para>The FDA recommends that a personal or family history of congenital heart disease or sudden death be screened with an ECG and possible cardiology consultation before beginning stimulant medication. á
- Precautions:
- If not responding, check compliance and consider another diagnosis.
- Some children experience withdrawal (tearfulness, agitation) after a missed dose or when medication wears off. A small, short-acting dose at 4 pm may help to prevent this.
- Stimulants are drugs of abuse and should be monitored carefully.
- Drug holidays are not recommended.
- Common adverse effects:
- Anorexia, insomnia, GI effects, and headache
- Significant possible interactions: may increase levels of anticonvulsants, SSRIs, tricyclics, and warfarin
- High caffeine energy drinks, albuterol inhalers and decongestants may increase side effects.
- The FDA reports permanent skin discoloration with Daytrana patches.
Pregnancy Considerations
Medications are Category C: caution in pregnancy
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Second Line
Nonstimulant: á
- SNRI
- Atomoxetine (Strattera):
- ÔëĄ70 kg: 0.5 mg/kg/day initial; increase after a minimum of 3 days to target dose of 1.2 mg/kg/day; maximum of 1.4 mg/kg/day
- >70 kg: 40 mg daily; increase after minimum of 3 days to target dose of 80 mg/day; dose may be increased to maximum of 100 mg/day after additional 2 to 4 weeks
- ╬▒2-Agonist
- Modest efficacy, high side effects. Consider consultation before use.
- Clonidine XR (Kapvay): 0.1 mg once daily at bedtime; increase by 0.1 mg weekly; doses should be taken twice daily with equal or higher split dosage given at HS; maximum of 0.4 mg/day; taper when discontinued
- Guanfacine XR (Intuniv): 1 mg daily; increase by 1 mg weekly until 1 to 4 mg daily; taper when discontinued
ALERT
á
ISSUES FOR REFERRAL
Should be considered for children <6 years old for psychological or medical complications, developmental disorder or intellectual disability, or poor response to medication á
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Surveys have shown that parents of children with ADHD use herbals and complementary treatments frequently (20-60%).
- Omega-3 fatty acids (found in fish oil and some supplements) showed improvement in rating scales in two double-blind, placebo-controlled studies of 116 and 130 patients (4).
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Parent/teacher rating scales
- Office visits to monitor side effects and efficacy: End points are improved grades, rating scales, family interactions, and peer interactions.
- Monitor growth (especially weight) and BP.
DIET
- "Insufficient evidence to suggest that dietary interventions reduce the symptoms of ADHD"Ł (4).
- The AAP recommends that "For a child without a medical, emotional, or environmental etiology of ADHD behaviors, a trial of a preservative-free food coloring-free diet is a reasonable intervention"Ł (4).
PATIENT EDUCATION
- Excellent reference: http://www.parentsmedguide.org
- Key points for parents:
- Find things the child is good at and emphasize these; reinforce good behavior; give one task at a time; stop behavior with quiet discipline; coordinate homework with teachers; have external organization tools-charts, schedules, tokens
- Develop an individualized education plan (IEP) with the school.
- Support groups:
- Children and Adults with Attention Deficit Disorder (CHADD): http://www.chadd.org
- Attention Deficit Disorder Warehouse: http://www.addwarehouse.com
- National Information Center for Children and Youth with Disabilities: http://www.nichcy.org
PROGNOSIS
- May last into adulthood; plan for a transition at age 17 years
- Relative deficits in academic and social functioning may persist into late adolescence/adulthood.
- Encourage career choices that allow autonomy and mobility.
COMPLICATIONS
- Untreated ADHD can lead to failing in school, parental abuse, social isolation, and poor self-esteem.
- Possible withdrawal when medication wears off.
- Monitor growth with stimulant use. If appetite is poor, eat before the medication is given and after it wears off. Consider a shorter duration medication.
- Risk of substance abuse is controversial and seems to decrease with treatment of ADHD increased automobile accidents and injuries; decreases with medication
REFERENCES
11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.22 Rader áR, McCauley áL, Callen áEC. Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 2009;79(8):657-665.33 Wolraich áM, Brown áL, Brown áRT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.44 Sinn áN. Nutritional and dietary influences on attention deficit hyperactivity disorder. Nutr Rev. 2008;66(10):558-568.
ADDITIONAL READING
- Laforett áDR, Murray áDW, Kollins áSH. Psychosocial treatments for preschool-aged children with attention-deficit hyperactivity disorder. Dev Disabil Res Rev. 2008;14(4):300-310.
- Larson áK, Russ áSA, Kahn áRS, et al. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics. 2011;127(3):462-470.
- Millichap áJG, Yee áMM. The diet factor in attention-deficit/hyperactivity disorder. Pediatrics. 2012;129(2):330-337.
CODES
ICD10
- F90.9 Attention-deficit hyperactivity disorder, unspecified type
- F90.0 Attn-defct hyperactivity disorder, predom inattentive type
- F90.1 Attn-defct hyperactivity disorder, predom hyperactive type
- F90.2 Attention-deficit hyperactivity disorder, combined type
- F90.8 Attention-deficit hyperactivity disorder, other type
ICD9
314.01 Attention deficit disorder with hyperactivity á
SNOMED
- 406506008 Attention deficit hyperactivity disorder (disorder)
- 35253001 attention deficit hyperactivity disorder, predominantly inattentive type (disorder)
- 7461003 Attention deficit hyperactivity disorder, predominantly hyperactive impulsive type
- 31177006 Attention deficit hyperactivity disorder, combined type (disorder)
CLINICAL PEARLS
- AAP recommends the use of stimulant medications as the first-line treatment.
- Children undergoing extreme stress (parent's divorce, illness, homelessness, abuse) may demonstrate ADHD behaviors secondary to stress.
- ADHD is 2 to 8 times more common in persons who have a first-degree relative with the condition.