Attention Deficit/Hyperactivity Disorder:

A Review and Update

Eileen Cormier, PhD, RN

Attention deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and pervasive childhood disorder characterized by
developmentally inappropriate activity level, impulsivity, and inability to sustain attention and concentration. Core symptoms of
the disorder are associated with impairment in multiple domains of functioning and often coexist with other psychiatric
disorders, the most prevalent being oppositional defiant disorder, conduct disorder, depression, and anxiety disorders. Concerns
have been expressed about the overdiagnosis of ADHD, an upsurge in prescription of stimulant medication, and wide variations
in practice patterns related to diagnosis and treatment of children with ADHD among primary care providers. Clinical research
and expert consensus guidelines over the past decade have increasingly clarified the most effective approaches to diagnosis and
treatment of the disorder. Hence, the purpose of this article was to provide primary care providers with the most current,
evidence-based information on the assessment and treatment of children with ADHD.
n 2008 Elsevier Inc. All rights reserved.
Key words: Attention deficit/hyperactivity disorder; Diagnosis; Treatment

TTENTION DEFICIT/HYPERACTIVITY
disorder (ADHD) is a chronic, pervasive
childhood disorder characterized by developmentally inappropriate activity level, low frustration
tolerance, impulsivity, poor organization of behavior, distractibility, and inability to sustain attention
and concentration (American Psychiatric Association, [APA], 2000). It is one of the more common
childhood disorders, occurring in 3% to 7% of
school-age children and representing one third to
one half of referrals to child mental health services
(Argold, Erkanli, Egger, & Costello, 2000; Faraone,
Sergeant, Gillberg, & Biederman, 2003). The core
symptoms of ADHD are associated with impairments in several domains of functioning, including
academic achievement and deportment at school,
interactions with parents and siblings, and peer
relationships (Barkley, 2006; Root & Resnick,
2003). Children diagnosed with ADHD also have
a higher likelihood of coexisting psychiatric disorders and usually continue to have problems
attributable to ADHD as adults that require treatment (Brassett-Harknett & Butler, 2007; Gillberg
et al., 2004; Resnick, 2000; Wender, 1995).
The core symptoms of ADHD, the associated
functional deficits and comorbid disorders, and the
risk for ongoing problems as adults underscore the
seriousness of ADHD as a childhood condition
and the importance of appropriate diagnosis and

Journal of Pediatric Nursing, Vol 23, No 5 (October), 2008

effective treatments. Public interest in the disorder

has increased, including debate in the public media
concerning the diagnostic process and treatment
choices (Timimi, 2006). Concerns have been
expressed about the overdiagnosis of ADHD,
including the increasing numbers of preschoolers
who are diagnosed, the severalfold increase in
prescription of stimulant medication, and wide
variations in practice patterns related to diagnosis
and treatment of children with ADHD among
primary care providers (Goldman, Genel, Bezman,
& Slanetz, 1998; Robison, Sclar, Skaer, & Galin,
1999; Stevens, 2005; Wilens et al., 2002; Zito
et al., 1999).
Although controversies in the medical literature
and popular media persist, there has been a
concerted effort on the part of the scientific
community to identify the most appropriate and
empirically supported diagnostic and treatment
approaches to children with ADHD. Furthermore,
clinical practice guidelines have been developed
From the Florida State University.
Corresponding author: Eileen Cormier, PhD, Florida State
University College of Nursing, 421 Vivian M. Duxbury Hall,
Tallahassee, FL 32306-4310.
E-mail: eCormier@nursing.fsu.edu
0882-5963/$ - see front matter
2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2008.01.003

345

346

EILEEN CORMIER

that provide evidence-based recommendations for

assessment and treatment of ADHD by primary
care providers (American Academy of Child and
Adolescent Psychiatry [AACAP], 1997, 2002;
American Academy of Pediatrics [AAP], 2000,
2001). Based on a review of pertinent research and
practice guidelines, the purpose of this article was
to provide primary care providers with the most
comprehensive, current information to date on the
assessment and treatment of children with ADHD.
HISTORICAL CONTEXT OF ADHD
Hyperactivity in children was first described
clinically in 1902, and the first report of stimulant
use to treat hyperactivity in that condition was in
1937 (Bradley, 1937). Initially, the condition was
called minimal brain dysfunction due to the high
frequency of soft neurological findings and the
expectation that consistent neurological legions
would eventually be found (Clements, 1966). As
the association of brain damage became less
certain, the nomenclature changed to reflect an
emphasis on hyperactivity as the primary behavioral deficit. Subsequently, in the Diagnostic and
Statistical Manual of Mental Disorders, Second
Edition (DSM-II), it was called hyperkinetic reaction of childhood disorder (APA, 1967).
In 1980, the DSM-III publicized a new name,
attention deficit disorder, and delineated the first
empirically based set of diagnostic criteria. Again,
the focus on hyperactivity as the primary deficit
shifted to inattention but was amended in the 1987
revision of DSM-III to give equal weight to
inattention and hyperactivity problems (APA,
1980, 1987). The currently accepted criteria
for making an ADHD diagnosis appears in the
fourth edition of the DSM (APA, 1994), which
enumerates three subtypes for ADHD: (a) predominantly inattentive type, (b) predominantly
hyperactive/impulsive type, and (c) combined
type (this includes inattention and hyperactivity/
impulsivity symptoms).

Table 1. Diagnostic Criteria for ADHD

A. Either 1 or 2:
1. Six (or more) of the following symptoms of inattention have persisted
for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level:
Inattention
(a) Often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
(b) Often has difficulty sustaining attention in tasks or play activities
(c) Often does not seem to listen when spoken to directly
(d) 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)
(e) Often has difficulty organizing tasks and activities
(f) Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
(g) Often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, or tools)
(h) Is often easily distracted by extraneous stimuli
(i) Is often forgetful in daily activities
2. Six (or more) 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
(a) Often fidgets with hands or feet or squirms in seat
(b) Often leaves seat in classroom or in other situations in which
remaining seated is expected
(c) 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)
(d) Often has difficulty playing or engaging in leisure activities quietly
(e) Is often on the go or often acts as if driven by a motor
(f) Often talks excessively
Impulsivity
(g)Often blurts out answers before questions have been completed
(h) Often has difficulty awaiting turn
(i) Often interrupts or intrudes on others (e.g., butts into conversations
or games)
B. Some hyperactive/impulsive or inattentive symptoms that caused
impairment were present before age 7
C. Some impairment from the symptoms is present in two or more
settings (e.g., at school [or work] and at home)
D. There must be clear evidence of clinically significant impairment in
social, academic, or occupational functioning
E. The symptoms do not occur exclusively during the course of a
pervasive
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 a personality disorder).
Note. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Copyright 2000. American
Psychiatric Association.

DIAGNOSTIC CRITERIA FOR ADHD

In DSM-IV-TR (APA, 2000), diagnostic decision-making centers on two 9-item symptom
listingsone related to inattention symptoms and
the other to hyperactivity-impulsivity concerns
(Table 1). Parents and/or teachers must report the
presence of at least six of nine behaviors from either
list to warrant consideration of an ADHD diagnosis

of predominantly inattentive type or hyperactive/

impulsive type. For a diagnosis of ADHD combined type, more than six symptoms must be
present from both lists. Such behaviors have an
onset prior to 7 years of age, duration of at least
6 months, and a frequency above and beyond that

ADHD REVIEW AND UPDATE

expected in children of a comparable level of

development. Furthermore, they must be evident in
two or more settings, have a clear impact on
psychosocial functioning, and not be due to other
types of mental health or learning disorders that
might better explain their presence (APA, 2000).
Clinical research has been supportive of the
validity of the DSM-IV subtypes of ADHD,
although there remain unresolved issues, such as
developmental variations in behavior, the influence
of comorbid learning disabilities, gender differences, and racial disparities (Hillemeier, Foster,
Heinrichs, & Brigitt, 2007; Lahey et al., 1998;
Morgan, Hynd, Riccio, & Hall, 1996). The
extensive review by Egger, Kondo, and Angold
(2006) suggests that ADHD can be reliably
diagnosed using DSM-IV-TR criteria in preschool
children. Younger children are more likely to be
diagnosed as predominantly hyperactive/impulsive.
Children with either the predominantly hyperactive/
impulsive or combined subtypes often as they
mature change in their presentation to meet the
diagnostic criteria for predominantly inattentive
type, as hyperactive and impulsive symptoms are
reduced or better controlled (Biederman, Mick, &
Faraone, 2000; Goldstein & Goldstein, 1998).
Many support a progression of the disorder from
predominantly hyperactive/impulsive as children to
predominantly inattentive as adolescents and adults
(Resnick, 2000; Trott, 2006).
PREVALENCE
Estimates of the incidence of ADHD vary
considerably, ranging 2% to 16%, depending on
the diagnostic criteria and assessment tools
employed (Brown et al., 2001; Faraone et al.,
2003). Using the criteria specified by DSM-IV-TR,
approximately 3% to 7% of school-age children
meet requirements for some type of ADHD
diagnosis (Sciutto & Eisenberg, 2007). Predominantly hyperactive/impulsive and combined subtypes are more common than the inattentive
subtypes among younger children (Egger et al.,
2006). ADHD also occurs more often in boys than
in girls, although estimates of the ratio of boys to
girls vary considerably, with ratios in clinic-based
samples reported to be as high as 6:1 and as low as
1:1 in community-based samples (Barkley, 2006).
Although prevalence rates have not been found to
vary by race in the United States (Centers for
Disease Control and Prevention, 2005), African
American and Hispanic children are less likely to

347

report and receive treatment for ADHD, regardless

of socioeconomic status (Pastor & Reuben, 2005).
DEVELOPMENTAL COURSE AND
OUTCOME
Many parents of children with ADHD recall that
their child was excessively active, intense, and
demanding as an infant and toddler (Bussing,
Lebninger, & Eyberg, 2006). Most, however, first
display clear signs of developmentally inappropriate inattentive and overactive behavior suggestive
of ADHD between 3 and 4 years of age (Barkley,
2006). For a smaller number of children, ADHD
symptoms may not be evident until 5 or 6 years of
age, corresponding with school entry. The ability to
sit still, sustain attention, inhibit impulsive behavior, organize actions, and follow through on
instructions, as well as interact appropriately with
other children is essential to a successful school
experience (Cohen, 1993). In view of the expanding
number of children participating in preschool
programs that incorporate school readiness curricula, it is not surprising that referrals of preschoolers for ADHD evaluations have increased so
dramatically (Wolraich, 2006).
Psychosocial impairment in relationships and
functioning across multiple settings becomes more
apparent in middle childhood (Barkley, 2006; Trott,
2006). At home, parents must contend with
ongoing behavior problems around chores, selfhelp activities (e.g., dressing, bathing, etc.), and
interactions with siblings. At school, academic
performance and classroom behavior are often
erratic over time, contributing to underachievement
relative to ability and impaired relationships with
teachers and peers. Poor social skills characterized
by high behavior rate and intensity, vocal noisiness,
intrusiveness, and inability to read and respond to
social cues eventually creates a pattern of social
rejection. By late childhood and preadolescence,
these patterns of academic, familial, and social
impairment have become well established, and
secondary comorbid problems have emerged
(Spencer, Biederman, & Mick, 2007).
Historically, it was believed that ADHD symptoms were remitted before or during adolescence
(Resnick, 2000). It is currently estimated that as
many as 70% of children diagnosed with ADHD in
childhood continue to exhibit developmentally
inappropriate levels of inattention and, to a lesser
extent, symptoms of impulsivity-hyperactivity during adolescence and adulthood (Biederman et al.,

348

EILEEN CORMIER

1998; Faraone, Biederman, & Monuteaux, 2002).

Many learn to compensate for these problems and
subsequently make a satisfactory adult adjustment
(Spenser et al., 2007). For those who do not,
comorbid problems such as depression, substance
abuse, and antisocial pathology are of greater
clinical concern than their ADHD symptoms
(Goodman, 2007; Sobanski, 2006; Weiss & Murray, 2003).
COMORBIDITY WITH ADHD
It is now well established that ADHD is usually
associated with the presence of one or more major
psychiatric disorders and that these problems are at
least as important as ADHD in predicting the longterm outcome of the individual child. It is estimated
that as many as two in three children with ADHD in
the general population meet criteria for one or more
DSM-IV-TR diagnoses (Gillberg et al., 2004; Jensen
et al., 2001; Jensen, Martin, & Cantwell, 1997;
Kadesjo & Gillberg, 2001). The most common
coexisting disorders in ADHD are developmental
coordination disorder, oppositional defiant disorder
(ODD), conduct disorder (CD), depression and
anxiety disorder, bipolar disorder, tic disorders,
obsessive compulsive disorder, and autism spectrum disorder (ASD; Banascheski, Neale, Rothenberger, & Roessner, 2007; Steinhausen et al., 2006).
Learning disabilities are also common, including
central auditory processing disorder, reading disorder, disorder of written expression, dysgraphia,
mathematics disorder, and mental retardation
(Gomez & Condon, 1999; Luca et al., 2007;
Maria, Martina, & Cornoldi, 2007; Plizka, 2000).
All of these disorders need to be considered in any
child diagnosed with ADHD.
ODD and CD are the most common comorbid
disorders, with 50% to 60% of children with ADHD
meeting criteria for ODD and 25% meeting criteria
for CD (Kadesjo & Gillberg, 2001; Lalonde,
Turgay, & Hudson, 1998). Although many clinicians (and researchers) believe that ADHD precedes ODD, which in turn precedes CD, which in
turn precedes adult antisocial personality disorder,
this developmental pathway has not been thoroughly examined in empirical studies (Lavigne
et al., 2001; Loeber, Burke, Lahey, Winters, & Zera,
2000). Depression and anxiety disorders are also
more common, seen in about one fourth of children
with ADHD (Root & Resnick, 2003). Comorbid
bipolar disorder has also been identified in a
number of children with ADHD (Kent & Craddock,

2003). Propositions that ADHD may be a childhood

precursor of bipolar disorder, or that bipolar
disorder with childhood onset may represent a
mistaken diagnosis of ADHD, have drawn considerable controversy but remain unresolved (Gillberg et al., 2004).
Developmental disorders are also commonly
associated with an ADHD diagnosis. Many children with ADHD experience developmental coordination disorder symptoms and perceptual motor
problems regardless of whether there is an associated learning disability, although clumsiness
becomes less problematic over time (Dewey,
Kaplan, Crawford, & Wilson, 2002; Pitcher, Piek,
& Hay, 2003; Raggio, 1999). Asperger's syndrome
has a highest rate of comorbidity with ADHD of the
ASDs (Brassett-Harknett & Butler, 2007; Ehlers &
Gillberg, 1993; Ke et al., 2007).
ETIOLOGY
Over the past 15 years, significant progress has
been made in understanding the etiology of childhood ADHD, largely due to the publication of
family, twin, and adoption studies, which are
consistent in suggesting genetic and neurological
influences (Brassett-Harknett & Butler, 2007;
Waldman & Gizer, 2006). About one fourth to
one third of biological parents with an ADHD child
are affected by ADHD themselves. A dopamine
transmitter gene (DAT-1) and dopamine receptor
gene (DAT-4) have been linked to children with
ADHD, and neuroimaging studies have identified
abnormalities of brain structure and function
(Faraone, 2006; Valera & Siedman, 2006).
Traumatic injuries to the brain have also been
associated with behaviors characteristic of ADHD
(Levin et al., 2007). Similarly, prenatal exposure to
alcohol and/or cocaine, birth trauma, and exposure
to lead or infections such as meningitis as a young
child have been linked to the later development of
ADHD Brassett-Harknett & Butler, 2007). Considerable attention has also focused on the role of
food components, in particular, food additives/
artificial colors, food allergies, and refined sugar,
suggesting a causal link to ADHD (Rojas & Chan,
2005; Schnoll, Bursheteyn, & Cea-Aravena, 2003).
Overall, scientific evidence has not supported these
hypotheses, although a small subset of children has
been identified who are sensitive to specific
artificial flavors, preservatives, and colors (Bateman et al., 2004; Dengate & Ruben, 2002; Schab &
Trinh 2004). Food sensitivities or allergies can also

ADHD REVIEW AND UPDATE

be involved in provoking behavior problems in

certain children but do not cause ADHD (Schmidt
et al., 1997).
ASSESSMENT OF ADHD
Primary care providers see a variety of schoolage children with developmental and behavioral
concerns. Based on the high prevalence of ADHD
in this population, AAP (2000) recommends asking
parents about behavioral and/or learning problems
at school during routine visits. In many cases,
requests for evaluation of the child for ADHD
derive from parents, teachers, other professionals,
or nonparental caregivers, who have identified
problems in the school setting such as inattentiveness, disruptive classroom behavior, academic
underachievement, difficulty establishing and
maintaining peer relationships, or poor self-esteem.
The overall goals of the assessment are to determine
whether the child meets diagnostic criteria for
ADHD and rule out other conditions that might
simulate it (Liu & Leslie, 2003). Thus, a complete
physical examination is recommended if one has
not been conducted in the past year. Establishing a
diagnosis of ADHD involves a synthesis of
information from multiple sources with parents as
key partners in the assessment process.
A primary diagnosis of ADHD is contingent on
the presence of developmentally inappropriate
levels of inattention and/or hyperactivity/impulsivity that are not better explained by other
medical, psychiatric, or developmental disorders
(AAP, 2000). The child's behavioral symptoms
must also demonstrate a pattern that is enduring,
present across multiple settings (e.g., at home, in
school, and with peers), and is causing functional
impairment. To make this appraisal, the clinician
must be familiar with normal variations in
development and behavior, solicit data from
multiple sources to evaluate the child's symptoms
in different contexts, and construct an appropriate
differential diagnosis for the presenting complaints
(AAP, 2000; Liu & Leslie, 2003). Information
regarding behavioral symptoms is obtained
through parental or caregiver and child interview,
behavioral observation, child behavior rating
scales (parent and teachers versions), school
reports, and other adjunctive evaluations that
might be relevant (achievement testing, psychoeducational assessment, speech, and language).
Information pertaining to core symptoms of
ADHD, onset, duration, situational variability, and

349

degree of functional impairment can be obtained

from parents or caregivers using open-ended
questions (e.g., What are your concerns about
your child's behavior at school?), focused questions
about specific behaviors, semistructured interview
schedules, questionnaires, and rating scales (AAP,
2000). Questionnaires and rating scales have been
developed that are specific for and quantify
behavioral characteristics of ADHD, such as the
Connors ADHD Index or the DSM-IV Symptoms
scales (both teacher and parent versions), have been
shown to discriminate adequately between children
with ADHD and those without it (Connors, 1997;
Green, Wong, Atkins, Taylor, & Feinleib, 1999;
Tripp, Schaughency, & Clarke, 2006). The AAP
(2000) guidelines recommend the use of these
scales and discourage the use of broadband scales
that assess a variety of behavioral conditions
because they have not been shown to distinguish
children with and without ADHD. If the child
spends considerable time in other structured
environments such as after-school programs,
ADHD-specific questionnaires can also be used to
evaluate the child's behavior in these settings.
Discrepancies between parent and teacher ratings
of child behavior are not unusual and may be in
either direction (Swanson, Lerner, March, &
Gresham, 1999; Wolraich et al., 2004). These
discrepancies may be due to differences between
the home and school in terms of expectations, level
of structure, behavioral management strategies,
and/or environmental factors. Finding a discrepancy between parents and teachers does not
preclude a diagnosis of ADHD, but there should
be further information seeking from informants
such as former teachers, coaches, or religious
leaders. The situational variability of ADHD
symptoms makes it essential that the clinician
obtain information from any individuals who
observe the child across multiple settings. The
ways that significant persons in the child's life
perceive and respond to the child's behavioral
symptoms are critical influences in the plan of care
(Magyary & Brandt, 2002).
Behavioral observations of the child's behavior
and parentchild interactions in the clinic waiting
area and during the interview can also be useful in
evaluating the child's ADHD symptoms, as well
as comorbid ODD or CD symptoms (Root &
Resnick, 2003). Assessment information regarding
parental, marital, and family functioning may not
clarify whether or not ADHD is present but
provide a context for understanding how problem

350

EILEEN CORMIER

child behaviors are being maintained. It may

also help to determine how likely it is that
parents will implement recommended parent
training and other treatment strategies on behalf
of the child (Chronis, Chacko, Fabiano, Wymbs,
& Pelham, 2004).
Another important consideration in the diagnosis
and evaluation of the child with ADHD is race and
ethnicity. Primary care providers should be aware
of differences in cultural norms, expectations of
children and parenting, and attitudes about mental
health that may influence treatment-seeking behavior (Chronis, Jones, & Raggi, 2006). National
health survey data suggest that parents of Hispanic
and African American children are less likely to
report a diagnosis of ADHD or use medication to
treat it (Kendall & Hatton, 2002; Pastor & Reuben,
2005). Parents of African American children, in
particular, report that they are less knowledgeable
about ADHD and are less likely to endorse
hyperactivity items on parental report screening
instruments than their Caucasian counterparts
(Bussing, Gary, Mills, & Garvan, 2007; Hillemeier
et al., 2007). Hence, parental knowledge and
perceptions of ADHD, including attributions
about child ADHD behavior should be addressed
in a culturally sensitive manner.
TREATMENT
Factors that complicate the assessment process
such as the situational variability of primary ADHD
symptoms, the likelihood of comorbid conditions,
and race/ethnicity, also affect the treatment process.
These issues make it improbable that any one
primary care provider or treatment approach can
respond to all of the clinical management needs of
the child with ADHD. Parents are key partners in
the treatment plan, and ongoing communication
among parents, teachers, and other school-based
professionals is essential in monitoring the progress
and effectiveness of specific interventions (Magyary & Brandt, 2002). Integration of services with a
child psychiatrist, psychologist, behavioral and/or
educational specialist, and/or other mental health
professionals may be indicated, especially if the
child with ADHD is affected by coexisting
conditions and continues to experience difficulties
despite treatment. National, grassroots, and parentled associations such as children and adults
with ADHD are also important sources of support
and education to families (DeMarle, Denke, &
Ernsthausen, 2003).

As is the case with common chronic conditions, a

broad variety of treatments have been tried and
continue to be employed with ADHD, many of
them controversial, including traditional individual
therapy, restrictive diets (e.g., Feingold/additive
free, sugar elimination, and oligoantigenic), fatty
acid supplementation, chiropractics, electroencephalogram biofeedback, and perceptualmotor
training, among others (Pelham, Wheeler, &
Chronis, 1998; Rojas & Chan, 2005). However,
none of these interventions have strong empirical
evidence to support their effectiveness in treating
ADHD. The current consensus based on extensive
empirical research and reflected in clinical practice
guidelines developed by the AACAP (1997) and
the AAP (2000) is that only three treatments have
been validated as effective short-term treatments:
behavior intervention, central nervous stimulants,
and a combination of these (Abikoff et al., 2004;
Brown et al., 2008; Multimodal treatment study of
ADHD [MTA] Cooperative Group, 1999, 2004;
Pelham et al., 1998; Valente, 2001; Wells et al.,
2006; Wolraich, 2003).
Current intervention guidelines for treatment of
ADHD have been significantly influenced by one
large randomized 5-year treatment study, the MTA
(Arnold et al., 1997; Hinshaw et al., 2000; Jensen et
al., 2001; MTA Cooperative Group, 1999, 2004).
The primary goal of the MTA study was to compare
the efficacy of medication management, behavioralpsychosocial treatment (this included parent
training, an intensive 8-week summer treatment
program, and school-based interventions), and a
combination of both against routine communitybased care (Richters et al., 1995). As reported by
the MTA Cooperative Group (1999), initial outcome data revealed that the medication alone and
combined treatment (medication and behavioral
intervention) groups showed greater improvements
on multiple measures of domains of child functioning. Subsequent reports using different approaches
to analysis of outcomes, however, found that a
combination of medication management and psychosocial treatment to be superior to either treatment alone (Connors, Eptstein, & Marsh, 2001;
Swanson, Kraemer, & Hinshaw, 2001). Furthermore, improvements in core symptoms of ADHD
were achieved using significantly lower medication
doses in the combination treatment group than were
used in the medication management group.
Expert consensus guidelines indicate that a
combination of stimulant medication and behavioral treatment is favored in the treatment of

ADHD REVIEW AND UPDATE

351

ADHD, in particular, children with significant

comorbid behavioral difficulties that are adversely
affecting family and school functioning (AAP,
2001; Connors, Marsh, Frances, Wells, & Ross,
2001). Numerous studies in addition to the MTA
study have demonstrated the short-term efficacy of
stimulant medication in reducing the core symptoms of ADHD as well as improving the child's
ability to follow rules and decrease emotional
reactivity, thereby leading to improved relationships with parents, teachers, and peers (Chacko
et al., 2005; Greenhill et al., 2002). The MTA study
extended the demonstrated efficacy to 14 months,
but the long-term effects of stimulants on prognosis
remain unclear (MTA Cooperative Group, 1999).
Two classes of stimulants are currently available,
including methylphenidate and dextroamphetamine; both are available in short-, intermediate-,
and long-acting forms. When administered and
dosed appropriately, at least 90% of children with
ADHD will have a positive response to at least one
stimulant without a major adverse event (AAP,
2001; AACAP, 2002). Although individual children may respond to and tolerate one stimulant
better than another, both methylphenidate and

dextroamphetamine have been found to be equally

effective in treating core symptoms of ADHD
(Jahad et al., 1999). AAP guidelines recommend a
trial of three types or formulations of stimulant
medication before considering alternative agents.
At present, only one nonstimulant, atomoxetine, a
selective norepinephrine reuptake inhibitor, has
received approval by the Food and Drug Administration (FDA) to treat ADHD in children (Lopez,
2006). Although current evidence also supports the
efficacy of two tricyclic antidepressants and
buproprion for ADHD treatment, these agents are
not approved for use in pediatric ADHD (Spencer
et al., 2002; Wood, Crager, Delap, & Heiskell,
2007). Similarly, clonidine and guanfacine, both
antihypertensive medications, are occasionally used
in the treatment of ADHD but are not FDA
approved (Rains & Scahill, 2006).
The FDA-approved medications used to treat
ADHD are listed in Table 2, including available
formulations, dosage, side effects with higher risk
potential, and implications for care providers. In
general, both stimulants and nonstimulants should
be initiated at low doses and titrated upward to a
maximally effective level. Adverse effects from

Table 2. FDA-Approved Medications of the Treatment of ADHD

Medication

Dosage

Side effects/Risks

Implications

Stimulants
Methylphenidate (MPH)
Short acting (Ritalin and Methylin)

5-20 mg BID-TID

Tachycardia, arrhythmia,
sudden death.
Growth suppression

Monitor heart rate and blood pressure; baseline

ECG or echocardiogram in high-risk cases only
Baseline height, weight, and periodic monitoring;
dietary consultation and/or nutritional supplementation

Tics

Monitor for appearance and/or exacerbation of tics;

decrease anxiety; adjust dose; change medication
Counsel; nonstimulants; extended release
form of stimulants
Monitor; topical skin cream; rotate sites

Intermediate acting (Ritalin SR,

Metadate ER, and Methylin ER)
Long acting (Concerta,
Metadate CD, and Ritalin LA)

Transdermal system

Amphetamine
Short acting (Dexedrine
and Dextrostat)
Intermediate acing (Adderall and
Dexedrine spansule)
Long acting (Adderall XR)
Nonstimulants
Atomoxetine (Strattera)

20-40 mg QD or
40 mg AM,
20 mg PM
18-72 mg QD

5-15 mg BID-TID

5-30 mg QD-BID

Potential for abuse

& diversion
Skin erythema; possible
reduced risk for
abuse/diversion
Side effects/risks similar
to MPH with some
individual variations

See recommendations for MPH

Hepatoxicity

Baseline history; monitor for abdominal pain/jaundice

Suicidal ideation

Monitor weekly when beginning treatment or

changing dose
Give BID; bedtime dosing
Same as MPH

5-15 mg BID
10-30 mg QD
N70 kg:
40-100 mg
70 kg:
0.5-1.4/kg

Sedation
Tachycardia, arrhythmia,
and sudden death

352

stimulants are generally transient and mild, usually

managed by adjusting dose and time of administration. The most common adverse effects include
decreased appetite, headache or stomachache,
delayed sleep onset, edginess, and social withdrawal (AAP, 2001). A small percentage of children
experience motor tics, most of which are transient
(Roessner, Robatzek, Knapp, Banaschewski, &
Rothenberger, 2006). Modest increases in pulse
and blood pressure may occur but are rarely a
problem. Nonetheless, expert guidelines on stimulants recommend a complete physical examination
before initiating medication and monitoring vital
signs at routine follow-ups visits (AACAP, 2002).
The child should be also be evaluated frequently
early in treatment for acute, undesirable emotional,
or behavioral changes as a result of medication.
Although stimulants may contribute to appetite
reduction and weight loss, tolerance to these effects
generally develops in the first few weeks of
treatment. The effects of long-term stimulant
treatment on growth remain controversial with
controlled studies reporting conflicting data
(Lopez, 2006). The consensus at this time is that
stimulant use is not associated with significant
impairment in height, with any decrease in growth
early in treatment compensated for later on (AAP,
2001). However, careful and accurate monitoring of
growth for all children using measurements of
height and weight is recommended throughout the
course of treatment.
The risk of adverse cardiovascular events in
children taking stimulants has received considerable recent attention, based on reports of 12 cases of
sudden cardiac death in children receiving amphetamines (Nissen, 2006). Subsequent review
revealed the presence of underlying structural
heart defects or other problems complicating the
assessment of medication-related risk, for example,
family history of ventricular tachycardia, heat
exhaustion, dehydration, very rigorous exercise,
and so forth. The most recent information indicates
that the risk for sudden cardiac death does not
exceed the base rate for the general population
and is usually associated with preexisting risk
factors (Wilens, Prince, Spenser, & Biederman,
2006). However, these occurrences highlight
the importance of verifying underlying cardiovascular problems, specifically structural cardiac
abnormalities as well as obtaining detailed family
histories regarding unexplained cardiac deaths
(especially under 30 years), in children prior to
beginning treatment and continuing to monitor

EILEEN CORMIER

cardiovascular function. Baseline electrocardiogram (ECG) is not considered essential, except in

high-risk cases, because it is unlikely to detect
structural cardiac defects.
Another concern raised by practitioners and
parents is the possibility of substance abuse or
diversion to others among children and adolescents
treated with stimulants. The results of a recent
meta-analytic review published by Wilens et al.
(2003) suggest that stimulant therapy for youths
with ADHD is actually associated with a decrease
in risk of subsequent drug and alcohol disorders. On
the other hand, studies indicate that a subgroup of
young people does engage in abuse and/or diversion of their prescription stimulants in the public
school system (McCabe, Teter, & Boyd, 2004;
Wilens, Gignac, Swezey, Monuteaux, & Biederman, 2006). The recent availability of extended
release forms of stimulants provides continuous
coverage for controlling ADHD symptoms
throughout the school day and has eliminated the
need for in-school dosing in most cases. Furthermore, the recently FDA-approved transdermal
system minimizes the potential for diversion
because once the patch is applied, it cannot be
reapplied to another individual.
Atomoxetine represents an alternative when
children are not responsive to or experience
intolerable adverse effects from stimulants. Atomoxetine is FDA approved for use with children
and has demonstrated efficacy in managing the
symptoms of ADHD, although the response is
generally lower than that of stimulants (Michelson
et al., 2002). The most common adverse effects
include upset stomach, decreased appetite, sedation, dizziness, tachycardia, and mood swings. Risk
for adverse cardiac events is similar to stimulants.
Although rare, the FDA requires that atomoxetine
carry a warning regarding the potential for liver
toxicity and suicidal ideation. Liver function tests
are not routinely obtained but should be conducted
if the child develops abdominal pain or jaundice
associated with treatment. The potential for suicidal
thoughts and/or behavior should be thoroughly be
discussed with the family prior to initiating
treatment and monitored carefully by parents and
care provider.
Empirically validated behavioral treatments for
ADHD include behavioral parent training and
classroom interventions with the common goal of
modifying physical and social environment factors
that may be maintaining problem child behavior.
Behavior therapy involves training parents and

ADHD REVIEW AND UPDATE

teachers in the use of specific techniques (e.g.,

positive reinforcement, time-out, and response cost)
to reward desirable behavior and applying consequences for noncompliance or disruptive behavior. Behavior therapy should be distinguished
from psychological interventions directed at the
child's emotional status (e.g., play therapy) or
thought patterns (e.g., cognitive therapy), which
have little documented efficacy (AAP, 2001).
Parent training typically involves 8 to 12 weekly
sessions with a trained therapist with the aim of
improving parents' or caregivers' understanding of
the child's behavior and teaching them skills to deal
with behavioral difficulties related to ADHD
(Breismeister & Shaefer, 1998; Daly, Creed,
Xanthopoulos, & Brown, 2007; Danforth, Harvey,
Ulaszek, & McKee, 2006). Current best practice
emphasizes a collaborative approach in both group
and individual formats (Chronis et al., 2004). A
collaborative approach consists of actively involving parents in the therapeutic process by soliciting
their ideas and viewpoints, mutually setting treatment goals that are realistic and meaningful to the
family, and teaching and suggesting, as opposed to
dictating alternative responses to behavior problems. Similar to parent training, classroom interventions that can be implemented by the child's
teacher are developed through a series of consultation sessions at school, including daily report cards
to provide feedback to parents on the child's school
performance, for which parents can provide
rewards or consequences at home (Chronis et al.,
2006; Pelham et al., 1998).
A wide range of clinicians with specialized
training can implement behavior therapy directly
or train parents or school personnel in behavioral
techniques. Many primary care providers favor
referral of families to community resources that
offer this service because behavior therapy with
parents is time consuming and often inconsistent
with the structure and schedule of the primary care
office. Schools may offer behavioral consultation
and training to school personnel in the context of
the section 504 of the 1973 Rehabilitation Act that
requires schools to make accommodations to help
children with ADHD function in that setting
(AAP, 2001).
IMPLICATIONS FOR PRIMARY
CARE PROVIDERS
The aim of this paper was to provide primary
care clinicians with a current and evidence-based

353

review of ADHD, which they could use to educate

families and involve them in treatment decisions.
Primary care clinicians routinely encounter ADHD,
yet approaches to diagnosis and treatment of the
disorder vary considerably in primary care settings
(Connors, Marsh, et al., 2001; Magyary & Brandt,
2002; Rushton, Fant, & Clark, 2004). The guidelines provided by the AAP (2000) recommend
applying DSM-IV diagnostic criteria, soliciting
information from parents and teachers, and using
rating scales to establish the developmental inappropriateness of ADHD symptoms. Evidence
regarding core symptoms should encompass age
of onset, duration of symptoms, and degree of
functional impairment across multiple settings.
Assessment for coexisting conditions, in particular,
conduct and oppositional defiant disorder, mood
and anxiety disorders, and learning disabilities, is
essential as a basis for intervention planning. Thus,
primary care providers should have some knowledge of the various possible coexisting disorders
and be prepared to either diagnose and treat them or
facilitate referrals.
The treatment guidelines of AAP (2001) emphasize the chronic nature of ADHD, necessitating
child-specific treatment plans and mechanisms for
monitoring target outcomes over the long term.
Primary care clinicians have important roles in
establishing a therapeutic alliance with families,
educating them about the disorder, and involving
them in developing and monitoring interventions.
Parents first need to understand the ways in which
core symptoms of ADHD can affect child behavior,
learning, social skills, self-esteem, and family
functioning. They also need accurate, current
information on the etiology of ADHD, factors that
may influence the course of the disorder, the
relative benefits of medication and/or psychosocial
treatment options, and community resources that
provide support and/or services to individuals and
families with ADHD. Information provided by
primary care providers should be evidence based,
practical, and reinforce the central role of parents
in the child's treatment, including ongoing collaboration among clinicians, parents, teachers, and
the child.
Expert consensus guidelines emphasize a comprehensive management plan that focuses on key
target outcomes and desired outcomes. Families
should be told that a combined medication and
behavioralpsychosocial approach is likely to be
more effective for addressing the comorbid problems that a large proportion of children with

354

EILEEN CORMIER

ADHD have, but a medication-only approach, if

this is their preference, also has empirical support.
When medication is prescribed, attention to safety
issues, including adverse events and/or risks (Table
2), is critical. It is important to counsel the child and
parents regarding potential benefits and adverse
effects of pharmacological treatments to help them
develop realistic expectations regarding treatment,

monitor medication response, and minimize anxiety

should adverse effects develop. If parents are
motivated to participate in behavioral treatment,
clinicians should have access to information
regarding community resources that are available
to provide parent training in behavior therapy and
classroom behavior interventions and facilitate
appropriate referral.

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