ADHD Update

Barbara J. Howard, MD [email protected]

www.childhealthcare.org

Disclosures

I have a financial relationship to disclose: Consultant, Total Child Health, Inc.

producer of CHADIS Off label medication will be discussed: psychotropics

Characteristics of AD/HD

 Prevalence - 3-5% of school- age children  Usually identified in the early elementary school years  4:1 to 9:1 male:female  <70% persist into adulthood  Often FH+ AD/HD

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DSM-IV Criteria for ADHD

>= 6 months of 6 of either (1) or (2)  (1)

Inattention

inattention to details doesn’t listen trouble organizing loses supplies forgetful trouble sustaining attention doesn’t finish avoids sustained tasks easily distracted

DSM-IV Criteria for ADHD

 (2)

Hyperactivity

fidgets excess running, climbing on the go

Impulsivity

blurts out answers interrupts or intrudes leaves seat trouble playing quietly talks too much trouble waiting turn

DSM-IV Criteria- 2

 Onset with impairment < 7 years old  Impairment in >= 2 settings  Significant impairment in social, academic, or occupational functioning  Not exclusively part of PDD, schizophrenia, or psychotic disorder nor better accounted for by another mental disorder

ADD without H and ADHD -Inattentive Type   ?Similarity to ADHD “Spacey”  Daydreamer  Sluggish responses - ?processing issues  Excessive confusion  Inconsistent memory retrieval  Shy/anxious passive  Deficits on measures of attention  Not impulsive & not oppositional

Codes for Attentional Disorders

314.01 AD/HD, Combined Type Meets criteria of both A1 & A2 314.00 AD/HD, Predominantly Inattentive Type Meets criteria for A1 but not A2 in last 6mos 314.01 AD/HD, Predominantly Hyperactive Impulsive Type Meets criteria for A2 but not A1 in last 6 mos 314.9 AD/HD, NOS Prominent symptoms but not to criteria

Newer Conceptual Model: Deficit of

INHIBITION

related to “Areas of Executive Functioning”  Deficient Self-Regulation  Impaired Temporal Organization of Behavior  Impaired Goal-Directed Persistence  Diminished Social Effectiveness & Adaptation

Etiology

 No consensus yet regarding precise transmitter defect or anatomic localization  PET study of hyperactive parents of hyperactive children showed decreased glucose metabolism in right frontal lobe  MRI studies showing abnormalities in corpus callosum

Neurotransmittors in ADHD

 Dopamine  Enhances signal  Improves attention  Focus   Vigilance On-task behavior  On-task cognition  Norepinephrine  Dampens noise  Enhances executive operations  Increases Inhibition

Genetics

 Pattern of single dominant gene or a single major gene  50 - 92% of monozygotic twins  Siblings at 2 to 3 times greater risk  Possible association with dopamine transporter gene (DAT1) and dopamine receptor (DRD4)

Differential Diagnosis Medical/neurological primary diagnosis

 Endocrine- hyperthyroidism, generalized resistance to thyroid hormone  Neurological- petit mal, migraine, chorea, lead poisoning, ?iron deficiency  Sensory- mild hearing and/or vision losses  Arousal- day time drowsiness associated with obstructive sleep apnea, lack of sleep  Drug induced- drug side effects (e.g. Phenobarbital, sympathomimetics)

Treatment Implications

 If it is not a problem of how or what then teaching what or how is not likely to help  Treatments or modifications at the site of performance are more likely to be effective  medication, seating arrangement, fm receivers, touching and redirecting, in class assistance  Immediate consequences for goal-directed and task-oriented behavior

Unproven Therapies

 Dietary Management  Megavitamins  Chiropractic Manipulations  Ocular Motor Exercises  Self control training outside performance site (e.g., in a clinic)  EEG biofeedback

Empirically Proven Treatments

 Pharmacologic (>300 double blind published studies)  Note- medication alone is usually not sufficient treatment  Parent counseling about ADHD (&ODD)  Parent training in child management  Teacher counseling and training in ADHD and classroom management  Special Education when indicated  Individual counseling as needed  Residential Treatment  Parent/Family Counseling when indicated

Components of Treatment

 Education of parent, other caregivers  Psychological/behavioral therapies  Parent training  Support groups  Social skills training  Psychoeducational interventions  Medication  Regular follow up

Class Room Adaptations

 Preferential seating  Cueing by teacher before instruction  Shorter work periods with frequent breaks  Visual and tactile stimuli with verbal instructions  Remediation when necessary  FM receivers

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Families as Advocates

504 Plans “other health impaired” with doctor note  Individual Educational Plan for LD  Request complete intelligence and achievement testing  Other specific assessments as needed e.g. VMI, educational assessment, projective testing  Don’t sign it unless satisfied  May need an educational advocate at ARD meeting  Especially key at change to KG, middle, high, graduation  Always appeal possible for higher level of service

Multisite Multimodal Treatment Study (MTA)

 600 children (age 7 – 9)  ADHD combined type  24 month outcomes  Groups  Medical management: monthly tailored  Behavioral Therapy: 8 week summer; training; in class aid, teacher consultation  Combined  Community standard: 67% meds mostly bid

MTA Results

 Medical management or combination therapy had better outcomes than behavioral therapy or community care  Combined therapy was equal to medical for ADHD sx but for subgroups combined may be preferable  Anxiety disorders; high levels of socio economic and/or family stressors

Medication Choice: Stimulants

      MPH and DA are approximately equivalent in efficacy (75%) & side effects  Some children respond better to one  MPH dose = 0.3 - .5 mg/kg/dose; DA = 0.15 0.25mg/kg/dose Ritalin SR is less effective and slower onset than short acting. Ritalin LA more reliable Long acting DA is more likely to cause sleep problems Dexedrine SR- 10-12 hours, greater anorexia, irritability?

Adderall- 4-6 hours, Adderall XR 10-12 smoother Pemoline (Cylert) is no available because of liver toxicity->death

Medication - Dosing

 Short acting lasts 3 1/2 to 4 hours  Children benefiting from school dosing usually can benefit from a 3rd dose  Long acting now recommended  Consider using a placebo trial  With weekly parent and teacher ratings to establish objectivity  Helps parents carefully sort out their fears from fact  Helps establish an optimal dosage early

CHADIS decision support:

 Parent takes

previsit

online questionnaires (behavior, development, health, family factors)     Clinician reviews questionnaire results, can consult linked textbook Clinician may exchange findings with school or mental health provider online Clinician finds relevant resources, handouts from links & prints for family Bill 96110

Graphic display of Vanderbilt

Other stimulants for ADHD

        Focalin- d MPH Short acting; ½ dose; same effectiveness and side effects Focalin XR (5,10,20)- 10-12 hours, same side effects Methylin liquid 5 or 10/5cc short acting Metadate CD- MPH, 6 hours, can sprinkle Ritalin LA- MPH, 8-10 hours Daytrana or MTS or MethyPatch Vyvanse = Slow release mixed salts of amphetamine Procentra = Liquid Dexedrine 5 mg/5 cc

Methylphenidate Transdermal System or Daytrana or MethyPatch

 Takes 2 hours for effect, remove at 9 hours, lasts 12  Signif. effective vs placebo  Potential for sensitization to methylphenidate due to topical route  MTS vs Concerta: Insomnia 13% vs 8%; anorexia 26% vs 19%  12.5 cm = 18 mg Concerta 18.75 cm = 27 mg Concerta 25 cm = 36 mg Concerta 37.5 cm = 54 mg Concerta

Non-stimulants for ADHD

 Atomoxetine  Modafinil  Intuniv = guanfacine er  Clonicel = long acting clonidine (pending)

Atomoxetine (Strattera)

 Norepinephrine reuptake inhibitor- not category II  CYP2D6 metabolized, T1/2 5.2 h  Signif better than placebo in child & adult  Side effects: anorexia 14%, N/V/D 12-15%, dizziness, fatigue 9%, mood swings 5%  Possible inc or dec BP, inc pulse, allergic rash  Recent reports liver abnormalities and failure  Contraindicated near MAO inhibitors  0.5mg/kg->2.0 q 3 d max 100mg div qd-bid. Less with paroxetine or fluoxetine

Modafinil or Provigil

 Indicated for sleep apnea and narcolepsy  100, 200 mg  Dose up to 200 mg q am  Onset 2-4 hours, delayed by food 1 hr, T1/2 15 hrs  CYP inhibitor. Also interferes with OCPs   Transient LFT elevations, palpitations, anorexia, headache all <2% “Euphoria” risk?

Intuniv

FDA approved 6/07  Selective agonist for alpha-2A-receptors in the prefrontal cortex  Nonstimulant  Monotherapy  Once daily long acting  Ages 6 to 17 years  1 mg to 4 mg daily  Better than placebo in 2 double blind trials

Other Nonstimulants

 Imipramine: 1-4 mg/kg /2-3 doses/day; EKG monitoring  Clonidine: 4-5 microgram/kg/day or Guanfacine (Tenex) long acting; esp for aggression and when sedation HS needed; cvs concerns  Bupropion

Bupropion (Wellbutrin)

1.

Antidepressant with stimulant action (beta noradrenergic receptors and prefrontal lobe) 2.

Significant effect on ADHD but less effect size than first line stimulants 3.

Better than nicotine patch for smoking cessation ("Zyban") 4.

Dosage: 3-6mg/kg (

Side-effects (especially if increase fast): Decreased seizure threshold (rate = .06%), agitation, insomnia

Stimulants and CV Risk

FDA reports showed: 25 patients (19 who were 18 years and younger) taking stimulants had suddenly died. 54 more patients on these pills had unusual heartbeats, heart attacks, or strokes. Some had preexisting heart problems, some were taking other pills, including cocaine. AAP advises continuing current practice FDA- no black box warning Prudent to avoid use in structural heart disease, arrythmia, ? if FH sudden cardiac death

Family Cardiac History

(Crosson)  Has your child ever experienced any of the following?  Unexplained seizures  Passing out/fainting during exercise, when startled, or when highly emotional   Dizziness during or after exercise Chest pain during or after exercise  Racing heart or skipped heartbeats  Getting extremely tired or short of breath more quickly than friends do during exercise   High blood pressure or high cholesterol None of these  Not sure

Has anyone in the family (including your child) had any of the following serious heart conditions? Please check all that apply.  Hypertrophic or dilated cardiomyopathy              Long-QT syndrome, short-QT syndrome, Brugada syndrome, or another ion channel disorder Other heart rhythm problems that required treatment Marfan syndrome or ruptured aorta Born with heart malformation (e.g. hole in heart, bad valves, etc.) Unexplained fainting or seizures Use of pacemaker or cardiac defibrillator Primary pulmonary hypertension Ventricular tachycardia Heart attack age 50 or younger Disability due to heart problems before age 50 Sudden death due to heart problems before age 50 None of these Not sure

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Managing Side Effects

Appetite “4th meal” at bedtime Abdominal pain food – disappears in 3 wks; try slow acting medication; ?bowel urgency; give with Headache – disappears in 3 wks; try slow acting, use 7 days/wk Growth – 1 kg, 1 cm; mostly nutrition related; reversible with drug holidays if needed  Tics - mostly due to comorbidity, may have

less

tics with stimulants; 0.5% chance of a persistent problem; try lower dose  Irritability- change family of meds, use another dose in pm

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Sleep problems in ADHD

85% of children with ADHD have sleep problems before using meds  Sleep debt makes ADHD and comorbid conditions worse  Mostly trouble falling asleep but also restless  Consider OSA if snore, bipolar if up for hours in the middle of the night  Start with routine bedtime, back rub, milk, white noise  Meds prn: evening stimulant dose, melatonin 1-8 mg, Clonidine 0.05-0.1 mg., guanfacine up to 1 mg

ADHD Follow-Up Visits- Goals

 To watch for and begin early intervention for co-morbid conditions  To monitor self concept of child, perception of parents and progress toward asset building (e.g., involvement in nonschool skill building)  To adjust medication as needed  Teacher and parent check lists and work samples and report card data are usually needed  Repeat placebo trials are helpful  To monitor for side effects

Adult Outcomes and Need for Continued Medication

 1/3 have “no symptoms” as adults  Consider various work demands:  Air traffic controller vs. salesperson  Accountant vs. CEO with 3 secretaries  Pathologist vs. pediatrician  May increase creativity, energy

References:

 Barkley, R. A. Attention Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. New York: Guilford Press, 72 Spring St., New York, NY, 1990.  Culbert TP, Banez, GA, Reiff, MI. Children who have Attentional Disorders: Interventions. Pediatrics in Review 15 (1), 5-14. 1994  Diller, L. H., Running on Ritalin, Bantam Books, New York, NY, 1998.

 Gorski P (Ed) 2002, Supplement, The Diagnosis and Treatment of ADHD in Early Childhood: Evidence –Based Controversies and Implications of Practice and Policy, J Dev Beh Ped 23(1S)

 Greenhill, L. L., Attention-Deficit Hyperactivity Disorder: The Stimulants. In Riddle, MA, (Ed), Pediatric Psychopharmacology I Child and Adolescent Psychiatric Clinics of North America, January. 123. 4:1, Saunders, Phila, PA. 1995  Papolos D and Papolos J: The Bipolar Child. Broadway Books, NY, 1999

 Reiff MI, Banez, GA, Culbert TP. Children Who Have Attentional Disorders: Diagnosis and Evaluation. Pediatrics in Review. 14. 455-469. 1993.

 Sturner RA, 2005, Attention Deficit Disorder, In The Child Health and Development Interactive System, www.childhealthcare.org

 Wolraich, M (Edit.), 1996, The Classification of Child and Adolescent Mental Diagnoses in Primary care. Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version, American Academy of Pediatrics  www.nichq.org

for Vanderbilt checklist

Appendix

Pediatric Evaluation of ADHD

“Factors and Trigger Questions”

Interviewing the child  General information: age, grade, name of school, name of teacher  Subjects, grades, favorite subject/hardest subject and why  Best friend, activities together  Family- members, kind of person, activities together, hardest part about  Chores, discipline, allowance, hobbies  Family kinetic drawing

Pediatric Evaluation of ADHD

“Factors and Trigger Questions”

Classroom Behavior  Parent: What are your concerns about him? What does/has his teacher say/said about him? (each grade)  Teacher: Ratings (e.g., Conners, DSM)  Child: Tell me about the teacher you have -- Is she nice or did you get one of the mean ones? What does she/he do that seems mean?

Pediatric Evaluation of ADHD

“Factors and Trigger Questions”

Classroom environment Is the child being compassionately, and competently managed? Or is the teacher overwhelmed and confrontational?

 Parent: How many children are in the class?  Child: Where do you sit?

Pediatric Evaluation of ADHD

“Factors and Trigger Questions”

Behavior at home  How is his behavior at home?

 What is the hardest part with him?

 How bad does it get?

 Focus on transitions: Tell me what it is like.. getting him ready for school....bedtime,... turning off TV,... putting his toys away?.

 Patience: Is he able to sit through a meal and take turns talking?

 Organization: What is his room like?

Pediatric Evaluation of ADHD

“Factors and Trigger Questions”

Sleep  Settling: Struggle suggests oppositionism or anxiety  Adequacy: When does he get up on the weekends?  Quality: Screen for sleep apnea

Differentiating ADHD from Typical-1

 Severity- impairs daily function “Have you changed family routines?”  Duration- Not just transient reaction to stress or environmental change “What else has been going on recently?”  Pervasiveness- outside home, occurs with people other than pa “How does he do with other people?”

Differentiating ADHD from Typical-2

 Comorbidity- Presence of other mental health problems Ask about all areas of functioning  Family History- of ADD/ADHD Vs. other psych Genogram  Higher scores on scales (not validated) Use some instrument eg CBCL

Pediatric Evaluation of ADHD “Performance Sampling”

 Review of report card and work samples  Do you have any hard work at your school?  Sample achievement performance (e.g. WRAT and standard reading & comprehension paragraph, alphabet, writing sample)  Hypothesis driven performance sampling- e.g. If problem listening: Do a standard 5 part command; writing -VMI; process related tasks from PEEX, etc.