Peter R. Loewenson
Arthur L. Robin
Lawrence S. Neinstein
School problems, including school phobia, truancy, dropout, academic performance problems, attention-deficit hyperactivity disorder (ADHD), and learning disabilities, represent common concerns for adolescents and their families. The adolescent's primary care clinician can play a critical role in the evaluation and management of such problems in the following manner:
School phobia or school avoidance is a persistent and irrational fear of going to school. The problem usually arises either because the adolescent cannot cope with the pressures and challenges at school or as a result of other stresses, usually related to family or peers. Common stress factors include the following:
The health care provider must explore with the adolescent his or her fears and reasons for disliking school. A gentle and accepting approach is critical as most adolescents with this disorder are embarrassed or afraid to disclose the nature of their fears or phobia. Depending on the home situation, the practitioner may recommend more parental involvement and an immediate return to school, or in overrestrictive families the health care provider may wish to lessen parental involvement by working out a contract regarding school attendance between the health care provider and the adolescent. Psychological referral may be advisable, depending on the severity and type of underlying problem (e.g., family dysfunction or clinical phobia). Because anxiety disorders such as social phobia or generalized anxiety disorder are a common cause of school phobia, medications for anxiety disorders can be useful as part of the overall management plan. The serotonin selective reuptake inhibitors (SSRIs) have been
shown to be useful for these disorders and are generally very well tolerated. Paroxetine (Paxil, usual doses of 10–40 mg every day), fluoxetine (Prozac, usual doses of 10–40 mg every day), and sertraline (Zoloft, usual doses of 50–150 mg every day) have been most often used. The adolescent must be monitored closely for new or worsening symptoms and for emergence of suicidal thinking after starting an SSRI. Buspirone (BuSpar, usual doses of 10–20 mg three times a day) may also be effective.
School Truancy and Dropout
Although the adolescent with school phobia has some fear of attending school, the adolescent who is truant or who drops out of school is making a conscious decision to miss school. It is clear that school failure is one of the common precursors to truancy and school dropout. And most importantly, school failure or school dropout often precedes high-risk social behaviors such as involvement in gangs and violence, running away, sexual promiscuity, and excessive drug or alcohol use. Therefore, an educational history that investigates potential causes of poor academic performance is important. School dropout is a major problem, particularly among lower socioeconomic classes, and can reach as high as 50% in certain school districts, particularly among male students. Data from college admissions reveal a significant gender difference, with males accounting for only 43% of students at colleges and universities at all levels. In addition to the risk behaviors seen in dropouts, they have higher rates of unemployment and lower incomes than those of high-school graduates.
As mentioned, one of the primary causes of truancy and dropout is poor academic performance and its antecedents. In addition, truancy and dropout may be caused or exacerbated by substance abuse, pregnancy, marriage, or the need to work to support family members.
It is critical to address the primary causes of truancy and dropout. For those at risk for dropping out (e.g., those with early school failure, truancy, high-risk behaviors, poor “fit” within a school system), it will be necessary to work with the adolescent and the family to identify any primary learning disabilities, ADHD, or related conditions, and then to establish appropriate goals for academic achievement and define an appropriate placement. In addition, the health care provider will need to assess the motivation of the adolescent and family for academic performance, their short- and long-term goals, conflicts at home or at school, relationships with peers and teachers, and medical causes of academic difficulties. This information is necessary to develop a plan to improve performance or resolve barriers to continuing involvement in school. A behavioral plan of rewards and consequences is often needed to reestablish parental control and motivate the adolescent to attend school and complete homework. The adolescent should be involved in the development of this type of plan to attempt to optimize compliance. It is critical to identify and support the academic or extracurricular strengths of an adolescent. Educational options may include work-study programs, vocational programs, independent study programs, early graduation, or adult education programs. Follow-up is essential to determine if the initial plan is working and what further steps need to be taken.
It should be kept in mind that some of the world's most accomplished and well known people had difficulties in traditional school settings, so there may be room for optimism (particularly for those who have above-average intelligence). However, the fact remains that most school dropouts have a tough road ahead of them in our present economic milieu.
Academic Performance Problems
Adolescents who are having difficulty with academic performance constitute a significant group of patients seen in the outpatient setting. During middle school and high school, there is increased dependence on reading, and an increased need to organize materials, develop appropriate study habits, and use abstract thought processes. Therefore, it is not uncommon for academic problems to arise during these years and in fact may be the presenting issue for an office visit. In addition, there will be a number of students who have never done well in school and now that they are adolescents, may have poor academic performance that becomes complicated by other health risk behaviors. An interview with a parent or guardian is crucial in uncovering academic performance problems, because the adolescent may be less concerned with a drop in grades.
Poor academic performance can be due to a wide variety of causes related to the individual adolescent, or to school, family, or community factors. However, it is also common to have multiple factors that coexist and thereby make the evaluation and management more complex. The specific causes of poor academic performance are not always clear. For example, it is commonly believed that substance abuse and membership in a gang are likely causes of school failure. However, academic failure may actually precede some of these health risk behaviors, as students gravitate toward other youth who are also failing at school. Motivation toward academic performance is a critical factor that often requires intensive interventions.
Defining and Identifying the Problem
The identification of academic performance problems is a critical step in the evaluation of every adolescent (see Chapter 4). This is particularly crucial because school performance may be an important marker of other health risk behaviors. Therefore, the adolescent's health care provider should inquire about grades and absences at all routine office visits.
If a potential problem is identified, it is important to clearly define the problem.
It is necessary to obtain information from the patient, the family, and the school to understand the nature of the problem and to begin an evaluation.
Causes of Poor Academic Performance
The history is the most important and often the most challenging part of the evaluation. It is necessary to develop rapport with the adolescent to let him or her know that your interest is to help him achieve his educational goals, rather than to “take the side of the parents or the school.”
Attention-Deficit Hyperactivity Disorder
ADHD is a developmental disorder affecting approximately 4% to 12% of children and adolescents, characterized by developmentally inappropriate degrees of inattention, impulsivity, and hyperactivity. It arises in early childhood, is relatively chronic and pervasive in nature, and is not accounted for on the basis of gross neurological, sensory, language, or motor impairment, mental retardation, or severe emotional disturbance. As a result of these core symptoms, adolescents with ADHD have difficulty getting their schoolwork done, organizing their personal lives, resolving disputes, communicating with their parents, following rules established by adult authority figures, and maintaining good peer relationships. Eventually, such cumulative life failure may thwart them from accomplishing the developmental tasks of adolescence, including independence seeking, identity formation, mature same-and opposite-sex interpersonal relationships, and vocational planning. As a result, many such adolescents develop low self-esteem and depressed affect.
Contemporary follow-up studies have suggested that ADHD is truly a life span disorder; 60% to 80% of ADHD
children continue to manifest the full clinical syndrome in adolescence, and >50% continue to manifest the full clinical syndrome in adulthood. In adolescence, paying attention and controlling impulses remain the greatest problems, whereas motoric hyperactivity usually diminishes and/or transforms into mental restlessness. Those adolescents with ADHD alone (i.e., without oppositional-defiant disorder or conduct disorder) may exhibit comorbid difficulties such as learning disorders, low self-esteem, depression, or other emotional problems (see subsequent text), whereas those with ADHD plus oppositional-defiant disorder, conduct disorder, or bipolar disorder are more likely to develop problems with truancy, dropout, substance abuse, and severe family conflict.
Although the exact cause of ADHD remains unknown, mounting evidence from neurochemical, brain imaging, genetic, and family studies converge to suggest that in most cases, ADHD is an inherited condition with a biochemical basis. Considerable evidence implicates the neurotransmitters dopamine and norepinephrine in the pathophysiology of ADHD. Brain imaging studies have shown differences between individuals with ADHD and controls in the structure of the basal ganglia and the right frontal anterior lobes and these small differences in brain volumes are present in children and adolescents with ADHD who have never been treated with stimulant medications. Family genetic studies show clustering of ADHD, as well as anxiety, affective disorders, and substance use disorders. In short, ADHD is a biologically disabling condition that cannot be “cured.” The goal of treatment is to maximize function and the quality of the adolescent's daily life and to facilitate completion of the developmental tasks of adolescence through flexible combinations of medical, psychosocial, and educational interventions.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR) includes a list of nine inattention criteria and a list of nine hyperactivity/impulsivity criteria. Subtypes of ADHD are based on various combinations of these lists (1a and 1b), together with criteria 2 to 5.
. 314.01. ADHD, combined type: If both criteria 1a and 1b are met for the past 6 months.
Although the DSM-IV criteria capture the core ADHD symptoms of inattention, impulsivity, and restlessness, contemporary conceptualizations of ADHD have placed these symptoms within the broader context of executive functions of the brain. Executive functions of the brain are higher order self-regulatory functions, often likened to the conductor of an orchestra. Just as the conductor directs the orchestra, telling various instruments when to start, stop, and how to interpret the music, the executive functions of the brain direct the individual to behave in a self-controlled, task-oriented manner. These executive functions include organizing and activating to work, sustaining concentration and attention, sustaining energy and controlling emotions, and utilizing working memory and recall (Brown, 1996). In ADHD executive functions are ineffective, as if the conductor of the orchestra were not doing a good job.
Although used for purposes of standardization, there are a number of problems with the DSM-IV approach to diagnosis: (a) The DSM-IV is developmentally insensitive in that the same number of symptoms are required for a positive diagnosis at all ages; research has suggested that fewer symptoms should be required in older adolescents (five out of nine) and adults (four out of nine); (b) the DSM-IV assumes that ADHD is a categorical diagnosis (e.g., you either have it or you do not); research clearly indicates that inattention and behavioral inhibition are dimensional, not categorical, and adolescents may have different degrees of difficulties in these areas; the practitioner is referred to the Diagnostic and Statistical Manual for Primary Care (DSM-PC)—Child and Adolescent Version for an approach to addressing this problem; and (c) the DSM-IV item set was developed with school-age boys in mind and does not adequately capture the phenomenology of ADHD in adolescents, particularly adolescent girls; readers interested in a detailed discussion of ADHD in middle-and high-school girls should consult Understanding Girls with ADHD (Nadeau et al., 1999).
Associated Features or Comorbidity
Psychosocial and/or psychiatric comorbidity is common in ADHD
Making a Diagnosis of Attention-Deficit Hyperactivity Disorder: Clinical Guidelines
In May 2000, the American Academy of Pediatrics (AAP) published evidence-based clinical guidelines for primary care evaluation and diagnosis of ADHD (Table 80.1). These guidelines were developed in conjunction with the National Initiative for Children's Healthcare Quality (NICHQ). The AAP and NICHQ released a toolkit for implementing these guidelines in 2002. “Caring for Children with ADHD: A Resource Toolkit for Clinicians” may be purchased from the AAP and may also be downloaded from the NICHQ Web site at http://www.nichq.org/NICHQ/Topics/ChronicConditions/ADHD/.
Three examples of ADHD-specific rating scales include the following:
Public schools define learning disabilities in accordance with the Individuals with Disabilities Education Act (IDEA), the recertified version of PL 94–142. Specific learning disabilities consist of disorders in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. The term includes such conditions as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. The term does not include learning problems that are primarily the result of visual, hearing, or motor disabilities; mental retardation; emotional disturbance; or environmental, cultural, or economic disadvantage.
An information processing model can help us understand how an individual adolescent's learning disability in reading, writing, mathematics, or language is a complex interplay of the following four stages of cognitive processing:
Educators commonly summarize such information processing disabilities in terms of reading, mathematics, writing, and language disorders. They commonly interpret the presence of a significant discrepancy between actual and expected achievement for a given adolescent's intellectual ability as evidence of a learning disability. Practically, a discrepancy of two standard deviations between scores on an IQ test and scores on an achievement test is often presumptive evidence of a learning disability. For example, an individual with a full-scale IQ score of 100 and a reading achievement test score of 78 would qualify (assuming these tests have a mean of 100 with a standard deviation of 10). Learning disabilities are also often suspected when a significant discrepancy exists between the verbal and performance scores on IQ testing.
In recent years educators have increasingly recognized the limitations of a discrepancy model for operationalizing learning disabilities. A new model, “Response to Intervention,” is evolving through educational practice and research. When a student exhibits difficulty with a basic learning process such as reading, the educator locates an evidence-based intervention and applies that intervention to remediate the student's difficulty. If the intervention is successful, it is continued in regular education and no learning disability is diagnosed. If the intervention is not successful, the student is considered to have a learning disability, and special education services are provided. The emphasis within this model is the prevention of later learning problems through the early identification and remediation of deficits using evidence-based interventions. The 2004 recertification of the Individuals with Disability Act authorized the public schools to switch from a discrepancy model to a response-to-intervention model for learning disabilities. To date, most applications of the response-to-intervention model have been in elementary schools, but the practitioner should be aware that this evolving model will increasingly be applied in middle-and high-school environments.
Reading involves (a) decoding (the act of transcribing a printed word back into speech) and (b) comprehension (the act of interpreting the message or meaning of the text). With dyslexia, the most common reading disorder, the adolescent's decoding skills are impaired, but comprehension is intact. Common clinical indicators of decoding difficulties include guessing at words, having trouble with sound-letter combinations, and making spelling errors involving mispronunciations of words. In addition, dyslexic teens may have trouble sequencing speech into words, syllables, and phonemes, and rearranging sounds into spoken words. If decoding is intact, but comprehension is impaired, this relatively rare reading disability is called hyperlexia. The hyperlexic adolescent can read any text but not understand what has been read; they often also have oral language disabilities.
The terms dyscalculia and acalculia are often applied to the disorders in teenagers with impairment in the ability to do arithmetic computations or develop number and spatial concepts, resulting in math achievement far below than that expected for grade and intellectual level. Such youngsters have trouble learning to use number words and facts and have difficulty applying math to common life problems. One subgroup of dyscalculic adolescents also has pervasive learning disorders in reading and spelling. There is a second group, however, with low math achievement and poor spatial skills, which have average to superior reading achievement and verbal abilities. This subset has been described as having a nonverbal learning disability. IQ testing reveals that these adolescents consistently show high verbal and low performance ability; neuropsychological testing confirms that their verbal abilities are intact, but their spatial abilities are deficient.
The term writing disorder refers to difficulty with spelling and other linguistic aspects of writing, such as composing
and punctuating sentences and organizing cohesive paragraphs; it does not refer to difficulties with handwriting. Because writing disorders often coexist with reading disorders, dyslexic adolescents should also always be evaluated for a possible writing disorder. The adolescent with a writing disorder is capable of formulating complex thoughts but because of difficulties with spelling is unable to express them in writing at the level expected for his or her intellectual ability. Paragraphs will be poorly organized; sentences will be short with abrupt endings; and expository writing will read more like a list of answers to test questions than a fluent essay. Writing disorders become particularly debilitating in high school and college, when there are increased demands for written expression.
Management of Learning and Achievement Problems
Legal Responsibilities of the Public Schools
Children with disabilities are guaranteed a free and appropriate education by the following three federal laws:
Also, specific state laws and local policies within school districts elaborate on the federal laws. Most state education departments provide free manuals to professionals and parents explaining special education procedures. Primary care clinicians should become familiar with these laws, inform parents about them, and encourage parents of adolescents suspected of having disabling conditions to make written requests for school-based evaluations and interventions. Although an exhaustive account of educational interventions is not possible in this chapter, a summary of the most common accommodations helpful to adolescents with ADHD and learning disabilities follows in the subsequent sections.
Failure to complete or hand-in assignments on time is a major deficit of ADHD and learning disabled teens. Some common accommodations for adolescents with ADHD include the following:
A continuum of alternative placements for students certified as learning disabled or otherwise health impaired includes resource rooms, separate self-contained rooms, separate schools, residential placements, and even home-bound instruction. Placement is usually in the least restrictive environment to best prepare the disabled individual to live in a society with nondisabled individuals. Instructional procedures for reading, mathematics, and writing disabilities rely heavily on contemporary cognitive and developmental psychology and emphasize selecting alternative teaching methods that help the learner bypass his or her area of disability.
Management of Attention-Deficit Hyperactivity Disorder
Management of ADHD requires a comprehensive plan that includes the adolescent in the decision-making process. A treatment plan that allows the adolescent to participate in setting goals and developing strategies is more likely to succeed. Many adolescents with ADHD have had significant conflicts with their parents, and often the treatment plan includes negotiation of those conflicts to help the parents and adolescent work toward common goals. As described
earlier in this chapter, many adolescents with ADHD have comorbid conditions, which should be considered in the treatment plan.
The principles of management of ADHD include education, medication, home interventions, counseling, school interventions (see previous discussion), and advocacy. In 2001, the AAP published evidence-based guidelines for ADHD treatment, emphasizing the importance of viewing this as a chronic condition (Table 80.2).
Education about ADHD should be provided for the adolescent, for the parents and family, for the school, and sometimes even for the friends of the adolescent. A wide array of useful pamphlets, books, and videos are available from the ADD Warehouse (800-233-9273, http://addwarehouse.com). In addition, the AAP has published ADHD: A Complete and Authoritative Guide, which many families might find helpful. However, it is critical to take some time to explain in person some of the basics to ensure that the teen has a clear understanding of the condition. This begins with the process of informing the adolescent and the parents of the diagnosis. It is common for adolescents to have some resistance to this diagnosis, as it may be regarded as a “psychological problem” that makes them feel different from their peers. It is important to explain the diagnosis fully and carefully to the adolescent and the parents. Blame for the condition can be deflected by describing the genetic origin and neurochemical nature of the disorder, which may make ADHD seem more acceptable to the family and adolescent.
Adolescents must know that there is hope for improved functional and academic performance. This is important, because adolescents with ADHD often have low self-esteem due to their poor grades, frequently hearing “they could do better if they only tried,” and seeing reports of “not living up to potential.” If health care providers take a small amount of time at each visit to offer some education about ADHD to the adolescent, they will find that the adolescent is more likely to accept the diagnosis and begin to understand why he or she may act in certain ways. This is the first step in the development of insight, which can play a crucial role in allowing the adolescent to consciously alter his or her behaviors. A useful analogy in explaining ADHD is that of poor eyesight. Poor eyesight is hereditary and not someone's “fault.” It causes one to have difficulty “focusing” and therefore may cause problems in school and in overall functioning. Simple interventions, such as wearing glasses, can help one see clearly and improve academic and overall performance. ADHD is an inherited “biochemical” condition that causes difficulty in focusing and organizing. Medical and behavioral interventions can help the person function better. If adolescents understand this line of reasoning, they will have an easier time in accepting the diagnosis and therapy. In addition, they may be less likely to feel some of the stigma that may be attached to the diagnosis.
Medication (Table 80.3) should not generally be the only treatment received by the adolescent, but it is frequently the cornerstone of treatment for ADHD, because when it is successful, it appears to correct the underlying disorder in the brain. Because 75% to 90% of adolescents respond to medical therapy, a medication trial should be undertaken for almost all adolescents diagnosed with ADHD. Results from the large Multimodal Treatment Trial of ADHD (MTA) show that medication therapy was the single most effective intervention, and that intensive and closely monitored medical therapy was more effective than the usual provision of stimulant medications in the community (The MTA Cooperative Group, 1999).
The stimulants are considered first-line agents because they are the most effective of the available medication options and have an excellent record of safety. They have been shown to be effective in improving the core symptoms of ADHD. Recent studies have also shown that social interactions, academic productivity, and normal reaction times (potentially important in preventing motor vehicle accidents) are also improved.
Immediate-release methylphenidate (Ritalin, Methylin, Focalin) has been the most commonly prescribed stimulant for ADHD. However, the development and acceptance of longer-acting stimulants has led to increased flexibility in providing individual patients with a medication regimen that meets their needs. Shorter-acting medications have the potential for the following disadvantages: (a) need for more frequent and “during school” doses and (b) increased likelihood of “wearing off” and “rebound” symptoms, such as irritability and fatigue. It should be recognized that
ADHD affects the whole fabric of an adolescent's life including their sports performance, relationships with friends and family, risk for injury (from their potential inattentive or impulsive actions while bicycling, skateboarding, rollerblading, boating, or driving), and decisions about lifestyle risks (e.g., impulsive use of drugs or alcohol). Therefore, as they mature, it makes sense to negotiate a treatment plan that considers coverage by medication throughout the day and on weekends. This is particularly important for those adolescents who experience irritability when the dose “wears off.” Therefore, many patients with ADHD benefit from using one of the longer-acting medications, such as dextroamphetamine spansule capsules (Dexedrine), combination dextroamphetamine and amphetamine (Adderall or Adderall XR), or methylphenidate in a timed-release preparation (Concerta, Metadate-ER and Metadate-CD, Methylin-ER, Focalin XR, or Ritalin-LA). Tolerance to stimulants rarely develops after the first month or two on medication, and drug “holidays” are not usually required (with the exception of those few adolescents who show decreases in their growth velocity).
Side Effects of Stimulants
Serious side effects (and relative contraindications to use) include the following:
Concerns about cardiovascular risks associated with the use of stimulant medications prompted the requirement of a “black-box warning.” Significantly increased risks have not been subsequently confirmed, nevertheless, careful screening of patients, including a family history, is essential to rule out the presence of cardiovascular disease or risk factors. Routine electrocardiogram (ECG) screening is not currently recommended.
There has been much debate about the development of tics in patients treated for ADHD (especially with stimulants). In children and adolescents with Tourette syndrome, 50% to 75% may also have ADHD; it is possible that the Tourette syndrome may become apparent after ADHD treatment has begun. Tics are not uncommon in childhood and adolescence, and are a relative, not absolute, contraindication for stimulant use. Of children and adolescents with ADHD who also have tics, approximately one third experience worsening of their tics on stimulant medication, one third notice no change, and one third experience improvement in their tics. Patients with comorbid ADHD and Tourette syndrome may respond well to a combination of a stimulant and an α2-agonist, for example, clonidine or guanfacine.
Minor side effects of stimulants include the following:
When a dosage trial is undertaken, persistent symptoms of nervousness or jitteriness and feeling “spaced out” or “overfocused” are indications that the dose is too high. Suppression of growth is rarely a problem in adolescents (particularly those receiving lower doses) but should be monitored. It has been shown that ultimate height is not compromised. Some patients develop rebound (periods of irritability or increased ADHD symptoms) when the dose of stimulant is wearing off. This is particularly common with short-acting stimulants. These patients should be given doses at shorter intervals or be switched to a longer-acting preparation.
There has been controversy around a possible association between stimulant use, particularly methylphenidate, and substance abuse. Routine use of methylphenidate as a prescribed therapy has been decried as a “gateway drug” to subsequent abuse of other substances. There is considerable evidence now that the opposite is true. Untreated ADHD is a risk factor for later substance abuse, and treatment of ADHD with stimulants appears to reduce later substance use by as much as 50%. Still, diversion of stimulants is a legitimate concern and adolescents for whom stimulants are prescribed should be warned of the legal and ethical consequences of providing these agents to other adolescents.
Short-acting methylphenidate is no longer recommended as first-line treatment for ADHD. The usual role of short-acting methylphenidate is as an adjunct to longer-acting medications (see subsequent text). If short-acting methylphenidate is used as primary therapy, it should be started at low doses before titrating up to the optimal dose. The dose range is usually 5 to 30 mg/dose, given at intervals of approximately 4 hours (two to three times daily), up to a maximum of 60 mg/day. A typical titration method is to start with 5 mg and increase by 5-mg doses at weekly intervals to 20-mg doses, checking weekly by telephone for positive effects and side effects. The onset of action is approximately 30 minutes. Doses are usually given in the morning, at lunchtime, and after school. A new preparation, the D-isomer of methylphenidate (Focalin), may have fewer side effects and requires approximately half of the usual dose to be effective.
Intermediate-Release Methylphenidate (Ritalin-SR, Metadate-ER, Methylin-ER)
Sustained-release methylphenidate can be useful, because its duration of action is approximately 4 to 8 hours and can be given once or twice daily. Ritalin-SR, however, only comes in a 20-mg preparation and is often not as effective as the short-acting tablet. Therefore, it is not commonly used as a single agent. However, it can be helpful for patients who require lower stimulant doses or those who experience too many “ups and downs” with the short-acting methylphenidate. A good strategy in these situations is to use both short-acting and intermediate-release methylphenidate together as one would use regular and long-acting insulin. A common regimen for this would be sustained-release 20-mg plus 10- to 20-mg short-acting methylphenidate three times a day. Metadate-ER and Methylin-ER are extended-release preparations, and may be given 20 to 40 mg daily, or in varied doses such as 40 mg in the morning and 20 mg in the early afternoon.
Timed-Release Methylphenidate Capsule (Concerta, Metadate-CD, Focalin XR, Ritalin-LA), and the Methylphenidate Patch (Daytrana Patch)
Concerta consists of methylphenidate packaged using a medication delivery system similar to that used in the long-acting medications for hypertension and diabetes mellitus. The capsule contains an outer coating of methylphenidate that is released quickly and a minute hole in the capsule that allows the active ingredient to be released at a constant rate for up to 12 hours. Preliminary studies show good efficacy in the treatment of ADHD and most patients do not need a dose during school hours. Concerta is available in 18-, 27-, 36-, and 54-mg capsules, with most patients requiring 36 to 72 mg/dose.
Metadate-CD consists of beads of methylphenidate with two different release patterns; 30% of the beads are immediately released and absorbed, while the other 70% are released slowly over 8 to 12 hours. Doses of 20 to 60 mg/day in the morning are usually required.
Focalin XR provides an extended-release form of d-methylphenidate. It comes in doses of 5, 10, and 20 mg and appears to be effective up to 12 hours.
Ritalin-LA consists of methylphenidate beads in a 1:1 ratio of immediate and slow release forms. Half of the dose is released immediately and the rest is released approximately 4 hours later to provide 8 hours of medication effect. Morning doses of 20 to 60 mg are used.
A methylphenidate sustained action transdermal system (Daytrana) is now available. For adolescents who are willing to wear a patch, it offers steady-state dosing and variable duration of action. The effects continue for 2 to 3 hours after removing the patch. Skin reactions may occur but are usually mild. It is very difficult to elute the methylphenidate from the patch for purposes of abuse.
Dextroamphetamine (Dexedrine Spansules)
Dextroamphetamine is an effective long-acting preparation and is also tolerated quite well. It comes in 5-, 10-, and 15-mg spansules. The duration of action is usually approximately 8 hours, so it is generally given before school and after school. The usual doses are 10 to 20 mg twice daily, with some patients requiring doses up to 30 mg twice daily. Short-acting dextroamphetamine in seldom used in ADHD.
Combination Dextroamphetamine and Amphetamine (Adderall and Adderall XR)
Adderall is another stimulant for the health care provider to consider. There is good evidence of its effectiveness and it is very well tolerated. Long-acting Adderall XR is effective for 10 to 12 hours with a single morning dose of 10 to 40 mg. Shorter-acting Adderall can be used as an adjunct to Adderall XR. Some adolescents will have better results with short-acting Adderall dosed before and after school. Commonly used doses are 10 to 20 mg two or three times a day, with some patients requiring up to 30 or 40 mg/dose.
Pemoline (Cylert), a long-acting stimulant rarely used because of its potentially fatal hepatotoxicity, is no longer available in the United States.
Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor, the only nonstimulant medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD, and is the only medication approved for the treatment of ADHD in adults.
It is available as 10-, 18-, 25-, 40-, 60-, 80-, and 100-mg tablets and is given in a single daily dose. The starting dose is 0.5 mg/kg body weight, which may be increased to 1.2 mg/kg/day after 3 to 7 days. The maximum daily dose is 1.4 mg/kg/day or 100 mg/day, whichever is lower. Common side effects include stomach upset, decreased appetite, nausea or vomiting, fatigue, dizziness, mild increase in pulse and blood pressure, and growth delay. There have been several reports of (apparently reversible) severe liver injury associated with atomoxetine use. A recent analysis showed an increased risk of suicidal thinking in children and adolescents during the first few months of treatment with atomoxetine, leading to a black-box FDA warning for this medication. However, the absolute risk of suicidal thinking is quite low.
Tricyclic antidepressants have been generally considered second-line agents in the medical treatment of ADHD, but some health care providers now prefer atomoxetine as a second-line medication because of tricyclic side effects. They may be the medication of choice for patients who do not tolerate stimulants (generally each of the stimulants should be tried before making this determination), for those who have coexistent enuresis, or in whom a tic disorder has developed. Imipramine (Tofranil) and desipramine (Norpramin) have been used successfully. A trial of 4 to 6 weeks at adequate doses should be attempted (blood levels are useful to confirm this because children often metabolize tricyclic medications faster than adults), and careful monitoring is important, including heart rate, blood pressure, complete blood count, and serum levels. ECG monitoring should be done initially and periodically to look for cardiac toxicity (heart rate >130 bpm, PR interval >0.20 seconds, QRS duration >0.12 seconds, QT interval >0.45 seconds). Relative contraindications include a history of cardiac arrhythmias, heart disease, syncope, or family history of sudden death. Side effects include drowsiness, dry mouth, constipation, nausea, sweating, tremor, and postural hypotension. Rarely, neurological side effects such as seizures, an acute organic brain syndrome, and hypomania can occur. Rare instances of sudden death have been reported in children and adolescents. The daily dose of imipramine and desipramine is approximately 3 to 5 mg/kg of body weight. Toxicity is more likely to occur at the higher dose ranges.
The antidepressant bupropion (Wellbutrin) has been shown to be effective for inattention and impulsivity in children and may be beneficial in some adolescents with ADHD, especially those with comorbid depression or anxiety. Bupropion (sold as Zyban) is also approved for use in nicotine addiction, and may be helpful in adolescents with ADHD and substance abuse, especially those desiring smoking cessation. It is available in sustained-release (Wellbutrin SR) and extended-release (Wellbutrin XL) formulations. The immediate-release preparation may have a higher incidence of side effects in adolescents. The usual doses are 100 to 150 mg twice daily for Wellbutrin SR and 150 to 300 mg daily for Wellbutrin XL. It is contraindicated in patients with seizures or eating disorders; common side effects include nausea, anorexia, agitation, restlessness, drowsiness, and headaches.
Clonidine (Catapres) is a central-acting α2-agonist that has been shown to have limited effectiveness in the treatment of ADHD. However, it can be useful in patients with comorbid conditions, such as sleep disturbances, tic disorders, or severe aggressiveness (associated with oppositional-defiant disorder or conduct disorder). Clonidine comes in tablets of 0.1, 0.2, and 0.3 mg, as well as skin patches of similar strengths. The tablets are taken 2 to 4 times a day (or at night only for insomnia) starting with 0.05 mg, and then increasing by 0.05 mg/day every 7 days. The maximum daily dose is 0.3 mg/day. The patch is effective for 3 to 7 days. Some experts recommend obtaining a baseline ECG and blood glucose before starting clonidine. Compliance must be carefully monitored since missed doses or abrupt discontinuation of clonidine can precipitate hypertensive crisis, even in those with no history of hypertension. A long-acting α2-agonist, guanfacine (Tenex), can be used in place of clonidine.
Behavioral or Psychological Interventions
In the large MTA study, a comprehensive behavioral intervention alone was compared with medication alone, a combination of behavioral intervention and medication, and standard community care (The MTA Cooperative Group, 1999). Medication was generally found to be more effective in reducing ADHD symptoms than behavioral intervention, and there were few differences between the combined treatment and medication alone in effectively managing ADHD symptoms. However, when it came to other domains of functioning, such as oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent–child relationships, and reading achievement, there was evidence that the combined treatment was superior to community care whereas medication alone was not. Behavioral interventions, when combined with medication, add an important dimension to the positive outcomes on the variables other than ADHD symptoms. In interpreting these results, the health care provider must keep in mind that the study was limited to school-age children, not adolescents.
The MTA study suggests the need to include behavioral interventions to have an impact on various issues other than ADHD symptoms (such as conduct disorder, oppositional-defiant disorder, poor self-esteem, family conflict, depression, anxiety disorders, and the use or abuse of alcohol and other drugs) that require attention. If the initial evaluation reveals a significant substance use disorder, the health care provider should refer the adolescent for a substance abuse work-up or treatment before undertaking any additional intervention. The presence of oppositional behavior, family conflict, peer relationship difficulties, depression, or anxiety is an indication to refer the family for behavioral or psychological interventions. The most common behavioral or psychological interventions include family therapy, individual therapy, and social skills training. It is often useful for families with adolescents who are newly diagnosed with ADHD to have a burst of 10 to 15 sessions of behavioral or psychological intervention, followed by less frequent checkups. If new problems surface during a follow-up checkup, another burst of therapy may be scheduled. Individual therapy is usually helpful in building self-esteem and reducing anxiety but does not reliably result in behavioral changes in the classroom or at home.
Behavioral family system therapy is the treatment of choice for the home-based problems and conflicts between
teenagers with ADHD and their parents. Early in treatment, the therapist divides the family issues into two categories: (a) nonnegotiable issues (basic rules for living in a family, such as no violence, drugs, or alcohol) and (b) negotiable issues (all other independence-related conflicts that may be subject to negotiation and compromise). Strategic structural intervention techniques are used to reinforce parental authority around the nonnegotiable issues (i.e., the therapist teaches the parents how to establish and consistently follow behavioral contracts for these basic rules). External authorities such as the juvenile justice system or mental health inpatient system are used to back up parents when they no longer have the ability to exert any control over the adolescents.
In the case of issues that can be negotiated between parents and adolescents, problem-solving communication training is used to teach parents and adolescents to work out mutually acceptable compromise solutions. The therapist instructs, models, and coaches the family to learn and practice the steps of problem solving: (a) clearly define the problem in a nonaccusatory manner; (b) brainstorm a list of alternative solutions; (c) systematically evaluate the positive or negative impacts of each solution, culminating in a mutually acceptable compromise solution; and (d) plan the details for implementing the solution. The family resolves a number of significant conflicts with the therapist present as a coach and then is given successively more complex assignments to apply problem-solving skills at home in weekly family meetings. As the family begins to practice problem-solving skills in the sessions and at home, the therapist targets negative communication patterns, again coaching families to replace accusatory, defensive language with more productive, goal-oriented language.
As part of an overall family intervention, it is also useful to teach parents the effective use of behavior modification techniques. A manual has been written to guide the health care provider in teaching parents contingency management techniques and integrating these techniques with problem-solving communication training (Barkley et al., 1999). These techniques are crucial for parents of adolescents with ADHD to help them teach their children to stay motivated to complete homework assignments and household chores. Setting up explicit rewards for appropriate activities and punishments for proscribed activities is a cornerstone of behavioral management. Health care providers can help parents with home interventions by offering advice on how to carry out simple behavioral contracts. Two clinical trials have now demonstrated the effectiveness of behavioral family systems therapy for reducing conflict between parents and their adolescents with ADHD (Barkley et al., 1992, 2001).
In summary, health care providers can best help adolescents with ADHD and learning disabilities by encouraging them, believing that they can succeed, helping them to understand their disorder and how it affects them, mediating conflict between them and their parents, finding the optimal medication regimen (if appropriate), and helping them obtain the services they require through their school system and within their community.
For Teenagers and Parents
http://www.chadd.org. Official Web site for the support group, Children and Adults with ADHD.
http://www.help4adhd.org/. National Resource Center on ADHD, funded cooperatively by the Centers for Disease Control and CHADD.
http://www.nimh.nih.gov/publicat/adhd.cfm. National Institutes of Health information on ADHD.
http://www.addvance.com. Commercial Web site, with link specifically for girls and women with ADHD.
http://www.add.org. National Attention Deficit Disorder Association (ADDA).
http://www.LDAAmerica.org. Learning Disabilities On Line.
http://www.wrightslaw.com. Commercial site for special education law and advocacy.
http://www.ideapractices.org. Information about the Individuals with Disabilities Act.
http://www.ldanatl.org. Learning Disabilities Association of America.
http://www.ed.gov/about/offices/list/osers/codi.html. Clearinghouse on Disability Information, Office of Special Education and Rehabilitative Services, U.S. Department of Education. Specializes in questions about funding, federal legislation, and federal programs that serve persons with disabilities at national, state, and local levels.
http://www.interdys.org. The International Dyslexia Association. http://www.nichcy.org. National Dissemination Center for Children and Youth with Disabilities. http://www.ncld.org. National Center for Learning Disabilities.
For Health Professionals
www.nichq.org/nichq/topics/chronicconditions/ADHD/ADHDhomepage.htm. National Initiative for Children's Healthcare Quality (NICHQ) Web site, with link to the ADHD Toolkit.
References and Additional Readings
Achenbach T. Subtyping ADHD: a request for suggestions about relating empirically based assessment to DSM-IV. ADHD Rep 1996;4(4):5.
Ahmann PA, Waltonen SJ, Olson KA, et al. Placebo controlled evaluation of ritalin side effects. Pediatrics 1993;91:1101.
Ambalavanan G, Holten KB. How should we evaluate and treat ADHD in children and adolescents. J Fam Pract 2005;54(12):1058.
Ambrosini PJ, Bianchi MD, Rabinovich H, et al. Antidepressant treatments in children and adolescents. 11. Anxiety, physical, and behavioral disorders. J Am Acad Child Adolesc Psychiatry 1993;32:483.
American Academy of Pediatrics. Diagnostic and statistical manual for primary care (DSM-PC), Child and adolescent version. Elk Grove, IL: American Academy of Pediatrics; 1996.
American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000;105:1158.
American Academy of Pediatrics. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108:1033.
American Psychiatric Association. The diagnostic and statistical manual of mental disorders, text revision, 4th ed. Washington, DC: American Psychiatric Association; 2000.
Barkley R. ADHD and the nature of self-control. New York: Guilford Press; 1997.
Barkley R. Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment. New York: Guilford Press; 1998.
Barkley RA, Edwards G, Laneri M, et al. The efficacy of problem-solving communication training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. J Consult Clin Psychol 2001;69:926.
Barkley R, Edwards G, Robin AL. Defiant teens: a clinician's manual for assessment and family intervention. New York: Guilford Press; 1999.
Barkley RA, Guevremont DG, Anastopoulous AD, et al. A comparison of three family therapy programs for treating family conflict in adolescents with attention-deficit hyperactivity disorder. J Consult Clin Psychol 1992;60:450.
Biederman J, Wilens T, Mick E, et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104(2):e20.
Brown TE. Brown attention-deficit disorder scales manual. San Antonio: The Psychological Corporation; 1996.
Brown RT, Amler RW, Freeman WS, et al. American Academy of Pediatrics Committee on Quality Improvement. American Academy of Pediatrics Subcommittee on Attention-Deficit/Hyperactivity Disorder. Treatment of attention-deficit/hyperactivity disorder: overview of the evidence. Pediatrics 2005;115(6):e749.
Castellanos FX, Lee PP, Sharp W, et al. Developmental trajectories of brain volume abnormalities in children and adolescents with attention deficit/hyperactivity disorder. JAMA2002;288:1740.
Christman AK, Fermo JD, Markowitz JS. Atomoxetine, a novel treatment for attention-deficit-hyperactivity disorder. Pharmacotherapy 2004;24:1020.
DePaul GJ, Stoner G. ADHD in the schools: assessment and intervention strategies. New York: Guilford Press; 1994.
DeVries BB, Halley DJ, Oostra BA, et al. The fragile X syndrome. J Med Genet 1998;35(7):579.
Dworkin PH. School failure. Pediatr Rev 1989;10:301.
Faigel HC, Sznajderman S, Tishby O, et al. Attention deficit disorder during adolescence: a review. J Adolesc Health 1995;16:174.
Fischer M, Barkley RA, Fletcher K, et al. The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment. J Am Acad Child Adolesc Psychiatry 1993;32:324.
Gadow KD, Sverd J. Attention deficit hyperactivity disorder, chronic tic disorder, and methylphenidate. Adv Neurol 2006;99:197.
Gadow KD, Sverd J, Sprafkin J, et al. Efficacy of methylphenidate for attention-deficit hyperactivity disorder in children with tic disorder. Arch Gen Psychiatry 1995;52:444.
Goyette CH, Conners CK, Ulrich RE, et al. Attention-deficit/hyperactivity disorder in children and adolescents: interventions for a complex costly clinical conundrum. Pediatr Clin North Am 2003;50:1049.
Illingworth R. Early failure of the famous. Pediatrician 1986;13:70.
Levy HB, Harper CR, Weinberg WA. A practical approach to children failing in school. Pediatr Clin North Am 1992;39:895.
Lipkin PH, Goldstein IJ, Adesman AR. Tics and dyskinesias associated with stimulant treatment in attention-deficit hyperactivity disorder. Arch Pediatr Adolesc Med 1994;148:859.
The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56:1088.
Nadeau KG, Littman EB, Quinn PO. Understanding girls with AD/HD. Silver Spring, MD: Advantage Press; 1999.
Palmer FB, Capute AJ. Mental retardation. Pediatr Rev 1994;15:473.
Palumbo D, Lynch PA. Psychological testing in adolescent medicine. Adolesc Med Clin 2006;17(1):147.
Prince JB. Pharmacotherapy of attention-deficit hyperactivity disorder in children and adolescents: update on new stimulant preparations, atomoxetine, and novel treatments.Child Adolesc Psychiatr Clin N Am 2006;15(1):13.
Rappley MD. Attention deficit-hyperactivity disorder. N Engl J Med 2005;352:165.
Reiff MI, Stein MT. Attention-deficit/hyperactivity disorder evaluation and diagnosis, a practical approach in office practice. Pediatr Clin North Am 2003;50:1019.
Robin AL. Training families with ADHD adolescents. In: Barkley R, ed. Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment, 2nd ed. New York: Guilford Press; 1998a:413.
Robin AL. ADHD in adolescents: diagnosis and treatment. New York: Guilford Press; 1998b.
Robin AL, Foster SL. Negotiating parent-adolescent conflict: a behavioral family systems perspective. New York: Guilford Press; 1989.
Rourke BP. Nonverbal learning disabilities. New York: Guilford Press; 1989.
Rubenstein JS, Hastings EM. School refusal in adolescence: understanding the symptom. Adolescence 1980;15:775.
Schubiner H, Robin AL. Attention-deficit/hyperactivity disorder in adolescence. Adolesc Health Update 1998;10(2):1.
Spencer T, Biederman J, Wilens T. Tricyclic antidepressant treatment of children with ADHD and tic disorders. J Am Acad Child Adolesc Psychiatry 1994;33:8.
Steingard R, Biederman J, Spencer T, et al. Comparison of clonidine response in the treatment of attention deficit hyperactivity disorder with and without comorbid tic disorders.J Am Acad Child Adolesc Psychiatry 1993;32:350.
Swank LK. Specific developmental disorders. Child Adolesc Psychiatr Clin N Am 1999;8:89.
Wilens TE, Biederman J, Spencer T. Clonidine for sleep disturbances with attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1994;33:424.
Wilens TE, Faraone SV, Biederman J, et al. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? a meta-analytic review of the literature. Pediatrics 2003;111:179.
Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications.Pediatrics 2005;115(6):1734.