New Approaches to the Management and Treatment of Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder(ADHD) is among the most prevalentpsychiatric disorders seen inchildren, affecting 8% to 10% of school-agedchildren,¹ and accounting for 30% to 50% ofall mental health referrals for children.² In40% to 70% of cases, childhood ADHD willpersist into adolescence.³ Some researchsuggests that anywhere from 43% to 75% ofchildren will experience ADHD into adulthood,^3-6 although individual symptoms maychange. Research suggests that left untreated,children with ADHD are likely to havesignificantly higher rates of antisocial andsubstance abuse disorders (32% and 10%,respectively) when compared with controls(8% and 1%, respectively).⁷ In older patients,the core symptoms of ADHD give rise tonumerous social and cognitive impairments.Attention problems frequently result inproblems with time management and difficultyswitching and completing tasks.⁸ Legaland employment problems, as well as maritaldiscord have all been associated withADHD.⁹

For decades, stimulants, in particularmethylphenidate (MPH), have been the cornerstoneof ADHD management.¹⁰ Immediate-releaseMPH requires dosing 3 to 4 times aday to achieve symptom managementthrough the day and is thus inconvenient forpatients, their parents, and school staffsupervising the administration of therapy.¹¹This leads to poor patient adherence and lowpersistence with therapy.¹²

The AmericanJournal of Managed Care

In recent years, a number of extended-releaseMPH formulations have been developedto avoid the need for repeated dosingduring the day. These formulations use variedtechnologies for the release of medication,resulting in varied and distinctpharmacokinetic and pharmacodynamicprofiles. In addition, in 2003 the first nonstimulantdrug for treatment of ADHDgained approval by the US Food and DrugAdministration, creating another therapeuticoption. This issue of reports on thecurrent medical evidence surrounding theseagents to guide clinicians in their treatmentdecisions.

Mark A. Stein, PhD, professor of psychiatryand director of HALP Clinic and ADHDClinical Research in Child and AdolescentPsychiatry at The University of Chicagoreviews innovations in ADHD treatment anddescribes research on the newer, long-actingstimulant and nonstimulant treatments forADHD. He reports that longer-acting stimulantsand nonstimulants provide increasedclinical utility compared to short-actingstimulants. Dr Stein suggests, however, thatdirect head-to-head studies are needed tobetter inform clinical decision making andto identify moderators and mediators of differentialresponse.

Kenneth W. Steinhoff, MD, associate clinicalprofessor at the University of California,Irvine, reports on recent evidence supportingoptimal treatment dosing across the day.He suggests that for stimulants, the value ofincreasing the dose to improve effect hasreplaced older notions of minimizing exposureto medication by treating at the lowestdose demonstrating effect.

Oscar G. Bukstein, MD, MPH, associateprofessor of psychiatry at the University ofPittsburgh, Pennsylvania, examines anaspect of ADHD not frequently considered:patient and family satisfaction with treatment.Since satisfaction is key to compliance,Dr Bukstein's report addresses asignificant gap in the ADHD literature. Hereviews the general determinants of satisfactionwith medical care and behavioral healthcare of children and adolescents, satisfaction with medication and specific medicationsfor ADHD, and differential satisfactionwith various treatment modalities for ADHD.

Mark Olfson, MD, MPH, professor of clinicalpsychiatry at Columbia University, NewYork, reviews the efficacy of stimulant medicationsin the treatment of ADHD, focusingon new stimulant preparations and othernew pharmacological options. The availabilityof a wider range of therapies gives physiciansmore opportunities to select the besttreatment regimen for their patients.

Recent years have seen many advances inthe treatment of ADHD. New compounds,including newly formulated extende-dreleasestimulants, as well as the new nonstimulantagent, atomoxetine, offer newoptions. These new agents not only offergreater convenience, but also promise gainsin symptom relief and improved outcomes.With adequate management of symptoms,this frequently life-long disorder need notlead to life-long impairment.

Pediatrics

1. American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child withattention-deficit/hyperactivity disorder. . 2000;105:1158-1170.

Arch Gen Psychiatry

2. A 14-month randomized clinical trial of treatment strategies for attention deficit/hyperactivity disorder. TheMTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. . 1999;56:1073-1086.

Am J Psychiatry

3. Mannuzza SR, Klein G, Bessler A, Malloy P, LaPadula M. Adult psychiatric status of hyperactive boysgrown up. . 1998;155:493-498.

Arch Gen Psychiatry

4. Gittelman RS, Mannuzza S, Bonagura N, Malloy P, Giampino TL, Addalli KA. Hyperactive boys almostgrown up. I. Psychiatric status. . 1985;42:937-947.

J Am Acad Child Psychiatry

5. Weiss G, Hechtman L. Psychiatric status of hyperactives as adults: a controlled prospective 15-year followupof 63 hyperactive children. . 1985;24:211-220.

J Abnorm Psychol

6. Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder intoyoung adulthood as a function of reporting source and definition of disorder. . 2002;111:279-289.

Arch Gen Psychiatry

7. Mannuzza SR, Klein G, Bonagura N, Malloy P, Giampino TL, Addalli KA. Hyperactive boys almostgrown up. V. Replication of psychiatric status. . 1991;48:77-83.

ADHD in Adulthood: A Guide to Current Theory, Diagnosis, andTreatment

8. Weiss MA, Hechtman LT, Weiss G. . Baltimore, Md: Johns Hopkins University Press; 1999.

Attention-Deficit Hyperactivity Disorder: A Clinical Workbook

9. Barkley RA, Murphy KR. . NewYork, NY: Guilford Publications; 1998.

Pediatrics

10. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committeeon Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. . 2001;108:1033-1044.

Pediatrics

11. Stein MA, Blondis TA, Schnitzler ER. Methylphenidatedosing: twice daily versus three times daily. . 1996;98:748-756.

12. Swanson J. Compliance with stimulants for attention-deficit/hyperactivity disorder: issues and approachesfor improvement. CNS Drugs. 2003;17:117-131.

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