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Current Directions in ADHD and Its Treatment
Edited by Jill M. Norvilitis
Published by InTech
Janeza Trdine 9, 51000 Rijeka, Croatia
Copyright 2012 InTech
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Notice
Statements and opinions expressed in the chapters are these of the individual contributors
and not necessarily those of the editors or publisher. No responsibility is accepted for the
accuracy of information contained in the published chapters. The publisher assumes no
responsibility for any damage or injury to persons or property arising out of the use of any
materials, instructions, methods or ideas contained in the book.
Publishing Process Manager Igor Babic
Technical Editor Teodora Smiljanic
Cover Designer InTech Design Team
First published February, 2012
Printed in Croatia
A free online edition of this book is available at www.intechopen.com
Additional hard copies can be obtained from orders@intechweb.org
Current Directions in ADHD and Its Treatment, Edited by Jill M. Norvilitis
p. cm.
ISBN 978-953-307-868-7
Contents
Preface IX
Part 1 Treatment Considerations 1
Chapter 1 ADHD in Children and Adolescents:
A Good Practice Guidance 3
Somnath Banerjee
Chapter 2 ADHD and Comorbid Conditions 25
Nitin Patel, Mita Patel and Harsha Patel
Chapter 3 Comorbidity in ADHD:
A Neuropsychological Perspective 47
Julio Csar Flores Lzaro and Mara Alejandra Salgado Soruco
Chapter 4 ADHD and Sleep Problems in Children 61
Elizabeth Hastings and Barbara T. Felt
Part 2 Psychopharmacology: Mechanisms and Effects 89
Chapter 5 The Neuropsychopharmacology
of Stimulants: Dopamine and ADHD 91
Paul E.A. Glaser and Greg A. Gerhardt
Chapter 6 Trends in the Prescribing and Adverse
Drug Reactions Patterns of Psychostimulants
Among Danish Children and Adolescents 111
Lise Aagaard and Ebba Holme Hansen
Chapter 7 Do Stimulant Medications for Attention-Deficit
/Hyperactivity Disorder (ADHD) Enhance Cognition? 125
Claire Advokat and Christine Vinci
Chapter 8 Motor Skills in Children with ADHD:
Comparative Study from the Farmacological Treatment 157
Jose Armando Vidarte Claros and Consuelo Velez Alvarez
VI Contents
Chapter 9 Methylphenidate and Dyslipidemia 185
Gideon Charach, Nechemia Kaysar, Alexander Rabinovich,
Ori Argov and Moshe Weintraub
Part 3 Non-Medication Interventions 193
Chapter 10 ADHD and Stress: The Role of Meditation to Reduce Stress,
and Improve Brain Function and Behavior Regulation 195
Sarina J. Grosswald and Fred Travis
Chapter 11 The Value of Coached Behaviour
Modification in the Effective Management of
Attention Deficit Hyperactivity Disorder (ADHD) 211
Tilla Olivier and Ana Gomes
Chapter 12 Distractor or Noise?
The Influence of Different Sounds on Cognitive
Performance in Inattentive and Attentive Children 233
Gran Sderlund and Sverker Sikstrm
Part 4 EEG Biofeedback 247
Chapter 13 QEEG Characteristics and Biofeedback
Modalities in Children with ADHD 249
Nada Pop-Jordanova
Chapter 14 EEG Findings in ADHD and the Application
of EEG Biofeedback in Treatment of ADHD 269
Mohammad Ali Nazari
Chapter 15 The Effect of Psycho-Educational Therapy
on Electroencephalographic Biofeedback
Scores in Attention Deficit Hyperactivity Disorder 287
Irene Nikaina, Aspa Paspali,
Georgia Kleidaria and Antigone Papavasiliou
Preface
Allenlion Deficil Hyeraclivily Disorder is one of lhe mosl videIy diagnosed behavior
disorders in chiIdhood, vilh a vorIdvide ooIed revaIence of 5.29 % (IoIanczyk el
aI., 2007). Il is aIso one of lhe mosl conlroversiaI diagnoses vilh concerns raised aboul
vhelher il is a cuIluraI conslrucl or a neurobehavioraI disorder (arkIey el aI., 2004,
Timimi el aI., 2004) and vhelher il is over diagnosed or under diagnosed. The
lrealmenl of ADHD is aIso a maller of ongoing research and debale, vilh considerabIe
dala suorling bolh sychoharmacoIogicaI and behavioraI aroaches. Researchers
conlinue lo search for nev inlervenlions lo be used in con|unclion vilh or in Iace of
lhe more lradilionaI aroaches. These inlervenlions run lhe gamul from sociaI skiIIs
lraining, lo cognilive behavioraI inlervenlions ,lo medilalion lo neurosychoIogicaIIy-
based lechniques.
This goaI of lhis voIume is lo exIore lhe slale-of-lhe-arl in consideralions of lhe
lrealmenl of ADHD around lhe vorId. The 16 chalers in lhis voIume reresenl lhe
vork of 27 researchers in counlries sanning lhe gIobe from Iran lo CoIumbia,
Denmark lo Soulh Africa , and lhe Uniled Slales. Some of lhe chalers in lhis book
rovide a nev vay of Iooking al veII-eslabIished lrealmenls vhiIe olhers examine
lrealmenls lhal are seeking lhe confirmalion of lhe research communily. This broad
survey covers issues reIaled lo comorbidily lhal affecl lhe lrealmenl choices lhal are
made, lhe effecls of sychoharmacoIogy, and non-medicalion lrealmenls, vilh a
seciaI seclion devoled lo lhe conlroversiaI nev lrealmenl, neurofeedback.
The firsl seclion of lhe book rovides an overviev of lrealmenl of ADHD and
comorbid condilions lhal may be of concern. Chaler 1, ADHD in ChiIdren and
AdoIescenls: A Good Iraclice Guidance rovides a summary of lhe assessmenl and
diagnosis of ADHD. Il aIso conciseIy describes lhe managemenl of lhe disorder,
covering such loics as choices and safely in medicalion, non-medicinaI lrealmenls,
and a consideralion of hov comorbid condilions may affecl lrealmenl. Chaler 2,
ADHD and Comorbid Condilions, examines in more delh lhe idenlificalion and
lrealmenl of sychoIogicaI robIems lhal are associaled vilh ADHD, such as
deression, anxiely, bioIar disorder, and oosilionaI defianl disorder. Chaler 3,
Comorbidily in ADHD: A NeurosychoIogicaI Ierseclive, lakes a differenl
aroach lo lhe issue from lhe firsl lvo chalers by examining lhe sublyes of ADHD
as reIaled lo differenl neurosychoIogicaI rofiIes. These rofiIes are in lurn reIaled lo
X Preface
differenl comorbid cognilive and behavioraI condilions. The finaI chaler in lhe firsl
seclion, ADHD and SIee IrobIems in ChiIdren, focuses on lhe need for lhe
consideralion of sIee robIems in chiIdren vilh ADHD because of lhe overIa
belveen lhe lvo calegories and lhe imIicalions for lrealmenl of ADHD.
The second seclion of lhe voIume examines lhe sychoharmacoIogicaI lrealmenl of
ADHD. Chaler 5, The NeurosychoIogy of SlimuIanls: Doamine and ADHD,
examines hov doamine's roIe in ADHD is reIaled lo lhe aclion of sychoslimuIanl
medicalions, as veII as lhe roIe of olher neurolransmillers and olher medicalions.
Chaler 6, Trends in lhe Irescribing and Adverse Drug Reaclion Iallerns of
IsychoslimuIanls among Danish ChiIdren and AdoIescenls, lakes advanlage of lhe
avaiIabiIily of dala regarding lhe individuaI use of medicalion in Denmark lo exIore
bolh changes in rescrilion rales over a 10 year eriod and lhe revaIence of adverse
reaclions lo lhe various medicalions. Chaler 7, Do SlimuIanl Medicalions for
Allenlion Deficil Hyeraclivily Disorder (ADHD) Inhance Cognilion`, revievs lhe
research on lhis loic and resenls lhe aulhors' ovn dala lhal indicale lhal, lhough
slimuIanls imrove allenlion and concenlralion, changes in olher areas of cognilive
and academic funclioning are inconsislenl such lhal slimuIanls do nol aear lo
imrove Iearning. Chaler 8, Molor SkiIIs in ChiIdren vilh ADHD: Comaralive
Sludy from lhe IharmacoIogicaI Trealmenl, summarizes lhe Iileralure indicaling lhal
50 % of chiIdren vilh ADHD have molor skiII robIems and describes lhe aulhors'
ovn research. AIlhough such robIems are common, lhe effecl of medicalion and
exercise on ADHD symloms and molor dislurbance remains uncIear. Chaler 9,
MelhyIhenidale and DysIiidemia, examines lhe reIalionshi belveen lhe drug
and Iiid rofiIes, concIuding lhal melhyIhenidale is reIaled lo some osilive
changes in lolaI choIesleroI and Iioroleins.
The lhird seclion of lhe book moves from sychoslimuIanls lo an examinalion of non-
medicalion lrealmenls. Chaler 10, Non-Medicalion Trealmenls of ADHD, rovides
an overviev of a variely of inlervenlions, summarizing lhe lechniques and research
regarding efficacy. Chaler 11, ADHD and Slress: The RoIe of Medilalion lo Reduce
Slress, and Imrove rain Iunclion and ehavior ReguIalion, reorls lhe resuIls of lvo
sludies examining TranscendenlaI Medilalion's effecls on ADHD symlomaloIogy lhal
indicale lhal chiIdren vilh ADHD are abIe lo Iearn lhe lechnique and lhal medilalion
may reduce slress and imrove execulive funclions. Chaler 12, The VaIue of Coached
ehavior Modificalion in lhe Iffeclive Managemenl of Allenlion Deficil Hyeraclivily
Disorder (ADHD), describes research suorling lhe use of coaches in lhe lrealmenl of
ADHD. Such coaches are nol reIacemenls for lheraisls, bul come aIongside lhose vilh
ADHD lo heI lhem Iearn lo manage lhe raclicaI chaIIenges lhal arise in lhe ursuil of
goaIs. Chaler 13, Dislraclor or Noise` The InfIuence of Differenl Sounds on Cognilive
Ierformance in Inallenlive and Allenlive ChiIdren, reorls lhe resuIls of a sludy
examining lhe differenliaI resonse of chiIdren vilh and vilhoul inallenlion symloms
lo background audilory noise. The aulhors reorl lhal such noise imroves cognilive
erformance in chiIdren vilh inallenlive symloms and rovide a lheorelicaI framevork
for underslanding lhis henomenon.
Preface XI
The finaI seclion of lhe book exIores lhe fairIy nev fieId of neurofeedback.
Neurofeedback, vhich uses quanlilalive IIG in biofeedback lraining, is a
conlroversiaI lechnique. Crilics oinl lo lhe Iack of conlroIIed research on lhe loic,
bul il remains ouIar vilh raclilioners and cIienls. Granls invesligaling lhe
lechnique are currenlIy funded by lhe NalionaI Inslilules of HeaIlh. CIearIy, more
research on lhis lechnique is needed and, in lhal siril, lhree chalers here address
neurofeedback. Chaler 14, QIIG Characlerislics and iofeedback ModaIilies in
ChiIdren vilh ADHD, describes lhe use of QIIG in lhe diagnosis of ADHD, vilh
resuIls from a sludy highIighling lhe differences among subgrous of lhe disorder.
The chaler aIso rovides a brief overviev of neurofeedback for ADHD. Chaler 15,
IIG Iindings in ADHD and lhe AIicalion of IIG iofeedback in Trealmenl of
ADHD, rovides a more exlensive descrilion of IIG biofeedback, incIuding
summaries of lhe lrealmenl rolocoIs. Chaler 16, The Iffecl of Isycho-IducalionaI
Theray on IIeclroencehaIograhic iofeedback Scores in Allenlion Deficil
Hyeraclivily Disorder, reorls lhe resuIls of a sludy examining lhe effecl of a
combinalion of neurofeedback and a cognilive-behavioraI academic inlervenlion. They
found lhal a combinalion of lrealmenls acceIeraled lhe imrovemenl in brain aclivily.
OveraII, lhe chalers resenled here la inlomuch of lhe breadlh of lhis fieId. I beIieve
lhal lhere is somelhing in lhis voIume for everyone inleresled in lhe lrealmenl of
ADHD, from sludenls examining lhe loic for lhe firsl lime lo researchers and
raclilioners Iooking for insiralion for nev research queslions or olenliaI
inlervenlions. I hoe lhal lhe chalers sark nev lhoughls and, erhas, debales.
This book is lhe resuIl of lhe vork of many individuaIs. I am arlicuIarIy gralefuI for
lhe assislance of Ms. Adriana Iecar and Mr. Igor abic for lheir assislance in
coordinaling lhis book. I aIso lhank aII of lhe aulhors vho conlribuled lo lhis voIume.
"#$$ %& '()*#$#+#,
Dearlmenl of IsychoIogy,
uffaIo Slale CoIIege,
uffaIo, NY 14222,
USA
-./.).01.,
arkIey, R. A., Duncan, M., Loney, }., MiIich, R., Werry, }., Cunningham, C..Hay, D.
(2004). Crilique or misreresenlalion` A reIy lo Timimi el aI. "#$%$&'# "($#)
'%) *'+$#, -.,&(/#/0, 123$245 65 65-69.
IoIanczyk, G., SiIva de Lima, M., Lessa Horla, ., iederman, }., & Rohde, L. A. (2007).
The vorIdvide revaIence of ADHD: A syslemalic reviev and melaregression
anaIysis. 7+28$&'% 9/:8%'# /; -.,&($'<8,5 =>?5 >5 942-948.
Timimi, S., Moncrieff, }., }ureidini, }., Leo, }., Cohen, D., WhilfieId, C.While, R. (2004).
A crilique of lhe InlernalionaI Consensus Slalemenl on ADHD. "#$%$&'# "($#)
'%) *'+$#, -.,&(/#/0, 123$245 65 59-63.
Part 1
Treatment Considerations
1
ADHD in ChiIdren and AdoIescents:
A Good Practice Guidance
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1. Introduction
The syndione of ieslIess, inallenlive, and inpuIsive lehavioui knovn as Allenlion Deficil
Hypeiaclivily Disoidei (ADHD) oi Hypeikinelic Disoidei (HKD) is a connon
neuiodeveIopnenlaI piolIen in chiIdien and adoIescenls. ChiIdien affecled vilh lhis
disoidei aie al iisk of acadenic faiIuie, sulslance aluse, and ciininaIily in adoIescence and
aduIlhood. ADHD is a iefIeclion of an undeiIying deficil lhal nay have seveiaI uIlinale
causes such as genelic piedisposilion, psycho-physioIogicaI faclois and psychoIogicaI
dysfunclion, lul a connon palhvay al lhe lehaviouiaI IeveI (HiII & Caneion, 1999). y
IaleIIing chiIdien vilh difficuIl lehavioui as suffeiing fion a disoidei, ve nake il easiei lo
lieal and lhis caiiies vilh il lhe dangei of ovei-diagnosis (Oifoid, 1998). On lhe olhei hand,
undei-diagnosis is aIso an issue (Dopheide, 2OO1).
2. Incidence
IievaIence of ADHD eslinales lhal 3 lo 7 chiIdien vouId neel lhe ciileiia of Diagnoslic
and SlalislicaI ManueI-IV (DSM-IV) of Aneiican Isychialiic Associalions diagnoslic ciileiia
(AIA, 1994). The ialio of loys lo giiIs is lelveen 3:1 and 9:1 lul lhis nay deciease vilh age
(Svanson ,' +6., 1998). Iail of lhe diffeience lelveen sexes nay le iefeiiaI lias (eideinan
,' +6., 1996). IoIIov-up sludies of chiIdien
vilh ADHD find lhal 15 sliII have lhe fuII
diagnosis al 25
yeais, and anolhei 5O aie in pailiaI ienission, vilh sone
synplons
peisisling (Iaiaone ,' +6., 2OO6).
3. AetioIogy
No genelic naikei has leen idenlified in chiIdien vilh ADHD. Neuioinaging sludies
confiin alnoinaIilies in lhose iegions of lhe liain lhal aie inpIicaled in ADHD (Svanson
,' +6., 1998, CasleIIanos ,' +6., 2OO2). These sludies iepoil significanlIy snaIIei asynneliicaI
piefionlaI and lasaI gangIia sliucluies, in chiIdien vilh ADHD.
CoiieIalions of nagnelic
iesonance inaging-lased analonicaI neasuies and specific-lask peifoinance in chiIdien
suggesl lhal lhe iighl piefionlaI coilex is invoIved in inhililing allenlionaI and lehaviouiaI
iesponses, vheieas lhe lasaI gangIia seen lo le invoIved in lhe execulion of lhese iesponses
(Koniad & Lickhoff, 2O1O). One lhiid of affecled individuaIs have al Ieasl one paienl vho
Current Directions in ADHD and ts Treatment
4
suffeis fion siniIai synplons. ADHD is aIso associaled vilh Iov liilh veighl (<15OOg),
lolacco and aIcohoI use duiing piegnancy (SICN, 2OO1).
AIlhough ADHD is highIy
heiilalIe, no specific suscepliliIily gene has leen idenlified (Iianke ,' +6., 2OO9).
4. Symptoms
The synplons of ADHD aie excessive and inpaiiing IeveIs of aclivily, inallenlion, and
inpuIsiveness. ChiIdien have gieal difficuIly ienaining sealed vhen iequiied in sliucluied
silualions such as in lhe cIassioon oi al lhe dinnei lalIe. They faiI lo pay allenlion lo
insliuclions in acadenic and sociaI silualions. The diffeience lelveen ADHD and noinaI
lehavioui is lhe degiee of inpaiinenl. The aIaining signaIs nay le a chiId vho is
acadenicaIIy undei-achieving lecause of his/hei lehavioui, despile having a noinaI
inleIIecl oi a chiId exhililing lehavioui piolIens lolh al hone and in schooI, vhich aie
consideialIy voise lhan vouId le expecled foi lhe slandaid of paienling and hone
enviionnenl. The synplons of ADHD change lhiough oul lhe IifecycIe. Hypeiaclivily and
inpuIsivily nay deciease as palienls gel oIdei lul lhe denands on lheii allenlion nay
inciease.
5. Assessment
Concein aloul lhe fuluie quaIily of Iife is heighlened vhen paienls olseive lheii chiIdien
sliuggIing lehaviouiaIIy al hone, acadenicaIIy in schooI and sociaIIy on lhe pIaygiound.
When loId lhal a chiId has ADHD, paienls aie ieIieved ly finding a ieason foi lheii chiIds
difficuIlies. The diagnosis confiins lhal il is nol lheii fauIl. Nol aII chiIdien and young
peopIe piesenling vilh difficuIl lehavioui viII vaiianl a speciaIisl iefeiiaI. This depends on
lhe seveiily of chiIds difficuIlies. ADHD can le piovisionaIIy diagnosed in pieschooI
chiIdien lul il shouId le confiined aflei lhe chiId has slailed schooI. Sone aigue lhal
piolIens vilh inallenlion, hypeiaclivily and inpuIsivily aie lhe iesuIls of cuIluiaI
phenonena (Iock, 1977).
Yel lhis poinl of viev appeais lo le changing vilh lhe acceplance
of ADHD as a cioss-cuIluiaI disoidei (Sandleig, 1996). Sone chiIdien aie inheienlIy noie
incIined lo le inallenlive, inpuIsive and hypeiaclive lhan olheis. Such liails nay iun in
faniIies e.g. paienls, silIings, and exlended faniIy nenleis and lheie seens lo le a genelic
piedisposilion lo lhen. MenlaI liails can le inheiiled jusl as heighl and veighl. Whal ve
aie deaIing vilh aie noinaI hunan vaiialions lhal aie onIy undeislood as leing disoideis
vhen lhey aie in confIicl vilh cuIluiaI expeclalions and noins. The ialing scaIes aie an
essenliaI looI lo ollain infoinalion lul aie nol a sulslilule foi a diagnosis. Repoils fion
paienls and leacheis nay nol agiee on lhe lypes of lehaviouis. This does nol nean lhey aie
necessaiiIy inaccuiale, il nay le alliiluled lo lhe facl lhal lhe paienls and lhe leacheis aie
seeing lhe chiIdien in diffeienl sellings. Theie aie nany ialing scaIes avaiIalIe, nosl of vhich
have leen deveIoped in lhe USA. The assessnenl shouId incIude infoinalion galheiing. Apail
fion ollaining lhe conpIeled ialing scaIes, "nfoinalion shouId le ollained fion lhe schooI
aloul peei ieIalionship and lhe chiIds acadenic piogiess. Infoinalion is galheied aloul
chiIds cuiienl difficuIlies, faniIy and sociaI hisloiy, chiIds deveIopnenlaI and nedicaI
hisloiy and lhe educalionaI piogiess. WhiIe inleivieving paienls, one needs lo ollain a
conpiehensive knovIedge of each paienls nedicaI and psychialiic hisloiy. IaniIy silualions,
such as a singIe voiking paienl, sepaialed oi divoiced paienls, oi ieconsliluled faniIies
vheie one oi lolh paienls have ienaiiied, aII affecl lhe chiId.
ADHD in Children and Adolescents: A Good Practice Guidance
5
5.1 MedicaI assessment
Since synplons of ADHD can occui due lo a vide vaiiely of undeiIying condilions, a
conpiehensive appioach lo lhe evaIualion of a chiId vilh ADHD is ieconnended (Reiff ,'
+6., 1993, AACAI, 1997)). MedicaI assessnenl shouId incIude a peiinalaI hisloiy,
lehaviouiaI/deveIopnenlaI hisloiy, faniIy hisloiy (SICN, 2OO1) and a physicaI exaninalion
foi any conliaindicalions foi possilIe nedicalion use, such as sone caidiac dysihylhnias.
IeiinalaI hisloiy shouId incIude aloul piegnancy and liilh, naleinaI exposuie lo diugs,
aIcohoI and snoking cigaielles, cannalis elc and high-iisk piegnancy (e. g. pienaluiily,
LW). ehaviouiaI/deveIopnenlaI hisloiy shouId incIude deveIopnenlaI niIeslones,
difficuIly engaging in quiel pIay and piolIens vilh oleying connands. IaniIy Hisloiy
shouId incIude hisloiy of ADHD, diug oi aIcohoI aluse, psychialiic iIInesses, piolIens vilh
lhe Iav, specific piecipilanl vheie synplons can le daled, evenls piecipilaling ADHD
synplons such as negIecl, physicaI oi sexuaI aluse, paienling issues and caidiac
aiihylhnias oi sudden dealh especiaIIy in 35 yeais oi youngei age, hone Lnviionnenl (key
caiegiveis, fiequenl noves oi fiequenl change in foslei caie, fiequenl changes of schooI,
hone enviionnenl and faniIy dynanics e. g. singIe faniIy, sane gendei pailneis),
inleipeisonaI ieIalionship/s in lhe faniIy, Iooi oi ciovded housing. Hisloiy shouId le
ollained aloul line spenl on TV-valching, conpulei and video ganes. Hisloiy shouId aIso
le ollained aloul peei ieIalionships, acadenic undei-achievenenl, liuancy, does lhe chiId
enjoy schooI, ask lhe schooI age chiId if she/he lhinks she/he has lioulIe concenlialing,
ieviev cuiienl schooI iepoil as veII as lhose fion eaiIiei yeais and psychoneliic evaIualion
ly educalion psychoIogisls foi cognilive aliIilies and acadenic achievenenl IeveIs. Hisloiy
of sIeep pallein needs lo le ollained. Laling Hisloiy shouId incIude appelile and ealing
halils and joining lhe olhei nenleis foi dinnei. IhysicaI exaninalion is done lo docunenl
a laseIine giovlh paianeleis (heighl and veighl) vhich shouId le pIolled on a cenliIe chail
and al each foIIov-up visil if lhe chiId is piesciiled nedicalion, lIood piessuie and puIse
iale aie iecoided and pIolled on lhe cenliIe chail, caidiac exaninalion incIuding
auscuIlalion foi nuinuis and fenoiaI puIses, dysnoiphic fealuies suggeslive of IelaI
AIcohoI Syndione (IAS) oi olhei genelic condilions, culaneous slignala, such as cafe au
Iail spols, liuising oi olhei evidence of injuiy, lonsiIIai hypeiliophy suggeslive of noulh
liealhing, neuioIogic exan and age-appiopiiale nenlaI slalus exan, lics, pIay skiIIs
(pailicuIaiIy piolIen soIving), olseiving lhe chiId/paienl inleiaclion, co-oidinalion lasks
and handviiling, nensliuaI/puleilaI slalus in adoIescenls and if deened necessaiy,
psychoIogicaI assessnenl. The assessnenl piocess shouId lake accounl of lhe olhei
condilions, vhich nay lellei accounl foi lhe chaIIenging lehavioui (AACAI, 1997). These
nighl incIude nedicaI disoideis such as #Ieep apnoea, seizuie disoideis, deveIopnenlaI
disoideis (e. g. InleIIecluaI disaliIily (Leaining disaliIily, LD ), Specific Leaining DifficuIly
(SpLD) foineiIy dysIexia and DeveIopnenlaI Cooidinalion Disoidei (DCI) foineiIy
dyspiaxia), liain injuiy, use of olhei nedicalions (e. g. anli-epiIeplic diug) oi sensoiy
inpaiinenls, nenlaI heaIlh disoideis such as OpposilionaI Defianl Disoidei
(ODD)/Conducl disoidei (CD), anxiely/depiession, adjuslnenl disoidei, allachnenl
disoidei oi sulslance aluse. Olhei condilions incIude Aulisn Specliun Disoidei (ASD)
and lhe noinaI aclive pieschooI chiId. In addilion lo lhe hisloiy nenlioned alove,
evaIualion of an adoIescenl shouId aIso incIude eIiciling hisloiy iegaiding use of aIcohoI
and diugs, cigaielle snoking, nunlei of accidenls and speeding lickels, sexuaI aclivily and
spending hisloiy. The alove assessnenls aie nol indicalive of ADHD lul nay heIp lo iuIe
Current Directions in ADHD and ts Treatment
6
oul lhe possiliIily of olhei undei-Iying nedicaI oi deveIopnenlaI condilions ninicking
ADHD synplons.
6. GuideIines
The guideIines foi assessnenl and liealnenl have leen issued ly Aneiican Acadeny of
ChiId and AdoIescenl Isychialiy (AACAI, 2OO7), lhe Aneiican Acadeny of Iedialiics
(AAI, 2OO1), lhe Luiopean CuideIines
(TayIoi ,' +6., 2OO4, anaschevski ,' +6., 2OO6),
NalionaI Inslilule foi HeaIlh and CIinicaI LxceIIence (NICL, 2OO8) and lhe Scollish
InleicoIIegiale CuideIine Nelvoik (SICN, 2OO4). WhiIe lheie is a degiee of consensus anong
lhese pulIicalions, lheie seens lo le sone inleinalionaI diffeience such as NICL
ieconnends diug liealnenl in seveie ADHD, vheieas lhe Aneiican guideIines advice lo
slail nedicalion and Ialei olhei nanagenenl slialegy nay le consideied (CADDRA, 2O1O).
7. Diagnosis
ADHD is a cIinicaI diagnosis foi vhich lheie aie no lesls. Il is inpoilanl lo galhei lhe
infoinalion fion paienls/caieis and schooI. The diagnosis is nade ly using lhe diagnosis
ciileiia eilhei of DSM -IV (AIA, 2OOO) oi ICD -1O (WHO, 1992). olh najoi syslens of
cIassificalion idenlify idenlicaI 18 synplons (lalIe 1).
$%&''(%'")% *$+, -./(0&1'"2"'. *-, $3/45#"2"'. *$67,
IaiIs lo allend lo delaiIs Iidgels vilh hands oi
feel
DifficuIly suslaining allenlion Leaves seal in
cIassioon
Does nol seen lo Iislen Runs aloul oi cIinls
IaiIs lo finish DifficuIly pIaying
quielIy
DifficuIly oiganising lasks Moloi access (on lhe
go, in DSM-IV)
Avoids suslained effoil TaIks excessiveIy
(DSM-IV)
TaIks excessiveIy (ICD-1O)
Loses lhings Iuils oul ansveis lo
queslions
Disliacled ly exlianeous
slinuIi
DifficuIly vailing luin
IoigelfuI Inleiiupls oi inliudes on
olheis
TalIe 1. Synplon donains foi ADHD in DSM-IV and ICD-1O
7.1 Differences between the two major diagnostic manuaIs (tabIe 2)
89:9: In lhe synplon donains of Inallenlion, Hypeiaclivily, and InpuIsivily, an ICD-1O
diagnosis of HKD needs sone synplons fion aII lhiee gioups vheieas DSM-IV ADHD
does nol, lul inslead specifies sullypes if synplons aie fion onIy one donain. HKD is
lioadIy siniIai lo seveie lype of ADHD.
ADHD in Children and Adolescents: A Good Practice Guidance
7
89:9; ecause of lhe high iale of conducl disoidei, ICD-1O uses lhe piesence oi alsence of
conducl disoidei as lhe lasis foi lhe nain suldivision of HKD. DSM-IV does aIIov lhe
diagnosis of conducl disoidei as a conoilid condilion.
89:9< Anolhei diffeience lelveen lhe lvo cIassificalions is lhe use of olhei condilions as
excIusion ciileiia. ICD-1O ains al a singIe diagnosis. DSM-IV ains lo iecognize, as nany
diagnoses as lheie aie synplons.
-=> *$?>@:A,
Six oi Six oi noie fion IN donain, lhiee oi noie fion
H donain and one oi noie fion IMI donain.
B>-> C #4D'./(# *>E6@$F,
Conlined lype Six oi Six oi noie fion IN donain and six oi noie
fion lhe H / IMI donain.
Inallenlive lype Six oi Six oi noie fion IN donain and Iess lhan six
fion H / IMI donain+/- H / IMI Iess lhan 6
Hypeiaclive/InpuIsive Six oi Six oi noie fion H / IMI donain and Iess lhan
six fion IN donain.
IN: Inallenlion, H: Hypeiaclivily, IMI: InpuIsivily
TalIe 2. HKD diagnosis and ADHD diagnosis sullypes
7.2 Limitations of diagnosis criteria
AIlhough lhe DSM-IV and ICD-1O aie videIy used as diagnoslic looIs, lheie aie a nunlei of
Iinilalions (AAI, 2OOO).
89;9: The nunleis of synplons iequiied lo nake lhe diagnosis of ADHD / HKD does nol
vaiy vilh lhe seveiily of lhe synplons oi vilh lhe age. Theiefoie an oIdei chiId vilh a fev
seveie synplons nay nol neel lhe diagnoslic ciileiia, vheieas a youngei chiId vilh nany
Iess seveie synplons nay neel lhe ciileiia, even lhough lhe foinei nay expeiience noie
funclionaI inpaiinenl. Ioi a chiId vilh fev seveie synplons, lhe diagnosis of ADHD nol
olheivise specified lhal is incIuded in DSM-IV nay le used, lul lhe nanuaI piovides no
ciileiia foi vhen lo nake lhis diagnosis.
89;9; The iequiienenls lhal synplons occui in al Ieasl lvo sellings can le piolIenalic al
lines. Il nay hindei lhe diagnosis foi chiIdien vho nay have significanl difficuIlies vilh
allenlion in schooI lul do nol have piolIens al hone.
89;9< AIlhough lhe ciileiia incIude synplons le piesenl lefoie 7 yeais is usefuI in
highIighling lhal ADHD iaieIy is lhe coiiecl diagnosis vhen inallenlion, hypeiaclivily, oi
inpuIsivily is occuiiing foi lhe fiisl line in adoIescence oi in aduIlhood,
hovevei, il nay le
piolIenalic in excIuding chiIdien vhose Iiniled allenlion spans lecones noie nolicealIe
vhen lhey slail secondaiy schooI lecause of incieased schooI and hone voik.
89;9G The leins "significanl" and "sone inpaiinenl" aie suljeclive and uncIeai.
89;9H The diagnosis is aIso enviionnenlaIIy dependenl, vhich expIains vhy cIinicians viII
see diffeiences in lhe chiId's lehavioui lelveen schooI and hone sellings.
Current Directions in ADHD and ts Treatment
8
89;9I Il is a chaIIenge lo nake a diagnosis vhen lheie aie no expIicil ciileiia foi defining
vhal is lypicaI foi a pailicuIai age`
89;98 CuiienlIy lhe najoi diagnosis ciileiia aie onIy appIicalIe lo adoIescenls up lo 18 yeais
of age. Theie aie no diagnosis ciileiia foi aduIls.
8. Management
IoIIoving diagnosis of ADHD, viillen infoinalion and avaiIalIe oplion of vaiious
nanagenenl slialegies, velsile addiesses, and conlacl delaiIs of lhe IocaI suppoil gioups
shouId le given lo lhe paienls and lhe chiId's schooI iegaiding lhe condilion and ils
nanagenenl. Iaienls/caieis shouId le infoined lhal ADHD is a neuio-lehaviouiaI
condilion vilh a possilIe genelic aelioIogy vhich is lhe iesuIl of Iov oi inlaIanced IeveIs of
specific neuioliansnilleis in ceilain aieas of lhe liain. AlnoinaIIy Iov IeveIs of lhese
neuioliansnilleis aie associaled vilh lhe inpaiinenls lhal aie lhe haIInaiks of ADHD. The
need lo iuIe oul olhei possilIe diagnoses shouId le expIained. SulsequenlIy vaiious
liealnenl oplions need lo le expIoied. Lnsuie lhal lhe palienl and faniIy have had an
adequale oppoilunily lo le educaled aloul ADHD (CADDRA, 2O1O). Do ask lhe faniIy lo
find oul noie aloul ADHD lhiough iepulalIe velsiles and ieconnended ieading. They
need lo le infoined of lhe synplons lhal indicale a diagnosis and lhe ains and ialionaIe
foi liealnenl (vilh an undeislanding lhal no nedicalion eIininales aII lhe synplons of
ADHD and lhal olhei slialegies aie aIso indicaled as pail of nanagenenl). Theie needs lo
le a discussion of lhe iisks and lenefils of lhe advised lheiapy and lhe aIleinalives. Theie
shouId aIso le discussion iegaiding lhe polenliaI iisks of no lheiapy. Il is inpoilanl lo
desciile lo lhe paienls lhe findings ollained fion lhe assessnenl, incIuding a cIeai
slalenenl aloul lhe diagnosis and lhe lasis on vhich lhe diagnosis is nade. The faniIy
shouId le loId lhal a copy of lhe cIinic Iellei, vilh lheii consenl, viII le senl lo lhe schooI.
The chiIds suiioundings shouId suppoil ioulines and deciease disliaclions. Consislenl age-
appiopiiale Iinil selling is inpoilanl. Relaining a posilive, enjoyalIe ieIalionship vilh lheii
chiId inpioves lhe chiIds seIf-esleen. Thus, doing lhings lhal lhe chiId enjoys is inpoilanl.
Iaienls/caieis need lo heIp lhe chiId lo deveIop appiopiiale sociaI lehaviouis vilh peeis
and aduIls. Whenevei possilIe, an allenpl shouId le nade lo voik vilh lolh paienls so
lhal lhey aie consislenl vilh each olhei in lheii appioaches. IaniIy suppoil shouId ain lo
inpiove ieIalionships vilhin lhe faniIy, pionole paienlaI enpoveinenl and deveIop
slialegies lo nanage lehavioui, e.g. lhiough a paienling gioup. In addilion, faniIies shouId
le advised of ADHD paienl suppoil gioups exisling in lheii aiea. In nany cases caiefuI
nanagenenl of lehavioui and advice lo paienls and leacheis and voiking vilh lhe chiId lo
conlioI inpuIsiveness and nainlain concenlialion nay le sufficienl lo nanage lhe piolIens
(AAI, 2OO1). Wheie lhese aie nol deened lo le sufficienl, nedicalion nay le liied. Liaison
vilh lhe schooI shouId heIp infoin lehavioui nanagenenl slialegies vilhin lhe cIassioon.
Iuilhei suppoil fion lehavioui speciaIisl leacheis nay le soughl vheie necessaiy. The
chiIds schooI and lhe schooI nuise shouId le nolified al lhe slail of nedicalion. Any change
of lhe dosage nusl le nolified lo schooI and schooI nuise ly lhe piesciiling docloi, ialhei
lhan sinpIy leing ieIayed lo lhen ly lhe paienls oi lhe chiId. IndividuaI counseIIing oi
gioup voik nay le offeied lo lhe chiId lo addiess issues of Iov seIf-esleen as veII as lo
pionole sociaI skiIIs and lhe peei ieIalionships and offei skiIIs in lhe aiea of angei
nanagenenl. Tine shouId le spenl vilh lhe chiId/young peison lo heIp lhen undeisland
ADHD in Children and Adolescents: A Good Practice Guidance
9
vhal ADHD is and if nedicalion is lo le used, hov il voiks and ils side effecls. In lhe noie
seveie cases, and usuaIIy foIIoving lehaviouiaI inleivenlions, a liiaI of nedicalion nay le
consideied. ADHD is a chionic condilion iequiiing access lo Iong-lein liealnenl and
suppoil, sonelines ovei nany yeais. Hovevei, lhe IeveI and lype of suppoil needed can
vaiy. The piincipaI ains of liealnenl aie lo pionole lhe chiId's deveIopnenl and lo ieduce
secondaiy difficuIlies.
8.1 Non psychopharmacoIicaI interventions
This liealnenl is a non-diug inleivenlion and is ieconnended in niId and nodeiale
degiee of seveiily of ADHD (NICL, 2OO8). The lheiapisl consuIls vilh paienls and leacheis
lo liain lhen lo change lhe Ieaining enviionnenl foi lhe chiId. Il neans lo physicaIIy
caIning lhe chiId, lo enalIe lhen lo slay sliII, even in a gioup. The goaI is lo leach paienls
and leacheis lo use ievaids and punishnenl consislenlIy and effecliveIy. Togelhei vilh lhe
lheiapisl, lhe paienls and leachei find ievaids lhal viII nolivale lhe chiId lo voik. Cioup
lased paienling piogiannes can heIp paienls/caieis lo deveIop lheii skiIIs and loosl
confidence in nanaging chaIIenging and difficuIl lehavioui of lheii chiIdien. Sone
paienling piogiannes incIude InciedilIe Yeais, vhich use Welslei Sliallon piogianne foi
paienls of chiIdien aged 2 - 8 yeais (InciedilIe yeais), TiipIe I foi paienls and lhe
piogianne iun ly lainaidos (ainaidos). Using effeclive connunicalion skiIIs lo
deveIop a Ioving, guiding, Iinil selling, consequence pioviding lhal ievaids lhe desiied
lehavioui and eIininales lhe undesiied lehavioui is lhe Iong lein ain of non
psychophainacoIogicaI inleivenlion.
8.2 Medications
Advice and suppoil aloul lhe chiIds seIf esleen, peei gioup piogiess, acadenic piogiess
and faniIy ieIalionships viII aIso le iequiied even if nedicalion is used. A posilive
iesponse lo nedicalion is nol diagnoslic and a good iesponse lo diugs does nol vaIidale lhe
diagnosis. The piesenlIy avaiIalIe nedicalions aie synplonalic lheiapies, lhey aie nol alIe
lo cuie lhe condilion. Medicalion ains lo ieduce lhe coie synplons and lo inpiove lhe
effecliveness of olhei inleivenlions. Medicalion liealnenl shouId focus on lehaviouiaI
inpiovenenl and nol on gelling lellei giades in schooI, giades nay le lhe nel iesuIl of a
nany faclois, incIuding Ieaining disaliIilies, nolivalion and faniIy alliludes.
Diugs used in lhe liealnenl of ADHD aie giouped inlo lvo najoi calegoiies: slinuIanls
and non slinuIanls. MelhyIphenidale (MIH) and Alonoxeline (ATX) aie nol Iicensed foi
use in chiIdien Iess lhan six yeais of age oi in aduIls. ATX is Iicensed aflei 6 yeais of age and
nay le conlinued in aduIlhood vheie lhey have leen slailed in adoIescence.
Dexanfelanine (DLX) nay le piesciiled aflei 3 yeais of age. SlinuIanls (MIH and DLX)
aie nol Iicensed foi chiIdien vilh naiked anxiely, agilalion oi lension, synplons oi faniIy
hisloiy of lics oi Touielles syndione, hypeilhyioidisn, angina oi caidiac aiihylhnia,
gIaucona oi lhyioloxicosis. SlinuIanls aie conlioIIed ly lhe Misuse of Diugs Acl 1971 and
aie suljecl lo lhe ieguIalions foi ConlioIIed Diugs. Ioi delaiIs lhe piaclilioneis aie advised
lo consuIl lhe Luiopean liealnenl guideIines (TayIoi ,' +6. 2OO4, anaschevski ,' +6, 2OO6).
Iaienls shouId have leen expIained lhe advanlages and disadvanlages of vaiious avaiIalIe
diugs. Conceins and queslions paienls nay have iegaiding lolh effecls and side effecls
need lo le addiessed. An expIanalion of vhal nedicalion can and cannol do, and vhal
Current Directions in ADHD and ts Treatment
10
olhei inleivenlions aie avaiIalIe shouId le given. Iaienls/caieis shouId le loId lhal nol
eveiy nedicalion is suilalIe foi eveiy palienl. The guiding piincipIe of diug inleivenlion is
lo achieve lhe oplinun iesponse vilh lhe Iovesl dose possilIe lhal does nol give side
effecls. Theiefoie, slail vilh a Iov dose and giaduaIIy incieased unliI lhe naxinun
ieconnended dose IeveI is ieached oi laigel synplons have inpioved oi side effecls
appeai. Theie aie ieconnendalions foi dosing foi diffeienl nedicalions in accoidance vilh
lheii Iicenses. Wheie lheie aie conoilidilies, addilionaI oi nuIlipIe nedicalions nay le
used. The sunnaiy of pioducl chaiacleiislics (SIC) conlains specific advice aloul a diug.
The nosl inpoilanl deveIopnenl in ADHD occuiied in 1937 vilh lhe discoveiy
of lhe
leneficiaI effecl of DLX on allenlion and lehavioui anong chiIdien (iadIey, 1937). The
nain lieaklhiough cane in 1957 vilh lhe inlioduclion of MIH and sulsequenlIy nuneious
liiaIs confiined safely and efficacy of slinuIanls (Laufei, 1971, Lisenleig, 1972). The
nechanisn of aclion of lolh lhe slinuIanls, DLX and MIH is siniIai, lhey acl piincipaIIy as
inhililois of lhe dopanine-uplake nechanisn in lhe liain. DLX, in addilion, pionoles lhe
ieIease of lhis neuioliansnillei, lhus slinuIaling dopanineigic nechanisns. The slinuIanls
aIso acl on noiepinephiine-conlaining neuiones lo pionole an incieased ieIease of lhis
nonoanine.
The nosl exlensiveIy used and ieseaiched slinuIanl is MIH, a deiivalive of
DLX vhich has a iapid onsel of aclion, shoil haIf-Iife. Dosage and fiequency iequiienenls
vaiy vilh each individuaI chiId and aie independenl of lhe veighl oi lhe age. SlinuIanls aie
iapidIy alsoiled and easiIy cioss lhe lIood- liain laiiiei. If lheie is a Iack of inpiovenenl
oi sulslanliaI side effecls, anolhei ADHD diug nay le consideied anolhei (e.g., MIH vs.
DLX). If a palienl is iesponding veII lo one nedicalion, il is advised lhal anolhei nedicalion
shouId nol le liied lo see if lheie is a lellei iesponse. TalIe 3 desciiles lhe piopeilies of lhe
ADHD diugs.
BJ(%' K%#(' 6&L (MM(1' >40&'")% -&5M@5"M( >)#&J(NO&.
EP)0'@&1'"%J 67-
:
MIH-IR
2
2O-3O nin 1-2 his 3- 5 his 2-3 his 2.5-6O ng
DLX
3
2O-6O nin 1-2 his 6 his 4-6his 1.25-4O ng
Q)%J@&1'"%J 67-
Conceila XL
4,
2O-3O nin 2 his 12 his 3.5 his 18-54 ng
Lquasyn XL 2O-3O nin 1-2 his 8 his 2 his 1O-6Ong
Medikinel XL 2O-3O nin 1-2 his 8 his 2 his 1O-6Ong
MIH-SR
5
1-3 his 2 his 5-6 his 2-6 his 2O-6Ong
+)% #'"345&%'
ATX
6
1 vk 1- 2 his 24 his 3.6 his in
iapid
nelaloIis
eis
O.5ng/kg x 7
days, lhen
1.2ng/kg,
nax
1OOng/day
MIH
1
= nelhyIphenidale, MIH-IR
2
= nelhyIphenidale-innediale ieIease, DLX
3
= dexanfelanine,
Conceila XL
4
= Iicensed up lo 54 ng pei day, MIH-SR
5
= nelhyIphenidale sIov ieIease,
ATX
6
=alonoxeline
TalIe 3. Iiopeilies of ADHD diugs.
ADHD in Children and Adolescents: A Good Practice Guidance
11
8.2.1 Medications
The Iicense slalus of ADHD nedicalions vaiies in lhe diffeienl Luiopean counliies. On
aveiage lhe diugs Iicensed and avaiIalIe in diffeienl Luiopean counliies aie:
MelhyIphenidale innediale ieIease (IR) avaiIalIe as 5, 1O and 2Ong lalIels (5 and 2Ong
onIy avaiIalIe as Medikinel and nelhyIphenidale lalIels).
Medikinel