Note from National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information, including detailed information on diagnosis, treatment regimens, and costs.
Epidemiology
Common
Attention-deficit hyperactivity disorder (ADHD) is the most common behavioral disorder in school-age children. Studies demonstrate a U.S. community prevalence of 8 to 12%. It is more common in boys.
Primary Care Provider
Most children with ADHD will receive most or all of their care through primary care physicians.
Diagnosis
Types
Diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria (see Tables 3 & 4 of the original guideline document). The three main types are primary hyperactive, primary inattentive, and mixed.
Multiple Sources
No specific test can make the diagnosis. Input from both parents and teachers is required. Some psychological rating tools are useful (e.g., Vanderbilt, Connors; see Figure 1, Tables 1 & 2, and Appendix A1 of the original guideline document). Formal neuropsychiatric testing may be useful in certain situations.
Confused and Associated Conditions
Diagnosis is complicated by overlapping symptoms or co-occurrence of other disorders (e.g., anxiety disorders, bipolar disorder, fetal alcohol syndrome, major depressive disorders, learning disorders, oppositional defiant disorder, post traumatic stress disorder, reactive attachment disorder; see Appendices B1 & B2 of the original guideline document).
Treatment
Drug Treatment
- Stimulants are the first-line treatment and have proven benefit to most people. If one class of stimulant fails or has unacceptable side effects then another should be tried (see Tables 5-7 of the original guideline document)
- Atomoxetine (Strattera®) is a secondary choice. (One reported side effect is suicidal thinking.)
- Other medications may be used alone or in combination depending upon the ADHD type or with comorbidity profile: e.g., Alpha-II agonists (clonidine, guanfacine) with hyperactivity or impulsivity; bupropion (over age 8) with comorbid depression; risperidone (atypical antipsychotic) for aggression (see Table 8 of the original guideline document).
- Tricyclic antidepressants may rarely be used to treat ADHD; selective serotonin reuptake inhibitors (SSRIs) may be useful for depressive disorders. (There is a reported increase of suicidal ideation for SSRIs but SSRIs are not used to treat ADHD.)
Non-Pharmacologic Treatments
- Parental interventions: education and support, parent training class, family therapy (see Table 9 and Appendix A2 of the original guideline document)
- Behavioral interventions: routines and clear limits; positively reinforce target behaviors
- School interventions: consider evaluation for intelligence testing (IQ) and to rule out learning disorders. Affected children may qualify for special education services and an individualized education plan (IEP) (see Appendices A3 & A4 of the original guideline document).
Special Populations or Circumstances
Special considerations apply to 3- to 5-year-olds, adolescents, head-injured patients, mentally retarded/autistic patients, fetal alcohol syndrome, substance-abusing patients (see Appendix B3 of the original guideline document).
Controversial Areas
Common Myths
Several common beliefs related to ADHD are untrue (e.g., that it is not a real disorder, it is an over-diagnosed disorder, children with ADHD are over-medicated).
Diets
Although a few studies suggest dietary modification may have promise (e.g., individually tailored hypoallergenic diets, essential fatty acids, flax seed), studies have shown the Feingold diet and modifying sugar consumption have no effect.
Complementary Alternative Medicine
Use is controversial, but common (see Appendix B4 of the original guideline document).
