Reducing the Risk of Fractures - The Options Narrow for Cost-Effective Therapeutic Alternatives

Disease Management of ADHD and Measures of Compliance Imagine living in a fast-moving kaleidoscope, where sounds, images, and thoughts are constantly shifting—feeling easily bored, yet helpless to keep your mind on tasks you need to complete, distracted by unimportant sights and sounds, your mind drives you from one thought or activity to the next—perhaps you are so wrapped up in a collage of thoughts and images that you don’t notice when someone speaks to you. This is how the National Institutes of Health introduces the term “attentiondeficit/hyperactivity disorder” (ADHD). People with ADHD may show several signs of being consistently inattentive, or they may have a pattern of being hyperactive and impulsive, or they may exhibit all 3 types of behavior. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the signs of inattention include (a) becoming easily distracted by irrelevant sights and sounds, (b) failing to pay attention to details and making careless mistakes, (c) rarely following instructions carefully and completely, or (d) losing or forgetting things like toys, or pencils, books, and tools needed for a task. The signs for hyperactivity and impulsivity may include (a) feeling restless, often fidgeting with hands or feet, or squirming; (b) running, climbing, or leaving a seat, in situations where sitting or quiet behavior is expected; (c) blurting out answers before hearing the whole question; or (d) having difficulty waiting in line or for a turn. The diagnostic criteria for ADHD in children require 6 elements: (1) the symptoms of inattention or impulsivity or hyperactivity persist for a period of at least 6 months to a degree that is maladaptive and immature; (2) the symptoms begin before the age of 7; (3) the symptoms must be present in at least 2 types of situations, such as school, work, or home; (4) the disorder impairs school, social, or occupational functioning; (5) the symptoms do not occur solely during a pervasive developmental disorder or any psychotic disorder including schizophrenia; and (6) the symptoms are not explained better by a mood, anxiety, dissociative or personality disorder. The diagnosis of ADHD depends primarily upon symptoms of inattention or hyperactivity-impulsivity. For ADHD associated with inattention (ICD-9-CM 314.00), the patient must have at least 6 of the following 9 criteria: • Fails to pay close attention to details or makes careless errors in schoolwork, work or other activities • Has trouble keeping attention on tasks or play • Doesn’t appear to listen when being told something • Neither follows through on instructions nor completes chores, schoolwork, or jobs (not due to oppositional behavior or failure to understand) • Has trouble organizing activities and tasks • Dislikes or avoids tasks that involve sustained mental effort (homework, schoolwork) • Loses materials needed for activities (assignments, books, pencils, tools, toys) • Is easily distracted by extraneous stimuli • Is forgetful Hyperactivity or impulsivity is the second category of symptoms used to make a diagnosis of ADHD. The ADHD patient must have at least 6 of the following 9 criteria to warrant the ICD-9-CM code 314.01 (the last 3 criteria are associated with impulsivity): • Squirms in seat or fidgets • Inappropriately leaves seat • Inappropriately runs or climbs (in adolescents or adults, this may be only a subjective feeling of restlessness) • Has trouble quietly playing or engaging in leisure activity • Appears driven or “on the go” • Talks excessively • Answers questions before they have been completely asked • Has trouble waiting in line or awaiting turn • Interrupts or intrudes on others While pharmacotherapy is often effective in ADHD, the relative effectiveness depends upon the measure. The ultimate measures of effectiveness in managing ADHD are social performance, scholastic performance for children and most young adults, or work performance for others. By these measures, pharmacotherapy is secondary to social-environmental changes to encourage better scholastic performance for children, such as parents spending time with their children on homework assignments or the use of tutors. Second-line therapy might involve the assistance of professional educators, counselors, psychologists, school personnel, community mental health therapists, or the primary care clinician. However, the medicalization of ADHD brings with it the tendency to skip first-line and secondline interventions and jump to third-line intervention with pharmacotherapy. For some ADHD patients, drug therapy is necessary and effective. However, the extent of compliance with pharmacotherapy to achieve the desired outcomes would appear to be a separate consideration. For children and adolescents, clinicians may use drug-free holidays to affirm the continued value of the drug therapy in the social environment outside of school, and national guidelines focus upon behavioral measures of disease management success such as improved academic performance and improvements in relationships with parents, siblings, teachers, and peers. These evidence-based guidelines state that if there is a need for relief of symptoms of ADHD only during school, a 5-day dose schedule may be sufficient. As suggested above, there is also the matter of uncertainty in diagnosis of ADHD. Diagnosis of ADHD is not easy because its symptoms may be manifest in other conditions such as oppositional defiant disorder, found in nearly one half of ADHD children, mostly boys. ADHD can be confused with other conditions such as underachievement at school due to a learning disability, attention lapses caused by petit mal seizures, a middle ear infection that causes an intermittent hearing problem, or disruptive or unresponsive behavior due to anxiety or depression. In this issue of the Journal, Perwien, Hall, Swensen, and