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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 involvement with the criminal legal system 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 To meet DSM-5 diagnostic criteria for ADHD, symptoms of inattention or hyperactivity-impulsivity, separately or all together, must be present during childhood and cause functional impairment in two different settings for 6 months . Adult-onset ADHD requires further study.

  • image Physical, mental health, and psychiatric comorbidities must be assessed, prior to initiating pharmacotherapy, and the 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 stimulants 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 Alpha-2 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 antiseizure medication (or mood stabilizer), or a second generation antipsychotic before adding an ADHD-specific medication such as a stimulant.

  • image Atomoxetine is a good option to manage ADHD symptoms in adolescents or adults with substance use disorders or when stimulants are intolerable. It has a delayed onset of effect (2–4 weeks) and has no potential for physical dependence. Viloxazine has similarities with delayed onset and also lacks physical dependence potential, but it requires further study compared to atomoxetine and stimulants to fully assess its place in therapy.

BEYOND THE BOOK

BEYOND THE BOOK

Watch the approximately 7-minute video (Video link) by an ADHD researcher and a child psychiatrist, Dr. Steven R. Pliszka, as he provides an example of a typical interview with a child undergoing evaluation for ADHD and he discusses the clinical assessment of ADHD. An ADHD diagnostic rating tool is used to collect and document information from the child utilized in the diagnostic assessment. Versions of validated diagnostic rating tools for parents and teachers are ...

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