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ADHD
Diagnosis, Treatment &
DSM-5 Considerations
Sala S.N. Webb, MD
Old Dominion Medical Society
June 8, 2013
Outline
Define ADHD
Highlight common comorbid & confounding
conditions
Discuss assessment &
treatment
considerations
The Diagnostic & Statistical Manual
of
Mental Disorders
Minimal Brain Dysfunction
Hyperkinetic Reaction of Childhood
(DSM-II, 1968)
Attention Deficit Disorder: With &
Without Hyperactivity (DSM-III, 1980)
Attention Deficit Hyperactivity Disorder
(DSM-IV, 1994)
Attention Deficit/Hyperactivity Disorder
(DSM-5, 2013)
Attention-Deficit/Hyperactivity
Disorder
Criteria: DSM-5
At least 6 symptoms of
Inattention
AND/OR
At least 6 symptoms of
HyperactivityImpulsivity
Persistent for at least 6
months
Maladaptive
Inconsistent with
developmental level
Present before age 12
years
Problems in two or
more settings
Impairment in social,
academic or
occupational
functioning
Not due to other
condition
Inattention
• Makes careless mistakes
• Difficulty with sustained
focus
• Does not follow through
on instructions
• Unable to organize
• Avoids tasks requiring
sustained attention
• Loses things needed for
tasks
• Easily distracted
• Often forgetful
Hyperactivity
Fidgets, squirms
Difficulty remaining seated
Runs & climbs excessively
Difficulty playing quietly
Acts as if “driven by a motor”
Talks excessively
Impulsivity
Blurts out answers
Can be intrusive
Limited
Interrupts
patience
others
Types
Combined Presentation
Predominantly Inattentive Presentation
Predominantly Hyperactive/Impulsive
Presentation
Mild/Moderate/Severe
Other Specified ADHD
Unspecified ADHD
Etiology
Deficits in executive functioning
Genetic & Neurobiological contributors:
perinatal stress, low birth weight, TBI,
maternal smoking, severe early deprivation
Decreased frontal & temporal
lobe volumes
Decreased activation of frontal
lobes, caudate and anterior
cingulate
Epidemiology
6%-12% prevalence
4%-10% treated with medications
60%-85% will continue to meet criteria
through teenage years
Adult prevalence varies: by self report (2%8%), parent report (46%), developmentally
modified criteria (67%)
Rule of 3rd’s
By adulthood:
1/3rd will continue to need
medications
1/3rd will have mild/residual
symptoms but functional
without medications
1/3rd will no longer meet
clinical criteria
Confounding & Co-Morbid
Conditions
Medical Conditions
Hearing impairment
Hyperthyroidism
Metals or toxins
In -utero exposure
Medical Conditions
Seizures
(Absence, Complex
Partial)
Severe head injuries
Sensory Integration
Disorders
Sleep Apnea
Disruptive, Impulse Control &
Conduct Disorders
Oppositional-Defiant
Disorder
Conduct Disorder
Intermittent Explosive
Disorder
Substance Related Disorders
Alcohol
Amphetamines
Cannabis
Caffeine
Cocaine
Hallucinogens
Inhalants
Nicotine
Opiate
Sedative or Hypnotic
Abuse
Dependence
Intoxication
Withdrawal
Neurodevelopmental Disorders
Communication
Disorders
Autism Spectrum
Disorders
Intellectual
Disabilities
Specific
Learning
Disorders
Motor
Disorders
Anxiety Disorders
Separation Anxiety Disorder
Generalized Anxiety Disorder
Specific Phobia
Social Anxiety Disorder
Adjustment Disorder with
Anxiety
Panic Disorder
Obsessive Compulsive Disorders
Obsessive Compulsive Disorder
Trichotillomania
Excoriation
Depressive Disorders
Major Depressive Disorder
Persistent Depressive Disorder
Disruptive Mood
Dysregulation Disorder
Adjustment Disorder
with depressed mood
Manic Disorders
Bipolar I
Disorder
Bipolar II
Disorder
Cyclothymic Disorder
Trauma – Related Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Evaluation
Presenting symptoms
Perinatal & developmental
histories
Medical history
Family history
Educational history
Social history
Patient & parent interviews
Physical examination
Collateral information
Assessment Considerations
Onset , frequency &
duration
Setting
Context
Level of disruption
Stressors or trauma
Intensity
Level of impairment
Ability to self-regulate
Insight
Scales
Conner’s Parent’s Rating Scale
Conner’s Teacher’s Rating Scale
Brown ADD
Vanderbilt ADHD
Child Behavior Checklist
Treatment
Psychoeducation
Clarify diagnosis
Give contextual framework
Be honest & sincere about your opinion
Anticipate developmental challenges
Provide or recommend resources: fact sheets,
books, websites etc.
School Resources
Talk with child’s main teacher
Talk with guidance counselor
If applicable, encourage parents to request in writing testing
or Child Study
Suggest accommodations, if solicited
Behavioral Therapies
Initial therapy for mild symptoms and
uncertain diagnosis
Per parental preference
Focuses in parental management and molding
of behaviors
Can be in-home or outpatient
Behavioral Therapies
Cognitive Behavioral Therapy (CBT) more
efficacious in adolescents & adults than
younger children
Metacognitive Therapy (MCT) combines CBT
with training on improving executive
functioning
Pharmacotherapy
First Line
Approved by FDA for ADHD
Stimulants
Atomoxetine
Second Line
Buproprion
α Agonists
Tricyclic Antidepressants
Stimulants
Methylphenidate
Short acting (2-6 hrs):
Focalin, Ritalin, Methylin
Intermediate acting (4-8
hrs): Metadate CD, Methylin
ER, Ritalin SR, Ritalin LA
Long acting (8-12 hrs):
Concerta, Focalin XR,
Daytrana Patch
Amphetamine
Short acting: Dexedrine,
Dextrostat, Adderall
Intermediate acting:
Dexedrine Spansules
Long acting: Adderall XR,
Vyvanse
Stimulants
Side Effects
Decreased appetite, weight loss
Insomnia, headaches
Tics, emotional lability, irritability
Visual & tactile hallucinations
Contra-indicated in pre-existing heart
condition
Atomoxetine
Selective Norepinephrine
Reuptake Inhibitor (SNRI)
Strattera
Not as effective as
stimulants
Can use if negative side
effects experienced on
stimulants
Requires 6 weeks to see
full effect
Effective in treating comorbid anxiety
Side Effects
Nausea, decreased
appetite
Headaches
Sedation (can give as
single night dose)
Suicidality
Buproprion
Dopamine
Norepinephrine Reuptake
Inhibitor (DNRI)
Wellbutrin, Wellbutrin SR,
Wellbutrin XL
Helpful in co-occurring
depression
Less effective for
inattention, no effect on
hyperactivity
Delayed onset of action
Side Effects
Insomnia
Headaches
Nausea
Contraindicated in seizure
disorders
Use with caution in eating
disorders
Can induce seizures in
overdose
α 2 Adrenergic Agonists
Guanfacine (Tenex,
Intuniv)
Clonidine (Catapres,
Kapvay)
Effective for impulsivity
and hyperactivity; not
inattention
Helpful in co-occurring
traumatic flashbacks,
aggression, insomnia &
tics
Side Effects
Sedation
Dizziness
Hypotension
Rebound hypertension
with rapid
discontinuation
Tricyclic Antidepressants
Imipramine,
Nortriptyline,
Desipramine
Inhibits reuptake of NE
EKG at baseline and
each dose increase
Once symptom control
achieved, check serum
level for toxicity
Side Effects
Dry mouth, constipation
Vision changes,
sedation
Tachycardia
Cases of sudden death
reported in children &
adolescents with
desipramine
When to Refer…
For evaluation & treatment
For consultation with
resumption of treatment
Concerns for safety
Significant impairment in
functioning
No improvement after 6-8
weeks of first-line
intervention
Diagnostic conundrum
History suggestive of
trauma with current impact
Difficulty coping with
chronic medical illness
Can always seek collegial
consultation without
face-to-face evaluation of
patient
References
Diagnostic and Statistical Manual of Mental
Disorders , Fifth Edition American Psychiatric
Association, 2013
Practice Parameter for the Assessment and
Treatment of Children and Adolescents with
Attention Deficit-Hyperactivity Disorder
J. Am. Acad. Child Adolesc. Psychiatry, 2007;
46 (7): 894-921
Questions??