Current Concepts in ADHD

I. Definition and Incidence of ADHD
a. ADHD-Impulsive/Hyperactive type
b. ADHD-Inattentive type
c. ADHD-Combined type
II. Diagnosis and assessment
III. Treatment
a. Lifestyle: sleep, diet, environment
b. Behavioral management, organization, structure
c. Medication
i. Stimulants
ii. Non-stimulants
IV. Outlook
Current Concepts in ADHD
The Center for Disease Control (CDC) states that ADHD affects approximately 5% of
children1 and 4% of adults2 in the U.S. Recent CDC monitoring suggests these
numbers continue to increase as awareness and public education have become
more widespread.3 The symptoms of Attention Deficit Hyperactivity Disorder
include high activity level, impulsivity, low frustration tolerance, difficulty
remaining focused on a task, forgetfulness and easy distractibility. These are all
personality traits that we all, to some degree, manifest. These traits must occur at a
high enough level to interfere with learning and daily activities to meet criteria for
ADHD.
Approximately one-quarter of those with ADHD symptoms display primarily high
activity, low frustration and intolerance. There persons are diagnosed with ADHD-
Impulsive/Hyperactive type. Individuals with primary symptoms of inattention,
easy distractibility and forgetfulness are considered to have ADHD-Inattentive type.
Is seems to be a misnomer that the inattentive individuals are still under the
heading of ADHD, with the “H” standing for hyperactivity. This is simply the
nomenclature of the medical literature. Approximately one-half manifest a
combination of both hyperactive and inattentive behaviors and are considered to
have the combined type.4,5
Assessment and diagnosis of ADHD is dependent on age.5,6 Young children naturally
have higher activity levels and shorter attention spans than older children, and
certainly adults. Therefore there cannot be strict measurements of an ability or
length of time a child should remain on a given task. The various assessments are
designed to determine if the limitations of a child’s ability to remain focused
interferes with age appropriate tasks. For example, a second grader should be able
to remain focused and complete 5 basic mathematics problems without getting
distracted. A forth grader should be able to accomplish more with increasing
distractions that are typical in an higher grade classroom or during homework time
at home.

The assessment of these “age appropriate” abilities must be carried out by a
professional trained, skilled and experienced in this type of assessment. The actual
“testing” or assessment can be carried out by a number of professionals, but since
the final diagnosis is of a medical condition, a physician should make this diagnosis.
This includes developmental pediatricians, pediatric neurologists and child
psychiatrists. Some general pediatricians that take the time to perform some testing
and review educational reports can appropriately make the diagnosis as well. The
assessment and diagnosis in adults is almost exclusively performed by adult
psychiatrist, since internist’s and adult neurologist have traditional not been
educate and trained in this diagnosis.
The corner stone in the treatment of ADHD, at any age, is education and lifestyle and
behavioral changes. Individuals with ADHD should learn strategies to compensate
for their weaknesses of limited attention span, easy distractibility and high activity
levels.7 For young children, frequent breaks with the opportunity for physical
activity can help them be more productive when returning to a complicated or
“boring” task such as homework. Those children with a high activity level and
impulsively often respond well to behavioral management programs that “reward”
accomplishable time periods that the child can remain on task or complete
assignments. Quit environments or headphones help prevent those with easy
distractibility. Many children and most adults with ADHD have poor organizational
abilities and frequent forgetfulness. There are an abundance of strategies and
professionals, primarily psychologists that can provide guidance in theses areas.
If lifestyle and behavioral interventions do not completely allow an individual to
perform age appropriate tasks, then medication should be considered. Many parents
are initially opposed to “medicating” their children. Parents should be counseled
that the goal of any treatment is to allow their children to be more successfully both
academically and socially. A cognitively average, or even about average, can have
significant academic and social problems solely related to their concentration and
distractibility weaknesses. These weaknesses become more prevalent and
problematic as children are presented with more complicated academic challenges
as they progress in school.
Medications administered in the treatment are primarily stimulants, but there are
several “non-stimulants” that are also used. Methylphenidate (Ritalin, etc.) has been
used safely in several different formulations for over 50 years. Other
methylphenidate formulations include: Concerta, Metadate, Methylin, Focalin,
Methylin and Quilivant. A second class of amphetamine stimulants include: Adderall,
Vyvanse, Dexedrine and Dextrostat.8 Despite frequent reports in the popular press
and internet, methylphenidate has been found to be safe and effective in the
treatment of children and adults with ADHD. Over the years there have been
additional formulations of methylphenidate and other stimulant medications. Some
individual’s react better to one formulation compare to another, but there has been
no “superior” stimulant ADHD medication compared to the others.

Non-stimulant medications FDA approved for ADHD treatment include atomoxetine
(Strattera), guanficine (Intuiv) and clonidine (Kapvay).8 These medications do not
have the long safety history of the stimulant medications, but are a good alternative
for those that do not tolerate stimulant medications. There are other medications
used by doctors that are not FDA approved for the treatment of ADHD including
several antidepressants.
The outlook for most individuals with ADHD is good with a “normal” life. A recent
meta-analysis, that included 1,057 children with ADHD, reported that combined
behavioral and medication interventions are effective in “managing” core ADHD
symptoms and academic performance. However, this is dependent on early
institution of lifestyle and behavioral interventions and the appropriate medical
interventions when required.9 In addition, the presence of coexisting conditions can
impact success as well. Individuals with ADHD have a higher incidence of also
having a learning disability, mood disorder and other behavioral conditions. Early
and effective treatment of ADHD in those with these “co-morbid” conditions
increases the successful outcome of both.
Continuing education of parents, children and adults with ADHD is essential to the
successful intervention on the affected persons dealing with the symptoms of ADHD.
Ongoing professional management of behavioral and medication may be necessary
for long-term success.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders: DSM-IV-TR. Washington: American Psychiatric Association, 2000.
http://www.cdc.gov/ncbddd/adhd/data.html#1
2. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone
SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB, Walters EE,
Zaslavsky AM. The Prevalence and Correlates of Adult ADHD in the United
States: Results from the National Comorbidity Survey Replication. American
Journal of Psychiatry. 2006. 163: 724-732.
http://www.nimh.nih.gov/news/science-news/2006/harvard-study-
suggests-significant-prevalence-of-adhd-symptoms-among-adults.shtml
3. www.cdc.gov/nchs/data/series/sr_10/sr10_247.pdf
4. ADHD factsheet. Centers for Disease Control and Prevention.
http://www.cdc.gov/ncbddd/adhd/
5. Attention-deficit/hyperactivity disorder. In: Diagnostic and Statistical
Manual of Mental Disorders DSM-IV-TR. 4th ed. Arlington, Va.: American
Psychiatric Association; 2000.
http://www.psychiatryonline.com.
6. Attention deficit/hyperactivity disorder. National Institute of Mental Health.
http://www.nimh.nih.gov/health/publications/attention-deficit-
hyperactivity-disorder/index.shtml

7. Bader A, et al. Complementary and alternative therapies for children and
adolescents with ADHD. Current Opinion in Pediatrics. 2012;24:760.
http://www.mayoclinic.com/health/adhd/DS00275/DSECTION=treatments
-and-drugs
8. http://www.webmd.com/add-adhd/adhd-medication-chart
9. Parker J, Wales G, Chalhoub N, Harpin V. The long-term outcomes of
interventions for the management of attention-deficit hyperactivity disorder
in children and adolescents: a systematic review of randomized controlled
trials. Psychol Res Behav Manag. 2013 Sep 17;6:87-99.
www.ncbi.nlm.nih.gov/pubmed/24082796

Current Concepts in ADHD

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