attention deficit

1. Attention Deficit/ Hyperactivity Disorder Dennis L. Hufford, CDR, MC, USN Faculty Development Fellowship Madigan Army Medical Center

2. Objectives Define Diagnostic Criteria Discuss Workup and Differentiation Discuss Therapy

3. ADHD: What is It? Triad: Inattentiveness, Hyperactivity, Impulsiveness Maladaptive and Pervasive Academic and Behavioral Problems Onset Prior to Age 7 Probable Organic Cause Exact Etiology Unknown

4. Prevalence 3-5 % of School Age Children (1:25) 2 % of Adolescents (1:50) 0.8 % of 20 year-olds (1:125) 0.2 % of 30 year olds (1:500) 0.05 % of 40 year olds (1:2000)

5. DSM IV Criteria EITHER: 6 symptoms of Inattention OR Hyperactivity & Impulsivity AND Onset before age 7 Impairment in at least 2 Settings Impairment in social, academic or occupational Function No other pervasive disorder

6. Pitfalls in Diagnosis DSM criteria also describe NORMAL kids! No Physical or Lab Markers Significant Overlap w/ Diff. Dx. Public Awareness, Misinformation

7. Diff. Dx. and Comorbid Conditions Oppositional Defiant Disorder Tic Disorders Learning Disabilities Mental Retardation Family Dysfunction/Discord Other Medical and Mental Disorders

8. Keys to Accurate Diagnosis History, History, and more History!! Standardized Checklists/Questionaires Exclusion of Diff. Dx. by Physical Exam IQ testing, audiometry, eye screening Multidiscliplinary Approach

9. History Behavioral incl. classroom, home, church, meals interactions with peers Medical: year by year school performance, developmental ROS: Neuro, GI esp. encopresis, psychiatric

10. History Family ADHD, tics, psychiatric disorders Social Family Dysfunction Parenting Skills Never the root of ADHD!

11. Useful Questions Is the child more apt to: do things without thinking ahead, or plan to misbehave? Refuse to do things or try to do things, but fails to finish? Does the child display aggression toward people or animals, destructiveness or theft? (inconsistent with ADHD)

12. Checklists/ Questionnaires �Objective� Data (?) Achenbach Behavior Checklist ADD II (ACTeRs) Connors Rating Scale Child Behavior Rating Scale Others

13. Physical Exam Directed Hearing and Vision Screening Developmental Milestones PE cannot rule-IN Diagnosis, only rules- OUT other Diff Dx.

14. Multidisciplinary Approach Primary Provider Psychoeducational Consultant academic, aptitude, and psychometric testing IQ measurement (usually done through the school) Social Services Counseling Services Individual and Family

15. Treatment/ Management Education Patient Parent Teachers and Caregivers Physician

16. Education Resources Books: Barkley RA. Taking Charge of ADHD: The Complete Authoritative Guide For Parents. New York, Guilford Press, 1995. Bain, LJ. A Parent�s Guide to Attention Deficit Disorders. New York,: Delta Books, 1991.

17. Education Resources Support Organization: CHADD: �Children and Adults with Attention Deficit Disorder� local chapters materials for children, adults, parents, schools 499 70th Ave NW, Suite 109, Plantation FL 33317. Ph. (800) 233-4050 Website: www.chadd.org/

18. Education Resources Special Education child may qualify for special services under Federal Law. (Individuals with Disabilities Education Act and section 504 of Rehabilitation Act of 1973) Schools responsible for determining eligiblility (they may need info from YOU)

19. Medical Therapy Medications Stimulants: methylphenidate (Ritalin) dextroamphetamine (Dexadrine) pemoline (Cylert) Others TCA�s, beta-blockers, bupropion, venlafaxine

20. Medication Doses: Methylphenidate: 0.3-0.5 mg/kg per dose administered bid or tid start low, titrate 5mg increments max 60 mg qd Dextroamphetamine 1/2 the methylphenidate dose Both meds have SR formulations

21. Medication Doses Pemoline Start 37.5 mg/day (1 pill) Increase by 18.75 mg at weekly intervals to response (1/2 pill) Usual effective range: 56.25-75 mg/day Maximum 112.5 mg/day (3 pills) Check LFTs at 6 month intervals

22. Stimulants Expected benefit Improved CONCENTRATION evidence: better grades, etc. All other benefits are secondary

23. Stimulants Problems Misinformation, Unrealistic Expectations Controlled Substance Adverse Effects Sleep disturbance Appetite Suppression Tics Anemias (rare)

24. Supportive Therapy Counseling/ Psychotherapy Behavior Modification Structured Schedule and Environment Regular Followups (not necessarily in person!) Social Services on-base support programs, training

25. Adult ADHD Relatively Rare, however� LOTS of Media Attention Lately! Comorbidity with Major Depression 12% of Adult MDD patients who had ADHD as children manifest ADHD symptoms May benefit from ADHD therapy

26. Adult ADHD Therapy Education Support Medication Stimulants TCA�s incl desipramine

27. Summary ADHD diagnosis and therapy is complex and labor intensive There are NO short-cuts in gathering necessary history and data! Emphasis on Diagnostic Accuracy by HISTORY Realistic Expectations of Therapies Multidisciplinary Approach

28. References Barbaresi, WJ. Primary Care Approach to the Diagnosis and Management of Attention-Deficit Hyperactivity Disorder. Mayo Clinic Proc, 1996 May, 71:5, 463-71. The best overview I found on the subject. Schneider, Steven and Tan, Grace. Attention-Deficit Hyperactivity Disorder: In Pursuit of Diagnostic Accuracy. Postgraduate Medicine, 1997 Apr., 101:4, 231-40. Concentrates on diagnostic features. Hill, JC and Schoener, EP. Age-Dependent Decline of Attention Deficit Hyperactivity Disorder. Am J Psychiatry, 1996 Sep, 153:9, 1143-6. Good picture of natural course of the disorder.

29. References (cont.) Mannuzza, S et al. Adult Psychiatric Status of Hyperactive Boys Grown Up. Am J Psychiatry, 1998 Apr, 155:4, 493-8. Abstract�s worth reading for what ADHD kids turn into! Johnson, TM. Evaluating the Hyperactive Child in Your Office: Is It ADHD? AFP, 1997 July, 56:1, 155-60. A middle of the road, �Here�s how I do it�. DSM IV, pp. 78-85. Criteria attached to handout. Descriptive.