Attention-Deficit/Hyperactivity Disorder

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Introduction

AACAP practice parameter recommendations are listed under corresponding headings. This article covers the general treatment guidelines, while properties of stimulants are covered here. MTA study is summarized below.

Evaluation

How to make the diagnosis

• Inquire about each of the 18 ADHD symptoms, specifically, the age of onset, severity, frequency, and duration. Various rating scales can speed up this process and should be a part of every ADHD evaluation, according to AACAP.(1)
• Establish chronicity of symptoms, age of onset, and settings in which impairment occurs. While home and school are typically inquired about, asking about other settings where a degree of impulse control and focusing are expected, may be revealing (restaurant, supermarket, church).

Differential diagnosis

The differential diagnosis must be considered for all children presenting with attention and hyperactivity problems, and it includes the following important conditions:

• lead exposure/toxicity
• learning and language disorders
• intellectual disability/MR/Fetal alcohol syndrome
• developmental disorder
• bipolar/mood disorder
• hearing/vision problems
• sensory processing disorders
• absence and other seizures
• drugs and medication side effects
• head trauma
• hyperthyroidism
• trauma/neglect/reactive attachment disorder

Special Topics

ADHD and Epilepsy

• Prevalence of epilepsy in children is about 0.05%; these children are more likely to have ADHD than their peers without seizures. This is particularly relevant in children with absence seizures, in whom pharmacologic seizure control may not adequately restore attention.

• Differentiating the symtpoms is important in children with comorbid epilepsy and ADHD, as well as in children with staring episodes (partial complex or absence seizures); the inattention of ADHD will generally respond to touch and redirection, and children do not experience postictal drowsiness. EEG is sometimes necessary for diagnosis.

• Further, children with ADHD are more likely to have subclinical/epileptiform EEG findings as compared to general population. While they are not considered to have seizures/epilepsy, periods of epileptiform changes are often associated with transient impairment of attention and cognition.

• Antiepileptics and ADHD - Children with epilepsy may experience a sudden improvement in learning, attention, social, and behavior domains when their seizures are treated. This was termed the release phenomenon; it is unclear if this effect is due to seizure control or a separate effect of an antiepileptic. However, phenobarbital and topiramate may cause deterioration in attention and behavior.

• ADHD Treatments and Seizures - It is unclear if stimulants lower seizure threshold; the concern is greater with methylphenidate stimulants. However, in children with epilepsy seizures frequency is not increased when methyphenidate is introduced. Bupropion had been found to cause an increase in seizure ferquency in a dose dependent fashion (SR preparation is safer as it results in lower serum levels). (1)

Further Reading

(1) Practice Parameter, ADHD. JACAP, 46:7, JULY 2007 (2) Schubert R. Attention Deficit Disorder and Epilepsy. Pediatric Neurology 2005;32:1-10.