Transcript Document

Attention Deficit
Hyperactivity Disorder
Royann Mraz, MD
Clinical Associate Professor
Center for Disabilities and Development
Dec 10, 2014
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No conflict of interest
Epidemiology of ADHD
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8-10% of school aged children
8% 4-10yr, 14% 11-17 yr.
Boys>Girls 2-4:1
High rates of Co-Morbidities –especially
psychiatric and learning
33% have one co-morbidity, 16% -2,
18% - 3
Neurobiology of ADHD
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Cerebellar-prefrontal-striatal network
hypothesis
Volume differences- caudate, smaller
cerebrum (esp. anterior) and
cerebellum
Genetics
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Genetic imbalance in dopamine and
noradrenergic systems- several genes
play a role
Strong genetic influence
Concordance -92% identical twins, 33%
dizygotic twins
Environment
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Increased risk with prenatal smoking
exposure *
Prematurity, Brain injury, fetal alcohol,
lead
Dietary factors do not play a role in the
majority of children – food additives,
essential fatty acids?, Fe or Zn
deficiency?
Attention Deficit Hyperactivity
Disorder- subtypes
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Predominately inattentive type – 8-9 yr
Predominately hyperactive-impulsivePr
start at 4yr, max 6-8 yr
Combined type- most common
DSM 5 ADHD
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Children - 6/9 symptoms of Inattention
(inconsistant with developmental level, impacts
activities, and not secondary to oppositional
behavior or failure to understand) and/or 6/9
symptoms of hyperactivity/impulsivity
Adolescent and adults – only require 5 symptoms
from either category
Some symptoms must be present by 12 years of
age (DSM-IV by 7 yrs and be impairing)
Diagnostic criteria - Inattention
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Careless mistakes
Difficulty sustaining attention
Does not seem to listen
Does not follow through on tasks
Not organized
Avoids sustained mental effort
Loses things
Is easily distracted
If forgetful
6/9
Diagnostic criteria –
Hyperactivity/Impulsivity
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Fidgets or squirms
Inappropriately leaves seat
Inappropriately runs or climbs
Has difficulty playing quietly
Is “on the go”
Talks excessively
Blurts out answers
Has Difficulty waiting his or her turn
Interrupts or intrudes on others 6/9
DSM-5 ADHD updates
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Most of changes recognize that ADHD is a
chronic illness and help with diagnosis in
adolescents and adults
18 symptoms remain the same (additional
examples provided)
Inattentive symptom f: Often avoids, dislikes, or is
reluctant to engage in tasks that require sustained
mental effort (eg. Schoolwork or homework; for older
adolescents and adults, preparing reports, completing
forms, reviewing lengthy papers)
ADHD Updates
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Cross-situational symptoms rather than
impairment
Symptoms interfere or reduce quality of
social, academic, or occupational functioning
Present for over 6 months
Symptoms aren’t secondary to other mental
disorder
Rate current severity of symptoms –mild,
moderate, severe
Consequences of DSM-5
ADHD
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Easier to diagnose in adolescents and adults
May increase the prevalence rates
Can diagnose ADHD in individuals with
Autism Spectrum disorder
Differential Diagnosis of ADHD
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Normal age appropriate behavior,
Unrealistic expectations
Lack of structure/limits
Family stress and dysfunction, abuse
PTSD, RAD, and adjustment disorders
Intellectual disability/Learning disorder
Autism, fetal alcohol, seizures, lead
exposure, sleep disorder, thyroid
COMORBIDITY
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Learning disorder 10-30%
Opposition defiant disorder/ Conduct
disorder 50-67%
Anxiety or Mood disorder 30%
Tourette’s and tic disorders
Coordination problems
Substance abuse
Sleep problems
DIAGNOSTIC EVALUATION
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Child’s history and functioning
Family history and functioning
School information
Rating scales – parent and teacher
Interview and physical exam of child
Consider psychological/educational
evaluation
AAP Practice Guidelines for ADHD
2011
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Initiate evaluation for ADHD in child 4-18
years of age if behavior or academic
problems and ADHD symptoms
Determine if DSM criteria are met in more
than one setting (teacher questionnaires) and
rule out other causes
AAP guidelines for ADHD
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Assess for co-existing conditions –
Emotional/behavioral (anxiety, depression,
ODD, conduct disorders)
Developmental (learning, language, etc.)
Physical (sleep apnea, tics, etc.)
AAP Guidelines for ADHD
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Treat ADHD as a chronic condition using
principles of chronic care model and medical
home
Titrate medication to achieve maximal benefit
with minimal side effects
AAP guidelines for preschoolers
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Addresses evaluation and management of 4
and 5 year olds with ADHD symptoms
Recommends behavior management
counseling and placement in structured
setting
Allows for stimulant treatment if above isn’t
sufficient
AAP Guidelines ADHD
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6-11 Years
Treat with FDA approved medication (strong
evidence for stimulants) and/or
Parent and/or Teacher behavior management
or preferably both
12-17 Years
Treat with FDA approved medication
May prescribe behavior therapy
Consider referring if
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Preschool child
Developmental delay or learning
problems
ADHD, inattentive type
Family dysfunction
Moderate to severe behavior problems
Anxiety or depression
Medical Treatment of ADHD
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Monitor or treat co-morbidities
Educate patient and family
Set goals with family and school
ADHD is a chronic disorder – 65% of
children with ADHD will have symptoms
as adolescents
Medical Management of ADHD
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Medication is most effective treatment
Good behavior management program
can provide additional benefit
Stimulants are first line treatment and
most effective
70-80% of children will respond to a
stimulant
Stimulants
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Methylphenidate, d-amphetamine,
mixed amphetamine salts are equally
effective
Probably act by increasing dopamine
and norepinephrine levels
Similar side effects
Stimulants
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Individualized dosing- often have better
results with higher dose
All day coverage for many/most
children
Frequent follow-up with health care
provider with teacher feedback
If one stimulant doesn’t work, try
another
Stimulants
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Improve attention span
Decrease hyperactivity and impulsivity
Improve work completion
Often improve behavior
Often improve academic performance
Common stimulant side effects
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Decreased appetite- give with or after
meals
Difficulty falling to sleep
Tics
Stomachaches – give with food
Headaches
Less common side effects
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Moodiness or irritability
Overly quiet “Zombie effect”
Weight loss
Small decrease in height velocity
Rebound symptoms as med wears off
Mild increase in heart rate and B/P
Rare risk of mania or hallucinations
Priapism- 15 cases reported
Stimulants
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Methylphenidate products (Ritalin,
Concerta, Metadate, Methylin, generics,
patch
D-methylphenidate (Focalin, Focalin XR)
D-amphetamine (Dexedrine, Dextrostat)
Mixed amphetamine salts (Adderall,
Adderall XR)
Methylphenidate –dose and
duration of action
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Short acting ( Ritalin, Methylin, etc.) 3-5 hrs
(.3-.7 mg/kg/dose 2-3 times/day) Dmethylphenidate Focalin(.15-.3 mg/kg/dose)
Intermediate acting (Ritalin SR, Metadate ER,
Methylin ER) – 3-8 hr
Extended release ( Metadate CD, Ritalin LA)
6-8 hr, Concerta-10-12 hr
Methylphenidate patch, wear for 9 hr
Usual maximum daily dose – 2 mg/kg
Methylphenidate Extended
Release
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Concerta – longest lasting,22%
immediate release, ascending plasma
level, must be swallowed whole
Ritalin LA 50% immediate release,
50% release at 4 hr, mimic bid dosing.
Can open capsule
Metadate CD 30% immediate release,
can open capsule
Methylphenidate patch
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Methylphenidate patch (Daytrana)
10,15,20,30 mg patches
Takes 2 hrs to take effect, wear 9
hours, lasts 12 hours
Same side effects, patch may come off
Useful for patients unable to take pills
or with fast metabolism
Amphetamines – dose and
duration of action
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Short acting (Dexedrine, Dextrostat) – 4-6 hr
Intermediate acting (Adderall, Dexedrine
spansules) 5-8 hr
Extended release (Adderall XR) 10-12 hr
Usual maximum daily dose – 1 mg/kg
Dose is ½ to 2/3 of methylphenidate dose
Other stimulant preparations.
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Lisdexamfetamine (Vyvanse)
Pro-drug, which is activated when aminoacid
is cleaved off
Effective for ADHD, same side effects
Aim is to provide protection against abuse
and addiction
6-12 years, start at 20-30 mg, can increase
weekly up to 70 mg max
Lisdexamfetamine 30 mg roughly equivalent
to dextroamphetamine 10 mg
Cardiac warnings
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27 unexplained deaths in children under 18 yrs on
ADHD medication reported between 1992-2004
11 on methylphenidate
13 on amphetamine salts (Adderall)
3 on atomoxetine (Strattera)
FDA recommends not using if heart disease,
arrhythmia, or FH of arrhythmia
Concern about patients with undiagnosed heart
disease and long term effects
EEG not needed if cardiac hx is negative
Benefits of stimulants in
Adolescents
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Medication reduces risk of auto
accidents for ADHD patients
Medication reduces risk of substance
abuse in ADHD patients
Other Medications for ADHD
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Atomoxetine (Strattera)
Bupropion (Wellbutrin), imipramine
Alpha2 agonists -clonidine or
guanfacine (Tenex) – useful for tics,
sleep, and aggression
Atomoxetine (Strattera)
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Selective norepinephrine reuptake inhibitor
Effective for ADHD, may take 3-4 weeks to
see full effect
No abuse potential, not controlled substance
Unlikely to worsen tics or anxiety
Dosage – start .5 mg/kg/day for 3 days, then
up to 1.2 to 1.4 mg/kg/day
10, 18, 25, 40, 60, 80, 100 mg capsules
Useful for ADHD with anxiety or depression
Atomoxetine (Strattera)- side
effects
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Somnolence – can give in evening or
divide dose
Anorexia, GI upset, weight loss – give
with food, divide dose
Dizziness
Rare risk of liver disease
Increased risk of suicidal ideation .4%
Alpha 2 Agonists
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Clonidine and guanfacine (Tenex)
Adjuctive medication
Useful for sleep, tics, aggression,
hyperarousal
Not as effective for inattention
May take 2 weeks to see
effect
Alpha 2 Agonists
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Clonidine .003-.01 mg/kg/day, tid,qid, often
start .025 - .05 mg per day, also available as
patch and long-acting form
Guanfacine .04-.08 mg/kg/day, max 4
mg/day, often start .5 mg perday (also once
daily form )
Side effects – sedation, especially with
clonidine, dry mouth, depression, low B/P,
headache
Withdrawal symptoms if stopped suddenly –
high pulse, B/P, headache, agitation
ADHD and Co-morbidities
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ADHD and anxiety – respond to
stimulants, may need to add SSRI,
another option is atomoxetine
ADHD and tics – stimulants and
clonidine or other meds for tics,
atomoxetine
ADHD and aggression – stimulant and
clonidine/guanfacine or other meds
Parenting and ADHD
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Brief clear instructions
Give immediate and frequent feedback
and consequences
Use incentive more than punishment
Try to be consistent and provide
structured environment
Plan for problem situations
Negotiable and non-negotiable issues
Special Education and ADHD
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Child with ADHD may be eligible for special
education, under “Other health impairment”
Child must be tested and qualify for special
education
“Limited alertness” for academics, which
adversely affects education, including grades,
tests, behavior, social skills.
504 Plan
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Section 504 of Rehabilitation Act
Schools receiving Federal funds and
employers can not discriminate against
people with disabilities (including
ADHD) and must make reasonable
accommodations
Educational Accommodations
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Tailor homework assignments and tests
Structured environment, help with
organization
Simplify and/or provide visual
instructions
Behavior management techniques
Use of tape recorders or notes
Daily or weekly report to parents
Medical management for ADHD
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Stimulants are first line treatment
70-80% effective
Titrate to optimal dose
All day coverage for many/most
children
Set and monitor goals
Close long-term follow-up
References
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AAP. ADHD Clinical Practice Guidelines.
Pediatrics 2011;128: 1007-1022.
American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders,
5th Ed.,2013, American Psychiatric
Association, Arlington, VA.
Resources
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www.chadd.org
www.dbpeds.org www.aap.org
www.help4adhd.org
www.ParentsMedGuide.org
www.aacap.org
www.nichq.org ADHD toolkit
Questions