Materials for this week:
- Case discussion
- CDC ADHD symptom checklist and overview of diagnosis
- Review of ADHD Treatment, by one of our local psychiatry experts, Dr. Will French, Pediatric Annals 2015
- Powerpoint shared by Dr. Abby Grant
- UW General Peds ADHD Clinical guideline and addendum developed by Dr. Julie Bledsoe
Take-home points for ADHD:
- Epidemiology: Estimates by the CDC are that 8-10% of youth in the US have been diagnosed with ADHD. Prevalence increased by ~1/3 between the 1990s to 2000s, but this coincided with increased marketing of ADHD medications. Concern remains about overdiagnosis, particularly among younger children where behavior may be developmentally appropriate. For example, children who are the youngest in their classrooms are more likely to be diagnosed with ADHD. However, girls with ADHD may be underrecognized, and most children with ADHD go under-treated.
- Risk factors: Both genes and environment contribute to ADHD risk. Twin studies suggest a strong genetic component, with up to 76% heritability. Environmental risk factors include perinatal and early childhood stress from toxins, compromised prenatal nutrition or birth complications, chronic deprivation, and early childhood adversity. Up to 2/3 of youth with ADHD have a comorbidity including anxiety, mood disorders, autism, ODD, tics, and/or substance abuse.
- Diagnosis: ADHD has 3 primary components: inattention, hyperactivity, and impulsivity, present to varying degrees. To diagnose ADHD, these must be present beyond appropriate for developmental stage, must cause significant impairment, should be present before age 12, and should be present in 2 or more settings (school, home, day care, camp, etc). In diagnosing ADHD, we should use clinical assessment along with ADHD rating scales (e.g., Vanderbilt), and also assess for co-morbidities with broad symptom checklists (e.g., Pediatric Symptom Checklist).
- Treatment: Behavioral (parent and/or classroom) and pharmacological treatments have been shown to work well, especially in combination. Usually, one of the two stimulant classes of medicines will be tried first: methylphenidate products (such as Ritalin, Concerta and Daytrana) or amphetamine products (such as Adderall and Vyvanse). Both stimulant classes are generally tried before switching to one of the non-stimulants: atomoxetine (Strattera), clonidine, or guanfacine, which have shown lower efficacy. However, atomoxetine would be considered first-line for treating ADHD with concurrent anxiety, or when there’s a risk of medication abuse with a stimulant. As above, given the high prevalence of co-morbidities, we must also screen for and treat these conditions.
- Local resources: Our state has terrific resources through the Partnership Access Line and SCH. For more complex cases and/or those where diagnosis / treatment is in question, consult the SCH Psychiatry and Behavioral Medicine team including ADHD specialists Mark Stein PhD and Will French MD. Dr. Sam Zinner’s developmental-behavioral screening tools webpage is a great resource to bookmark.