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Transcript
TREATMENT ISSUES
AND PHARMACOLOGY
IN PEDIATRIC ADHD
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of
academic medicine, and medical author. He graduated
from Ross University School of Medicine and has
completed his clinical clerkship training in various
teaching hospitals throughout New York, including
King’s County Hospital Center and Brookdale Medical
Center, among others. Dr. Jouria has passed all USMLE
medical board exams, and has served as a test prep
tutor and instructor for Kaplan. He has developed several medical courses and
curricula for a variety of educational institutions. Dr. Jouria has also served on multiple
levels in the academic field including faculty member and Department Chair. Dr. Jouria
continues to serves as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also developed several
continuing medical education courses covering various topics in clinical medicine.
Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial
Hospital’s Department of Surgery to develop an e-module training series for trauma
patient management. Dr. Jouria is currently authoring an academic textbook on
Human Anatomy & Physiology.
ABSTRACT
Attention Deficit Hyperactivity Disorder is a diagnosis that tends to cause a
lot of fear and confusion in parents and caregivers, but receiving the proper
information in a timely manner from health clinicians can help alleviate
many of those feelings. It includes a combination of symptoms, including
hyperactivity, impulsivity, and difficulty sustaining attention. Millions of
children struggle with these symptoms, which frequently ease as the patient
reaches adulthood. It is important for clinicians to carefully screen patients
according to current medical standards before making a diagnosis of
attention deficit hyperactivity disorder.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content is 1 hour.
Statement of Learning Need
Depending on their role and training, clinicians may or may not have primary
responsibility to diagnose ADHD; however, often nurses and therapists
contribute to the formulation of a diagnosis and plan of care through
observation and interaction with children, parents and teachers and rely
upon expert knowledge to use the right screening tool and methods to
identify behaviors and social challenges associated with ADHD.
Course Purpose
To prepare clinicians to have knowledge of pediatric ADHD, methods of
diagnosing associated disorders and behavioral outcomes, and to participate
in interprofessional collaborative treatment that involves the patient and
their family.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1.
Attention deficit hyperactivity disorder or ADHD is
a.
b.
c.
d.
2.
As high as ____ of all children with ADHD have an
associated learning disorder.
a.
b.
c.
d.
3.
15%
25%
30%
45%
Studies have shown that adverse side-effects of
medications for ADHD may include:
a.
b.
c.
d.
4.
disease of the central nervous system.
a neurological disorder.
a rare brain disorder.
a relatively common brain disorder.
suppression of growth
sleep problems
stomach upset
All of the above
True or False: The role if nortriptyline in pediatric ADHD is
that at higher doses it improves symptoms within several days of
starting therapy.
a. True
b. False
5.
Atomoxetine (Strattera) is a non-stimulant medication
approved for the treatment of pediatric ADHD in children between
_______ years old.
a.
b.
c.
d.
2 to 17
3 to 17
6 to 17
None of the above
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Introduction
Attention deficit hyperactivity disorder or ADHD is a relatively common brain
disorder that is often diagnosed at childhood and continues to adolescence
and adulthood.1 Children with ADHD sometimes exhibit uncontrollable
behavioral symptoms that are frequent and severe which interferes with
their ability to cope at school and live normal lives outside of it.
Hyperactivity and impulsivity and/or inattention occur in children affected
with ADHD. While these are behaviors that many children exhibit at some
time during their childhood, in children with ADHD, these behavioral
problems persist over a long period of time. To be diagnosed with ADHD,
such behaviors must continue for at least 6 months and be present in two
environments such as home and school. Clinicians should be able to
diagnose this disorder early on to evaluate the patient and provide for all the
necessary pharmacotherapeutic and behavioral interventions that will help to
minimize symptoms and restore social and academic functions. This course
on pediatric ADHD expands on prior courses with a sharper focus on the
effective management of ADHD, including psychopharmacology. The two
arms of behavioral and pharmocological treatment are highlighted in this
course.
Screening For Related Disorders
Health clinicians need to be aware of current recommendations for patient
monitoring and complications of treatment that may arise. A strong
professional liaison between a child’s pediatrician and mental health team
will ensure implementation and follow up of current best practice guidelines
for children with ADHD at home and school. Disorders that appear either as
a part of the symptoms of ADHD or develop because of its existence are
considered comorbid conditions. Comorbidities in the context of ADHD are
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those disorders that may worsen the presence of ADHD or cause it to have
different presenting symptoms. These may already be present when the
main problem was first diagnosed or occur later on during the course of the
disorder, leading to complex problems and difficulties in symptom
management in the future.
Children diagnosed with ADHD may experience a variety of related disorders
or comorbidities. These comorbidities vary according to the prevailing type
of ADHD, their severity, as well as the developmental stage of the child
when they were first seen (i.e., preschool, school-age or adolescence).
Comorbidities are divided into two broad categories of learning disorders and
psychiatric disorders.12,102
Learning Disorders
Due to the complex nature of behavior problems in ADHD, children often
face learning difficulties at school. These are not limited or entirely rooted in
their academic performance alone but include disruptive behaviors which are
often triggered by and exhibited in response to challenges posed to them in
a variety of school environments. Their behaviors result in apparent
difficulties to learn new concepts, and subsequent poor or lack of academic
achievements.
It cannot be overemphasized that children with both ADHD and coexisting
learning disorders often suffer from overall poor school performance and
corresponding low self-esteem. They especially face difficulty in keeping up
with subjects wherein control is needed by the child. The worst outcome for
these children is frustration from having to face and accept failing grades
from teachers, and the need to repeat the course or take special classes in
order to catch up with the rest of the children. These problems in academics
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and learning are not limited to the preschool and grade school years. Most of
these learning problems continue to persist during the late adolescent years,
leading to a host of new problems related to academic underachievement
and failure in school.
It may be true that while most of the difficulties experienced by children with
ADHD, in terms of academic and non-academic performance at school, are
clearly evident in many children, it is quite another story when the problems
are not always consistent with the known criteria for ADHD. This is because
the symptoms exhibited by these children often overlap with a coexisting
learning disorder which makes differential diagnosis all the more difficult for
the clinician. Moreover, some of the symptoms presented by children with
ADHD can also mimic specific learning difficulties. One of the ways to avert
this problem is to simply take note of specific difficulties and delays faced by
children such as failing grades in school subjects of spelling, math or reading,
and then comparing these with the child’s IQ scores.
Other difficulties stem from developmental delays, which can also impair the
overall performance of the child in the school environment. Some of the
most common examples of these difficulties include:

Language problems

Speech and communication disorders

Self-expression, which affects approximately a majority of children who
have been found to have ADHD
The following section discusses in detail some of the most common learning
difficulties experienced by children with ADHD.12,102,103
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Intellectual Development Problems
Perhaps one of the most common learning problems encountered by children
with ADHD are problems associated with intellectual development. It also
happens to be the most serious of conditions. This is because there is a very
high possibility that children who are diagnosed with ADHD may either be or
not be at par with their peers who do not have ADHD.
Most of these children attain IQ scores that may be lower by 15 points or so
when compared with their peers, and may experience problems in verbally
expressing themselves. However, since most tests are standardized and not
necessarily developed to assess children with ADHD per se, it is still unclear
whether the results really denote the presence of a problem or just a result
of a child’s behavior while taking the test. Moreover, as IQ tests are basically
used to assess problems related to intellectual development, factors such as
the child’s age while taking the test and the number of times the same test
has been taken by the same child may also play a large role. It may be that
some children who have taken the same tests have developed a form of
mastery of the subjects instead of actually gaining the intellectual function
expected from the specified age group.
Difficulties in Speech
Children with ADHD have been found to manifest delays in speech
development. This is primarily based on the observation that they have the
tendency to experience delays in speech development as compared to
children who do not have the condition. Additionally, difficulties in speech in
children with ADHD has also been backed by results of studies showing that
they demonstrate a greater tendency to start speech later on in their
childhood, despite the lack of problems in language reception. Although
children with ADHD are able to process and understand the spoken language,
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it may be a little while before they are able to fully express their response to
them. They also show problems achieving language fluency, particularly in
verbal context.
Dyslexia
A common comorbidity in children with
ADHD is dyslexia. It is manifested by a
child’s difficulty to read fluently and to
comprehend reading materials. This may be
present with or without any
neuropsychological deficits on the part of
children with ADHD and may manifest as an
inability of the child to comprehend written language, problems with selfexpression using verbal or written language, inability to hold information in
memory, and problems with phonetics.104
Problems with Task Performance Variability
Children with ADHD are known mostly for their impulsivity and hyperactivity.
This is also seen in terms of how they accomplish and perform tasks given to
them. Observation over time has yielded results that strongly suggest ADHD
children to be lacking consistency in terms of school performance, quality of
homework, and general academic performance. This is because they tend to
start a lot of tasks without actually finishing them.
Difficulties in Motivation
One of the challenges faced by teachers of children with ADHD is their
apparent lack of motivation. Children diagnosed with ADHD usually present
with a very low motivation level accompanied by lack of interest in tasks
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appointed to them. This is especially true when these children are required
to respond repetitively to certain tasks and requirements without outside
reinforcement from their teachers.
Psychiatric Disorders
Psychiatric and other psychological disorders are other comorbidities that are
of great concern among children with ADHD. Since most of these conditions
exist as a result of the negative emotions, social pressure, and stigma that
occur, it is imperative for the clinician to take notice of these comorbidities
before they get worse. This section addresses the most commonly seen
psychiatric disorders among patients with ADHD.12,17,27-29,36,37,102-108
Depression
A significant number of children and adolescents who are diagnosed with
ADHD suffer from episodes of depression throughout their lives. Symptoms
of depression seen among them include:
•
Irritability and mood irritation
•
Apparent lack of interest in engaging in pleasurable activities
•
Sleep problems (either too much or too little)
•
Appetite suppression
In 2007 the risk of depression in children was studied and revealed the
prevalence of depression was as follows: 3 to 5 years – 0.5 percent, 6 to 11
years – 1.4 percent, and 12 to 17 years – 3.5 percent. The rates of
depression grew higher during a survey of adolescents aged 12 to 17 years
in the U.S. between 2010 and 2011; it was found that the one-year
prevalence of major depression was 8 percent.
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The existence of depression in children with ADHD usually occurs a few
years after ADHD is diagnosed. It is usually a result of the constant battle
with stressors in the immediate environment, which may include peers,
bullying, and academic pressures to perform well. When these external
stressors become too overwhelming to bear, depression sets in.
Symptoms of depression in children
with ADHD may not be apparent right
away because the resulting symptoms
and social isolation often hide the
disorder. The clinician must therefore
be vigilant when observing children for
depression and address symptoms as
soon as possible before conditions
worsen to lead to suicidal ideation and
self-harming behaviors develop.
Suicidal Ideation
Suicidal ideation is one of the most common problems and comorbid
conditions in children who are diagnosed with ADHD and also suffering from
depression. This is more common in boys who are also more likely to
develop phobias from peer rejection and associated environmental stressors.
The clinician must observe the behavior and listen carefully to overt and
covert communication patterns that might be suggestive of the desire to end
life. Interventions such as early treatment with stimulant medications may
help reduce the risk of suicide.
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Bipolar Disorder
Aside from being a comorbid condition in children with ADHD, bipolar
disorder can also mimic most ADHD symptoms, making definitive diagnosis
rather difficult to do. The occurrence of bipolar disorder as a comorbid
condition in ADHD patients occurs is approximately 50% among male
patients and 25% among female patients. Most children who exhibit bipolar
behavior, on top of ADHD symptoms, present with hyperactivity, extremely
strong emotional feelings, overbearing manners, and difficulty with waking
up in the mornings. They may also show temper tantrums that are longer
than other children with ADHD, and exhibit destructive behaviors and angry
demeanors. Additionally, these children have a greater tendency to talk
excessively, act inappropriately with apparent disregard to time and place,
make verbal responses that are demeaning to others, lack self-control in
social situations, are easily distracted and irritated.
Oppositional Defiant Disorder
One of the most common psychiatric
comorbidities associated with ADHD is
oppositional defiant disorder (ODD),
usually affecting around 60% of
children with the condition. The
presence of this comorbidity is
highlighted when children do things to
intentionally defy rules and regulations,
and act out against them, often
through violent means. The symptoms
of oppositional defiant disorder are
usually more prevalent when a caregiver or parent of a child with ODD is in
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close proximity to them, stimulating their behavior from an added sense of
safety brought on by their familiar presence.
Conduct Disorders
The comorbidity of a conduct disorder occurs in approximately 45% of
children with ADHD, and quite uncommon in children who do not have
ADHD. The main symptom associated with conduct disorder is the apparent
aggression towards animals or even people, the habit to destroy things
willfully, engage in violation of rules both in school and in society, and
stealing other peoples’ belongings. This is also considered to be a precursor
to antisocial personality disorder when the condition is left untreated.
Anxiety
Anxiety may be defined as a state of psychological and physical discomfort,
which is focused on emotions, perceptions, feelings, and behavior necessary
to deal with certain life issues. It manifests in children with ADHD through
symptoms such as:
•
Difficulty in keeping with normal routine of things
•
Separation anxiety
•
Generalized anxiety disorders
Most ADHD children who also suffer from this comorbidity often display an
extreme preoccupation with a specific fear, making them unable to focus on
accomplishing tasks at present. This is mostly attributed to a perceived
inability to function satisfactorily in everyday life and the difficulty in
adjusting to the limitations set by ADHD symptoms in both social and
academic settings.
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Tic and Tourette Syndrome
Two of the most common disorders
that can be classified as
neurodevelopmental and coexisting
among ADHD patients are tic and
Tourette Syndrome. These two
disorders affect approximately 47% of
children with ADHD, although they are
not usually diagnosed individually.
Most of the diagnoses made of these
two disorders are commonly present
in one patient. The most common
manifestations of tic disorders in
children with ADHD include intermittent vocal and motor tics, which tend to
become less severe over time. Tourette Syndrome, however, manifests itself
as motor tics that are concomitant with vocal tics (i.e., sudden increase in
tone of voice with associated facial muscle twitches which are
uncontrollable). Such comorbidities usually occur in children with ADHD
approximately 2-3 years after the diagnosis of ADHD is made. Tics are
frequently seen as a comorbidity of ADHD in children with a family history of
it.
Obsessive Compulsive Disorder
Obsessive-compulsive disorder (OCD) is a psychiatric problem that is defined
by the presence of intrusive thoughts. These thoughts are usually selfinjecting and serve to heighten feelings of guilt and anxiety in the ADHD
patient, leading to the compulsion or need to avert or relieve them.
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There are approximately 30% of children with ADHD who are also diagnosed
with obsessive-compulsive disorder. The symptoms of OCD in these patients
are usually seen early on during its course. The severity of OCD in children
with ADHD is likely to increase over time, which makes early treatment and
care very imperative in these patients.
Substance Use Disorders
Substance use is a common problem among individuals who experience
difficulties in coping with life challenges, and patients with ADHD are
especially vulnerable to their effects. In fact, more ADHD patients are
vulnerable to commit themselves to alcohol, drug, and other substance use
because of the myriad of social, personal and other problems they are facing
due to their disorder. Apart from this, there is also a greater tendency for
patients with ADHD to engage in self-medication, and associate themselves
(almost impulsively all the time) with individuals who also encounter the
same coping challenges and difficulties while in school and socially.
Children and adolescents who are diagnosed with ADHD tend to identify with
individuals who also cannot seem to fit into society the same as they do.
One of the most common substances used by children with ADHD is tobacco.
Cigarette smoking in children with ADHD usually starts at a younger age and
continues to be a habit throughout their life. In fact, patients with ADHD are
more prone to start smoking cigarettes as compared to the rest of the
population by at least 20%. Another substance commonly used by
individuals with ADHD is alcohol, with approximately 35% of patients using
it. Illicit drugs and prescription and over-the-counter drugs are substances
that also tend to be frequently used by ADHD patients.
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Personality and Other Psychiatric Disorders
The presence of psychiatric and personality disorders is usually
acknowledged in adult ADHD patients. However, when these conditions or
their associated symptoms occur in children and adolescents, they are
simply put in the category of conduct or oppositional defiant disorders.
Personality disorders usually manifest themselves in the late adolescent
years and may occur as more than one syndrome in an individual. The
majority of personality disorders appear as schizoid or schizotypal,
obsessive-compulsive tendencies, borderline personality, and avoidant
personality profiles. The most important thing for the clinician to take note
of is that these disorders may also mimic typical symptoms of ADHD and
must therefore be properly assessed before a complete diagnosis is made.
Personality profiles, behavior, and even thought content should be well
assessed to determine and differentiate the presence of simple
hyperactivity/impulsiveness or inattentiveness associated with ADHD from
the major presenting symptoms of these disorders. Moreover, because these
disorders usually affect the individual’s personality, treatment must be
started as early as possible for better prognosis.
Pervasive Developmental Disorders
Autism and other pervasive developmental disorders usually manifest as a
severe impairment or difficulty in social interactions and communications in
a social context, accompanied by behaviors, which can be considered as
restrictive and repetitive in nature. Along with these symptoms, there is also
intelligence impairment as well as a grave restriction in the ability to take in
new information and learn from it.
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Due to the similarity between many of the symptoms of pediatric ADHD and
autism, there is greater risk for a mixed diagnosis early on, which can be
corrected later on in life, once the symptoms become more distinguishable
from each other. Symptoms of autism in children with ADHD include:

Short attention span

Greater tendency to show temper tantrums

Hyperactivity

Impulsivity

Aggressiveness

Impaired executive functioning
The table below shows diagnostic tips for differentiating between ADHD and
other psychiatric and learning disorders.
Oppositional Defiant 
Lacks disinhibited behavior or restraint
Disorder (ODD) and 
Defiance primarily directed toward mother initially
Conduct Disorder

Unble to cooperate and complete tasks requested by others
(CD)

Lacks poor sustained attention and marked restlessness

Resists initiating demands, whereas ADHD children may
initiate but cannot stay on task

Often associated with parental child management deficits
or family dysfunction

Neuromaturational delays in motor abilities not present
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Learning Disorders

Has a significant IQ or achievement discrepancy
(+1 standard deviation)

Places below the 7th percentile in an academic
achievement skill

Lacks an early childhood history of hyperactivity

Attention problems arise in middle childhood and
appear to be task or subject specific
Anxiety Disorders

Not socially aggressive or disruptive

Not impulsive or disinhibited

Likely to have a focused not sustained attention deficit

Not impulsive or aggressive; often over-inhibited

Has a strong family history of anxiety disorders

Restlessness is more like fretful, worrisome behavior
not the “driven,” inquisitive, or over-stimulated type
Asperger’s

Lacks preschool history of hyperactive, impulsive behavior

Not socially disruptive; typically socially reticent

Show oddities or atypical patterns of thinking not
Syndrome
and Schizotypal
seen in ADHD

Personality Disorder 
Peculiar sensory reactions
Odd fascinations and strange aversions

Socially aloof, schizoid, disinterested

Lacks concern for personal hygiene or dress in adolescence

Atypical motor mannerisms, stereotypes, and postures

Labile, capricious, unpredictable moods not tied to reality

Poor empathy, cause-effect perception,

Poor perception of meaningfulness of events
Juvenile

Characterized by severe and persistent irritability
Onset

Depressed mood exists more days than not
Mania or Bipolar I

Irritable/depressed mood typically punctuated
Disorder
by rage outbursts

Mood swings often unpredictable/related to minimal events

Severe temper outbursts and aggression with
minimal provocation (thus, ODD is often present and severe)

Later onset of symptoms than ADHD (but comorbid
early ADHD is commonplace)
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
Pressure of speech and flight of ideas often present

Psychotic-like symptoms often present during manic
episodes

Family history of Bipolar I Disorder more common

Expansive mood, grandiosity of ideas, inflated
self-esteem, hypersexuality often seen in adults with
Bipolar Disorder are sometimes present though not
as well formed; children may, however, have the
dysphoric type of disorder

Requires that sufficient symptoms of Bipolar Disorder
be present after excluding distractibility and
hyperactivity
(motor agitation) from Bipolar symptom list in DSM-IV before
granting Bipolar I diagnosis to a child with symptoms of ADHD

Suicidal ideation is more common in child (and
suicide attempts more common in family history)
Legal And Ethical Issues
The evaluation of children suspected of ADHD can raise several legal and
ethical issues often secondary to family stressors related to correlating
behaviors of the disorder. Some of the legal and ethical issues are listed and
further discussed in the sections below.111,116,117

Custody and guardianship of the child

Disclosure to state agencies of any suspected physical or sexual abuse
or neglect of the child

Legal accountability of actions
Custody and Guardianship of the Child
The custody or guardianship of the child is related to who can request the
assessment of the child who is suspected to have ADHD. Children with ADHD
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and associated comorbidities such as ODD or CD will often have parents who
are divorced or separated or experiencing marital issues. Because of this,
the clinician must first determine who has legal custody of the child, and
especially determine who has the right to ask for mental health services on
behalf of the child. In cases of joint custody, the clinician must also
determine whether the parent who is not living with the child has the legal
right to refuse the referral for the evaluation, consent to the evaluation, to
attend on the day of appointment, and have access to the final report.
The right to assess or refuse mental health services may also include the
provision of treatment. If these issues are not determined prior to the
evaluation, it may fuel contention and even legal action among the parties to
the evaluation.
Disclosure and Reporting of Abuse
A second issue related to the evaluation of ADHD children is the duty of the
clinician to report to state agencies any suspected abuse or neglect of the
child. It is also the duty of clinicians to inform parents of this duty to report
prior to the start of the formal evaluation process. Because of the relatively
greater stress that ADHD or ODD children pose to their parents, clinicians
will do well to remember that the risk for abuse of defiant children may be
higher than average.
It is widely believed that there exists a genetic component to the origins of
ADHD, therefore, it stands to reason that children with ADHD may also be
under the guardianship of parents with ADHD or other psychiatric disorders
themselves. This in turn, leads to a greater likelihood that evaluations of
children with disruptive behavior disorders will also include suspicions of
abuse. Each state has their own legal requirements regarding such cases,
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which clinicians must be familiar with in order to ensure close adherence
while, at the same time, remain sensitive to the bigger clinical issues.
The widespread awareness of ADHD and the special needs of children with
ADHD and co-occurring disorders have been growing steadily over the last
20 years. As a result, these children have also been gaining access to
government grants and aid, all of which clinicians must be well informed
about, especially if they are to give appropriate advice and support to the
parents and school staff. For example, children with ADHD that is
remarkably severe enough to interfere with regular schooling have the right
to formal special educational services under the Other Health Impaired
Category of the Individuals with Disabilities in Education Act. Additionally,
these children also have legal protections and entitlements under Section
504 of the Disability Rights Act or the more recent Americans with
Disabilities Act as it applies to the provision of an appropriate education for
children with disabilities.
Children belonging to low-income families may be eligible for financial
assistance under the Social Security Act. Generally speaking, clinicians
working with ADHD children need to be familiar with the federal and state
laws concerning the rights and entitlements of children with these specific
needs.
Legal Accountability of Actions
Last but not least, the third legal issue concerning ADHD children is
accountability for their own actions, usually as it pertains to their
developmental disorder, which undermines self-control. Some of the
important questions that arise from this issue are:
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
Should children with ADHD be held legally responsible for the damage
they may cause to property?

Should children with ADHD be held legally responsible for the injury they
may inflict on others?

Should children with ADHD be legally responsible for the crimes they
may commit?
The answers to the questions above are unclear and merit further attention
from medical and legal experts. ADHD can explain why the actions were
committed and despite the incomplete understanding of the origins and
nature of the disorder, the disorder is not an excuse to forego legal
accountability. It is worth noting that there has been no solid scientific
evidence to help predict criminal conduct within samples of ADHD children
followed into adulthood.
Treatment And Management
The treatment and management of ADHD in children has two essential
components, which are psychotherapy interventions and pharmacotherapy.
Research data in recent years have found that medication alone is
insufficient to address the core issues of ADHD. Medication can help manage
the symptoms, allowing children to live relatively normal lives while
psychotherapy and behavior interventions help them learn the necessary
skills to be successful while living with the disorder.
Behavior management (psychotherapy), and medication management
(pharmacotherapy) are discussed in detail later on; however, certain criteria
are first raised here that are helpful to clinicians deciding the course of
treatment to follow based on three key factors of age, severity of symptoms
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and comorbid conditions. An overview of the preliminary criteria that the
parents, teachers and clinicians review and act upon all together when
deciding the best course of care for the child with ADHD will be highlighted
below.77-84,86-89,91,92
Pre-school Children
According to the NICE Clinical Guidelines, parent-training and education
programs are the initial treatment for parents or caregivers of pre-school
children. These programs are very similar to the ones recommended for the
parents or caregivers of children with a conduct disorder.
Medication therapy is not recommended for pre-school children with ADHD.
After a diagnosis of ADHD in a child of pre-school age has been made or
confirmed, clinicians need to contact the parents or caregivers and obtain
their consent to initiate contact with the child's pre-school teacher to explain
the diagnosis and severity of symptoms and deficits, interventional plan, and
special educational needs. Also, following the diagnosis, clinicians should
advise parents or caregivers of pre-school children with ADHD to enter a
parent-training and education program.
Group-based parent-training and education programs, intended for the
management of children with conduct disorders should be available to such
parents or caregivers, and parent training should be started regardless of
whether or not the child has been diagnosed formally with a comorbid
conduct disorder.
Individual-based parent-training and education programs are recommended
in the management of children with ADHD in the following situations:
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
a group program is unavailable due to low participation

there are specific challenges for families in attending group sessions
such as physical disability, language differences, parental ill-health,
transport problems

the family needs are multifaceted and cannot be met by group-based
parent-training and education programs
It is important to note that the skills training stages of the individual-based
parent-training and education programs require the involvement of both
parents or caregivers and the child.
Once the parent-training and education program and other treatment
interventions have been found to be effective to manage ADHD symptoms
and associated deficits in pre-school children, and when considering
termination of training and discharge from the parent-training program,
clinicians should follow the child as recommended below:

Re-assess the child, with their parents or caregivers and siblings, for any
outstanding comorbidities and develop a subsequent treatment plan

Monitor the child, through routine follow up and best practice screening
tools for the recurrence of ADHD symptoms and associated deficits once
the child enters school
On the other hand, if the parent-training and education programs and other
treatment interventions have not been found to be effective to manage
ADHD symptoms and associated deficits in pre-school children, clinicians
must consider giving them a referral to tertiary services for further care.
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School-age Children with ADHD and Moderate Impairment
Similar to pre-school age children with ADHD, the group-based parenttraining and education programs are considered the first-line treatment for
parents and caregivers of school-age children with ADHD and moderate
deficit. In addition to this, young school age children may also benefit
greatly from group psychological treatment such as cognitive behavioral
therapy (CBT) and/or social skills training, all of which are discussed later in
this section. Those who are older can benefit the most from individual
psychological treatment if they have not responded well to group behavioral
or psychological approaches or simply refused them.
Medication therapy is the second line of treatment and may be initiated for
those school-age children with ADHD who present with moderate levels of
deficit. It is important to note that medications should only be reserved for
those with severe symptoms and deficit or for those with moderate levels of
impairment who have either refused or not responded to psychological or
behavioral interventions.
After a diagnosis of ADHD in a school-age child or young person has been
made or confirmed, clinicians need to obtain the consent of parents or
caregivers to contact the child or young person's teacher to discuss the
following the diagnosis and severity of symptoms and deficit, interventional
plan and special educational needs. It would be very beneficial to the family
and the school systems if school-age children with ADHD are placed under
the supervision of teachers who have received training about ADHD and its
management so they can receive adequate behavioral interventions in the
classroom.
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If the school-age child with ADHD only has moderate levels of impairment,
the parents or caregiver should be given a referral to a group parent-training
and education program, mentioned earlier, either individually or together
with a group treatment program that includes interventions such as CBT
and/or social skills training. It is important to note that when enrolling
school-age children in group treatment interventions such as CBT and/or
social skills training in conjunction with a parent-training and education
program, special importance must be given to targeting a range of areas,
including social skills with peers, problem solving, self-control, listening skills
and dealing with and expressing feelings. In addition, active learning
strategies need to be employed, and rewards given when important aspects
of learning are achieved.
Older adolescents with ADHD and moderate impairment stand to benefit the
most from individual psychological interventions such as CBT or social skills
training instead of the group parent-training and education programs or
group CBT and/or social skills training that younger counterparts require.
Whereas, older school-age children and adolescents with ADHD along with a
coexisting learning disability will stand to benefit the most from parenttraining and education program on either a group or individual basis,
whichever is the preference.
When a parent training and education program is initiated, the professional
in charge of the program may want to obtain parental consent to contact the
school and provide the child's teacher with written information on the
aspects of behavioral management tackled in these programs. Once the
outcomes of the parent-training and education program have been achieved,
the child, parents or caregiver may be discharged from the program. Prior to
discharge from the program, the clinician must first perform the
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interventions of 1) re-assessing the child with their parents or caregivers
and siblings, 2) looking for outstanding problems such as anxiety,
aggression or learning difficulties, and 3) developing treatment plans if
coexisting conditions are found. On the other hand, if the parent-training
and education program has proven to be unsuccessful, school-age children
with ADHD and persisting deficits must be offered medication treatment.
School-age Children with Severe ADHD and Impairment
When symptoms of ADHD and other associated deficits are severe, the firstline treatment for school-age children and young people is medication
therapy. If it is still refused, either by the child or the parents or caregivers,
a psychological intervention can be initiated. In this group of patients,
medications are clearly the better choice but often can be foregone because
of a lack of consent between parties involved in the care and education of
the child.
Like parents of children with ADHD from other age groups, parents of
school-age children with ADHD should also be offered a group-based parenttraining and education program. Medication therapy should only be started
by a qualified healthcare professional with expertise in ADHD and when
based on a comprehensive evaluation and sound diagnosis.113 The
medications may be prescribed continually and monitored regularly by
general practice clinicians under shared care planning.
Medication therapy requires the consent and full cooperation of the child,
parents or caregiver. If either one refuses it the clinician should advise them
of the benefits and superiority of medication therapy. If it is still not
accepted, a group parent-training and education program should be offered.
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If a group parent-training/education program is indeed effective in children
with severe ADHD who have refused drug treatment, clinicians need to
evaluate for the presence of comorbidities and develop a longer-term care
plan. On the other hand, if a group parent-training and education program is
ineffective for children with severe ADHD who have not consented to
medication therapy, clinicians need to again raise the issue of starting drug
treatment or other psychological treatment, making sure to underline its
benefits and superiority.
After school-age children are diagnosed with severe ADHD, clinicians need to
obtain the consent of parents or caregivers to contact their teacher to
discuss the following aspects of care.

The diagnosis and severity of symptoms and deficit

The interventional plan

Any special educational needs
As raised earlier, ideally, children with ADHD should be placed under the
supervision of teachers who have received training on ADHD and its
management.
Role of School Nurses in School-age Children with ADHD
School teachers, nurses and support staff are a vital part of the
multidisciplinary team required to successfully manage ADHD in school-age
children. School nurses can bridge the gap between specialist ADHD
services, schools and families. It is their duty to lend support and training to
children and families, schools and professionals in the primary care setting.
The school nurse plays an important role in the management and treatment
of school-age children during school hours. They are part of the team that
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monitors the status of the child during school hours. Additionally, they are
also among the first person to notice the existence of comorbid conditions
such as learning and conduct disorders or simple visual and hearing
impairments. School nurses are also the most qualified healthcare
professional in the school environment to administer prescribed ADHD
medications and monitor their effectiveness and adverse effects.
In many cases, the school nurses become the primary person managing the
case of the child with ADHD. In this role, they help parents or guardians
identify and access resources where the child can receive appropriate care
and they support and make appointments with the appropriate resources,
provide counseling, and assist in the follow-up assessments. The school
nurses may also serve as an advocate for the child and the family. In this
role, they coordinate with teachers and school staff to develop suitable
classroom management techniques, assist parents/guardians with their
insurance needs, ensuring that the child continues to receive coverage of the
effective treatments. As mentioned previously, school nurses do not work
alone with children with ADHD. They play a very crucial role in the treatment
and management. They interact with many professionals and support
resources to achieve the best possible outcome for the child diagnosed with
ADHD.
Together with various primary health clinicians, school psychologists,
pediatricians, neurologist, community counselor, psychiatrists, teachers,
school support staff, parents/guardians, and social workers, school nurses
are able to provide well-coordinated and effective care. The teamwork
ensures that the team addresses the child’s psychological, physical,
emotional and academic needs appropriately. The combined monitoring
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efforts of the team members ensure that the child is given the best chances
of succeeding at school and at home.
The school nurse is also among the most qualified health professionals
(along with child psychologists) who can educate teachers and other school
staff about ADHD and how to identify those in the class who need
assistance. Teachers need to be able to understand ADHD in order to be able
to help those children diagnosed with it. In addition to this, they can help
teachers select the most effective interventions that can be applied in their
specific classes to help children with ADHD cope better.
The role of team members, including school nurses, teachers, and school
counselors in the school is to provide a reasonable and effective
accommodation that meet the needs of children with ADHD, and to help
them adapt and live with their condition.
Nursing Interventions
Some of the nursing interventions that school nurses can provide for
children with ADHD are highlighted below.

Gather academic information including the child’s progress and behavior
at school. The nurse should gather initial information and track the
changes so the team will have a chart or history of the child’s symptoms
while on treatment.

Assess vision and hearing status yearly. The presence of visual and
hearing problems may help explain the lack of progress of a child already
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on ADHD medication or behavioral therapy. Additionally, these problems
should be brought to the attention of a medical professional.

Identify barriers to pharmacotherapy and behavioral therapy.

Help parents/guardians identify and access various resources for the
further evaluation and treatment of the child.

Refer to support groups such as a child study group and pupil assistance
team.

Offer educational resources to the child to help understand their condition
and expectations.

Provide clinicians and other members of the multidisciplinary team
feedback regarding academic performance and behavior at school.

Communicate openly with parents/guardians regarding the
implementation of the prescribed treatment plan.

Educate parents/guardians on ADHD diagnosis, treatment options, and
follow-up assessments.

Identify behavioral problems.

Formulate behavior plan that teach and encourage appropriate behavior.

Identify factors that motivate the child to exhibit and maintain
appropriate behaviors.

Advice teachers and parents/guardians on how to provide consistent
structure and expectations to the child.

Identify appropriate behaviors and motivate the student to maintain it
through reinforcement and token rewards.

Work with school psychologist or counselor in educating the child about
self-monitoring techniques, including finding social cues from peers and
adults, strategies that help refocus attention, differentiating between
significant and insignificant stimuli, and relaxation exercises.

Educate teachers and school support staff about academic expectations
and classroom interventions that help manage symptoms. These may
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include preferential seating arrangements, alternative methods of
completing schoolwork and other related activities, personalized behavior
modification plans, and reward system.

Obtain parent/guardian and clinician consent to administer medication
during school hours according to school policy and procedure.

Evaluate the child regularly for the incidence of adverse effects to the
prescribed medications.

Provide support to the child whenever needed during school hours.

Allow the child time to express feelings about the ADHD diagnosis and
treatment plan.

Help the child find support sources within the school environment.

Record injuries of the child, if any.
Child Abuse And ADHD In Children
A study by Briscoe-Smith, et al., explored the link between child abuse in
girls and ADHD. The behavioral impairments following child abuse and the
symptoms of children with ADHD have several similar features, such as
aggression, externalizing behavior, depression and cognitive problems. The
overlap has brought to mind the possible link between ADHD and child abuse,
which brings up the possibilities of the 1) precipitating and exacerbating role
of child abuse in the development of ADHD, and 2) misdiagnosis of abuserelated post-traumatic stress symptoms as ADHD. Children who were abused
and have ADHD may also be more likely to re-experience the trauma of the
abuse and be hypervigilant both of which manifest as poor concentration and
hyperactivity, as described more specifically below.77-87,110-112
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Outcomes of Child Abuse
Child abuse results in “acting out” in the later years of the child’s life; female
children who were abused exhibit marked aggression and externalizing
problems, such as:

Hostility

Difficulty with anger management

Impulsivity

Physical attacks
Physical abuse is particularly linked to externalizing problems while sexual
abuse is linked to childhood post-traumatic stress disorder symptoms and,
later on, internalizing problems. In addition, girls who experienced sexual
abuse also have been reported to exhibit patterns of “sexual acting out”,
including:

Sexualized talk

Preoccupation with sexual themes

Sexual aggression toward other peers

Provocative behaviors at early ages
On the other hand, girls with ADHD who were not abused usually present
with externalizing problems later on in life. This partly explains why there is
a greater rate of diagnosis of ADHD among young boys. Child abuse has also
been found to precipitate distorted self-perceptions and perceptions of the
world, which in turn lead to helplessness, anxiety and depression, selfdestructive and suicidal tendencies.
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Girls who were abused also tend to suffer from poor social interaction skills
and difficulties in cultivating peer relationships. Their peers often see them
as more rejected, less popular, and more disruptive than those who were
not abused. Parents and teachers have also observed them to be excluded
socially by their peers. Additionally, girls who were abused or neglected are
associated with both poor academic functioning and late development of
cognitive functions. They score lower than non-abused children in verbal
ability and comprehension tests.
As mentioned, ADHD is reported as a predominantly male disorder. However,
ADHD affects many girls as well. The behavioral patterns of symptoms
exhibited by abused and neglected girls often overlap with those who have
ADHD.
Parenting, and Risk of Abuse
Several studies in recent years suggest the etiologic roots of ADHD have
genetic and neurodevelopmental origins. It does not mean, however, that
school and social environments are not significant in the development or
maintenance of ADHD. Abuse and violence are in fact environmental factors
that can exacerbate ADHD. The primary neurodevelopmental origin of ADHD
eliminates the prior belief that parenting is a major cause of ADHD.
Additionally, given the role of genetics in the development of ADHD,
biological parents of children with ADHD have greater likelihood of
experiencing and exhibiting poor impulse control and attentional problems
themselves, possibly contributing to the likelihood of abusive tendencies.
Study data collected over the past few years show that parents of children
with ADHD report experiencing more stress and dysfunctional parent/child
interaction styles in contrast to their counterparts who do not have children
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with ADHD. In addition to these, parents of children with ADHD also
experience greater feelings of self-blame, incompetence, isolation, and
depression. In fact, many mothers with hyperactive children are either
separated or divorced compared to those whose children without ADHD.
Observed Link Between ADHD and Abuse
Research studies demonstrate a link exists between ADHD and child abuse.
Wozniak, et al. studied whether children with ADHD are at greater risk of
experiencing trauma and PTSD symptoms. The results showed that 7% of
their ADHD population reportedly experienced child abuse. Ford, et al. also
examined the association between a history of trauma and both ADHD and
oppositional defiant disorder (ODD). The study found that children with
comorbid ADHD and ODD had a history of trauma.
At infancy, the human brain is comparatively immature compared to other
mammals. As a result, during the first two years of life, a child will
experience remarkable growth and development. It is during this growth
spurt that the brain will either establish or lose many of its cellular
interconnections. A mix of genetic and environmental factors influences
brain development during this early development. The rapidly growing
science of epigenetics have mapped out and offered some explanation to
how these processes are interrelated and affect each other.
There is a growing body of literature focused on study data and descriptive
analysis and explanation of the impact of environmental violence on the
developing brain. In particular, a most informative finding in the literature
for clinicians to keep in mind is that children exposed to violence early in
their lives tend to exhibit permanently altered responses to confrontation
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and conflict. This gives rise to the idea that these children have been “hardwired” to respond with anxiety, poor concentration, and impulsive
aggression in situations of conflict. Because they exhibit the three key
symptoms of ADHD, of hyperactivity, distractibility and impulsive aggression,
they can easily be misdiagnosed with the disorder.
Similar to their younger counterparts, adolescents who are currently
exposed to violence and abuse are also anxious, highly aroused, and have
greater levels of cortisone. However, adolescents who only experienced
violence and abuse later on in their lives do not experience the same longterm impact on the brain structure. The difficulties with attention and
concentration are attributed to the constant re-living of previous experiences
of trauma, a notable symptom of post-traumatic stress disorder. On the
other hand, the physical agitation they exhibit is a function of hypervigilance.
For these children, these symptoms can be treated and the rate of recovery
among them is especially high after they have been removed from the
abusive environment and placed into safe homes.
When it comes to the treatment and diagnosis of ADHD in abused children,
The American Academy of Pediatrics (AAP) states that its guidelines are
inappropriate for use on such patient groups. This serves as a reminder to
clinicians to avoid the mistake of misdiagnosing abused children with ADHD
because they fulfill the criteria stated in the guidelines. However, according
to the American Academy of Child and Adolescent Psychiatry (AACAP)
practice guidelines, screening for psychological trauma and an interview is
recommended for children at risk for abuse.
There are very limited studies, if any, on the appropriate treatment and
management of children, especially girls, who have both ADHD and a history
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of abuse. This is an area that requires urgent study since there are a greater
number of children with ADHD who have been referred to child protective
services. What is certain is that it is crucial to find safe and permanent
homes for such children in order to successfully manage their symptoms.
This is not to say that abused children with ADHD will necessarily have
greater chances of positive outcomes as a result of placing them in a
different home environment. Therapy for such children will need to be longterm and thoughtfully planned (involving modalities specifically aimed at
treating abuse/trauma).
On the other hand, there are also those children diagnosed with ADHD
whose abuse history was not uncovered diagnostically, either as a
precipitating factor or an exacerbating factor. If the trauma is not addressed
early on, the symptoms associated with it may go unchecked for years to
come and even worsen, as the child grows older. As mentioned previously,
the standard interventions recommended for the treatment and
management of ADHD such as behavioral modification strategies and
stimulant medications may not be the appropriate treatments for
traumatized children.
Many of these children actually develop a personality disorder when they
reach adulthood. A study by Philipsen, et al., showed that adults, especially
women, who were diagnosed with a severe form of borderline personality
disorder actually have a history of symptoms of pediatric ADHD. Since ADHD
is a lifetime disorder, it often overlaps with other psychiatric disorders that
develop later on in life. Moreover, severe borderline personality disorder
diagnosed in adulthood has been frequently found among adults who were
abused emotionally as children.
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Behavioral Management
Attention deficit hyperactivity disorder is a clinical syndrome with core
symptoms of hyperactivity, inattention, and impulsivity. The core symptoms
have been discussed previously and we will now focus more specifically on
the various methods of behavioral management of these symptoms. ADHD is
one of the most common childhood-onset psychiatric disorders; and, ADHD
may be accompanied by learning disabilities, depression, anxiety, conduct
disorder, and oppositional defiant disorder. ADHD is a chronic disorder
affecting individuals of all ages and requires developmentally-sensitive
interventions.
It has been raised that children and adolescents with ADHD often have poor
social skills, learning difficulties, and disruptive behaviour, which can all
result in low self-esteem, disrupted relationships, and academic failure. It is
important to remember that as high as 30% of all children with ADHD have
an associated learning disorder of reading, writing, and/or mathematics; and,
out of this cohort of children with ADHD, up to 80-85% continues to be
impaired by ADHD symptoms as adolescents and up to 60% into adulthood.
Keeping in mind that comorbid disorders in children with ADHD include
behavioral disorders, depression, anxiety, tics, bipolar disorder, motor skill
development difficulties, learning difficulties, and verbal and cognitive
difficulties there are various preventive/complimentary and often combined
therapeutic approaches to treatment that must be considered. Although
pharmacological treatment is the first line measure for ADHD, evidencebased psychological interventions like behavioral therapy are still widely
preferred. This is due to the following considerations.
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Pharmacologic Side Effects and Limits to Efficacy
Although pharmacological treatment is relatively safe, some patients
experience significant functional impairment with psychiatric drugs. Studies
have shown that adverse side-effects, such as, suppression of growth, sleep
problems, tiredness, loss of appetite, stomach upset, headaches, nausea,
and increases in heart rate and blood pressure can occur with long-term
treatment.
There are also short-term effects of medications that require consideration.
Although the psychostimulant drugs used in the treatment of ADHD are
effective in controlling the core symptoms, they may not be effective over a
longer term and improvements may not be maintained into adolescence.
Additionally, there are narrow clinical benefits of some medication and the
secondary problems and comorbid conditions associated with ADHD may not
be relieved with drugs alone.
A significant number of children and adults either fail to respond or exhibit a
weak response to drugs used in ADHD treatment. These patients do not
experience symptom alleviation, as expected from the administration of
these medications.
Treatment in young children requires close observation when administering
ADHD medication. The psychostimulant drugs used in the treatment of
ADHD (except dexamphetamine) are not approved for clinical use in children
less than 6 years of age. Therefore, treatment of younger children with
ADHD requires nonpharmacological measures.
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Ethical concerns regarding the use of psychotropic medications are often
involved. Psychological and behavioral treatments alone are not advisable in
moderate to severe ADHD, but they are recommended as first-line treatment
in the management of preschool-aged children, patients with mild symptoms,
and as an adjunct to medication in patients with comorbid disorders or
suboptimal responses to pharmacotherapy.
Because of the wide array of symptoms and comorbid conditions associated
with ADHD, a long-term multimodal treatment plan is the most ideal. It
helps to reduce the symptoms as well as addresses other areas of difficulty.
Long-term multimodal treatment plan for ADHD may involve any of the
following methods and considerations.

Psychoeducation, which is information, explanation and counselling for
children with ADHD, parents and others

Psychological and behavioral approaches

Social assistance such as parent support groups, financial assistance, and
respite care

Appropriate education strategies in school including assistance for
children with coordination difficulties

Discussion and consideration of pharmacotherapy
Clinicians responsible for the management of ADHD have to liaise with
multidisciplinary professionals, including behavioral therapists from a variety
of theoretical and training backgrounds. Behavioral therapy for ADHD
generally includes cognitive behavioral approaches and interventions as well
as parent training.
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In children less than 6 years of age, treatment is primarily focused on the
behavioral approach including parent-training interventions. For older
children, the treatment modalities are cognitive behavioral treatment (CBT),
social skills training and self-instructional training coupled with parent
training.
Objectives of Behavioral Management in ADHD
The clinical syndrome of ADHD in children and adults comprises behavioral
problems coexisting with mental disorders like depression, poor self-esteem,
anxiety, defiant and oppositional behaviour, relationship problems, and
learning difficulties. The mainstay of treatment is to improve the behavior as
well as the peer, social and family relationships. There is moderate-to-highlevel evidence suggesting that non-pharmacological interventions, like
behavioral measures, can be effective in managing the core ADHD
symptoms, conduct disorders, social skills, self-efficacy, and emotional
outcomes at 6 months follow-up.
Behavioral treatment approaches have also been shown to be effective in
improving on-task behavior, reducing aggression, and improving short-term
academic and behavioral performance. Moreover, behavioral management
measures can be used as an adjunct to pharmacological measures to reduce
the dose of psychostimulant drugs. The parent training measures are
designed to help parents cope with the difficult behaviors of the child.
Cognitive behavioral therapy is used for controlling the impulsivity,
inattention and hyperactivity aspects of ADHD. Cognitive behavioral therapy
aims at helping parents and patients understand the link between thoughts,
feelings, and actions and how this can lead to destructive consequences.
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Cognitive behavioral therapy also trains the patient how to reframe and
challenge their thoughts to alter feelings and behaviour into those that
produce desirable outcomes.
Methods and Strategies
Behavioral strategies like positive and negative reinforcement methods,
‘time out’ methods are highlighted below.
Positive reinforcement strategies:
Positive reinforcement strategies are interventions designed to produce a
targeted change in motor, impulse or attention control. The rewards can
include more time allowed for recreational activities or giving of valuable
things. Younger children use tokens like stars, chips, or marbles as rewards
and may be effective, but for older children the reward has to be something
that is of value. Social approval like praise or achievement certificates can
also be used as rewards for this age group.
Negative Reinforcement Method:
The negative reinforcement method includes measures like a verbal
reprimand or reproof by a parent, caregiver, or teacher when the child
behaves undesirably. This approach is effective in changing actions such as
impulsive behaviour that have disruptive effects and require immediate
cessation. There is a reward cost strategy to this method, which involves
loss of a potential reinforcement such as an earned token or deduction of a
promised reward, at the time of an inappropriate behavior.
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Time Out Method:
The Time Out Method is short for “time out from social reinforcement.” In
this method, the child is required to spend a specific duration of time away
from the attention of others and is expected to be quiet and cooperative.
This approach is effective when the hyperactive, impulsive behavior is
provoked by the attention of others like parents, peers, or siblings.
Behavioral strategies like positive and negative reinforcement methods, time
out methods may be used, which include or overlap with strategies such as
token economy (explained in more detail later on) and task simplifying.
Other helpful strategies to augment the above methods include maintaining
home and/or school diaries. The methods here have to be continued over
time to be effective. Appropriate support for associated learning difficulty
should also be included in the behavioral management interventions.
Parent Management Training
Parent management training as already mentioned, is a type of behavioral
therapy intervention that teaches parents coping skills to deal with their
children with ADHD. It is raised here in more detail as part of a family
systems approach to therapy considered integral to successful outcomes for
the child and parent(s)/caregiver(s).
The term parent training, is applicable not only to parents but also to others
who are instrumental in providing care for the child, including caregivers and
guardians of the child. The parents, or caregiver, or guardian, and therapist
form a collaborative team. They are taught to target and keep track of
problematic behaviors, put in place clear and developmentally-appropriate
behavioral expectations, and provide positive reinforcement for appropriate
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behavior and negative consequences for inappropriate behavior. When done
correctly, parent management training decreases child behavior problems,
increases homework completion, and results in better parent–child
interactions. This type of intervention primarily focuses on issues that hinder
the parent’s coping mechanisms and responses to internal and external
stressors, such as poor self-esteem, social isolation, depression and marital
difficulties.
The main aims of parent training are listed below:

Teach parents the basics of child behavioural management

Increase confidence in parental capabilities

Develop competence in raising children with ADHD

Improve parent-child relationship by using good communication and
positive attention to aid the child’s development
Parent training programs follow a set curriculum, which usually runs for
several weeks. It is usually conducted in groups, but can also be modified for
individual training. Triple P and Webster-Stratton are some of the wellrecognized parent training programs. The American Academy of Child and
Adolescent Psychiatry recommend that parent management training of
preschool children with ADHD be the initial intervention before using
stimulants. Children with ADHD are much more difficult to parent. It is not
uncommon for parents to eventually become less effective, and feel
overwhelmed and unable to manage the behavioral symptoms of ADHD.
Parent management training programs are designed to aid in stabilizing the
home situation.
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Parent management training may include video clips and role-playing, which
can aid in the analysis and demonstration of parenting skills that are
especially important for ADHD children. They may include the following
measures.

Improve structure and daily routine

Keep consistent supervision

Obtain the child's attention prior to giving instructions

Give step-by-step instructions

Provide positive experiences such as praises and rewarding
experiences
One very important element present in interactions between parents and
child with ADHD is power struggle. The children react to parents, and
parents react to them, in a vicious cycle that employs less effective but more
coercive behaviors. The continuous struggle often leads to parents lowering
their expectations and refusing to give the children attention. This can be
corrected with parent management training; if done correctly, the parents
will learn how to interact with their children without power struggles. They
will learn about giving rewards for appropriate behaviors, and creating
prospects that will change the pattern.
While parent management training for disruptive behavior is backed by very
strong evidence-based studies in mental health, it is not available to many
families who could benefit from it. The strong prospects of parent
management training and its vital role in evidence-based mental health
practices should make it accessible to parents and families who need it the
most. Wider availability will not only benefit families and parents, it will also
help bring down mental health costs.
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In a report published by the U.S. Department of Health and Human Services'
Agency for Healthcare Research and Quality (AHRQ), parent management
training involving parenting strategies is both a low-risk and effective
method for improving behavior in children with ADHD at the preschool age
(< 6 years old). It is an ideal first line treatment in these cases. This is
especially important since there is very limited available data supporting the
safety and efficacy of ADHD medications in this age group. However, there is
one huge barrier to the success of parent management training, which is the
large number of parents who drop out of therapy programs. This is
especially true among parents whose children were initially diagnosed with
disruptive behavior. In fact, a large number of preschool-age children with
aggressive or noncompliant behavior who eventually develop ADHD usually
first receive an initial diagnosis of disruptive behavior disorder.
Cognitive Therapy
Cognitive therapy is another psychological treatment approach used among
children with ADHD. It involves the following approaches:

Cognitive modelling

Self-evaluation

Self-reinforcement

Response cost
Self-instructional training is the most commonly used cognitive modeling
approach. Children are taught to adopt a systematic, reflective, and goaldirected approach to tasks and problem solving, thus helping them develop a
planned and reflective way of thinking and behaving. The learning strategies
include abstract learning schemas, concrete step-by-step approaches and
physical cues or reminders.
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Think Aloud is a program with an abstract reasoning strategy devised by
Camp and Bash in 1981 based on the ideas of Meichenbauem. Children are
taught to adopt a 4-point schema when faced with a problem, which are:
1. What is the problem?
2. What is my plan?
3. Do I use my plan?
4. How did I do?
This strategy is taught initially with cognitive modelling that involves an
adult verbalising a response to a problem-solving task. Children are
encouraged to emulate this by first talking out loud, and then whispering
and finally using self-talk to solve problems. Self-evaluation is then
encouraged. In this type of program, children are instructed in task-specific
strategies related to activities like schoolwork, social activities, and leisure
pursuits. Other methods taught are self-reinforcement and response-cost
techniques wherein the children have to pay a penalty for mistakes or earn
rewards for following the strategies taught.
Family Therapy
Family therapy is focused on improving interpersonal relationships within the
family and subsequently, family function. The different models used are
briefly listed below, and involve extensive research, theory as well as
extensive therapist training for these therapy approaches:

Structural family therapy

Strategic family therapy

Brief solution-focused therapy
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Behavioral Interventions in Educational Settings
Schools are ideal settings for intervention since school-based services are
easy to access and the stigma associated with accessing behavioral services
in a clinic is minimized. Schools are also ideal settings for the
implementation of evidence-based interventions (EBI) aimed at preventing
or minimising academic, peer-social or behavioral problems in ADHD.
Since children with ADHD most likely have associated learning difficulties,
exhibit difficult class room behaviors, show significant time-off task, and
often fail to comply with instructions of the teacher, teachers have to spend
a greater amount of time with them, compared to their peers. This can lead
to conflicts in teacher-student relationships. As mentioned previously,
children with ADHD have stressful and conflicting relationships with their
parents because of behavior problems at home. This can have a negative
impact on the parent-child relationship and the ability of parents to support
their education.
Aside from the teacher-student and parent-child conflicts, parents and
teachers themselves may not see eye-to-eye. This conflict most likely arises
from parental dissatisfaction with the teacher due to the inability to meet the
child’s educational needs. Additionally, the teacher’s concern for the child’s
behavior in the class room can be interpreted negatively and subsequently
lead to strained relations with the parents.
Treatments that support children with ADHD in school include the use of
stimulant medications and psychosocial interventions, such as strategies to
support home-school collaboration. Another example of a psychosocial
intervention is strategies to improve both performance and skill deficits.
Interventions aimed at performance deficits include environmental
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adaptations and accommodations to intervene at the point of performance,
such as techniques to modify the antecedents and consequences in the
environment to change child behavior. Interventions aimed at addressing
skills deficits include direct instruction and increasing opportunities for
repeated practice of new skills.
Children with ADHD function poorly in unstructured and unpredictable
environments. It is, therefore, advisable for teachers to keep the classroom
structured and predictable. In a group, ADHD children are more likely to
exhibit unruly behavior, but they may not require disciplinary interventions
and are more likely to obey clear behaviour rules and a system of
consequences if applied consistently. Two of these school approaches are:
1) Response to Intervention (RTI) and 2) Effective Behavioral Supports
(EBS) or School-wide Positive Behavior Support (PBS).
Positive Behavioral Support (PBS) is defined as a systems approach to
enhancing the capacity of schools to adopt and sustain the use of effective
practices for all students. Primary strategies focus on implementing schoolwide discipline, classroom-wide behavioral management, and effective
instructional practices. For an effective program, the involvement of expert
consultants in school such as school and clinical psychologists, child and
adolescent psychiatrists and other behavioral health professionals in
implementing evidence-based psychosocial interventions (EBI) in the school
setting is crucial.
A key member of the PBS team is the PBS coach who has been extensively
trained in applied behavioral analysis. The PBS coach can be trained to form
school-home partnerships and to use conjoint behavioral consultation (CBC)
in school-home relations. CBC is a structured problem-solving process
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wherein parents and teachers work together as partners throughout the four
stages of behavioral consultation, which are identified as:
 Problem identification
 Problem analysis
 Plan implementation
 Plan analysis
The PBS coach, through a structured process, such as CBC, is specifically
trained to provide support to behavioral health staff and teachers in the
implementation of universal and individualised behavioral interventions for
classroom and school.
Strategies to Support Individual Students
Teachers of students with ADHD have to adapt their classroom routine and
expectations in order to minimize individual student’s deficits in performance.
This is done by an individual education plan (IEP) which advises teachers on
modifications to routine classroom work, tests, and homework assignments
for children with ADHD. Modifications in the classroom include seating of the
child with ADHD close to the teacher to avoid potential environmental
distractions like doors, windows and other students, and allow the teacher to
use a private attention cue to prompt the student to stay on task. Students
with ADHD have to be given extended time for completing tests or allowed
to take tests in a quiet room.
Students with ADHD often lag behind their peers in academic performance
as well as acquisition of skills that affect academic productivity, classroom
behavior and peer relations. They are also more likely to have impaired
planning ability, poor sense of time and inaccurate time estimation, lack of
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effort and motivation, poor self-regulation of emotion, greater problems with
frustration tolerance which result in academic performance problems,
disruptive classroom behavior, and peer difficulties.
Many behavioral interventions have been proven effective, but clinical gains
are hard to sustain and only when they remain in place in the settings and
during times of difficulties. Since most difficulties encountered by ADHD
students occur because of performance defects, interventions are geared
towards enhancing performance, such as improving impulse control and time
given to a task. For children who lack skills, interventions are focused on
teaching new skills like social and organisational skills. Most school-based
interventions are geared to affect the antecedents/consequences of behavior.
An example of antecedent is the way in which the teacher gives commands
to the students.. Consequences, on the other hand, can be defined as
responses that follow behaviors that can either increase or decrease the
probability of them happening again.
Positive Reinforcements
Interventions based on modification of antecedents and consequences are
used in schools. Teachers are taught how to alter the antecedents and
contingencies in the environment to shape the behavior of children with
ADHD. This includes components such as:

Setting consistent limits and reasonable expectations

Giving instructions in a clear and consistent manner

Providing positive reinforcement contingent on appropriate behavior

Using effective and strategic consequences for specifically identified
inappropriate behavior
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One of the primary goals of behavioral intervention programs is to increase
teachers’ use of positive reinforcement contingent upon appropriate behavior.
Specifically, it allows teachers to provide differential attention, which is
attention and verbal praise as positive reinforcement when students
demonstrate expected behavior, and systematically ignore inappropriate
behavior. Positive attending, which is making positive remarks in response
to appropriate child behavior, is very effective in strengthening teacherstudent relationships.
Token Economy or Token Reward System
In the Token Economy system, the teacher dispenses tokens, chips, stickers
or points to any student in the class (as a class wide intervention) or to
individual students with ADHD (individualised intervention) for exhibiting
previously determined behavior. This intervention can be used to encourage
on-task behavior and appropriate classroom behavior. It can be made more
effective by coupling it with a reinforcement system in which the student can
exchange the tokens or points to gain small prizes or preferred activities.
The token or point system is more effective when children are given a group
of reinforcements to choose from and also when the system is made
effective consistently. Some children respond to the token system only when
it is combined with positive reinforcement and response cost. A response
cost refers to the procedure wherein children earn points by doing specified
desirable actions, but lose points when exhibiting undesirable behavior.
Daily Report Card (DRC)
The daily report card is a behavioral intervention with strong research
support. This type of intervention requires planning that involves the school
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and the family with inputs from children, implementation of elements
involving the teacher and parents, and evaluation of implementation quality
and outcomes. It is easy to keep track of the points children earn or the
percentage of days they have achieved their goals. Below is an example of
how to construct a daily report card of a child with ADHD.
Step 1
Identifying 2 or 3 target behaviours
These should be adaptive behaviour for the classroom rather than
non-adaptive responses.
Consider including the child in the process to increase child investment.
Step 2
Identify a method for recording child behaviour.
Option 1: Tally the occurrence of target behaviour.
Option 2: Rate the child’s behaviour on a 3- or 4-point scale at designated times.
Step 3
Educate the parents about DRC.
Set reasonable goals for child’s behaviour each day. Goals should be 10%
higher than base-line performance.
Reinforce the child for goal attainment. The child might earn privileges at home
each time he gains a goal at school.
Step 4
Educate the child about the DRC goals, parent, teacher, and child roles,
and opportunities for rewards contingent on appropriate behaviour.
Step 5
Monitor implementation and outcomes.
Review complete DRC to ensure proper use by parents and teachers.
Adjust goals according to child’s progress.
There is considerable evidence supporting the effectiveness of DRC
intervention in children with ADHD behavioral problems. Moreover, this
intervention is acceptable and feasible for teachers to use.
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Self-management
The self-management method is suitable for older children with ADHD and
includes self-monitoring and self-reinforcement. Self-management is used in
conjunction with an incentive system through which children can reward
themselves for achieving certain goals.
In this intervention, the children are taught to recognize and record
instances of on-task behavior. At first, the teachers help the children to keep
the count, until such a time they become proficient enough to manage on
their own.
Social Skills Training
Children with ADHD present with difficulty in maintaining family and peer
relationships due to poor social interactive skills, which are necessary for
developing and maintaining constructive social and personal relationships.
Therefore, social skills training aims at teaching children social interactive
skills like eye contact, smiling and appropriate body posture necessary for
social interactions.
Social skills training use techniques from both cognitive and behavioral
approaches and are conducted in groups. It teaches affected children how to
self-regulate responses. The ability to self-regulate is the capacity to initiate,
delay, modify or modulate the amount or intensity of a thought, emotion,
behavior or psychological response. It also teaches children how to manage
stressful events. Studies have shown that social skills training in children
with ADHD consisting of an intense, multimodal behavioral intervention
focusing on multiple areas of impairment and conducted within the child’s
social milieu is very effective. It is conducted in clinical settings, away from
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the environments where these children have relationship problems and are
lacking social validity.
There is evidence that participation in intense social skills training sessions,
such as those offered during summer treatment programs (STPs) and those
used in the Multimodal Treatment Study for children with ADHD, results in
long-lasting improvement in behavioral functioning, social skills, and peer
relations. Such sessions usually last between 6–8 hours a day, five days a
week, for a period of many weeks. The STP interventions involve social skills
training followed by coached recreational activities and the use of
contingency behavior management systems, such as token/point systems
and concurrent home rewards given to the child by the parents for meeting
goals related to peer relations. The behavioral effects of STPs on children’s
propensity to externalize behavior and peer relations are comparable to
those obtained through psychostimulant medication treatment.
Organizational Skills Training
Children with ADHD have organizational skills deficits, and unless they learn
these, they will have difficulties during their secondary education and
vocational performance. Although some children exhibit improvements in
organisational skills with medication, many children with ADHD on
medication still continue to have deficits in this area. Strategy training for
improving organizational skills includes interventions targeted at the
children’s ability to take accurate notes, organise study materials, and study
more efficiently. They have to be taught how to take notes during classroom
lectures, to write down homework assignments with accuracy, to organize
their school binders and other school materials, and to memorize
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information to help them study for tests and exams. The effectiveness of
organizational skills training is enhanced with contingency reinforcement.
Behavioral Homework Intervention
Problems with homework completion are widely prevalent among children
with ADHD. Strategies to improve homework performance are important as
they can improve home-school relations and improve academic performance.
Homework interventions have two elements of 1) antecedent strategies that
create the content for homework performance, and 2) consequences which
refer to contingencies of homework behavior.
Antecedent strategies involve assignment of a reasonable amount of
homework given the children’s age and abilities as well as work that can be
completed with minimal parental supervision. The place for homework
should be free from distractions and time allotted for homework should be
the time of the day when children are most attentive.
Computer Assisted Instruction
Children with ADHD have academic skill deficits, which include
comprehension and retrieval of basic facts. If instructional tasks are novel
and stimulating and if there is regular feedback, then children with ADHD
exhibit increased academic success. Computer assisted instruction (CAI)
supports the academic requirements of children with ADHD. It allows for
lessons and specific goals to be tailored to each child’s instructional level.
The learning environment tends to be more stimulating than typical paper
and pencil classroom tasks, and children receive immediate feedback from
the computer about the accuracy of their responses.
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Limitations of Behavioral Therapy in ADHD
Some studies have shown that, despite improvement in certain outcome
targets with behavioral management, the core symptoms of inattention,
hyperactivity, and impulsivity remain largely unchanged at the end of 8months of behavioral therapy alone for ADHD children.
Current research evidence has not shown significant benefits of cognitive
behavioral therapy in ADHD, despite cognitive processes to be strongly
linked with ADHD. Whalen, Henker, and Hinshaw reviewed cognitive
behavioral approaches in the literature, and concluded that evidence of
benefit was weak for many studies. Kendall and Braswell found that CBT
reduced impulsivity but had little effect on other features of ADHD. Abikoff
and Gittleman compared the efficacy of CBT combined with medication to
medication alone in ADHD and found limited advantage over the medication
group.
Effectiveness of Behavioral Interventions in ADHD
Studies reveal that treatment with either medication or behavioral
interventions have several drawbacks. Pelham suggests that these can be
reduced when the two approaches are combined, and that the primary
symptoms are most successfully treated by medication and the secondary
symptoms by behavioral approaches. Gittleman and colleagues studied the
efficacy of three treatment approaches, which are behavior modification plus
placebo, behavior modification plus methylphenidate, and methylphenidate
alone. The combination of behavior modification plus methylphenidate was
the most effective followed by methylphenidate alone and then behavior
modification plus placebo.
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Patients with ADHD exhibit impaired functioning, quality of life (QOL),
adaptive skills, and executive function that often persist throughout their
lives. Although ADHD symptoms are a core aspect of diagnosis, focusing on
symptom improvement as a treatment outcome is insufficient, because
symptoms represent only part of the outcome. When initiating a new
treatment, it is appropriate to collect symptom ratings to assess response,
because ADHD symptom ratings are most sensitive to treatment response in
the short term. After stabilization of treatment, additional domains can be
assessed for improvement. During initial titration, and during maintenance
of treatment, ratings should be collected from multiple raters such as
parents and teachers because the level of agreement among raters may be
low.
The complex combination of primary, secondary, comorbid symptoms and
social factors, should be considered for each individual child in order to plan
and carry out the most effective treatment approaches. Pelham and Bender
suggested that treatment approaches for children with ADHD should begin
with behavioral management and parent training. Behavioral interventions
are effective as a psychological intervention for controlling core symptoms
and other aspects like behavior, conduct, emotional and learning problems.
Medication Management Of ADHD
The American Academy of Pediatrics (AAP) has collaborated with various
notable organizations in creating the latest version of Clinical Practice
Guidelines including. These organizations include:

American Academy of Child and Adolescent Psychiatry

Child Neurology Society

Society for Pediatric Psychology
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
National Association of School Psychologists

Society for Developmental and Behavioral Pediatrics

American Academy of Family Physicians

Children and Adults With Attention-Deficit/Hyperactivity Disorder
(CHADD)

Centers for Disease Control and Prevention (CDC)
The representatives from each of these organizations formulated together a
series of research questions to direct an extensive evidence-based review for
both diagnostic and treatment issues. The questions directed at the
diagnostic issues were:
1.
ADHD prevalence, specifically: (a) What percentage of the general U.S.
population aged 21 years or younger has ADHD? (b) What percentage
of patients presenting at pediatricians' or family physicians' offices in
the United States meet diagnostic criteria for ADHD?
2.
For co-occurring mental disorders of people with ADHD, what
percentage has 1 or more of the following co-occurring conditions:
sleep disorders, learning disabilities, depression, anxiety, conduct
disorder, and oppositional defiant disorder?
3.
What are the functional impairments of children and youth diagnosed
with ADHD? Specifically, in what domains and to what degree do youth
with ADHD demonstrate impairments in functional domains, including
peer relations, academic performance, adaptive skills, and family
functioning?
4.
Do behavior-rating scales remain the standard of care in assessing the
diagnostic criteria for ADHD?
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5.
What is the prevalence of abnormal findings on selected medical
screening tests commonly recommended as standard components of an
evaluation of a child with suspected ADHD? How accurate are these
tests in the diagnosis of ADHD compared with a reference standard
(i.e., what are the psychometric properties of these tests)?
The questions directed at the treatment issues in particular were:
1. What new information is available regarding the long-term efficacy and
safety of medications approved by the U.S. Food and Drug
Administration (FDA) for the treatment of ADHD (stimulants and
nonstimulants) and, specifically, what information is available about the
efficacy and safety of these medications in preschool-aged and
adolescent patients?
2. What evidence is available about the long-term efficacy and safety of
psychosocial interventions (behavioral modification) for the treatment of
ADHD for children, and specifically, what information is available about
the efficacy and safety of these interventions in preschool-aged and
adolescent patients?
3. Are there any additional therapies that reach the level of consideration
as evidence based?
According to the AAP guidelines, stimulant medications are very effective in
decreasing the main symptoms of pediatric ADHD.114,115 Other non-stimulant
medications have also shown promising results by demonstrating efficacy at
symptom reduction. These are shown to be 1) Atomoxetine (selective
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norepinephrine-reuptake inhibitor, and 2) Extended release selective α2adrenergic agonists (guanfacine and clonidine).
Both classes of medications are fairly new in the field of pediatric ADHD
treatment and the evidence that back their role in this disorder is smaller
and weaker compared to the stimulant medications. Moreover, these
medications have not received FDA approval for use in preschool-aged
children. Below is a summary table of the currently FDA-approved
medications for ADHD with their pharmacokinetic profiles and dosing
schedules.118
Medication
(Generic name)
Mixed amphetamine
salts
Dextroamphetamine
Lisdexamfetamine
Methylphenidate
Dexmethylphenidate
Atomoxetine
Extended release
guanfacine
Extended release
clonidine
Initial
Frequency
Time to
Duration Maximum
titration dose
initial effect
dose
2.5-5 mg
QD-BID
20-60 min
6 hours
40 mg
2.5, 5 mg
20 mg
5 mg, 10 mg,
18 mg, 20 mg
2.5 mg, 5 mg
0.5 mg/kg per
day, then
increase to QDBID for children
>154 lbs
1 mg/day
BID-TID
QD
QD
20-60 min
60 min
20-60 min
4-6 hours
40 mg
10-12 hours 70 mg
3-12 hours 54-60 mg
BID
QD-BID
20-60 min
1-2 weeks
3-12 hours 20-30 mg
At least 10- 1.4 mg/kg
12 hours
QD
1-2 weeks
0.1 mg/day
QD-BID
1-2 weeks
At least 10- 4 mg/day
12 hours
At least 100.4
12 hours
mg/day
Among the most common adverse effects of stimulant medications are:

Loss of appetite

Abdominal pain

Headaches

Sleep disturbance
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Other adverse effects of stimulant medications reported by studies include:

Decreased growth velocity

Hallucinations and other psychotic symptoms

Cardiac death
The non-stimulant medication, atomoxetine, is also implicated in many
adverse effects, including:

Initial somnolence

Gastrointestinal tract symptoms (especially if the dosage is titrated
upward too rapidly)

Decreased appetite

Increase in suicidal thoughts

Hepatitis (rare)
The non-stimulant α2-adrenergic agonists extended-release guanfacine and
extended-release clonidine, are implicated in the development of
somnolence and dry mouth.
Adjunctive therapy is an important part of managing pediatric ADHD. The
FDA has approved only 2 medications for this use: 1) Extended-release
guanfacine, and 2) Extended-release clonidine. Other medications mentioned
as part of the management are off-label, with only anecdotal evidence for
their safety or efficacy.
Psychostimulants
Stimulants are the first line of medications prescribed to children with ADHD.
According to the CDC, 70-80% children diagnosed with ADHD who were
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given stimulants responded positively. Although some of them have reported
experiencing a funny feeling during the course of their treatment,
psychostimulants at their therapeutic doses do not induce feelings of being
high. To date, there are three type of stimulants that are commonly
prescribed in treating ADHD: 1) Methylphenidate (Concerta and Ritalin),
2) Amphetamine (Adderall), and 3) Dextroamphetamine (Dexadrine).
Stimulants are thought to exert their therapeutic effects by acting on the
neurotarnsmitters in the brain. The result is more balanced levels of
neurotransmitters and decreased inattention and hyperactivity.
The stimulants mentioned above are sympathomimetic compounds that do
not share similar structures except for a phenylethylamine backbone with
endogenous catecholamines. The mechanism of action of psychostimulants
is primarily attributed to its blockade of catecholamine reuptake into
presynaptic nerve endings, thus, preventing their degradation by the
enzyme, monoamine oxidase. Additionally, amphetamine compounds are
thought to initiate the retrograde release of catecholamines through the
transporter as well as other actions on the vesicular storage of
catecholamines.
Stimulants are contraindicated in the following conditions:

Any type of heart defect or disease

Hypertension

Hyperthyroidism

Glaucoma

Anxiety states

History of drug abuse
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Methylphenidate
The role of Methylphenidate in pediatric ADHD is that it corrects the
hyperactivity and increases the attention span. It promotes nerve impulse
transmission by releasing nerve terminal stores of norepinephrine.
Dose and Administration:
The tablet formulations are availabele in various doses, ranging from 2.5 20 mg. Clinicians usually start with very small doses that can be gradually
titrated upward depending on patient response and tolerance to adverse
effects.
Pediatric patients age 6 years and older usually start with 5 mg given twice
daily; followed by a daily maintenance dose of 60 mg. These patients require
frequent monitoring for adverse effects. Patients prescribed with the
transdermal patch, Daytrana, are usually between 6 to 12 years old. They
may apply one 10 mg patch to clean skin, preferrably on the hip and alter
administration sites regularly.
Chemical Structure and Available Preparations:
Methylphenidate hydrochloride is methyl α-phenyl-2-piperidineacetate
hydrochloride. Available preparations include:

Methylin: Oral solution 5 mg/5 ml, 10 mg/5 ml
Tablets (chewable) 2.5 mg, 5 mg, 10 mg

Ritalin: 5 mg, 10 mg, 20 mg
Extended-release 
Metadate CD: capsule 10 mg, 20 mg, 30 mg

Ritalin LA: capsule 20 mg, 30 mg, 40 mg
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
Concerta: tablet 18 mg, 27 mg, 36 mg, 54 mg

Metadate ER, Methylin ER: tablet 10 mg, 20 mg
Sustained-release 
Ritalin SR: tablet 20 mg
Transdermal system 
Daytrana: patch 10 mg, 15 mg, 20 mg, 30 mg
Adverse effects:
Patients may frequently experience nervousness and sleeplessness. Others
may experience weight loss and suppression of appetite. Dizziness, increase
in blood pressure and gastrointestinal upset are also frequent adverse
reactions of the drug. Life-threatening reactions include exfoliative
dermatitis, uremia and thrombocytopenia.
FDA Warnings:
Due to its psychotropic effects, methylphenidate (Metadate CD) is often
abused. This is why it is classified under the Schedule II controlled
substances. Its sale and administration without valid prescription is illegal.
Elimination:
Methylphenidate is absorbed from the gastrointestinal tract and 40% is
excreted unchanged in the urine.
Metabolism:
The drug undergoes extensive first-pass metabolism via de-esterification to
form a minimally active metabolite. Its major metabolite is ritalinic acid.
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Contraindications:
Patients who are hypersensitive to methylphenidate, with a history of
Tourette syndrome, seizures and motor tics should not be given the drug. It
should not be given to pediatric patients who are 6 years old or below.
Drug interactions:
Methylphenidate decreases the effects of decongestants and increases the
effects of other ADHD drugs such as tricyclic antidepressants.
Dexmethylphenidate
The role if dexmethylphenidate in pediatric ADHD is that it increases the
concentration of norepinephrine and dopamine by inhibiting their reuptake
and stimulating their release from the presynaptic vesicles.
Dose and Administration:
Children who are 6 years and older and not on methylphenidate, are usually
given 2.5 mg tablets which to be taken twice daily and 4 hours apart. The
dose may be increased within a week by 2.5 mg to 5 mg daily. The
maximum daily dose is 20 mg.
Chemical Structure and Available Preparations:
Dexmethylphenidate hydrochloride is methyl α-phenyl-2-piperidineacetate
hydrochloride, (R,R’)-(+)-. Its empirical formula is C14H19NO2•HCl. Its
molecular weight is 269.77. Available preparations include: Extendedrelease - Capsule: 5 mg, 10 mg, 20 mg; and Tablet: 2.5 mg, 5 mg, 10 mg.
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Adverse effects:
Children may experience headaches, feelings of jitterness, insomnia,
tachycardia, twitching and other hypersensitivity reactions.
Elimination:
Studies showed that 90% of dexmethylphenidate is excreted in the urine.
Metabolism:
Dexmethylphenidate is metabolized primarily to d-α-phenyl-piperidine acetic
acid by de-esterification. It has little or no pharmacological activity.
Contraindications:
Dexmethylphenidate is contraindicated in patients who are hypersensitive to
methylphenidate, its parent compound. It is also not prescribed to children
with structural cardiac abnormalies or other serious heart problems.
Drug interactions:
Avoid using dexmethylmephenidate with antacids for it may alter the release
of extended-release form. Patient must be monitored cautiously when used
in conjunction with other centrally-acting alpha agonists.
Amphetamine-dextroamphetamine
The role of amphetamine-dextroamphetamine in pediatric ADHD is such that
its specific mechanism of action of amphetamines and its derivatives in the
management of ADHD is not very clear. It is a norepinephrine and dopamine
reuptake inhibitor so it stimulates the release of monoamines into the
extraneuronal space.
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Dose and Administration:
For children 6 years and older, a dose of 5 mg immediate-release tablet is
given daily or twice daily. It may be titrated upward weekly by 5 mg until
optimal response is seen. The daily dose should not exceed 40 mg.
For children between 3 years to 5 years old, a dose of 2.5 mg immediaterelease tablet is initially given daily. It may be titrated upward on a weekly
basis by 2.5 mg until optimal response is seen. The daily dose may be given
2 to 3 times separated by 4 to 6 hours interval.
Chemical Structure and Available Preparations:
Amphetamine products combine the neutral sulfate salts of
dextroamphetamine and amphetamine, with the dextro isomer of
amphetamine saccharate and d, l-amphetamine aspartate. Available
preparations include: Tablet: 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg,
30 mg. In 2001, the FDA approved the extended-release capsule. The drug
is contained within the tiny beads in the capsule; it provides 10-hour
coverage.
Adverse Effects:
Children may experience palpitations, weight loss, and increased
hyperactivity. Thrombocytopenia, uremia and exfoliative dermatitis are some
of the drug’s life-threatening effects.
FDA Warnings:
Children under 3 years old and diagnosed with ADHD are not recommended
to use amphetamines.
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Elimination:
The urinary recovery of amphetamine has been reported to range from 1%
to 75%, depending on the urinary pH, with the remaining fraction
metabolized in the liver.
Metabolism:
Amphetamine is reported to be oxidized at the 4 position of the benzene ring
to form 4-hydroxyamphetamine, or on the side chain α or β carbons to form
alpha-hydroxy-amphetamine or norephedrine, respectively.
Contraindications:
Patients with known hypersensitivity to sympathomimetic amines are not
advised to use this drug. Sudden death has been reported in association
with central nervous system (CNS) stimulant treatment at usual doses in
children with structural cardiac abnormalities or other serious heart
problems.
Drug interactions:
If used with gastrointestinal acidifying agents, a decrease in amphetamine
absorption can be observed. It may also increase the effects of
sympathomimetic or tricyclic agents if given concomittantly.
Dextroamphetamine sulfate
The role of dextroamphetamine sulfate in pediatric ADHD is that it releases
stored dopamine and norepinephrine from nerve terminals in the brain and
probably promotes nerve impulse transmission.
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Dose and Administration:
Children 6 years and older are given 5 mg tablets to be taken once or twice
daily. It may be titrated upward on a weekly basis by 5 mg. The daily dose
must not exceed 40 mg.
Chemical Structure and Available Preparations:
Dextroamphetamine sulfate is the dextro isomer of the compound d,lamphetamine sulfate, a sympathomimetic amine of the amphetamine
group. Chemically, dextroamphetamine is d-alpha-methylphenethylamine,
and is present in all forms of dextroamphetamine sulfate extended-release
capsules as the neutral sulfate. Available preparations include:

Capsules: 5 mg, 10 mg, 15 mg

Tablets: 5 mg, 10 mg
Adverse effects:
Patients may experience nervousness, insomnia, tremor, headache,
palpitations, diarrhea, anorexia, and other gastrointestinal problems.
Elimination:
It is eliminated renally. Excretion is enhanced by urine ph and 99% of each
dose is ionized by glomerular filtration, with the remaining portion
reabsorbed by the body.
Metabolism:
Single pharmacological doses of amphetamines produce peak plasma levels
within 1-2 hours and are rapidly absorbed from the gastrointestinal tract.
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Contraindications:
It is contraindicated in patients with known hypersensitivity to
sympathomimetic amines. It should also not be prescribed to children with
structural cardiac abnormalities or other serious heart problems.
Drug interactions:
The central stimulant effects of amphetamine may be inhibited if given
together with chlorpromazine.
Methamphetamine hydrochloride (Formulation: Desoxyn)
The FDA approved Desoxyn as treatment for ADHD, although it is not
commonly prescribed and considered as controlled substance because of its
abuse potential or propensity to cause a drug use and addiction disorder.
Non-stimulant Medication for ADHD
Non-stimulants include selective norepinephrine reuptake inhibitor (NRI)
medication, such as atomoxetine.
Atomoxetine
Atomoxetine (Strattera) was approved in 2002 for the treatment of pediatric
ADHD in children between 6 to 17 years old. It is the first non-stimulant
approved for children diagnosed with ADHD, and its role is that it increases
the levels of both dopamine and norepinephrine in the postsynaptic junction.
Dose and Administration:
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Children who weigh 70 kg or less, are given an initial dose of 0.5 mg/kg
daily. After a minimum of 3 days, it may be titrated upward to a target daily
dose of 1.2 mg/kg.
Chemical Structure and Available Preparations:
Its chemical designation is (-)-N-Methyl-3-phenyl-3-(o-tolyloxy)propylamine hydrochloride. The molecular formula is C17H21NO•HCl, which
corresponds to a molecular weight of 291.82. Available preparations include:
Capsule: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg
Adverse effects:
Pediatric patients may experience headaches, dizziness, irritability, abnormal
dreams, and sleep disturbances. Some may also experience palpitations, ear
infection, urinary retention, and weight loss.
FDA Warnings:
The FDA warns that atomoxetine must be discontinued if the patient reports
jaundice since the drug is associated with the development of liver injury.
Latest studies show that patients under atomoxetine treatment are more
likely to have suicidal thoughts than those who are not. Therefore, clinicians,
guardians and parents need to pay close attention to the patient’s behavior
and monitor any changes.
Elimination:
Atomoxetine is excreted via the kidneys, mainly as 4-hydroxyatomoxetineO-glucuronide (greater than 80%). Less than 17% of the drug is eliminated
via the feces and 3% usually remains unchanged.
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Metabolism:
The half life of atomoxetine is 21 ½ hours.
Contraindications:
The safety and efficacy of atomoxetine has not been established in patients
younger than 6 years old.
Drug interactions:
Atomoxetine may increase cerebrovascular effects given concomittantly with
albuterol.
Alpha-2 agonists
Alpha-2 agonists work by stimulating the neurotransmitter, norepinephrine,
which is important for concentration. It may be used in conjunction with a
stimulant or when psychostimulant drugs failed in pediatric patients with tics.
The two most common alpha-2 agonists used in ADHD treatment are
1) Guanfacine hydrochloride, and 2) Clonidine.
Guanfacine hydrochloride
The role of guanfacine hydrochloride in pediatric ADHD is that it improves
hyperactivity and insomnia symptoms. It decreases the symptoms of
Tourette syndrome. It stimulates the neurotransmitter norepinephrine.
Dose and Administration:
The initial dose is usually 0.05 to 0.08 mg given once daily. A daily dose up
to 0.12 mg/kg may provide additional benefit.
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Chemical Name And Available Preparations:
The chemical designation is N-amidino-2-(2,6-dichlorophenyl) acetamide
monohydrochloride. The molecular formula is C9H9Cl. Available preparations
include: Tenex; tablet; 1 mg, 2 mg.
Adverse Effects:
Patients on guanfacine may experience fatigue, dizziness, dry mouth,
irritablity, and behavioral problems.
Advantage over other drugs used in pediatric ADHD:
Guanfacine is used to treat pediatric patients between 6 to 17 years old and
may be used in conjunction with an ADHD stimulant.
In the latest studies relative Intuniv (which is Guanfacine, Extended Release
form) in pediatric patients less than 6 years of age show that its safety and
efficacy have not been established.
Metabolism:
After oral administration of Intuniv, the time to peak plasma concentration is
approximately 5 hours in children.
Contraindications:
The drug is contraindicated in patients who are hypersensitive to guanfacine
or other products containing guanfacine.
Drug interactions:
If taken with rifampin, guanfacin efficacy decreases.
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Clonidine
The role of clonidine in pediatric ADHD is that its another alpha-2 agonist
used as an adjunctive treatment. It improves excessive hyperactivity and
insomnia but does not improve inattention in children with ADHD. It
decreases facial and vocal tics and has a positve side effect on defiant
behavior.
Dose and Administration:
Initially, a dose of 0.05 mg is given at bedtime. The dosage may be
increased cautiously over 2 to 4 weeks. For maintenance, the daily dose is
usually 0.05 to 0.4 mg.
Chemical Structure and Available Preparations:
Clonidine hydrochloride is an imidazoline derivative and exists as a
mesomeric compound. The chemical name is 2-(2,6-dichlorophenylamino)2-imidazoline hydrochloride. Available preparations include:

Patch releases 0.1 mg//24 hours, 0.2 mg/24 hours, 0.3 mg/24 hours

Tablet 0.1 mg, 0.2 mg, 0.3 mg
Adverse effects:
Patients may experience drowsiness, dizziness, weakness and fatigue. Life
threatening reactions include bradycardia and severe rebound hypertension.
FDA Warnings:
Children taking clonidine may be susceptible to hypertensive crisis because
of is cardiac effects. Additionally, patients may experience gastrointestinal
illness that leads to vomiting.
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Elimination:
About 40% -60% is eliminated in the urine.
Metabolism:
About 50% of the absorbed dose is metabolized in the liver. Its half-life is 6
to 20 hours.
Contraindications:
Children should be first examined by clinicians and once under treatment
with the drug, must be cautiously monitored for any adverse reactions.
Drug interactions:
It must be used cautiously with antidepressants since it may increase CNS
depression.
Antidepressants
Antidepressants are sometimes used for ADHD as off-label drugs. These
drugs have not received FDA-approval but are still used sometimes by
clinicians as adjuncts in ADHD treatment. Moreover, these drugs, such as
bupropion, are also helpful in alleviating hyperactivity, anxiety, or serious
sleeping problems.
Bupropion
The role of bupropion in pediatric ADHD is that it affects the reuptake of the
serotonin, norepinephrine, and dopamine neurotransmitters.
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Dose and Administration:
No single dose of bupropion should exceed 150 mg. It should be
administered 3 times daily, preferably with at least 6 hours intervals
between successive doses.
Chemical Structure and Available Preparations:
It is designated as (±)-1-(3-chlorophenyl)-2-[(1,1-dimethylethyl)amino]-1propanone hydrochloride. Available preparations include:

Wellbutrin tablet (extended-release) 150 mg, 300 mg

Wellbutrin tablet (immediate-release) 75 mg, 100 mg

Wellbutrin tablet (sustained-release) 100 mg, 150 mg, 200 mg
Adverse effects:
The side effects of bupropion include restlessness, agitation, sleeplessness,
headache, and stomach problems.
Elimination:
About 87% of the drug is eliminated via the urine and 10% is excreted via
feces.
Metabolism:
Its half–life is 8 to 24 hours.
Contraindications:
Patients with seizure disorder should not take bupropion. Bupropion can also
induce suicide ideation in patients with no history of depression.
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Drug interactions:
Other antidepressants may lower the seizure threshold. Sun exposure may
increase the risk of photosensitivity.
Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) inhibit norepinephrine and serotonin
reuptake at the postsynaptic nerve terminal, causing their levels to increase
at the synaptic cleft and resulting in the potentiation of neurotransmitter
action. TCAs are an older class of antidepressants that have proven to be
beneficial but also loaded with many side effects.
These drugs, such as nortriptyline, can cause disturbances in heart rhythm
which is why an electrocardiogram to rule out arrhythmias is necessary
before starting the treatment.
Nortriptyline
The role of nortriptyline in pediatric ADHD is that at lower doses it improves
symptoms within several days of starting therapy; however, it may take 1-3
weeks for full effect to be evident. Higher doses may improve depressive
symptoms and mood swings.
Dose and Administration:
A low dose nortriptyline is usually initiated by the physician and gradually
titrated upward until optimal response is seen.
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Chemical Structure and Available Preparations:
Nortriptyline hydrochloride is 1-propanamine, 3-(10,11-dihydro-5Hdibenzo[a,d] cyclohepten-5-ylidene)-N-methyl-, hydrochloride. Available
preparations include:

Pamelor capsules 10 mg, 25 mg, 50 mg, 75 mg.

Pamelor oral solution 10 mg/5 ml (contains alcohol)
Adverse effects:
Nervousness, sleep problems, fatigue, stomach upset, dizziness, dry mouth,
and accelerated heart rate are some of the adverse effects of nortriptyline.
FDA Warnings:
The effectiveness and safety of nortriptyline has not been established in the
pediatric population. Anyone considering the use of nortriptyline
hydrochloride in a child or adolescent must balance the potential risks with
the clinical need.
Metabolism:
The half-life of notriptyline is 18 to 24 hours.
Contraindications:
Nortriptyline is contraindicated in patients who are hypersensitive to it. It
should be used cautiously in patients with history of seizure.
Drug interactions:
Nortriptyline may cause life-threatening hypertension when taken together
with clonidine.
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Imipramine Hydrochloride
The role of imipramine hydrochloride in pediatric ADHD is that it is a tricyclic
antidepressant that increases serotonin and norepinephrine in the CNS by
blocking their reuptake by the presynaptic neurons.
Dose and Administration:
The effectiveness of the drug in children for conditions other than nocturnal
enuresis has not been established.
Chemical Structure and Available Preparations:
Imipramine is a member of the dibenzazepine group of compounds. It is
designated 5-[3- (dimethylamino)propyl]-10,11-dihydro-5Hdibenz[b,f]azepine monohydrochloride. Available preparations include:
Tablet 10 mg, 25 mg, 50 mg
Adverse effects:
Children may experience drowsiness, dizziness and life-threatening effects
such as seizures and stroke.
FDA Warnings:
A dose of 2.5 mg/kg/day of imipramine hydrochloride should not be
exceeded. Pediatric patients given twice this amount can develop significant
ECG changes.
Metabolism:
The half-life of imipramine is 18 to 25 hours.
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Contraindications:
Imipramines is contraindicated in patients who have a histroy of
hypersensitivity to it.
Drug interactions:
Barbiturates and taken with other other CNS depressants may enhance CNS
depression.
Desipramine Hydrochloride
The role of desipramine hydrochloride in pediatric ADHD is that it restores
the normal levels of neurotransmitters by blocking the re-uptake of these
substances from the synapse.
Chemical Structure and Available Preparations:
Desipramine hydrochloride, USP is an antidepressant drug of the tricyclic
type, and is chemically:5H-Dibenz[b,f]azepine-5-propanamine,10,11dihydro-N-methyl-, monohydrochloride. Available preparations include:
Tablet 10 mg, 25 mg, 50 mg, 75 mg, 100 mg 150 mg.
Adverse effects:
Patients may experience drowsiness, dizziness, tachycardia, blurred vision,
rash, urticaria and hypersensitivity reactions. Life threatening reactions
include seizures, hypoglycemia, and sudden death in children. Recent
studies show that there have been no suicides reported in any of the
pediatric trials done.
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Elimination:
70% of the drug is excreted in the urine.
Metabolism:
Desipramine is rapidly absorbed from the gastrointestinal tract and
metabolized in the liver.
Contraindications:
It should not be given if the patient is on treatment with other tricyclics. It is
known to cause sudden death in some children. A patient with family history
of arrhythmias should not be given desipramine.
Drug Interactions:
Desipramine may enhance CNS depression if used together with barbiturates
and other CNS depressants. If used together with clonidine, it may cause
life-threatening blood pressure elevations. Patients on this medication must
avoid exposure to sunlight so as not to increase the risk of photosensitivity.
Special Considerations During Medication Management
Many of the medications for use in pediatric ADHD are approved only for
patients more than six years old. Clinicians need to consider the risk versus
benefit of using such medications on very young patients. One of the most
important criteria in initiating drug therapy in this special subset of
population is the severity of the ADHD symptoms. Current research data
considers the use of medications on preschool children to only those who
exhibit moderate to severe impairments. The factors deciding the severity of
the symptoms include:
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
Persistent symptoms of at least 9 months

Impairments in more than just one setting such as both the home and
child care

Deficits that have failed to respond positively to behavior therapy
In addition to these, the clinician’s evaluation of the developmental
impairment, safety risks, or consequences for school or social engagement
that can lead to skipping medications can also play a role. Since the
management of pediatric ADHD requires the cooperation of a
multidisciplinary team, the clinician can look to a mental health expert to
help with the assessment.
As mentioned previously, only dextroamphetamine is the medication
approved by the FDA for use in children below 6 years old. However, the
approval should not be taken for granted and heralded as a safe option since
its approval was largely due to the strict regulations in force at the time of
the medication’s approval rather than on concrete scientific evidence of its
safety and efficacy in this particular subset of the population.
The majority of studies supporting the safety and efficacy of stimulant drugs
in the treatment of ADHD in preschool-aged children came from
methylphenidate. One multisite study of 165 children and 10 other smaller
single-site studies included from 11 to 59 children (total of 269 children); 7
of the 10 single-site studies found stimulant medications to exhibit
significant efficacy. Even though there is some data pointing out the safety
and efficacy of methylphenidate in preschool-aged children, its use in this
subset of the population is still off-label.
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Pediatric ADHD treatment usually involves behavioral therapy. This is why
medications should only be prescribed if patients do not exhibit symptom
improvement with behavior therapy. Additionally, there is evidence that
suggests children between 4-5 years of age metabolize stimulant
medications at a slower pace than their older peers, which is why they
should only be given a low dose to start with, and allowed an increased dose
gradually. On top of this, there are no studies on the drug’s safe maximum
dose in this subset of the population.
When clinicians evaluate newly diagnosed adolescent patients for signs and
symptoms of substance use and addiction, should the assessment be
remarkable for substance use the assessment and treatment of this primary
concern must precede treatment for ADHD. This is because these patients
are at greater risk of misusing stimulants, using them other than for their
intended medical purposes. Clinicians must not only monitor symptoms, they
must also learn to monitor requests for prescription-refills and look out for
signs of misuse or diversion of medications.
To discourage substance use and addiction, clinicians should also consider
prescribing medications with no potential to misuse, such as atomoxetine,
extended-release guanfacine, and extended-release clonidine; or, stimulant
medications with less abuse potential, such as lisdexamfetamine, dermal
methylphenidate, or OROS methylphenidate. Lisdexamfetamine is
dextroamphetamine, which contains an additional lysine molecule, is only
activated following oral administration when it is converted by red blood cells
to dexamphetamine. The other preparations are difficult to chemically
manipulate, making extraction of the stimulant also very difficult.
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Because many ADHD adolescents already have their driver’s license, it is
important for clinicians to take into account the natural risks associated with
it, particularly in providing adequate control of symptoms while driving.
DSM-5 or ICD Criteria
Medications are not indicated for children whose symptoms do not meet
either the DSM-5 or ICD’s criteria for diagnosis of ADHD. Alternatively,
children may benefit from behavior therapy, which does not require a
specific diagnosis, and whose efficacy has been backed by numerous studies
of children without specific mental behavioral disorders.
Food and Nutrition
Diet affects the mental state and behavior of children. Therefore, it makes
sense to monitor and modify the type of diet, meal times, and amount of
food that children with ADHD receive on a daily basis. Generally speaking,
children with ADHD will benefit the most from fresh foods, regular meal
times, and abstinence from junk food. These basic principles will help
children with ADHD whose impulsiveness and distractedness often result in
missed meals, disordered eating, and overeating.
As mentioned previously, children with ADHD are well known erratic eaters.
Without proper parental guidance, they may not eat for hours and suddenly
binge on anything they can get their hands on. This behavior towards food
results in very poor physical and emotional well being of children. Parents
can avoid unhealthy eating habits by setting routines or schedules for meals
and snacks. Some of the ways they can ensure that such schedule is
followed are by: 1) Eliminating junk food from the diet, 2) Discouraging
intake of fatty and sugary foods when dining out, 3) Turning off the TV
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shows that promote junk-foods, and 4) Ensuring that the daily vitamins and
minerals requirements are fulfilled through a balanced diet and
supplementation.
Lifestyle and Exercise
Adopting healthy lifestyle choices that includes regular exercise aids in
improving a sense of overall wellbeing. Children with ADHD that follow
regular exercise routine experience better outcomes to sleep habits and
moods than those that does not.
Summary
Children diagnosed with ADHD experience a variety of related disorders or
comorbidities. These comorbidities vary according to the prevailing type of
ADHD, their severity, as well as the developmental stage of the child when
they were first seen. These comorbidities are divided into two broad
categories of learning disorders and psychiatric disorders. There are legal
issues that need to be addressed and smoothened out prior to the start of
evaluation and treatment. These issues are related to the child’s legal
custody and responsibility, and legal duty by the clinician to report
suspected child abuse.
Because of the complexity of the disorder, its therapy requires a multimodal
approach. Psychotherapy, which includes behavioral interventions, and
pharmacotherapy, which includes stimulants, are the two most effective
approaches employed in the treatment and management of pediatric ADHD.
The efficacy and safety of medications for ADHD have not been studied
extensively in children below 6 years old, which makes the management of
this particular subgroup primarily consist of psychotherapeutic interventions.
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Psychotherapeutic interventions are largely made up of behavioral
interventions for the child, parent and teacher to help each one cope with
each other’s burdens related to ADHD.
The first line of drugs used in pediatric ADHD is stimulants. They include
amphetamine derivatives and methylphenidate. They demonstrate the
greatest efficacy in symptom reduction. Other drugs used in the
management and treatment of ADHD is atomoxetine and alpha adrenergic
agonists.
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1.
Attention deficit hyperactivity disorder or ADHD is
a.
b.
c.
d.
2.
As high as ____ of all children with ADHD have an
associated learning disorder.
a.
b.
c.
d.
3.
15%
25%
30%
45%
Studies have shown that adverse side-effects of
medications for ADHD may include:
a.
b.
c.
d.
4.
disease of the central nervous system.
a neurological disorder.
a rare brain disorder.
a relatively common brain disorder.
suppression of growth
sleep problems
stomach upset
All of the above
True or False: The role if nortriptyline in pediatric ADHD is
that at higher doses it improves symptoms within several days of
starting therapy.
a. True
b. False
5.
Atomoxetine (Strattera) is a non-stimulant medication
approved for the treatment of pediatric ADHD in children between
_______ years old.
a.
b.
c.
d.
2 to 17
3 to 17
6 to 17
None of the above
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6.
Learning disorders that are present in children with ADHD
are
a.
b.
c.
d.
7.
Hyperactivity and impulsivity and/or inattention are
behaviors associated with ADHD
a.
b.
c.
d.
8.
symptomatic of all children with ADHD.
a comorbidity that may worsen the presence of ADHD.
said to have a comorbid psychiatric disorder.
due to excessive hyperactivity.
because children do not otherwise exhibit these behaviors.
because they are present in all ADHD cases.
because ADHD is a psychiatric disorder.
if they persist over a long period of time.
Clonidine in pediatric ADHD improves excessive
hyperactivity and insomnia but does not improve _________ in
children with ADHD.
a.
b.
c.
d.
9.
impulsivity
inattention
anxiety
facial tics
True or False: The existence of depression in children with
ADHD usually occurs a few years after ADHD is diagnosed.
a. True
b. False
10.
To be diagnosed with ADHD, hyperactivity, impulsivity
and/or inattention must continue for at least ___________ and
be present in two environments such as home and school.
a.
b.
c.
d.
3
6
1
2
months
months
year
years
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11.
Medication therapy is the __________ line of treatment
and may be initiated for those school-age children with ADHD
who present with __________ levels of deficit.
a.
b.
c.
d.
12.
____________________ is a non-stimulant medication
that it increases the levels of both dopamine and norepinephrine
in the postsynaptic junction.
a.
b.
c.
d.
13.
Dexmethylphenidate
Methamphetamine hydrochloride
Atomoxetine (Strattera)
Imipramine
There is moderate-to-high-level evidence that nonpharmacological interventions, like behavioral measures,
_______________ managing the core ADHD symptoms.
a.
b.
c.
d.
14.
second, moderate
first, severe
second, mild
first moderate
are the only option in
are not effective in
can be effective in
Answers a., and c., are correct
True or False: Children with ADHD will benefit the most
from fresh foods, regular meal times, and abstinence from junk
food.
a. True
b. False
15.
Children with ADHD are known mostly for their
a.
b.
c.
d.
dyslexia.
neuropsychological deficits
problems with phonetics.
impulsivity and hyperactivity.
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16.
One of the most common problems and comorbid
conditions in children who are diagnosed with ADHD and who
also suffer from depression is
a.
b.
c.
d.
17.
A child exhibiting aggression towards animals, who
destroys things willfully, and who steals and violates rules is
exhibiting
a.
b.
c.
d.
18.
phobia from peer rejection.
oppositional defiant disorder.
conduct disorder.
anxiety.
When psychiatric and personality disorders or their
associated symptoms occur in children and adolescents, children
or adolescents with these symptoms are diagnosed with
a.
b.
c.
d.
20.
peer rejection.
oppositional defiant disorder.
conduct disorder.
anxiety.
One of the most common psychiatric comorbidities
associated with ADHD is ________________________, usually
affecting around 60% of children with the condition.
a.
b.
c.
d.
19.
phobia from peer rejection.
neuropsychological deficit.
oppositional defiant disorder.
suicidal ideation.
ADHD.
conduct or oppositional defiant disorders.
anxiety disorder.
depression and social isolation.
____________ may be defined as a state of psychological
and physical discomfort, which is focused on emotions,
perceptions, feelings, and behavior necessary to deal with
certain life issues.
a. Anxiety
b. Phobia
c. Hyperactivity
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d. Tourette Syndrome
21.
Two of the most common disorders that can be classified
as neurodevelopmental and coexisting among ADHD patients are
a.
b.
c.
d.
22.
depression and social isolation.
guilt and anxiety.
tic and Tourette Syndrome.
impulsivity and hyperactivity.
True or False: Patients with ADHD are 20% less likely to
start smoking cigarettes as compared to the rest of the
population because of their obsessive behavior.
a. True
b. False
23.
__________________ is a psychiatric problem that is
defined by the presence of intrusive thoughts.
a.
b.
c.
d.
24.
After a diagnosis of ADHD in a child of pre-school age has
been made or confirmed, clinicians need to
a.
b.
c.
d.
25.
Tourette Syndrome
Conduct disorder
Obsessive-compulsive disorder (OCD)
Suicidal ideation
determine the appropriate medication for the child.
immediately refer the child to tertiary services for further care.
contact the child's pre-school teacher regarding the diagnosis.
advise parents/caregivers to enter a parent-training and education
program.
The first line of treatment for school-age children with
ADHD who present with moderate levels of deficit is
a.
b.
c.
d.
to place them under the supervision of a teacher, not parent.
to remove them from the school classroom setting.
the group-based parent-training and education program.
medication therapy.
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26.
School-age children and young people with severe ADHD
may be given medication only with the consent
a.
b.
c.
d.
27.
of the child’s teacher.
and full cooperation of the child and parents or caregiver.
of the child’s parents/caregiver.
of a court.
True or False: Antidepressants are FDA-approved for
ADHD treatment.
a. True
b. False
28.
The most commonly used cognitive modeling approach
used for children with ADHD is
a.
b.
c.
d.
29.
______________________ are the first line of
medications prescribed to children with ADHD.
a.
b.
c.
d.
30.
Non-stimulants
Antidepressants
Stimulants
Selective norepinephrine reuptake inhibitors
Due to their psychotropic effects, ___________________
is often abused and is classified as a Schedule II controlled
substances.
a.
b.
c.
d.
31.
self-instructional training.
negative reinforcement.
positive reinforcement.
the time out method.
nortriptyline
methylphenidate (Metadate CD)
bupropion
clonidine hydrochloride
True or False: Nortriptyline may cause life-threatening
hypertension when taken together with clonidine.
a. True
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32.
b. False
Children who take ______________ may experience
drowsiness, dizziness and life-threatening effects such as
seizures and stroke.
a.
b.
c.
d.
33.
The FDA warns that ____________ must be discontinued
if the patient reports jaundice since the drug is associated with
the development of liver injury.
a.
b.
c.
d.
34.
the concentration of norepinephrine and dopamine.
monoamines into the extraneuronal space.
mood and energy.
the attention span.
______________refers to the procedure wherein children
earn points by doing specified desirable actions, but lose points
when exhibiting undesirable behavior.
a.
b.
c.
d.
36.
imipramine
atomoxetine
nortriptyline
wellbutrin
The role of Methylphenidate in pediatric ADHD is that it
corrects the hyperactivity and increases
a.
b.
c.
d.
35.
imipramine
atomoxetine
nortriptyline
bupropion
A response cost
The token system
The negative reinforcement method
The daily report card (DRC)
True or False: Atomoxetine (Strattera) is the first nonstimulant approved for children diagnosed with ADHD, and its
role is that it increases the levels of both dopamine and
norepinephrine in the postsynaptic junction.
a. True
b. False
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37.
________________ is the only medication approved by
the FDA for use in children below 6 years old.
a.
b.
c.
d.
38.
To discourage substance use and addiction, clinicians
should also consider prescribing medications with no potential
to misuse, such as
a.
b.
c.
d.
39.
the home to teach self-regulation skills.
the classroom setting.
the environments where children have relationship problems.
clinical settings.
The role of ___________________ in pediatric ADHD is
that it improves hyperactivity and insomnia symptoms, and it
decreases the symptoms of Tourette syndrome.
a.
b.
c.
d.
41.
methamphetamine hydrochloride.
atomoxetine.
nortriptyline.
lisdexamfetamine.
Social skills training use techniques from both cognitive
and behavioral approaches and are conducted in
a.
b.
c.
d.
40.
Atomoxetine
Nortriptyline
Dextroamphetamine
Bupropion
methylphenidate
chlorpromazine
guanfacine hydrochloride
methamphetamine hydrochloride
True or False: The effectiveness and safety of nortriptyline
has been established in the pediatric population.
a. True
b. False
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42.
Three key factors are helpful to clinicians in deciding the
course of treatment to follow: ______________, severity of
symptoms and comorbid conditions.
a.
b.
c.
d.
43.
Physical abuse is particularly linked to
a.
b.
c.
d.
44.
externalizing problems.
internalizing problems.
autism.
phobia from peer rejection.
Tricyclic antidepressants (TCAs) are an older class of
antidepressants that
a.
b.
c.
d.
45.
self-regulation
parent training
side effects
child’s age
that have proven to be beneficial.
many side effects.
can cause disturbances in heart rhythm.
All of the above
True or False: The etiologic roots of ADHD have genetic
and neurodevelopmental origins, which means that school and
social environments are not significant in the development or
maintenance of ADHD.
a. True
b. False
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CORRECT ANSWERS:
1. Attention deficit hyperactivity disorder or ADHD is
d. a relatively common brain disorder.
“Attention deficit hyperactivity disorder or ADHD is a relatively
common brain disorder that is often diagnosed at childhood and
continues to adolescence and adulthood.”
2. As high as ____ of all children with ADHD have an associated
learning disorder.
c. 30%
“It is important to remember that as high as 30% of all children
with ADHD have an associated learning disorder of reading, writing,
and/or mathematics.”
3. Studies have shown that adverse side-effects of medications for
ADHD may include:
a.
b.
c.
d.
suppression of growth
sleep problems
stomach upset
All of the above [Correct answer]
“Although pharmacological treatment is relatively safe, some
patients experience significant functional impairment with
psychiatric drugs. Studies have shown that adverse side-effects,
such as, suppression of growth, sleep problems, tiredness, loss of
appetite, stomach upset, headaches, nausea, and increases in heart
rate and blood pressure can occur with long-term treatment.”
4. True or False: The role if nortriptyline in pediatric ADHD is that at
higher doses it improves symptoms within several days of starting
therapy.
b. False
“The role of nortriptyline in pediatric ADHD is that at lower doses it
improves symptoms within several days of starting therapy; ....”
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5. Atomoxetine (Strattera) is a non-stimulant medication approved
for the treatment of pediatric ADHD in children between _______
years old.
c. 6 to 17
“Atomoxetine (Strattera) was approved in 2002 for the treatment
of pediatric ADHD in children between 6 to 17 years old.”
6. Learning disorders that are present in children with ADHD are
b. a comorbidity that may worsen the presence of ADHD.
“Comorbidities in the context of ADHD are those disorders that may
worsen the presence of ADHD or cause it to have different
presenting symptoms. Comorbidities are divided into two broad
categories of learning disorders and psychiatric disorders.”
7. Hyperactivity and impulsivity and/or inattention are behaviors
associated with ADHD
d. if they persist over a long period of time.
“Hyperactivity and impulsivity and/or inattention occur in children
affected with ADHD. While these are behaviors that many children
exhibit at some time during their childhood, in children with ADHD,
these behavioral problems persist over a long period of time.”
8. Clonidine in pediatric ADHD improves excessive hyperactivity and
insomnia but does not improve _________ in children with ADHD.
b. inattention
“The role of clonidine in pediatric ADHD is that its another alpha-2
agonist used as an adjunctive treatment. It improves excessive
hyperactivity and insomnia but does not improve inattention in
children with ADHD. It decreases facial and vocal tics and has a
positve side effect on defiant behavior.”
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9. True or False: The existence of depression in children with ADHD
usually occurs a few years after ADHD is diagnosed.
a. True
“The existence of depression in children with ADHD usually occurs a
few years after ADHD is diagnosed. It is usually a result of the
constant battle with stressors in the immediate environment, which
may include peers, bullying, and academic pressures to perform
well.”
10. To be diagnosed with ADHD, hyperactivity, impulsivity and/or
inattention must continue for at least ___________ and be
present in two environments such as home and school.
b. 6 months
“To be diagnosed with ADHD, such behaviors must continue for at
least 6 months and be present in two environments such as home
and school.”
11. Medication therapy is the __________ line of treatment and
may be initiated for those school-age children with ADHD who
present with __________ levels of deficit.
a. second, moderate
“Medication therapy is the second line of treatment and may be
initiated for those school-age children with ADHD who present with
moderate levels of deficit….”
12. ____________________ is a non-stimulant medication that it
increases the levels of both dopamine and norepinephrine in the
postsynaptic junction.
c. Atomoxetine (Strattera)
“Atomoxetine (Strattera) was approved in 2002 for the treatment
of pediatric ADHD in children between 6 to 17 years old. It is the
first non-stimulant approved for children diagnosed with ADHD, and
its role is that it increases the levels of both dopamine and
norepinephrine in the postsynaptic junction.”
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13. There is moderate-to-high-level evidence that nonpharmacological interventions, like behavioral measures,
_______________ managing the core ADHD symptoms.
c. can be effective in
“There is moderate-to-high-level evidence suggesting that nonpharmacological interventions, like behavioral measures, can be
effective in managing the core ADHD symptoms, conduct disorders,
social skills, self-efficacy, and emotional outcomes at 6 months
follow-up.”
14. True or False: Children with ADHD will benefit the most from
fresh foods, regular meal times, and abstinence from junk food.
a. True
“Generally speaking, children with ADHD will benefit the most from
fresh foods, regular meal times, and abstinence from junk food.”
15. Children with ADHD are known mostly for their
d. impulsivity and hyperactivity.
“Children with ADHD are known mostly for their impulsivity and
hyperactivity.”
16. One of the most common problems and comorbid conditions in
children who are diagnosed with ADHD and who also suffer from
depression is
d. suicidal ideation.
“Suicidal ideation is one of the most common problems and
comorbid conditions in children who are diagnosed with ADHD and
also suffering from depression.”
17. A child exhibiting aggression towards animals, who destroys
things willfully, and who steals and violates rules is exhibiting
c. conduct disorder.
“The main symptom associated with conduct disorder is the
apparent aggression towards animals or even people, the habit to
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destroy things willfully, engage in violation of rules both in school
and in society, and stealing other peoples’ belongings.”
18. One of the most common psychiatric comorbidities associated
with ADHD is ________________________, usually affecting
around 60% of children with the condition.
b. oppositional defiant disorder.
“One of the most common psychiatric comorbidities associated with
ADHD is oppositional defiant disorder (ODD), usually affecting
around 60% of children with the condition.”
19. When psychiatric and personality disorders or their associated
symptoms occur in children and adolescents, children or
adolescents with these symptoms are diagnosed with
b. conduct or oppositional defiant disorders.
“The presence of psychiatric and personality disorders is usually
acknowledged in adult ADHD patients. However, when these
conditions or their associated symptoms occur in children and
adolescents, they are simply put in the category of conduct or
oppositional defiant disorders.”
20. ____________ may be defined as a state of psychological and
physical discomfort, which is focused on emotions, perceptions,
feelings, and behavior necessary to deal with certain life issues.
a. Anxiety
“Anxiety may be defined as a state of psychological and physical
discomfort, which is focused on emotions, perceptions, feelings, and
behavior necessary to deal with certain life issues.”
21. Two of the most common disorders that can be classified as
neurodevelopmental and coexisting among ADHD patients are
c. tic and Tourette Syndrome.
“Two of the most common disorders that can be classified as
neurodevelopmental and coexisting among ADHD patients are tic
and Tourette Syndrome.”
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22. True or False: Patients with ADHD are 20% less likely to start
smoking cigarettes as compared to the rest of the population
because of their obsessive behavior.
b. False
“… patients with ADHD are more prone to start smoking cigarettes
as compared to the rest of the population by at least 20%.”
23. __________________ is a psychiatric problem that is defined
by the presence of intrusive thoughts.
c. Obsessive-compulsive disorder (OCD)
“Obsessive-compulsive disorder (OCD) is a psychiatric problem that
is defined by the presence of intrusive thoughts.”
24. After a diagnosis of ADHD in a child of pre-school age has been
made or confirmed, clinicians need to
d. advise parents/caregivers to enter a parent-training and
education program.
“Medication therapy is not recommended for pre-school children
with ADHD. After a diagnosis of ADHD in a child of pre-school age
has been made or confirmed, clinicians need to contact the parents
or caregivers and obtain their consent to initiate contact with the
child's pre-school teacher to explain the diagnosis and severity of
symptoms and deficits, interventional plan, and special educational
needs. Also, following the diagnosis, clinicians should advise
parents or caregivers of pre-school children with ADHD to enter a
parent-training and education program. On the other hand, if the
parent-training and education programs and other treatment
interventions have not been found to be effective to manage ADHD
symptoms and associated deficits in pre-school children, clinicians
must consider giving them a referral to tertiary services for further
care.”
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25. The first line of treatment for school-age children with ADHD
who present with moderate levels of deficit is
c. the group-based parent-training and education program.
“Medication therapy is the second line of treatment and may be
initiated for those school-age children with ADHD who present with
moderate levels of deficit…. After a diagnosis of ADHD in a schoolage child or young person has been made or confirmed, clinicians
need to obtain the consent of parents or caregivers to contact the
child or young person's teacher to discuss the following the
diagnosis and severity of symptoms and deficit, interventional plan
and special educational needs. It would be very beneficial to the
family and the school systems if school-age children with ADHD are
placed under the supervision of teachers who have received training
about ADHD and its management so they can receive adequate
behavioral interventions in the classroom.”
26. School-age children and young people with severe ADHD may be
given medication only with the consent
b. and full cooperation of the child and parents or caregiver.
“When symptoms of ADHD and other associated deficits are severe,
the first-line treatment for school-age children and young people is
medication therapy. Medication therapy requires the consent and
full cooperation of the child, parents or caregiver. If either one
refuses it the clinician should advise them of the benefits and
superiority of medication therapy. If it is still not accepted, a group
parent-training and education program should be offered.”
27. True or False: Antidepressants are FDA-approved for ADHD
treatment.
b. False
“Antidepressants are sometimes used for ADHD as off-label drugs.
These drugs have not received FDA-approval but are still used
sometimes by clinicians as adjuncts in ADHD treatment.”
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28. The most commonly used cognitive modeling approach used for
children with ADHD is
a. self-instructional training.
“Self-instructional training is the most commonly used cognitive
modeling approach.”
29. ______________________ are the first line of medications
prescribed to children with ADHD.
c. Stimulants
“Stimulants are the first line of medications prescribed to children
with ADHD.”
30. Due to their psychotropic effects, ___________________ is
often abused and is classified as a Schedule II controlled
substances.
b. methylphenidate (Metadate CD)
“Due to their psychotropic effects, methylphenidate (Metadate CD)
is often abused and is classified as a Schedule II controlled
substances. Its sale and administration without valid prescription is
illegal.”
31. True or False: Nortriptyline may cause life-threatening
hypertension when taken together with clonidine.
a. True
“Nortriptyline may cause life-threatening hypertension when taken
together with clonidine.”
32. Children who take ______________ may experience drowsiness,
dizziness and life-threatening effects such as seizures and
stroke.
a. imipramine
“Imipramine: ... Children may experience drowsiness, dizziness and
life-threatening effects such as seizures and stroke.”
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33. The FDA warns that ____________ must be discontinued if the
patient reports jaundice since the drug is associated with the
development of liver injury.
b. atomoxetine
“The FDA warns that atomoxetine must be discontinued if the
patient reports jaundice since the drug is associated with the
development of liver injury.”
34. The role of Methylphenidate in pediatric ADHD is that it corrects
the hyperactivity and increases
d. the attention span.
“The role of Methylphenidate in pediatric ADHD is that it corrects
the hyperactivity and increases the attention span.”
35. ______________refers to the procedure wherein children earn
points by doing specified desirable actions, but lose points when
exhibiting undesirable behavior.
a. A response cost
“A response cost refers to the procedure wherein children earn
points by doing specified desirable actions, but lose points when
exhibiting undesirable behavior.”
36. True or False: Atomoxetine (Strattera) is the first non-stimulant
approved for children diagnosed with ADHD, and its role is that
it increases the levels of both dopamine and norepinephrine in
the postsynaptic junction.
a. True
“Atomoxetine (Strattera) is the first non-stimulant approved for
children diagnosed with ADHD, and its role is that it increases the
levels of both dopamine and norepinephrine in the postsynaptic
junction.”
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37. ________________ is the only medication approved by the FDA
for use in children below 6 years old.
c. Dextroamphetamine
“Dextroamphetamine is the only medication approved by the FDA
for use in children below 6 years old.”
38. To discourage substance use and addiction, clinicians should
also consider prescribing medications with no potential to
misuse, such as
b. atomoxetine.
“To discourage substance use and addiction, clinicians should also
consider prescribing medications with no potential to misuse, such
as atomoxetine, extended-release guanfacine, and extendedrelease clonidine; or, stimulant medications with less abuse
potential, such as lisdexamfetamine, dermal methylphenidate, or
OROS methylphenidate.”
39. Social skills training use techniques from both cognitive and
behavioral approaches and are conducted in
d. clinical settings.
“Social skills training use techniques from both cognitive and
behavioral approaches and are conducted in groups…. It is
conducted in clinical settings, away from the environments where
these children have relationship problems and are lacking social
validity.”
40. The role of ___________________ in pediatric ADHD is that it
improves hyperactivity and insomnia symptoms. It decreases
the symptoms of Tourette syndrome.
c. guanfacine hydrochloride
“The role of guanfacine hydrochloride in pediatric ADHD is that it
improves hyperactivity and insomnia symptoms. It decreases the
symptoms of Tourette syndrome.”
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41. True or False: The effectiveness and safety of nortriptyline has
been established in the pediatric population.
b. False
“The effectiveness and safety of nortriptyline has not been
established in the pediatric population.”
42. Three key factors are helpful to clinicians in deciding the course
of treatment to follow: ______________, severity of symptoms
and comorbid conditions.
d. child’s age
“Behavior management (psychotherapy), and medication
management (pharmacotherapy) are discussed in detail later on;
however, certain criteria are first raised here that are helpful to
clinicians deciding the course of treatment to follow based on three
key factors of age, severity of symptoms and comorbid conditions.”
43. Physical abuse is particularly linked to
a. externalizing problems.
“Physical abuse is particularly linked to externalizing problems while
sexual abuse is linked to childhood post-traumatic stress disorder
symptoms and, later on, internalizing problems.”
44. Tricyclic antidepressants (TCAs) are an older class of
antidepressants that
a.
b.
c.
d.
that have proven to be beneficial.
many side effects.
can cause disturbances in heart rhythm.
All of the above [Correct answer]
“Tricyclic antidepressants (TCAs) ... are an older class of
antidepressants that have proven to be beneficial but also loaded
with many side effects. These drugs can cause disturbances in heart
rhythm which is why an electrocardiogram to rule out arrhythmias
is necessary before starting the treatment.”
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45. True or False: The etiologic roots of ADHD have genetic and
neurodevelopmental origins, which means that school and social
environments are not significant in the development or
maintenance of ADHD.
b. False
“Several studies in recent years suggest the etiologic roots of ADHD
have genetic and neurodevelopmental origins. It does not mean,
however, that school and social environments are not significant in
the development or maintenance of ADHD.”
References Section
The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading. [This is Part 2 of a 2 Part series on Pediatric ADHD.]
1.
2.
3.
4.
National Institute of Mental Health. Attention Deficit Hyperactivity
Disorder. Retrieved from
http://www.nimh.nih.gov/health/publications/attention-deficithyperactivity-disorder/index.shtml
Crichton, A. (1798). An inquiry into the nature and origin of mental
derangement: comprehending a concise system of the physiology and
pathology of the human mind and a history of the passions and their
effects. Cadell, T. Jr, Davies, W., London [Reprint: Crichton, A. (2008).
An inquiry into the nature and origin of mental derangement. On
attention and its diseases. Journal of Attention Disorder 12:200–204.
Bukstein, O. (2016). Attention deficit hyperactivity disorder in adults:
Epidemiology, pathogenesis, clinical features, course, assessment, and
diagnosis. Up To Date. Retrieved online at
https://www.uptodate.com/contents/attention-deficit-hyperactivitydisorder-in-adults-epidemiology-pathogenesis-clinical-features-courseassessment-anddiagnosis?source=search_result&search=adhd&selectedTitle=2~150
Diagnostic and statistical manual of mental disorders (DSM-II), 4th
edn Text revision. Washington DC: American Psychiatric Association;
2000.
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5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Still, G.F. (1902). Some abnormal psychical conditions in children: the
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