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ADHD

ADHD. Clinical Features. Mainly: Attention deficit Hyperactivity Impulsivity Functional impairment Above features must be present before age 7 yrs Impairment in > 1 setting DSM-IV criteria for ADHD. Clinical Features. Salient manifestations change during adolescence

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ADHD

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  1. ADHD

  2. Clinical Features • Mainly: • Attention deficit • Hyperactivity • Impulsivity • Functional impairment • Above features must be present before age 7 yrs • Impairment in > 1 setting • DSM-IV criteria for ADHD

  3. Clinical Features • Salient manifestations change during adolescence • Hyperactivity diminishes • Academic and peer problems magnify

  4. Clinical Features • Other characteristics of adolescents with ADHD • Often seem emotionally immature • Procrastinate • Easily distracted and have difficulty completing projects • Have significant sleep disturbances

  5. Comorbidities • There is a high rate of comorbidity • Oppositional defiant disorder • Conduct disorder • Substance use disorder • Mood disorder • Antisocial personality disorder • Ask about symptoms of these disorders also

  6. Co-Existing Diagnoses • Children with mild to moderate degrees of intellectual disability may have symptoms consistent with ADHD and may respond to medications • Children with pervasive developmental disorders may also have ADHD symptoms and may benefit from medical treatment for ADHD

  7. Assessment • Parents and primary classroom teacher are rich resources • Homework patterns • School grades • Daily routines • Classroom behavior • Social relationships • Children with ADHD tend to under-report their level of impairment dramatically

  8. Assessment • At increased risk of specific learning disorders • Reading • Math • Written expression • Encourage parents to request (in writing) that school complete a multidisciplinary evaluation

  9. Assessment • In the ADHD evaluation, clinician must also assess for co-existing conditions • Emotional or behavioral • Anxiety, depression, ODD, conduct disorder • Developmental • Learning or language disorder, other neurodevelopmental disorders • Physical • Tics, sleep apnea

  10. ADHD Rating Scales • Vanderbilt parent and teacher scales • Conners’ parent and teacher rating scales • Swanson, Nolan and Pelham Questionnaire IV teacher and parent rating scale (SNAP-IV) • Disruptive Behavior Disorder Scale • ADHD Rating Scale • All free except Conners’

  11. Pharmacologic Management • Methylphenidate • Ritalin • Ritalin LA • Ritalin SR • Concerta • Focalin • Methylin • Methylin ER • Metadate ER • Metadate CD • Amphetamine compounds • Adderall • Adderall XR • Dexedrine • Dexedrine Spansule • DextroStat

  12. Pharmacologic Management • Short-term adverse effects of stimulants: • Appetite suppression • Sleep disturbances • Abdominal pain • Controversial association with stimulant use and… • Motor tic development • Height / weight decrement

  13. Pharmacologic Management • Straterra (atomoxetine) • Highly specific noradernergic reuptake inhibitor • Efficacy for ADHD + anxiety/tics/depression • Consider if: • Unresponsive to stimulants • Family prefers nonstimulant • Concern for stimulant abuse

  14. Pharmacologic Management • Atomoxetine adverse effects • Sedation (during initial titration) • Appetite suppression • Nausea / vomiting • Headaches

  15. Pharmacologic Management • Anti-depressants are off-label and 2nd-line • Tricyclics • Wellbutrin (buproprion)

  16. Pharmacologic Management • Tricyclics • Block the reuptake of neurotransmitters including norepinephrine • Consider only when: • Adequate trials with both stimulant medications have failed, • Atomoxetine is ineffective, AND • Behavioral interventions have been tried

  17. Pharmacologic Management • Common adverse effects of tricyclics • Sedation • Weight gain • Dry mouth • Constipation • Headache • EKG monitoring at baseline and at therapeutic dose is suggested

  18. Pharmacologic Management • Clonidine (Catapres) • Antihypertensive • 2nd line esp. with adolescents with ADHD + tics/aggression/conduct disorder • Commonly used as adjuvant

  19. Pharmacologic Management • Clonidine short term adverse effects • Sedation • Dry mouth • Depression • Confusion • EKG changes • Hypertension with abrupt withdrawal

  20. Pharmacologic Management • Guanfacine (Tenex) • Alpha-2 agonist • Used to treat ADHD + tic disorders • Venlafaxine (Effexor) • Noradrenergic reuptake inhibitor • May have mild efficacy for ADHD

  21. Pharmacologic Management • Monoamine oxidase inhibitors (Nardil, Parnate) • Limited usefulness due to: • Potential hypertensive crises with tyramine-containing foods (most cheeses) • Interactions with prescribed, illicit, OTC drugs • Pressor amines, most cold medicines, amphetamines

  22. Psychosocial Treatments • Behavior therapy • Broad set of specific interventions that have common goal of modifying physical and social environment to change behavior • Academic interventions • Services enhanced if child is eligible under: • Section 504 of Rehabilitation Act • “Other Health Impaired” of Individuals with Disabilities Education Act • Family therapy • Care coordination

  23. Anticipatory Guidance • Substance abuse • Youths with ADHD experiment earlier than other children • Auto accidents and traffic violations • Parents can restrict passengers and time of day car is used • Parents should discuss these topics often and follow up aggressively on any suspicions

  24. First-Line Management • Preschool-aged children (4 - 5 years of age) • Parent and/or teacher-administered behavior therapy is first line • Methylphenidate if no significant improvement and moderate-to-severe functional impairment • Elementary school-aged children (6 - 11 years) • Medication and/or behavior therapy, preferably both • Adolescents (12 – 18 years) • Medication + behavior therapy, preferably both

  25. Education • Provide basic understanding of the disorder • Destigmatize by comparing it to less stigmatizing conditions (ex: asthma) • Remind patients it is not a reflection of their intelligence

  26. Factors Promoting Adherence • Self-concept • Family stability • Internal locus of control • Increased motivation • Simplified medication regimen • Lack of adverse effects • Characteristics of the doctor-patient relationship

  27. References • Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011 Nov;128(5):1007-22 • WolraichML, Wibbelsman CJ, Brown TE, Evans SW, Gotlieb EM, Knight JR, Ross EC, Shubiner HH, Wender EH, Wilens T. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005 Jun;115(6):1734-46.

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