Treating ADHD in children and adolescents

Content provided by the Faculty of the Harvard Medical School

An update about the latest clinical guidance and controversies.

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder in children. It affects at least 3% to 5% of American children, although two nationwide surveys suggest that the percentage has been increasing, and it may currently affect as many as 8% to 9%.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), defines three ADHD subtypes: predominantly inattentive, predominantly hyperactive-compulsive, or combined. Although symptom severity varies, ADHD can be devastating, wreaking havoc with attention and causing irrepressible energy and impulsive behavior that can strain family relationships and impair achievement at school.

Co-occurring disorders are common. For example, 54% to 84% of children and adolescents with ADHD also meet diagnostic criteria for oppositional defiant disorder, and about 45% have a learning or language difficulty. Anxiety, conduct disorder, and substance abuse problems also frequently develop in youngsters with ADHD.

Given the multiple challenges facing children and adolescents with ADHD, the most effective treatment involves some combination of psychoeducation, medication, behavioral interventions, parent training, and school support — an approach known as multimodal treatment because it encompasses different modes of therapy. Both research and clinical practice indicate that components of a treatment plan may change as a child develops, and as symptoms or circumstances evolve.

Evaluation and diagnosis

Experts recommend a rigorous approach to diagnosis. The consensus remains that a comprehensive evaluation involves an assessment of symptoms, a detailed personal and family medical history, and determination of a child's functioning at home, at school, and with peers.

In its updated guidelines, the American Academy of Child and Adolescent Psychiatry (AACAP) discourages ordering any routine laboratory, neurological, or psychological testing unless something in the child's medical history or symptoms indicates such testing may be necessary. Neuropsychological testing may be necessary in some patients, however, to better define symptoms or to identify co-existing disorders. This is best carried out by clinicians experienced in ADHD.

More controversial is whether routine electrocardiogram (ECG) testing is necessary before a child starts taking a medication for ADHD. In April 2008, the American Heart Association (AHA) released a scientific statement recommending that it was reasonable — although not mandatory — for clinicians to consider ordering an ECG in children diagnosed with ADHD before beginning treatment with stimulants or other medications. In August 2008, however, the American Academy of Pediatrics (AAP) published a statement recommending against routine ECG testing — supporting the earlier recommendations of the AACAP. In its position paper, the AAP cited data that sudden cardiac deaths, while tragic, are also rare. Such deaths occur in about two children for every million taking ADHD medications — fewer than the eight to 62 sudden deaths per million that occur in the general pediatric population.

The discussion about the relationship between cardiac risk and ADHD is likely to continue, however. Stimulant medications in particular raise blood pressure and heart rate, and some drugs carry warning labels for patients with heart problems. For now, the best advice is for pediatricians and other clinicians to assess heart disease risk by doing a physical exam and taking a careful medical history (for example, asking about fainting spells, palpitations, and family history) while a mental health professional does an evaluation for ADHD.

Resources on ADHD

American Academy of Child and Adolescent Psychiatry 202-966-7300 www.aacap.org

Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) 301-306-7070 www.chadd.org

CHADD's National Resource Center on ADHD 800-233-4050 (toll-free) www.help4adhd.org