Pediatric Pathways

A 12-year-old Male with Memory Concerns

After reading this article and answering the review questions the reader will be able to:

  1. Recognize that Attention-Deficit/Hyperactivity Disorder (ADHD) can present in multiple ways and throughout childhood
  2. List diagnostic criteria for ADHD
  3. Describe most effective treatments for ADHD, and reasons for referral
  4. Describe typical side effects of stimulant medications

Case

James, a 12-year-old male, is brought to your office for a second opinion regarding memory concerns. James’ teachers have had concerns about his academic performance since he was in first grade. He has also had an Individualized Education Program (IEP) due to problems with reading comprehension and has had his homework and tests read to him in the past. His comprehension has been improving and he no longer has an IEP.

Despite his academic struggles, he has maintained good grades prior to this year. However, both his mother and teachers are now starting to notice problems with his memory. He has always been a little absent-minded, but now his mother will ask him to do something and, when she reminds him 15 minutes later he does not remember her telling him. His teachers comment that he will “space out” during class. He is having trouble completing his homework mainly because he forgets that it has been assigned. When he remembers his homework it is always complete and correct. His grades have dropped from A’s and B’s to D’s, primarily due to not turning in assignments.

His past medical history is negative for chronic disorders and his family history is negative for learning or attention problems. He does not take any medications, and denies illicit drug use. He transferred to a new school this year, but has several friends and is fitting in socially. Mom recently met with school officials, who recommended neuropsychology testing to determine the cause of his memory concerns.

Physical Examination: Wt 103 kg (>99%), Ht 185 cm (99%), BMI 32 (98%). He is well appearing. HEENT exam is normal, except that he wears glasses. Neck is supple without lymphadenopathy. Lungs are clear to auscultation. Heart has a regular rhythm without murmurs. Abdomen is soft, not distended nor tender. He is alert and oriented x 3. He is conversational and remembered content of the visit. Cranial nerves 2-12 are intact. He has normal strength and tone throughout. Patellar reflexes are 2+. Normal finger-nose touch and Romberg is negative. MMSE is normal.

Evaluation: A screen for ADHD using the Vanderbilt ADHD Diagnostic Rating Scales for both parents and teachers was performed in the clinic. James screened positive for inattention symptoms on all screening forms. He was given the diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), inattentive subtype. After discussion of treatment options he was placed on an intermediate acting stimulant medication and both attention and grades quickly improved. He is now getting A’s and B’s, is feeling much better about school, and his memory problems have resolved.

Overview of ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common problem in pediatric practice. Most recent estimates state that between 8 and 9.5% of children between the ages of 4 and 17 have been diagnosed with ADHD, making it the most common mental health disorder in pediatrics. ADHD is twice as common in boys, and over 2.7 million children in the US are currently taking medication for ADHD. Given the high percentage of children with ADHD, the mental health system cannot treat them all, and primary practitioners should be familiar with diagnosis and available treatments.

Diagnosis

The diagnosis of ADHD currently follows the criteria published in the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (DSM-5)3 published by the American Psychiatric Association. Diagnostic criteria are listed in Table 1. Combining diagnostic criteria allows the possibility of three separate diagnoses:

  1. ADHD, predominantly inattentive subtype (At least 6 of 9 inattentive symptoms)
  2. ADHD, predominantly hyperactive subtype (at least 6 of 9 hyperactive/impulsive symptoms)
  3. ADHD, combined subtype (symptoms of both).3

Table 1: Diagnostic Criteria of ADHD (Adapted from DSM-5)3

Inattentive Symptoms

Hyperactive/ Impulsive Symptoms

Careless mistakes, does not pay close attention to details

Fidgety

Trouble keeping attention

Gets up from seat frequently

Doesn't seem to listen when spoken to

Runs, climbs excessively/ restlessness

Does not follow through or finish tasks

Trouble playing quietly

Trouble organizing activities

Always on the go, can't keep still

Avoids activities that require sustained mental effort

Talks excessively

Often misplaces necessary materials

Blurts out answers

Easily Distractible

Trouble waiting turn

Forgetfulness is daily activities

Interrupts others conversations/ activities

  • Symptoms must be present for at least 6 months
  • Symptom onset prior to 12 years of age
  • Functional impairment in at least two settings (i.e., school and home)
  • Clinically significant impairment in functioning at school, work, or home
  • Symptoms are not due to Pervasive Developmental Disorder, Schizophrenia, or Psychotic Disorder
  • Symptoms are not better accounted by another mental disorder ( i.e. anxiety, mood, etc)

Changes in the DSM-5  versus the DSM-IV-TR (4th Ed) include allowing diagnosis in adults (over 17-years-old), the need for only five out of nine symptoms for diagnosis in adults, removing the exclusion for autistic spectrum disorders, and increasing the lowest age of symptom onset to 12-years-old.4

Diagnosis usually involves careful interviewing of the patient, parents/guardians, and teachers to illicit concerns of ADHD symptoms. As there is often a strong genetic component5, family history should be sought. Evaluation is usually brought on by parents of children who are struggling in school, or at the request of teachers who recognize ADHD symptoms in the student. Diagnosis should be considered in any child age 4-18 who presents with symptoms consistent with ADHD.6

There are many comorbid and confounding mental health conditions that need to be considered when making a diagnosis. These include: anxiety, obsessive-compulsive, affective, and oppositional defiant/ conduct disorders. Developmental disorders including autistic spectrum disorders and fetal alcohol spectrum disorders, and undiagnosed learning disorders should be considered. Symptoms can also be attributed to chaotic household, or sequela of abuse/trauma.

The diagnosis of ADHD can be aided by the use of a validated screening tool. While there are many options available, our office uses the Vanderbilt Attention Deficit/ Hyperactivity Disorder Parent and Teacher Rating Scales.7, 8 This tool is endorsed by the AAP in the Bright Futures Guidelines. There are several reasons we prefer the Vanderbilt scale. First, the tool closely follows the DSM-IV criteria. Second, it includes a section addressing problems with function in school and home. Third, it screens for comorbid and confounding conditions such and oppositional/ defiant disorder, conduct disorder, and mood disorders. Lastly, it includes follow-up screening tools for tracking symptoms and side effects of medication once treatment is initiated. One limitation of the Vanderbilt scale is that it is not validated for preschool children.

Treatment

Treatment for ADHD is multimodal and includes both behavioral therapies and medication. The 2011 AAP guidelines on ADHD6 currently recommend differing treatments depending on the age of the child. For 4 to 5 year-old children, behavioral therapy is first line, and the clinician may try methylphenidate if behavioral therapy is not helpful. For elementary age children (6 to 11), both stimulant medication and behavioral therapy should be used. For adolescents, medication is first line therapy and behavioral therapy can be used as an adjunct. Medication should be titrated to achieve maximum benefit with minimal side effects.6

1. Behavioral strategies: Several behavioral therapies have been shown to be effective for ADHD.6 Most strategies revolve around the concept of training parents and teachers to provide positive reinforcement when tasks are met, ignoring of certain behaviors, and consequences when tasks are not completed. Rewards and punishments need continual adjustment as tasks are mastered and behaviors are changed. One method commonly used is a token economy where the child earns tokens for good behavior, and loses tokens for not meeting tasks. The child can use the tokens for rewards at the end of the week. Several modifications can also occur at school including use of untimed tests, modification of work assignments, use of organizational tools such as homework folders, and preferred seating at the front of the class.6

2. Stimulant medications: Stimulant medications (methylphenidate, dextroamphetamine) remain the mainstay of treatment for ADHD, with strong evidence to support their use. Stimulant medication is very effective; with approximately 70% of children responding to an appropriate dose of stimulant medication.9 Stimulants come in a variety of short-term and extended-release preparations (Table 2). Initiation of therapy with a low dosage of an intermediate acting medication (0.5-0.75 mg/kg/day) allows for once daily administration eliminating need for dosing at school. If symptoms are present after school, consider an afternoon short-term stimulant administration or once daily long acting medication. No medication is FDA approved for preschool children.

Table 2. Stimulant Medications for ADHD

Methylphenidate products

Duration of Action

Name

Pediatric Starting Dose

Short Acting

methylphenidate (Ritalin *, Methylin*)

5-20 mg given 3 times daily

≤4 hours

Intermediate Acting

methylphenidate (Ritalin SR*,Metadate ER*)

20-60 mg (divided in 1-2 doses daily)

4-6 hours

methylphenidate (Methylin ER*)

10-60 mg daily

 

dexmethylphenidate (Focalin*)

2.5-10 mg daily

6-8 hours

methylphenidate (Metadate CD)

10-60 mg daily

 

methylphenidate ER (Ritalin LA)

20-60 mg daily

Long Acting

methylphenidate (Concerta*)

18-54 mg daily

10 hours

10-12 hours

dexmethylphenidate (Focalin XR)

5-40 mg daily

12 hours

methylphenidate (Daytrana Patch)

10-30 mg patch daily

Amphetamine Products

Short Acting

dextroamphetamine*

2.5-15 mg two to three times daily

4-6 hours

Intermediate Acting

dextroamphetamine capsule (Dexedrin*)

5-15 mg 2 times daily

6-8hours

amphetamine mixes salts (Adderall*)

5-30 mg one to 2 times daily

Long Acting

amphetamine mixes salts (Adderall XR*)

10-30 mg daily

10 hours

10-12 hours

lisdexamphetamine (Vyvanse)

20-70 mg daily

* denotes generic equivalent available

Once medication is started, frequent follow up for medication titration is needed either in the office or by phone to until steady improvement is noted. As the effects of medication are immediate, dose adjustments can occur as early as every 3-7 days,6 then every 3-6 months once stable. Titrate medication until an effect is noted, or until the patient develops side effects. Within a few months of starting medication many children develop a tolerance requiring dosage increase. If a child develops side effects without benefit, try the other class of stimulant medication. Common side effects include insomnia, appetite loss, headaches and stomach aches, and the potentiation of motor tics.

Stimulant medications are not recommended for children with Tourette syndrome. Controversy exists regarding potential for sudden cardiac death in children on stimulant medications. The AAP recommends asking about family history of Wolf-Parkinson-White syndrome, long QT syndrome, and hypertrophic cardiomyopathy during evaluation.6

3. Non-stimulant medications: Three non-stimulant medications have been approved by the FDA for use in ADHD in children; atomoxetine, extended-release guanfacine, and extended-release clonidine (Table 3). Atomoxetine is a selective norepinephrine reuptake inhibitor. Side effects include somnolence, GI symptoms, and, rarely, suicidal ideation. Guanfacine and clonidine are α2-adrenergic agonists. Side effects of guanfacine and clonidine include somnolence, dry mouth, and lower blood pressure/dizziness. Buproprion has shown effectiveness in adults, but it is not approved for ADHD use in children. As these medications are newer there is less evidence for their use compared to stimulant medications. They are typically used for children who are having severe side effects with stimulant medications or when stimulant medications are contraindicated or not recommended (such as Tourette syndrome).

Table 3. Non stimulant Medication for ADHD

Name

Duration of Action

Pediatric Starting Dose

atomoxetine (Strattera)

10-12 hours

0.5 to 1.4 mg/kg/day (<70 kg) or 40-100 mg/day (>70 kg)

clonidine ER (Kapvay)

10-12 hours

0.1-0.4 mg/day

guanfacine ER(Intuniv)

10-12 hours

1-4 mg/day

 

When to Refer

While most pediatricians can manage ADHD in the office, if multiple comorbid mental health conditions are present (such as ODD, anxiety) referral to psychiatry is warranted. Referral is also warranted if the child fails a trial of stimulant medication and the diagnosis of ADHD is in question, or if the pediatrician is not comfortable with use of non-stimulant medication. As learning disorders are a common comorbid condition, referral to neuropsychology or a developmental pediatrician may be warranted.

Conclusion

ADHD is a common behavioral problem in pediatrics and prevalence is increasing. Diagnosis should be considered in children ages 4 to-18 who exhibit signs of inattention or hyperactivity. Diagnosis follows criteria set forth in the DSM-IV-TR and is simplified though the use of validated screening tools such as the Vanderbilt ADHD Rating Scale. Treatment is tailored towards the age of the child, but both medication and behavioral therapies remain mainstays of treatment.

ADHD is a chronic condition, often lasting until adulthood, that requires follow up and adjustment of medication/ behavioral therapy. Frequent communication between provider, parents, teachers, and child is necessary to ensure adequate treatment and minimize side effects of medication.

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References

  1.  Centers for Disease Control and Prevention (CDC). Increasing prevalence of patient-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007.MMWR Morb Mortal Wkly Rep. 2010; 59(44):1439-1443
  2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. Am J Psychiatry. 2006; 163(4):724-732.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed, (DSM-5). Washington, DC: American Psychiatric Association; 2013.
  4. American Psychiatric Association. DSM-5 Attention Deficit/Hyperactivity Disorder Fact Sheet. Accessed July 11, 2013.
  5. Khan SA, Farone SV. The genetics of ADHD: a literature review of 2005. Curr Psychiatry Rep. 2006; 8(5): 393-397
  6. American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011; 128(5):1007-1022
  7. Wolraich ML, Lambert W, Doffing MA, Bickman L, Simmons T, Worley K. Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. J Pediatr Psychol. 2003; 28(8): 559-567
  8. Wolraich ML, Feurer ID, Hannah JN, et al. Obtaining systematic teacher reports of disruptive behavior disorders utilizing DSM-IV. J Abnorm Child Psychol. 1998; 26(2): 141-152
  9. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder (ADHD). Arch Gen Psychiatry. 1999;56(12):1073-1086