Attention deficit hyperactivity disorder (ADHD) is a neurobiological behavioral disorder characterized by inattention, impulsivity, and overactivity. This chronic disorder begins early in childhood and interferes with an individual’s ability to attend to tasks, inhibit behavior, and regulate activity level in developmentally appropriate ways.
DIAGNOSTIC CRITERIA
| Table. Diagnostic Criteria for ADHD.
(A) Either (1) or (2): (1) Six (or more) of the following symptoms of inattention that have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (2) Six (or more) of the following symptoms of hyperactivity-impulsivity that have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity Impulsivity (B) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7. |
The specific criteria for ADHD, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), are displayed in the Table.1 There are 3 subtypes of the disorder. First, there are those individuals who struggle with both inattention and impulsivity/overactivity. They must meet at least 6 of the 9 DSM-IV criteria for inattention and 6 of the 9 DSM-IV criteria for impulsivity/overactivity. These individuals will likely be diagnosed with ADHD—combined type. This is the most common form of ADHD and the subtype about which most is known.2 The next most common subtype of ADHD describes individuals with primarily inattention difficulties; they will likely receive a diagnosis of ADHD—predominantly inattentive type. In the past, this subtype was referred to as ADD. These individuals must meet at least 6 of the 9 DSM-IV criteria for inattention. Some children, initially diagnosed with the combined subtype of the disorder, will “grow out” of their hyperactive/impulsive symptoms in adolescence and meet criteria for this subtype instead.3 Other children are diagnosed with this subtype in early childhood and continue to experience the symptoms as they mature. Finally, individuals with primarily impulsivity and/or overactivity symptoms will likely receive the diagnosis of ADHD—predominantly hyperactive/impulsive subtype. This subtype often describes young children who are at risk for the combined type of the disorder but have not yet reached the age where their attention problems are evident.3 Individuals with the predominantly hyperactive/impulsive subtype must meet at least 6 of the 9 DSM-IV criteria for hyperactivity/impulsivity.
It is important to note that it is not sufficient only to meet the DSM-IV criteria described above. To receive any diagnosis of ADHD, symptoms causing impairment must have been present before the age of 7 years, symptoms must cause impairment in at least 2 settings (ie, home, school, public), symptoms must cause significant impairment, and symptoms cannot be better accounted for by another disorder. ADHD can range from mild to severe. No one person has all the symptoms of the disorder.
PREVALENCE
ADHD is not an uncommon disorder. It has been estimated that 3% to 7% of children have the condition.4 Until recently, it was thought that ADHD was a “childhood disorder” that affected children outgrew. However, it is now known that many children diagnosed with ADHD will continue to experience symptoms of the disorder in adolescence and adulthood.5 With regard to gender, boys are diagnosed more frequently than are girls.6 However, the predominantly inattentive subtype of the disorder seems to have a more equal gender ratio.
ETIOLOGY
With regard to causes of ADHD, it is now believed that heredity accounts for approximately 80% of cases.3 Family, twin, adoption, and molecular genetic studies show that genes influence the etiology of the disorder. The children of ADHD adults are at high risk for the disorder.7 Further, ADHD is more prevalent in the relatives of ADHD children than in the relatives of non-ADHD children.3 Studies of identical twins have shown that when one twin has ADHD, the other twin is highly likely to have the disorder.8 Several candidate genes have been related to the susceptibility to ADHD (eg, dopamine transporter gene, dopamine receptor gene9). Other causes of ADHD include prenatal exposure to smoke, lead, or alcohol, prematurity, intrauterine growth retardation, and brain infections.10,11 In addition, a number of genetic disorders (eg, Turner syndrome, fragile X syndrome) are associated with the symptoms of ADHD.
COMORBIDITIES
It is not unusual for individuals diagnosed with ADHD to have comorbid or co-occurring disorders. In fact, it has been found that up to 87% of children who have been diagnosed with ADHD have at least one other psychiatric disorder, and 67% have at least 2 other psychiatric disorders.12 Specifically, research suggests that 54% to 67% of children and adolescents diagnosed with ADHD are also diagnosed with oppositional defiant disorder (a condition characterized by high levels of defiance and argumentativeness13). Approximately 25% of children with ADHD also have an anxiety disorder.14-16 Similarly, between 20% and 30% of children with ADHD are also diagnosed with a mood disorder.17-19 Bipolar disorder, a condition that has recently received much research attention, appears to co-occur with ADHD at a rate of 10% to 20%.20-23
EVALUATION
In order to diagnose ADHD, a thorough evaluation is critical. Currently, there are no available medical or psychological tests to make the diagnosis of ADHD. Rather, the diagnosis depends on the judgment of a clinician who can evaluate whether ADHD symptoms are present, impairing, and whether or not they are not accounted for by another condition. Accordingly, a comprehensive history is crucial. Often, structured methods for obtaining information on symptoms of ADHD and other conditions are helpful to the clinician, but these measures only enhance the clinical interview. In addition, in order to rule out other conditions, it is often necessary for the individual to receive a physical or neurological examination. Finally, a psychological evaluation is often indicated to rule out learning problems and assist in identifying comorbid mental health issues.
It is important to emphasize the fact that many symptoms of ADHD are also symptoms of other medical and psychological conditions. Therefore, in diagnosing ADHD, it is imperative that the clinician rule out all other conditions that may be mimicking the symptoms of ADHD. Further, as mentioned previously, other conditions frequently co-occur with ADHD. Therefore, another goal of the evaluation is to identify comorbid conditions, as these conditions will likely impact treatment.
TREATMENT
As in the case of asthma and diabetes, the goal of treatment is to contain the disorder or reduce the symptoms rather than to cure the condition. The benefit of pharmacotherapy for the treatment of ADHD has been well established.26 The medications used to treat ADHD mainly impact the neurotransmission of catecholamines.23 Most ADHD medications fall into the category of stimulants. Some stimulants, such as Ritalin, are short-acting and are only effective for 3 to 4 hours. Children generally take these short-acting stimulants several times per day and frequently experience “rebound” or extreme irritability between doses. Long-acting stimulants, such as Concerta, can last up to 12 hours and therefore do not produce the rebound effect. They are only taken once a day.
Common side effects of stimulant medications include appetite suppression and in-somnia. Due to these side effects and others, some children are unable to tolerate stimulant medication, and nonstimulant medications are thus indicated. Recently, a nonstimulant medication, Strat-tera, has become popular for the treatment of ADHD. This medication is pharmacologically similar to antidepressant medications.
Psychosocial interventions are often very helpful with this population. One modality that is especially popular is behavior management training (eg, contingency management, positive reinforcement, time out). With behavior management training, parents and teachers can learn a variety of strategies to help them handle children’s ADHD behaviors. Behavior management training can be conducted in an individual or group format and is most helpful when dealing with preschool- and grade school-age children. Further, social skills training is often employed with ADHD children, given that many children with ADHD have social skills deficits. Social skills training is most often conducted in a group format so that children can practice the skills learned with their peers in the group. Once children become more capable of “talk therapy,” individual therapy and family therapy are particularly useful in targeting the associated symptoms of ADHD (eg, low self-esteem, demoralization). Finally, academic accommodations can be implemented to enable ADHD children to be successful in the classroom environment. Specifically, children with ADHD can benefit from a variety of classroom accommodations that include preferential seating, untimed testing, and incentives for remaining on task.
IMPLICATIONS FOR DENTAL PRACTICE
Given the prevalence and chronic nature of ADHD, it is probable that these patients will be seen in all dental practices. A number of the core symptoms of ADHD are likely to present challenges in a dental setting. For example, ADHD children tend to be restless, fidgety, and talkative, and they have difficulty remaining seated. These behaviors can certainly interfere with treatment. What follows are some issues that the clinician may wish to keep in mind when treating ADHD children.
1. Medication: Timing Is the Key
Many children with the disorder take medication. It is important to find out from the parent if the child is on any ADHD medications and if so, which medications. Further, information about the dosing schedule is crucial. Children are likely to experience the effects of stimulants 30 to 60 minutes after dosing. Therefore, in the case of an early morning dental appointment, clinicians will want to ensure that sufficient time has elapsed between dosing and the appointment. Further, as mentioned, some children will take several doses of medication per day. Between doses of short-acting stimulants, children are not covered by medication and thus may be highly symptomatic of ADHD. Further, they may experience “rebound” between doses. One would certainly want to avoid scheduling dental appointments during these “rebound” periods. Finally, information about type of medication and dosing schedules also has implications for late afternoon appointments. For example, a 4 PM appointment, which is a popular time slot for school-age children, would be far from ideal for a child on short-acting Ritalin.
2. Setting the Stage
Children with behavioral conditions such as ADHD do best when they know what to expect. Therefore, at the outset of the appointment, the clinician should inform the child about what is going to be accomplished during the appointment. Obviously, this should be done in a way that is appropriate to the child’s developmental level. If the child is having difficulty separating from the parent, the initial discussion can be done with the parent in the room. If the clinician has any indication that the child may be difficult to manage, the clinician should consider reviewing his or her expectations for this child’s behavior at this time. Finally, any incentives that can be earned by the child should be discussed, and the schedule for breaks should be reviewed.
3. Instructions
By definition, ADHD children are inattentive, and it is therefore best for the clinician to issue one instruction at a time to these children. Adults who issue multistep instructions to ADHD children often become frustrated because inattentive children are easily distracted, and consequently, they tend to forget all instructions that come later in a sequence. Due to the short attention span of these children, instructions should be relatively short and direct. When providing instructions to be implemented upon leaving the dental office, the clinician should be sure to put all important information in writing. Given that ADHD children are likely to be forgetful, disorganized, and prone to losing things, important information should always be reviewed with a parent, even in the case of adolescent patients.
4. Positive Reinforcement
Positive reinforcement, in terms of praise and small, tangible rewards (eg, stickers, pretend tattoos, baseball cards) can be useful in obtaining compliance from an ADHD child. It is known from basic behavioral theory that behaviors that are rewarded will increase in frequency. Therefore, it follows that if the clinician lets the child know that he or she is doing well (via praise or other rewards), the child will be more likely to continue good behavior. Reinforcements can be issued frequently, with younger children requiring more frequent reinforcement than older children. In addition to reinforcing unusually positive behaviors, consider reinforcing the behaviors that most adults would generally expect from a child and generally go unnoticed (eg, great job following directions, great job listening, great job sitting patiently). There is really no such thing as too much reinforcement, al-though the clinician should at-tempt to be genuine when issuing praise.
If a child is particularly challenging, the clinician might consider providing the child with a token every few minutes if he or she is on task. (Of course, it would be important to explain to the child at the outset exactly what is expected of him or her.) At the end of the appointment, the child could be given the opportunity to cash in his or her tokens for a small treat from the dental office or from the parent. The clinician should be sure that the incentive that is being offered is something that the child really values and will work toward, otherwise this strategy will be ineffective. It might be useful to create a “treasure chest” filled with a variety of small tangible rewards that would appeal to both boys and girls of a variety of developmental levels. Feel free to consult with a parent about what reinforcers might be effective with a particular child and do not hesitate to ask a parent to bring reinforcements to the dental office to be used during the appointment.
5. Behavioral Contracting
Clinicians may find behavioral contracting to be a useful technique, particularly when dealing with especially challenging children. Contracts can be either verbal or written. Verbal contracts often take the form of a “when…then” statement. For example, the clinician might offer that when he or she is done polishing the child’s teeth, then the child can play his or her Gameboy for a brief period of time. Written contracts are similar but seem more formal, particularly since they are signed by the patient and clinician. With a written contract, children may feel more accountable for keeping up their end of the agreement than they would if only a verbal contract was utilized.
6. Breaks
Breaks are an important component in working with ADHD children. Breaks are likely to be effective even if they are very brief. So, when it is possible to provide breaks during a procedure, the clinician should consider doing so. If possible, allow the child to get out of the dental chair during the break. The clinician may opt to set a timer during breaks so that the child will know that the break is “officially” over. Clinicians might consider asking parents to provide a favorite activity (eg, coloring supplies, book) or preferred toy (eg, Gameboy, toy cars, doll) for the child to use during the breaks. For guidelines on whether breaks will be necessary, how often to provide breaks, and duration of breaks, the clinician should consider consulting with the child’s parents. If the clinician has decided to use breaks, he or she should inform the child at the beginning of the appointment that breaks will be given during which the child will be able to play. The clinician can take this opportunity to let the child know what he or she expects from the child during the rest of the appointment when they are not on a break.
7. Transitions
ADHD children live in the moment and often experience difficulties transitioning from one activity to another. It is unlikely that they will resist taking a break from a dental procedure, but they very well may have difficulty transitioning from a break back to the dental chair. To facilitate such transitions, be sure to give the child advance notice that the break is almost over (eg, “you can play for 2 more minutes and then we need to get back to work”). When the time comes to make the transition, be sure to praise the child for complying if the transition was accomplished in a timely manner without the child fussing.
DISCUSSION
ADHD is a complex disorder. Those who are affected by it can be quite significantly impaired, presenting challenges to all who work with them. It can be very difficult and frustrating to work with these children, particularly when operating within typical time constraints. Clinicians should not hesitate to let parents know that they are having difficulty managing their children. In all likelihood the parents have heard this before from other professionals. Further, parents will likely appreciate the fact that the clinician is deferring to their expertise in this area. Parents may be able to provide the clinician with some simple tips that will likely work with their child. If the clinician feels that he or she is becoming too involved in behavior management with a particular child, it is reasonable to ask the parent to remain in the treatment room so that the parent can manage the child’s challenging behaviors while the clinician is engaged in the dental procedure. Do not forget to make use of parents as a valuable resource. They are truly the experts in regard to their children.
SUMMARY
ADHD is a common disorder that affects individuals of all ages. A thorough evaluation is necessary to make an accurate diagnosis. Symptoms of the disorder can be managed by pharmacological and psychosocial interventions. Due to the high baserate of the disorder as well as its chronic nature, ADHD patients are likely seen frequently in any dental practice. Accordingly, it is necessary for the clinician to be familiar with the disorder as well as with strategies for managing it.
References
1. Applegate B, Lahey BB, Hart EL, et al. Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry. 1997;36:1211-1221.
2. Barkley RA. Primary symptoms, diagnostic criteria, prevalence, and gender differences. In: Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1998:56-96.
3. Stein MA, Efron LA, Schiff WB, et al. Attention deficits and hyperactivity. In: ML Batshaw. Children With Disabilities. 5th ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2002:389-416.
4. Szatmari P. The epidemiology of attention-deficit hyperactivity disorders. In: Weiss G, ed. Child and Adolescent Psychiatry Clinics of North America: Attention Deficit Hyperactivity Disorder. Philadelphia, Pa: WB Saunders; 1992:361-371.
5. Barkley RA. Developmental course and adult outcome. In: Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1998:186-224.
6. Sharp W, Walter JM, Marsh WL, et al. ADHD in girls: clinical comparability of a research sample. J Am Acad Child Adolesc Psychiatry. 1999;38:40-47.
7. Biederman J, Faraone SV, Mick E, et al. High risk for attention deficit hyperactivity disorder among children of parents with childhood onset of the disorder: a pilot study. Am J Psychiatry. 1995;152:431-435.
8. Cook EH Jr. Genetics of attention-deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities Research Reviews. 1999;5:191-198.
9. Faraone SV. Report from the third international meeting of the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network. Am J Med Genet. 2002;114:272-276.
10. Accardo P. A rational approach to the medical assessment of the child with attention-deficit/hyperactivity disorder. Pediatr Clin North Am. 1999;46:845-856.
11. Mercugliano M, Power TJ, Blum NJ. The Clinician’s Practical Guide to Attention-Deficit/Hyperactivity Disorder. Baltimore, Md: Paul H. Brookes Publishing Co; 1999.
12. Kadesjo B, Gillberg C. The comorbidity of ADHD in the general population of Swedish school-age children. J Child Psychol Psychiatry. 2001;42:487-492.
13. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40:57-87.
14. Tannock R. Attention-deficit/hyperactivity disorder with anxiety disorders. In: Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press; 2000:125-170.
15. Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry. 1991;148:564-577.
16. Pliszka SR. Comorbidity of attention-deficit hyperactivity disorder and overanxious disorder. J Am Acad Child Adolesc Psychiatry. 1992;31:197-203.
17. Fischer M, Barkley RA, Smallish L, et al. Young adult follow-up of hyperactive children: self-reported psychiatry disorders, comorbidity, and the role of childhood conduct problems and teen CD [published correction appears in J Abnorm Child Psychol. 2003;31:563]. J Abnorm Child Psychol. 2002;30:463-475.
18. Biederman J, Faraone SV, Lapey K. Comorbidity of diagnosis in attention-deficit hyperactivity disorder. In: Weiss G, ed. Child Adolescent Psychiatry Clinics of North America: Attention-Deficit Hyperactivity Disorder. Philadelphia, Pa: WB Saunders; 1992:335-360.
19. Cuffe SP, McKeown RE, Jackson KL, et al. Prevalence of attention-deficit/hyperactivity disorder in a community sample of older adolescents. J Am Acad Child Adolesc Psychiatry. 2001;40:1037-1044.
20. Carlson GA. Child and adolescent mania—diagnostic considerations. J Child Psychol Psychiatry. 1990;31:331-341.
21. Wozniak J, Biederman J, Kiely K, et al. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry. 1995;34:867-876.
22. Wozniak J, Biederman J. Prepubertal mania exists (and coexists with ADHD). The ADHD Report. 1994;2:5-6.
23. Wilens TE, Faraone SV, Biederman J. Attention-deficit/hyperactivity disorder in adults. JAMA. 2004;292:619-623.
Dr. Efron is a clinical psychologist at Children’s National Medical Center, Washington, DC, where she serves as training director for psychology and director of the Hyperactivity, Attention, and Learning Problems (HALP) Clinic. Dr. Efron has research interests relating to ADHD, children’s sleep difficulties, and parenting practices. She is an assistant professor of psychiatry and pediatrics at the George Washington University Medical Center in Washington, DC. Dr. Efron received her bachelor’s degree from Columbia University in New York City and her master’s degree and doctorate from Duke University in North Carolina. She did her clinical internship at Johns Hopkins University and the Kennedy Krieger Institute. She can be reached at (571) 226-8339 or lefron@cnmc.org.
Dr. Sherman is a diplomate of the American Board of Oral Electrosurgery and a fellow of the American College of Dentists and the International College of Dentists. He is the executive director of the World Academy of Radiosurgery and maintains a private general dental practice in Oakdale, NY. He can be reached at (631) 567-2100 or esurg@aol.com.
