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Am Fam Physician. 2002;65(5):931-932

Attention-deficit/hyperactivity disorder (ADHD) presents as inappropriate-for-age hyperactivity, impulsivity, and inattention. ADHD cannot be easily diagnosed by a specific test or biologic marker, and it is unclear if the disorder is a truly pathologic condition or just one end of the behavioral spectrum. ADHD is more frequently diagnosed in children with behavioral difficulties and academic underachievement. Guevara reviewed the prevalence of ADHD using evidence obtained from well-established databases, systematic reviews, and several large-scale, randomized clinical trials.

The pooled prevalence of ADHD is between 6.8 and 10.3 percent, with boys having a three-fold higher rate. Psychiatric comorbidities, including oppositional-defiant disorder, conduct disorder, depressive disorder, and anxiety disorders are common.

The Conners' ADHD Index and symptom scales from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), which are ADHD-specific checklists, have a high sensitivity for identification of children with the disorder. Reviews of the pharmacologic management of ADHD with methylphenidate hydrochloride, dextroamphetamine sulfate, and pemoline show these drugs to be generally effective. Tricyclic antidepressants showed some beneficial effect on behavior patterns, but comparison studies with stimulants have not demonstrated a consistent advantage of one over the other.

Nonpharmacologic treatments that have some beneficial effect on behavior and academic performance are behavioral modification and intensive contingency management therapy. Combining drug therapy with psychosocial therapy shows no clear advantage when compared to drug therapy alone. However, the addition of behavioral therapies to medication may have some benefit, including reduction of anxiety and improvement in social skills.

The author concludes that ADHD is best diagnosed using the DSM-IV diagnostic criteria and the Conners' Parent and Teacher Rating Scales. Other psychiatric comorbidities are common and should be identified and properly managed. The symptoms of ADHD tend to decrease over the long-term but may continue into adolescence and adulthood. The most common treatment is stimulant medication.

editor's note: In a comprehensive review of ADHD, Hunt and associates point out the need to diagnose comorbid conditions such as learning disabilities and affective or conduct disorders. Accurate diagnosis requires obtaining behavioral information from parents and teachers. Pharmacologic treatment may require more than one medication. Psychostimulants remain the most effective treatment for enhancing attention and social skills. Combination treatment may be needed to manage multiple symptoms. Medications should be targeted at specific symptoms and started one at a time. Target symptoms should be monitored, and medications or dosages changed one at a time. Once the patient is stabilized, medication dosages can be lowered or discontinued if indicated. Psychosocial interventions, including conflict resolution, increased social support within the family and community, and modifications to work or home environment may be helpful.—r.s.

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