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Adhd Deficit Atencion Aafp
Adhd Deficit Atencion Aafp
Adhd Deficit Atencion Aafp
in Children
BARBARA T. FELT, MD, MS, and BERNARD BIERMANN, MD, PhD, University of Michigan, Ann Arbor, Michigan
JENNIFER G. CHRISTNER, MD, State University of New York Upstate Medical University, Syracuse, New York
PARAM KOCHHAR, MD, MBBS, and RICHARD VAN HARRISON, PhD, University of Michigan, Ann Arbor, Michigan
Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder in children, and the prevalence is increasing. Physicians should evaluate for ADHD in children with behavioral concerns (e.g., inattention, hyperactivity, impulsivity, oppositionality) or poor academic progress using validated assessment tools with observers from
several settings (home, school, community) and self-observation, if possible. Physicians who inherit a patient with a
previous ADHD diagnosis should review the diagnostic process, and current symptoms and treatment needs. Coexisting conditions (e.g., anxiety, learning, mood, or sleep disorders) should be identified and treated. Behavioral treatments are recommended for preschool-aged children and may be helpful at older ages. Effective behavioral therapies
include parent training, classroom management, and peer interventions. Medications are recommended as first-line
therapy for older children. Psychostimulants, such as methylphenidate and dextroamphetamine, are most effective for
the treatment of core ADHD symptoms and have generally acceptable adverse effect profiles. There are fewer supporting studies for atomoxetine, guanfacine, and clonidine, and they are less effective than the psychostimulants. Height,
weight, heart rate, blood pressure, symptoms, mood, and treatment adherence should be recorded at follow-up visits.
(Am Fam Physician. 2014;90(7):456-464. Copyright 2014 American Academy of Family Physicians.)
Patient information:
A handout on this topic is
available at http://family
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en/diseases-conditions/
attention-deficit-hyper
activity-disorder-adhd.
html.
This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See
CME Quiz Questions on
page 447.
CME
456
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ADHD in Children
ADHD diagnosed?
No
Yes
No
Developmental variation
or subthreshold for
ADHD: provide education,
enhance surveillance
Yes
Yes
No
Evaluate and
treat as needed
Reevaluate. Is ADHD
management still needed?
Yes
No
Continue
surveillance
Treatment
Education
Behavioral management (Table 4)
Medication management (Table 6)
Symptoms improve?
No
Reevaluate
Yes
Continue management
*In general, the overall sequence of evaluation and treatment is similar in children
and adults.
The treatment for preschoolers begins with behavioral management; treatment
for older children, adolescents, and adults begins with medication therapy.
Figure 1. Overview of the evaluation and treatment of attentiondeficit/hyperactivity disorder (ADHD) in children older than four years
and adolescents.
Information from references 8 through 11.
ADHD cannot be reliably diagnosed in children younger than four years. Although it
is difficult to determine whether symptoms
are beyond the expected behavior of four- and five-yearolds,8-10,23 validated behavioral rating scales for this age
group (Table 4) can improve diagnostic confidence.9
OLDER CHILDREN
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ADHD in Children
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ADHD in Children
Table 2. Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized
by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least six months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or
instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g.,
overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts
tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and
belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for
older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying
bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least six months to a degree that is
inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or
instructions. For older adolescents and adults (age 17 or older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or
other workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often on the go, acting as if driven by a motor (e.g., is unable to be or uncomfortable being still for extended time, as in
restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes peoples sentences; cannot wait for turn in
conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other peoples things
without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends
or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained
by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or
withdrawal).
Reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va.:
American Psychiatric Association; 2013:59-60.
PHARMACOLOGIC TREATMENT
Medications reduce core ADHD symptoms for most children.6,8-11 Table 6 summarizes common ADHD medications.8,9,32 Psychostimulants (e.g., methylphenidate
[Ritalin], dextroamphetamine, and mixed amphetamine
salts such as dextroamphetamine/amphetamine [Adderall]) are the most effective and safe option, and are the first
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ADHD in Children
Table 3. Conditions that May Mimic or Coexist
with Attention-Deficit/Hyperactivity Disorder
Free
stimulant are less likely to be held back a grade.6 Stimulant medication does not increase the incidence of substance abuse and may improve driving performance in
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ADHD in Children
Table 6. Common Medications for Attention-Deficit/Hyperactivity Disorder
Medications
Formulations
Approximate onset;
duration
Starting dosage
Estimated cost*
Short-acting
Methylphenidate
(Ritalin, Methylin)
Chewable tablet:
2.5, 5, or 10 mg
20 to 30 minutes;
3 to 6 hours
Chewable tablet:
NA ($190)
Tablet: 5, 10, or
20 mg
Solution: 5 or 10
mg per 5 mL
Dexmethylphenidate
(Focalin)
2.5, 5, or 10 mg
30 minutes; 3 to
6 hours
$30 ($45)
Dextroamphetamine/
amphetamine
(Adderall)
30 minutes; 5 to
7 hours
$30 ($150)
Dextroamphetamine
(Zenzedi, Procentra)
Tablet: 5, 10, or
15 mg
20 to 60 minutes;
4 to 6 hours
20 mg
60 to 180 minutes;
3 to 8 hours
5, 10, or 15 mg
60 to 90 minutes;
6 to 10 hours
$145 ($700)
Capsule: 10 to 20 mg (maximum,
60 mg per day)
Capsule: $100
($100 to $205)
Tablet: 30 to 60
minutes; 8 to
12 hours
Solution: 5 mg per
5 mL
Intermediate-acting
Methylphenidate (Ritalin,
Metadate ER)
Dextroamphetamine
(Dexedrine)
Long-acting
Methylphenidate
(Ritalin, Metadate,
Concerta, Daytrana,
Quillivant)
Transdermal patch:
10, 15, 20, or
30 mg
Solution: 5 mg
per mL
Transdermal patch:
3 hours; 10 to
12 hours
Oral solution:
2 hours; 12 hours
Solution: $240
($360)
Transdermal patch:
NA ($250)
Oral solution:
NA ($95)
Dextroamphetamine/
amphetamine
(Adderall XR)
30 minutes;
8 hours
$100 ($230)
Dexmethylphenidate
(Focalin XR)
30 minutes;
12 hours
$130 ($225)
Lisdexamfetamine
(Vyvanse)
2 hours; 10 hours
NA ($220)
continued
NOTE:
Psychostimulants are first-line and nonpsychostimulants second-line in terms of effectiveness for attention-deficit/hyperactivity disorder.
*Estimated retail price for 30 days at the starting dosage, based on information obtained at http://www.goodrx.com (accessed April 21, 2014).
Generic price listed first; brand price listed in parentheses.
May sprinkle contents of capsule on food.
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ADHD in Children
Table 6. Common Medications for Attention-Deficit/Hyperactivity Disorder (continued)
Formulations
Approximate onset;
duration
Atomoxetine (Strattera)
Clonidine (Catapres,
Kapvay)
Medications
Estimated cost*
1 to 2 hours;
24 hours
NA ($240)
Regular release:
0.1, 0.2, or
0.3 mg
Regular release:
30 minutes; 6 to
8 hours
Regular release:
$5 ($60)
Extended release:
0.1 or 0.2 mg
Extended release:
1 to 2 hours;
24 hours
Nonpsychostimulants
Guanfacine (Tenex,
Intuniv)
Regular release:
1 or 2 mg
Extended release:
1, 2, 3, or 4 mg
NOTE:
Regular release:
60 minutes; 8 to
12 hours
Extended release:
5 to 6 hours; 24
hours
Extended release:
$80 ($145)
Regular release:
$10 ($80)
Extended release:
NA ($275)
Psychostimulants are first-line and nonpsychostimulants second-line in terms of effectiveness for attention-deficit/hyperactivity treatment.
*Estimated retail price for 30 days at the starting dosage, based on information obtained at http://www.goodrx.com (accessed April 21, 2014).
Generic price listed first; brand price listed in parentheses.
May sprinkle contents of capsule on food.
Information from references 8, 9, and 32.
patient, and teachers. No evidence shows that one psychostimulant agent is superior.8,9,41 A younger child who
cannot swallow pills may benefit from liquid or spansule
preparations (which can be sprinkled on food). An older
child or teenager may benefit from long-acting preparations and/or the addition of a short-acting compound
after school to provide sufficient coverage for homework
or other activities. Long-acting preparations have the
advantage of less frequent dosing but can be more costly
than short-acting options.
Atomoxetine. Atomoxetine is a nonstimulant medication that affects noradrenergic systems. Atomoxetine
may also be effective for comorbid mood or anxiety
disorders and has no abuse risk. These factors may be
beneficial in the treatment of adolescents with ADHD.3,9
Adverse effects include somnolence, gastrointestinal
upset/nausea (particularly if the dose is advanced too
quickly), and reduced appetite. Full therapeutic effect is
reached in about four to six weeks.8,9
Alpha-2 receptor agonists. These antihypertensive
agents are also beneficial as alternatives or adjuncts to
stimulant treatment for ADHD. Potential advantages of
guanfacine over clonidine include a longer half-life and
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ADHD in Children
References
Children four years and older and adolescents with poor attention, distractibility, hyperactivity,
impulsiveness, poor academic performance, or behavioral problems at home or at school should be
evaluated for ADHD.
8-10, 16
Behavioral therapy should be the primary treatment for ADHD in children younger than six years, and it
may be helpful at older ages.
4, 8-10, 30,
31
Treatment of ADHD in children six years and older should start with medication.
8-10
Psychostimulants (e.g., methylphenidate [Ritalin], dextroamphetamine) are the most effective therapy for
core ADHD symptoms and have generally acceptable adverse effect profiles.
Clinical recommendation
The Authors
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ADHD in Children
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