ADHD

Dr. Manuel Mota-Castillo’s description of “Five red flags that rule out ADHD in children” (Pearls, April) is remarkably at variance with current research and clinical practice in the diagnosis and treatment of children with attention-deficit/hyperactivity disorder.

Mood disorders are well-known comorbidities of ADHD and, unfortunately, numerous young adults with a childhood history of ADHD do “get high on” and become addicted to cocaine and other street drugs. Further, impairing, problematic symptoms often are not noted until the second grade or later in the elementary school years, especially in children who have the inattentive type of ADHD. Absence of a history of symptoms in kindergarten certainly does not contradict a diagnosis of ADHD.

The Multimodal Treatment Study for ADHD, or MTA study, among others, found that about 40% of carefully diagnosed children with ADHD also had oppositional-defiant disorder (ODD), and that 10% to 20% had conduct disorder (CD). These are common ADHD comorbidities.

Finally, a child’s response to initial medication treatment never confirms nor refutes this diagnosis. This point has been emphasized in every major publication in our field for a decade.

Corydon G. Clark, MD
Medical Director,
ADD Clinic Inc Las Vegas, Nev.

I have several problems with Dr. Mota-Castillo’s comments:

First, moodiness can be a part of ADHD. Also, some unfortunate children have ADHD with comorbid bipolar or mood disorders.

Second, depending on the demands of the child, the environment, and the response to the child’s behavior (among other things), ADHD can appear to be intermittent.

Third, ADHD symptoms are present in kindergarten. Some kids do not get diagnosed that early, especially those with ADHD, inattentive type, but they still meet the criteria for ADHD.

Fourth, comorbidity is usually the rule with ADHD. Fifth, response to a stimulant does not make a diagnosis of ADHD. I do not have ADHD, but I would likely “think better” on a stimulant!

Finally, a follow-up appointment at 2 weeks does not confirm a diagnosis of ADHD. The diagnosis is made only after a thorough review of the child's history, a review of the pediatric record, a physical examination by the pediatrician, a clinical interview with the parents or primary caregiver, an interview and examination of the child, a review of school records, and input from current and previous teachers as well as all others who provide care for the child in structured and unstructured settings.

Lori W. Bekenstein, MD
Child and Adolescent Psychiatrist,
Richmond, Va

Dr. Mota-Castillo responds:

Dr. Clark’s letter is not surprising; his statements echo other ADHD experts and the ADHD clinics around the country. Let me clarify several misconceptions around this illness, however.

I don’t blame people who follow dictates from the MTA study, considering the high academic level of the researchers involved. Still, their findings are not immune to further investigation and clinical testing. In fact, other prominent investigators such as Charles Huffine, MD, and Andres Pumariega, MD, have requested the deletion of the CD diagnosis from DSM-IV. Several others have questioned ODD as a valid entity.

I am not a famous scholar from a prestigious school, but I can point to hundreds of children previously diagnosed with ODD who became “non-oppositional” after treatment for their real conditions—either a mood, anxiety, or psychotic disorder.

Other prominent researchers, including Kay Redfield-Jamison, have refuted the assumption that all children diagnosed historically with ADHD were correctly differentiated from other disorders that may display some similar symptoms. Jamison recently cited a tragic patient outcome: A young boy was misdiagnosed with ADHD, placed on stimulants, and ultimately hanged himself.

Most studies on ADHD, including the MTA, are statistically irrelevant because they are based on samples that include many wrongly diagnosed children. I can prove that the combination of ADHD, CD, and ODD really means that these diagnoses are erroneous. The same rationale also explains why statistics about the alleged lack of diagnostic relevance of medication trials are unreliable: Many patients who “failed” did not really have ADHD.

Major published papers do not carry an imprimatur. Remember that several decades ago, experts said that because of lack of ego development, children could not get depressed. Also remember the many papers that acknowledged that bipolar patients were being wrongly diagnosed with schizophrenia.

In regard to labeling with ADD people who abuse illegal stimulants such cocaine or “speed,” I want to emphasize that it is chemically absurd to believe that somebody can get “high” on cocaine and also respond focused and calm on Ritalin. Multiple psychopharmacological and addiction studies have demonstrated that these two substances are identical twins both chemically and in brain responses.

Finally, my clinical findings, described as “remarkably at variance with current research and practice” are based on my research of the files of hundreds of youths in the correctional system. These youths’ attitudes, behavior, and lives completely changed when stimulants were replaced with mood stabilizers or antipsychotics. Many of them stayed on stimulant medications despite overly elevated mood, hallucinations, and aggressive behavior. Aggravated assault charges landed them behind bars.

With regard to Dr. Bekenstein’s comments, I can only say that if she thoughtfully rereads my article, she will realize that I did not say some of the things she perceived.

In the end, I have hundreds of former “treatment failures” to corroborate my statements. I am not alone either in my perspectives on these ADHD issues if all research and practice are considered, or in the conviction that science and patient treatment is advanced by divergent research that tests current views.

Editor’s note:

Thanks to Drs. Clark, Bekenstein, and Mota-Castillo.

The concept of publishing clinical “Pearls” is to allow experienced clinicians to share what they have learned in practice. The somewhat sad truth is that a lot of what we do in practice every day is not “evidence-based.” As Dr. Mota-Castillo points out, much of what was generally accepted not long ago has turned out not to be true.

For the purpose of determining whether a clinician has met “the standard of care” in a professional liability case, the standard is not that what they did would be agreed to by all clinicians, or even by a majority of clinicians. The standard is whether a “reasonable minority” of clinicians would agree. In the case of “Pearls,” we are willing to print recommendations that are endorsed by a reasonable minority, even if they do not represent the majority opinion.

In our regular articles, we are careful to differentiate majority from minority opinion. We have not done that so far in the “Pearls” section. In the future, we will make sure to include an editorial comment in cases like this where most practitioners probably would not endorse the author’s opinion.

To be honest, I am pretty sure that I have seen patients who had ADHD who also became cocaine abusers.

J. Randolph Hillard, MD
Editor-in-chief

Dr. Manuel Mota-Castillo’s description of “Five red flags that rule out ADHD in children” (Pearls, April) is remarkably at variance with current research and clinical practice in the diagnosis and treatment of children with attention-deficit/hyperactivity disorder.

Mood disorders are well-known comorbidities of ADHD and, unfortunately, numerous young adults with a childhood history of ADHD do “get high on” and become addicted to cocaine and other street drugs. Further, impairing, problematic symptoms often are not noted until the second grade or later in the elementary school years, especially in children who have the inattentive type of ADHD. Absence of a history of symptoms in kindergarten certainly does not contradict a diagnosis of ADHD.

The Multimodal Treatment Study for ADHD, or MTA study, among others, found that about 40% of carefully diagnosed children with ADHD also had oppositional-defiant disorder (ODD), and that 10% to 20% had conduct disorder (CD). These are common ADHD comorbidities.

Finally, a child’s response to initial medication treatment never confirms nor refutes this diagnosis. This point has been emphasized in every major publication in our field for a decade.

Corydon G. Clark, MD
Medical Director,
ADD Clinic Inc Las Vegas, Nev.

I have several problems with Dr. Mota-Castillo’s comments:

First, moodiness can be a part of ADHD. Also, some unfortunate children have ADHD with comorbid bipolar or mood disorders.

Second, depending on the demands of the child, the environment, and the response to the child’s behavior (among other things), ADHD can appear to be intermittent.

Third, ADHD symptoms are present in kindergarten. Some kids do not get diagnosed that early, especially those with ADHD, inattentive type, but they still meet the criteria for ADHD.

Fourth, comorbidity is usually the rule with ADHD. Fifth, response to a stimulant does not make a diagnosis of ADHD. I do not have ADHD, but I would likely “think better” on a stimulant!

Finally, a follow-up appointment at 2 weeks does not confirm a diagnosis of ADHD. The diagnosis is made only after a thorough review of the child's history, a review of the pediatric record, a physical examination by the pediatrician, a clinical interview with the parents or primary caregiver, an interview and examination of the child, a review of school records, and input from current and previous teachers as well as all others who provide care for the child in structured and unstructured settings.

Lori W. Bekenstein, MD
Child and Adolescent Psychiatrist,
Richmond, Va

Dr. Mota-Castillo responds:

Dr. Clark’s letter is not surprising; his statements echo other ADHD experts and the ADHD clinics around the country. Let me clarify several misconceptions around this illness, however.

I don’t blame people who follow dictates from the MTA study, considering the high academic level of the researchers involved. Still, their findings are not immune to further investigation and clinical testing. In fact, other prominent investigators such as Charles Huffine, MD, and Andres Pumariega, MD, have requested the deletion of the CD diagnosis from DSM-IV. Several others have questioned ODD as a valid entity.

I am not a famous scholar from a prestigious school, but I can point to hundreds of children previously diagnosed with ODD who became “non-oppositional” after treatment for their real conditions—either a mood, anxiety, or psychotic disorder.

Other prominent researchers, including Kay Redfield-Jamison, have refuted the assumption that all children diagnosed historically with ADHD were correctly differentiated from other disorders that may display some similar symptoms. Jamison recently cited a tragic patient outcome: A young boy was misdiagnosed with ADHD, placed on stimulants, and ultimately hanged himself.

Most studies on ADHD, including the MTA, are statistically irrelevant because they are based on samples that include many wrongly diagnosed children. I can prove that the combination of ADHD, CD, and ODD really means that these diagnoses are erroneous. The same rationale also explains why statistics about the alleged lack of diagnostic relevance of medication trials are unreliable: Many patients who “failed” did not really have ADHD.

Major published papers do not carry an imprimatur. Remember that several decades ago, experts said that because of lack of ego development, children could not get depressed. Also remember the many papers that acknowledged that bipolar patients were being wrongly diagnosed with schizophrenia.

In regard to labeling with ADD people who abuse illegal stimulants such cocaine or “speed,” I want to emphasize that it is chemically absurd to believe that somebody can get “high” on cocaine and also respond focused and calm on Ritalin. Multiple psychopharmacological and addiction studies have demonstrated that these two substances are identical twins both chemically and in brain responses.

Finally, my clinical findings, described as “remarkably at variance with current research and practice” are based on my research of the files of hundreds of youths in the correctional system. These youths’ attitudes, behavior, and lives completely changed when stimulants were replaced with mood stabilizers or antipsychotics. Many of them stayed on stimulant medications despite overly elevated mood, hallucinations, and aggressive behavior. Aggravated assault charges landed them behind bars.

With regard to Dr. Bekenstein’s comments, I can only say that if she thoughtfully rereads my article, she will realize that I did not say some of the things she perceived.

In the end, I have hundreds of former “treatment failures” to corroborate my statements. I am not alone either in my perspectives on these ADHD issues if all research and practice are considered, or in the conviction that science and patient treatment is advanced by divergent research that tests current views.

Editor’s note:

Thanks to Drs. Clark, Bekenstein, and Mota-Castillo.

The concept of publishing clinical “Pearls” is to allow experienced clinicians to share what they have learned in practice. The somewhat sad truth is that a lot of what we do in practice every day is not “evidence-based.” As Dr. Mota-Castillo points out, much of what was generally accepted not long ago has turned out not to be true.

For the purpose of determining whether a clinician has met “the standard of care” in a professional liability case, the standard is not that what they did would be agreed to by all clinicians, or even by a majority of clinicians. The standard is whether a “reasonable minority” of clinicians would agree. In the case of “Pearls,” we are willing to print recommendations that are endorsed by a reasonable minority, even if they do not represent the majority opinion.

In our regular articles, we are careful to differentiate majority from minority opinion. We have not done that so far in the “Pearls” section. In the future, we will make sure to include an editorial comment in cases like this where most practitioners probably would not endorse the author’s opinion.

To be honest, I am pretty sure that I have seen patients who had ADHD who also became cocaine abusers.

J. Randolph Hillard, MD
Editor-in-chief

Dr. Manuel Mota-Castillo’s description of “Five red flags that rule out ADHD in children” (Pearls, April) is remarkably at variance with current research and clinical practice in the diagnosis and treatment of children with attention-deficit/hyperactivity disorder.

Mood disorders are well-known comorbidities of ADHD and, unfortunately, numerous young adults with a childhood history of ADHD do “get high on” and become addicted to cocaine and other street drugs. Further, impairing, problematic symptoms often are not noted until the second grade or later in the elementary school years, especially in children who have the inattentive type of ADHD. Absence of a history of symptoms in kindergarten certainly does not contradict a diagnosis of ADHD.

The Multimodal Treatment Study for ADHD, or MTA study, among others, found that about 40% of carefully diagnosed children with ADHD also had oppositional-defiant disorder (ODD), and that 10% to 20% had conduct disorder (CD). These are common ADHD comorbidities.

Finally, a child’s response to initial medication treatment never confirms nor refutes this diagnosis. This point has been emphasized in every major publication in our field for a decade.

Corydon G. Clark, MD
Medical Director,
ADD Clinic Inc Las Vegas, Nev.

I have several problems with Dr. Mota-Castillo’s comments:

First, moodiness can be a part of ADHD. Also, some unfortunate children have ADHD with comorbid bipolar or mood disorders.

Second, depending on the demands of the child, the environment, and the response to the child’s behavior (among other things), ADHD can appear to be intermittent.

Third, ADHD symptoms are present in kindergarten. Some kids do not get diagnosed that early, especially those with ADHD, inattentive type, but they still meet the criteria for ADHD.

Fourth, comorbidity is usually the rule with ADHD. Fifth, response to a stimulant does not make a diagnosis of ADHD. I do not have ADHD, but I would likely “think better” on a stimulant!

Finally, a follow-up appointment at 2 weeks does not confirm a diagnosis of ADHD. The diagnosis is made only after a thorough review of the child's history, a review of the pediatric record, a physical examination by the pediatrician, a clinical interview with the parents or primary caregiver, an interview and examination of the child, a review of school records, and input from current and previous teachers as well as all others who provide care for the child in structured and unstructured settings.

Lori W. Bekenstein, MD
Child and Adolescent Psychiatrist,
Richmond, Va

Dr. Mota-Castillo responds:

Dr. Clark’s letter is not surprising; his statements echo other ADHD experts and the ADHD clinics around the country. Let me clarify several misconceptions around this illness, however.

I don’t blame people who follow dictates from the MTA study, considering the high academic level of the researchers involved. Still, their findings are not immune to further investigation and clinical testing. In fact, other prominent investigators such as Charles Huffine, MD, and Andres Pumariega, MD, have requested the deletion of the CD diagnosis from DSM-IV. Several others have questioned ODD as a valid entity.

I am not a famous scholar from a prestigious school, but I can point to hundreds of children previously diagnosed with ODD who became “non-oppositional” after treatment for their real conditions—either a mood, anxiety, or psychotic disorder.

Other prominent researchers, including Kay Redfield-Jamison, have refuted the assumption that all children diagnosed historically with ADHD were correctly differentiated from other disorders that may display some similar symptoms. Jamison recently cited a tragic patient outcome: A young boy was misdiagnosed with ADHD, placed on stimulants, and ultimately hanged himself.

Most studies on ADHD, including the MTA, are statistically irrelevant because they are based on samples that include many wrongly diagnosed children. I can prove that the combination of ADHD, CD, and ODD really means that these diagnoses are erroneous. The same rationale also explains why statistics about the alleged lack of diagnostic relevance of medication trials are unreliable: Many patients who “failed” did not really have ADHD.

Major published papers do not carry an imprimatur. Remember that several decades ago, experts said that because of lack of ego development, children could not get depressed. Also remember the many papers that acknowledged that bipolar patients were being wrongly diagnosed with schizophrenia.

In regard to labeling with ADD people who abuse illegal stimulants such cocaine or “speed,” I want to emphasize that it is chemically absurd to believe that somebody can get “high” on cocaine and also respond focused and calm on Ritalin. Multiple psychopharmacological and addiction studies have demonstrated that these two substances are identical twins both chemically and in brain responses.

Finally, my clinical findings, described as “remarkably at variance with current research and practice” are based on my research of the files of hundreds of youths in the correctional system. These youths’ attitudes, behavior, and lives completely changed when stimulants were replaced with mood stabilizers or antipsychotics. Many of them stayed on stimulant medications despite overly elevated mood, hallucinations, and aggressive behavior. Aggravated assault charges landed them behind bars.

With regard to Dr. Bekenstein’s comments, I can only say that if she thoughtfully rereads my article, she will realize that I did not say some of the things she perceived.

In the end, I have hundreds of former “treatment failures” to corroborate my statements. I am not alone either in my perspectives on these ADHD issues if all research and practice are considered, or in the conviction that science and patient treatment is advanced by divergent research that tests current views.

Editor’s note:

Thanks to Drs. Clark, Bekenstein, and Mota-Castillo.

The concept of publishing clinical “Pearls” is to allow experienced clinicians to share what they have learned in practice. The somewhat sad truth is that a lot of what we do in practice every day is not “evidence-based.” As Dr. Mota-Castillo points out, much of what was generally accepted not long ago has turned out not to be true.

For the purpose of determining whether a clinician has met “the standard of care” in a professional liability case, the standard is not that what they did would be agreed to by all clinicians, or even by a majority of clinicians. The standard is whether a “reasonable minority” of clinicians would agree. In the case of “Pearls,” we are willing to print recommendations that are endorsed by a reasonable minority, even if they do not represent the majority opinion.

In our regular articles, we are careful to differentiate majority from minority opinion. We have not done that so far in the “Pearls” section. In the future, we will make sure to include an editorial comment in cases like this where most practitioners probably would not endorse the author’s opinion.

To be honest, I am pretty sure that I have seen patients who had ADHD who also became cocaine abusers.

J. Randolph Hillard, MD
Editor-in-chief

Attention-deficit/hyperactivity disorder, or ADHD, affects 4% to 5% of youths worldwide and is the most common neurobehavioral disorder treated in children.¹ Recent research and clinical experience are changing our understanding of ADHD in two important ways:

First, we now recognize that ADHD is often chronic. Its symptoms and/or associated impairment persist into adolescence in approximately three-quarters of cases and into adulthood in approximately one-half of childhood cases.^2-3 Throughout the lifespan, ADHD is associated with significant psychopathology, school and occupational failure, and peer and emotional difficulties.⁴

Second, the presence of impaired cognition has largely replaced the view that ADHD was characterized primarily by overactivity and impulsivity.⁵ This insight is leading to innovations in pharmacotherapy that offer youths and adults improved control of ADHD symptoms, with less-frequent dosing and lower risk of side effects.

Neurobiology

Although the precise neurobiology of ADHD remains unknown, frontal network abnormality or frontal-striatal dysfunction appears critical.⁶ Catecholamine dysregulation affecting both the dopaminergic and noradrenergic systems appears to be important in the underlying pathophysiology.⁶ For example, a small replicated study using SPECT imaging found adults with ADHD had twice the dopamine transporter binding potential of age-matched controls.⁷ Recent data also suggest the cholinergic system is involved in mediating symptoms of ADHD, particularly attentional regulation. Data from adoption, twin, and family-genetic studies suggest a genetic contribution in ADHD, with molecular studies focusing on the dopamine D2, D4, and the dopamine transporter as candidate genes.⁸

Diagnosis

Symptoms of ADHD are related to the patient’s age at presentation. In youth, ADHD is characterized by inattention, distractibility, impulsivity, and hyperactivity excessive for the child’s developmental level.^1,5 Other symptoms include low frustration tolerance, frequent shifting of activities, difficulty organizing tasks, and daydreaming. While these symptoms are typically pervasive, they may not occur in all settings.

Older adolescents and adults tend to present with prominent attentional difficulties (distractibility, shifting activities frequently, forgetfulness, disorganization) that affect work, schooling, and relationships.⁹ These older patients frequently also manifest residual impulsivity (intrusiveness, impatience) and hyperactivity (fidgetiness, restlessness).⁶ Adults with ADHD have a history of childhood onset of the disorder, with persistence through adolescence and beyond. Diagnosis of adult ADHD requires evidence of impairment in academic, work, and interpersonal domains.

Table 1

DSM-IV CRITERIA FOR DIAGNOSING ADHD

1. Either (1) or (2)
2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7.
3. Some impairment from the symptoms is present in two or more settings (e.g., at school/work or at home).
4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
5. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychiatric disorder and are not better accounted for by a mood, anxiety, dissociative, personality, or other mental disorder.

Code based on type:

314.01 ADHD, Combined Type—if both criteria A1 and A2 have been met for the past 6 months.

314.00 ADHD, Predominantly Inattentive Type—if criterion A1 has been met but criterion A2 has not been met for the past 6 months.

314.01 ADHD, Predominantly Hyperactive-Impulsive Type—if criterion A2 has been met but criterion A1 has not been met for the past 6 months.

(Specify “In partial remission” in patients whose symptoms no longer meet full criteria).

Adapted from: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision. Washington: American Psychiatric Association, 2000.

DSM-IV recognizes three subtypes of ADHD based on presenting symptoms:

• predominantly inattentive (20% to 30% of cases);
• predominantly hyperactive-impulsive (<15%);
• combined inattentive and hyperactive-impulsive (50% to 75%).

ADHD is diagnosed by clinical history, applying DSM-IV criteria ( Table 1). Rating scales, checklists, and neuropsychological batteries—although not diagnostic—may help provide evidence for the disorder and accompanying comorbid conditions (e.g., Conners Rating Scales, Brown Rating Scales).⁵

Complicating the clinical picture of ADHD is the common co-occurrence of other psychiatric disorders. Almost three-quarters of individuals with ADHD have psychiatric comorbidity, including:

• oppositional disorders (40% to 60% of ADHD cases);
• conduct disorders (10% to 20%);
• anxiety disorders (30% to 40%);
• mood disorders (20% to 30%).¹⁰

For example, although few people with ADHD develop bipolar illness, an excess of ADHD is reported in depressed (20% to 30%) and bipolar youth (50% to 90%).¹¹ ADHD and its associated comorbid conditions also place sufferers at risk for higher rates and younger onset of cigarette smoking and substance abuse.¹² Most studies, however, indicate that pharmacotherapy reduces the risk for later drug and alcohol use disorders.¹³

Treatment

Management of ADHD includes nonpharmacologic and pharmacologic interventions.¹ Support groups (e.g., Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), www.chadd.org) are invaluable and inexpensive sources of information about ADHD.

For children in school, a specialized educational plan with frequent re-evaluations of the child’s progress is recommended. Encourage parents to work closely with the child’s teacher, guidance counselor, or school psychologist. Children with ADHD tend to perform better in school when given structure, a predictable routine, checked homework, learning aids, and resource room time.⁵ Specific remediation plans are recommended for comorbid learning disorders, found in approximately one-third of individuals with ADHD.

Adults with ADHD may need to modify their school or work settings to function well. College students should be encouraged to use their school’s study center, and may require accommodations for taking examinations.

Focused cognitive behavioral therapies have shown benefit in children, adolescents, and adults with ADHD.¹⁴ Training children and their parents in behavioral modification can help control the child’s disruptive behaviors, inflexibility, anxiety, or outbursts. Other useful adjuncts to treatment include remediation to improve interpersonal skills and coaching to address organization and study skills.

Pharmacotherapy

Medications are fundamental in treating ADHD¹ (Table 2). In fact, a 14-month, multisite study demonstrated that medication management of ADHD was the most important variable in outcome when patients received combined pharmacologic and nonpharmacologic therapies.¹⁵ Stimulants, antihypertensives, and antidepressants are used to treat ADHD symptoms. Children, adolescents, and adults with ADHD respond similarly to pharmacotherapy.¹⁶

Psychostimulants: First-line agents

Psychostimulants are first-line agents for ADHD, based in part on extensive data showing efficacy (>250 controlled trials) and safety.^17,18 Stimulants are sympathomimetic drugs that increase intrasynaptic catecholamines (mainly dopamine) by inhibiting the presynaptic reuptake mechanism (amphetamine, methylphenidate, and pemoline) and releasing presynaptic catecholamines (amphetamine).¹⁹ Methylphenidate, dextroamphetamine, amphetamine compounds, and magnesium pemoline are among the most commonly used compounds in this class.

New approaches Prescribing stimulants for ADHD has changed in two fundamental ways. Frist, in the past we covered a child’s ADHD symptoms only during school hours, but we now include time after school and weekends and holidays. Second, we also are using longer-acting stimulant preparations, which recently became available. Extended-release preparations are usually preferred for lack of in-school dosing requirements, improved compliance, reduced stigma and wear-off, and lower risk of abuse or diversion—i.e., the medication being given or sold by an individual with ADHD to someone who is using it recreationally.

Short-acting compounds such as methylphenidate, D-methylphenidate, and D-amphetamine begin working within 30 to 60 minutes. Their clinical effect usually peaks 1 and 2 hours after administration and lasts 2 to 5 hours. The amphetamine compounds (e.g., Adderall) and older sustained-release methylphenidate begin working within 60 minutes, with a clinical effect that usually peaks between 1 and 3 hours and is maintained for 5 to 8 hours).

Table 2

RECOMMENDED DOSING OF PSYCHOSTIMULANTS FOR ADHD

Newer extended-release methylphenidate products (e.g., Ritalin LA and Metadate CD), with 8 to 9 hours’ duration of action, were developed to approximate twice-daily short-acting methylphenidate. The Concerta brand of methylphenidate, with 10 to 12 hours’ duration of action, approximates short-acting methylphenidate given three times daily. The extended-release Adderall XR brand of amphetamine compound, with a 10- to 12-hour duration of action, is similar to twice-daily Adderall.

Methylphenidate is the most studied, but among the available stimulants the literature suggests more similarities than differences in patient response.^17,18 Because of the agents’ marginally different mechanisms of action, however, some patients who do not respond satisfactorily to one stimulant or manifest adverse effects may respond more favorably to another agent of this type.

Start stimulants at the lowest available dose and increase every 3 to 4 days until a response is noted or adverse effects emerge. Dose-response data indicate more robust response at higher dosages of stimulants; therefore, efficacy—rather than onset of side effects—should guide titration to an optimal dose.

Predictable short-term adverse effects include reduced appetite, insomnia, edginess, and GI upset.²⁰ To manage these effects, consider when they occur:

• Within 2 hours after administration may signal the need to reduce the dose or change to another preparation.
• Within 4 to 6 hours after administration (e.g., moodiness) suggests the need for a longer-acting preparation or low dosing prior to the anticipated wear-off.

For insomnia, strategies include using a shorter-acting stimulant preparation, reducing the stimulant load in the afternoon, or providing adjunct treatment for the insomnia (i.e., clonidine, imipramine, mirtazapine).¹⁷ Edginess and headaches—more common in adolescents and adults—can be reduced with low-dose beta blockers. For diminished appetite in youths, caloric intake can be enhanced with a hearty breakfast, late-afternoon and evening snacks, and caloric supplements. Appetite enhancers such as cyproheptadine given nightly may be considered. Pemoline may rarely cause hepatitis and requires liver function monitoring.

Chronic use of stimulants is controversial.^17,18 Although stimulants may produce anorexia and weight loss, their effect on a youth’s ultimate height is less certain. Initial reports of a persistent stimulant-associated growth decrease have not been substantiated. Other studies suggest that growth deficits may represent maturational delays related to ADHD rather than to stimulant treatment.²¹

Stimulants may precipitate or exacerbate tic symptoms in children with ADHD. Recent work suggests that stimulants can be used safely in youth with tic disorders,²² although up to one-third may experience worsening of tic symptoms.

Despite case reports of stimulant misuse, there is little data to support stimulant abuse among treated children with ADHD.¹³ However, the diversion of stimulants to youth without ADHD is a concern.

Antidepressants

Antidepressants are generally considered second-line drugs for ADHD.^1,16 Bupropion, an antidepressant with indirect dopamine and noradrenergic effects, has been shown effective in ADHDin controlled trials of both children and adults.^23,24

Bupropion is often prescribed first for complex patients with ADHD and substance abuse or an unstable mood disorder because of its ability to reduce cigarette smoking and improve mood, lack of monitoring requirements, and few adverse effects. Dosing is typically initiated at 100 mg of the sustained-release preparation and increased weekly to a maximum of 300 mg in younger children and 400 mg in older children or adults (i.e., 200 mg bid). Adverse effects include insomnia, activation, irritability, and (rarely) seizures.

The tricyclic antidepressants (TCAs) used in ADHD—imipramine, desipramine and nortriptyline—block the reuptake of neurotransmitters including norepinephrine. TCAs are effective in controlling abnormal behaviors and improving cognitive impairments associated with ADHD, but less so than the stimulants. TCAs are particularly useful when:

• stimulants fail to control ADHD symptoms;
• oppositional behavior, anxiety, tics, or depressive symptoms coexist within ADHD or occur during its treatment.

Desipramine appears to be the most effective TCA for ADHD, followed by nortriptyline and imipramine.^25,26 TCAs are dosed starting with 25 mg/d and slowly increased to a maximum of 5 mg/kg/day (2 mg/kg/day for nortriptyline). Although immediate relief can be seen, a delay of up to 6 weeks for maximal effect is common. Typical adverse effects include dry mouth, constipation, sedation, and weight gain.

Four deaths have been reported in children with ADHD treated with desipramine; however, independent evaluation of these cases failed to support a causal link. As minor increases in heart rate and ECG intervals are predictable with TCAs, ECG monitoring at baseline and at therapeutic dosages is recommended.

Although serotonin reuptake inhibitors are not generally useful for ADHD, venlafaxine appears to have mild efficacy, perhaps because of its dose-dependent noradrenergic reuptake inhibition.²⁷

Monoamine oxidase inhibitors (MAOIs) have been shown effective in juvenile ADHD. Response to treatment is rapid, and standard antidepressant dosing is often necessary.¹⁶ A major limitation to the use of MAOIs is the potential for hypertensive crisis associated with dietetic transgressions and drug interactions.

Other treatment options

Antihypertensives The antihypertensive agents clonidine²⁸ and guanfacine²⁹ are used to treat the hyperactive-impulsive symptoms of ADHD in youth. Clonidine is relatively shortacting, with usual daily dosage ranges from 0.05 to 0.4 mg.²⁸ Guanfacine is longer acting and less potent, with usual daily dosage ranges from 0.5 to 4 mg.²⁹

Antihypertensives have been used to treat ADHD and associated tics, aggression, and sleep disturbances, particularly in younger children.¹⁶ Although sedation is more common with clonidine than guanfacine, both agents may cause depression and rebound hypertension. Cardiovascular monitoring (vital signs, ECG) remains optional.

New agents Novel compounds, along with new preparations and delivery systems of existing stimulant medications, are being investigated for managing ADHD. New agents are being tested in adults with ADHD because adults and youth respond similarly to ADHD medications, and there are ethical concerns about drug testing in children.

Atomoxetine, a noradrenergic reuptake inhibitor under development, has been shown in open and controlled studies of adults and youth³⁰ to be effective in treating ADHD. Atomoxetine appears well tolerated, with no blood monitoring requirements.

Cholinergics and genes Selective use of cholinergic agents (e.g., donepezil) may also be helpful for the cognitive dysfunction in ADHD,²⁴ either as monotherapy or in combination with other agents for ADHD. Multiple centers are investigating the possible link between response to pharmacologic therapy and ADHD genotype.

Combination therapy

Combinations of pharmacologic agents can be used to treat comorbid ADHD, to augment response to a single agent, for pharmacokinetic synergism, and to manage adverse effects that emerge during treatment. Examples include:

• a tricyclic antidepressant and a stimulant to heighten response to treatment;
• an antidepressant plus a stimulant for ADHD and comorbid depression;
• adjunctive use of clonidine for sleep or to manage aggressive behavior;
• use of mood stabilizers with ADHD medications for comorbid bipolar disorder.¹⁶

Pharmacologic intervention for prominent concomitant mood disorders (depression and bipolarity) and anxiety should be sequenced prior to ADHD treatment.

Summary of treatment recommendations

Based on efficacy and safety, stimulants are first-line agents for routine management of ADHD, followed by antidepressants and antihypertensives. Patients who do not respond to the initial stimulant or who manifest adverse effects should be considered for a trial with an alternate stimulant. If two stimulant trials are unsuccessful, bupropion and the tricyclic antidepressants are reasonable second-line agents.

Antihypertensives alone or in combination with other ADHD medication may help youths with tics,³¹ prominent hyperactivity, impulsivity, or aggressiveness. MAOIs may be considered for refractory patients, and cholinergic agents (e.g., donepezil) may be used for excessive cognitive difficulties such as organization, planning, and time management.

Related resources

• Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: The Guilford Press, 1998.
• Wilens T. Straight Talk About Psychiatric Medications for Kids. New York: The Guilford Press, 1998.
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), www.chadd.org

Drug brand names

• Atomoxetine • (under development)
• Bupropion • Wellbutrin
• Clonidine • Catapress
• Dextro-amphetamine • Dexedrine
• Dexmethylphenidate • Focalin
• Donepezil • Aricept
• Guanfacine • Tenex
• Methylphenidate • Ritalin, Concerta, Metadate
• Pemoline • Cylert
• Venlafaxine • Effexor

Disclosure

Dr. Biederman reports that he receives research/grant support from, and is on the speaker’s bureau and advisory boards of Eli Lilly & Co. and Shire Laboratories. He also reports that he receives research/grant support from Wyeth-Ayerst Pharmaceuticals, Pfizer Inc., Cephalon Pharmaceutical, Janssen Pharmaceutica, and Noven Pharmaceutical; is on the speaker's bureau of GlaxoSmithKline, Pfizer Inc., Wyeth-Ayerst Pharmaceuticals, Alza/McNeil Pharmaceutical and Cephalon Pharmaceutical; and is on the advisory board of Cell Tech, Noven Pharmaceutical, and Alza/McNeil Pharmaceuticals.

Drs. Wilens and Spencer report that they receive research/grant support from, are on the speakers bureau of, and/or serve as consultants to Abbott Laboratories, McNeil Pharmaceuticals, Celltech Medieva, GlaxoSmithKline, Eli Lilly & Co., Novartis Pharmaceuticals Corp., Pfizer Inc., Shire Pharmaceuticals Group, and Wyeth-Ayerst Pharmaceuticals.

Attention-deficit/hyperactivity disorder, or ADHD, affects 4% to 5% of youths worldwide and is the most common neurobehavioral disorder treated in children.¹ Recent research and clinical experience are changing our understanding of ADHD in two important ways:

First, we now recognize that ADHD is often chronic. Its symptoms and/or associated impairment persist into adolescence in approximately three-quarters of cases and into adulthood in approximately one-half of childhood cases.^2-3 Throughout the lifespan, ADHD is associated with significant psychopathology, school and occupational failure, and peer and emotional difficulties.⁴

Second, the presence of impaired cognition has largely replaced the view that ADHD was characterized primarily by overactivity and impulsivity.⁵ This insight is leading to innovations in pharmacotherapy that offer youths and adults improved control of ADHD symptoms, with less-frequent dosing and lower risk of side effects.

Neurobiology

Although the precise neurobiology of ADHD remains unknown, frontal network abnormality or frontal-striatal dysfunction appears critical.⁶ Catecholamine dysregulation affecting both the dopaminergic and noradrenergic systems appears to be important in the underlying pathophysiology.⁶ For example, a small replicated study using SPECT imaging found adults with ADHD had twice the dopamine transporter binding potential of age-matched controls.⁷ Recent data also suggest the cholinergic system is involved in mediating symptoms of ADHD, particularly attentional regulation. Data from adoption, twin, and family-genetic studies suggest a genetic contribution in ADHD, with molecular studies focusing on the dopamine D2, D4, and the dopamine transporter as candidate genes.⁸

Diagnosis

Symptoms of ADHD are related to the patient’s age at presentation. In youth, ADHD is characterized by inattention, distractibility, impulsivity, and hyperactivity excessive for the child’s developmental level.^1,5 Other symptoms include low frustration tolerance, frequent shifting of activities, difficulty organizing tasks, and daydreaming. While these symptoms are typically pervasive, they may not occur in all settings.

Older adolescents and adults tend to present with prominent attentional difficulties (distractibility, shifting activities frequently, forgetfulness, disorganization) that affect work, schooling, and relationships.⁹ These older patients frequently also manifest residual impulsivity (intrusiveness, impatience) and hyperactivity (fidgetiness, restlessness).⁶ Adults with ADHD have a history of childhood onset of the disorder, with persistence through adolescence and beyond. Diagnosis of adult ADHD requires evidence of impairment in academic, work, and interpersonal domains.

Table 1

DSM-IV CRITERIA FOR DIAGNOSING ADHD

1. Either (1) or (2)
2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7.
3. Some impairment from the symptoms is present in two or more settings (e.g., at school/work or at home).
4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
5. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychiatric disorder and are not better accounted for by a mood, anxiety, dissociative, personality, or other mental disorder.

Code based on type:

314.01 ADHD, Combined Type—if both criteria A1 and A2 have been met for the past 6 months.

314.00 ADHD, Predominantly Inattentive Type—if criterion A1 has been met but criterion A2 has not been met for the past 6 months.

314.01 ADHD, Predominantly Hyperactive-Impulsive Type—if criterion A2 has been met but criterion A1 has not been met for the past 6 months.

(Specify “In partial remission” in patients whose symptoms no longer meet full criteria).

Adapted from: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision. Washington: American Psychiatric Association, 2000.

DSM-IV recognizes three subtypes of ADHD based on presenting symptoms:

• predominantly inattentive (20% to 30% of cases);
• predominantly hyperactive-impulsive (<15%);
• combined inattentive and hyperactive-impulsive (50% to 75%).

ADHD is diagnosed by clinical history, applying DSM-IV criteria ( Table 1). Rating scales, checklists, and neuropsychological batteries—although not diagnostic—may help provide evidence for the disorder and accompanying comorbid conditions (e.g., Conners Rating Scales, Brown Rating Scales).⁵

Complicating the clinical picture of ADHD is the common co-occurrence of other psychiatric disorders. Almost three-quarters of individuals with ADHD have psychiatric comorbidity, including:

• oppositional disorders (40% to 60% of ADHD cases);
• conduct disorders (10% to 20%);
• anxiety disorders (30% to 40%);
• mood disorders (20% to 30%).¹⁰

For example, although few people with ADHD develop bipolar illness, an excess of ADHD is reported in depressed (20% to 30%) and bipolar youth (50% to 90%).¹¹ ADHD and its associated comorbid conditions also place sufferers at risk for higher rates and younger onset of cigarette smoking and substance abuse.¹² Most studies, however, indicate that pharmacotherapy reduces the risk for later drug and alcohol use disorders.¹³

Treatment

Management of ADHD includes nonpharmacologic and pharmacologic interventions.¹ Support groups (e.g., Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), www.chadd.org) are invaluable and inexpensive sources of information about ADHD.

For children in school, a specialized educational plan with frequent re-evaluations of the child’s progress is recommended. Encourage parents to work closely with the child’s teacher, guidance counselor, or school psychologist. Children with ADHD tend to perform better in school when given structure, a predictable routine, checked homework, learning aids, and resource room time.⁵ Specific remediation plans are recommended for comorbid learning disorders, found in approximately one-third of individuals with ADHD.

Adults with ADHD may need to modify their school or work settings to function well. College students should be encouraged to use their school’s study center, and may require accommodations for taking examinations.

Focused cognitive behavioral therapies have shown benefit in children, adolescents, and adults with ADHD.¹⁴ Training children and their parents in behavioral modification can help control the child’s disruptive behaviors, inflexibility, anxiety, or outbursts. Other useful adjuncts to treatment include remediation to improve interpersonal skills and coaching to address organization and study skills.

Pharmacotherapy

Medications are fundamental in treating ADHD¹ (Table 2). In fact, a 14-month, multisite study demonstrated that medication management of ADHD was the most important variable in outcome when patients received combined pharmacologic and nonpharmacologic therapies.¹⁵ Stimulants, antihypertensives, and antidepressants are used to treat ADHD symptoms. Children, adolescents, and adults with ADHD respond similarly to pharmacotherapy.¹⁶

Psychostimulants: First-line agents

Psychostimulants are first-line agents for ADHD, based in part on extensive data showing efficacy (>250 controlled trials) and safety.^17,18 Stimulants are sympathomimetic drugs that increase intrasynaptic catecholamines (mainly dopamine) by inhibiting the presynaptic reuptake mechanism (amphetamine, methylphenidate, and pemoline) and releasing presynaptic catecholamines (amphetamine).¹⁹ Methylphenidate, dextroamphetamine, amphetamine compounds, and magnesium pemoline are among the most commonly used compounds in this class.

New approaches Prescribing stimulants for ADHD has changed in two fundamental ways. Frist, in the past we covered a child’s ADHD symptoms only during school hours, but we now include time after school and weekends and holidays. Second, we also are using longer-acting stimulant preparations, which recently became available. Extended-release preparations are usually preferred for lack of in-school dosing requirements, improved compliance, reduced stigma and wear-off, and lower risk of abuse or diversion—i.e., the medication being given or sold by an individual with ADHD to someone who is using it recreationally.

Short-acting compounds such as methylphenidate, D-methylphenidate, and D-amphetamine begin working within 30 to 60 minutes. Their clinical effect usually peaks 1 and 2 hours after administration and lasts 2 to 5 hours. The amphetamine compounds (e.g., Adderall) and older sustained-release methylphenidate begin working within 60 minutes, with a clinical effect that usually peaks between 1 and 3 hours and is maintained for 5 to 8 hours).

Table 2

RECOMMENDED DOSING OF PSYCHOSTIMULANTS FOR ADHD

Newer extended-release methylphenidate products (e.g., Ritalin LA and Metadate CD), with 8 to 9 hours’ duration of action, were developed to approximate twice-daily short-acting methylphenidate. The Concerta brand of methylphenidate, with 10 to 12 hours’ duration of action, approximates short-acting methylphenidate given three times daily. The extended-release Adderall XR brand of amphetamine compound, with a 10- to 12-hour duration of action, is similar to twice-daily Adderall.

Methylphenidate is the most studied, but among the available stimulants the literature suggests more similarities than differences in patient response.^17,18 Because of the agents’ marginally different mechanisms of action, however, some patients who do not respond satisfactorily to one stimulant or manifest adverse effects may respond more favorably to another agent of this type.

Start stimulants at the lowest available dose and increase every 3 to 4 days until a response is noted or adverse effects emerge. Dose-response data indicate more robust response at higher dosages of stimulants; therefore, efficacy—rather than onset of side effects—should guide titration to an optimal dose.

Predictable short-term adverse effects include reduced appetite, insomnia, edginess, and GI upset.²⁰ To manage these effects, consider when they occur:

• Within 2 hours after administration may signal the need to reduce the dose or change to another preparation.
• Within 4 to 6 hours after administration (e.g., moodiness) suggests the need for a longer-acting preparation or low dosing prior to the anticipated wear-off.

For insomnia, strategies include using a shorter-acting stimulant preparation, reducing the stimulant load in the afternoon, or providing adjunct treatment for the insomnia (i.e., clonidine, imipramine, mirtazapine).¹⁷ Edginess and headaches—more common in adolescents and adults—can be reduced with low-dose beta blockers. For diminished appetite in youths, caloric intake can be enhanced with a hearty breakfast, late-afternoon and evening snacks, and caloric supplements. Appetite enhancers such as cyproheptadine given nightly may be considered. Pemoline may rarely cause hepatitis and requires liver function monitoring.

Chronic use of stimulants is controversial.^17,18 Although stimulants may produce anorexia and weight loss, their effect on a youth’s ultimate height is less certain. Initial reports of a persistent stimulant-associated growth decrease have not been substantiated. Other studies suggest that growth deficits may represent maturational delays related to ADHD rather than to stimulant treatment.²¹

Stimulants may precipitate or exacerbate tic symptoms in children with ADHD. Recent work suggests that stimulants can be used safely in youth with tic disorders,²² although up to one-third may experience worsening of tic symptoms.

Despite case reports of stimulant misuse, there is little data to support stimulant abuse among treated children with ADHD.¹³ However, the diversion of stimulants to youth without ADHD is a concern.

Antidepressants

Antidepressants are generally considered second-line drugs for ADHD.^1,16 Bupropion, an antidepressant with indirect dopamine and noradrenergic effects, has been shown effective in ADHDin controlled trials of both children and adults.^23,24

Bupropion is often prescribed first for complex patients with ADHD and substance abuse or an unstable mood disorder because of its ability to reduce cigarette smoking and improve mood, lack of monitoring requirements, and few adverse effects. Dosing is typically initiated at 100 mg of the sustained-release preparation and increased weekly to a maximum of 300 mg in younger children and 400 mg in older children or adults (i.e., 200 mg bid). Adverse effects include insomnia, activation, irritability, and (rarely) seizures.

The tricyclic antidepressants (TCAs) used in ADHD—imipramine, desipramine and nortriptyline—block the reuptake of neurotransmitters including norepinephrine. TCAs are effective in controlling abnormal behaviors and improving cognitive impairments associated with ADHD, but less so than the stimulants. TCAs are particularly useful when:

• stimulants fail to control ADHD symptoms;
• oppositional behavior, anxiety, tics, or depressive symptoms coexist within ADHD or occur during its treatment.

Desipramine appears to be the most effective TCA for ADHD, followed by nortriptyline and imipramine.^25,26 TCAs are dosed starting with 25 mg/d and slowly increased to a maximum of 5 mg/kg/day (2 mg/kg/day for nortriptyline). Although immediate relief can be seen, a delay of up to 6 weeks for maximal effect is common. Typical adverse effects include dry mouth, constipation, sedation, and weight gain.

Four deaths have been reported in children with ADHD treated with desipramine; however, independent evaluation of these cases failed to support a causal link. As minor increases in heart rate and ECG intervals are predictable with TCAs, ECG monitoring at baseline and at therapeutic dosages is recommended.

Although serotonin reuptake inhibitors are not generally useful for ADHD, venlafaxine appears to have mild efficacy, perhaps because of its dose-dependent noradrenergic reuptake inhibition.²⁷

Monoamine oxidase inhibitors (MAOIs) have been shown effective in juvenile ADHD. Response to treatment is rapid, and standard antidepressant dosing is often necessary.¹⁶ A major limitation to the use of MAOIs is the potential for hypertensive crisis associated with dietetic transgressions and drug interactions.

Other treatment options

Antihypertensives The antihypertensive agents clonidine²⁸ and guanfacine²⁹ are used to treat the hyperactive-impulsive symptoms of ADHD in youth. Clonidine is relatively shortacting, with usual daily dosage ranges from 0.05 to 0.4 mg.²⁸ Guanfacine is longer acting and less potent, with usual daily dosage ranges from 0.5 to 4 mg.²⁹

Antihypertensives have been used to treat ADHD and associated tics, aggression, and sleep disturbances, particularly in younger children.¹⁶ Although sedation is more common with clonidine than guanfacine, both agents may cause depression and rebound hypertension. Cardiovascular monitoring (vital signs, ECG) remains optional.

New agents Novel compounds, along with new preparations and delivery systems of existing stimulant medications, are being investigated for managing ADHD. New agents are being tested in adults with ADHD because adults and youth respond similarly to ADHD medications, and there are ethical concerns about drug testing in children.

Atomoxetine, a noradrenergic reuptake inhibitor under development, has been shown in open and controlled studies of adults and youth³⁰ to be effective in treating ADHD. Atomoxetine appears well tolerated, with no blood monitoring requirements.

Cholinergics and genes Selective use of cholinergic agents (e.g., donepezil) may also be helpful for the cognitive dysfunction in ADHD,²⁴ either as monotherapy or in combination with other agents for ADHD. Multiple centers are investigating the possible link between response to pharmacologic therapy and ADHD genotype.

Combination therapy

Combinations of pharmacologic agents can be used to treat comorbid ADHD, to augment response to a single agent, for pharmacokinetic synergism, and to manage adverse effects that emerge during treatment. Examples include:

• a tricyclic antidepressant and a stimulant to heighten response to treatment;
• an antidepressant plus a stimulant for ADHD and comorbid depression;
• adjunctive use of clonidine for sleep or to manage aggressive behavior;
• use of mood stabilizers with ADHD medications for comorbid bipolar disorder.¹⁶

Pharmacologic intervention for prominent concomitant mood disorders (depression and bipolarity) and anxiety should be sequenced prior to ADHD treatment.

Summary of treatment recommendations

Based on efficacy and safety, stimulants are first-line agents for routine management of ADHD, followed by antidepressants and antihypertensives. Patients who do not respond to the initial stimulant or who manifest adverse effects should be considered for a trial with an alternate stimulant. If two stimulant trials are unsuccessful, bupropion and the tricyclic antidepressants are reasonable second-line agents.

Antihypertensives alone or in combination with other ADHD medication may help youths with tics,³¹ prominent hyperactivity, impulsivity, or aggressiveness. MAOIs may be considered for refractory patients, and cholinergic agents (e.g., donepezil) may be used for excessive cognitive difficulties such as organization, planning, and time management.

Related resources

• Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: The Guilford Press, 1998.
• Wilens T. Straight Talk About Psychiatric Medications for Kids. New York: The Guilford Press, 1998.
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), www.chadd.org

Drug brand names

• Atomoxetine • (under development)
• Bupropion • Wellbutrin
• Clonidine • Catapress
• Dextro-amphetamine • Dexedrine
• Dexmethylphenidate • Focalin
• Donepezil • Aricept
• Guanfacine • Tenex
• Methylphenidate • Ritalin, Concerta, Metadate
• Pemoline • Cylert
• Venlafaxine • Effexor

Disclosure

Dr. Biederman reports that he receives research/grant support from, and is on the speaker’s bureau and advisory boards of Eli Lilly & Co. and Shire Laboratories. He also reports that he receives research/grant support from Wyeth-Ayerst Pharmaceuticals, Pfizer Inc., Cephalon Pharmaceutical, Janssen Pharmaceutica, and Noven Pharmaceutical; is on the speaker's bureau of GlaxoSmithKline, Pfizer Inc., Wyeth-Ayerst Pharmaceuticals, Alza/McNeil Pharmaceutical and Cephalon Pharmaceutical; and is on the advisory board of Cell Tech, Noven Pharmaceutical, and Alza/McNeil Pharmaceuticals.

Drs. Wilens and Spencer report that they receive research/grant support from, are on the speakers bureau of, and/or serve as consultants to Abbott Laboratories, McNeil Pharmaceuticals, Celltech Medieva, GlaxoSmithKline, Eli Lilly & Co., Novartis Pharmaceuticals Corp., Pfizer Inc., Shire Pharmaceuticals Group, and Wyeth-Ayerst Pharmaceuticals.

Attention-deficit/hyperactivity disorder, or ADHD, affects 4% to 5% of youths worldwide and is the most common neurobehavioral disorder treated in children.¹ Recent research and clinical experience are changing our understanding of ADHD in two important ways:

First, we now recognize that ADHD is often chronic. Its symptoms and/or associated impairment persist into adolescence in approximately three-quarters of cases and into adulthood in approximately one-half of childhood cases.^2-3 Throughout the lifespan, ADHD is associated with significant psychopathology, school and occupational failure, and peer and emotional difficulties.⁴

Second, the presence of impaired cognition has largely replaced the view that ADHD was characterized primarily by overactivity and impulsivity.⁵ This insight is leading to innovations in pharmacotherapy that offer youths and adults improved control of ADHD symptoms, with less-frequent dosing and lower risk of side effects.

Neurobiology

Although the precise neurobiology of ADHD remains unknown, frontal network abnormality or frontal-striatal dysfunction appears critical.⁶ Catecholamine dysregulation affecting both the dopaminergic and noradrenergic systems appears to be important in the underlying pathophysiology.⁶ For example, a small replicated study using SPECT imaging found adults with ADHD had twice the dopamine transporter binding potential of age-matched controls.⁷ Recent data also suggest the cholinergic system is involved in mediating symptoms of ADHD, particularly attentional regulation. Data from adoption, twin, and family-genetic studies suggest a genetic contribution in ADHD, with molecular studies focusing on the dopamine D2, D4, and the dopamine transporter as candidate genes.⁸

Diagnosis

Symptoms of ADHD are related to the patient’s age at presentation. In youth, ADHD is characterized by inattention, distractibility, impulsivity, and hyperactivity excessive for the child’s developmental level.^1,5 Other symptoms include low frustration tolerance, frequent shifting of activities, difficulty organizing tasks, and daydreaming. While these symptoms are typically pervasive, they may not occur in all settings.

Older adolescents and adults tend to present with prominent attentional difficulties (distractibility, shifting activities frequently, forgetfulness, disorganization) that affect work, schooling, and relationships.⁹ These older patients frequently also manifest residual impulsivity (intrusiveness, impatience) and hyperactivity (fidgetiness, restlessness).⁶ Adults with ADHD have a history of childhood onset of the disorder, with persistence through adolescence and beyond. Diagnosis of adult ADHD requires evidence of impairment in academic, work, and interpersonal domains.

Table 1

DSM-IV CRITERIA FOR DIAGNOSING ADHD

1. Either (1) or (2)
2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7.
3. Some impairment from the symptoms is present in two or more settings (e.g., at school/work or at home).
4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
5. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychiatric disorder and are not better accounted for by a mood, anxiety, dissociative, personality, or other mental disorder.

Code based on type:

314.01 ADHD, Combined Type—if both criteria A1 and A2 have been met for the past 6 months.

314.00 ADHD, Predominantly Inattentive Type—if criterion A1 has been met but criterion A2 has not been met for the past 6 months.

314.01 ADHD, Predominantly Hyperactive-Impulsive Type—if criterion A2 has been met but criterion A1 has not been met for the past 6 months.

(Specify “In partial remission” in patients whose symptoms no longer meet full criteria).

Adapted from: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision. Washington: American Psychiatric Association, 2000.

DSM-IV recognizes three subtypes of ADHD based on presenting symptoms:

• predominantly inattentive (20% to 30% of cases);
• predominantly hyperactive-impulsive (<15%);
• combined inattentive and hyperactive-impulsive (50% to 75%).

ADHD is diagnosed by clinical history, applying DSM-IV criteria ( Table 1). Rating scales, checklists, and neuropsychological batteries—although not diagnostic—may help provide evidence for the disorder and accompanying comorbid conditions (e.g., Conners Rating Scales, Brown Rating Scales).⁵

Complicating the clinical picture of ADHD is the common co-occurrence of other psychiatric disorders. Almost three-quarters of individuals with ADHD have psychiatric comorbidity, including:

• oppositional disorders (40% to 60% of ADHD cases);
• conduct disorders (10% to 20%);
• anxiety disorders (30% to 40%);
• mood disorders (20% to 30%).¹⁰

For example, although few people with ADHD develop bipolar illness, an excess of ADHD is reported in depressed (20% to 30%) and bipolar youth (50% to 90%).¹¹ ADHD and its associated comorbid conditions also place sufferers at risk for higher rates and younger onset of cigarette smoking and substance abuse.¹² Most studies, however, indicate that pharmacotherapy reduces the risk for later drug and alcohol use disorders.¹³

Treatment

Management of ADHD includes nonpharmacologic and pharmacologic interventions.¹ Support groups (e.g., Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), www.chadd.org) are invaluable and inexpensive sources of information about ADHD.

For children in school, a specialized educational plan with frequent re-evaluations of the child’s progress is recommended. Encourage parents to work closely with the child’s teacher, guidance counselor, or school psychologist. Children with ADHD tend to perform better in school when given structure, a predictable routine, checked homework, learning aids, and resource room time.⁵ Specific remediation plans are recommended for comorbid learning disorders, found in approximately one-third of individuals with ADHD.

Adults with ADHD may need to modify their school or work settings to function well. College students should be encouraged to use their school’s study center, and may require accommodations for taking examinations.

Focused cognitive behavioral therapies have shown benefit in children, adolescents, and adults with ADHD.¹⁴ Training children and their parents in behavioral modification can help control the child’s disruptive behaviors, inflexibility, anxiety, or outbursts. Other useful adjuncts to treatment include remediation to improve interpersonal skills and coaching to address organization and study skills.

Pharmacotherapy

Medications are fundamental in treating ADHD¹ (Table 2). In fact, a 14-month, multisite study demonstrated that medication management of ADHD was the most important variable in outcome when patients received combined pharmacologic and nonpharmacologic therapies.¹⁵ Stimulants, antihypertensives, and antidepressants are used to treat ADHD symptoms. Children, adolescents, and adults with ADHD respond similarly to pharmacotherapy.¹⁶

Psychostimulants: First-line agents

Psychostimulants are first-line agents for ADHD, based in part on extensive data showing efficacy (>250 controlled trials) and safety.^17,18 Stimulants are sympathomimetic drugs that increase intrasynaptic catecholamines (mainly dopamine) by inhibiting the presynaptic reuptake mechanism (amphetamine, methylphenidate, and pemoline) and releasing presynaptic catecholamines (amphetamine).¹⁹ Methylphenidate, dextroamphetamine, amphetamine compounds, and magnesium pemoline are among the most commonly used compounds in this class.

New approaches Prescribing stimulants for ADHD has changed in two fundamental ways. Frist, in the past we covered a child’s ADHD symptoms only during school hours, but we now include time after school and weekends and holidays. Second, we also are using longer-acting stimulant preparations, which recently became available. Extended-release preparations are usually preferred for lack of in-school dosing requirements, improved compliance, reduced stigma and wear-off, and lower risk of abuse or diversion—i.e., the medication being given or sold by an individual with ADHD to someone who is using it recreationally.

Short-acting compounds such as methylphenidate, D-methylphenidate, and D-amphetamine begin working within 30 to 60 minutes. Their clinical effect usually peaks 1 and 2 hours after administration and lasts 2 to 5 hours. The amphetamine compounds (e.g., Adderall) and older sustained-release methylphenidate begin working within 60 minutes, with a clinical effect that usually peaks between 1 and 3 hours and is maintained for 5 to 8 hours).

Table 2

RECOMMENDED DOSING OF PSYCHOSTIMULANTS FOR ADHD

Newer extended-release methylphenidate products (e.g., Ritalin LA and Metadate CD), with 8 to 9 hours’ duration of action, were developed to approximate twice-daily short-acting methylphenidate. The Concerta brand of methylphenidate, with 10 to 12 hours’ duration of action, approximates short-acting methylphenidate given three times daily. The extended-release Adderall XR brand of amphetamine compound, with a 10- to 12-hour duration of action, is similar to twice-daily Adderall.

Methylphenidate is the most studied, but among the available stimulants the literature suggests more similarities than differences in patient response.^17,18 Because of the agents’ marginally different mechanisms of action, however, some patients who do not respond satisfactorily to one stimulant or manifest adverse effects may respond more favorably to another agent of this type.

Start stimulants at the lowest available dose and increase every 3 to 4 days until a response is noted or adverse effects emerge. Dose-response data indicate more robust response at higher dosages of stimulants; therefore, efficacy—rather than onset of side effects—should guide titration to an optimal dose.

Predictable short-term adverse effects include reduced appetite, insomnia, edginess, and GI upset.²⁰ To manage these effects, consider when they occur:

• Within 2 hours after administration may signal the need to reduce the dose or change to another preparation.
• Within 4 to 6 hours after administration (e.g., moodiness) suggests the need for a longer-acting preparation or low dosing prior to the anticipated wear-off.

For insomnia, strategies include using a shorter-acting stimulant preparation, reducing the stimulant load in the afternoon, or providing adjunct treatment for the insomnia (i.e., clonidine, imipramine, mirtazapine).¹⁷ Edginess and headaches—more common in adolescents and adults—can be reduced with low-dose beta blockers. For diminished appetite in youths, caloric intake can be enhanced with a hearty breakfast, late-afternoon and evening snacks, and caloric supplements. Appetite enhancers such as cyproheptadine given nightly may be considered. Pemoline may rarely cause hepatitis and requires liver function monitoring.

Chronic use of stimulants is controversial.^17,18 Although stimulants may produce anorexia and weight loss, their effect on a youth’s ultimate height is less certain. Initial reports of a persistent stimulant-associated growth decrease have not been substantiated. Other studies suggest that growth deficits may represent maturational delays related to ADHD rather than to stimulant treatment.²¹

Stimulants may precipitate or exacerbate tic symptoms in children with ADHD. Recent work suggests that stimulants can be used safely in youth with tic disorders,²² although up to one-third may experience worsening of tic symptoms.

Despite case reports of stimulant misuse, there is little data to support stimulant abuse among treated children with ADHD.¹³ However, the diversion of stimulants to youth without ADHD is a concern.

Antidepressants

Antidepressants are generally considered second-line drugs for ADHD.^1,16 Bupropion, an antidepressant with indirect dopamine and noradrenergic effects, has been shown effective in ADHDin controlled trials of both children and adults.^23,24

Bupropion is often prescribed first for complex patients with ADHD and substance abuse or an unstable mood disorder because of its ability to reduce cigarette smoking and improve mood, lack of monitoring requirements, and few adverse effects. Dosing is typically initiated at 100 mg of the sustained-release preparation and increased weekly to a maximum of 300 mg in younger children and 400 mg in older children or adults (i.e., 200 mg bid). Adverse effects include insomnia, activation, irritability, and (rarely) seizures.

The tricyclic antidepressants (TCAs) used in ADHD—imipramine, desipramine and nortriptyline—block the reuptake of neurotransmitters including norepinephrine. TCAs are effective in controlling abnormal behaviors and improving cognitive impairments associated with ADHD, but less so than the stimulants. TCAs are particularly useful when:

• stimulants fail to control ADHD symptoms;
• oppositional behavior, anxiety, tics, or depressive symptoms coexist within ADHD or occur during its treatment.

Desipramine appears to be the most effective TCA for ADHD, followed by nortriptyline and imipramine.^25,26 TCAs are dosed starting with 25 mg/d and slowly increased to a maximum of 5 mg/kg/day (2 mg/kg/day for nortriptyline). Although immediate relief can be seen, a delay of up to 6 weeks for maximal effect is common. Typical adverse effects include dry mouth, constipation, sedation, and weight gain.

Four deaths have been reported in children with ADHD treated with desipramine; however, independent evaluation of these cases failed to support a causal link. As minor increases in heart rate and ECG intervals are predictable with TCAs, ECG monitoring at baseline and at therapeutic dosages is recommended.

Although serotonin reuptake inhibitors are not generally useful for ADHD, venlafaxine appears to have mild efficacy, perhaps because of its dose-dependent noradrenergic reuptake inhibition.²⁷

Monoamine oxidase inhibitors (MAOIs) have been shown effective in juvenile ADHD. Response to treatment is rapid, and standard antidepressant dosing is often necessary.¹⁶ A major limitation to the use of MAOIs is the potential for hypertensive crisis associated with dietetic transgressions and drug interactions.

Other treatment options

Antihypertensives The antihypertensive agents clonidine²⁸ and guanfacine²⁹ are used to treat the hyperactive-impulsive symptoms of ADHD in youth. Clonidine is relatively shortacting, with usual daily dosage ranges from 0.05 to 0.4 mg.²⁸ Guanfacine is longer acting and less potent, with usual daily dosage ranges from 0.5 to 4 mg.²⁹

Antihypertensives have been used to treat ADHD and associated tics, aggression, and sleep disturbances, particularly in younger children.¹⁶ Although sedation is more common with clonidine than guanfacine, both agents may cause depression and rebound hypertension. Cardiovascular monitoring (vital signs, ECG) remains optional.

New agents Novel compounds, along with new preparations and delivery systems of existing stimulant medications, are being investigated for managing ADHD. New agents are being tested in adults with ADHD because adults and youth respond similarly to ADHD medications, and there are ethical concerns about drug testing in children.

Atomoxetine, a noradrenergic reuptake inhibitor under development, has been shown in open and controlled studies of adults and youth³⁰ to be effective in treating ADHD. Atomoxetine appears well tolerated, with no blood monitoring requirements.

Cholinergics and genes Selective use of cholinergic agents (e.g., donepezil) may also be helpful for the cognitive dysfunction in ADHD,²⁴ either as monotherapy or in combination with other agents for ADHD. Multiple centers are investigating the possible link between response to pharmacologic therapy and ADHD genotype.

Combination therapy

Combinations of pharmacologic agents can be used to treat comorbid ADHD, to augment response to a single agent, for pharmacokinetic synergism, and to manage adverse effects that emerge during treatment. Examples include:

• a tricyclic antidepressant and a stimulant to heighten response to treatment;
• an antidepressant plus a stimulant for ADHD and comorbid depression;
• adjunctive use of clonidine for sleep or to manage aggressive behavior;
• use of mood stabilizers with ADHD medications for comorbid bipolar disorder.¹⁶

Pharmacologic intervention for prominent concomitant mood disorders (depression and bipolarity) and anxiety should be sequenced prior to ADHD treatment.

Summary of treatment recommendations

Based on efficacy and safety, stimulants are first-line agents for routine management of ADHD, followed by antidepressants and antihypertensives. Patients who do not respond to the initial stimulant or who manifest adverse effects should be considered for a trial with an alternate stimulant. If two stimulant trials are unsuccessful, bupropion and the tricyclic antidepressants are reasonable second-line agents.

Antihypertensives alone or in combination with other ADHD medication may help youths with tics,³¹ prominent hyperactivity, impulsivity, or aggressiveness. MAOIs may be considered for refractory patients, and cholinergic agents (e.g., donepezil) may be used for excessive cognitive difficulties such as organization, planning, and time management.

Related resources

• Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: The Guilford Press, 1998.
• Wilens T. Straight Talk About Psychiatric Medications for Kids. New York: The Guilford Press, 1998.
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), www.chadd.org

Drug brand names

• Atomoxetine • (under development)
• Bupropion • Wellbutrin
• Clonidine • Catapress
• Dextro-amphetamine • Dexedrine
• Dexmethylphenidate • Focalin
• Donepezil • Aricept
• Guanfacine • Tenex
• Methylphenidate • Ritalin, Concerta, Metadate
• Pemoline • Cylert
• Venlafaxine • Effexor

Disclosure

Dr. Biederman reports that he receives research/grant support from, and is on the speaker’s bureau and advisory boards of Eli Lilly & Co. and Shire Laboratories. He also reports that he receives research/grant support from Wyeth-Ayerst Pharmaceuticals, Pfizer Inc., Cephalon Pharmaceutical, Janssen Pharmaceutica, and Noven Pharmaceutical; is on the speaker's bureau of GlaxoSmithKline, Pfizer Inc., Wyeth-Ayerst Pharmaceuticals, Alza/McNeil Pharmaceutical and Cephalon Pharmaceutical; and is on the advisory board of Cell Tech, Noven Pharmaceutical, and Alza/McNeil Pharmaceuticals.

Drs. Wilens and Spencer report that they receive research/grant support from, are on the speakers bureau of, and/or serve as consultants to Abbott Laboratories, McNeil Pharmaceuticals, Celltech Medieva, GlaxoSmithKline, Eli Lilly & Co., Novartis Pharmaceuticals Corp., Pfizer Inc., Shire Pharmaceuticals Group, and Wyeth-Ayerst Pharmaceuticals.

Making a quick diagnosis in a hyperactive, inattentive child is often difficult. The National Institutes of Health concluded in a consensus statement that no independent diagnostic test for attention-deficit/hyperactivity disorder (ADHD) exists.¹ Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a treatment guideline classifying ADHD as a clinical diagnosis.

With the time constraints imposed by managed care organizations, questioning and history gathering must be precisely aimed to elicit specific information. Over the years, I have identified the following 5 red flags that help distinguish ADHD from mood problems,² anxiety, psychosis, obsessions, and other psychiatric disorders.

1. Moodiness is not part of ADHD. The DSM-IV criteria for ADHD do not include elevated mood. “Mood swings,” persistent clowning, or angry affect should prompt further questioning about similar features in relatives. Frequently we hear that “his father was never diagnosed with anything, but he was the class clown.”
2. ADHD is not an intermittent condition. By asking if the child has “good days and bad days,” we can obtain valuable information. ADHD has a biological basis and is present every day, like Parkinson’s disease or diabetes. Obviously, some days can be more challenging than others, but if a parent says, “Some days she is a perfect child,” the possibility of ADHD is small.
3. Symptoms are not present in kindergarten. The child with ADHD begins to show signs of this condition very early in life; parents are frequently informed of problems by preschool and kindergarten teachers. The usual complaints are inability to stay with a task and disrupting the class. Start of these symptoms as late as first or second grade is a red flag to question the ADHD diagnosis.
4. More than one diagnosis probably means “none of the above.” When a child has been diagnosed with conduct disorder (CD) and/or oppositional-defiant disorder (ODD) along with ADHD, chances are that we are missing the real diagnosis. I have seen cases of social anxiety disorder that had been diagnosed as ADHD/ODD because the child was inattentive secondary to nervousness. Incidentally, DSM-IV does not allow the diagnosis of ODD in the presence of CD.
5. Worsening of symptoms is not an expected outcome of stimulant medications for ADHD. Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with histories of getting worse after starting medication for presumed ADHD.

Making a quick diagnosis in a hyperactive, inattentive child is often difficult. The National Institutes of Health concluded in a consensus statement that no independent diagnostic test for attention-deficit/hyperactivity disorder (ADHD) exists.¹ Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a treatment guideline classifying ADHD as a clinical diagnosis.

With the time constraints imposed by managed care organizations, questioning and history gathering must be precisely aimed to elicit specific information. Over the years, I have identified the following 5 red flags that help distinguish ADHD from mood problems,² anxiety, psychosis, obsessions, and other psychiatric disorders.

1. Moodiness is not part of ADHD. The DSM-IV criteria for ADHD do not include elevated mood. “Mood swings,” persistent clowning, or angry affect should prompt further questioning about similar features in relatives. Frequently we hear that “his father was never diagnosed with anything, but he was the class clown.”
2. ADHD is not an intermittent condition. By asking if the child has “good days and bad days,” we can obtain valuable information. ADHD has a biological basis and is present every day, like Parkinson’s disease or diabetes. Obviously, some days can be more challenging than others, but if a parent says, “Some days she is a perfect child,” the possibility of ADHD is small.
3. Symptoms are not present in kindergarten. The child with ADHD begins to show signs of this condition very early in life; parents are frequently informed of problems by preschool and kindergarten teachers. The usual complaints are inability to stay with a task and disrupting the class. Start of these symptoms as late as first or second grade is a red flag to question the ADHD diagnosis.
4. More than one diagnosis probably means “none of the above.” When a child has been diagnosed with conduct disorder (CD) and/or oppositional-defiant disorder (ODD) along with ADHD, chances are that we are missing the real diagnosis. I have seen cases of social anxiety disorder that had been diagnosed as ADHD/ODD because the child was inattentive secondary to nervousness. Incidentally, DSM-IV does not allow the diagnosis of ODD in the presence of CD.
5. Worsening of symptoms is not an expected outcome of stimulant medications for ADHD. Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with histories of getting worse after starting medication for presumed ADHD.

Making a quick diagnosis in a hyperactive, inattentive child is often difficult. The National Institutes of Health concluded in a consensus statement that no independent diagnostic test for attention-deficit/hyperactivity disorder (ADHD) exists.¹ Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a treatment guideline classifying ADHD as a clinical diagnosis.

With the time constraints imposed by managed care organizations, questioning and history gathering must be precisely aimed to elicit specific information. Over the years, I have identified the following 5 red flags that help distinguish ADHD from mood problems,² anxiety, psychosis, obsessions, and other psychiatric disorders.

1. Moodiness is not part of ADHD. The DSM-IV criteria for ADHD do not include elevated mood. “Mood swings,” persistent clowning, or angry affect should prompt further questioning about similar features in relatives. Frequently we hear that “his father was never diagnosed with anything, but he was the class clown.”
2. ADHD is not an intermittent condition. By asking if the child has “good days and bad days,” we can obtain valuable information. ADHD has a biological basis and is present every day, like Parkinson’s disease or diabetes. Obviously, some days can be more challenging than others, but if a parent says, “Some days she is a perfect child,” the possibility of ADHD is small.
3. Symptoms are not present in kindergarten. The child with ADHD begins to show signs of this condition very early in life; parents are frequently informed of problems by preschool and kindergarten teachers. The usual complaints are inability to stay with a task and disrupting the class. Start of these symptoms as late as first or second grade is a red flag to question the ADHD diagnosis.
4. More than one diagnosis probably means “none of the above.” When a child has been diagnosed with conduct disorder (CD) and/or oppositional-defiant disorder (ODD) along with ADHD, chances are that we are missing the real diagnosis. I have seen cases of social anxiety disorder that had been diagnosed as ADHD/ODD because the child was inattentive secondary to nervousness. Incidentally, DSM-IV does not allow the diagnosis of ODD in the presence of CD.
5. Worsening of symptoms is not an expected outcome of stimulant medications for ADHD. Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with histories of getting worse after starting medication for presumed ADHD.