Chapter 84. Hyperactivity and Inattention

A high level of activity and short attention span are part of normal development in infants and toddlers. Many typically developing preschool children continue to manifest these same characteristics. When they develop impulse control around 4 years of age, overactive and distractible behaviors diminish. Attention span, activity level, persistence, and adaptability to change also reflect a child’s temperament or behavioral style. These traits may affect learning and social interactions when they are discordant with expectations of the child’s environment—of teachers, parents, and peers.

More than a century ago, British physician George Still described a behavior pattern that presented with restlessness and inattentive and overaroused behaviors and that involved a child’s inability to internalize rules and limits. He attributed the condition to a defect in moral character. Following the worldwide epidemic of influenza with encephalitis of 1917 to 1918, some of the recovering children displayed symptoms of restlessness, inattention, impulsivity, easy arousability, and hyperactivity; it was described as a postencephalitic behavior disorder. A description of attention deficit hyperactivity disorder (ADHD) has appeared in subsequent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. As newer neuropsychological and clinical research emerged, the name of the disorder changed from hyperkinetic impulse disorder (DSM-II), to attention deficit disorder (DSM-III), and most recently to attention deficit hyperactivity disorder (DSM-IIIR, DSM-IV, and the latest version, DSM-IV-TR, published in 2000).

Core symptoms of ADHD are inattention, hyperactivity, and impulsivity. ADHD is the most common and most extensively studied biopsychosocial problem in school-aged children. It is a chronic condition that persists into adolescence and adulthood in 60% to 80% of individuals diagnosed with ADHD during childhood.1,2

Attention deficit hyperactivity disorder (ADHD) has been identified in children in every country and culture studied. The prevalence rate of ADHD varies depending on diagnostic criteria, the population studied, and the number of sources used to establish a diagnosis. The absence of a biologic marker to establish a diagnosis of ADHD and dependency on parent and teacher reports of behavior is a challenge to research on prevalence. A prevalence of 4% to 12% was found in an analysis of 11 studies using community samples. In a recent national study, 8.7% of children met DSM-IV criteria for ADHD.3 Poor children were more likely to fulfill criteria for ADHD. However, wealthier children were more likely to receive regular medication treatment. Less than half of children meeting DSM criteria for ADHD in this study had received either a diagnosis or regular treatment for ADHD. There is a male predominance of ADHD with a male-female ratio of 3:1 for the combined type and 2:1 for the predominantly inattentive type. In community samples, predominantly inattentive ADHD is the most prevalent subtype, about 1.5 times more common than the combined type and twice as common as the hyperactive/impulsive subtype. School-aged and adolescent girls are more likely to comprise the inattentive subtype. ADHD does occur in preschool children, a group in whom the diagnosis is more challenging.4

Many etiologies for attention deficit hyperactivity disorder (ADHD) have been considered. Because ADHD is a heterogeneous disorder, a multifactorial etiology is more likely than a single unifying neuropsychological construct or biologic marker. A diverse set of biobehavioral pathways can lead to the behavioral expression of the core symptoms of ADHD.5

A multifactorial etiology takes into account that genetic, epigenetic, and environmental factors all interact to give rise to the ADHD phenotypes. A neuropsychologic model integrates genetic, neural, cognitive, and behavior mechanisms. Barkley identified behavioral disinhibition as the major core deficit in ADHD.6 This includes difficulty mobilizing delayed gratification, inability to interrupt ongoing responses (eg, inability to stop playing a video game because it is time for homework), and interference control (eg, inability to refrain from reacting to a friend walking past the classroom door while the child is working on a math problem).

Imbalances in dopaminergic and noradrenergic regulation have been shown to influence the core symptoms of ADHD. These neurotransmitters may increase the inhibitory influences of frontal cortical activity on subcortical structures. Serotonin appears to be minimally involved. Deficits in frontal lobe functioning and subcortical connections with the frontal lobes, particularly the caudate, putamen, and globus pallidus, have been found in neurobiologic, neuroimaging, and neuropsychologic studies. Stimulant medications and other medications found effective in ADHD treatment appear to increase the inhibitory influences of frontal lobe activity through these dopaminergic and noradrenergic influences.

There is debate about whether ADHD results from a delay of brain maturation or a deviation from typical brain development. Cortical development in children with ADHD lags behind that of typically developing children by years but follows the normal sequence of brain development, suggesting that ADHD represents a delay rather than a deviance in cortical brain maturation.7 Cortical delay is most prominent in the lateral prefrontal cortex, an area that supports the ability to suppress inappropriate responses, executive control of attention, evaluation of reward contingencies, higher-order motor control, and working memory. These are the domains of functioning that have been found impaired in children with ADHD. The primary motor cortex is one area that has been shown to have earlier maturation. This early maturation of the primary motor cortex and the late maturation of higher-order motor control regions may help to explain the excessive and poorly controlled motor activity seen in children with ADHD.

ADHD has strong familial associations. Parents and siblings of a child with ADHD carry a 2-fold to 8-fold increase in the risk for ADHD. There is also evidence for genetic heterogeneity in ADHD. Some families with ADHD are also vulnerable for major depressive disorder. Children with ADHD who also have conduct disorder and bipolar disorder may make up another distinct familial subtype. ADHD and anxiety disorders do not appear to be linked in families. Twin studies have found that 77% of the variance of phenotype can be attributed to genetic factors. Genomic linkage studies suggest that risk genes for ADHD may be on chromosomes 16p13 and 17p11. Associations have also been made between ADHD and the dopamine transporter gene (DAT) and dopamine receptor D4 gene. This suggests that dopamine is a significant factor in the etiology of ADHD, and complements the fact that stimulant medications are primarily dopamine reuptake inhibitors.

Biologic and psychosocial factors also contribute to ADHD. Several pregnancy and delivery complications have been found to predispose to ADHD. These include toxemia, eclampsia, poor maternal health, maternal age, postmaturity, duration of labor, fetal distress, low birth weight, and antepartum hemorrhage. Maternal smoking during pregnancy appears to be another risk factor. Psychosocial adversity is also an important risk factor. Chronic family conflict, decreased family cohesion, and parental psychopathology have been found to be more common in families of children with ADHD than in controls.

The diagnosis of attention deficit hyperactivity disorder (ADHD) should not be made without evidence of impairment in functioning, and treatment is not warranted without such evidence. Children with ADHD have been found to have significant functional impairment in the areas of academic achievement, family relationships, peer relationships, self-esteem and self-perception, accidental injuries, and overall adaptive function.8-10 They are likely to underachieve in school regardless of whether they have diagnosed learning disabilities. They are also more likely to qualify for special education, repeat a grade, receive more suspensions, and drop out of school. Families of children with ADHD are more likely to experience impairment in parental harmony, parenting distress, perceived incompetence in parenting, and parent-child interaction problems. Children with ADHD often receive high levels of negative peer rankings of social standing. The self-esteem of children with ADHD is often lower than that of their peers, and as a self-protective mechanism, children and adolescents may inflate initial levels of self-regard. In adults, ADHD is associated with lower educational attainment, occupational level, marital stability, role functioning, social functioning, and cognitive functioning.

Having problems with attention, activity level, and impulsivity creates problems for children, adolescents, and adults in carrying out activities and tasks and participating in school life, relationships, and other functions. Problems brought on by the core symptoms of ADHD can be thought of as impairments in mental functions, limitations of activities, and restrictions in participation. Mental impairments include global functions, such as intellectual functioning and impulse control; specific mental functions, such as attention and memory; and higher-level cognition impairments including organization, time management, and judgment. Activity limitations include learning and applying knowledge (reading, writing, mathematics); general tasks such as carrying out single or multiple tasks; studying; self-managing behavior; and impact on numerous other activities, including interpersonal interactions, communication, and self-care. Restrictions in participation include adjusting to and succeeding in educational programs, leaving school to enter work, and establishing a community, social, and civic life. These broad functional disabilities, rather than the core symptoms themselves, often become the targets for intervention in individuals with ADHD.

ADHD is accompanied by coexisting conditions more often than not. The most prevalent coexisting conditions include other disruptive behavior disorders (oppositional defiant disorder and conduct disorder), anxiety disorder, depressive disorders, and learning disabilities. Each of these conditions carries its own risks for functional impairment. When followed into adolescence, prospective studies of children in clinical samples from referral centers indicate rates of oppositional defiant disorder of 59% to 73%. Prevalence rates of conduct disorder in these clinical samples of adolescents range from 20% to 50%. By adolescence, 44% of children with ADHD are reported to have anxiety disorder. The prevalence of coexisting major depression in most studies of clinical populations range from 9% to 32%.11 When learning disabilities are strictly defined as significant discrepancies between abilities (IQ) and achievement (as measured by individually administered achievement tests) in different academic subjects, approximately 15% of students with ADHD qualify for the diagnosis of coexisting learning disorders12 (see eTable 84.1).

The core behaviors associated with ADHD (hyperactivity, impulsivity, and inattention) are observed in many children and adolescents at some time during their development. It is only when the symptoms are persistent, pervasive (present in multiple situations), and shown to impair critical functions of learning and social development consistent with developmental age that a diagnosis of ADHD is considered. Most ADHD studies are with school-aged and adolescent patients. Diagnosis of ADHD is challenging in the preschool child since the behaviors associated with ADHD are part of normal development, to some degree, in this age group.

To establish an organized framework for the clinical assessment of ADHD, The Diagnostic and Statistical Manual (DSM), an empirically based classification system of behavior disorders, is utilized by pediatricians. The DSM facilitates communication among professionals and patients, provides information relevant to treatment and prevention, and encourages research in understanding behavioral problems that impact development.

The Diagnostic and Statistical Manual (DSM) criteria for diagnosis of ADHD in school-aged children and adolescents include documentation of the following criteria:

• At least 6 of the 9 behaviors described in the hyperactive/impulsive domain and/or at least 6 of the 9 behaviors described in the inattentive domain.
• Symptoms occur often and to a degree inconsistent with child’s developmental age.
• Presence of these behaviors in 2 or more major settings (eg, home and school) for at least six months.
• Presence of some symptoms of ADHD (by history) prior to 7 years of age.
• Significant impairment in learning and/or social interactions.
• Symptoms are not attributable to another mental health condition.

Eighteen specific behaviors must be ascertained as part of the diagnostic process (see Table 84-1). Three subtypes of ADHD (predominantly hyperactive-impulsive type, predominantly inattentive type, and combined type) are delineated.

The diagnostic process must include ascertainment of how many of the 18 ADHD-associated behaviors occur frequently and in most situations. An appreciation of normal development reveals that many school-aged children (and most preschool children) demonstrate some ADHD behaviors some of the time. The Diagnostic and Statistical Manual for Primary Care (DSM-PC) is a guide to distinguish normal developmental variation from the behaviors associated with ADHD.20 Documenting that the behaviors occur frequently is the first step toward good practice. The DSM criteria can be used for school-aged children and adolescents, although hyperactivity is usually not as prominent in adolescent patients.

A clinician must establish whether the behaviors are limited to a particular environment or situation or are present in a variety of situations. There must be evidence that core ADHD behaviors occur in a child’s major environments, including home and school. Knowledge about behaviors in social activities outside of school and home (eg, during sports, camp, scouting, or religious activities) may be useful. Ascertaining that the duration of symptoms is longer than 6 months is crucial. Many of the 18 ADHD symptoms may occur in response to life event changes (eg, marital discord, divorce, economic stress, a family move, a new school, an illness in a family member) or during the early stages of a disease process (eg, posttraumatic encephalopathy, petit mal seizures, an acquired hearing loss, adrenoleukodystrophy). See Table 84-2.

Symptoms of ADHD that are not associated with impairments in schoolwork or with successful social relationships do not meet the diagnostic criteria for ADHD. An inadequate assessment of functional impairment is a common cause of overdiagnosis. The hyperactivity, impulsivity, or inattentiveness in some school-aged children is either not severe enough or is situational in an educational or social environment and outside the boundaries of ADHD. Overactivity associated with situational inattentiveness in a school-aged child who is doing well in the classroom, achieving academically, and engaging socially is not ADHD! In other children, isolated core ADHD behaviors may be adaptive to a particular situation in the child’s life. Clinical judgment is important in assessing the effect of the core ADHD symptoms, academic achievement, classroom performance, family life, social skills, independent functioning, self-esteem, leisure activities, and self-care. Asking the parent or teacher, “Do you think that Billy’s inattention and hyperactivity are causing his poor school performance or social problems?” is another piece of information that can help to establish the presence of functional impairment.

The American Academy of Pediatrics published an evidenced-based practice guideline for the diagnosis of school-aged child with attention deficit hyperactivity disorder.17 It is the gold-standard for primary care clinicians, and is shown in Table 84-3 as a scale that ascertains coexisting psychological disorders, learning disabilities, environmental stressors, and impairment. Items from these scales are reviewed in eTable 84.2.

A complete physical examination should include visual acuity; an audiogram; measurements for height, weight, head circumference, and blood pressure; and a neurologic examination. Dysmorphic features that suggest a syndrome with a high prevalence of ADHD (eg, fetal alcohol syndrome, fragile X syndrome) should be assessed. A minority of children with ADHD display signs of inattention, hyperactivity, or impulsivity in a medical office setting, and a diagnosis of ADHD should not be made contingent on whether or not these behaviors are observed in a medical environment.

Neurodevelopmental tasks assess a variety of components of neurologic function that are associated with attention and learning. They may provide a clue to a specific learning disability or language disorder. The mild stress induced by the task may be associated with hyperactivity (fidgetiness, getting up from seat, constant motion, etc) and inattentiveness (distractibility, not on task, daydreaming), signs that emerge in the office only during this part of the examination (see eTable 84.3).

Another method to engage a child during the evaluation is to ask him or her to draw a picture of “your family doing something.” Kinetic family drawings within the context of a pediatrician’s office can be valuable in several ways. They may reduce the stress of the visit by giving the child something enjoyable to do while the clinician and parent talk. The drawing can be used to assess fine-motor and visuoperceptual skills that are important in learning. Finally, the drawings provide an opportunity to open new areas of communication with both parents and children. Ask the child to tell about the drawing, and ask specific questions about people or objects in the picture. Then give the parent an opportunity to comment. One cautionary note: Do not overinterpret the drawings; they are best used in pediatric practice as an alternative source for communication.22

Similar to other chronic conditions, the diagnosis of attention deficit hyperactivity disorder is often not accomplished in a single visit to a primary care clinician. Data gathering, clinician interview and examination, and summary of results requires at least 60 minutes. An adaptation to primary care is to schedule 3 visits of 20 to 30 minutes each in order to accurately assess each patient.

Effective treatments for children and adolescents with attention deficit hyperactivity disorder (ADHD) include medication, behavior modification, and a combination of both therapies. Educating the family (including the child and caregivers) about ADHD is the first step to insure a good outcome. A discussion of the condition should include an understanding of ADHD as a biologic condition (“brain based”), not a result of poor parenting or intentional misbehavior, that is amenable to change through medication and behavior modification and is responsive to accommodations in the home and classroom. Most parents appreciate an empathic clinician who makes a clear statement about how difficult it must be to raise a child with ADHD and clarifies her role as the coordinator of care among the family, school, and medical office. The American Academy of Pediatrics clinical guideline on the treatment of the school-aged child with ADHD emphasizes this approach.19eTable 84.4 presents the complete guideline. Salient clinical points include the following:

• Recommendation 1: Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition. The chronic disease model of care includes parent/patient education, continuous availability for questions and counseling, coordination with other services, setting specific goals, and monitoring.
• Recommendation 2: The treating clinician, parent, and child, in collaboration with school personnel, should specify appropriate target outcomes to guide management. For the child with ADHD, target outcomes should reflect key symptoms the child manifests and the specific impairments these symptoms cause. Impairments and problem behaviors differ greatly from child to child.
• Recommendation 3: The clinician should recommend medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD.
• Recommendation 4: When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and the presence of coexisting conditions.
• Recommendation 5: The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring of the ongoing treatment plan should be directed to target outcomes and adverse effects of medication by obtaining specific information from parent, teacher, and the child.

Medication

Methylphenidate, amphetamine, and atomoxetine are approved by the Federal Drug Administration (FDA) for use in children and adolescents on the basis of evidenced-based safety and efficacy studies. Other medications with limited randomized controlled studies and not with FDA approval include bupropion, clonidine, guanfacine, and tricyclic antidepressants.

Stimulants

The most widely prescribed medication for children and adolescents with attention deficit hyperactivity disorder (ADHD) are the psychostimulants methylphenidate and amphetamine.20 Over 200 scientific studies support their value for children with ADHD. Stimulants act on dopamine and norepinephrine brain pathways that are critical in frontal lobe functioning by increasing the inhibitory influences of frontal lobe activity. They also regulate core ADHD behaviors through their action in the striatum and cerebellar vermis by binding to the dopamine transporter, making synaptic dopamine more available.

Stimulant medications are now available in short-acting (3–6 hours), intermediate-acting (6–8 hours), and long-acting (10–12 hours) preparations (see Table 84-4). Behavioral effects are seen within 30 to 45 minutes. The available short-acting stimulants are similar. Intermediate-acting methylphenidate is released slowly through a wax-matrix system, such that it begins to act about 90 minutes after ingestion (as opposed to 30 minutes for immediate-release methylphenidate) and reaches its peak benefit at 3 hours with a gradually decreasing plasma concentration. A 20-mg slow release methylphenidate is less effective than the equivalent dose of 10 mg methylphenidate twice daily. Extended-release Methylin and slow-release methylphenidate have equivalent pharmacokinetics and pharmacodynamics. Extended-release Metadate is also designed to parallel the pharmacokinetics of slow-release methylphenidate. Long-acting Ritalin is another new preparation that exerts behavioral and cognitive effects for about 8 hours. It uses bead technology (“sprinkles”) and has a biphasic release pattern (50% immediate release and 50% delayed-release beads). The development of long-acting stimulants was a response to problems observed by parents, teachers, and clinicians. Gaps in the behavioral effects of multiple daily doses of immediate-release stimulants occur at some of the least structured times of the day (bus rides, lunch time, and recess). In addition, many children feel embarrassed to take medication in school under the scrutiny of the school nurse and their peers, and compliance then becomes an issue. Homework time remains uncovered unless an afternoon dose is prescribed. Osmotic-release methylphenidate (Concerta) is delivered as an initial bolus followed by a progressive 8-hour release of methylphenidate (22% immediate release and 78% extended release) by an osmotic pump mechanism, maintaining a rising methylphenidate level through the day. It is as efficacious as thrice-daily dosing of immediate-release methylphenidate. Metadate CD (methylphenidate hydrochloride) is also a preparation available in sprinkles, with a biphasic release pattern (30% immediate release and 70% extended release). Extended-release Adderall is designed to parallel a 4-hour, twice-daily regimen of Adderall. It is available in a capsule with sprinkles, and its delivery is similar to long-acting Ritalin with 50% immediately released and 50% gradually released after 4 hours.

There is little evidence of the development of tolerance to stimulants and little evidence of the need to increase doses to get the same behavioral response, even as children grow. While behaviors are affected rapidly following a dose of stimulants, increased attention to subjects like math may take up to 1.5 hours after administration. Stimulants work at school to increase on-task behavior and decrease interrupting and fidgeting. At home, they improve on-task behavior, parent-child interactions, and compliance. They also improve peer perceptions of social standing and increase attention while playing sports.

The most frequent side effects to stimulants include stomachaches, and headaches (these symptoms typically resolve spontaneously after the first week), decreased appetite, difficulty with sleep initiation, and jitteriness. Motor tics may also occur in some children. These side effects often occur early in treatment, are usually mild, and can often be ameliorated by alterations in dose, timing, or change in stimulant medication. There are no differences in potential side effects among stimulants. A child or adolescent with a specific side effect on one stimulant medication may not experience it on another. While there is no evidence that chronic use of stimulants causes significant impairment in adult height, the 3-year follow-up MTA study (discussed later in this chapter) reported that growth in newly treated children averaged 2.0 cm less in height and 2.7 kg less in weight than growth in unmedicated children. The reduced growth occurred mostly in the first year of treatment and was absent in the third year.25 While stimulant medication is effective for preschool children with attention deficit hyperactivity disorder, they experience more frequent and more intense side effects.22

There is no evidence that stimulant treatment leads to an increased risk for substance abuse. In fact, the use of stimulants has been associated with a reduction in risk for subsequent drug and alcohol use disorders.23 The use of stimulants is contraindicated in cases of previous sensitivity, glaucoma, or drug abuse and in patients who are taking a monoamine oxidase inhibitor or who are actively psychotic. Stimulants are not contraindicated in cases of tics, and stimulants do not appear to lower the seizure threshold. The controversy about an association between the use of stimulant medication and sudden cardiac death is under investigation.

Nonstimulants

Stimulants remain the first-line psychopharmacologic treatment for ADHD. It is estimated that at least 80% of children will respond to one of the stimulants if they are used in a systematic way. Nonstimulants remain an option for children and adolescents for whom stimulants are not effective, cause significant adverse side effects, or exacerbation of other coexisting disorders or where nonstimulants are a preferred option for treating ADHD and a coexisting disorder with a single medication (see Table 84-5).

Atomoxetine (Strattera) is a nonstimulant medication approved for use in school-aged children, adolescents, and adults with ADHD. It is a norepinephrine reuptake inhibitor and blocks the presynaptic norepinephrine transporter in the prefrontal cortex. It is found to have a beneficial effect on children and adolescents with ADHD and to have efficacy similar to that of stimulants. Atomoxetine may provide symptom relief during the evening and early morning hours. Motor and verbal tics associated with atomoxetine have not been reported. In addition, atomoxetine may have less effect than stimulants have on delayed sleep onset. The side effects are similar to those of stimulants, but atomoxetine may be associated with more fatigue and nausea than are stimulants. Atomoxetine may be effective in children with ADHD and coexisting anxiety. The initial studies of atomoxetine reported a 2-fold increase compared to control subjects in suicidal ideation, usually occurring in the first month of treatment; actual suicide attempts were not increased.

The tricyclic antidepressants include imipramine, desipramine and nortriptyline. They work by inhibiting norepinephrine reuptake. Desipramine produces a response rate for ADHD symptoms comparable to that of stimulants, as well as fewer tics in patients with coexisting tics and Tourette disorder, but there are associated cardiac side effects. The use of tricyclic antidepressants is limited by their cardiac side effects, the need for cardiac monitoring, and the possible association with sudden death in a small number of 6- to 14-year-old patients taking desipramine. Bupropion is an aminoketone antidepressant with both noradrenergic and dopaminergic properties. It is found to improve ADHD with coexisting depression. Improvement in core ADHD behaviors on bupropion is generally not as complete as improvement with stimulants.

Clonidine and guanfacine are presynaptic, central-acting α-2-adrenergic agonists that work by affecting norepinephrine discharge rates in the locus ceruleus, which may indirectly affect dopamine. Although there is modest evidence from open trials, there is no clear research support for their use as an ADHD medication. Clonidine has been used clinically to counteract the stimulant side effect of delayed sleep initiation and for children and adolescents with ADHD who also have significant aggressive behavior. Guanfacine may also be effective in children with ADHD, tics, and aggression.

The 3 medications approved by the FDA for treating children and adolescents with ADHD have a similar efficacy. Seventy percent of patients on these medications will experience a significant decrease in core ADHD behaviors. Among those who do not respond sufficiently or who develop intolerable side effects, about half will respond to one of the other medicines. There is variability in dose response among patients; it is recommended to begin with a small dose and titrate upward every 2 to 4 weeks to reach the optimal effect while monitoring side effects. Most children are treated with medication daily, including on weekends.24

Behavioral Treatment

Effective psychosocial treatment for ADHD employs the principles of behavior modification and social learning theory, which emphasize contingency management and shaping children’s behaviors through observing and modeling appropriate behaviors, attitudes, and emotional reactions of others. These principles have been used to train both parents and teachers in behavior management with good evidence for effectiveness among children with ADHD.

The goals of parent training are to help parents learn to achieve consistent and positive interactions with their children, gain a better understanding of what behaviors are developmentally normal, cut down on negative interactions such as arguing or constantly having to repeat commands, provide appropriate consequences for their child’s behaviors and to become more empathic to their child’s viewpoint, and help children to improve their abilities to manage their own behaviors.25 Parent training can be done as in individual sessions for parents or in groups. Parents learn to conceptualize “discipline” as teaching self-control rather than as punishment. They are taught what behaviors can be reinforced by praise and extinguished by active ignoring as well as appropriate punishments for intolerable behaviors.30 Parents are taught how to

• deliver and follow through on clear commands.
• shape behaviors in gradual increments.
• use daily contingency charts (star or “happy face” charts).
• establish procedures such as “time-out,” token economies (earning rewards and privileges contingent on performing desired behaviors), and response cost (losing tokens or privileges for noncompliance).

The same principles of clinical behavior therapy have been used effectively in training teachers in classroom behavior management. Once parents and teachers have been trained, they can learn to implement systems that provide continuity from home to school, such as a daily behavior report card that can be used to report on target behaviors that are being monitored daily and allow parents to provide either positive reinforcement or consequences at home (see eTable 84.5).

Collaborative problem solving arises from the same principles as parent training but focuses more on helping adults and children become proficient at resolving problems in ways that avoid the disruptive behaviors that often occur when children with ADHD have a coexisting oppositional defiant disorder or conduct disorder. Through this cognitive behavior approach, parents learn to pursue their expectations regarding their child’s behavior without increasing the likelihood of oppositional outbursts and without resorting to imposing their will or abandoning their expectations. Social skills training and family therapy may be useful in some situations, but there is limited evidence for efficacy as a treatment for ADHD.

Behavioral interventions alone are often insufficient for effective treatment of core ADHD behaviors. For parents who are hesitant to use prescribed medications to treat their child, initiating treatment with a behavior modification program should be supported with frequent monitoring.

Combined Medication and Psychosocial Treatments: The MTA Study

The short-term benefits of medications and behavioral therapy have been well established. Few studies have also looked at medication treatment and behavioral therapies in head-to-head comparisons. The National Institute of Mental Health Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) clinical trial followed 579 children, ages 7 to 9, in 6 sites over a 14-month period. The children were randomly assigned to 1 of 4 groups: (1) intensive medication management (MedMgt), (2) intensive behavioral treatments (Beh), (3) combined MedMgt and Beh (Comb), and (4) study diagnostic procedures and then routine care in the community (CC). Medication management was initiated with methylphenidate, using alternative stimulants or nonstimulants for those who did not respond to methylphenidate.14 The intensive behavioral treatments included 8 sessions of parent training with concurrent teacher consultation and an intensive child-focused treatment consisting of an 8-week, daily summer school treatment program. In addition, a school-based treatment program was carried out involving 10 to 16 teacher behavior management consultation sessions, 12 weeks of a part-time paraprofessional/aide working with the child, and daily home/school report cards.

For the core symptoms of ADHD (inattention, impulsivity, hyperactivity), the MTA medication management was superior to routine care in the community despite that over two thirds of the children receiving care in the community were being treated with stimulant medication. The Comb treatment did not yield significantly greater benefits than the MedMgt alone for the core symptoms of ADHD, but outcomes in the Comb group could sometimes be achieved at lower medication doses than the group that received MedMgt alone. Combined treatment was superior to MedMgt alone for many non-ADHD domains of functioning, including oppositional or aggressive symptoms, symptoms of depression and anxiety, parent-child relations, and reading achievement. Based on a composite of parent and teacher ratings, 68% of the Comb children “normalized” by the end of the 14-month study, as compared to 56% of the MedMgt alone, 34% of the Beh management alone, and only 25% of the care in the community children. The benefit seen in the medication groups persisted at 24 months but not at 36 months.27 For clinicians, an important implication of the study results is that systematic monitoring with a plan for follow-up office visits is a critical component of successful treatment for children with ADHD.

In the MTA study, the benefits of medication were no longer present at the 36-month follow-up (84% of the original cohort). Although all groups showed improvements in attention deficit hyperactivity disorder (ADHD) symptoms and overall functioning, no treatment group differed significantly on any outcome measure, including rates of ADHD diagnosis and coexisting behavioral conditions. Compared with the 14-month follow-up, the percentage of children who took medication more than 50% of the time decreased in the medication groups (from 91% to 71%), increased in the behavior management alone group (from 14% to 45%), and remained the same in the community treatment group. Regardless of original treatment assignment, factors associated with worse outcomes at 36 months were initial symptom severity, male gender, oppositional/disruptive behaviors, public assistance, and ADHD in a parent.

The loss of a treatment effect after 36 months from mediation alone or medication plus behavioral management in school-aged children with ADHD is disappointing. Possible reasons for the decline in benefits include parent-initiated changes in medication management, age-related decline in ADHD symptoms, and cessation of systematic monitoring of medication and behavior management. The authors note that the improvements in all 4 groups at 36-months may reflect attention from study participation or natural waning of symptoms among children with severe ADHD symptoms. Results of the MTA study are limited by the absence of a control group and the use of short-acting stimulant mediations (long-acting formulations were not available).

Comprehensive pediatric care for children and adolescents with ADHD is achieved when the clinician communicates effectively with the school. With the parents’ approval, it begins with informing the teacher about the diagnosis and treatment. A monitoring system for transferring information to the clinical office about the patient’s school behavior and educational achievement should be in place. Communication works best when parents partner with the school and the clinician.27

United States laws support school interventions for children with ADHD. For mild cases, section 504 of the Rehabilitation Act requires that a school provide classroom accommodations to improve learning. These accommodations include preferential seating, reduced assignments and homework, and parent-teacher collaboration in formulating a classroom behavioral program. For more severe cases, the Individuals with Disabilities Education Act (IDEA) requires schools to provide comprehensive educational testing followed by an individual education plan (IEP) with measurable behavioral and academic achievement goals. Periodic monitoring and reassessment is incorporated into the IEP. The daily report card is an effective method to monitor classroom behaviors. Parents and teacher decide on 3 to 5 behaviors that impair success in school. Each behavior is monitored daily, and a report is sent home with the child. The daily report card is attached to an award system (eg, privileges or prizes) to encourage compliance. This system allows for frequent, immediate feedback that can be motivating to the child, parents, and teacher. The daily report card with directions can be downloaded from http://ccf.buffalo.edu/pdf/daily_report_ card.pdf.28

Many parents seek complementary or alternative therapies either alone or in combination with evidenced-based medication and behavioral management.29 Most of these treatments have not undergone randomized controlled trials and cannot be recommended. Some alternative therapies have side effects and may be harmful to children; others are safe. For the parent who is set on trying an alternative treatment or who has already found it helpful, many clinicians incorporate the alternative plan with a proven treatment. If the treatment is not dangerous and does not interfere with the clinician’s management strategies, it is best not to alienate a parent because the goal should be one of partnership in doing what is best for the child. Alternative therapies are listed in eTable 84.6.

The long-term outcome for children with ADHD is related to the severity and type of symptoms, coexisting conditions (eg, mental health disorders and learning disabilities), intelligence, family situation, and treatment. About 15% to 20% of school-aged children no longer meet criteria for ADHD by adolescence, while 70% to 85% have symptoms persisting into adolescence. Hyperactivity diminishes, but impulsivity and inattention often persist. Peer interactions are often immature, and sleep disturbances are common.30,31

Adolescents with ADHD have more driving tickets and more motor vehicle accidents. They also initiate intercourse sooner and with more sexual partners, use birth control less, and have higher rates of sexually transmitted diseases and teenage pregnancy. Teenagers with ADHD smoke at a younger age and have a higher prevalence of smoking. Those with conduct disorders are more at risk for substance abuse. The risk of substance use disorders over the life span is up to twice as great in individuals with ADHD. Adolescent girls with ADHD have more depression, anxiety, poor teacher relationships, an external locus of control, and impaired academic performance compared to their peers.32

Compared to boys with ADHD, they are more impaired by self-reported anxiety, distress, depression, and an external locus of control. ADHD is associated with academic underachievement in reading and impaired school functioning.

Children and adolescents with ADHD have greater rates of absenteeism, grade retention, and school dropout. They are more frequent users of school-based services and have increased rates of detention and expulsion. Coexisting learning disabilities and psychiatric disorders add to the magnitude of poor school outcomes. Treatment with stimulant medication is associated with better long-term school outcomes, although medication treatment does not necessarily improve standardized test scores or ultimate educational attainment.33 Stimulant treatment is also associated with a significant decrease in the rate of substance abuse disorder.

Studies suggest that adults with ADHD have lower socioeconomic status, more work difficulties, and more frequent job changes as well as fewer years of education and lower rates of professional employment. Adults with ADHD also report more psychological maladjustment, more speeding violations and suspension of driver licenses, poorer work performance, and more employment changes due to either quitting or being fired.34