2019-20 TOW #14: ADHD

As we get fully immersed in the school year, assessment for Attention Deficit Hyperactivity Disorder (ADHD) may be on the agenda for more patient visits. Fortunately, we have more data and tools than ever to diagnosis and treat ADHD.

Materials for this week:

Take home points for ADHD:

  1. What are the rates of ADHD? 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.
  2. What are specific risk factors for ADHD? 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.
  3. How do we diagnosis ADHD? ADHD has 3 primary components: inattention, hyperactivity, and impulsivity, present to varying degrees. To diagnose ADHD, these must be present beyond what’s 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).
  4. What are the best treatments? Behavioral (parent and/or classroom) and pharmacological treatments 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 generally lower efficacy. However, atomoxetine may be considered first-line for treating ADHD with anxiety, or when there’s a risk of abuse with a stimulant. Given the high prevalence of co-morbidities, we must also screen and treat these conditions.
  5. Local resources: Our state has terrific resources through the Partnership Access Line. 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.

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