Attention-Deficit Hyperactivity Disorder Across the Lifespan
Abstract
Epidemiology
Comorbidity
Etiology and Risk Factors
Pathophysiology
Cognitive Deficits
Neuroanatomical Findings
Functional Neuroimaging
Course and Prognosis
Clinical Evaluation
Interview
Topic | Preschool | School Age | Adolescent | Adult |
---|---|---|---|---|
Symptom presentation | Hyperactivity and impulsivity predominate, difficulty attending to story time, refusal to nap, climbing on furniture, will not hold hand in store | Combined presentation of ADHD most common; failure to attend to and complete school work leads to referral; shows classic DSM-5 symptoms | Inattentive presentation becomes more common, hyperactivity presents as internal restlessness, impulsivity as poor choices; milder cases may present for first time, but symptoms should have started in childhood | Failure to enter or complete college despite intelligence, job terminations; moving from job to job; disorganization and poor time management |
Interview with patient | Observation of child, only, take note of developmental milestones particularly language | Interview patient alone to explore mood/anxiety issues, only a minority of children will acknowledge ADHD symptoms; sitting still in interview does not rule out ADHD | Separate interviews of parent and child preferred; ask adolescent about illicit drug/alcohol use, relationship issues; adolescent more aware of symptoms but may minimize impact | Adult is primary source of history; review 18 ADHD symptoms with focus on job and social functioning; adult ADHD rating scales are highly useful to prompt interview; must establish childhood onset of impairment |
Collateral information | Obtain reports from preschool or daycare | Rating scales from teacher, school conduct folder | More difficult to get rating scales from middle/high school teachers; report cards can be useful substitutes | Spouse or parents can provided useful collateral; negative work evaluations may show evidence of ADHD symptoms |
Common comorbidities | Language delays, ask about social skills, screen for autism spectrum disorders | Oppositional defiant disorder, anxiety disorders | Oppositional defiant disorder, anxiety, depression, substance use disorders | Anxiety, depression, mania, or early-onset dementia in 40- to 50-year-old group; substance use and diversion |
Health issues | If developmental delays present, review medical history for any congenital conditions | Medical history negative in most cases, pediatric referral for specific medical conditions only | Obesity, accidental injury, sexually transmitted diseases | Hypertension, thyroid issues, and diabetes become more common; counsel patient to see primary care physician regularly |
Treatment issues | Stimulant response rate somewhat lower than in other age groups | Stimulant response rate up to 90% | Stimulant response rate up to 90%; beware of diversion of stimulant | Stimulant response rate up to 90%; be aware of drug interactions with other agents |
Psychological Testing
Medical Evaluation and Laboratory Tests
Pharmacotherapy
Stimulants
Medication and Dosing | Preschool Age Range (<25 kg) | Later School Age and Younger Adolescents (25–40 kg) | Older Adolescents and Adults (>40 kg) |
---|---|---|---|
Stimulants | |||
Methylphenidate (t.i.d.) | 2.5–10 | 15–20 | 25–30 |
Methylphenidate OROS (every morning) | 18–36 | 54–72 | 90–108 |
Dexmethylphenidate (b.i.d.) | 1.25–5 | 7.5–10 | 12.5–15 |
Controlled-release dexmethylphenidate (every morning) | 5–10 | 15–20 | 30 |
Amphetamine (b.i.d.) | 1.25–5 | 7.5–10 | 12.5–30 |
Controlled-release amphetamine | 5–10 | 15–20 | 25–60 |
Lisdexamfetamine (every morning) | 20–30 | 40–50 | 60–70 |
Nonstimulants | |||
Clonidine | 0.05–0.1 h.s. | 0.1 b.i.d. to 0.1 t.i.d. | 0.1 q.i.d. |
Extended-release clonidine | 0.1 h.s. | 0.1 b.i.d. to 0.1 every morning/0.02 h.s. | 0.2 b.i.d. |
Guanfacine | 0.5 h.s. to 0.5 b.i.d. | 1 b.i.d. to 1 every morning/2 h.s. | 2 b.i.d. or 1 q.i.d. |
Extended-release guanfacine | 1 every morning | 2–3 every morning | 4 every morning |
Atomoxetine | 10–20 every morning/10 every night | 18–25 b.i.d. | 40 b.i.d. |
Atomoxetine
Alpha-Agonists
Psychosocial Interventions
Conclusions
References
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