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Attention-deficit/hyperactivity disorder: assessment, diagnosis, and management.

Children and adolescents with attention-deficit/hyperactivity disorder (AD/HD) frequently present to family physicians for evaluation and treatment. Recently, revised criteria for diagnosis of this condition were presented in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. Attention-deficit/ hyperactivity disorder is often difficult to differentiate from other disruptive behavior syndromes, such as oppositional defiant disorder and conduct disorder. Using a systematic process of differential diagnosis and integrating the mental status examination with history and teacher and parent reports, the family physician will be able to diagnose AD/HD with greater accuracy. Treatment with stimulant medication and behavioral strategies yields positive outcomes with these children.

Key words. Attention deficit disorder with hyperactivity; child behavior disorders; adolescent behavior; diagnosis treatment outcome; family physicians. (J Fam Pract 1995; 40:270-279)

Children and adolescents with overactive, impulsive, and distractible behavior are frequently brought to family physicians. The parents and teachers of these young patients are often bewildered, frustrated, and caught in a recurring cycle in which the usual methods of discipline and reward have little behavioral impact. By the time a physician is contacted, there may be an atmosphere of growing anger, helplessness, and demoralization among adults involved with the child. Because childhood behavioral problems have multiple causes, the family physician encountering this clinical situation also may experience bewilderment. Some parents are emphatic about the child's behavior being unmanageable at home and at school but provide no explanation for the pattern. At other times, the physician encounters specific requests for treatment from parents, teachers, or both.

Because these patients present fairly frequently to primary care physicians, knowledge about current diagnostic criteria, clinical presentations, assessment strategies, differential diagnosis, and treatment approaches is essential. Recently, the American Psychiatric Association presented revised criteria for the diagnosis of attention-deficit/hyperactivity disorder (AD/HD) in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).[1] Although these criteria are, helpful, diagnosis of AD/HD in the family physician's office is often confounded by several factors. These issues include the overlap between psychiatric criteria and normal childhood behavior, inconsistencies among informants' observations of the child, and overt similarities between AD/HD and several other childhood behavior disorders. Accurate diagnosis is further complicated by heavy reliance on reports of adults for determining the presence of AD/HD and the absence of laboratory or radiographic data diagnostic of the syndrome.

Diagnostic Criteria and Prevalence

The DSM-IV criteria for AD/HD are summarized in Table 1. The disorder is characterized by impulsivity, inattention, and motor resdessness.[1] These symptoms are typically first evident in the preschool years, are exhibited in a range of settings, and are consistent over time.

The population prevalence is 3% to 5% among school-aged children.[1] In clinical studies, boys are six times as likely as are girls to have AD/HD; the ratio falls to 3:1 in population-based studies.[2,3] It is estimated that up to 50% of children with AD/HD continue to exhibit symptoms in adolescence and adulthood.[4,5]

Clinical Presentation

Despite the systematic presentation of these symptoms in DSM-FV, controversy continues regarding the essential or defining features of the disorder. Barkley[2] asserts that the central deficit in AD/HD is behavioral disinhibition, ie, the child is unable to delay responding when necessary. Other writers, stressing hyperactivity as the critical feature, emphasize the excessive bodily movement and frequent vocalization ("talking out of turn") of the child with AD/HD.[6] Inattention, usually manifested through an inability to retain information long enough to act upon it, has been highlighted by other clinicians.[7]

The inattentiveness of children with AD/HD is manifested by their inability to follow through on requests, particularly when the directions must be retained for a time before being carried out. Schoolwork is often only partially completed and completed sections are carelessly done. Many children with AD/HD are able to remain engaged with television or video games, which have relatively low demands for complex concentration or memory.[8]

Hyperactivity is usually apparent in elementary school-aged children by their inability to remain seated. When they are sitting, children with AD/HD are often tapping their feet or fingers, rocking, and manipulating objects. These children appear to be "driven." The child with AD/HD also alienates peers by grabbing objects from them or failing to wait for a turn in games. Rewards or feedback about behavior have only a brief impact. This feature of AD/HD also appears to contribute to a higher incidence of accidental injury among these children.[2,9]

Impulsivity emerges as the child with AD/HD experiences difficulty appropriately delaying a response, such as waiting for a turn, raising a hand before speaking, or not interrupting conversations. Some clinical investigators have noted that children with AD/HD perform normally in novel situations. Thus, they may not exhibit substantial problems during the first few weeks of the school year with a new teacher and classroom. It is important for family physicians to recognize that the office visit in itself also provides a new stimulus for the child with AD/HD. Thus, it is common for these children to demonstrate few behavioral symptoms during the initial office visit.[2,10] The physician should not rely on this observation alone to conclude that AD/HD is absent.

Developmental Issues and Variations

Overactivity and inattention among preschool children is a common parental concern.[2,11] In most preschoolers, however, these concerns spontaneously remit in 3 to 6 months.[2,12] Thus, overactivity and inattention among 3-and 4-year-olds is not, by itself, predictive of later AD/ HD, and caution should be used in diagnosing the syndrome in children under the age of 5 years. Because of these developmental issues, Barkley[2] has suggested that 12 months' duration of symptoms, rather than 6 months as indicated in the DSM-IV, be used as the threshold for diagnosing AD/HD in younger children.

Symptoms of AD/HD in adolescence, by contrast, are likely to be more subtle. Hyperactive motor behavior is not as apparent, and impulsivity may be less dramatic. Based on Barkley's[2] Suggestions for DSM-III-R for evaluating teenagers with AD/HD, a less stringent criterion of five rather than six DSM-IV symptoms may be useful.

The majority of children with AD/HD demonstrate hyperactive and impulsive motor behavior. In some children, however, inattention may be predominant without the accompanying elevated activity level. In DSM-IV, this variant is called "attention-deficit hyperactivity disorder, predominantly inattentive type" (in DSM-III-R, this condition is labeled "undifferentiated attention-deficit disorder"). This form is much less frequent, with an estimated prevalence of 1 in 7 children with AD/HD.[1] In addition to their inattention, these children exhibit apathy, psychomotor slowness, and inconsistent performance on short-term memory tasks.[2] While this subtype has not been well studied, it has been suggested that these patients are more likely to be girls and to have an accompanying learning disability.[1,2]

Etiology

Over the past 10 to 15 years, multiple causes have been posited for AD/HD. Causes touted in the popular media, such as food additives and sugar, have not been empirically supported.[4] In the past, AD/HD was labeled minimal brain dysfunction (MBD), with the assumption of underlying central nervous system disturbance; MBD is no longer used as a diagnostic label.[2] The vast majority of children with AD/HD do not exhibit gross abnormalities on neurological examination. Measures such as the electroencephalogram and computed tomographic scan have not generally proved useful for diagnosis.[2,4]

There is evidence, however, that children with AD/HD demonstrate a greater incidence of neurological "soft signs," such as difficulties with fine and gross motor coordination and balance.[4,13] With younger children, gross motor and balance skills may be assessed by having them stand and hop on one foot. These skills are typically assessed indirectly among older children by inquiring about athletic skills and recreational activities (eg, bicycle riding). This pattern has led many investigators to examine prenatal factors among children with AD/HD. Although there is evidence that maternal cigarette smoking and alcohol consumption during pregnancy may increase the risk of "soft" neurological damage, no consistent link to AD/HD has been found.[2] Excessive reliance on prenatal or subtle neurological patterns in diagnosing AD/HD will lead to a high number of both false positives and false negatives.

Two potentially profitable lines of investigation currently being explored focus on localized areas of central nervous system deficit and neurotransmitter mechanisms. Children with AD/HD appear to demonstrate pronounced weaknesses on neuropsychological tests sensitive to frontal lobe dysfunction.[14] In conjunction with the observed difficulties such children have with self-monitoring and behavioral disinhibition, maturational deficits in the frontal cortex have been suggested as a causative factor.[14] The role of neurotransmitters has been suggested by the positive response of these children to stimulant medications. These medications are known to affect the release and reuptake of dopamine and norepinephrine.[2,4]

Evaluation

Differential Diagnosis and Comorbidity

One particular challenge in accurately diagnosing AD/HD is distinguishing the disorder from other related psychiatric syndromes. DSM-IV groups AD/HD with oppositional defiant disorder and conduct disorder in the category labeled "Disruptive Behavior Disorders." These latter two syndromes share many outward similarities with AD/HD in that they both involve impulsive, disruptive behavior. Conduct disorder and oppositional defiant disorder may be misdiagnosed as AD/HD and vice versa.

The defining feature of oppositional defiant disorder is a pattern of negativistic, angry behavior that has been consistently present for at least 6 months[1] (Table 1). When interacting with parents and teachers, these children are frequently defiant and argumentative, typically Without clear precipitants.[2] Developmentally, this behavioral pattern is relatively common among very young children ("the terrible twos") and is not usually considered to be clinically significant until the age of 5 or 6 years. The prevalence of oppositional defiant disorder is estimated to be 2% to 3%.[1] The disorder is more common among boys before adolescence but appears equally prevalent among boys and girls after puberty.[1]

[TABULAR DATA 1 OMITTED]

The distinguishing feature of conduct disorder is an enduring pattern in which social rules and others' rights are often violated' (Table 1). DSM-IV identifies four basic symptom categories: aggression toward people and animals, destruction of property, deceitfulness and theft, and serious rule violations. A history of childhood conduct disorder is one of the single best predictors of adult antisocial personality disorder.[15]

While there is significant comorbidity between AD/HD and these two disorders, several guidelines are helpful for diferential diagnosis. Although the child with uncomplicated AD/HD may be physically restless and may not follow rules because of inattention, distractibility, or both, the child does not typically exhibit overt defiance and hostility toward parents characteristic of the child with oppositional defiant disorder. The negativistic pattern of the latter is often readily observable during a conjoint medical interview, in which the child's disrespectful and angry verbalizations, rather than being met with direct parental confrontation, typically provoke an ineffectual parental response, such as smiling or changing the subject.

Conduct disorder is more distinguishable from AD/HD during the early elementary school years. Children with conduct disorder, in contrast to those with AD/HD, are more likely to exhibit destructive behavior and legal infractions such as fire-setting, vandalism, cruelty to animals, or theft. Children with AD/HD may violate school and home rules, but their misbehavior does not usually have the same destructive and disturbed quality. On the other hand, the mental status of the child with conduct disorder is more likely to be normal. Whereas the child with AD/HD may exhibit distractibility, fidgeting, and difficulties with sustained concentration and attention, these signs are usually not as significant in the child with conduct disorder.

Family history can be very useful in the diferential diagnosis of these conditions. Overt family dysfunction including a chaotic, inconsistent, and unstructured home environment is much more likely to be found among children with conduct disorder and oppositional defiant disorder.[2] Overt antisocial behavior on the part of one or both parents should direct the physician to seriously consider a conduct disorder diagnosis. Barkley[2] suggests that among children with AD/HD alone, there is likely to be a higher incidence of parental AD/HD as well as maternal dysthymic disorder. The disorganization and stress within families of children with AD/HD may be a reaction to the child's difficulties and arc likely to exacerbate the behavioral aspects of the pre-existing neuromaturational deficit.[2]

The emphasis on differential diagnosis should not lead the physician to conclude that these two syndromes are incompatible with AD/HD. Oppositional defiant disorder and conduct disorder are both very prevalent among children and adolescents with AD/HD. It is estimated that approximately 40% of the children and 65% of the adolescents who have AD/HD exhibit concurrent oppositional defiant disorder.[2,5] Between 21% and 45% of children and 45% to 50% of adolescents with AD/HD meet the diagnostic criteria for conduct disorder.[2,5]

Learning disabilities, while not in the disruptive behavior category, are also prevalent among children with AD/HD. Although definitions of learning disabilities differ, one widely accepted diagnostic criterion is a significant discrepancy between intellectual functioning as measured by an IQ test and academic skill level as measured by an achievement test.[2,16] Approximately 20% of children with AD/HD exhibit a learning disability in reading, spelling, and mathematics. The relative role of AD/HD in the etiology of these types of learning disabilities is, at present, unclear. Thus, it is impossible to determine whether AD/HD simply coexists with these academic skill deficits, or whether the difficulties with sustained concentration and behavioral self-regulation impair acquisition of academic skills. Learning disabilities appear to be particularly pronounced among adolescents with AD/HD.[5]

Speech and language disorders also appear to be more prevalent among children with AD/HD. Language-delayed preschool children with elevated motor activity and apparent distractibility are a diferential diagnostic challenge. These children, who periodically present to primary care physicians, often exhibit delays in language skills of 6 to 18 months. Because of their young age and the presence of an expressive language disorder, it is often advisable to defer diagnosing AD/HD until a thorough speech and language evaluation has been completed. Clinically, these children often have receptive language skills that are better developed than their expressive language skills, and thus, they comprehend more information than they can convey. The child's elevated activity may be related to an inability to communicate verbally.

Physicians who see children with AD/HD infrequently may be unclear about the distinction between AD/HD and a childhood anxiety disorder or depression. Both disorders, particularly in children, may be associated with restlessness, irritability, and difficulty concentrating. There are several guidelines to assist the physician in making the differential diagnosis. Children with anxiety disorders are unlikely to be impulsive and behaviorally disruptive. They are more likely to be socially withdrawn and to exhibit functional somatic symptoms, such as headaches and stomachaches.[17] Barkley[2] notes that AD/HD is not typically associated with an anxiety syndrome as a comorbid diagnosis.

Childhood depression has been increasingly recognized during the past two decades.[18] Among early elementary and preschool children, depression may be associated with irritability, aggression, agitation, and difficulty concentrating. In addition to pervasive dysphoric mood, however, depressed children are more likely to be inattentive because of internal preoccupation and apathy rather than because of the distractibility and behavioral disinhibition of AD/HD.[2] Additionally, sleep problems are much more common among depressed children and adolescents and take the form of intermittent insomnia or hypersomnia rather than the difficulty in "settling down" to fall asleep that is common among children with AD/ HD.[2] Similar to the anxiety disorders, depression is an infrequent comorbid syndrome with AD/HD.[2]

Mental Status Examination

The physician should conduct a thorough mental status examination with an emphasis on assessing distractibility, attention, concentration, and short-term memory (Table 2). For school-aged children, attention can be assessed with a digit span task as described in Table 3, which contains a brief screening test developed by the second author. Concentration and the ability to retain information in working memory to perform mental operations is often assessed with a digits backwards task, also described in Table 3, and verbally presented arithmetic problems. For preschool and kindergarten children, numbers may not be meaningful stimuli, and the physician may substitute sentences of increasing length. With older children and adolescents, orally presented arithmetic problems may be useful in assessing concentration.
Table 2. Mental Status Examination for Attention-deficit/
Hyperactivity Disorder
Mental Status
Dimension                             Examination Process
Attention            Assess with digit span task or ask child to
                       repeat sentence
Concentration        Assess with digits backwards or verbally
                       presented arithmetic problems
Short-term memory    Assess by asking child to recall 4 words or
                       4 hidden objects for 5 and 10 minutes
Speech               Note if articulation is clear and
                       appropriate for age. Note rate of speech
Language             Note if language is coherent and
                       organized
Motor activity       Note if appropriate for year level and
                       situation
Mood                 Note if normal, irritable, or dysphoric
Affect               Note if stable, labile, or flat


Table 3. Office Screening Test for Attention-deficit/
Hyperactivity Disorder
The test is scored by observing behaviors with regard to DSM-IV
criteria. After completing the five steps, review the DSM-IV criteria,
section A, and circle the behaviors that are seen. The diagnosis is
not secure until they also meet the exclusionary criteria listed in the
DSM-IV
1. Pencil keeping
   Ask the subject to hold a pencil for the entire time
   he/she is with you.
2. Four-word recall
   Ask the subject to repeat four words for you now,
   and remember them since you will ask them again in
   five minutes. Any random words can be used (eg,
   key, dog, blue, happy).
3. Three-step command
   Ask the subject to do the following:
   (1) Hand me the pencil
   (2) Close (open) the door
   (3) Sit back down
4. Digit spans
   Ask the subject to repeat three digits forward (eg, 3,
   8, 6) then four digits forward (eg, 6, 11, 5, 8); then
   three digits backward and four digits backward.
5. Take turns
   Draw a Tic-Tic-Toe grid, and play one game.
The test takes about five minutes, and can be repeated with follow-up
visits to check response to treatment.
Copyright by James E. Nablik, MD, 1994. Reproduced with permission.




Delayed recall tasks are also useful for evaluating short-term memory as well as the ability to retain material with intervening interference. Delayed verbal recall is often assessed through presentation of four words with testing of memory at 5- and 10-minute intervals. During the intervening period, the physician should assess other mental status dimensions or engage in conversation to serve as a distraction. All four words should generally be retained at 5 minutes, with at least three words recalled at 10 minutes. Nonverbal memory may be assessed by hiding four small objects in the examination room while the child observes, and then asking the child to recall the objects and their locations.

In addition to thought processes, other mental status dimensions important in assessing AD/HD include speech and language, activity level, mood, and affect. Younger children with AD/HD may exhibit delayed speech and language development.19 The physician may note that school-aged children with AD/HD exhibit a mild degree of tangentiality or circumstantiality in their verbal expression. Pragmatic problems involving poor attention to the social cues or contexts that surround language use (eg, frequently interrupting others) are also common among children with AD/HD. A press of speech (rapid speech) also may be evident.

While elevated levels of motor activity are considered a cardinal symptom of AD/HD, it is important for the physician to recognize that this symptom may not be exhibited during the office visit.[10] A frequent clinical error is to dismiss the possibility of AD/HD on the basis of apparently normal motor activity in the physician's office.8 Although children with AD/HD often exhibit a relatively normal mood, irritability is frequently encountered. Children with AD/HD also may exhibit predominantly normal emotional expression with a tendency toward mild to moderate lability.

AD/HD Among Adolescents and Adults

It was formerly believed that AD/HD underwent spontaneous remission in adolescence, and that this remission was maintained through adulthood. In the past decade, there has been a growing consensus that AD/HD continues through adolescence and into adulthood, although in a somewhat altered form.[5] Based on several longitudinal studies, it is estimated that AD/HD symptoms continue into adulthood in about 30% to 70% of those diagnosed with AD/HD in childhood.[2,5,8]

With increasing age, the symptoms of AD/HD become more subtle. Adults and adolescents do not typically present with the "driven" motor activity seen in younger patients. A further difficulty in diagnosing AD/HD among adolescents is a marked increase in comorbid syndromes, particularly conduct disorder and oppositional defiant disorder.[2,5]

Adolescents with AD/HD typically exhibit impaired concentration and attention. These deficits are usually manifested as poor self-organization and difficulty structuring time and activities.[5] This weakness, in turn, contributes to poor academic performance typically observed among these teenagers. By adolescence, up to 40% to 60% of children with AD/HD have repeated a school grade.20 Adolescents with AD/HD are also more likely to be suspended or expelled from school as well as to use cigarettes, alcohol, or both.[12,16] The incidence of these behaviors is greatly magnified when a comorbid conduct disorder or oppositional defiant disorder is present.[2]

Attention-deficit/hyperactivity disorder in adults has only recently become a focus of study. In addition to poor concentration, adults with AD/HD report cognitive confusion and dysphoric mood. Additionally, they appear to have significant difficulty maintaining close interpersonal relationships. Comorbid disorders reported among adults with AD/HD include antisocial personality, substance abuse, and intermittent explosive disorder[6,21] (unpublished data, P. Halfmann, 1994).

Bebavioral Assessment

As noted earlier, teachers often make the initial referral to the physician for children exhibiting hyperactivity. Since direct classroom observation is impractical for most family physicians, the teacher's description of the child's classroom behavior is invaluable in making a diagnosis. Several standardized classroom behavioral rating scales are currently used. Conners' Teacher Rating Scale[22] is commonly employed in primary care and child mental health settings. Conners' Teacher Rating Scale is a 28-item instrument requiring approximately 5 to 10 minutes to complete. Edelbrock and Achenbach[23] developed the Child Attention Problems instrument to assess the classroom response of children with AD/HD to stimulant medication. Several studies have shown this 12-item rating scale to be sensitive to behavioral changes associated with pharmacological treatment.[24]

Rating scales are also available for parents. The parental version of Conners' scale consists of 48 items and requires approximately 10 minutes for completion.[22] Another commonly employed parental rating scale is the Child Behavior Checklist (CBCL).[25] The CBCL is a more broadly based instrument assessing nine specific dimensions of childhood psychopathology grouped into internalizing or externalizing categories. In addition to detecting hyperactive and aggressive behavior, the CBCL also assesses childhood depression and somatization.

While parent and teacher ratings are useful in assisting with diagnosis, the physician should be aware of these instruments' limitations. First, these instruments have not yet been revised to reflect DSM-IV criteria. For both the teacher and parent rating scales of Conners, a cutoff score of 1.5 standard deviation above the mean is strongly suggestive of AD/HD.[2] Second, halo effects, in which children are nonspecifically rated as "all good" or "all bad are a common limitation of these scales. In addition to placing rating data in the context of the clinical evaluation described earlier, there is some suggestion that teachers' ratings should be given somewhat more credence.6 Symptoms of AD/HD are typically most evident in children in a school setting. When parents perceive these symptoms occurring with high frequency at home with little evidence of problem behavior at school, the possibility of family conflict or unrealistic parental standards should be investigated. Recent research has found that depressed mothers are particularly prone to perceiving their children as exhibiting behavioral problems. Webster-Stratton[26] found that in these families, there was greater agreement between fathers and teachers in their perceptions of children's behavior than there was between depressed mothers and either fathers or teachers.

Psychoeducational Assessment

With many patients, the clinical evidence for an AD/HD diagnosis is, at best, equivocal. This ambiguity may be attributable to concerns about possible distortion by parents or teachers or both in reporting a child's behavior. Additionally, the physician may suspect a learning disability or other comorbid disorder. Another confounding situation is the child with suspected AD/HD who is being treated with medication but does not respond as expected.

In these situations, a referral to a psychologist for formal testing is useful. While there is no single AD/HD "test," psychoeducational evaluation may detect a learning disability. The 3rd edition of the Wechsler Intelligence Scale for Children (WISC-III)[27] provides a global appraisal of cognitive functioning. The WISC-III is composed of 12 specific tasks; three of these subtests form a freedom-from-distractibility dimension. Although the specificity of these tasks for AD/HD is questionable, it is often useful to compare the freedom-from-distractibility dimension with the other WISC-III dimensions.

While the WISC-III is the most commonly employed cognitive test for children, there are several narrower bandwidth measures that emphasize vigilance and impulse control. The Gordon Diagnostic System28 is a portable computerized instrument in which the child is to press a button whenever a particular numerical sequence appears on a screen. The Matching Familiar Figures Test[29] assesses the child's impulsivity by asking him or her to select a matching figure from six very similar patterns. The possibility of a frontal lobe cause for AD/HD has recently raised interest in neuropsychological assessment. The Stroop Word-Color Association Test,[30] an inhibition task in which children are asked to name the color of ink in which a color word is printed (the word "green" is printed in red ink), has demonstrated preliminary usefulness in distinguishing children with AD/HD from normal children.[14] Tests such as the Stroop Test and the Gordon Diagnostic System have potential value as part of an AD/HD evaluation, but most other psychoeducational instruments share the poor specificity of the behavioral measures.[2]

Treatment

Medication

Stimulant medication is the most common treatment for AD/HD. Methylphenidate hydrochloride (Ritalin) appears to benefit about 70% to 80% of children with AD/ HD. Dosages of 0.3 mg/kg have been associated with improved attention and concentration; improved social behavior requires dosages of 0.6 mg/kg or slightly higher.[14] Some physicians initiate the medication in a double-blind placebo trial for the first few weeks, with the methylphenidate for 1 week alternated with placebo for the same period. Obtaining detailed parent and teacher reports, often with behavioral checklists, for each week will control for parent and teacher expectations.[6] The peak effects on behavior occur between 1 to 2 hours after ingestion and diminish in 4 to 6 hours postingestion.[31] Typically, school children receive an initial 10-mg dose in the morning at breakfast and a second 10-mg dose at around noon. In some schools, the second administration may be problematic for personnel reasons or because the child may feel stigmatized in the eyes of peers. An option in these situations is the use of Ritalin-SR (20 mg), a sustained-release formula. The few comparative reports available, however, suggest that the sustained-release medication is less effective than 10 mg twice daily.[32] Because these medications are short-acting, their efficacy is usually evident within 1 to 2 weeks within the classroom or home.

Pemoline (Cylert) is occasionally prescribed for patients who do not respond to methylphenidate. It is estimated that about 20% of children who do not respond to an initial stimulant trial show improvement with a different stimulant drug. Pemoline is a steady-state medication and is typically given once per day, usually in the morning. An initial dose of 37.5 mg is usually increased by 18.75 mg every 3 to 5 days until behavioral change is noted.[14] Patients receiving pemoline should be monitored for possible liver toxicity. Pharmacotherapy for AD/HD is summarized in Table 4.

[TABULAR DATA 4 OMITTED]

Pliszka[6] has highlighted a number of management issues that often arise in prescribing stimulants for children with AD/HD. Parents or teachers may report that doses that had previously been effective are now ineffective. Before changing medication or increasing the dosage, several potential contributing factors should be explored. One possibility is that the medication is not being administered consistently. This failure may be attributable to the child's self-consciousness and refusal to take the medication or to personnel issues in the school setting. Increased stress at home also may lead to reduced parental tolerance for the child's behavior. The physician should be particularly cautious when parents request medication changes because of a specific conduct problem such as stealing, fighting, or refusal to perform chores. These problems typically are not resolved by medication and are best treated with family therapy or behavioral management. Pliszka[6] notes that changes in parents' and teachers' perceptions of the child may occur during the course of stimulant therapy. When treatment is initiated, improvement appears dramatic because the child's behavior and performance level are being compared with his or her previous functioning without medication. Over time, however, the point of reference may "drift" to the child's peers, siblings, or classmates. Rather than being compared in terms of past and present performance, the child with AD/HD who continues exhibiting some deficits while on medication may be inappropriately compared with children who do not have AD/HD.

The question of "medication vacations" for children with AD/HD often arises. A common practice has been to discontinue stimulant medication during weekends, summer vacations, and school holidays. More recently, however, a growing number of physicians have made these medication-free periods contingent on the types of activities in which the child is engaged. Continuing medication during school holiday periods may be appropriate if the degree of impairment is severe or if the child is engaging in cognitively demanding activities.

Stimulant medications may be associated with side effects such as headache, loss of appetite, and insomnia. The majority of children do not have pronounced adverse reactions to conventional therapeutic dosages. In cases where stimulants are contraindicated, however, such as when AD/HD is present with Tourette syndrome, tricyclic antidepressants are a possible option. Imipramine, desipramine, and amitriptyline appear to be effective in reducing hyperactivity but do not seem to substantially improve cognitive function.[33] Clonidine has also demonstrated some clinical efficacy with AD/HD children who do not tolerate stimulants. Available research suggests that globally, stimulants are more effective than other medications in treating AD/HD.

Behavioral and Family Intervention

The effectiveness of stimulant medication may be enhanced with concurrent behavioral intervention.[34] This is particularly true in families with parental disagreement or inconsistency regarding discipline, or when AD/HD coexists with conduct disorder or oppositional defiant disorder. Basic principles for behavioral management include targeting one or two selected behaviors (eg, remaining seated through dinner, completing homework) for a period of time, employing immediate consequences, and using rewards rather than punishment. Consistent predictable implementation of consequences is particularly important. Barkley[35] notes that, particularly with young children, planning for difficult situations such as long car trips or shopping excursions and reviewing the rules immediately beforehand can be very helpful.

Parents of children with AD/HD need to constantly work at depersonalizing their child's behavioral difficulties. There is considerable evidence that this disorder is biologically based and not caused by parental negligence. Parents should recognize that their child's inattentiveness and distractibility are not willful antagonism but are generally beyond the child's control. With this recognition, it is hoped that parents will maintain a healthy detached warmth and concern for their child.[35]

Treatment of families of children with AD/HD usually emphasizes education about the disorder, development of structured household routines, and generation of consistent behavioral consequences. Some family therapists, however, have included broader systems goals, including redistribution of child management responsibilities and improved parental communication.[36] Assessment, while including such instruments as Conners' rating scales,[22] may extend to measures of marital satisfaction, such as the Marital Adjustment Test[37] or the McMaster Family Assessment Device.[38] The broader family approach may be particularly helpful with adolescents with AD/HD when developmental issues such as separation from the family and increased desires for decision-making become prominent.[2]

Conclusions

Table 5 summarizes the major issues in diagnosing AD/ HD. A thoughtful systematic approach to the differential diagnosis is critical prior to implementing treatment. Since normal children demonstrate improved attention with methylphenidate, drug response cannot be heavily relied upon to verify an AD/HD diagnosis.[39] After a diagnosis of AD/HD has been made, the physician should explain the implications to the parents as well as to the child. For children being treated with medication, continued follow-up with periodic data-gathering from parents and teachers is helpful in adjusting dosages. Additionally, the mental status examination should be repeated at 3- to 6-month intervals after medication effects have stabilized. With thoughtful and aggressive management, patients with AD/HD can be treated very successfully in the primary care setting.

[TABULAR DATA 5 OMITTED]

NOTE

Families seeking more information should contact the national office of the organization Children and Adolescents with Attention Deficit Disorders (CHADD), 499 Northwest 70th Ave, Suite 308, Plantation, FL 33317. Telephone: (305) 587-3700. Local chapters of CHADD are being established. Local meetings provide both current information about AD/HD and opportunities for families to share experiences and obtain mutual support. CHADD publishes a newsletter that includes information about books on the subject and helpful devices for AD/HD children, adolescents, and adults and their families.

Acknowledgment

The authors would like to thank Cheryl K. Miller, PharmD, Director of the Deaconess Family Medicine Research Center, St Louis, Missouri, for her assistance with information about the pharmacotherapy of AD/HD.

References

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From Deaconess Family Medicine (H.R.S., J.E.N., D.C.C.), the Departments of Community & Family Medicine (H.R.S.,J.E.N., D.C.C) and Psychology (H.R.S.), St Louis University, St Louis, Missouri. Requests for reprints should be addressed to H. Russell Searight, PhD, Deaconess Family Medicine, 6125 Clayton Ave, St Louis, MO 63139.
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Author:Searight, H. Russell; Nahlik, James E.; Campbell, David C.
Publication:Journal of Family Practice
Date:Mar 1, 1995
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