University of Iowa Family Practice Handbook, Fourth Edition, Chapter 18

Psychiatry: Attention Deficit Disorder

Alison C. Abreu, MD and Julie Kay Filips, MD
Departments of Psychiatry and Family Medicine
University of Iowa Hospitals and Clinics
Peer Review Status: Externally Peer Reviewed by Mosby

1. Overview: The prevalence of ADHD in school-age children is 3%-6% with males outnumbering females. Onset is in childhood with symptoms first being apparent in early grade school (by definition by age 7). Contrary to previously held beliefs, approximately 65% will have symptoms that persist into adulthood. Patients can have primarily mixed, inattentive, or hyperactive subtypes. Many patients with ADHD have a comorbid psychiatric disorder.
2. Diagnosis of ADHD (Box 18-7).
3. Diagnostic Tools.
   1. Interview with child's caregivers
   2. Mental status exam of the child
   3. Physical exam for general and neurologic health with a hematocrit drawn if the patient has a history of lead exposure, hearing and vision testing.
   4. Cognitive ability screen
   5. ADHD rating scales to be filled out by teacher and parent
   6. School reports on the patient.
4. Pharmacologic Treatment.
   1. Stimulants such as methylphenidate, dextroamphetamine, and pemoline are first line treatment. Response rate is 70-90 per cent. REMINDER: favorable response does not confirm the diagnosis of ADHD. Side effects include decreased appetite, headache, insomnia, jitteriness, stomachache, and occasional mood dysphoria. There have been rare cases of amphetamine abuse reported. Pemoline is associated with infrequent hepatotoxic effects and should be considered for use only after methylphenidate and dextroamphetamine have failed. Dosage range for regular release methylphenidate is 0.3-0.6 mg/kg/dose and is given as BID or TID dosing. Dosage range for dextroamphetamine is 0.15-0.3 mg/kg/dose and is given twice daily. Both medications come in sustained release formulations along with regular release.
   2. Antidepressants such as imipramine are used in patients with ADHD and tic disorders. Side effects are anticholinergic in nature. Tricyclic medications are known to be associated with prolongation of the QT interval and as such EKG monitoring is recommended.
   3. Alpha-adrenergic agents such as clonidine and guanfacine are helpful for hyperactivity. The primary side effects are sedation and hypotension. Doses should be titrated slowly from 0.05 mg TID as a starting dose for clonidine. Avoid use in children with cardiovascular disease.
5. Nonpharmacologic Therapies.
   1. Includes parental and patient psychoeducation, behavioral therapy, and supportive therapy. Multimodal therapy is most recommended.

See related Provider Topics Attention Deficit Disorder with Hyperactivity, Brain and Nervous System, Child and Teen Health, Food, Nutrition and Metabolism or Mental Health and Behavior.

See related Patient Topics Attention Deficit Disorder with Hyperactivity, Brain and Nervous System, Child and Teen Health, Food, Nutrition and Metabolism or Mental Health and Behavior.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

http://www.vh.org/adult/provider/familymedicine/FPHandbook/Chapter18/07-18.html