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Pediatricians cannot rest in quest for optimum, evidence-based ADHD care, expert says

Wednesday, October 15 2008 | Comments

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What's This? By Yvonne Poindexter

Pediatricians face a number of challenges as they seek to implement evidenced-based care for patients with attention-deficit/hyperactivity disorder (ADHD), including the shortcomings of existing guidelines, which address care only for children aged 6 to 12 years, said Dr. Laurel Leslie, associate professor of medicine and pediatrics at Tufts University School of Medicine in Boston.


Dr. Leslie urged pediatricians to stay abreast of the latest research while recognizing that "findings" do not always translate easily into enhanced care. In the real world, pediatricians must contend with pressure to practice evidence-based medicine and patient-centered care, for example, goals that can be conflicting.

As a starting point, she noted that clinicians should be sure to adhere to the recommendation--from the American Academy of Pediatrics (AAP), the National Institutes of Health, the American Psychiatric Association, and other authorities--that calls for the strict adherence to Diagnostic and Statistical Manual of Mental Disorders IV diagnostic criteria. Adhering to these criteria helps physicians accurately and uniformly define ADHD subtypes (predominately hyperactive-impulsive, predominately inattentive, and combination), Dr. Leslie said. Adherence to the criteria also aids in accurately distinguishing ADHD from other diagnoses, such as juvenile bipolar disorder.

An important objective is to screen for, and if necessary, treat co-existing conditions. Approximately two-thirds of children with ADHD have co-existing disorders likely to affect social skills or the ability to learn. These include mental health disorders, such as anxiety; speech/language impairments; motor disorders, such as clumsiness or poor handwriting; and learning disabilities. The Vanderbilt ADHD rating scales can help assess ADHD symptoms as well as oppositional defiant disorder and conduct disorder.

In addition, she stated that clinicians should be careful to screen for underlying medical conditions that could mimic or provoke ADHD symptoms, such as hearing or vision loss, medication complications, genetic syndromes, prematurity, seizure disorders, central nervous system injury or infection, obstructive sleep apnea, or a chronic illness complication.

Two tools physicians can use in gathering and reviewing such information efficiently are the comprehensive health questionnaires available at www.help4kidswithADHD.com and www.brightfutures.org. Both are available in English and Spanish translations.

A staged approach to diagnosis works well in many cases, she said. With this approach, clinicians conduct an initial physical at which the family is provided with evaluation questionnaires. A repeat visit follows, at which the physician does an in-depth review of the patients' history. A third visit focuses on sharing the diagnosis, documenting baseline behavior, and negotiating treatment.

Evidence-based treatments for ADHD are limited to drug therapy, parent-mediated behavioral modification, and school-based interventions, Dr. Leslie said.

Stimulants are still the first-line drug therapy for ADHD, but physicians must be aware of a joint advisory from the AAP and the American Heart Association, which stated that children who need to receive treatment with drugs for ADHD should be carefully assessed for heart conditions. Furthermore, the statement noted that a review of data suggests that children with heart conditions have a higher incidence of ADHD. Physicians considering drug therapy for patients with ADHD should also conduct a physical exam focused on cardiovascular disease risk factors, with careful attention to family and individual medical history.

Clinicians should also be alert to the potential for neuropsychiatric adverse events among children who receive drug therapy, she added. Recent published studies suggest that the incidence of such side effects is higher than previously thought, affecting 6% to 7% of patients receiving ADHD drug therapy. Such adverse events are often visual or tactile hallucinations, especially in young children, "usually bugs," Dr. Leslie noted. She added that physicians should be aware that nuances in aggression could also be side effects.

Behavioral therapy is often a vital component of ADHD treatment, an intervention that may be particularly important for the youngest ADHD patients, she stated.

"In some cases, we have found that it might be enough to change their trajectory," said Dr. Leslie, noting that the Preschool ADHD Treatment Study (PATS) has found that behavioral training was sufficient for 33% of children.

Clinicians should look for updates to the AAP treatment and diagnostic guidelines for ADHD in the coming years as a panel of experts is working now to revise the existing guidelines. Potential updates include guidelines specific to both preschoolers and adolescents.

Pediatricians should also be aware of a new drug in the pipeline for the possible treatment of ADHD, extended-release guanfacine. The earliest it might be approved by the Food and Drug Administration is likely some time in 2010, Dr. Leslie said.

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