Since the earliest descriptions of the condition, controversy has prevailed as to the existence of as well as appropriate management of attention deficit hyperactivity disorder. Often diagnosed in childhood, symptoms of attention deficit hyperactivity disorder can continue into adolescence and adulthood, requiring lifelong therapy. Effective therapeutic interventions include stimulant medications with all their respective potential side effects, including the cardiovascular system. However, although initial studies raised concerns for an increase in serious adverse cardiovascular effects among children receiving these drugs, more recent and extensive reports have failed to substantiate those findings among young patients.
Key points
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Stimulants improve behavior yet can be associated with cardiovascular effects of increased heart rate and blood pressure changes.
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The risk of sudden death is not increased over that of the general population.
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Routine ECG monitoring is not indicated.
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Patient compliance with medication regimens is often suboptimal.
Introduction
Although possibly described as early as the 17th century, distraction of attention was recognized and reported as an adverse behavioral condition by Dr Alexander Crichton in 1789 in his medical treatise on mental illness, “An Inquiry into the Nature and Origin of Mental Derangements.” In his series of 3 books, he describes patients who are easily distracted by even the slightest extraneous stimuli. This inability to focus on any one task, which he describes as a morbid alteration of attention among such patients, causes them to become hyperexcited and exhibit what was described as having the fidgets. In 1846, as 1 of 10 short stories of various childhood behaviors included in his children’s book, Struwwelpeter (Slovenly Peter), Dr Heinrich Hoffmann introduced the fictitious character of “Zappel-Philipp” (Fidgety Philip). Fidgety Philip, although perhaps not directly implying any mental disorder, does illustrate several of the now-accepted criteria for attention deficit hyperactivity disorder (ADHD): inattention, hyperactivity, and impulsivity. In addition, he describes his character’s behavioral effects on parents and family.
However, a more definitive description of the disorder was published by Dr George Still (of the innocent Still’s murmur fame). A pediatrician, Dr Still became involved in childhood disease research and in his treatise, “On Some Abnormal Psychical Conditions in Children,” published in 1902, he described children with a morbid defect of moral control but without evidence of physical disease or impairment of intellect, to distinguish these children from those with associated physical conditions such as meningitis, brain tumor, head injury, or mental illness. His work was followed by numerous authors over the ensuing decades, with descriptions of childhood hyperactivity, inattentiveness, compulsive behavior, ease of excitability, and inability to concentrate. Accordingly, the condition itself has been associated with controversy as to its actual existence as a neurodevelopmental disorder and has undergone several name changes, culminating in the current ADHD designation in 1987.
In 1994, the condition was subdivided according to clinical presentation:
- •
ADHD inattentive
- •
ADHD hyperactive-compulsive
- •
ADHD combined.
Between 5% and 20% of school-aged children are currently diagnosed with ADHD; boys more frequently than girls. Although previously thought to be only a childhood disorder, over 50% of individuals diagnosed in childhood continue to exhibit symptoms as adults. Causal theories have varied over the years. Although a precise single cause of ADHD remains controversial, at present, environmental, genetic, as well as neuropsychological factors have been included. A genetic inheritance factor has been indicated in 75% of affected children.
Possible cause includes
- 1.
Environmental factors
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Preterm and very low birth weight infants
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Fetal alcohol and tobacco exposure
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Fetal or childhood infections
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Lead exposure
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Food additives
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Polychlorinated biphenyls exposure
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History of physical or emotional abuse
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Congenital heart repair before 1 year of age
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- 2.
Genetics
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Genes associated with dopamine transportation
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LPHN3 gene, which facilitates responsiveness to stimulant medications
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- 3.
Neuropsychological
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Inability to regulate and manage daily tasks (executive functioning)
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Because executive functioning evolves with age and brain maturation, this last concept helps to explain why symptoms of ADHD may not become fully manifest until adolescence or young adulthood.
Introduction
Although possibly described as early as the 17th century, distraction of attention was recognized and reported as an adverse behavioral condition by Dr Alexander Crichton in 1789 in his medical treatise on mental illness, “An Inquiry into the Nature and Origin of Mental Derangements.” In his series of 3 books, he describes patients who are easily distracted by even the slightest extraneous stimuli. This inability to focus on any one task, which he describes as a morbid alteration of attention among such patients, causes them to become hyperexcited and exhibit what was described as having the fidgets. In 1846, as 1 of 10 short stories of various childhood behaviors included in his children’s book, Struwwelpeter (Slovenly Peter), Dr Heinrich Hoffmann introduced the fictitious character of “Zappel-Philipp” (Fidgety Philip). Fidgety Philip, although perhaps not directly implying any mental disorder, does illustrate several of the now-accepted criteria for attention deficit hyperactivity disorder (ADHD): inattention, hyperactivity, and impulsivity. In addition, he describes his character’s behavioral effects on parents and family.
However, a more definitive description of the disorder was published by Dr George Still (of the innocent Still’s murmur fame). A pediatrician, Dr Still became involved in childhood disease research and in his treatise, “On Some Abnormal Psychical Conditions in Children,” published in 1902, he described children with a morbid defect of moral control but without evidence of physical disease or impairment of intellect, to distinguish these children from those with associated physical conditions such as meningitis, brain tumor, head injury, or mental illness. His work was followed by numerous authors over the ensuing decades, with descriptions of childhood hyperactivity, inattentiveness, compulsive behavior, ease of excitability, and inability to concentrate. Accordingly, the condition itself has been associated with controversy as to its actual existence as a neurodevelopmental disorder and has undergone several name changes, culminating in the current ADHD designation in 1987.
In 1994, the condition was subdivided according to clinical presentation:
- •
ADHD inattentive
- •
ADHD hyperactive-compulsive
- •
ADHD combined.
Between 5% and 20% of school-aged children are currently diagnosed with ADHD; boys more frequently than girls. Although previously thought to be only a childhood disorder, over 50% of individuals diagnosed in childhood continue to exhibit symptoms as adults. Causal theories have varied over the years. Although a precise single cause of ADHD remains controversial, at present, environmental, genetic, as well as neuropsychological factors have been included. A genetic inheritance factor has been indicated in 75% of affected children.
Possible cause includes
- 1.
Environmental factors
- •
Preterm and very low birth weight infants
- •
Fetal alcohol and tobacco exposure
- •
Fetal or childhood infections
- •
Lead exposure
- •
Food additives
- •
Polychlorinated biphenyls exposure
- •
History of physical or emotional abuse
- •
Congenital heart repair before 1 year of age
- •
- 2.
Genetics
- •
Genes associated with dopamine transportation
- •
LPHN3 gene, which facilitates responsiveness to stimulant medications
- •
- 3.
Neuropsychological
- •
Inability to regulate and manage daily tasks (executive functioning)
- •
Because executive functioning evolves with age and brain maturation, this last concept helps to explain why symptoms of ADHD may not become fully manifest until adolescence or young adulthood.
Diagnosis
Depending on which criteria are used (DSM-IV or ICD-10), children may or may not be correctly identified as actually having ADHD. It is beyond the scope of this writing to elaborate on actual testing techniques but suffice to say that all are based on an assessment of individual behavior and cognitive development, especially in regards to age-matched peers, taking in account parental and educator assessments. ADHD is based on behavior and is not a neurologic disease. As such, it differs from other psychotic/mental disorders, such as schizophrenia, anxiety, or personality disorders. It is classified as a disruptive behavior disorder with oppositional defiance associated with adverse conduct and social interaction. As indicated above, currently ADHD is classified according to symptoms (inattention, hyperactive-impulsive, or combination). Most children are diagnosed as having the combination type.
Management
Once the appropriate diagnosis of ADHD is made, effective management is required to permit the child to function appropriately. This managements typically includes psychotherapy, medications, or both. Among psychological interventions, behavioral, cognitive, and interpersonal therapies have been advocated. Other modalities include school-based interventions, social skill training, parental management, and neuro-feedback. Medications included amphetamine and methylphenidate stimulants, atomoxetine, α-adrenergic agonists as well as antidepressants and antihypertensives. A study done by the National Institute of Mental Health-funded multisite trial showed that parent and teacher ratings had greater improvement with pharmacotherapy when compared with behavioral therapy alone. The response to both methylphenidate and amphetamine has been shown to be greater than 70% as compared with 12% for placebo controls. There have been multiple studies that have confirmed the importance of treating ADHD from not only a patient standpoint but also the effect a patient with ADHD has on a family and society. As might be expected, management issues differ between the young child and adolescent, as discussed below. Because psychological counseling would not be expected to have any adverse cardiac effects, this review focuses primarily on pharmacologic interventions.
Pharmacologic treatment
Effective pharmacologic treatment of ADHD was found by chance. While attempting to treat headaches associated with pneumoencephalograms, performed to examine structural brain abnormalities in the 1930s, Dr Charles Bradley noticed that use of Benzedrine to stimulate the choroid plexus resulted in behavioral improvement in some children. In addition, previously hyperactive and inattentive children were found to exhibit improved school performance as well as a decrease in motor activity. This seemingly paradoxic effect of stimulant medications laid the foundation for current therapeutic modalities of ADHD intervention.
As the term implies, “stimulant” medications can be associated with secondary cardiovascular effects such as sinus tachycardia and hypertension. These effects have caused considerable debate recently as to the cost/risk/benefits as well as need for or against close cardiac monitoring of patients prescribed pharmacologic agents, such as methylphenidate, amphetamine, or atomoxetine. Concerns of adverse cardiovascular events associated with use of such stimulant medications, including sudden cardiac death, have lead to conflicting scientific publications.
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Five to 20% of children are currently diagnosed with ADHD
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Symptoms of ADHD can be seen during adolescence and adulthood
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A precise cause for ADHD is not known
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ADHD is diagnosed after detailed assessment of the behavior of the individual
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Management includes medications and psychotherapy
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Cardiovascular adverse effects have become a significant concern in society
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