Continuing Education Column Treatment of Attention- Deficit Hyperactivity Disorder Young Key Kim, MD Dong Ho Song, MD Department of Psychiatry Institute of Behavioral Science in Medicine, Yonsei University College of Medicine E - mail : dhsong@yuhs.ac J Korean Med Assoc 2009; 52(5): 489-499 Abstract This article presents the knowledges regarding the evaluation and the management of attention-deficit/hyperactivity disorder (ADHD). Probably the most important components to a comprehensive evaluation of patients with ADHD, are the clinical interview, the medical examination, and the completion and scoring of behavior rating scales. The treatments of ADHD are followings: pharmacologic treatment such as stimulants, atomoxetine, modafinil, and bupropionn, and non-pharmacologic treatment such as parental education/training and cognitivebehavioral treatment. Keywords: ADHD; Epidemiology; Evaluation; Treatment 489
Kim YK Song DH Table 1. Diagnostic criteria for Attention-Deficit / Hyperactivity Disorder (ADHD) A. Either (1) or (2): (1) Inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) Often has difficulty sustaining attention in tasks or play activities (c) Often does not seem to listen when spoken to directly (d) Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) Often has difficulty organizing tasks and activities (f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) Is often easily distracted by extraneous stimuli (i) Is often forgetful in daily activities (2) Hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) Often fidgets with hands or feet or squirms in seat (b) Often leaves seat in classroom or in other situations in which remaining seated is expected (c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) Often has difficulty playing or engaging in leisure activities quietly (e) Is often "on the go" or often acts as if "driven by a motor" (f) Often talks excessively Impulsivity (g) Often blurts out answers before questions have been completed (h) Often has difficulty awaiting turn (i) Often interrupts or intrudes on others (e.g., butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder). 490
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Treatment of Attention-Deficit Hyperactivity Disorder Table 2. Clinical and research scales for assessment and treatment response of ADHD Scales Notes Conners Parent Rating Scale-Revised, CPRS-R Self-report forms by parent and adolscent were developed Conners Teacher Rating Scale-Revised, CTRS-R Noh JS et al. developed Korean version of Conners Scale Child Behavior Checklist, CBCL Korean version of CBCL was developed by Oh KJ and Lee HR Child Behavior Checklist-Teacher Rating Form, CBCL-TRF Home Situation Questionnaire-Revised, HSQ-R HSQ-R consists of 14 items, rated 0~9 School Situations Questionnaire-Revised, SSQ-R Academic Performance Rating Scale, APRS APRS is 19- item scale, rated 1~6 and designed for assessment of academic performances and accuracies ADHD Rating Scale-IV for Parents and Teachers, ADHD RS-IV includes 18 items and Korean version was ADHD RS -IV standardized by So YK et al Inattention/Overactivity With Aggression (IOWA) IOWA CTRS was 10- item scale for assessing inattention, Conners Teacher Rating Scale, IOWA CTRS hyperactivity, and oppositional defiant problems Korean version was standardized by Shin MS et al Swanson, Nolan, and Pelham Rating Scale-IV, SNAP-IV SNAP-IV was 26- item scale 493
Kim YK Song DH Table 3. Available medications approved by food and drug administrations for ADHD in Korea Generic class Brand name Duration of How supplied Usual dosing Typical FDA Formulation activity Range starting Max/day and (hours) (mg/kg/day) dose mechnism Methylphenidate IR Methylpen, 3~4 5, 10 mg tablet 0.3~2.0 5 mg bid 60 mg Tablet of 50: Penid 10 racemic mixture D, I-threomethylphenidate Methylphenidate ER Metadate CD 8 10, 20, 30 mg 0.3~2.0 20 mg qam 60 mg Two types of beads capsule; can be sprinkled give bimodal delivery (30% immediate and 70% delayed release) of 50 : 50 racemic mixture D, I-threomethylphenidate OROS - Concerta 12 18, 27 mg caplet 0.3~2.0 18 mg qam 72 mg Osmotic pressure Methylphenidate system delivers 50:50 racemic mixture D,I-threomethylphenidate Atomoxetine Strattera 24 10, 18, 25, 40, 1.2 0.5 mg/kg/day 1.4 mg Capsule of 60 mg capsule for 4 days; then /kg/day atomoxetine 1 mg/kg/days; or 100 mg then 1.2 mg /kg/day 494
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