- 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.
- ADHD is 80% genetic in origin, and it is associated with decreased brain volume, a delay in cortical thickening, and dysregulation of the “default mode network,” a brain system that regulates attention, prioritization of information, memory, and impulse control.
- 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 diagnostic criteria for ADHD.
- Pretreatment assessment of overall physical and mental health, psychiatric comorbidities, and goals of treatment must be set prior to initiating pharmacotherapy.
- 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 cognitive and behavioral treatments.
- The psychostimulants, methylphenidate or amphetamine salts, are the most effective pharmacologic treatment options for all ages with a rapid therapeutic effect, typically within 1 or 2 hours of an effective dose.
- α2-Adrenergic agonists such as extended-release preparations of guanfacine and clonidine are less effective than stimulants in monotherapy and are used as adjuncts to improve symptom control, particularly oppositional behaviors and insomnia.
- 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.
- When ADHD coexists with other psychiatric conditions, such as anxiety disorders, major depression, or Tourette’s 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.
- Atomoxetine is a good option to manage ADHD symptoms in adolescents and adults with substance abuse disorders. It has a delayed onset of effect (2 to 4 weeks), but it has no abuse potential.
On completion of the chapter, the reader will be able to:
Identify the signs and symptoms of attention deficit/hyperactivity disorder (ADHD) and determine if a patient meets criteria for diagnosis.
Differentiate well-established from proposed etiologies for ADHD.
Discuss neuroanatomical and functional brain changes that contribute to the clinical presentation of ADHD.
Explain how the symptoms of ADHD may present differently in adults compared with preschoolers, school-age children, and adolescents.
Determine if a dietary intervention or supplement is appropriate and evidence-based for managing ADHD in a given patient.
Recommend appropriate cognitive and behavioral interventions for managing ADHD in preschoolers, school-age children, adolescents, and adults.
Compare and contrast pharmacologic treatment options with regard to efficacy, tolerability, and appropriate dosing recommendations.
Compare extended-release formulations for ADHD, and explain which preparations have a longer onset of effect and which preparations have a longer duration of effect.
Recommend an appropriate dosing and titration schedule for stimulants, atomoxetine, and α2-adrenergic agonists in the treatment of ADHD.
Discuss the role of mood stabilizers ...