Attention-Deficit/Hyperactivity Disorder ADHD Nursing CE Course for APRNs

ale are then used to evaluate the child's symptoms based on the APA diagnostic guidelines and rule out other conditions with similar symptomatology. Screenings for other disorders are completed because many of the symptoms of ADHD are seen with other mental health conditions. Similar conditions include oppositional defiant disorder, intermittent explosive disorder, other neurodevelopmental disorders (e.g., autism), anxiety, depression, bipolar disorder, and disruptive mood dysregulation disorder (APA, 2022; Krull, 2022; Wolraich et al., 2019).

Parents are generally good historians regarding a child's behavior. Usually, parents report their child first became challenging in toddlerhood. However, toddlers tend to be enthusiastic, and it is often difficult to diagnose ADHD during that time. During the school-age years, symptoms of ADHD become more apparent. Students will have an impairment in learning and often become frustrated with their inability to meet classroom expectations. As the child reaches adolescence, parents and others may notice a worsening of symptoms and the development of behaviors that are considered antisocial (APA, 2022).

Because ADHD begins in childhood, the diagnosis is typically made during that time. The symptoms of ADHD should be present before the age of 12 for a definitive diagnosis. Adults may recall periods during childhood when they may have exhibited inattentiveness or impulsivity. However, those reports can be unreliable and should not be used to diagnose ADHD in adulthood; other supporting information should be provided by the adult to better understand the onset of symptoms. Many children with ADHD continue to experience symptoms into their adult years. The characteristics of inattentiveness will lessen with age, but many patients still feel restless (APA, 2022).

The APA (2022) revised the diagnostic criteria for ADHD in 2013, changing prior "subtypes" to "presentations" that can change throughout life, adding a severity scale, and requiring a greater pervasiveness of symptoms in various settings. When diagnosing ADHD in adults, clinicians are advised by the APA in the DSM-5-TR to gather information about each patient’s middle childhood (age 12) and teen years when determining the beginning of symptoms instead of back to childhood (age 7), as previously advised in the DSM-IV. Furthermore, the DSM-5-TR recognizes that a diagnosis of ADHD and autism spectrum disorder can coexist (APA, 2022).  

There are three presentations of ADHD: inattentive, hyperactive-impulsive, and combined inattentive and hyperactive-impulsive. While no diagnostic laboratory or biomarker test exists for these disorders, several symptom criteria are listed in Table 1. To obtain a diagnosis of ADHD, children should have six or more symptoms, whereas older teens and adults should have at least five symptoms (APA, 2022).

Table 1

Criteria for the Diagnosis of ADHD

At least six symptoms of inattention OR hyperactivity/impulsivity are required when diagnosing pediatric patients up to age 16 years or five or more for adults and older adolescents (17+). Symptoms must frequently occur for at least 6 months and appear inappropriate given the patient’s developmental level.

Inattention: lack of organizational skills. poor ability to sustain focus, even when playing may appear absent-minded or forget things daily difficulty completing schoolwork, chores, or duties in the workplace completely does not appear to hear or respond, even when addressed directly avoidance of activities that necessitate extended concentration poor attention to detail prone to distraction frequently misplaces important or crucial items (e.g., school materials, tools, wallet, keys, eyeglasses, telephone)

Hyperactive-impulsive: extremely talkative may struggle to sit still when asked may struggle to wait until called on, often calling out answers frequently barging into conversations or activities despite not being invited or welcome, borrowing without asking, or intruding may struggle to play quietly may struggle to take turns tends to fidget reports feeling restless (adolescents) or excessive climbing/running (younger children) often active, on the go at all times

Combined inattentive & hyperactive-impulsive has symptoms from both parts (1) and (2)

Multiple signs and symptoms must be obvious by age 11, even if identified in retrospect as an adult.

Signs and symptoms occur in at least two environments (such as at work, school, home, socially, etc.).

It is obvious that the signs impede purpose or cause dysfunction at school, work, or with friends/family.

Another disorder (such as an anxiety, personality, dissociative, or mood disorder) does not provide an enhanced reason for the symptoms, and they do not happen only during periods of psychosis.

(APA, 2022; Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD], 2017)

Children must have a pattern of inattention combined with hyperactivity or impulsivity that has been ongoing for at least 6 months that is considered excessive for their developmental age. Symptoms must be negatively impacting the child's home life and school performance. Other symptoms that may correlate to a diagnosis of ADHD include a delay in social skills or language. Children with ADHD may become frustrated and appear irritable. As the child gets older, a risk for suicidal ideation becomes a concern; this primarily occurs when ADHD occurs alongside other emotional disorders (APA, 2022).

An assessment should include determining if ADHD is combined, predominantly inattentive, or predominantly hyperactive. The symptoms of ADHD affect each individual to varying degrees and can be categorized by severity (APA, 2022). The DSM-5-TR helps clinicians designate the severity of a patient’s condition as mild, moderate, or severe, based on the following criteria:

• mild: few symptoms beyond the required number for diagnosis; symptoms result in minor impairment at home, school, work, or social settings
• moderate: simply defined as symptoms or functional impairment between “mild” and “severe”
• severe: many symptoms are present in excess, beyond the number required to diagnose the disorder; multiple symptoms are severe, or symptoms significantly impair the individual at home, school, work, or in social settings (CHADD, 2017)

When evaluating a child for inattention and hyperactivity, the evaluator must also determine if the child has any other mental disorder(s) that could resemble ADHD. For example, anxiety disorders, personality disorders, or mood disorders can be similar to ADHD in their presentation. Symptoms must also be exhibited in more than one setting, such as in the home and at school or work if the child is older. ADHD is a complicated diagnosis to make accurately, and a child may not exhibit symptoms if they are in a setting with less stimulation or if they have become conditioned by rewards for tasks completed. A language or social delay may manifest in the school setting, so an interview with the child’s teacher could elicit more information. The child may be frustrated by their inability to concentrate at school when others are able to do so (APA, 2022).

Treatment

According to the AAP Clinical Practice Guidelines, ADHD is a chronic condition that requires effective treatment. The AAP suggests using behavioral management before initiating pharmacological treatments in children younger than 6 diagnosed with ADHD due to the increased risk of adverse pharmacological effects in younger children. However, medication management should be initiated if behavioral therapy is ineffective or if significant improvements do not accompany its use. Thorough education on the benefits and risks of ADHD medication management must be discussed with the patient (when age appropriate) and their parent(s) or guardian (Wolraich et al., 2019).

The AAP revised its clinical practice guidelines for treating ADHD disorders in children and adolescents in 2019. Among preschool-aged children (age 4-6), parent training in behavioral management (PTBM) is recommended as the primary intervention for ADHD and children with ADHD-like behaviors whose diagnosis is not yet confirmed. Psychotherapy can be the key to a child's success. A therapist for behavioral management who will actively involve the parents in the child’s care is ideal. The therapist should offer a parent training program to teach parents how to deepen their relationship with the child and use positive reinforcement and consistency to help the child manage their hyperactivity or impulsivity. Therapy should include regular follow-up appointments to re-evaluate the child and the effectiveness of the intervention and determine whether treatment modification is needed. A collective effort from the child and their support system—including their parents, teachers, and therapist—will best assist them in reaching their maximum potential. Behavioral management can work as effectively as medication with appropriate parental training (Solanto, 2022; Wolraich et al., 2019).

For children over 6, behavioral therapy with medications can be an effective treatment model for ADHD. When treating a young child with medication, providers must use only agents approved by the US Food and Drug Administration (FDA) for ADHD and not use off-label medications until children reach adulthood (Wolraich et al., 2019). The NIMH (n.d.) reports that more than 65% of children with ADHD are prescribed medication to treat the disorder, with males using such options more than females. The AAP encourages providers to consider delaying pharmacological treatment until the school-aged years, ideally between ages 6 and 11. Even if medication management is initiated, behavioral therapy should remain a part of the treatment plan in this age group. Parents should learn the behavioral therapy components to utilize at home, and teachers should model and implement them during school hours. Once a child reaches adolescence, medications are often used, but behavioral therapy may still be a helpful adjunct. Medications should be started at the lowest dose possible and titrated up as needed until the child reaches their maximum benefit while avoiding any significant adverse effects. If the child has a "medication vacation" and does not take their medicine for a period, such as during a school break, the dose should be adjusted down when the medication is restarted and then titrated back up slowly (Wolraich et al., 2019).

Pharmacologic treatment should only be considered if behavioral therapy is ineffective or does not provide significant improvement and there is a moderate-to-severe continued disturbance in the 4- to 5-year-old child's functioning. The guidelines encourage clinicians to weigh the risks of prescribing medication before age 6 against the harm of delaying treatment. Elementary and middle school-aged children (6-12) should receive treatment with PTBM, behavioral classroom intervention, and medication. Educational interventions and individualized instructional support should be provided within the school environment, classroom placement, and additional essential components of the treatment plan, which often includes an individualized education program (IEP) or a rehabilitation plan. Adolescents (ages 12-18) should receive medications approved by the FDA with their consent, preferably with the same behavioral and educational interventions outlined above. Medications are also commonly used during adulthood, as up to one-third of children with ADHD continue to have symptoms into adulthood. There is no cure for ADHD; therefore, medication use aims to lessen hyperactivity and impulsivity symptoms and improve the patient’s ability to concentrate, focus, work, and learn (CDC, 2021c; CHADD, 2022; Wolraich et al., 2019).

The pathophysiology of ADHD is not entirely clear but is premised on a complex neurobiological basis involving multiple brain pathways. Neurotransmitters are endogenous chemical messengers within the brain that help transmit signals necessary for normal functioning. They are thought to play a role in ADHD disorders, so pharmacotherapy is the mainstay of treatment for adolescents and adults. Dopamine, norepinephrine, and serotonin are the three neurotransmitters implicated in ADHD disorders. A deficiency in these vital chemical messengers may be linked to the development of ADHD symptoms. Dopamine influences movement, attention, and motivation; norepinephrine plays a role in maintaining mental activity, regulating mood and excitability, problem-solving, and memory; and serotonin influences mood, sleep, memory, and social behavior. Therefore, medications targeting these neurotransmitters are considered the mainstay of pharmacological treatment (Tarraza & Barry, 2017).

Two classes of medications are commonly prescribed for treating ADHD: stimulants and non-stimulants. These medications work primarily by blocking the reuptake and increasing the release of dopamine and norepinephrine neurotransmitters, improving cognition and attention. Stimulants are the most widely used and well-known class of medications for managing ADHD-related symptoms and have been shown to reduce symptoms in 70%-80% of children with ADHD. Non-stimulants were approved for the treatment of ADHD in 2003, and their effects can last longer, up to 24 hours, but are slower to take effect. Stimulants consist of both amphetamines and methylphenidates, and they are available in immediate-release (IR), sustained- or extended-release (SR, ER, XR), and long-acting (LA) formulations. The development of longer-acting ER stimulants is relatively new and provides increased treatment options for patients. Longer-acting agents are associated with improved compliance with treatment, as they are only dosed once a day instead of the 2-3 times per day required with IR formulations (CDC, 2021c; NIMH, 2022).

Stimulants

The most common medications used to treat ADHD are stimulants. Most children (70%-80%) diagnosed with ADHD and medicated with a stimulant exhibit significantly improved ADHD behaviors. Stimulants are all categorized by the US Drug Enforcement Administration (DEA) as Schedule II with high abuse potential and previously by the FDA as pregnancy category C (i.e., risk cannot be ruled out). These medications were first administered to children with behavioral and learning disorders in 1937. Hundreds of controlled studies have been conducted (involving more than 6,000 children, adolescents, and adults) to determine the short-term effects of these medications. There are no long-term studies (i.e., more than a few years) on the effects of these medications, as this research would necessitate the withholding of treatment over many years from patients with significant impairment, which has been deemed unethical. However, individuals have used these medications for many years without serious adverse effects. Stimulants generally contain different types of methylphenidate and amphetamines and produce a calming effect on hyperactivity by increasing brain dopamine levels. The most common stimulants used for ADHD are methylphenidate (Ritalin, Concerta, Aptensio, Jornay PM), dextroamphetamine (Dexedrine), and dextroamphetamine/amphetamine (Adderall). They are available as IR formulas (lasting about 4 hours), LA formulas (ranging from 6-12 hours), and ER preparations (lasting up to 24 hours). Many parents and patients prefer LA or ER formulations, as these may reduce the "ups and downs" experienced throughout the day and eliminate the need to dose medication at school or work (CHADD, n.d.; Wolraich et al., 2019).

Amphetamines induce central nervous system (CNS) activity, activating the acute stress response (fight or flight) and producing a paradoxical calming effect. CNS activation creates physiological changes, just as if the body were stressed or under threat. Amphetamines stimulate the release of adrenaline and raise cortisol and other stress hormone levels, causing increased heart rate and blood pressure. As a result, blood flow is redirected to the muscles and away from the brain. In small doses, amphetamines can alleviate tiredness and help patients feel alert and refreshed. Some common types include dextroamphetamine (Dexedrine), dextroamphetamine/amphetamine (Adderall), amphetamine salt combo XR (Adderall XR), and lisdexamfetamine (Vyvanse; NIMH, 2022; Wolraich et al., 2019; Woods, 2023).

Dextroamphetamine/amphetamine (Adderall) is considered the first-line pharmacological treatment for ADHD and is widely used in individuals 6 years and older. Initial dosing for patients 6 and over is 5 mg (IR tabs) by mouth once or twice daily, increasing the dose by 5 mg every week until optimal symptom management is achieved up to 40 mg/day. IR dosing for children ages 3-5 is 2.5 mg by mouth once daily, increasing the dose by 2.5 mg weekly in 1-3 divided doses per day until optimal results are achieved. With ER tabs, the initial dosing for children ages 6-12 is 5-10 mg by mouth once daily in the morning, increasing the dose by 5 mg or 10 mg weekly up to 30 mg/day. For adolescents ages 13-17, the initial dosing is 10 mg by mouth daily in the morning, increasing to 20 mg/day after a week if symptoms are not controlled. The adult dose is 20 mg daily in the morning, with a maximum dose of 30 mg/day. Proton pump inhibitors (PPIs) such as omeprazole (Prilosec) and esomeprazole (Nexium) can interfere with the absorption of this medication, and there is a rare risk of sudden death in patients with a cardiac history. Dextroamphetamine/amphetamine (Adderall) can be administered with or without food but should be taken in the morning to avoid insomnia. Patients taking the ER formulation should swallow capsules whole, or the contents can be sprinkled on a bite of food that does not require chewing (e.g., applesauce or pudding; NIMH, 2022; Woods, 2023).

Dextroamphetamine (Dexedrine) is similar to dextroamphetamine/amphetamine (Adderall) but without pure amphetamine. Initial dosing for children 6 and older is 5 mg by mouth once or twice daily. The dose can be increased by 5 mg weekly until optimal results are obtained. The dose rarely needs to exceed 40 mg/day. For children ages 3-5, the initial dosing is 2.5 mg by mouth once daily, increasing by 2.5 mg weekly until optimal response is obtained. Dextroamphetamine (Dexedrine) should not be administered in the late evening due to the risk of insomnia. This medication interacts with antihypertensives (diminishes effects), monoamine oxidase inhibitors (MAOIs; may cause severe hypertension), and acidic foods or fruit juice due to delayed absorption and decreased effectiveness. It should be used cautiously in patients experiencing agitation, motor or phonic tics, or Tourette syndrome (Woods, 2023).

Lisdexamfetamine (Vyvanse) is a LA preparation and differs from other medications in this class due to its pharmacokinetics. It is considered a prodrug, which means it must undergo chemical conversion by metabolic processes before becoming an active agent. It does not convert to its active formulation until it reaches the gastrointestinal tract; therefore, its effects take 60 to 90 minutes to occur. The drug has less abuse potential than medications such as dextroamphetamine/amphetamine (Adderall), as it cannot be absorbed intravenously or transmucosally. For adults and children ages 6-17, the initial dose is 30 mg by mouth once daily in the morning, increasing by 10 to 20 mg at weekly intervals to a maximum dose of 70 mg daily. Dosing must be adjusted for patients with severe renal impairment. For patients with a glomerular filtration rate (GFR) of 15-30 mL/min/m², the maximum dose is 50 mg/day. For those with end-stage renal disease (ESRD) or a GFR below 15 mL/min/m², the maximum dose is 30 mg/day. Lisdexamfetamine (Vyvanse) should be taken in the morning with or without food to prevent insomnia (NIMH, 2022; Wolraich et al., 2019).

Methylphenidates stimulate the release of terminal norepinephrine stores, promoting nerve impulse transmission. At high doses, the effects are mediated by dopamine. The most common is methylphenidate (Ritalin, Concerta, Aptensio, Jornay PM), which is available orally. Methylphenidate is also available as a transdermal patch called Daytrana. Dosing instructions for each formulation of methylphenidate are listed in Table 2. Chewable tablets must be taken with at least 240 mL of water. IR formulations should be administered in divided doses throughout the day, at least 30-45 minutes before meals and no later than 6 p.m., due to the risk of insomnia. The exception is Jornay PM which should be administered between 6:30 and 9:30 p.m. If using methylphenidate (Daytrana), the patch should not be placed along the waistline or where tight clothing could pull the patch away from the skin. When changing patches, the site should be moved to the alternate side of the body. Drug interactions include antacids, H2 antagonists, proton pump inhibitors (PPIs), and MAOIs. Because methylphenidate (Concerta) does not dissolve after ingestion, it is contraindicated for patients with a history of peritonitis or conditions that cause gastrointestinal tract narrowing (e.g., short-gut syndrome, cystic fibrosis, or small-bowel inflammatory disease). These medications should be used cautiously in patients with a history of bipolar disorder, EEG abnormalities, psychosis, or emotional disorders (Woods, 2023).  

Table 2

Dosing of Methylphenidate 

Drug	Initial Dose	Titration	Considerations
Concerta	Adults ages 18-65 not taking other stimulants: 18 mg or 36 mg by mouth daily	May increase the dosage in 18 mg increments weekly to a maximum dose of 72 mg daily	No considerations
	Adolescents ages 13-17 not currently taking methylphenidate or for patients taking other stimulants: 18 mg by mouth once daily in the morning	Increase dose by 18 mg at weekly intervals to a maximum of 72 mg daily
	For children ages 6-12 not currently taking methylphenidate or for patients taking other stimulants: 18 mg by mouth once daily	Adjust the dose at weekly intervals to a maximum of 54 mg daily
	Adults and adolescents ages 13-17 currently taking methylphenidate: if the previous dose was 5 mg 2-3 times a day, start 18 mg by mouth once daily if the previous dose was 10 mg 2-3 times a day, start 36 mg by mouth once daily if the previous dose was 15 mg 2-3 times daily, give 54 mg by mouth once daily if the previous dose was 20 mg 2-3 times daily, give 72 mg by mouth once daily	The maximum conversion dose is 72 mg daily
	Children ages 6-12 currently taking methylphenidate: if the previous dose was 5 mg 2-3 times daily, give 18 mg by mouth once daily if the previous dose was 10 mg 2-3 times daily, give 36 mg by mouth once daily if the previous dose was 15 mg 2-3 times daily, give 54 mg by mouth once daily	The maximum conversion dose is 54 mg daily
Ritalin LA	Adults and children ages 6 and older: 20 mg by mouth once daily	Increase dosage by 10 mg at weekly intervals to a maximum dose of 60 mg daily	If using to replace the current methylphenidate twice daily dosage, give the total daily dosage once daily
Aptensio XR	Adults and children ages 6 and older: 10 mg by mouth daily in the morning	Increase dosage by 10 mg at weekly intervals to a maximum dose of 60 mg daily	No considerations
Jornay PM	For children ages 6 and older: 20 mg by mouth once daily in the evening	Increase dosage by 20 mg at weekly intervals to a maximum dose of 100 mg daily	Can adjust the timing of administration between 6:30 and 9:30 p.m.
Daytrana	Adults and children ages 6-17: apply one 10 mg patch daily	Increase the dose weekly as needed to a maximum of 30 mg daily	Apply the patch 2 hours before the desired effect and remove 9 hours later

(Woods, 2023)

The side effects of stimulants include hypertension, tachycardia, anxiety, decreased appetite, sleep problems, personality changes, tics, stomach pain, and headaches. Less commonly reported side effects include allergic reaction, fever, arthralgia, psychosis, and depression. Sudden death is a rare adverse effect in patients with preexisting cardiac conditions. These drugs should be used with caution in patients with hypertension, seizures, a history of myocardial infarction, stroke, liver disease, kidney disease, or anxiety disorders. Stimulants are contraindicated for patients with advanced arteriosclerosis, hyperthyroidism, symptomatic cardiovascular disease, structural cardiac abnormalities, cardiomyopathy, serious arrhythmia, or glaucoma. Clinicians should counsel patients on strategies to manage insomnia, including taking the medication before noon, limiting or avoiding caffeine, and maintaining healthy sleep hygiene. When insomnia requires pharmacological management, melatonin is encouraged as the initial intervention, as it naturally occurs in the body and is non-addicting. Some patients may require adjunctive prescriptive sleep aids, such as clonidine (Catapres, Kapvay) or trazodone (Desyrel), which may be used in children and adults. Medications such as eszopiclone (Lunesta) and zolpidem (Ambien) should only be prescribed for adults and should be taken 30 to 60 minutes before bedtime (NIMH, 2022; Tarraza & Barry, 2017; Woods, 2023).

Determining which medication to use to treat ADHD depends on a range of factors, including but not limited to the presence of comorbidities, the risk of experiencing side effects, consideration of the individual's compliance potential, and the potential for drug diversion. Stimulants carry a risk for diversion (i.e., when legitimate stimulant prescriptions for ADHD are diverted and used for reasons other than treating ADHD). When taken at doses and via routes other than those prescribed, stimulants can increase dopamine levels in the brain in a rapid and highly amplified manner (similar to other drugs commonly abused, such as opioids), thereby disrupting normal communication between brain cells and producing euphoria. As a result, these biochemical processes and subsequent euphoric effects increase the risk of addiction. Therefore, before prescribing these medications, clinicians must assess each patient's risk for diversion and continue to reassess at each follow-up visit while continuing treatment. Following drug selection, clinicians are advised to "start low and go slow" when prescribing these agents, initially prescribing the lowest dose possible and gradually titrating the dose upward to minimize side effects. Most side effects of stimulants can be eliminated or decreased with this medication initiation plan. Some people describe a stimulant rebound during the period between dosing as the medication is wearing off, in which they can experience a negative mood, fatigue, or hyperactivity. These symptoms can be managed by changing the dose or schedule of IR formulas or switching to an LA formula if possible (CHADD, 2022; Wolraich et al., 2019).

Patients prescribed stimulants should have specific monitoring performed by prescribers at particular points during treatment. At baseline, all patients should have their blood pressure, heart rate, height, and weight evaluated. Height should be monitored when taking stimulants, especially in children who have not reached their full adult height, as stimulants can slow their growth rate. During dose adjustments, a weekly phone check-in or follow-up appointment is advised to monitor for side effects and assess patients for tics or adverse effects. This follow-up allows the prescriber to track changes and the severity of symptoms closely. Once the optimal dose is established, patients should have follow-up visits every 1-3 months. Routine laboratory testing is not advised unless there are specific concerns based on the patient's clinical presentation. When applicable, patients should be educated that amphetamines may increase plasma corticosteroid levels and interfere with urine steroid test results (Wolraich et al., 2019; Woods, 2023).

Non-Stimulants

Non-stimulants are also highly effective in reducing ADHD symptoms, but they generally take longer to start working. Non-stimulants are often used in place of stimulants in patients with unacceptable adverse effects, with inadequate results with stimulants, or in combination with stimulants to enhance effects. Non-stimulants can help improve focus and attention and decrease impulsivity. Some of the most common non-stimulant medications include atomoxetine (Strattera) and guanfacine ER (Intuniv). Atomoxetine (Strattera) alleviates inattention and hyperactivity symptoms of ADHD by selectively inhibiting the reuptake of norepinephrine. It is not a controlled substance and is thus determined to have low abuse potential. Atomoxetine (Strattera) has a slower onset, taking up to 4 weeks to see the full effects of the medication. Initial dosing for adults and children older than 6 and adolescents weighing more than 70 kg is 40 mg by mouth daily, increasing after at least 3 days to a total of 80 mg/day as a single dose in the morning or two evenly divided doses. For children 6 or older and adolescents weighing less than 70 kg, initial dosing is 0.5 mg/kg by mouth daily, increasing after at least 3 days to a target total daily dose of 1.2 mg/kg given either once daily in the morning or twice daily in equally divided doses. Atomoxetine (Strattera) should not be used with albuterol (which may increase cardiovascular effects) or MAOIs (which may cause hyperthermia, rigidity, and myoclonus). Adverse effects include headaches, insomnia, dizziness, irritability, fatigue, abnormal dreams, sleep disorder, anxiety, orthostatic hypotension, tachycardia, palpitations, hot flashes, abdominal pain, constipation, dyspepsia, nausea, vomiting, anorexia, urinary retention, and ejaculatory problems. Due to these effects, atomoxetine (Strattera) should be used cautiously in patients with hypertension, tachycardia, hypotension, urinary retention, or cerebrovascular disease (NIMH, 2022).

Antihypertensives such as clonidine (Catapres, Kapvay) and guanfacine (Tenex, Intuniv) have been approved for ADHD symptoms in children, such as hyperactivity and aggression; they may help adults, but studies are limited at this point. Dosing of clonidine ER (Kapvay) for ADHD in children ages 6-17 is initially 0.1 mg by mouth at bedtime. The dose can be adjusted by 0.1 mg weekly until desired effects are reached up to 0.4 mg/day. Only the ER form of guanfacine (Intuniv) is approved to treat ADHD. Initial dosing in children ages 6-17 is 1 mg by mouth once daily in the AM or PM at the same time each day. If needed, the dose can be adjusted by 1 mg per week. Dosages over 4 mg/day in children 6-12 or above 7 mg in children 13-17 have not been evaluated. These drugs pose a risk for significant adverse effects, such as hypotension, sedation, and hypertensive rebound. Clonidine (Catapres, Kapvay) is an alpha-2 noradrenergic agent, and guanfacine (Tenex, Intuniv) is an alpha-2a noradrenergic agent. However, both are believed to work by affecting the available levels of norepinephrine and dopamine. Another treatment option for adult ADHD patients is modafinil (Provigil), a wake-promoting agent that the FDA currently approves for narcolepsy and extreme fatigue in patients with multiple sclerosis. It does not seem to affect central dopamine or norepinephrine pathways but indirectly activates the frontal cortex. A small study of adults with diagnosed ADHD showed favorable results from modafinil (Provigil) after a 2-week trial in 48% of patients. Data are limited and preliminary but warrant further long-term studies and consideration (CHADD, n.d.; Woods, 2023).

Antidepressants that target the neurotransmitter norepinephrine are sometimes used to treat ADHD, but they are not FDA-approved for this indication and are thus considered off-label. Venlafaxine (Effexor) inhibits the reuptake of norepinephrine, serotonin, and dopamine. Bupropion (Wellbutrin) is a norepinephrine and dopamine reuptake inhibitor (NDRI) that helps improve concentration and focus and reduces hyperactivity. Since it does not influence serotonin, it differs from many other antidepressants. Possible side effects of bupropion (Wellbutrin) include anxiety, agitation, increased motor activity, insomnia, tremors or tics, dry mouth, headaches, nausea, and an increased risk for seizures in susceptible individuals or those with a history of eating disorders. Less commonly, duloxetine (Cymbalta) may be used; it works by blocking the reuptake of norepinephrine and serotonin. Like atomoxetine (Strattera), these drugs are not controlled substances and have low abuse potential but should be used with caution and in conjunction with extensive patient counseling regarding the possible side effects and risks. They are not recommended for children with depression and should be used with caution in adolescents due to the increased risk of suicide accompanying antidepressant use (CHADD, n.d.; World Health Organization [WHO], 2022).

In June 2020, the FDA approved EndeavorRx, a new treatment option for ADHD in children. EndeavorRx is presented as an immersive video game played on a mobile device. The game is approved for children ages 8-12. To obtain access to the game, the patient must have the treatment prescribed by their primary ADHD treatment provider. The game is considered a medical device designed to be used in conjunction with other therapies and should not be used as monotherapy. EndeavorRx uses sensory stimuli and motor challenges to stimulate areas of the brain that are involved in attention. The game challenges players to multitask while ignoring distractions by navigating courses, collecting tokens, and avoiding obstacles. The game measures the player's performance and adjusts the gameplay to meet the player's real-time needs. Suggested use is 5 days a week for 25 minutes each day. The game should be played for at least 4 consecutive weeks for optimal results. Results of 5 randomized clinical control studies, including over 600 children, showed that 68% of parents reported improvement in their children's symptoms after 2 months of this treatment, and 73% of child participants self-reported improved attention. No adverse effects were experienced by any of the participants across all five studies (Akili Interactive Labs, 2022).

Environmental Modifications 

Along with medications, environment modifications can help reduce symptoms and improve outcomes for patients diagnosed with ADHD. These modifications focus on providing a structured environment that supports each individual and helps them be more successful (Betker, 2017). Examples of environmental modifications include:

• implementing structure and routine in daily activities
• using checklists
• using cues to stay on task
• minimize visual and auditory distractions
• provide workstation options
• provide focus tools (e.g., stress balls or fidget toys)
• allow for movement breaks
• repeat instructions and encourage eye contact before speaking
• assist with organization
• provide extra time for chores at home or academic tasks at school (Betker, 2017)

Barriers to Treatment

Per the AAP, a barrier to treatment is limited access to mental health services. Most children diagnosed with ADHD seek treatment with their primary healthcare provider, and health insurance may not reimburse for additional provider evaluations such as mental health therapies. Because appropriate treatment is time-consuming—involving interacting with parents and the child, communicating with the school and the teachers, and ensuring continuity of care—the burden of care is significant. Certain underrepresented ethnic groups, such as African American and Latino children, are less likely to receive a diagnosis and subsequent treatment for ADHD. This demonstrates the need to ensure equity in evaluating all children for ADHD (Wolraich et al., 2019).

There is also a decline in medication usage for ADHD over time. Although the NIMH has reported that more than 65% of children with ADHD are prescribed medication, numerous studies show these numbers are declining yearly. Although medications are prescribed for ADHD treatment, over half of the children in the US and Europe stop taking their prescribed medications within 6 months of initiation. By the end of adolescence, only 10% of children taking ADHD treatment still use the prescribed medication, even half the time. Short-term medication compliance is also difficult, with only 40% of children taking every dose as prescribed. Barriers to medication compliance include stigma, discord between a parent and a child, negative past treatment experiences, the financial cost of follow-up appointments and medications, a lack of autonomy regarding treatment goals, and parental knowledge or beliefs about ADHD and treatment options (Baweja et al., 2021).

Comorbidities

Although ADHD is diagnosed more often in males, there is an increased number and prevalence of comorbidities in females diagnosed with ADHD. Comorbid disorders that occur in children with ADHD to varying degrees include oppositional defiant disorder, autism spectrum disorder, substance use disorder, conduct disorder, depression, anxiety, and obsessive-compulsive disorder (OCD). Oppositional defiant disorder occurs with ADHD in approximately 50% of children with a combined presentation of ADHD and 25% in the predominantly inattentive presentation of ADHD. Oppositional defiant disorder is characterized by a child resisting directions from the people they are most familiar with, such as their parents or teachers. The child may be irritable, argumentative, lose their temper often, and have a low frustration tolerance. Oppositional defiant disorder generally manifests in the school-age years and disappears in adolescence. Conduct disorder is diagnosed in 25% of children or adolescents with the combined presentation of ADHD. Children with conduct disorder may be aggressive toward individuals or animals, destroy property intentionally, and appear unemotional and impersonal. Often, children with conduct disorder get into legal trouble and then become trapped in the legal system. This pattern may continue through adulthood, when conduct disorder can develop into antisocial personality disorder. Anxiety and depression can also cause difficulties in children with ADHD. ADHD and anxiety share similar symptoms, such as inattentiveness, but children with ADHD are less likely to worry repeatedly over the same things. While many of these disorders can occur with ADHD, not all children with ADHD will have comorbid conditions. Children with additional comorbidities with ADHD are more difficult to treat and may have more challenges in their academic and home environments (APA, 2022).

Supporting Healthy Habits 

Since ADHD is associated with poor health outcomes, initiating and supporting healthy habits from childhood into adulthood is essential. Undesirable lifestyle factors can contribute to and directly affect inattention and symptoms of hyperactivity. Insomnia and sleeplessness can affect individuals with ADHD due to the side effects of stimulants. Not getting enough sleep negatively influences health. The current recommendation for children aged 6 to 13 years is to aim for 9 to 11 hours of sleep per night; however, lifestyle choices like screen time right before bed, caffeine intake, and physical activity can all affect sleep. These factors should be considered, in addition to stimulant medication use, when assessing contributors to sleep problems in ADHD. A recent study noted the benefits of improved sleep hygiene, where healthcare providers taught parents (through handouts) about sleep hygiene interventions like using a set bedtime, maintaining bedtime routines, removing all media from the bedroom, and avoiding caffeine consumption. Results showed improvements in ADHD symptoms and health-related outcomes. Other habits that can improve health outcomes include developing healthy eating habits such as eating plenty of fruits, vegetables, and whole grains and drinking more water instead of drinks containing artificial sweeteners. Children with ADHD tend to drink more artificially sweetened juices than their peers; the intake of these drinks could exacerbate ADHD symptoms. Encouraging children to drink more water can help reduce ADHD symptoms and prevent other health concerns such as caries or tooth decay (CDC, 2021b; Hiscock et al., 2015).

Individuals diagnosed with ADHD are also at an increased risk of unintentional injuries, such as falls, drowning, burns, and poisoning in children. Adolescents and young adults are at an increased risk of being involved in motor vehicle accidents due to inattention. Individuals with ADHD have an increased risk of other mental, behavioral, and emotional concerns. Due to the stigma surrounding mental illness, adolescents and young adults with ADHD may be the victim of bullying, increasing their risk of depression and suicide. These individuals may also engage in risky behavior, such as sexual promiscuity and the use of high-risk drugs. Building healthy habits in the early years can help patients cope with their illness throughout life and learn effective coping strategies (CDC, 2021b; Holton & Nigg, 2020).

References

Akili Interactive Labs. (2021). EndeavorRx. https://www.endeavorrx.com/about-endeavorrx

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR). American Psychiatric Association Publishing.

Baweja, R., Soutullo, C. A., & Waxmonsky, J. G. (2021). Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care. World Journal of Psychiatry, 11(12), 1206-1227. https://doi.org/10.5498/wjp.v11.i12.1206

Betker, C. (2017). Environmental strategies for managing attention deficit hyperactivity disorder. Journal of Childhood & Developmental Disorders, 3(24). https://doi.org/10.4172/2472-1786.100062

Centers for Disease Control and Prevention. (2021a). Data and statistics about ADHD. https://www.cdc.gov/ncbddd/adhd/data.html

Centers for Disease Control and Prevention. (2021b). Protecting the health of children with ADHD. https://www.cdc.gov/ncbddd/adhd/features/protecting-adhd-children.html

Centers for Disease Control and Prevention. (2021c). Treatment of ADHD. https://www.cdc.gov/ncbddd/adhd/treatment.html   

Children and Adults with Attention-Deficit/Hyperactivity Disorder. (n.d.). The role of medication. Retrieved July 27, 2022, from https://chadd.org/for-professionals/the-role-of-medication/

Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2017). About ADHD. https://chadd.org/wp-content/uploads/2018/03/aboutADHD.pdf

Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2022). Understanding ADHD. http://www.chadd.org/Understanding-ADHD/For-Professionals/For-Healthcare-Professionals.aspx

Hiscock, H., Sciberras, E., Mensah, F., Gerner, B., Efron, D., Khano, S., & Oberklaid, F. (2015). Impact of a behavioral sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: Randomized controlled trial. BMJ, 2015(350), h68. https://doi.org/10.1136/bmj.h68

Holton, K. F., & Nigg, J. T. (2020). The association of lifestyle factors and ADHD in children. Journal of Attention Disorders, 24(11), 1511-1520. https://doi.org/10.1177/1087054716646452

Krull, K. R. (2022). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. UpToDate. Retrieved July 30, 2022, from https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis

National Institute of Mental Health. (n.d.). Attention-deficit/hyperactivity disorder (ADHD): Statistics. Retrieved July 26, 2022, from https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd.shtml

National Institute of Mental Health. (2021). Attention-deficit/hyperactivity disorder. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd

National Institute of Mental Health. (2022). Mental health medications. https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149857

Okano, L., Ji, Y., Riley, A. W., & Wang, X. (2019). Maternal psychosocial stress and children's ADHD diagnosis: A prospective birth cohort study. Journal of Psychosomatic Obstetrics & Gynecology, 40(3), 217-225. https://doi.org/10.1080/0167482X.2018.1468434

Sciberras, E., Mulraney, M., Silva, D., & Coghill, D. (2017). Prenatal risk factors and the etiology of ADHD: A review of existing evidence. Current Psychiatry Reports, 19(1), 1. https://doi.org/10.1007/s11920-017-0753-2

Soheilipour, F., Shiri, S., Ahmadkhaniha, H. R., Abdollahi, E., & Hosseini-Baharanchi, F. S. (2020). Risk factors for attention-deficit/hyperactivity disorder: A case-control study in 5 to 12 years old children. Medicine and Pharmacy Reports, 93(2), 175-180. https://doi.org/10.15386/mpr-1407

Solanto, M. V. (2022). Psychotherapy for attention deficit hyperactivity disorder (ADHD) in adults. UpToDate. Retrieved July 30, 2022, from https://www.uptodate.com/contents/psychotherapy-for-attention-deficit-hyperactivity-disorder-adhd-in-adults

Tarraza, M., & Barry, L. (2017). Integrative management of disordered attention. In K. R. Tusaie & J. J. Fitzpatrick (Eds.), Advanced practice psychiatric nursing: Integrating psychotherapy, psychopharmacology, and complementary and alternative approaches across the lifespan (2nd ed., pp. 405-442). Springer Publishing Company.

Wang, B., Zeng, H., Liu, J., & Sun, M. (2021). Effects of prenatal hypoxia on nervous system development and related diseases. Frontiers in Neuroscience, 15(755554). https://doi.org/10.3389/fnins.2021.755554

Wolraich, M. W., Hagan, J. F., Jr., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. (2019). Clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528

Woods, A. D. (2023). Nursing 2023 drug handbook. Wolters Kluwer.

World Health Organization. (2022). Mental disorders. https://www.who.int/en/news-room/fact-sheets/detail/mental-disorders