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Slide 1 - Attention Deficit Hyperactivity Disorder (ADHD) Justin A. Glass, MD 21 February 2008 Emory Family Medicine
Slide 2 - Attention Deficit Hyperactivity Disorder (ADHD) What is the role of the primary care physician in diagnosis and treatment of ADHD?
Slide 3 - 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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Slide 6 - 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
Slide 7 - ADHD Pathogenesis Multiple theories Imbalance of catecholamine metabolism in cerebral cortex Impaired executive functions Impaired response inhibition
Slide 8 - Diagnosis of ADHD Inattention Hyperactivity Impulsivity
Slide 9 - Diagnosis of ADHD Inattention Forgetful outside of school Incomplete performance on school tasks Missing details Missing homework Poor performance on schoolwork
Slide 10 - Diagnosis of ADHD Hyperactivity Always in motion Difficulty during “quiet times” Constant talking
Slide 11 - Diagnosis of ADHD Impulsivity Unable to “wait turn” Answers for others Unsafe behavior
Slide 12 - 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.
Slide 13 - 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.
Slide 14 - 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
Slide 15 - DSM IV Criteria - ADHD Three types Inattention predominant (ADHD-IA) (30-40%) Hyperactivity predominant (ADHD-H/I) (10%) Combined type (ADHD-C) (50-60%)
Slide 16 - 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?
Slide 17 - Diagnosis of ADHD Objective approach Data needs to be collected from more than one source Parents Teachers Others
Slide 18 - Diagnosis of ADHD What kind of data? Standardized forms Conners Rating Scale (CATRS) ACTeRS Form Vanderbilt ADHD Diagnostic Rating Scale
Slide 19 - Diagnosis ADHD Need to develop a differential diagnosis
Slide 20 - Diagnosis of ADHD Oppositional Defiant Disorder Conduct Disorder Depression Anxiety Learning disability Special senses disability Substance Abuse Pervasive Developmental Delay NOS
Slide 21 - 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.
Slide 22 - 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
Slide 23 - 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.
Slide 24 - Learning Disability Schoolwork performance issues Reading Writing Mathematics
Slide 25 - Special Senses Disability Visual disturbance Hearing loss
Slide 26 - Substance Abuse High index of suspicion in teens
Slide 27 - Pervasive Developmental Delay NOS Autistic spectrum, but not meeting autism criteria
Slide 28 - When should I refer a child I suspect has ADHD? Age younger than six Co-existent psychiatric conditions Co-existent neurologic conditions
Slide 29 - Let’s go to Vanderbilt
Slide 30 - ADHD Management Plan Clear communication with parents and teachers Phone calls Email Progress notes Daily School-Home Report Card
Slide 31 - ADHD Management Plan Parenting skills Homework rules Sleep rules T.V. / Videogame rules
Slide 32 - 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
Slide 33 - ADHD Management Plan Stimulant Medications Adverse effects Anorexia Weight loss Sleep disturbance Tics Tachycardia Hypertension
Slide 34 - 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
Slide 35 - 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
Slide 36 - 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
Slide 37 - 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!)
Slide 38 - 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
Slide 39 - 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
Slide 40 - 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.
Slide 41 - 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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Slide 43 - Adult ADHD Childhood ADHD commonly persists: 22-85% of adolescents 4-50% of adults
Slide 44 - Adult ADHD Symptom complex can differ from childhood Inattention and impulsivity > hyperactivity
Slide 45 - 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
Slide 46 - Adult ADHD Treatment Stimulants Response rate decreased versus childhood ADHD Atomoxetine Lower cadiovascular risk profile Minimal abuse potential
Slide 47 - 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