What are the key features and management of Attention Deficit Hyperactivity Disorder (ADHD)?

Key Features and Management of ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by persistent symptoms of inattention, hyperactivity, and impulsivity that cause significant impairment in multiple settings and should be managed with a combination of FDA-approved medications and behavioral interventions tailored to the patient's age. 1

Diagnostic Features

Core Symptoms

• Inattention:

  • Lack of attention to details/careless mistakes
  • Poor sustained attention
  • Poor listening
  • Failure to follow through on tasks
  • Poor organization
  • Avoidance of tasks requiring sustained mental effort
  • Losing things
  • Easy distractibility
  • Forgetfulness 2

• Hyperactivity/Impulsivity:

  • Fidgeting/squirming
  • Leaving seat inappropriately
  • Running/climbing excessively
  • Difficulty with quiet activities
  • Often "on the go"
  • Excessive talking
  • Blurting answers
  • Difficulty waiting turn
  • Interrupting others 2

Diagnostic Requirements

• Symptoms must be:
  • Present before age 7 years
  • Persistent for at least 6 months
  • More severe than typically observed in individuals at comparable developmental level
  • Causing clinically significant impairment in social, academic, or occupational functioning
  • Present in 2 or more settings (e.g., school/work and home)
  • Not better explained by another mental disorder 2

ADHD Subtypes

1. Predominantly Inattentive Type (≥6 inattentive symptoms)
2. Predominantly Hyperactive-Impulsive Type (≥6 hyperactive-impulsive symptoms)
3. Combined Type (meets criteria for both) 2

Comorbid Conditions

Assessment for comorbidities is essential as they frequently co-occur with ADHD and affect treatment approach 1:

• Emotional/Behavioral:

  • Anxiety disorders
  • Depression
  • Oppositional defiant disorder
  • Conduct disorders
  • Substance use disorders

• Developmental:

  • Learning disabilities
  • Language disorders
  • Autism spectrum disorders

• Physical:

  • Tic disorders
  • Sleep disorders (including sleep apnea)

Management Approach

Age-Specific Treatment Recommendations

1. Preschool-aged children (4-5 years):

   • First-line: Evidence-based parent/teacher-administered behavior therapy
   • Second-line: Consider methylphenidate if behavior interventions are insufficient and moderate-to-severe impairment persists 1

2. Elementary school-aged children (6-11 years):

   • FDA-approved medications for ADHD (strongest evidence for stimulants)
   • Evidence-based parent/teacher-administered behavior therapy
   • Preferably both medication and behavioral interventions 1

3. Adolescents (12-18 years):

   • FDA-approved medications with patient assent
   • Behavioral therapy
   • Preferably both medication and behavioral interventions 1

Medication Options

1. Stimulants (first-line):

   • Methylphenidate (short, intermediate, and long-acting formulations)
   • Amphetamines (short and long-acting formulations) 1

2. Non-stimulants:

   • Atomoxetine (Strattera)
   • Extended-release guanfacine (Intuniv)
   • Extended-release clonidine (Kapvay) 1

Important Medication Considerations

• Suicidality risk: Atomoxetine carries a warning for increased risk of suicidal ideation in children and adolescents. Monitor closely for suicidality, clinical worsening, or unusual behavior changes 2

• Substance abuse: Assess adolescents for symptoms of substance abuse before initiating stimulant treatment 1

• Titration: Medication doses should be titrated to achieve maximum benefit with minimum adverse effects 1

Comprehensive Care Approach

ADHD should be recognized as a chronic condition requiring ongoing management:

• Follow principles of the chronic care model and medical home approach 1
• Implement school environment management and accommodations 1
• Provide parent training in behavior management techniques 1
• Implement behavioral classroom interventions 1
• Establish communication systems between healthcare providers, schools, and families 1

Regional Variations in Treatment Approach

Treatment approaches vary globally:

• Western guidelines (e.g., AAP, NICE) typically recommend FDA-approved medications along with behavioral interventions
• Japanese guidelines recommend school environment management and psychosocial treatment as first-line, with medication as second-line
• Other Asian countries (Malaysia, Singapore, India, Republic of Korea) have guidelines that differ from Western approaches 1

Functional Impact and Long-term Outcomes

ADHD significantly impacts multiple domains of functioning:

• Academic achievement and attainment
• Occupational performance
• Social relationships
• Risk-taking behaviors
• Driving safety (traffic violations, car accidents)
• Family burden (including healthcare costs) 3

Early identification and consistent treatment are essential to mitigate these long-term negative outcomes and improve quality of life.