CE/CME

ADHD: Putting the Pieces Together

Clinician Reviews. 2015 January;25(1):28-36

References

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18. Daley D, Jones K, Hutchings J, Thompson M. Attention deficit hyperactivity disorder in pre-school children: current findings, recommended interventions and future directions. Child Care Health Dev. 2009;35(6):754-766.

19. Bruchmüller K, Margraf J, Schneider S. Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. J Consult Clin Psychol. 2012;80(1):128-138.

20. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.

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24. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder. Supplemental information. Implementing the key action statements: an algorithm and explanation for process of care for the evaluation, diagnosis, treatment, and monitoring of ADHD in children and adolescents. http://pediatrics.aappublications.org/content/suppl/2011/10/11/peds.2011-2654.DC1/zpe611117822p.pdf. Accessed December 15, 2014.

25. Olfson M, Huang C, Gerhard T, et al. Stimulants and cardiovascular events in youth with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(2):147-156.

26. Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117(18):2407-2423.

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Hyperactivity, impulsivity, disruptive behavior, lack of focus—the symptoms of attention-deficit/hyperactivity disorder can negatively impact children and their families. Primary care providers have the opportunity to bring a semblance of order to chaos, and improve quality of life for all involved, by identifying affected patients and providing effective treatment options. Here is everything you need to know.

Attention-deficit/hyperactivity disorder (ADHD) is a diagnosis on the rise. In 2011, approximately 11% of school-aged children had ever been diagnosed with ADHD—an increase of 2 million children since 2003.¹ Another analysis found that, while more children ages 8 to 15 years were diagnosed with ADHD than with any other mental health disorder, only about half had received treatment for it.² Since the majority of children—65% to 85%—are diagnosed in the primary care setting,³ there is a clear need for primary care clinicians to be up-to-date on the diagnosis and treatment of this disorder.

To enhance both evidence-based practice and quality outcomes for the child and family dealing with this chronic and challenging disorder, an overview of the latest information about ADHD is presented here. In addition to diagnostic criteria, clinical presentation, screening methods, and treatment options, a discussion of the parental role in ADHD management and a medication reference guide are also provided (the latter to facilitate appropriate selection of initial pharmacologic therapy).

INTRODUCTION
ADHD is characterized by persistent patterns of hyperactivity-impulsivity and/or inattention⁴ and is diagnosed about twice as often in boys as in girls.² The hyperactive-impulsive form usually manifests before age 7, while the inattentive form may not be apparent until age 8 or 9.⁵ Although symptoms may wane with maturity, they persist into adulthood for about 50% of patients.⁶

ADHD can impair academic performance, disrupt familial and interpersonal relationships, and lead to social isolation and low self-esteem.⁴ Clinicians should be mindful of the potential negative long-term effects of ADHD, which include increased risk for substance abuse and other antisocial activities and fewer vocational opportunities.⁷

The economic impact of ADHD is also significant. An often-cited 2007 cost-of-illness analysis estimated a minimum annual societal cost of $42.5 billion for pediatric ADHD. A more likely estimate is twice that and highlights the public health importance of ADHD to health care practitioners, families, and society.⁸

ETIOLOGY
Currently, a single cause for ADHD has not been established, although research supports a genetic basis, with secondary factors (eg, environmental influences) also involved.⁹ Ongoing studies have identified numerous genes that contribute to ADHD.¹⁰ The disorder has also been seen in children with brain damage, including perinatal brain damage, fetal alcohol syndrome, and Down syndrome.¹¹

MRI studies have shown brain patterns that link ADHD with decreased functioning in the cingulo-frontal-parietal (CFP) cognitive-attention network. Specifically, impairment in the dorsal anterior midcingulate cortex, termed the daMCC, is responsible for inappropriate or excessive motor behavior, while alterations in the dorsolateral prefrontal cortex, or DLPFC, have adverse effects on the ability to think ahead, plan, and reason.¹² With this knowledge, clinicians can choose medications that target specific areas of the brain, if appropriate.

Environmental influences
Two factors hypothesized to influence ADHD symptoms are nutrition and the home environment. Many studies have examined the effects of refined sugar, additives, and preservatives on ADHD symptoms. Results indicate that, while monitoring a child’s intake of these ingredients may be beneficial from a nutritional standpoint, it is unlikely that they significantly affect ADHD symptoms.^10,13,14

Given ADHD’s genetic component, parents may have ADHD themselves—making it more difficult for them to provide consistency and structure in the home environment.^15,16 Chaotic living situations can exacerbate ADHD symptoms,¹¹and research indicates that mothers with ADHD are more likely to engage in negative parenting, with higher demands and little praise, than mothers without the disorder.¹⁵ They may exhibit less patience and feel the need to control the child’s environment, even during playtime.¹⁷ Preschool hyperactivity has been identified in children whose parents exhibit coercive, overstimulating, negative, or inconsistent parenting.¹⁸

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