Attention Deficit Hyperactivi... Health Article

Diagnosis

Well-established and research-validated clinical guidelines for the diagnosis of ADHD are provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The DSM-IV criteria for diagnosis include multiple symptoms of inattention or hyperactivity-impulsivity that persist for at least six months across multiple settings such as school or work and home. These symptoms must exist to a degree that is inconsistent with other individuals at the same developmental level. Some of the hyperactive-impulsive or inattentive symptoms must have been present before the age of seven years. The symptoms must not occur exclusively during the course of another developmental disorder, schizophrenia, or psychotic disorder and should not be better accounted for by any other mental disorder. Although fidgeting and inattentiveness are common childhood behaviors, the DSM-IV criteria indicate a diagnosis of ADHD for children in whom such behavior occurs so frequently that it produces continuing, pervasive dysfunction. A diagnostic evaluation requires histories from multiple sources, a medical evaluation of general and neurological health, and a full cognitive assessment. In practice, the diagnosis is often made in individuals who meet only some of the criteria established by the DSM-IV.

Treatment and management

The American Academy of Child and Adolescent Psychiatry (AACAP) established treatment as the support and education of family members, appropriate school placement, and pharmacology. Both pharmacological treatment and psychosocial treatment such as behavioral modification may be used.

Pharmacological treatment

Pharmacological treatment with psychostimulants is the most widely researched treatment for ADHD. This treatment has been used for childhood behavioral disorders since the 1930s. Psychostimulants are highly effective for approximately 75–90% of children with ADHD. There are four psychostimulant treatments that have been demonstrated by hundreds of randomized controlled trials to consistently reduce the primary symptoms of ADHD: methylphenidate, dextroamphetamine, pemoline, and a mixture of amphetamine salts. These medications are only effective for one to four hours and so must be administered with the individual's school or work schedule. The medications are most effective for symptoms of hyperactivity, impulsivity, inattention, and the associated features of rebelliousness, aggression, and argumentativeness. They promote improved overall performance. Individuals who do not respond to one stimulant may respond to another. Individuals in whom psychostimulant treatment has been indicated require an assessment to determine which, if any, psychostimulant may improve their symptoms with the least side effects. According to guidelines established by the AACAP, stimulants are usually started at a low dose and adjusted weekly. According to the NIMH, the stimulants most commonly prescribed for ADHD include methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and amphetamine (Adderall).

In December 1999, the National Institutes of Mental Health (NIMH) began an ongoing Multimodal Treatment Study of Children with ADHD (MTA) that was one of the largest clinical studies ever conducted by the National Institutes of Health. The MTA utilized 18 nationally recognized authorities in ADHD at six different university medical centers and hospitals to evaluate the leading psychosocial and pharmacological treatments for ADHD. The MTA indicated that long-term combination treatments and pharmacological treatment alone are both significantly superior to intensive behavioral treatments and routine community care in reducing most ADHD symptoms. Combined treatment was equal in efficacy to medication alone in modifying the core ADHD symptoms of inattention, hyperactivity, impulsivity, and aggression. Combined treatment was superior to medication alone in treating anxiety symptoms and in improving academic performance and social skills. Combined treatment also allowed children to be successfully treated with lower doses of medication. The NIH ADHD Consensus Conference of 1998 reported that several decades of research have proven behavioral therapies to be very effective. However, the NIMH MTA study demonstrated that carefully monitored medication management is even more effective for the treatment of ADHD symptoms.

Some common side effects of psychostimulant therapy include insomnia, decreased appetite, stomachaches, headaches, and jitteriness. There may be rebound activation (a sudden increase in attention deficit and hyperactivity) after medication levels drop. Most side effects are mild, diminish over time, and respond to changes in dosage. There is no evidence that height or weight is affected by psychostimulant treatment, but precautionary monitoring of growth for children taking stimulants is still recommended. Atomoxetine (Strattera) is the only nonstimulant medication approved for the treatment of ADHD. Atomoxetine has effects on the neurotransmitter norepinephrine, which may also play a role in ADHD. Research contrasting atomoxetine with psychostimulants is being implemented. As of 2004, more than 70% of children with ADHD given Strattera have significant improvement in their symptoms.

Between 10–30% of individuals with ADHD do not respond to stimulant medication. For such non-responders and those who cannot tolerate the side effects, there are other useful medications. The antidepressant bupropion has been shown to be effective in a lower percentage of patients than stimulant medication. Certain types of antidepressants are sometimes used to augment psychostimulant treatment.