Stimulant medication therapy in the treatment of children with attention deficit hyperactivity disorder

Despite the tremendous research advances that have increased our knowledge regarding the pharmacodynamics, clinical pharmacology, pharmacokinetics, and adverse effects of stimulant medications in the treatment of children with ADHD, our knowledge is yet incomplete. Perhaps the most central unresolved issue concerns our understanding of the pathogenesis, pathophysiology, and diagnosis of ADHD. This review has touched briefly on the controversy and confusion surrounding this issue. Although our understanding of the use of stimulant medications in this disorder is similarly incomplete, a review of the literature does allow certain conclusions to be made that are helpful to the practitioner. 1. Stimulant medications are an effective treatment modality for most children with ADHD. Short-term efficacy is well documented, and long-term outcome may be improved when stimulants are used with other therapeutic strategies. Stimulants in and of themselves are not a panacea. 2. It is impossible to predict which children will have a favorable response to stimulant medications and which children may have a placebo response. The use of individual single-blind medication trials is a practical solution to this problem and should be considered for all children who are candidates for stimulant therapy as a means for preventing overuse or inappropriate use of these medications. 3. The precise mechanism of action of stimulants is not yet completely understood, but stimulants appear to exert their therapeutic effects through their influence on multiple neurotransmitters in the catecholamine, dopamine, norepinephrine axis in the central nervous system. 4. The three major stimulants--methylphenidate, dextroamphetamine, and pemoline--appear to be equally efficacious, although methylphenidate has emerged as the most commonly used and most studied drug. Because of its potential for causing liver toxicity, pemoline has remained a second-line medication. 5. The three major stimulants appear to have somewhat different mechanisms of action so that failure of a patient to respond to one medication does not mean that he or she will not respond to another. 6. The recommended starting doses for the stimulants are 0.3 mg per kg of methylphenidate, 0.15 mg per kg of dextroamphetamine, and 37.5 mg of pemoline. There is a great deal of individual variability in dose response, so doses must be titrated for optimal effects in each child. Sustained release preparations are much more expensive than regular preparations and may be less effective. 7. There is no evidence that stimulants have any effect on ultimate adult height. 8. Although relatively uncommon, motor tics have been observed in children on stimulants, and all children on stimulants need to be carefully monitored for the development of tics. (ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnostic practices for attention deficit hyperactivity disorder: a national survey of primary care physicians.

BACKGROUND: The American Academy of Pediatrics (AAP) clinical practice guideline emphasizes the appropriate diagnosis of attention deficit hyperactivity disorder (ADHD) in school-aged children. Although previous studies have shown wide variation in diagnostic practices for ADHD, few recent studies have examined nationally representative samples. OBJECTIVE: To describe practice patterns of primary care physicians evaluating school-aged children for ADHD in the late 1990s and compare the patterns with subsequently published AAP guidelines. METHODS: We surveyed a national sample of 2000 primary care pediatricians and family physicians. Of the 1076 returned surveys, 861 (43%) met data quality criteria and were included in the analysis. We tabulated frequencies for each item and used a chi2 test to examine relationships between survey items and physician characteristics. RESULTS: Primary care physicians most commonly reported conducting 1-2 new evaluations for ADHD per month, the majority spending 15-45 minutes and at least 2 office visits to confirm a diagnosis of ADHD. Although 58% of physicians used formal diagnostic criteria, only 28% reported using criteria according to the Diagnostic and Statistical Manual of Mental Disorders. Eighty-three percent reported using any teacher or school information such as report cards and rating scales. Approximately 70% used ADHD-specific rating scales, and 60% used global behavior scales. A quarter of respondents obtained laboratory tests such as hematocrit, lead, and thyroid function profile. Most physicians reported routinely assessing for coexisting conditions, ranging from 74% for tic disorders to 91% for depression and conduct disorder. CONCLUSIONS: Before the publication of AAP guidelines, primary care physicians' evaluation practices for school-aged children with ADHD varied widely, especially with respect to use of Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria and inappropriate diagnostic tests.     

Update: attention deficit/hyperactivity disorder in the primary care office

PURPOSE OF REVIEW: Attention-deficit/hyperactivity disorder (AD/HD) affects 7.5% of children, making it among the more common behavioral disorders of childhood. Pediatricians increasingly are expected to recognize AD/HD, as well as diagnose and manage it in the primary care setting. This article reviews recent developments in the care of the pediatric AD/HD patient, with emphasis on information enhancing primary care management. RECENT FINDINGS: Studies published in 2004 provide evidence to guide the treatment of AD/HD. The AD/HD literature continues to support the important role of genetics in its etiology. The absence of universal genetic or neuroimaging findings indicates that history from multiple sources and physical exam remain the standard diagnostic method. Comorbid medical problems, such as sleep disruption and growth suppression, continue to be better understood in the setting of AD/HD, as do the substantial impacts of comorbid learning and psychiatric disorders. Despite great interest in alternative, nonstimulant and behavioral treatments, methylphenidate and amphetamine-based medications remain the mainstay of AD/HD intervention. SUMMARY: AD/HD is a common medical condition with implications for long-term safety and life function, such as academic success, accident occurrence, and drug use. Identification and treatment is increasingly based in the primary care office, where children must be monitored for co-occurring disorders and referred for additional supports when necessary. Tools and guidelines provided by the American Academy of Pediatrics (AAP) provide a framework for consistent and competent AD/HD care supported by current evidence.     

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1保护自尊和自信与对待各类其他发育行为障碍一样,对于注意缺陷多动障碍(ADHD)这一最常见的发育行为障碍,无论我们将采取什么样的方法进行诊治,必须将保护孩子的自尊与恢复自信放在首要位置。这是医生在咨询中应该作为重点反复指出的,更是家长和老师在每日与孩子教养和教育中必须时刻牢记的宗旨。阿德勒[1]指出,每一个人、每一个儿童都存在自卑以及因此而引发的追求卓越的本能,对儿童的教育重要的并不是知识和技能,而是健全人格的培养,而人格的健全依赖我们对儿童自卑以及超越的了解和恰当的教育。ADHD儿童由于注意力缺陷和多动,往往在…     

Attention deficit hyperactivity disorder: comorbidity and medication use

Children evaluated for attention deficit hyperactivity disorder (ADHD) may have other disorders resembling ADHD leading to inappropriate stimulant medication use. This study was completed to identify relationships between referral complaints of ADHD, behavior problems or learning problems and age, gender, final diagnosis, and medication use. One hundred eighty-nine children ages 2 to 15 years referred for evaluation of ADHD, behavior or learning problems were evaluated by an interdisciplinary team. Diagnoses of ADHD, specific learning disability (SLD), mental retardation (MR), developmental language disorders (LANG), and other behavior disorders (DIS) were established. Medication use pre- and post-evaluation was reviewed. Forty-three percent of all subjects had a final diagnosis of ADHD. Forty percent referred specifically for presumed ADHD did not have it. More children older than 5 years were diagnosed as having ADHD than those 5 years old or younger (p < 0.0001). More subjects 5 years old or younger were diagnosed as having LANG than those older than 5 years (p < 0.0001). Fewer subjects with a chief complaint of ADHD were diagnosed with MR than those with behavior or learning problems (p = 0.001). In subjects 5 years old or younger, 35% were diagnosed with MR and 49% with other DIS. In children older than 5 years, 41% were diagnosed with SLD. Ten percent of subjects without ADHD were using stimulants. Only 48% of subjects with confirmed ADHD took stimulants. Children presenting with behavior problems or those 5 years old or younger are at higher risk for MR, LANG, and DIS and less likely to have ADHD. Children presenting with learning problems or those older than 5 years are more likely to have SLD or ADHD. Multiple diagnoses were common for all ages and presentations. Ten percent of children without confirmed ADHD used stimulants before evaluation.     

Transmission of primary nocturnal enuresis and attention deficit hyperactivity disorder

Primary nocturnal enuresis (PNE) is a prevalent disorder among children with a complex mode of inheritance. Family, twin, and linkage studies have provided evidence that genetic factors underlie the familiality of PNE. Linkage investigations support the hypothesis that PNE is heterogeneous, and the genetic heterogeneity may be reflected in co-morbid clinical conditions such as attention deficit hyperactivity disorder (ADHD). This study used a family study method and examined the transmission of PNE in relatives of PNE and control probands with and without ADHD, to determine if these disorders co-occur due to common genetic susceptibilities or other, i.e. non-genetic, reasons. This study concluded that the pattern of inheritance found is consistent with the independent transmission of PNE and ADHD.     

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ADHD的治疗不像其他疾病只对确诊有病的儿童进行治疗,而临床对注意缺陷、多动或冲动的儿童,即使不完全符合ADHD诊断标准,儿科医生仍给予父母咨询,对患儿行为治疗、教育指导、社会技能训练等;如果儿童的症状明显地干扰了在家的生活功能,或在校的学习功能,则儿科医生提供更为综合性的治疗计划[1]。2001年美国儿科学会对学龄儿童的ADHD发表了临床治疗指南,主要有如下5点:(1)ADHD应视为一种慢性疾病———症状表现随年龄变化而不同,但可持续至青少年、甚至成人期,故治疗需要长期性;(2)父母、儿童、儿科医生及其他专业人员应与教师一起制…     

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20世纪60年代,医学界一直认为注意缺陷多动障碍(ADHD)是只见于儿童期的行为障碍疾病。但积累性资料表明,儿童期的ADHD可持续至成年期,有些可发展为成年期人格障碍或其他更严重的精神障碍。一般认为儿童期ADHD患病率在5%左右,而他们当中的30%~50%到了成年期仍存在相应的症状,成人期ADHD患病率大约在2%左右。有报道认为,由于成人期自行服用利他林之类的药物来控制个人症状,或自我隐瞒病情而导致患病率的报道偏低,他们的实际患病率可能远不止于此。由于成人期患病率报道不明确,导致出现成人ADHD的许多公共卫生问题,诸如影响医疗卫生财…     

Ferritin and hyperactivity ratings in attention deficit hyperactivity disorder

Background: Iron is a co‐factor of tyrosine hydroxylase which is a critical enzyme in dopamine synthesis. Dopamine has been implicated in the pathophysiology of attention deficit hyperactivity disorder (ADHD). Our objective was to investigate the association of ferritin level with parent and teacher ratings and cognitive measures after controlling for age, sex, ADHD subtype, comorbid conditions, hemoglobin, mean corpuscular volume and reticulocyte distribution width in a large sample. Methods: The study included 713 children and adolescents with ADHD (613 boys; age 7–15 years). Conners' Parent Rating Scale (CPRS) and Conners' Teacher Rating Scale (CTRS) were obtained. In a subgroup of patients we conducted Digit Span, Digit Symbol, Trail‐making Tests as measures of attention and executive functioning. Results: Multiple regression analysis indicated that CPRS Hyperactivity score was significantly associated with ferritin level (B =?0.12; t =?3.1; P < 0.01). Other CPRS and CTRS scores as well as cognitive measures were not associated with ferritin level. Conclusions: Although it is not possible to make an inference on causality in cross‐sectional studies, the results of this largest‐scale cross‐sectional field study to date suggest that lower ferritin level might be associated with parent‐reported hyperactivity after controlling for important confounding factors.     

Update on attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is now the most frequent diagnosis in children seen by Australian general paediatricians. It is a heterogeneous neurodevelopmental disorder and is usually accompanied by one or more co-morbid developmental and/or mental health conditions. In addition to daily symptoms, which often impair quality of life, ADHD can compromise educational and social development for the individual, and impact on families, schools and the broader community. Draft revised National Health and Medical Research Council Guidelines on ADHD were published in November 2009. This comprehensive document discusses the evidence in relation to many aspects of ADHD, which inform the large number of practice recommendations. Although there is an enormous literature on the causes, neurobiology and management of ADHD, there is still much to be learned particularly in relation to early intervention, behavioural therapies and factors influencing long-term outcomes.     

Methylphenidate-associated enuresis in attention deficit hyperactivity disorder

This is a case report of possible association of methylphenidate and enuresis in an 11-year-old boy with attention deficit hyperactivity disorder.     

Stimulant medication for the child with attention-deficit/hyperactivity disorder

Stimulant medications have been used to manage the associated symptoms of ADHD including inattention, developmentally inappropriate levels of activity, distractibility, and impulsivity. To date, clinical trials clearly have established the efficacy of the stimulants on the core symptoms of ADHD and associated aggression. Although the stimulants improve classroom productivity and behavior, few data have demonstrated the effectiveness of the stimulants on academic achievement. Finally, there has been a paucity of data on the long-term efficacy and safety of stimulants. Recommendations are made for future research studies that examine the integration of stimulant medication with other psychosocial therapies, particularly behavior management.     

注意缺陷多动障碍的多维度诊断

注意缺陷多动障碍（ADHD）是当今儿科疾病中最为多见的一种生物．行为障碍,已引起跨学科各专业人士的普遍关注。尽管国际上已有ADHD的诊断标准,诸如美国精神科协会关于精神疾病的诊断和统计手册第四版（DSM-Ⅳ）,但是标准中缺乏从儿童至青少年的动态化描述,更没有从年龄、疾病及严重程度这3个维度来鉴别儿童行为的性质,即正常的发育偏离、有问题或ADHD,而初级保健的诊断和统计手册（DSM-PC）则弥补了上述种种不足之处,如能把DSM-Ⅳ和DSM-PC的标准综合起来,则有助于专业人士作出正确的诊断。     

关注注意缺陷多动障碍的共患病

注意缺陷多动障碍(attention deficit hyperactivity disorder,ADHD),亦称儿童多动症,是最常见的儿童行为障碍性疾病,主要表现为与年龄不相称的注意力涣散、活动过度和冲动任性.除此之外,还常会有自卑感、情感和社交障碍等情感发展和社会功能方面的问题.     

脑电生物反馈治疗儿童注意缺陷多动障碍的临床分析

目的：注意缺陷多动障碍(attention deficit hyperactivity disorder,ADHD)是儿童常见的一种行为障碍性疾病,在完成认知任务时脑电慢波（θ）活动增强,快波（β）活动减弱。该研究通过观察θ/β比值的变化、结合整和视听连续执行测试（integrated visual and auditory continuous performance test,IVA CPT）进行评估,探讨脑电生物反馈对儿童注意缺陷多动障碍的治疗效果。方法：对30例ADHD儿童进行脑电生物反馈治疗,抑制4~8 Hz的θ波,强化16~20 Hz的β波,观察θ/β比值的变化,采用IVA-CPT进行评估。结果：30例ADHD儿童经2个以上疗程的治疗,治疗后较治疗前脑电θ/β比值显著下降（P< 0.01）,综合反应控制商数、听反应控制商数、视反应控制商数,综合注意力商数、听注意力商数、视注意力商数均较治疗前有明显提高（P< 0.01）。结论：脑电生物反馈治疗可以降低θ/β比值,提高注意力,减少多动,是治疗儿童ADHD的一种有效方法。