ADHD WORKSHOP FOR PAEDIATRICIANS

1. ADHD WORKSHOP FORPAEDIATRICIANS UCT Paediatric Refresher Course Feb 2010

2. The role of the Paediatrician in the treatment of ADHD • Diagnosis and management • Increase in presentation • More presentations to Paediatricians and reluctance to visit a Psychiatrist • Families need from Paediatrician • Awareness of differential diagnosis • Awareness of co-morbidity • Medication cornerstone of treatment but holistic approach very NB • Paediatrician may be first professional to notice ADHD

3. General concepts of ADHD • Aetiological and symptomatic understanding

4. Predominantly a neurobiological condition • Strong family history • Constellation of symptoms (vs. signs) • Core symptoms: Inattention • Hyperactivity/Impulsivity • DSM IV criteria

5. criteria • INATTENTION • Failure to give close attention to detail • Difficulty sustaining attention • Not listening when spoken to directly • Inability to finish work / follow through instructions • Difficulty organizing tasks or activities • Avoidance of tasks requiring sustained mental effort

6. Often looses things required for tasks • Easily distracted • Forgetful in daily activities • 6 symptoms required • HYPERACTIVITY • Fidgety • Difficulty remaining in seat • Excessive running about / subjective feeling of restlessness • Difficulty engaging in leisure activity quietly • On the go / “driven by motor” • Excessive talking

7. IMPULSIVITY • Blurting out of answers • Difficulty waiting turn • Often interrupts or intrudes on others • 6 criteria required

8. ALSO • Symptoms present before age 7 years • Impairment in 2 or more settings • Impaired functioning • Symptoms not due to other causes

9. Spectrum of presentation i.e.. Below threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions • Up to 50% of children have co morbid disorder(s)

10. Impairment in social, family and academic functioning • Occurrence in at least 2 settings • Onset during childhood • Longitudinal course - 2/3 of patients progress into adulthood

11. Why are more children presenting now? • “Evolutionary” concept of ADHD • How/why do most patients/families present? • Disruption (in class) probably most common reason for referral

12. Has modern society created a disorder from a previous strength? • Genetic and adaptive factors in ADHD • Information overload • Stimulation overload • Academic overload • Outsourcing of care • Is it normal for a child to sit still at a desk for 6 – 8 hours • Societal issues vs mental health issues

13. Why NB to treat • Academic potential • Disruption • Self esteem • Impaired functioning (academic, social, family ) • co morbidity

14. Evaluation of/Clinical approach to the child presenting with ADHD • May depend on referral source e.g.. Psychologist, school, parents etc • N.B. to take ones time, i.e. extended consult, 2-3 consultations • Differential diagnosis and co morbidity always need to be born in mind

15. Interview with parents (may need to start off without the child) • Child interview • Family observation • Physical information/evaluation of the child • Additional information/investigation

16. Interview with parents • May initially be necessary to exclude the child • Presenting complaint • History of presenting complaint • DSM IV checklist • Context of symptoms • Resulting impairments

17. Differential diagnosis i.e. may the child’s symptoms be due to another cause other than ADHD • Co morbidity i.e. are there additional emotional symptoms that the child is displaying e.g.. Mood, anxiety, conduct, defiance, intellectual impairment etc.

18. Past psychiatric history including ADHD and treatment, past alternative treatments • Developmental history • Areas of strength • Medical history including medications

19. Family history • History of ADHD or co morbid disorder • Learning difficulty • Family coping style, level of organisation and resources • Family stressors • Signs of abuse and neglect (especially in younger children)

20. Child Interview • Note symptoms of ADHD (may however be absent during one on one consultation) • Note and explore: • Defiance • Aggression • Anxiety • Obsessions and compulsions

21. Form, content and logic of thinking and perception • Fine and gross motor coordination • Tics and movement disorders • Speech and language ability • Clinical estimate of intellect

22. Family observation • Patients behaviour with siblings and parents • Parental responses to child’s behaviour • Parental level of agreement around child rearing principles and discipline

23. Physical evaluation • Past medical history and medication • Medical record over past 12 months • Stability of any illnesses e.g. asthma, allergies etc (may tip the balance) • Visual acuity • Hearing • Height, weight and growth chart • Other evaluation as indicated e.g. neurological, cardiology, developmental assessment

24. Additional information/investigations • Forms/rating scales completed by parents, teachers and significant others • Conner’s forms: basic and extended, also important to complete once patient being treated • School reports (especially the comments)

25. Collateral information from teacher and others (aftercare, other carers) • Depending on presentation child may need: • Psychometric assessment • Speech and language assessment • OT assessment • No “special tests” available

26. Differential and co morbid scan • Diagnostic formulation • Treatment plan

27. The younger and older child • Young child: rule out neglect, abuse and other environmental factors, mother/parent: child relationship difficulties may be important contributor • Older child: NB. To make patient an active participant in treatment

28. Treatment/Intervention • Non pharmacological • Pharmacological (cornerstone of treatment)

29. Non pharmacological interventions • Psycho education: parents, child, others • Collaboration with/ interventions at school • Additional school/ remedial resources • Support group for parents • Books and other materials • Behavioural interventions

30. Behavioural interventions • Should be part of overall intervention • May be used on own if symptoms mild or parents refusing meds • Attend to child’s misbehaviours and complaints (target symptoms) • Token systems (target symptoms) • Time out • Manage non compliant behaviour in public places PTO

31. Daily school report and other school interventions • Anticipate future misconduct • Structure, routine, boundaries, predictability • *** may all be impossible if family stressors or if parent(s) have ADHD

32. Play therapy, CBT and social skills training not helpful in children who only have ADHD/ADD • May be useful for co morbid disorders • No empirical evidence for dietary intervention unless proven food intolerance • ? Food colorants in the very young

33. Pharmacological interventions • Methylphenidate: Ritalin IR • Ritalin LA • Concerta • Atomoxetine: Strattera • Other: Imipramine • Clonidine

34. Side effects and their management:Methylphenidate • Loss of appetite (daily quantity N.B.) • Weight loss (monitor) • Headache, abdominal pain • Rebound phenomena • Anxiety • Tics • Depression • Affective blunting/ emotional lability • insomnia

35. Management of stimulant S/E • loa • loss of wt • early insomnia • blunted affect • tic • stereotypic movement • growth delay

36. l o a decrease dosage increase breakfast + supper if early - dev of tolerance monitor wt and ht if symptoms severe -- change to 2nd line meds

37. loss of wt decrease dose increase caloric intake (breakfast and supper) no meds over w/e and holidays monitor wt, growth curve hope for tolerance

38. early insomnia if IR - no meds after 3pm if LA - lower dosage, give dose earlier, give before breakfast for faster absorption ensure bedtime routine eg reading Clonidine, anntihisamine,melatonin

39. blunted affect decrease dosage change preparation

40. tic discontinue, if tic disappears restart if tic recurs - change meds

41. stereotypic movement decrease dosage • growth delay decrease dosage drug holidays bone age monitoring on radiograph

42. Atomoxetine • Gastrointestinal disturbances • Sedation • Decreased appetite • Hepatic disorder • Black box warning: suicidality • “feeling ill” but unable to verbalize • Severe acting out behaviour

43. N.B. to discuss side effects before commencing treatment • Monitor for side effects

44. Use of different methylphenidate preparations i.e. which one to use • Advantages and disadvantage

45. Ritalin vs. Strattera • Ritalin generally considered 1st line • Consider Strattera if: tics, anxiety, Ritalin intolerance, patient preference

46. Introducing medication • Dosage • Start over weekend (parents feel in control) • Warn re side effects • Ritalin : fast onset • Strattera : 4-6 weeks onset (may start in holidays) • Drug holidays ; depends on side effects and level of functioning off meds • Follow up regularly including Connors form and collateral (see later)

47. A 9 year old girl is on Concerta 36mg daily. Reports from school indicate that her concentration remains poor until 1st break. What would your approach be?

48. Establish at what time meds are taken • Consider adding 5 - 10mg Ritalin mane

49. An 8 year old girl refuses to take Ritalin LA 20mg as she feels she cannot swallow it. What would you advise?

50. An 8 year old boy commenced on Strattera complains of persistent midday nausea. How would you manage him?