by Agent G

Created on: July 30, 2009   Last Updated: July 31, 2009

Attention-deficit/hyperactivity disorder (ADHD) is typically characterized by inattention, excessive motor activity, impulsivity, and distractibility.1 ADHD significantly impairs functioning in many areas of a patient's life. Patients with ADHD are more likely to drop out of school, lose jobs, get divorced, abuse alcohol or street drugs, and have traffic accidents. Estimates of the societal cost of ADHD range into the tens of billions of dollars.2 Despite the impact, ADHD remains underrecognized and undertreated.3 Individuals with ADHD have significant impairment in family and peer relations and academic functioning, and they show high comorbidity with a wide range of psychiatric disorders, including oppositional defiant disorder, conduct disorder, anxiety disorder, depression, substance use disorder, and pervasive developmental disorder.1

ADHD in children and adolescents also remains undertreated, often because it is difficult to extrapolate a diagnosis when symptoms present in conjunction with oppositional symptoms. 2,4 Adolescents diagnosed with ADHD and comorbid disruptive behavior disorders during childhood report high levels of aggression associated with increased emotionality in the form of anger.5

Oppositional defiant disorder (ODD) is a condition characterized by a pattern of defiance of rules and authorities not compatible with the child or adolescent's level of development. It is frequently comorbid with ADHD and is of great concern to pediatricians. Often, unmanaged ADHD with ODD results in failure in school and may sometimes evolve into full-blown conduct disorder (CD)6 Often, combination pharmacotherapy is necessary to manage children who suffer these symptoms, as there can be more than one causational factor.7

Stimulants remain the mainstay of ADHD treatment for both children and adults.8 Their effect is greater than that of the nonstimulants atomoxetine, although some individuals respond better to atomoxetine than to stimulants.9 In addition, stimulants are generally the first choice for treatment because their effectiveness can be determined quickly, while an adequate trial of atomoxetine takes 4 to 6 weeks. Additionally, long-acting stimulant formulations are comparable in efficacy and safety to short-acting agents, without the inconvenience of midday dosing.9 Short-acting agents are often prescribed for adults and adolescents to provide coverage in the late evening.

Stimulants, however, are contraindicated in many medical and psychiatric

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