ADHD for Primary Care
Several times in clinical practice, I've experienced parents or grandparents, come into the office with concerns that their child or grandchild has problems with focusing and behavior.
They will often display concern about how their teacher, extracurricular leader, or themselves state that they need to be on medication for ADHD.
Today we will discuss the evaluation, diagnosis, and treatment options for patients with ADHD.
Remember the old saying: “not all that wheezes is asthma”?
Well, in this instance, remember not all children who seem to be hyperactive, have behavioral concerns, and/or attention issues have ADHD.
Other psychiatric diagnoses must be ruled out in these instances, and other times, a child may just be a normal child in some instances as well.
What Causes ADHD?
Attention-deficit hyperactivity disorder (ADHD) has been found to be the most common behavioral disorder in childhood. The prevalence of cases of ADHD has been increasing annually by three percent between 1997 and 2006.1 A recent study found that up to 11 percent of four to seventeen-year-olds have had an ADHD diagnosis, 8.8 percent of children currently have the diagnosis, and 6.1 percent are now being treated for ADHD.1
The etiology of ADHD is not completely known at this point; however, neurologic factors and genetics seem to play important roles. ADHD is seen to be two to eight times more common in those patients who have a sibling or parent with the diagnosis as well.
Additionally, ADHD has been seen to be associated with deficits in brain structure and neuronal functionality, which appears to be related to the severity of the disease.
The diagnosis of ADHD should be considered for patients who are four years or older with concerns of distractibility, impulsiveness, poor attention, inadequate academic performance, or behavioral problems at home or at school.
More boys are found to have ADHD overall; however, the inattentive subtype is more common in girls. No evidence currently supports screening for ADHD in children at well-child visits, but healthcare providers should focus on concerns of guardians about performance in school or behavioral concerns.
The evaluation of ADHD in children includes a full history and physical examination, review of information in both home and school or social settings, and application of the DSM-5 criteria.
The healthcare provider should inquire about the duration and presence of ADHD symptoms and the degree in which they impair the patient from family and school activities. The patient should also be evaluated for other conditions that may mimic or exist along with ADHD.
An example may include sleep problems which can affect daytime behavior and can contribute to mild ADHD cases. One-third of patients with ADHD will be found to have a comorbid diagnosis that is contributing to their symptoms.
Validated behavior rating scales should be used across multiple different settings to collect data. These include teachers, parents, and self-reporting for older children. The healthcare provider’s direct observation of fidgeting, distractibility, interactions with others, and hyperactivity may be helpful as well. However, the lack of ADHD symptoms in office does not rule out the diagnosis.
ADHD includes three main subtypes: primary inattentive, primary hyperactive, and combined. No specific test can be done to diagnose ADHD, and the DSM-5 requires the presence of a sufficient number of core symptoms and impairments to make this diagnosis.
ADHD cannot be diagnosed reliably in those patients who are under four years of age. In these patients, it is difficult to determine whether symptoms are outside of the expected behavior of a patient that is four or five years of age.
Children will typically present with ADHD symptoms during the early school years. Those with primary hyperactive-impulsive or combined types of ADHD may present with behaviors that are considered problematic before those who have inattentive features.
Those patients with inattentive subtype may not present until academic strains become higher. A comorbid learning disorder should be considered in patients where academic progress is poor.
Patients with ADHD should be assessed for sleep issues, such as obstructive sleep apnea, particularly if they have snoring and daytime behavioral problems, tonsillar hypertrophy on examination, or obesity.
In adolescents, new onset ADHD symptoms are less common, but may occur in some instances due to increased academic demands or if mild symptoms have not been recognized at a younger age. In these cases, learning disabilities, sleep problems, mental health conditions, and substance abuse should be considered as they can mimic ADHD or be a complicating condition.
In addition to parental concerns and information, two additional sources such as teachers or coaches should provide information about the patient’s symptoms as well.
Treating and Managing ADHD
Next, let us dive in the treatment of ADHD. The goal of treatment of ADHD is to improve a patient’s symptoms, as well as optimize functional performance, and aim to reduce behavioral concerns. Those children who have ADHD can often be eligible for ADHD-specific resources and modifications within the school system under section 504 of the Rehabilitation Act or under the Individuals with Disabilities Education Act.
Parents with children that have ADHD can inquire about testing to determine the need for these modifications or for an individualized education plan (IEP).
Treatment for those patients with ADHD that are younger than six years of age should begin with behavioral therapy. Medications are not first-line in these patients but may be considered if ADHD symptoms are severe and are unresponsive to behavioral therapy. In those patients who are six years and older, treatment should still begin with behavioral therapy as well.
The Multimodal Treatment Study evaluated children who received intensive behavioral therapy, medication, or combined behavioral therapy and medication. It was found that those patients who received medication alone and those who received medication and behavioral therapy showed similar benefits.
A longer-term analysis suggests that behavioral therapy provides additional benefit beyond medication alone, especially regarding treatment fulfillment for teachers and parents, and in children with lower socioeconomic status.1
Medications aim to reduce the core ADHD symptoms for children who suffer from ADHD. Psychostimulants have been seen to be the most effective medications and are safe options. These are considered first-line when it comes to medications for ADHD.
Atomoxetine and alpha-2 receptor agonists, such as guanfacine and clonidine, are also effective but these have fewer corroborating studies and are less effective than psychostimulants. However, if there are adverse effects with stimulants or risk/concern of medication diversion with psychostimulants, these are suitable options for treatment. Other options for treatment of ADHD include bupropion, trazodone, atypical antipsychotics such as Risperdal, Abilify, or mood stabilizers such as carbamazepine. However, these medications are not approved by the U.S. FDA for treating ADHD are used off label in these instances.
Let’s next dive into the psychostimulants a little more!
These medications affect the central nervous system, affecting the dopaminergic pathways. In addition to symptomatic improvement, academic performance may improve as well with the use of these medications.
Around 70 percent of patients will show improvement in symptoms with their first stimulant trial, and 90 to 95 percent will respond to a second stimulant trial.
Adverse effects of stimulant medications are often dose-dependent. These may include reduced appetite, headache, abdominal discomfort, anxiousness, irritability, reduction in weight and height velocity, and sleep problems. All of these side effects appear to dissipate after discontinuation of medication.
Although suicidal or homicidal ideation is rare, family members should be made aware of this risk with these medications prior to initiating therapy. Other effects that may be observed include slight increases in pulse and blood pressure readings; however, reports of increased risk of cardiac problems are unfounded.
It is recommended that patients who have baseline cardiac disorders be screened with an EKG or cardiology referral before initiation with stimulant medications. Lastly, tics and Tourette syndrome symptoms affect around 20 percent of patients on ADHD medications.
Atomoxetine is a nonstimulant medication that affects the noradrenergic systems. This medication is beneficial in ADHD symptoms but also in mood or anxiety disorders as well. Unlike the psychostimulants, there is no abuse potential with this medication. Adverse effects may include drowsiness, nausea, and reduced appetite.
Clonidine and guanfacine are often used as adjusts to stimulant therapy in the treatment of ADHD. Guanfacine often will be preferred over clonidine due to its longer half-life and risk of fewer sedative and hypotensive side effects.
Monitoring of patient’s symptoms, progress, as well as stability is necessary for those patients with ADHD. Follow up in recommended one month after starting therapy as well as with dose or medication changes. Height, weight, pulse, blood pressure, symptoms, and treatment adherence should be evaluated at each office visit.
Once a patient is stable on a treatment regimen without adverse effects noted, follow up is recommended every three months for the first year, then two to three times annually thereafter. If there are concerns of growth delay or weight reduction a trial of a different medication can be attempted, or a medication holiday can be trialed where medication is not taken when a patient is not in school.
- Am Fam Physician. Diagnosis and Management of ADHD in Children. 2014;90(7):456-464. Copyright © 2014 American Academy of Family Physicians.
- UpToDate. Attention Deficit Hyperactivity Disorder in Children and Adolescents: Overview of Treatment and Prognosis. Accessed: March 25, 2019.