Adolescent Health Care: A Practical Guide

Chapter 80

School Problems and Attention-Deficit Hyperactivity Disorder

Peter R. Loewenson

Howard Schubiner

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:

  1. Evaluating the adolescent for biomedical disorders such as hearing and vision dysfunction, ADHD, learning disorders, sleep disorders, thyroid disorders, subtle cognitive impairments, and seizure disorders
  2. Screening the adolescent for emotional disorders such as depression, anxiety, and family conflict and initiating referrals as necessary
  3. Assessing the impact of chronic illness (or its treatment) on the adolescent and his or her family
  4. Assessing the impact of family, school, or community factors on academic performance
  5. Initiating and coordinating appropriate referrals for the psychological and psychometric testing necessary to determine the presence of learning disabilities, ADHD, and related problems
  6. Demystifying learning disabilities, ADHD, and related problems, educating the adolescent and the family about such disabilities, and encouraging the adolescent to develop appropriate attitudes for coping effectively with these disabilities
  7. Educating the patient and the family about the legal obligations of public schools to meet the educational needs of youngsters with disabilities
  8. Cooperating with public schools in determining the eligibility for special education services, and providing physician certification when required
  9. Contributing to the development and coordination of an overall school-based intervention plan and serving as an advocate for the adolescent
  10. Providing short-term counseling for milder school-and home-related problems and anticipatory guidance to prevent the development of additional complications (e.g., adjustment reactions and parent–teen conflict)
  11. Providing medical therapy for anxiety and affective disorders, as well as for ADHD
  12. Serving as care coordinator with whom the adolescent can periodically “check in” to monitor the overall progress of comprehensive medical, educational, and psychological services

School Phobia/Avoidance

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:

  1. Fear of undressing in a group
  2. Fear of confrontations with teachers or students
  3. Fear of poor grades
  4. Fear of being picked first or last for a team or school project
  5. Fears related to participation in athletics
  6. Family dysfunction
  7. Fear of being criticized by peers (openly or otherwise)
  8. Fears related to poverty or financial circumstances
  9. Fears related to sexual expression or sexual orientation
  10. Fear of inadequate vocational or academic preparation
  11. Fear of individuating or separating from parents

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

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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.

  1. What is the specific problem?
  2. Has there been a drop in grades, behavior problems, inconsistent performance, emotional issues, or underachievement for the presumed level of intelligence?
  3. Who “owns” the problem?
  4. Does the adolescent have concerns about his or her progress?
  5. Are parents concerned with “average” work because it may not be sufficient for matriculation into certain elite colleges?
  6. Have the teachers identified particular issues that should be resolved?

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.

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Causes of Poor Academic Performance

  1. Biomedical causes
  2. Hearing or vision problems: Such problems are unlikely to be the primary cause for an adolescent but may contribute to the overall picture.
  3. Mental impairment or low intellectual ability: Subtle forms of mental impairment may not have been picked up earlier. For example, patients with fragile X syndrome (or female carriers of this syndrome), Klinefelter syndrome, Turner syndrome, XXX chromosome syndrome (females only), tuberous sclerosis, neurofibromatosis, or the fetal alcohol syndrome may not have been formerly diagnosed. Some teenagers may not have severe cognitive impairments, but they may score in the borderline range of intellectual ability (an intelligence quotient [IQ] of 70–79). Youngsters with borderline intellectual ability often cannot meet the demands of a regular education curriculum and are considered slow learners. They typically need additional help, but may not qualify for special education services.
  4. Chronic illness: Patients with severe asthma, cystic fibrosis, diabetes mellitus, sickle cell anemia, juvenile rheumatoid arthritis, epilepsy, congenital heart diseases, or other disorders may have had sufficient absences to cause academic problems. In addition, the side effects of medications may impair cognitive function. Chronic infections, such as sinusitis, or obstructive sleep apnea, may also adversely affect school performance.
  5. Neurological disorders: Certain seizure disorders such as simple generalized or partial complex seizures may be subtle enough to be missed. Borderline forms of cerebral palsy may also present difficulties in early diagnosis. Rarely, progressive neurological diseases such as Wilson disease or subacute sclerosing panencephalitis may present as cognitive impairment. Antiepileptic medications may also cause mild cognitive impairments.
  6. Sleep disorders: It is increasingly recognized that some adolescents suffer from undiagnosed obstructive sleep apnea, central hypoventilation syndrome, or have poor sleep hygiene, any of which may have adverse effects on learning.
  7. ADHD: Some adolescents may not have been diagnosed as a child, whereas others may have been diagnosed but never treated. In particular, females with attention-deficit disorder without hyperactivity are often not diagnosed in elementary school.
  8. Learning disabilities: Specific learning disabilities are common (occurring in approximately 3%–5% of students); usually related to specific problems in reading, spelling, mathematics, or written expression.
  9. Psychological and behavioral causes: An adolescent's school performance may be affected by depression, substance abuse, anxiety disorders, conduct disorder, or physical, sexual, or emotional abuse.
  10. Family issues: Various family problems may affect academic performance, including parental depression, drug or alcohol abuse, and divorce; conflict within the family (parent–teen or parent–parent); or mismatches between parent–adolescent–school expectations for achievement.
  11. School and peer relationships: Adolescents who have poor peer relationships or interact with a peer group that does not value academic achievement may present with academic problems. The school may not be able to meet the needs of certain students (e.g., the bright and bored, those with special needs, those who learn in different ways, or those who do not value the educational experience).
  12. Cultural or environmental factors: Adolescents who did not have an opportunity to achieve adequately, who received poor teaching, or had cultural or economic disadvantages that interfere with appropriate education may also present with academic performance problems. Children from ethnic or cultural backgrounds that are different from the prevailing school norm, or in which English is not the primary language may also experience difficulty with a standard curriculum. The practitioner should attempt to distinguish such cultural or environmental factors from all of the other previously mentioned causes of academic performance problems.

Evaluation

History

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.”

  1. Interview with the parents
  2. Developmental history
  • Prenatal history (use of drugs, alcohol, medications)
  • Perinatal history (prematurity, birth history, sepsis, asphyxia)
  • Developmental milestones (for delays in language acquisition, communications skills, and other discrete areas)
  • Speech, vision, or hearing problems
  1. Medical history
  • Chronic illnesses such as asthma, otitis media
  • Neurological disorders such as head injuries, neurological symptoms
  • Hospitalizations
  • Family history of neurological or psychological disorders, ADHD, or learning disabilities (a family history of resistance to thyroid hormone is strongly associated with ADHD)
  1. Behavioral history
  • Peer and family relationships
  • Suspected drug or alcohol use
  • Psychological symptoms
  • Antisocial behaviors
  • Symptoms of ADHD (inattention, impulsivity, restlessness)
  1. School history (attempt to get similar information from the school)
  • History of prior problems
  • Behaviors reported in school
  • Specific problems (i.e., which classes, which hours, which teachers, missing assignments, missing homework, poor test scores)
  • Motivation and goals
  • Grades, attendance, suspensions

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  • Parents' educational level and their expectations for their adolescent
  • Prior attempts to improve the situation
  • Prior educational or IQ testing
  1. Interview with the adolescent
  2. School history
  • The perspective of the adolescent on the problem or lack thereof
  • Assessment of motivation and goals
  • Likes and dislikes about school
  • Specific problem areas in school: This area is important to assess both for motivation and for specific deficits that may be indicative of a learning disorder or ADHD. Ask about difficulties in specific classes (to screen for learning disorders in math, reading, language skills), difficulties with specific teachers unrelated to course content, capability and willingness to do homework, difficulty with tests (what kind of tests pose particular problems), overall workload, and difficulty of the assignments.
  • Factors that prevent academic achievement
  • Future plans for employment
  • Specific strengths: This is a critical area to identify. If an adolescent has one strong area (e.g., art, music, computers, sports), you can often build self-esteem by encouraging development in that area while using it as a “hook” to keep the adolescent motivated to stay in school.
  1. Medical and behavioral history
  • Psychological symptoms (particularly anxiety and depression)
  • Symptoms of acute or chronic illness
  • Drug and alcohol use
  • Peer support and influences
  • Family conflicts or problems with parents
  1. School records or telephone interviews with teachers are helpful to obtain the school's perspective and to identify the interventions that have been attempted.

Physical Examination

  1. Height, weight, body mass index (BMI), and blood pressure.
  2. General inspection
  3. For nutritional status
  4. For minor anomalies (e.g., short palpebral fissures, epicanthal folds, thin upper lip of fetal alcohol syndrome; clinodactyly, wide-set eyes, epicanthal folds of XXX syndrome)
  5. Ears, nose, and throat; neck: For otitis, tonsillar, or thyroid enlargement
  6. Genital: For sexual maturity rating, testicular size (large testes in fragile X syndrome, small testes in Klinefelter syndrome)
  7. Neurological: Neurological examination is indicated when a neurological problem is suspected. This may include testing of cranial nerves, muscle strength and tone, gait, coordination, involuntary movements (particularly looking for tics) and reflexes, and sensory examination. Some recommend testing for “soft” neurological signs. These may include reflex asymmetry, strabismus, hyperkineses, coordination difficulties, poor fine visual-motor coordination, confused laterality, choreiform movements, overflow and mirror movements, and extinction to double simultaneous tactile stimulation. Five percent of healthy children display one or two “soft” signs.

Testing

  1. Audiometric testing.
  2. Visual acuity testing.
  3. Cognitive ability testing: General intellectual ability test such as the Wechsler Intelligence Scale for Children-IV for up to age 16 years and the Wechsler Adult Intelligence Scale, third edition, for those older than 16 years. The Woodcock-Johnson III Tests for Cognitive Abilities are sometimes used by schools as well.
  4. Achievement testing: Such as Woodcock-Johnson III Test of Achievement, Wechsler Individual Achievement Test II, Kaufman Test of Educational Achievement.
  5. Learning disability analysis: Compare IQ and achievement test results, looking for significant discrepancies between average IQ and below-average achievement (usually discrepancies of at least two standard deviations). Occasionally, further educational testing of specific reading, mathematics, writing, and language skills must be done after determining that there is a significant discrepancy.
  6. Neuropsychological testing: Testing is indicated if there is either an unusual pattern of functioning on IQ or achievement tests that defy a traditional learning disability explanation or if there are indications of neurological problems.
  7. ADHD screening: See next section on ADHD.
  8. Psychopathology screening: May ask parent or youth to complete a standardized self-report that broadly screens for psychopathology such as the Child Behavior Checklist (CBCL) or the Behavior Assessment System for Children (BASC-2). T scores higher than 70 would suggest the need for a follow-up clinical interview.
  9. Family problems screening: May ask the adolescent or parent to complete a self-report screening of family conflict such as the Conflict Behavior Questionnaire.
  10. Adolescents with low or borderline IQ scores should be screened for chromosomal anomalies, such as the Fragile X syndrome.

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

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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.

Epidemiology

  1. Prevalence: Four percent to 12% of school-aged children are estimated to have ADHD by combining recent community prevalence studies.
  2. Sex: Male to female ratio is approximately 3:1 in community samples.
  3. Age: The problem typically starts in early grade school, with an increased prevalence of school-and home-based problems in adolescence. Because the transitions to middle and high school entail increased organizational demands, many brighter youngsters or less hyperactive youngsters with ADHD may first become educationally impaired by attention problems in adolescence, resulting in diagnosis and treatment. For 50% to 60% of adolescents with ADHD, there will be residual impairments into adulthood.

Etiology

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.

Diagnostic Criteria

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.

  1. Either inattention (a) or hyperactivity/impulsivity (b)
  2. Inattention: At least six of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level
  • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • Often has difficulty sustaining attention in tasks or play activities
  • Often does not seem to listen when spoken to directly
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  • Often has difficulty organizing tasks and activities
  • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, book, tools)
  • Is often easily distracted by extraneous stimuli
  • Is often forgetful in daily activities
  1. Hyperactivity/impulsivity: At least six of the following symptoms of hyperactivity/impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level
  • Hyperactivity
  • –Often fidgets with hands or feet or squirms in seat
  • –Often leaves seat in classroom or in other situations in which remaining seated is expected
  • –Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
  • –Often has difficulty playing or engaging in leisure activities quietly
  • –Is often “on the go” or often acts as if “driven by a motor”
  • –Often talks excessively
  • Impulsivity
  • –Often blurts out answers before questions have been completed
  • –Often has difficulty awaiting turn
  • –Often interrupts or intrudes on others (e.g., butts into conversations or games)
  1. Some symptoms that caused impairment were present since 7 years of age.
  2. Some impairment caused by the symptoms is present in two or more settings (e.g., at school, work, or at home).
  3. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
  4. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).
  5. DSM-IV subtypes

 .    314.01. ADHD, combined type: If both criteria 1a and 1b are met for the past 6 months.

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  1. 314.00. ADHD, predominantly inattentive type: If criterion 1a is met but criterion 1b is not met for the past 6 months.
  2. 314.01. ADHD, predominantly hyperactive/impulsive type: If criterion 1b is met but criterion 1a is not met for the past 6 months.
  3. 314.09. ADHD, not otherwise specified: If prominent symptoms of inattention or hyperactivity/impulsivity are present that do not meet criteria for ADHD.

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

  1. Oppositional-defiant disorder: A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, involving loss of temper, frequent arguments with adults, refusing to comply with requests, deliberately annoying others, being angry and vindictive, and blaming others for one's mistakes. Thirty-five percent of children with ADHD have oppositional-defiant disorder.
  2. Conduct disorder: A repetitive pattern of antisocial behavior violating others' basic rights or societal norms, involving physical aggression, threats, use of weapons, cruelty to people or animals, destruction of property, deceitfulness and theft, repeated running away from home, frequent truancy, or sexual assault. Approximately 26% of children with ADHD have conduct disorder. There is sometimes a progression from oppositional-defiant disorder to conduct disorder, and persistent conduct disorder is termed antisocial personality disorderin adulthood.
  3. Learning disabilities or academic achievement problems: A significant discrepancy between average to above-average intellectual ability and below-average academic achievement in reading, math, spelling, handwriting, or language may reflect a processing deficit. At least 20% to 30% of children with ADHD have learning disabilities in at least one area. Although most adolescents with ADHD do not have learning disabilities, they do consistently show academic achievement problems, with scores on Standardized Achievement Tests lower than those of matched controls, and a greater likelihood of grade retentions, school dropout, or expulsions.
  4. Depressive and anxiety disorders: Many adolescents with ADHD are somewhat depressed because of their school and home problems. As a result, their self-esteem suffers. A coexisting depressive disorder is present in 18% of children with ADHD, which further impairs functioning. Anxiety disorders are present in 26% of children with ADHD.
  5. Substance abuse: Adolescents with ADHD show more cigarette and alcohol use than matched controls, with these findings accounted for primarily by the subgroup with comorbidity for conduct disorder. A substance use disorder is more likely to be diagnosed in adolescents with ADHD, and is also diagnosed at an earlier age. Some have attributed this to the use of methylphenidate, labeling it “a gateway drug.” Effective treatment with stimulant medication, however, has been clearly shown to reduce the risk of subsequent substance use disorder in individuals with ADHD. Marijuana is a commonly used illicit drug among adolescents with ADHD.
  6. Driving behavior: Adolescents with ADHD show less sound driving skills or habits than matched control groups, with greater likelihood of accidents, more bodily injuries associated with crashes, and more traffic citations, particularly for speeding. The subgroup with comorbid oppositional-defiant disorder or conduct disorder is at the highest risk for such deficient driving skills or habits. Medical treatment for ADHD has been shown to improve driving performance in adolescents.
  7. Family relationships: Adolescents with ADHD and their parents display more negative, controlling interactions, fewer positive, facilitative interactions, and more conflicts than matched controls. Mothers of adolescents with ADHD report more personal psychological distress than mothers of matched controls. The adolescents themselves underestimate the degree of family conflict, compared with their mothers.
  8. High-risk sexual behaviors: Adolescents with ADHD have an earlier age at first sexual intercourse, more sexual partners, less use of birth control, more sexually transmitted diseases, and more teen pregnancies that their non-ADHD peers.
  9. Sleep disorders: Sleep disturbances are more common in children with ADHD. Because insomnia is a common side effect of stimulant therapy, it is important to thoroughly assess sleep before and after starting stimulant medication.

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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/.

TABLE 80.1
American Academy of Pediatrics Clinical Guidelines for Attention-Deficit Hyperactivity Disorder Diagnosis and Evaluation

ADHD, attention-deficit hyperactivity disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition.

In a child 6- to 12-years-old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems primary care clinicians should initiate an evaluation for ADHD

The diagnosis of ADHD requires that a child meet DSM-IV criteria

The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, age at onset, duration of symptoms, and degree of functional impairment

The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions

Evaluation of the child with ADHD should include assessment for associated (coexisting) conditions

Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions (e.g., learning disabilities and mental retardation)

  1. Inclusion criteria: Does the adolescent meet the DSM-IV inclusion criteria for ADHD? Because of performance inconsistency, information from parents, adolescents, and teachers is required to answer this question. Interview the parents and the adolescent with reference to the DSM-IV criteria. Some health care providers prefer to rely upon an in-depth clinical interview performed by an experienced psychologist. There has been some concern that the DSM-IV criteria lack developmental perspective, that is, they remain the same over the spectrum of childhood and adolescence. Symptoms of inattention tend to remain stable across this developmental spectrum, but symptoms of hyperactivity/impulsiveness may diminish significantly. The DSM-PC can provide a developmental perspective on normal behavioral differences across the age spectrum.
  2. Differential diagnosis: If the adolescent meets the DSM-IV inclusion criteria, can alternative syndromes that resemble ADHD be ruled out? Refer the adolescent for psychological testing to explore learning disabilities, and conduct (or refer for) a thorough interview to address other psychiatric syndromes. Inquire about the major life stressors in the adolescent's history, and examine the temporal relationship between the ADHD symptoms and the major life stressors. For example, poor concentration is a frequent clinical feature of major depression.
  3. Rating scales: A number of questionnaires and rating scales have been developed to assess behavioral characteristics. There are both ADHD-specific and global (“broadband”) scales available. The AAP guidelines consider the ADHD-specific scales an option in clinical assessment, with several caveats. These scales may not function as well in a primary care clinic as in the ideal conditions of the study setting (e.g., comparison of apparently healthy children in referral sites). The questions in the rating scales are subjective; bias may be introduced and a false sense of validity may result. The use of broadband scales in the evaluation of ADHD is discouraged by the AAP guidelines. These global scales, however, are helpful in screening for coexisting conditions. The practitioner should use at least one psychometrically sound parent, teacher, and adolescent self-report rating scale.

Three examples of ADHD-specific rating scales include the following:

  1. NICHQ Vanderbilt Parent and Teacher Scales: These scales are included in the AAP toolkit, and may be copied for use in the office or clinic. Each of the 18 DSM-IV behavior descriptions is addressed, and scoring is based on number of behaviors endorsed on a four-point scale. Screening questions for comorbid conditions, for example, conduct disorder, oppositional-defiant disorder, and anxiety/depression are also included. One advantage of this scale is that impairment measures are included for assessing the degree of impairment in the home setting, in academic performance, and in classroom behaviors. These are normed scales for children 5 to 11 years of age.
  2. Conners Rating Scales-Revised (CRS-R): There are short and long versions of each of the parent, teacher, and adolescent self-report scales. All DSM-IV symptom subscales are included, and scoring is based on conversion of raw scores into T scores. Conners forms have been in use for 20 years, and are normed forms for adolescents up to age 17 (available from Multi-Health Systems, http://www.mhs.com/).

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  1. Brown Attention-Deficit Disorder (ADD) Scale for Adolescents. The Brown ADD Scale for Adolescents (Brown, 1996) is a psychometrically sound adolescent self-report measure which can be administered either as a semistructured interview or as a written rating scale. It consists of 40 items rated on a four-point Likert scale yielding total summary scores and five subscale scores for the following executive functions—organizing and activating to work, sustaining attention and concentration, sustaining energy and effort, managing affective interference, and utilizing working memory and accessing recall.
  2. Integration of information from ratings and interview: Make a diagnosis and clearly present it to the family and the adolescent.

Learning Disabilities

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:

  1. Input: Input disabilities include visual perception problems, auditory perception problems, and sensory integration problems.
  2. Integration: Integrative disabilities involve understanding information, sequencing, abstracting, and organizing.
  3. Memory: Memory difficulties may involve short-or long-term memory.
  4. Output: Output disabilities may involve language or writing problems and motor disabilities.

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 Disorders

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.

Math Disorders

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.

Writing Disorder

The term writing disorder refers to difficulty with spelling and other linguistic aspects of writing, such as composing

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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:

  1. IDEA: This basic special education act outlines that schools are obligated to conduct multidisciplinary evaluations for adolescents suspected of having a disability, and if the disability is confirmed, provide special education interventions. These interventions are encoded in an Individualized Education Program written at a team meeting that includes the parents. This law outlines specific types of disabilities such as learning disabilities, emotional impairment, mental impairment, and other health impairments. Since 1997, the other health impairment category has been revised to cover children with both ADHD and educational handicaps. IDEA has a funding stream associated with it at the local, state, and federal levels.
  2. Section 504 of the Rehabilitation Act of 1973: Section 504 is a civil rights law that outlaws discrimination against individuals with a disability in federally funded programs in education and at the workplace. Schools are required to make reasonable accommodations to educate individuals with disabilities. ADHD has been interpreted as an educational disability under Section 504. Children suspected of having a disability must be evaluated and, if confirmed, reasonable accommodations are typically made first in regular education. Section 504 has no funding stream associated with it.
  3. Americans with Disabilities Act: This law basically extends the protections of Section 504 to college students, adults, and the private sector, and therefore may apply to older adolescents who are working.

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.

Accommodations

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:

  1. Modifying lesson presentation: This will make it easier for the inattentive youngster to remain on task and complete assignments. It often involves breaking lessons into short segments, frequently monitoring on-task behavior, redirecting the adolescent to the task if the adolescent's attention wanders, and providing frequent positive feedback for successful task completion. When a paper is due in 1 month, for example, the teacher might construct intermediate steps to monitor the adolescent: (a) hand in a reference list, (b) hand in notes, and (c) hand in a first draft.
  2. Adjusting testing procedures: Adjusting testing procedures by permitting extended time to complete examinations, providing a quiet environment, or administering oral tests.
  3. Organizational assistance: This may take the form of note-taking training, assignment sheets, a second set of textbooks at home, checks to make sure students have the materials they need to complete assignments, and monitoring of hand-in assignments.
  4. Computers: Students with writing disorders often benefit from an early emphasis on computers, using word processors in school to complete examinations and home assignments.
  5. Weekly home or school progress reports: Coordination of weekly home or school progress reports, with home-based incentives for positive teacher ratings, motivates task completion, and cements teacher–parent communication.

Special Education

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

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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).

TABLE 80.2
American Academy of Pediatrics Clinical Guidelines for Attention-Deficit Hyperactivity Disorder Treatment

ADHD, attention-deficit hyperactivity disorder.

Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition

The treating clinician, parents, and child, in collaboration with school personnel, should specify appropriate target outcomes to guide management

The clinician should recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD

When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions

The clinician should periodically provide a systematic follow-up for the child with ADHD; monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child

Education

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

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).

Stimulants

 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

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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).

TABLE 80.3
Stimulant Medications

Generic Name

Trade Name

Available Doses

Length of Action (hr)

Dose Range

Methylphenidate

Ritalin

5, 10, 20 mg

3–5

5–30 mg b.i.d.–t.i.d.

 

Methylin

5, 10, 20 mg; 2.5, 5 mg chewable; 5 and 10 mg/5 mL

3–5

5–30 mg b.i.d.–t.i.d.

 

Focalin

2.5, 5, 10 mg

3–5

2.5–10 mg b.i.d.

Intermediate-release methylphenidate

Ritalin-SR

20 mg

4–8

20 mg q.d.–b.i.d.

 

Metadate-ER,

10, 20 mg

4–8

10–20 mg q.d.–b.i.d.

 

Methylin-ER

     

Extended-release methylphenidate

Concerta

18, 27, 36, 54 mg

8–12

18–72 mg q.d.

 

Metadate-CD

10, 20, 30, 40, 50, 60 mg

8–12

20–60 mg q.d.

 

Focalin XR

5, 10, 20 mg

8–12

5–20 mg q.d.

 

Ritalin-LA

20, 30, 40 mg

8–12

20–60 mg q.d.

Methylphenidate patch

Daytrana

10, 15, 20, 30 mg

Up to 12

10–30 mg q.d.

Dextroamphetamine tablets

Dexedrine

5 mg

3–4

5–20 mg b.i.d.–t.i.d.

Dextroamphetamine Spansules

Dexedrine, Dextrostat

5, 10, 15 mg

6–8

5–30 mg q.d.–b.i.d.

Amphetamine and dextroamphetamine

Adderall

5, 7.5, 10, 12.5, 15, 20, 30 mg

4–8

5–30 mg b.i.d.–t.i.d.

 

Adderall XR

5, 10, 15, 20, 25, 30 mg

10–12

20–60 mg q.d.

Side Effects of Stimulants

Serious side effects (and relative contraindications to use) include the following:

  1. Elevated blood pressure
  2. Arrhythmias (particularly when used in association with alcohol, caffeine, or sympathomimetics such as decongestants)
  3. Development of psychosis

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:

  1. Weight loss (usually mild)
  2. Headaches
  3. Abdominal pain
  4. Dizziness
  5. Dry eyes or mouth
  6. Nausea
  7. Irritability
  8. Insomnia (sleep onset): This may occur if the medication is taken too late in the evening, although many patients seem to have an easier time falling asleep while taking stimulants.

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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.

Immediate-Release Methylphenidate

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

 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.

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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

 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.

Bupropion

 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 

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

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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).

Summary

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.

Web Sites

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.

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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.

  1. S. Food and Drug Administration, Center for Drug Evaluation and Research. (September 29, 2005). FDA Alert [9/05]: Suicidal Thinking in Children and Adolescents(Alert posted on the World Wide Web). Washington, DC. Retrieved November 1, 2005 from the World Wide Web:. http://www.fda .gov/cder/drug/infosheets/hcp/atomoxetinehcp.htm

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.