Authors: Yousef Raslan Hakim (1) and Yonis Hakim (2); Geisinger Commonwealth School of Medicine, M3 (1) and Tulane University School of Medicine, M3 (2)
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in pediatric patients [1]. ADHD affects males more than females [2]. 7% to 10% of pediatric patients have ADHD, and this is expected to increase [1]. A study found that in children of the ages 3 to 12 years old, 7.6% had ADHD, and, in children of the ages 12 to 18 years old, 5.8% had ADHD [3]. Out of ADHD patients, 30% to 50% have comorbid autism [1]. 60% to 80% of ADHD patients retain the disorder into adulthood [2].
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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
According to DSM-5, ADHD is characterized by inattention, such as having difficulty focusing; hyperactivity, such as excessive movement; and impulsivity, such as making hasty actions without taking into consideration their consequences [4]. DSM-5 focuses on symptoms instead of impairment [1]. It also bases its definition of functional impairment on any effects on the quality of life [1]. This is unlike DSM-4 that focuses on “both” symptoms and impairment and defines functional impairment as any significant impairment in different areas of life [1]. DSM-5 also allows for a comorbid diagnosis of ADHD with autism, which is important given the high percentage of ADHD patients who have been found to have autism [1]. To diagnose ADHD, the physician should assess the presence of risk factors, such as a family history of ADHD, and other problems, such as sleep disorders, anxiety, or depression [1]. For the diagnosis, symptoms of inattention and/or hyperactivity-impulsivity have to be present [4]. These symptoms of ADHD should also persist for at least 6 months as a diagnostic criterion [4].
Treatment of ADHD
To manage ADHD in the ages of 4 to 5 years old, the American Academy of Pediatrics (AAP) recommends Parent Training in Behavior Management (PTBM), with or without classroom interventions [1]. PTBM teaches parents the appropriate approaches to their children’s problematic behaviors and expected developmental milestones, and it aims to strengthen parent-child relationships [1]. Managing children with both PTBM and classroom interventions is more effective [1]. During this age, children may be prescribed methylphenidate if ADHD is moderate to severe and behavioral therapy did not result in improvements [1].
In children of the ages 6 to 11 years old, the recommendations are to prescribe medications approved by the U.S. Food and Drug Administration (FDA), in addition to PTBM with or without classroom interventions [1]. First-line medical therapy, in these ages, is methylphenidate or amphetamine, which are stimulants [1]. Non-stimulants may be used as well [1]. These include atomoxetine, guanfacine, or clonidine [1]. However, non-stimulants are less effective [1].
For pediatric patients of ages 12 to 18 years, it is recommended to prescribe FDA-approved medications and provide behavioral and educational interventions [1]. In these patients, care must be taken to prescribe a long-acting formulation and short-acting formulations as needed [1].
Recently, more medications have been approved for the treatment of ADHD in patients of the ages of 6 years old and beyond [5]. These include pro-drug, extended-release, and delayed-release formulations of methylphenidate [5].
Conclusion
ADHD is one of the most common neurodevelopmental disorders in pediatric patients [1]. Its prevalence is expected to increase in the future [1]. It is diagnosed in accordance with DSM-5 criteria [1]. ADHD’s treatment in pediatric patients varies with age but consists of behavioral therapy with or without pharmacological therapy [1].
References
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2. Kessi M, Duan H, Xiong J, Chen B, He F, Yang L, Ma Y, Bamgbade OA, Peng J, Yin F. Attention-deficit/hyperactive disorder updates. Front Mol Neurosci. 2022 Sep 21;15:925049. doi: 10.3389/fnmol.2022.925049. PMID: 36211978; PMCID: PMC9532551.
3. Salari N, Ghasemi H, Abdoli N, Rahmani A, Shiri MH, Hashemian AH, Akbari H, Mohammadi M. The global prevalence of ADHD in children and adolescents: a systematic review and meta-analysis. Ital J Pediatr. 2023 Apr 20;49(1):48. doi: 10.1186/s13052-023-01456-1. PMID: 37081447; PMCID: PMC10120242.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington (VA): The Association; 2013.
5. O’Connor L, Carbone S, Gobbo A, Gamble H, Faraone SV. Pediatric attention deficit hyperactivity disorder (ADHD): 2022 updates on pharmacological management. Expert Rev Clin Pharmacol. 2023 Jul-Dec;16(9):799-812. doi: 10.1080/17512433.2023.2249414. Epub 2023 Aug 22. PMID: 37587841.