Attention Deficit Hyperactivity Disorder (ADHD) PowerPoint Presentation

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Attention Deficit Hyperactivity Disorder (ADHD) Justin A. Glass, MD 21 February 2008 Emory Family Medicine

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Attention Deficit Hyperactivity Disorder (ADHD) What is the role of the primary care physician in diagnosis and treatment of ADHD?

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ADHD Talk Objectives You will understand ADHD diagnostic criteria You will will know where to find and how to use assessment tools for diagnosing ADHD You will know when to refer a patient w/ ADHD for specialty care You will understand tx options for ADHD You will want to see a child with ADHD in your clinic in the near future

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ADHD Epidemiology Prevalence Survey average: 8-10% in children of school age Parent reported prevalence age 4-17 Boys 11% Girls 4.4% Male: Female ratio 2:1 - 4:1

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ADHD Pathogenesis Multiple theories Imbalance of catecholamine metabolism in cerebral cortex Impaired executive functions Impaired response inhibition

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Diagnosis of ADHD Inattention Hyperactivity Impulsivity

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Diagnosis of ADHD Inattention Forgetful outside of school Incomplete performance on school tasks Missing details Missing homework Poor performance on schoolwork

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Diagnosis of ADHD Hyperactivity Always in motion Difficulty during “quiet times” Constant talking

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Diagnosis of ADHD Impulsivity Unable to “wait turn” Answers for others Unsafe behavior

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DSM IV Criteria – ADHD (Inattention) Often fails to give close attention to detail or makes careless mistakes in schoolwork, work or other activities. Often has difficulty sustaining attention in tasks of play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish homework, chores or other duties Often has difficulty organizing tasks and activities Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort Often loses things required to complete tasks Is often easily distracted Is often forgetful in daily activities Six (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

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DSM IV Criteria – ADHD (Hyperactivity) Often fidgets with hands or feet or squirms in seat Often leaves seat in situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate Often has difficulty in playing quietly Is often “on the go” or acts as if “driven by a motor” Often talks excessively Often blurts out answers before questions are completed Often has difficulty waiting turn Often interrupts of intrudes on others Six (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

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Diagnosis of ADHD Additional Criteria: Some inattentive or hyperactive/impulsive symptoms were present before the age of seven. Some impairment from the symptoms is present in two or more settings (e.g. at school and at home) Clear evidence of clinically significant impairment in social, academic or occupational functioning

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DSM IV Criteria - ADHD Three types Inattention predominant (ADHD-IA) (30-40%) Hyperactivity predominant (ADHD-H/I) (10%) Combined type (ADHD-C) (50-60%)

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Diagnosis of ADHD Screening questions How is your child doing in school this year? Is your child happy to go to school? Have you heard from the teacher(s) regarding any concerns about behavior or performance in school? How does your child do with chores around the house? How does your child do with homework?

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Diagnosis of ADHD Objective approach Data needs to be collected from more than one source Parents Teachers Others

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Diagnosis of ADHD What kind of data? Standardized forms Conners Rating Scale (CATRS) ACTeRS Form Vanderbilt ADHD Diagnostic Rating Scale

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Diagnosis ADHD Need to develop a differential diagnosis

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Diagnosis of ADHD Oppositional Defiant Disorder Conduct Disorder Depression Anxiety Learning disability Special senses disability Substance Abuse Pervasive Developmental Delay NOS

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Oppositional Defiant Disorder A pattern of negativistic, hostile and defiant behavior lasting at least six months, during which four or more of the following are present: Often loses temper Often argues with adults Often actively defies or refuses to follow adults rules Often deliberately annoys people Often blames others for his/her mistakes Often is touchy / easily annoyed by others Often is resentful Often is spiteful / vindictive The disturbance in behavior causes significant impairment in social, academic or occupational functioning. The symptoms are not due to a mood disorder or conduct d/o.

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Conduct Disorder Repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate norms or rules of society are violated. Aggression to people or animals Destruction of property Deceitfulness or theft Serious violation of rules

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Depression Depressed mood Change in sleep (S) Loss of interest / pleasure in activities (I) Thoughts of worthlessness or guilt (G) Loss of energy (E) Trouble concentrating (C) Change in appetite or weight (A) Change in psychomotor activity (P) Thoughts of suicide or death (S) 5 of the 9 symptoms present frequently for at least two weeks. One of the 5 symptoms must be depressed mood or loss of interest in usual activities. Symptoms can not be due to substance use of another psychiatric diagnosis.

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Learning Disability Schoolwork performance issues Reading Writing Mathematics

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Special Senses Disability Visual disturbance Hearing loss

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Substance Abuse High index of suspicion in teens

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Pervasive Developmental Delay NOS Autistic spectrum, but not meeting autism criteria

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When should I refer a child I suspect has ADHD? Age younger than six Co-existent psychiatric conditions Co-existent neurologic conditions

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Let’s go to Vanderbilt

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ADHD Management Plan Clear communication with parents and teachers Phone calls Email Progress notes Daily School-Home Report Card

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ADHD Management Plan Parenting skills Homework rules Sleep rules T.V. / Videogame rules

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ADHD Management Plan Stimulant Medications Dextroamphetamine / Levoamphetamine Adderall Adderall XR Dextramphetamine Dexedrine Dexedrine Spansule Dextrostat Methyphenidate Ritalin Ritalin LA Ritalin SR Concerta Methylin Metadate ER Metadate CD Focalin Daytrana

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ADHD Management Plan Stimulant Medications Adverse effects Anorexia Weight loss Sleep disturbance Tics Tachycardia Hypertension

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ADHD Management Stimulant Medication Use the least amount needed Use extended release preparations when possible Give drug holidays if appropriate Reassess regularly as to response

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ADHD Management Stimulant Medications are Schedule 2 drugs 30 day supply with written prescription Rule change 2007 allows up to 90 day supply Three 30 day scripts Each dated sequentially for fill date Atomoxetine is not a restricted medication

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ADHD Management Plan Non – stimulant medication Atomoxetine (Strattera) Norepinephrine reuptake inhibitor Starting dose 0.5 mg/kg Maximum dose 1.4 mg/kg or 100 mg /day ADHD scores improve with atomoxetine vs placebo ADHD scores are equal to / slightly worse than stimulant medications

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ADHD Management Non-stimulant Medication Atomoxetine side effects Anorexia Weight loss Abdominal pain Nausea / Vomiting Sleep disturbance Suicidal ideation (0.4% vs 0% placebo) Liver injury (VERY RARE -- 2 cases!)

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When else should I refer a child I suspect has ADHD? Failure to respond to a reasonable trial of stimulant / non-stimulant medications and behavior interventions

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Conclusions: ADHD Performing an ADHD evaluation is within the spectrum of practice of a family doctor Observer data is needed from at least two settings in the child’s life Co-morbid / alternate diagnoses should be ruled out A comprehensive management plan offers the patient the best chance for success in school

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ADHD Resources Caring for Children with ADHD: A Resource Toolkit for Clinicians, AAP, 2008. http://www.nichq.org/NICHQ/Topics/ChronicConditions/ADHD/Tools/ Individual forms are available here for download http://www.nichq.org/resources/toolkit A compressed folder of all ADHD forms is available for download.

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Additional References Changes and Challenges: Managing ADHD in a Fast-Paced World, Michael J Manos, et al, Manag Care Pharm. 2007;13(9)(suppl S-b):S2-S13 Obtaining Systematic Teacher Reports of Disruptive Behavior Utilizing DM-IV, Mark L. Woraich, et al, Journal of Abnormal Child Psychology, Vol 26(2), 1998: 141-152.

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Adult ADHD Childhood ADHD commonly persists: 22-85% of adolescents 4-50% of adults

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Adult ADHD Symptom complex can differ from childhood Inattention and impulsivity > hyperactivity

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Adult ADHD Wender (Utah) Criteria Hyperactivity and inattention plus (2) of below Labile emotions Hot temper Inability to complete tasks Inability to tolerate stresss Impulsivity

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Adult ADHD Treatment Stimulants Response rate decreased versus childhood ADHD Atomoxetine Lower cadiovascular risk profile Minimal abuse potential

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Management of ADHD Stimulant Misuse (22%) / Diversion (11%) Continuously escalating dosage Repeated lost prescriptions / “dispensing errors” Demand for immediate release preparation Infrequent user Psychosis Palpatations