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Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI

5. GU

6. Orthopedics

7. Neurological
--Breath-Holding Spells
--Benign Febrile Seizures
--Treating Children with Seizures

  

ADHD 

Drs. Jennings, Logan, Carter, Moulton, Flanders

Definition: Developmentally inappropriate levels of attention, impulse control, and motor activity that are consistent across two or more settings. 

Incidence:
Found in 2-4% of school-aged children with 75% male.  ADD more likely in females.

The natural history is that cases decrease by 50% every five years between the ages of 10-25.

ADHD is seen in 50% of child psychiatric problems but also seen in adults.

Co-morbidities: Learning disabilities, conduct disorders, autism, anti-social behavior, developmental disorders. Teenagers and older: anxiety, depression, drug abuse, oppositional.

Symptoms: Decreased attention span, inability to concentrate, impulsivity, overactivity, motor restlessness, difficulty with planning and organizing tasks, losing things, fidgeting, emotional lability (outbursts, fighting, over excitement), fidgety, shift from one incomplete task to another, poor peer relations, inability to follow through on instructions given. 

Evaluation: History and physical exam including neurologic, hearing and vision screen, hemoglobin and lead level, T4 and TSH.  Look for signs of Tourette syndrome (60% of Tourette Syndrome patients have ADHD). Consider doing chromosomes if Fragile X syndrome is a possibility.  There is no single test that clearly identifies ADHD.  Connors scales or their equivalent by parent and teacher.  May need testing for Learning Disabilities and measurement of the Distractibility Index of the WISC-R.  Many bright children do not show up with problems until 3rd grade because they were able to get through on their verbal skills alone until that time.  Be sure and involve the teacher as well as the parents in this evaluation.

Therapy:
1. Behavioral: Positive reinforcement, tokens, star charts, time out, extinction (ignoring inappropriate behaviors); set up the environment for success (decrease distractions and give lots of affirmation with minimal corporal punishment), work together at home and school; have structure and rules with consistency at home.  Give rules in clear, simple language, and make few in number; set firm limits with clear rewards.  CHADD parent groups can be quite important; social skills groups

2. Medications: Most commonly used are stimulants, others if comorbidities: decreased growth has been found to be related to ADHD, not meds. (Peds 98:August supplement)

Medication Dose Side Effects/Monitoring
Ritalin 0.3 - 1.0 mg/kg/day Insomnia, decreased appetite, irritability, tics, headache
Dexedrine 0.2 - 0.5 mg/kg/day Same
Adderall (combo Dex/amphet) 5 mg qd or bid up to 40 Same

Comorbidities

Clonidine (conduct disorder) 0.05 - 0.3 mg Sedation, weakness, tremors, paresthesia, rebound;
Desipramine (use in depression) 10-25 mg Sudden death, dry mouth, blurred vision
Bupropion (use in depression) 50 mg Seizures, agitation, dry mouth, insomnia, headache;
Tegretol (rage reactions) Same as anticonvulse Rash, neutropenia, liver function

3. Diet, sugar: play no role in the treatment of ADHD

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004