/publications/issue/2004/2004-11/2004-11-4740

Management of Attention-Deficit/Hyperactivity Disorder

Author: Lauren S. Schlesselman, PharmD

Attention-deficit/hyperactivity disorder, or ADHD, is the most commonly diagnosed behavioral disorder in children and teenagers. According to the Centers for Disease Control and Prevention (CDC), nearly 2 million children in the United States have ADHD. A survey by the CDC also found that parents of 7% of children aged 6 to 11 years have been told by a physician that their child has ADHD. The disorder affects boys 3 times more often than girls. ADHD also is receiving more attention as a condition affecting adults, with an estimated 2% of adults afflicted.

The exact cause of ADHD is unknown. Although a specific gene has not been identified, the condition is known to run in families. Studies show that, if one twin has ADHD, the other twin commonly has symptoms as well. Many parents do not recognize the symptoms in themselves until their children are diagnosed with ADHD.

What Are the Symptoms?

The symptoms of ADHD are classified into 3 groups: inattention, hyperactivity, and impulsiveness.

Inattention

People with this ADHD symptom often have difficulty staying focused, paying close attention to details, or organizing tasks. They do not seem to listen when addressed directly and are easily distracted by external stimuli. They often lose items and are forgetful.

Hyperactivity

Children with hyperactivity may fidget and squirm or leave their seat. They tend to run and climb excessively, as if "driven by a motor." They also may talk excessively. Adults with ADHD feel restless and fidgety. They are unable to enjoy reading or other quiet activities.

Impulsivity

Children prone to impulsiveness often blurt out answers before the question is completed and have difficulty waiting their turn. They often butt into conversations. As adults, these people may have difficulty maintaining relationships or keeping a job.

Some people with ADHD exhibit primarily inattentive symptoms, whereas others mostly display hyperactivity and impulsiveness. The majority of people with ADHD have symptoms from all 3 categories. Girls are more likely to have symptoms of inattention than hyperactivity.

To meet the criteria for ADHD, the individual must have experienced inattentive or hyperactive?impulsive symptoms that caused impairment before 7 years of age. These symptoms must be present in 2 or more settings, typically school/work and home, and clearly impair social, academic, or occupational functioning.

The symptoms of ADHD are more easily identified in children during their elementary school years. Before that age, many of the symptoms are considered age-appropriate during various stages of development. In a controlled setting, such as school, the symptoms of inattentiveness, hyperactivity, and impulsiveness become obvious. Children with ADHD often are disruptive to the class and have difficulty focusing.

How Is ADHD Diagnosed?

If parents are concerned that their child is showing symptoms of ADHD, the pharmacist should refer them to a doctor for a complete medical examination. The pharmacist may recommend a pediatrician, psychologist, neurologist, or child psychiatrist.

The first step involves performing a full physical examination, including screenings of vision, hearing, and verbal and motor skills. The physician also may check for low red blood cell counts, thyroid disease, and lead poisoning. A complete neurologic examination should be performed. These checks are necessary to rule out other health or psychological problems.

Next the physician will gather information from the parents, other family members, and teachers. The physician also will want to interview the child and observe his or her behavior. A social and family history is obtained. Evaluations to assess intelligence, aptitude, and personality traits are completed by the parents and teachers. This information gathering is necessary to assess whether the child meets the criteria for ADHD listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

How Is ADHD Treated?

Currently there is no cure for ADHD, but treatment can control the symptoms. Treatment can involve behavior modification and medications.

Behavior Modification

Although using both behavior modification and medications may prove more effective, some parents are concerned about having their child take medications and prefer to use behavior modification alone. Only a small percentage of children will benefit from behavioral therapy alone, however. This therapy involves learning techniques to control behavior. Parents will learn to set a routine and make instructions simple and specific, along with rewarding good behavior promptly. They also will learn to promote the child's self-esteem by recognizing and promoting his or her strengths. Often behavioral therapy is combined with emotional counseling, because children with ADHD tend to have low self-esteem.

Medications

The use of medications to treat ADHD is increasing. Researchers from the Center for Health Care Policy and Evaluation, studying prescriptions during a 5-year period, found that the use of stimulants for this disorder had increased by 26% and the use of antidepressants by 62%.

Stimulant medications?such as amphetamine, dextroamphetamine sulfate, and methylphenidate?are the most prescribed treatments. Although these medications currently are approved only for use in children, they have been shown to be effective in adults. Adults may prefer the longeracting formulations that allow for once-daily administration.

Parents should expect to see a sudden and dramatic improvement in their children's behavior after initiating therapy. Doses usually are started low and are titrated to meet the desired outcomes. If the child does not respond to one agent, he or she usually will respond to another one. The pharmacist should inform the parents that side effects may occur early in therapy but tend to disappear. The most common adverse effects include decreased appetite, sleep disturbances, headache, and jitteriness.

The use of atomoxetine is rapidly increasing, because it is not a stimulant and has not been associated with drug dependence. It is the only medication approved for use in children and adults. The exact mechanism of action remains unknown, but atomoxetine is believed to regulate norepinephrine, a chemical responsible for activity and attention. Adverse effects include nausea, decreased appetite, and dizziness.

Other medications, including antidepressants and antihypertensives, often are used to control symptoms if other medications are ineffective. Many children with ADHD also have other psychological conditions that benefit from antidepressants in combination with stimulant therapy. Some antihypertensives, such as clonidine and guanfacine, help control aggressive and impulsive behaviors.

The pharmacist should remind parents to give all medications on a consistent schedule. If doses will be given at school, the pharmacist should advise the parents to send only a limited quantity to school to make sure that they will not run out of medication at home. The parents should work with the physician to closely monitor the child for desired outcomes and adverse effects.

What Are the Desired Treatment Outcomes?

Although it cannot cure the condition, treatment should help control symptoms, including reducing disruptive behavior and improving attention span. Parents also should notice an improvement in the child's relationships with family members and friends, along with improved self-esteem. With treatment, the child's performance in school should improve, including the quality of work, ability to work independently, and ability to complete tasks.

What Role Can the Family Play?

Because ADHD can add stress to the household, family members can help by learning about the condition. The pharmacist should provide parents with information about medications, including monitoring and drug interactions. Many Web sites contain further information about the condition and various treatment options (Table). Support groups also are available for families dealing with ADHD.

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In addition, pharmacists can advise parents to learn what rights are federally mandated for children with ADHD. As of the 1997 reauthorization of the Individuals with Disabilities Act, some children with ADHD qualify for special education services, under the category of "Other Health Impaired." For children who qualify, an individualized education plan is designed by school administrators, teachers, psychologists, and parents.

Parents should understand that symptoms of ADHD in their children often continue into adulthood. With appropriate treatment, however, ADHD does not need to be a life sentence.

Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.

For a list of suggested reading, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@mwc.com.