ADHD and behavioral disorders: Assessment, management, and an update from DSM-5
ABSTRACTBehavioral disorders in pediatric patients—primarily attention deficit hyperactivity disorder (ADHD)—pose a clinical challenge for health care providers to accurately assess, diagnose, and treat. In 2013, updated diagnostic criteria for behavioral disorders were published, including ADHD and a new diagnostic entity: disruptive mood dysregulation disorder. Revised criteria for ADHD includes oldest age for occurrence of symptoms, need for symptoms to be present in more than one setting, and requirement for number of symptoms in those aged 17 and older. Assessment of ADHD relies primarily on the clinical interview, including the medical and social history, along with the aid of objective measures. The clinical course of ADHD is chronic with symptom onset occurring well before adolescence. Most patients have symptoms that continue into adolescence, and some into adulthood. Many patients with ADHD have comorbid disorders such as depression, disruptive behavior disorders, or substance abuse, which need to be addressed first in the treatment plan. Treatment of ADHD relies on a combination of psychopharmacologic, academic, and behavioral interventions, which produce response rates up to 80%.
MANAGEMENT STRATEGIES
Stimulants
The first-line pharmacologic treatment of ADHD is stimulants: methylphenidate, dexmethylphenidate, mixed amphetamine salts, dextroamphetamine, and lisdexamfetamine. Head-to-head trials of medications versus behavioral management favor medication use, even over the long term.12–14
Methylphenidate and amphetamines are equally effective and have similar adverse effect profiles. Insomnia and anorexia are the most common side effects of stimulants. Cardiac effects include tachycardia, chest pain, and hypertension. Very rarely, stimulants have been associated with sudden cardiac death syndrome in patients with underlying cardiac problems. The consensus is that stimulants are safe in the general population. The need to obtain an electrocardiogram before initiating a stimulant was removed by the US Food and Drug Administration (FDA) unless it is otherwise indicated.15
The response rate to stimulants is in the range of 70%. About one-third of patients have side effects, and approximately 15% have side effects severe enough to requiring changing or withdrawing the medication.16,17
Stimulants are available in several delivery systems. For the best effect, medications should be combined with behavioral management.
Alternatives to stimulants
If stimulants are ineffective, atomoxetine can be used to treat patients with inattention; however, its effect on hyperactivity and impulsivity is less pronounced than that of stimulants. Bupropion is another option for inattention. Both agents are well tolerated. Irritability and insomnia are side effects of atomoxetine, and liver damage is possible, so liver function tests must be ordered if the patient complains of upper-right-quadrant pain.
The evidence to support the use of modafinil is equivocal.18,19 Unlike stimulants, modafinil is associated with a slight increase in motivation.
Alpha-2 agonists are effective for treating aggression in the setting of ADHD, especially in younger children, and are well tolerated.20 Extended-release forms are available.
Combination therapy
Polypharmacy is sometimes indicated in the treatment of ADHD. A stimulant used in combination with atomoxetine was shown to be superior to either treatment alone in improving symptoms of hyperactivity and inattention.21 The combination, however, markedly increased the incidence of appetite loss, insomnia, and irritability.
A more promising combination is a stimulant with an alpha agonist. Symptoms of hyperactivity and inattention were improved more with this combination than with a stimulant plus placebo, with no difference in side effects.22
ADHD with comorbidities
Patients with ADHD, both adults and children, often have comorbid externalizing disorders and other emotional disorders, such as depression and anxiety, occurring in up to half of cases (Table 2).23,24 These comorbidities are important to consider when developing a treatment strategy. The following describes treatment options for the most common ADHD comorbidities (Table 3).
ODD or conduct disorder. The first-line therapy for these patients is a stimulant plus behavioral therapy. Adding an alpha agonist to this combination may be indicated if the comorbidity is severe. Second-generation antipsychotics also have been used as add-ons to stimulants with behavioral therapy, but weight gain and hormonal side effects are common.
Behavioral interventions are effective in targeting disruptive behavioral disorders, specifically multisystemic therapy. Multisystemic therapy is intensive therapy that involves working with the patient’s peer group or school, but most children must enter the legal system to receive this intervention. Multisystemic therapy is the only intervention shown to improve symptoms associated with comorbid ADHD and conduct disorder.25
Mood disorders. For these patients, the mood disorder is treated first. In doing so, symptoms of ADHD may disappear. For those with bipolar disease, a second-generation antipsychotic agent is superior to lithium in efficacy, maintenance of remission, and side effects in patients with a clear bipolar affective disorder, after which a stimulant can be added with less risk of developing manic symptoms. Using a stimulant first for this indication risks mood destabilization.
For patients with a major depressive disorder, bupropion can be used, although this indication is not FDA-approved, followed by the addition of a stimulant. One alternative is a selective serotonin reuptake inhibitor plus a stimulant; another is cognitive behavioral therapy plus atomoxetine and an alpha agonist.
Substance abuse. Patients with ADHD have high rates of substance abuse.26,27 Whether treatment of ADHD with stimulants reduces the risk of substance abuse is controversial. Because abuse of stimulants is common, start treatment with atomoxetine, bupropion, an alpha agonist, or a stimulant that is difficult to abuse (eg, lisdexamfetamine). Refer patients who are abusing substances to a specialist in substance abuse for behavioral management.
Anxiety. Atomoxetine is recommended for the treatment of anxiety that coexists with ADHD. A selective serotonin reuptake inhibitor in combination with a stimulant or alpha agonist, plus cognitive behavioral therapy, is another option for treating anxiety and ADHD. Tricyclic antidepressants have shown benefit in pediatric anxiety. Bupropion should not be used to target anxiety as it has been shown to have a limited effect on anxiety.
Tics. Stimulants may transiently exacerbate underlying tic disorders, but no longstanding difference in the course of tics has been observed with stimulant use.28 Alpha-2 antagonists target both tics and ADHD, so their use is preferred.29 Atomoxetine does not exacerbate tics but may reduce their frequency and severity.30
Dietary factors
Although challenging to accomplish, management of diet, specifically removal of artificial food coloring and sodium benzoate preservatives, has been more efficacious than behavioral management in the long-term reduction of core symptoms of ADHD.31,32 No herbal remedy has demonstrated efficacy in improving ADHD symptoms. The use of omega-3 fatty acids as a complement to stimulants has demonstrated efficacy in reducing core symptoms in ADHD.33
Behavioral therapy
Several forms of behavioral therapy have shown utility in improving symptoms in ADHD. Evidence supports that ADHD responds to cognitive behavioral therapy.34 In-school neurofeedback training for ADHD was shown to be better than cognitive training in improving inattention and hyperactivity-impulsivity at 6 months of follow-up.35
Parental training has the most evidence to support its use in children with ADHD. The two most common forms are Pathways Triple P (Positive Parenting Program) and The Incredible Years. Triple P is an early intervention designed to promote positive parent-child relationships to reduce behavior problems.36 The Incredible Years is a multicomponent program that emphasizes creating opportunities for active involvement, reinforcement of positive behavior, teaching skills, and setting clear limits, all of which are central to the social development strategy.37
Many children with ADHD respond to in-school interventions, at least an evaluation to rule out learning disorders, which typically have high morbidity. Children may qualify for Individualized Education Program (IEP) services, such as peer tutoring,38 computer-assisted instruction,39,40 and task-modification instruction.41 All of these have evidence to support their use.
