidate(Drug information on methylphenidate)--which has been used in multiple controlled trials and in one large National Institute of Mental Health (NIMH) multi-site trial in this age group.^7-9 The trials involved preschoolers aged 3 to 5 years. Trials lasted from 3 to 8 weeks and compared at least 1 dose of methylphenidate with placebo. In all trials, methylphenidate was superior to placebo in reducing ADHD symptoms. Results of the NIMH trial have not yet been reported.

There are no published trials of the treatment of preschool ADHD with atomoxetine.

Most experts recommend starting with the unapproved methylphenidate, then trying dextroamphetamine or mixed amphetamine salts. Because most preschoolers cannot swallow pills, the best choices are chewable tablets or liquid formulations (some methylphenidate formulations). The long-acting beaded formulations of any of these stimulants (Adderall XR, Metadate CD, Ritalin LA, and Focalin XR), which can be sprinkled on food and do not need to be swallowed whole, can also be tried.

Most guidelines recommend using short-acting agents for initial titration followed by a long-acting agent for maintenance. Start toddlers at half the starting dose for school-aged children, and then titrate up every 7 days, with close monitoring of side effects and growth patterns. Most guidelines also recommend monthly visits after the initial titration period. Because preschoolers with ADHD who require pharmacotherapy are usually symptomatic in all settings (home, school or day care, and social), the guidelines recommend 7-days-per-week treatment.

At the request of his second grade teacher, LB--a 7-year-old European American boy--presented for treatment of his ADHD. In kindergarten, he had struggled with sitting during story time and talked all the time. By first grade, LB was still routinely getting out of his seat to sharpen pencils, was trapped in a tree, and was not invited for playdates. No one wanted him on the soccer team because he would not pass the ball to teammates. He lost his Game Boy and rarely completed or turned in his homework. Homework time was impossible and his parents were frustrated when they tried to get him to complete his homework assignments.

When the behaviors persisted in second grade, the parents brought him in for an assessment.

School-aged children with ADHD present for evaluation at one of two different points; the timing depends on the ADHD subtype. The two presentations have different differential diagnoses and medical workups. I will discuss these issues separately here. The treatment options are similar, however, and these are discussed together.

Combined type ADHD. The vignette above describes a typical first or second grader with classic combined type ADHD who presents with symptoms in all settings and who has serious impairment in school functioning. Children with combined type ADHD usually have had symptoms since kindergarten or preschool; however, the family often does not seek help until late in the first-grade year--after the teacher finally becomes overwhelmed and calls the parents with an ADHD academic or behavioral crisis.

Typically, in September and October, the child's ADHD symptoms are usually chalked up to the need to adjust to school; disruptive behavior in November and December is often overlooked by the teacher as being caused by the excitement of the upcoming holidays; and it is likely to be ignored a third time in January, when it is attributed to readjustment after the winter break. Then in February, the ADHD behavior that has been present for the entire school year is suddenly seen as a big problem. The child and parent(s) are referred to you with a diagnosis by the teacher of ADHD who recommends that the parents ask for a prescription for a stimulant.

Teachers are often good at recognizing signs and symptoms of ADHD. However, the classroom Connors scale or Vanderbilt scales do not replace a thorough office assessment.

The differential diagnosis for combined type ADHD includes other disruptive behavior disorders, such as:

•Oppositional defiant disorder.

•Conduct disorder.

•Bipolar disorder.

•Post-traumatic stress disorder.

•Tourette syndrome (if the patient has any tics). Include the following in the history taking:

•Family history of mood and disruptive behavioral disorders.

•Response to prior medications trials (if every stimulant trial makes the child worse, the diagnosis is probably not ADHD).

•Assessment for cardinal symptoms of bipolar disorder. (Although symptoms of bipolar disorder and ADHD do overlap, certain symptoms are characteristic of bipolar disorder and can help differentiate between the diagnoses in your office [Table 1].)