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KEY CONCEPTS

KEY CONCEPTS

  • image Untreated or ineffectively treated childhood attention deficit/hyperactivity disorder (ADHD) can lead to poor school performance, poor socialization, and increased risk for traffic accidents, psychiatric comorbidities, unemployment, and incarceration during adolescence and adulthood.

  • image ADHD is 74% genetic in origin, and is associated with decreased brain volume, a delay in cortical maturation, and possible dysregulation of the “default mode network,” a brain system that regulates attention, prioritization of information, memory, and impulse control.

  • image Symptoms of inattention or hyperactivity and impulsivity or all three must be present during childhood and cause functional impairment in two different settings for 6 months to meet DSM-5 diagnostic criteria for ADHD. Adult-onset ADHD requires further study.

  • image Prior to initiating pharmacotherapy, overall physical and mental health and psychiatric comorbidities must be assessed, and goals of treatment must be set.

  • image Preschoolers, school-age children, adolescents, and adults with ADHD all can benefit from nonpharmacologic interventions that include a healthy diet, education on ADHD, and potentially effective educational, cognitive, and behavioral treatments.

  • image The psychostimulants are the most effective pharmacologic treatment option for all ages with a rapid therapeutic effect, typically within 1 or 2 hours of an effective dose. Methylphenidate is recommended as first-line for children and adolescents while amphetamines are first-line treatment for adults based on efficacy and tolerability.

  • image α2-Adrenergic agonists such as extended-release preparations of guanfacine and clonidine are less effective than stimulants as monotherapy and are used in combination with stimulants or as monotherapy in youth to improve symptom control, particularly oppositional behaviors and insomnia.

  • image When ADHD coexists with other neuropsychiatric conditions, such as anxiety disorders, major depression, autism spectrum disorder (ASD) or Tourette disorder, it is optimal to treat the most functionally impairing disorder first (whether it is ADHD or the co-occurring condition) and then treat the second disorder.

  • image When ADHD coexists with bipolar disorder, it is necessary to first stabilize the mood with lithium, an anticonvulsant, or an atypical antipsychotic before adding an ADHD-specific medication such as a psychostimulant.

  • image Atomoxetine is a good option to manage ADHD symptoms in adolescents and adults with substance-use disorders or when stimulants are intolerable. It has a delayed onset of effect (2–4 weeks), but it has no abuse potential.

PATIENT CARE PROCESS

Patient Care Process for Attention Deficit/Hyperactivity Disorder (ADHD)

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Collect

  • Patient characteristics (eg, age, gender, sex, pregnancy status)

  • Social and family history (eg, foster care, single parent home, extended family involvement; marital status for adults)

  • Substance use history (eg, cigarettes, marijuana, alcohol, methamphetamine, hallucinogens, cocaine, opioids)

  • Dietary issues (eg, “picky” eater, gluten-sensitive, food allergies)

  • Sleep patterns (eg, latency, duration, restless legs)

  • Current medications including OTCs, herbal products, dietary supplements, and prior medications for ADHD

  • Cardiovascular health history (eg, history of sudden death in family)

  • Goals of treatment (eg, finish homework assignments, prevent injury, await turn in lines, positive peer interactions)

  • Information on past and current co-occurring neuropsychiatric conditions (eg, Tourette disorder, conduct disorder, bipolar disorder, autism spectrum disorder, epilepsy)

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