Nejm 2006;354:2637 (adults); 2005;352:165; Jama 2004;292:619 (adults)

Cause:Genetic? Multifactorial? 25% of cases have h/o ADHD in a parent

Pathophys:Perhaps metabolic dysfunction in the brain. Decreased glucose metabolism in brain areas associated with attention and motor activity by PET (Nejm 1990;323:1361). Neurotransmitter imbalance? Sugar or aspartame in diet does not correlate w behavioral worsening (Nejm 1994;330:301). Worsened by psychosocial deprivation.

3-5% of adults and children; male/female = 2:1 in children, 1:1 in adolescents, 1:2 in adults; high (50%) prevalence in special education students (Am J Publ Hlth 1998;88:881), and in adults w addictions; motor vehicle violations and life failures

Associated with lead burden, poverty, familial chaos, Tourette’s syndrome (60% of Tourette’s have ADHD), and positive family hx

Sx:Inattention, hyperactivity, impulsivity, aggression. Trouble with peers, parents, and/or school; underachievers in school from poor self-esteem (see Table 13.1).

Si:Short attention span; poor inhibitory control; aimless restlessness

Table 13.1 Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder^*.

1. Either (1) or (2):
1. Inattention: 6 (or more) of the following symptoms of inattention have persisted for at least 6 mo to a degree that is maladaptive and inconsistent with developmental level:
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. Often has difficulty sustaining attention in tasks or play activities
3. Often does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in workplace (not due to oppositional behavior or failure to understand instructions)
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools)
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities
2. Hyperactivity–impulsivity: 6 (or more) of the following symptoms of hyperactivity–impulsivity have persisted for at least 6 mo to a degree that is maladaptive and inconsistent with developmental level:
1. Often fidgets with hands or feet or squrims in seat
2. Often leaves seat in classroom or in other situations in which remaining seated is expected
3. Often runs about or climbs excessively in situations in which its is inappropriate (in adolscents or adults, may be limited to subjective feelings of restlessness)
4. Often has difficulty playing or engaging in leisure activities quietly
5. Is often "on the go" or often acts as if "driven by a motor"
6. Often talks excessively
7. Often blurts out answers before questions have been completed
8. Often has difficulty awaiting turn
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)
2. Some hyperactive–impulsive or inattentive symptoms that caused impairment were present before age 7 yr
3. Some impairment from the symptoms is present in 2 or more settings (eg, at school [or work] and at home).
4. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.
5. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorders, or a personality disorder).

* Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,code based on type: 314.01 Attention Deficit/Hyperactivity Disorder, Combined Type: if both criteria A(1) and A(2) are met for the past 6 months; 314.00 Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if criterion A(1) is met but criterion A(2) is not met for the past 6 months; 314.01 Attention Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: If criterion A(2) is met but criterion A(1) is not met for the past 6 months. Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified.

Reproduced with permission from Okie S. ADHD in Adults. New Eng J Med 2006;354:2637. Copyright 2006 Mass. Med Soc., all Rights Reserved.

Onset usually before school age at least before age 7 yr; 8-10% (Jama 1995;273:1871) continue to have problems in adulthood

Learning disabilities in 25%; conduct (lying, stealing, fights) or oppositional disorders (disobedience, defiance, rule breaking) in 40%, but only if other comorbid dx’s; depression/bipolar d/o. Parental discord/divorce

r/o abuse/neglect, sleep d/o, lead toxicity, learning disability, petit mal seizures, substance abuse, depression, PTSD

Rx:

(Nejm 2005;352:165)

Very complicated teacher/parent/child psychosocial dynamics usually present; best strategy when requested to prescribe meds is to request a school “individual education plan” evaluation, which will pay for a multidisciplinary clinic eval and result in less unnecessary medication rx (S. Sewall 10/95)

Behavioral modification strategies not clearly helpful (Nejm 1999;340:780). Training in social skills. Remedial education. Parental support systems; sugar intake does not increase hyperactivity in normal or ADHD child (Jama 1995;274:1617)

Medications (Med Let 2001;43:83; Nejm 1999;340:780), clearly help short-term (Jama 1998;279:1100), useful into adulthood, but black box warning re cardiovascular risks (Nejm 2006;354:1445); AHA now recommends EKG screening and monitoring BP yearly in all kids taking stimulants; response to meds does not prove dx

• 1st:
• Methylphenidate (Ritalin) 2.5-10 mg po tid-qid, or as slow-release tabs (Ritalin SR, Concerta, and others) at 10-18 mg po qd under age 10 yr and 20-36 mg po qd over age 10 yr, $30/mo. Or as dexmethylphenidate (Focalin) (Med Let 2002;44:45) 10 mg po bid 4 h apart; $55/mo
• 2nd:
• Dextroamphetamine (Dexedrine) 2.5-5 mg po tid-qid or as qd spansules; $20/mo Or as racemic amphetamine mixture (Adderall)
• 3rd:
• Atomoxetine (Strattera) (Med Let 2003;45:11) 1.2 mg/kg up to 100 mg po qd; a nonstimulating selective norepinephrine reuptake inhibitor, usually not as effective as the older drugs but can be if patient has intolerable side effects or fails to respond to multiple stimulants, so use if they fail (Med Let 2004;46:65); $100/mo
• 4rd:
• Bupropion (Wellbutrin) 100-200 mg SR bid in adults; not approved for children; lowers seizure threshold
• Last:
• Pemoline (Cylert) 5-6 mo po qd; rarely used because of unpredictable severe hepatotoxicity even if safely used for yrs; get consent and q 2 wk LFTs; $40/mo
• Other adjunctive meds:
• Antidepressants (tricyclics) like desipramine (Norpramin) but potential sudden death and other cardiac toxicity esp when used w stimulants; or
• Clonidine po or patch (Med Let 1996;38:109); but also has sudden death risk, as well as OD potential in younger sibs w even one 0.1-mg pill