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Attention deficit hyperactivity disorder in childhood and adolescence

October 2014

Position statement 55


Summary

ADHD is associated with higher rates of behavioural and conduct problems, accidents and injuries, school and learning difficulties, alcohol and drug abuse and family conflict. Medication and therapy can moderate symptoms, but there is no proven cure for the condition. 

Definition

Attention Deficit Hyperactivity Disorder (ADHD) is a clinical syndrome of pervasive inattention and/or hyperactivity and impulsivity in excess of that typical for developmental age that adversely affects learning, socio-emotional development and overall functioning. Studies generally show that between 2% - 5% of school-aged children have ADHD, with boys three to five times more likely to be affected (US Department of Health and Human Services, 2006; Froehlich et al, 2007). Symptoms and associated impairments of ADHD continue to affect the individual in adolescence and sometimes into adulthood (see RANZCP Adult ADHD Practice Guidelines). Medication and therapy can moderate symptoms, but there is no proven cure for the condition.

Evidence

ADHD is a significant family and community issue, as it is associated with higher rates of behavioural and conduct problems, accidents and injuries, school and learning difficulties, alcohol and drug abuse and family conflict.

As many as two-thirds of clinically referred children with ADHD in US studies have additional problems; 30% - 50% will have Conduct problems, and 20% - 25% will have anxiety problems (US Department of Health and Human Services, 2006; Spence et al, 2007; Schatz and Rostain, 2006; Jensen et al, 2001). These problems are also influenced by parenting, discipline strategies, and social environment.

Comorbid disorders can make finding the proper diagnosis and the right overall treatment more costly and time-consuming (Jense et al, 2005). ADHD with comorbid behavioural disorder will typically still respond to monotherapy with an approved treatment such as a psychostimulant or the noradrenergically active drug atomoxetine. The comorbid behavioural disorder will likely require parent behavioural management training, and in some circumstances the addition of another medication such as an alpha-2 agonist. ADHD in the presence of comorbid emotional disorder requires thoughtful selection of pharmacotherapy, and will usually require additional individual or family focussed therapy.

Research suggests that genetic and neurobiological factors contribute to the disorder. Parents and siblings of people affected by ADHD have a two to eight fold increased risk of having the condition compared with the relatives of unaffected controls (Biederman et al, 1990). Environmental factors such as maternal smoking and exposure to lead and certain pesticides make an additional small contribution to the disorder. Psychosocial adversity does not cause ADHD, but can affect the development, presentation, course and response to treatment of the syndrome (Thapar et al, 2012).

Recommendations

  • Symptoms of ADHD appear early in a child’s life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the initial assessment or diagnosis of ADHD is conducted by a well-qualified professional, such as paediatrician or child and adolescent psychiatrist.
  • Diagnosis of ADHD should be based on a comprehensive multimodal assessment which includes accounts of the child’s functioning in a variety of situations. It is important to exclude developmentally appropriate levels of inattention and hyperactivity-impulsivity. ADHD symptoms can overlap, co-occur and exacerbate autistic- spectrum disorders, learning disorders, mood and anxiety disorders, behavioural disorders, attachment disorders, sequelae of trauma, neglect and abuse. Assessment should seek to identify/ exclude this extensive comorbidity and comorbidity should be addressed in treatment planning. Psychometrics, language and developmental assessments provide additional information which may contribute to diagnostic clarification. Physical health assessment should be undertaken and neurological examination is specifically relevant in the presence of developmental delay, autistic features, neurological signs or disorder.
  • Families and schools of children being treated for ADHD should be educated about the appropriate use and limitations of psychotropic medication, including possible side effects and need for non-pharmacologic treatments and behavioural management. Children with ADHD should be assessed and monitored for presence of depressive and anxiety symptoms, which may be induced or exacerbated by some treatments.
  • Continuing review and monitoring of learning, socioemotional development and behaviour should occur utilising direct observation and school and family reports. Monitoring of medication, particularly efficacy and presence of side effects and effects on growth should occur at least every six months. Aims of management are to support socioemotional development, minimise behavioural disorders and to avoid polypharmacy. Coordination of services and support of primary care and school-based interventions is integral to ongoing care.
  • Management of ADHD should involve the family, school and social network, and should be tailored to the needs of the individual child.

Resources

Biederman J, Farone SV, Keenan K, Knee D, Tsuang MT (1990) Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child & Adolescent Psychiatry 29(4): 526–533.

Froehlich TE, Lanphear BP, Epstein JN, Barbaresi WJ, Katusic SK, Kahn RS (2007) Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Archives of Pediatrics & Adolescent Medicine 161(9): 857–864.

Jense PS, Barcia JA, Glied S, Crowe M, Foster M, Schlander M, Wells K (2005) Cost-effectiveness of ADHD treatments: findings from the multimodal treatment study of children with ADHD. American Journal of Psychiatry 162(9): 1628–1636.

Jensen PS, Hinshaw SP, Kraemer HC, Lenora N, Newcorn JH, Howard B, Abikoff FS, March J et al (2001) ADHD comorbidity findings from the MTA study: comparting comorbid subgroups. Journal of the American Academy of Child & Adolescent Psychiatry 40(2): 147–158.

Schatz DB, Rostain AL (2006) ADHD with comorbid anxiety a review of the current liberature. Journal of Attention Disorders 10(2): 141–149.

Spence TJ, Biederman J, Mick E (2007) Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Journal of Pediatric Psychology 32(6): 631–642.

Thapar A, Cooper M, Jefferies R, Stergiakouli E (2012) What causes attention deficit hyperactivity disorder? Archives of Disease in Childhood 97(3): 260–265.

US Department of Health and Human Services (2006) Attention Deficit Hyperactivity Disorder. United States: National Institute of Mental Heath.


Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.