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What is ADHD?. Chronic neurobiologic disorderHyperactivityImpulsivityInattention. ADHD statistics. 2 million American children3-5% of school aged childrenMale>Female by 2-4:160-70% persist into adolescence. What causes ADHD?. Genetics/familialNorepinephrine/dopamine imbalancesMaternal smokingDisordered breathing during sleep.
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1. Attention Deficit/Hyperactivity Disorder Tracy Hardwick, Capt, USAF, MC
Grand Forks AFB, ND
March 2007
4. ADHD statistics 2 million American children
3-5% of school aged children
Male>Female by 2-4:1
60-70% persist into adolescence
5. What causes ADHD? Genetics/familial
Norepinephrine/dopamine imbalances
Maternal smoking
Disordered breathing during sleep
6. Differential diagnosis General medical conditions
Hearing/vision impairment
Medication effect
Malnutrition
Hypothyroidism
Lead toxicity
Sleep disordered breathing
7. Differential diagnosis Neurologic conditions
Learning disability
Seizure disorder
Mental retardation
Tic disorder
Other neurologic conditions
8. Differential diagnosis Psychiatric
Oppositional defiant disorder
Conduct disorder
Substance abuse
Anxiety
Depression
Bipolar disorder
9. Differential diagnosis Environmental
Abuse/neglect
Poor parenting
Mismatch of school curriculum with child’s ability
Stressful home environment
11. Diagnosis of ADHD Inattention
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
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 necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
12. Diagnosis of ADHD Hyperactivity
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate
Often has difficulty playing or engaging in leisure activities quietly
Is often "on the go" or often acts as if "driven by a motor"
Often talks excessively
Impulsivity
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn
Often interrupts or intrudes on others
13. Physical exam General appearance
Neurologic exam
Mental status exam
Cardiac exam
16. Co-morbidities frequently seen with ADHD ODD – 35%
CD – 26%
Anxiety – 26%
Depression – 18%
Learning disabilities – 20-60%
19. Medications for ADHD Stimulants
Rapid onset
Methylphenidate
Dextroamphetamine
Dexmethylphenidate
Mixed amphetamine salts
20. Medications for ADHD Stimulants
Slower onset, Longer duration
Methylphenidate
Dextroamphetamine
Dexmethylphenidate
21. Medications for ADHD Stimulants
Rapid onset and long duration
Mixed amphetamine salts (Adderall XR)
Methylphenidate
22. Medications for ADHD Second line medications
Atomoxetine
Clonidine (not approved by the FDA)
Modafanil (not yet approved by the FDA)
Antidepressants (especially TCAs)
23. Other therapies for ADHD Behavior therapy
Family counseling
Educational modification
Unproven and not recommended therapies
Cognative, cognative-behavioral therapy, or play therapy
Modifications of diet
No TV time
24. Summary Complex disorder
Rule out other causes of symptoms
Stimulants are the primary treatment
25. References Abramowicz, Mark (ed.). Drugs for Treatment of ADHD. Treatment guidelines from The Medical Letter. Nov 2006; 4 (51).
Barkley RA, et al. Does the treatment of attention-deficit/hyperactivity disorder with stimulants contribute to drug use/abuse? A 13 year prospective study, Pediatrics. Jan 2003; 111:97-109.
Chervin RD et al. Inattention, hyperactivity, and symptoms of sleep disordered breathing. Pediatrics, Mar 2002; 109:449-56.
Cincinnati Children’s Hospital Medical Center. Evidence based clinical practice guideline for outpatient evaluation and management of attention deficit/hyperactivity disorder. Apr 2004.
Herrerias, Carla T et al. The Child with ADHD: Using the AAP Clinical Practice Guideline. Am Fam Phys, May 1, 2001; 63(9).
Johnson EO, Roth T. An epidemiologic study of sleep-disordered breathing symptoms among adolescents. Sleep, Sep 1, 2006; 29:1135-42.
Kahn RS et al. Role of dopamine transporter genotype and maternal prenatal smoking in childhood hyperactive-impulsive, inattentive, and oppositional behaviors. J Pediatr, Jul 2003; 143:104-10.
Krull, Kevin R. Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents. UpToDate. 2006
Krull, Kevin R. Evaluation and diagnosis of attention deficit hyperactivity disorder in children and adolescents. UpToDate. 2006.
Krull, Kevin R. Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents. UpToDate. 2006
26. References Middleton, Donald B, Wolraich, Mark L. Diagnosis and Management of Childhood
ADHD in the Family Practice Setting. AAFP CME program. Released Mar 2003.
Millichap JG et al. Serum ferritin in children with Attention-deficit hyperactivity
disorder. Pediatr Neruol Mar 2006; 34:200-3.
Molina BS and Pelham WE Jr. Childhood predictors of adolescent substance use in a
longitudinal study of children with ADHD. J Abnorm Psychol. Aug 2003;112:497-507.
New Drug: Daytrana (methylphenidate transdermal system). Pharmacist’sLetter/Prescriber’s Letter 2006; 22(6):220606.
Schab DW and Trinh NH. Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind placebo-controlled trials. J Dev Behav Pediatr Dec 2004; 25:423-34.
Smucker, William D and Hedayat Marjaneh. Evaluation and Treatment of ADHD, Am Fam Phys. Sept 1, 2001; 64(5).
Stein, Martin T. Diversion and Misuse of Stimulant Medications Prescribed for ADHD. J Am Acad Child Adolesc. Psychiatry. Apr 2006; 45:408-14.
Stevens T and Mulsow M. There is no meaningful relationship between television exposure and symptoms of attention-deficit/hyperactivity disorder. Pediatrics Mar 2006; 117:665-72.
Wilens, TE et al. Does stimulant therapy of attention deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. Jan 2003:111:179-85.