Attention Deficit Hyperactivity Disorder

1. Attention Deficit Hyperactivity Disorder Royann Mraz, MD Clinical Associate Professor Center for Disabilities and Development Dec 10, 2014

2. No conflict of interest

3. Epidemiology of ADHD • 8-10% of school aged children • 8% 4-10yr, 14% 11-17 yr. • Boys>Girls 2-4:1 • High rates of Co-Morbidities –especially psychiatric and learning • 33% have one co-morbidity, 16% -2, 18% - 3

4. Neurobiology of ADHD • Cerebellar-prefrontal-striatal network hypothesis • Volume differences- caudate, smaller cerebrum (esp. anterior) and cerebellum

5. Genetics • Genetic imbalance in dopamine and noradrenergic systems- several genes play a role • Strong genetic influence • Concordance -92% identical twins, 33% dizygotic twins

6. Environment • Increased risk with prenatal smoking exposure * • Prematurity, Brain injury, fetal alcohol, lead • Dietary factors do not play a role in the majority of children – food additives, essential fatty acids?, Fe or Zn deficiency?

7. Attention Deficit Hyperactivity Disorder- subtypes • Predominately inattentive type – 8-9 yr • Pr • Predominately inattentive type • Predominately hyperactive-impulsive- start at 4yr, max 6-8 yr • Combined type- most common

8. DSM 5 ADHD • Children - 6/9 symptoms of Inattention (inconsistant with developmental level, impacts activities, and not secondary to oppositional behavior or failure to understand) and/or 6/9 symptoms of hyperactivity/impulsivity • Adolescent and adults – only require 5 symptoms from either category • Some symptoms must be present by 12 years of age (DSM-IV by 7 yrs and be impairing)

9. Diagnostic criteria - Inattention • Careless mistakes • Difficulty sustaining attention • Does not seem to listen • Does not follow through on tasks • Not organized • Avoids sustained mental effort • Loses things • Is easily distracted • If forgetful 6/9

10. Diagnostic criteria – Hyperactivity/Impulsivity • Fidgets or squirms • Inappropriately leaves seat • Inappropriately runs or climbs • Has difficulty playing quietly • Is “on the go” • Talks excessively • Blurts out answers • Has Difficulty waiting his or her turn • Interrupts or intrudes on others 6/9

11. DSM-5 ADHD updates • Most of changes recognize that ADHD is a chronic illness and help with diagnosis in adolescents and adults • 18 symptoms remain the same (additional examples provided) • Inattentive symptom f: Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg. Schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers)

12. ADHD Updates • Cross-situational symptoms rather than impairment • Symptoms interfere or reduce quality of social, academic, or occupational functioning • Present for over 6 months • Symptoms aren’t secondary to other mental disorder • Rate current severity of symptoms –mild, moderate, severe

13. Consequences of DSM-5 ADHD • Easier to diagnose in adolescents and adults • May increase the prevalence rates • Can diagnose ADHD in individuals with Autism Spectrum disorder

14. Differential Diagnosis of ADHD • Normal age appropriate behavior, Unrealistic expectations • Lack of structure/limits • Family stress and dysfunction, abuse • PTSD, RAD, and adjustment disorders • Intellectual disability/Learning disorder • Autism, fetal alcohol, seizures, lead exposure, sleep disorder, thyroid

15. COMORBIDITY • Learning disorder 10-30% • Opposition defiant disorder/ Conduct disorder 50-67% • Anxiety or Mood disorder 30% • Tourette’s and tic disorders • Coordination problems • Substance abuse • Sleep problems

16. DIAGNOSTIC EVALUATION • Child’s history and functioning • Family history and functioning • School information • Rating scales – parent and teacher • Interview and physical exam of child • Consider psychological/educational evaluation

17. AAP Practice Guidelines for ADHD 2011 • Initiate evaluation for ADHD in child 4-18 years of age if behavior or academic problems and ADHD symptoms • Determine if DSM criteria are met in more than one setting (teacher questionnaires) and rule out other causes

18. AAP guidelines for ADHD • Assess for co-existing conditions – • Emotional/behavioral (anxiety, depression, ODD, conduct disorders) • Developmental (learning, language, etc.) • Physical (sleep apnea, tics, etc.)

19. AAP Guidelines for ADHD • Treat ADHD as a chronic condition using principles of chronic care model and medical home • Titrate medication to achieve maximal benefit with minimal side effects

20. AAP guidelines for preschoolers • Addresses evaluation and management of 4 and 5 year olds with ADHD symptoms • Recommends behavior management counseling and placement in structured setting • Allows for stimulant treatment if above isn’t sufficient

21. AAP Guidelines ADHD • 6-11 Years • Treat with FDA approved medication (strong evidence for stimulants) and/or • Parent and/or Teacher behavior management or preferably both • 12-17 Years • Treat with FDA approved medication • May prescribe behavior therapy

22. Consider referring if • Preschool child • Developmental delay or learning problems • ADHD, inattentive type • Family dysfunction • Moderate to severe behavior problems • Anxiety or depression

23. Medical Treatment of ADHD • Monitor or treat co-morbidities • Educate patient and family • Set goals with family and school • ADHD is a chronic disorder – 65% of children with ADHD will have symptoms as adolescents

24. Medical Management of ADHD • Medication is most effective treatment • Good behavior management program can provide additional benefit • Stimulants are first line treatment and most effective • 70-80% of children will respond to a stimulant

25. Stimulants • Methylphenidate, d-amphetamine, mixed amphetamine salts are equally effective • Probably act by increasing dopamine and norepinephrine levels • Similar side effects

26. Stimulants • Individualized dosing- often have better results with higher dose • All day coverage for many/most children • Frequent follow-up with health care provider with teacher feedback • If one stimulant doesn’t work, try another

27. Stimulants • Improve attention span • Decrease hyperactivity and impulsivity • Improve work completion • Often improve behavior • Often improve academic performance

28. Common stimulant side effects • Decreased appetite- give with or after meals • Difficulty falling to sleep • Tics • Stomachaches – give with food • Headaches

29. Less common side effects • Moodiness or irritability • Overly quiet “Zombie effect” • Weight loss • Small decrease in height velocity • Rebound symptoms as med wears off • Mild increase in heart rate and B/P • Rare risk of mania or hallucinations • Priapism- 15 cases reported

30. Stimulants • Methylphenidate products (Ritalin, Concerta, Metadate, Methylin, generics, patch • D-methylphenidate (Focalin, Focalin XR) • D-amphetamine (Dexedrine, Dextrostat) • Mixed amphetamine salts (Adderall, Adderall XR)

31. Methylphenidate –dose and duration of action • Short acting ( Ritalin, Methylin, etc.) 3-5 hrs (.3-.7 mg/kg/dose 2-3 times/day) D-methylphenidate Focalin(.15-.3 mg/kg/dose) • Intermediate acting (Ritalin SR, Metadate ER, Methylin ER) – 3-8 hr • Extended release ( Metadate CD, Ritalin LA) 6-8 hr, Concerta-10-12 hr • Methylphenidate patch, wear for 9 hr • Usual maximum daily dose – 2 mg/kg

32. Methylphenidate Extended Release • Concerta – longest lasting,22% immediate release, ascending plasma level, must be swallowed whole • Ritalin LA 50% immediate release, 50% release at 4 hr, mimic bid dosing. Can open capsule • Metadate CD 30% immediate release, can open capsule

33. Methylphenidate patch • Methylphenidate patch (Daytrana) • 10,15,20,30 mg patches • Takes 2 hrs to take effect, wear 9 hours, lasts 12 hours • Same side effects, patch may come off • Useful for patients unable to take pills or with fast metabolism

34. Amphetamines – dose and duration of action • Short acting (Dexedrine, Dextrostat) – 4-6 hr • Intermediate acting (Adderall, Dexedrine spansules) 5-8 hr • Extended release (Adderall XR) 10-12 hr • Usual maximum daily dose – 1 mg/kg • Dose is ½ to 2/3 of methylphenidate dose

35. Other stimulant preparations. • Lisdexamfetamine (Vyvanse) • Pro-drug, which is activated when aminoacid is cleaved off • Effective for ADHD, same side effects • Aim is to provide protection against abuse and addiction • 6-12 years, start at 20-30 mg, can increase weekly up to 70 mg max • Lisdexamfetamine 30 mg roughly equivalent to dextroamphetamine 10 mg

36. Cardiac warnings • 27 unexplained deaths in children under 18 yrs on ADHD medication reported between 1992-2004 • 11 on methylphenidate • 13 on amphetamine salts (Adderall) • 3 on atomoxetine (Strattera) • FDA recommends not using if heart disease, arrhythmia, or FH of arrhythmia • Concern about patients with undiagnosed heart disease and long term effects • EEG not needed if cardiac hx is negative

37. Benefits of stimulants in Adolescents • Medication reduces risk of auto accidents for ADHD patients • Medication reduces risk of substance abuse in ADHD patients

38. Other Medications for ADHD • Atomoxetine (Strattera) • Bupropion (Wellbutrin), imipramine • Alpha2 agonists -clonidine or guanfacine (Tenex) – useful for tics, sleep, and aggression

39. Atomoxetine (Strattera) • Selective norepinephrine reuptake inhibitor • Effective for ADHD, may take 3-4 weeks to see full effect • No abuse potential, not controlled substance • Unlikely to worsen tics or anxiety • Dosage – start .5 mg/kg/day for 3 days, then up to 1.2 to 1.4 mg/kg/day • 10, 18, 25, 40, 60, 80, 100 mg capsules • Useful for ADHD with anxiety or depression

40. Atomoxetine (Strattera)- side effects • Somnolence – can give in evening or divide dose • Anorexia, GI upset, weight loss – give with food, divide dose • Dizziness • Rare risk of liver disease • Increased risk of suicidal ideation .4%

41. Alpha 2 Agonists • Clonidine and guanfacine (Tenex) • Adjuctivemedication • Usefulforsleep, tics, aggression, hyperarousal • Not as effectiveforinattention • Maytake 2 weeks to see effect

42. Alpha 2 Agonists • Clonidine .003-.01 mg/kg/day, tid,qid, often start .025 - .05 mg per day, also available as patch and long-acting form • Guanfacine .04-.08 mg/kg/day, max 4 mg/day, often start .5 mg perday (also once daily form ) • Side effects – sedation, especially with clonidine, dry mouth, depression, low B/P, headache • Withdrawal symptoms if stopped suddenly –high pulse, B/P, headache, agitation

43. ADHD and Co-morbidities • ADHD and anxiety – respond to stimulants, may need to add SSRI, another option is atomoxetine • ADHD and tics – stimulants and clonidine or other meds for tics, atomoxetine • ADHD and aggression – stimulant and clonidine/guanfacine or other meds

44. Parenting and ADHD • Brief clear instructions • Give immediate and frequent feedback and consequences • Use incentive more than punishment • Try to be consistent and provide structured environment • Plan for problem situations • Negotiable and non-negotiable issues

45. Special Education and ADHD • Child with ADHD may be eligible for special education, under “Other health impairment” • Child must be tested and qualify for special education • “Limited alertness” for academics, which adversely affects education, including grades, tests, behavior, social skills.

46. 504 Plan • Section 504 of Rehabilitation Act • Schools receiving Federal funds and employers can not discriminate against people with disabilities (including ADHD) and must make reasonable accommodations

47. Educational Accommodations • Tailor homework assignments and tests • Structured environment, help with organization • Simplify and/or provide visual instructions • Behavior management techniques • Use of tape recorders or notes • Daily or weekly report to parents

48. Medical management for ADHD • Stimulants are first line treatment • 70-80% effective • Titrate to optimal dose • All day coverage for many/most children • Set and monitor goals • Close long-term follow-up

49. References • AAP. ADHD Clinical Practice Guidelines. Pediatrics 2011;128: 1007-1022. • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.,2013, American Psychiatric Association, Arlington, VA.

50. Resources • www.chadd.org • www.dbpeds.orgwww.aap.org • www.help4adhd.org • www.ParentsMedGuide.org • www.aacap.org • www.nichq.org ADHD toolkit