The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder

1. The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder Carla M. Thacker PAS 646 March 22, 2007

2. Basic ADHD Information • Most common neurological and behavioral disorder in childhood • One of the most frequently identified chronic childhood disorders seen in the primary care setting • Core symptoms are inattentiveness, hyperactivity, and impulsiveness

3. Statistics • In 2003, the CDC reported that approximately 4.4 million children ages 4-17 in the US had a diagnosis of ADHD • An estimated 4-12% of children in the community are affected by ADHD • There is a significant difference in the prevalence of ADHD in boys and girls, with estimates of 10% and 4%, respectively

4. ADHD often results in the following: • Difficulties in school • Poor relationships with parents and peers • Low self-esteem • Various other behavioral, learning, and emotional problems • Difficulties for the child’s parents, including marital problems, increased stress, and poor relationships with their child

5. Etiology • Exact etiology of ADHD is unknown • Thought to be a complex interaction between neurological, biological, & environmental factors • Genetics and biological factors play the major roles • Variation in genes regulating dopamine, norepinephrine, & serotonin in the brain

6. Predisposing Factors • Low birth weight • Low social status • Severe conflicts among parents • Being placed in foster care • Mother who smoked, consumed alcohol and/or drugs while pregnant.

7. Symptoms Suggestive of ADHD: • Easily distracted by sights and sounds in their environment • Difficulty concentrating for long periods of time • Becomes restless easily • Excessive impulsiveness • Frequent daydreaming • Slow to complete tasks

8. Diagnosis • Use of AAP guidelines: • Evaluate children 6-12 yrs. presenting with core symptoms of ADHD • Must meet DSM-IV criteria • Gather information about symptoms from various settings from the parents & school system • Assess for coexisting mental health & learning problems • Order diagnostic tests as indicated by findings

9. Diagnosis • Need a detailed patient & family history • Interview with patient & family • Obtain report cards & teacher reports • Obtain a thorough physical examination including visual & auditory screening • Refer patient to mental health specialist if coexisting mental disorders or learning disabilities suspected

10. Subtypes of ADHD (Based on DSM-IV Criteria) • Predominantly hyperactive-impulsive type – no significant inattention • Predominantly inattentive type – no significant hyperactive-impulsive behavior (previously known as ADD) • Combined type- both inattentive & hyperactive-impulsive behaviors

12. Treatment • Currently no cure for ADHD • Three types of treatment: • Medication management • Behavioral therapy • Combination of medication & behavioral therapy

13. Medications for ADHD • Stimulants – shown to improve core symptoms by increasing & maintaining balance of dopamine & serotonin in brain • Non-stimulants (atomoxetine) – enhances noradrenergic function through presynaptic reuptake of norepinephrine

14. Stimulants • Some available in short-acting, long-acting, and extended release forms. • Produce relatively quick response in patient • Schedule II controlled substance – potential for abuse • Side effects – loss of appetite, insomnia, HA, dizziness, abdominal pain • Begin with lowest dosage & titrate up as necessary

15. Commonly Used Stimulants • Methylphenidate (Ritalin) – long-acting form is Concerta, extended-release forms are Ritalin SR, Metadate ER, & Metadate CD • Amphetamine (Adderall) • Dextroamphetamine (Dexedrine, Dextrostat, and Focalin) • Pemoline (Cylert) – no longer considered first-line due to risk of hepatotoxicity

16. Non-Stimulants (atomoxetine) • Slower response times than stimulants • Non-scheduled drug – no potential for abuse • Side effects similar to those of stimulants • Atomoxetine (Straterra) is the only non-stimulant approved by the FDA to treat childhood ADHD • More expensive than stimulants • Others sometimes used are antidepressants; including bupropion (Wellbutrin) & despiramine, & antihypertensives; including clonidine & guanfacine

17. Methylphenidate (Ritalin) vs. Atomoxetine (Straterra) • Recent study analyzed all clinical trials which compared the two drugs • More patients responded to Ritalin than Straterra & responses were quicker with Ritalin • Study confirmed that stimulants are the most efficacious treatment for childhood ADHD • Straterra is a good alternative treatment when stimulants are not well tolerated or when drug abuse is a potential problem

18. New ADHD Treatment Option • The 1st and only stimulant prodrug, lisdexamphetamine (Vyvanse) was granted market approval by FDA in Feb. 2007 • Therapeutically inactive until contact is made with GI tract – only active if swallowed • May prevent abuse of drug by those who snort or inject crushed pills • Recent study showed that 95% of children taking Vyvanse produced “much improved” or “very much improved” rating on Clinical Global Impressions rating scale

19. Conclusion • ADHD is a disorder in which research must continue in order to determine it’s etiology & to obtain more information regarding safety of treatments. • Due to increasing numbers of children with ADHD, it is very important for primary care physicians to become skilled at diagnosing and treating the disorder.

20. References • Adesman, A. The diagnosis and management of attention-deficit/hyperactivity disorder in pediatric patients. Primary Care Companion J Clin Psychiatry 2001; 3: 66-77. • Foy, J., Earls, M. A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics 2005; 115: e97-e104. • Furman, L. What is attention-deficit hyperactivity disorder (ADHD)? J Child Neurol 2005; 20(12): 994- 1003. • Gibson, A.P., Bettinger T.L., Patel, N.C., Crismon, M.L. Atomoxetine versus stimulants for treatment of attention deficit/hyperactivity disorder. Ann Pharmacother 2006 Jun; 40(6): 1134-42. • Greydanus, D.E. Pharmacologic treatment of attention-deficit hyperactivity disorder. Indian J Pediatr 2005; 72: 953-960. • Harpin, V.A. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Child 2005; 90: i2-i7. • Karande, S. Attention deficit hyperactivity disorder: A review for family physicians. Indian J Med Sci 2005; 59: 547-556. • Kuntsi, J., McLoughlin, G., Asherson, P. Attention deficit hyperactivity disorder. Neuromolecular Med. 2006; 8(4): 461-84. • Leslie, L. The role of primary care physicians in attention deficit hyperactivity disorder (ADHD). Pediatr Ann 2002 August; 31(8): 475-484.

21. References (Continued) • Leslie, L. et al. Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings. Pediatrics 2004 July; 114(1): 129-140. • Mental health in the United States. Prevalence of diagnosis and medication treatment for attention- deficit/hyperactivity disorder—United States, 2003. MMWR Morb Mortal Wkly Rep 2005; 54(34): 842-7. • Olfson, M. New options in the pharmacological management of attention-deficit/hyperactivity disorder. Am J Manag Care 2004; 10: s117-s124. • Steer, C.R. Managing attention deficit/hyperactivity disorder: unmet needs and future directions. Arch Dis Child 2005; 90: i19-i25. • Wolraich, M.L. et al. Attention-deficit/hyperactivity disorder among adolescents: A review of the diagnosis, treatment, and clinical implications. Pediatrics 2005; 115(6): 1734-46. • www.cdc.gov • www.nimh.nih.gov • www.shire.com • www.webcenter.health.webmd.netscape.com • www.wellmark.com

22. Questions?