Attention Deficit Hyperactivity Disorder (ADHD)

1. Attention Deficit Hyperactivity Disorder (ADHD) Justin A. Glass, MD 21 February 2008 Emory Family Medicine

2. Attention Deficit Hyperactivity Disorder (ADHD) • What is the role of the primary care physician in diagnosis and treatment of ADHD?

3. ADHD Talk Objectives • You will understand ADHD diagnostic criteria • You will will know where to find and how to use assessment tools for diagnosing ADHD • You will know when to refer a patient w/ ADHD for specialty care • You will understand tx options for ADHD • You will want to see a child with ADHD in your clinic in the near future

6. ADHD Epidemiology • Prevalence • Survey average: 8-10% in children of school age • Parent reported prevalence age 4-17 • Boys 11% • Girls 4.4% • Male: Female ratio 2:1 - 4:1

7. ADHD Pathogenesis • Multiple theories • Imbalance of catecholamine metabolism in cerebral cortex • Impaired executive functions • Impaired response inhibition

8. Diagnosis of ADHD • Inattention • Hyperactivity • Impulsivity

9. Diagnosis of ADHD • Inattention • Forgetful outside of school • Incomplete performance on school tasks • Missing details • Missing homework • Poor performance on schoolwork

10. Diagnosis of ADHD • Hyperactivity • Always in motion • Difficulty during “quiet times” • Constant talking

11. Diagnosis of ADHD • Impulsivity • Unable to “wait turn” • Answers for others • Unsafe behavior

12. DSM IV Criteria – ADHD (Inattention) • Often fails to give close attention to detail or makes careless mistakes in schoolwork, work or other activities. • Often has difficulty sustaining attention in tasks of play activities • Often does not seem to listen when spoken to directly • Often does not follow through on instructions and fails to finish homework, chores or other duties • 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 required to complete tasks • Is often easily distracted • Is often forgetful in daily activities Six (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

13. DSM IV Criteria – ADHD (Hyperactivity) • Often fidgets with hands or feet or squirms in seat • Often leaves seat in situations in which remaining seated is expected • Often runs about or climbs excessively in situations in which it is inappropriate • Often has difficulty in playing quietly • Is often “on the go” or acts as if “driven by a motor” • Often talks excessively • Often blurts out answers before questions are completed • Often has difficulty waiting turn • Often interrupts of intrudes on others Six (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

14. Diagnosis of ADHD • Additional Criteria: • Some inattentive or hyperactive/impulsive symptoms were present before the age of seven. • Some impairment from the symptoms is present in two or more settings (e.g. at school and at home) • Clear evidence of clinically significant impairment in social, academic or occupational functioning

15. DSM IV Criteria - ADHD • Three types • Inattention predominant (ADHD-IA) (30-40%) • Hyperactivity predominant (ADHD-H/I) (10%) • Combined type (ADHD-C) (50-60%)

16. Diagnosis of ADHD • Screening questions • How is your child doing in school this year? • Is your child happy to go to school? • Have you heard from the teacher(s) regarding any concerns about behavior or performance in school? • How does your child do with chores around the house? • How does your child do with homework?

17. Diagnosis of ADHD • Objective approach • Data needs to be collected from more than one source • Parents • Teachers • Others

18. Diagnosis of ADHD • What kind of data? • Standardized forms • Conners Rating Scale (CATRS) • ACTeRS Form • Vanderbilt ADHD Diagnostic Rating Scale

19. Diagnosis ADHD • Need to develop a differential diagnosis

20. Diagnosis of ADHD • Oppositional Defiant Disorder • Conduct Disorder • Depression • Anxiety • Learning disability • Special senses disability • Substance Abuse • Pervasive Developmental Delay NOS

21. Oppositional Defiant Disorder • A pattern of negativistic, hostile and defiant behavior lasting at least six months, during which four or more of the following are present: • Often loses temper • Often argues with adults • Often actively defies or refuses to follow adults rules • Often deliberately annoys people • Often blames others for his/her mistakes • Often is touchy / easily annoyed by others • Often is resentful • Often is spiteful / vindictive The disturbance in behavior causes significant impairment in social, academic or occupational functioning. The symptoms are not due to a mood disorder or conduct d/o.

22. Conduct Disorder • Repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate norms or rules of society are violated. • Aggression to people or animals • Destruction of property • Deceitfulness or theft • Serious violation of rules

23. Depression • Depressed mood • Change in sleep (S) • Loss of interest / pleasure in activities (I) • Thoughts of worthlessness or guilt (G) • Loss of energy (E) • Trouble concentrating (C) • Change in appetite or weight (A) • Change in psychomotor activity (P) • Thoughts of suicide or death (S) 5 of the 9 symptoms present frequently for at least two weeks. One of the 5 symptoms must be depressed mood or loss of interest in usual activities. Symptoms can not be due to substance use of another psychiatric diagnosis.

24. Learning Disability • Schoolwork performance issues • Reading • Writing • Mathematics

25. Special Senses Disability • Visual disturbance • Hearing loss

26. Substance Abuse • High index of suspicion in teens

27. Pervasive Developmental Delay NOS • Autistic spectrum, but not meeting autism criteria

28. When should I refer a child I suspect has ADHD? • Age younger than six • Co-existent psychiatric conditions • Co-existent neurologic conditions

29. Let’s go to Vanderbilt

30. ADHD Management Plan • Clear communication with parents and teachers • Phone calls • Email • Progress notes • Daily School-Home Report Card

31. ADHD Management Plan • Parenting skills • Homework rules • Sleep rules • T.V. / Videogame rules

32. ADHD Management Plan • Stimulant Medications • Dextroamphetamine / Levoamphetamine • Adderall • Adderall XR • Dextramphetamine • Dexedrine • Dexedrine Spansule • Dextrostat • Methyphenidate • Ritalin • Ritalin LA • Ritalin SR • Concerta • Methylin • Metadate ER • Metadate CD • Focalin • Daytrana

33. ADHD Management Plan • Stimulant Medications • Adverse effects • Anorexia • Weight loss • Sleep disturbance • Tics • Tachycardia • Hypertension

34. ADHD Management • Stimulant Medication • Use the least amount needed • Use extended release preparations when possible • Give drug holidays if appropriate • Reassess regularly as to response

35. ADHD Management • Stimulant Medications are Schedule 2 drugs • 30 day supply with written prescription • Rule change 2007 allows up to 90 day supply • Three 30 day scripts • Each dated sequentially for fill date • Atomoxetine is not a restricted medication

36. ADHD Management Plan • Non – stimulant medication • Atomoxetine (Strattera) • Norepinephrine reuptake inhibitor • Starting dose 0.5 mg/kg • Maximum dose 1.4 mg/kg or 100 mg /day • ADHD scores improve with atomoxetine vs placebo • ADHD scores are equal to / slightly worse than stimulant medications

37. ADHD Management • Non-stimulant Medication • Atomoxetine side effects • Anorexia • Weight loss • Abdominal pain • Nausea / Vomiting • Sleep disturbance • Suicidal ideation (0.4% vs 0% placebo) • Liver injury (VERY RARE -- 2 cases!)

38. When else should I refer a child I suspect has ADHD? • Failure to respond to a reasonable trial of stimulant / non-stimulant medications and behavior interventions

39. Conclusions: ADHD • Performing an ADHD evaluation is within the spectrum of practice of a family doctor • Observer data is needed from at least two settings in the child’s life • Co-morbid / alternate diagnoses should be ruled out • A comprehensive management plan offers the patient the best chance for success in school

40. ADHD Resources • Caring for Children with ADHD: A Resource Toolkit for Clinicians, AAP, 2008. http://www.nichq.org/NICHQ/Topics/ChronicConditions/ADHD/Tools/ Individual forms are available here for download http://www.nichq.org/resources/toolkit A compressed folder of all ADHD forms is available for download.

41. Additional References • Changes and Challenges: Managing ADHD in a Fast-Paced World, Michael J Manos, et al, Manag Care Pharm. 2007;13(9)(suppl S-b):S2-S13 • Obtaining Systematic Teacher Reports of Disruptive Behavior Utilizing DM-IV, Mark L. Woraich, et al, Journal of Abnormal Child Psychology, Vol 26(2), 1998: 141-152.

43. Adult ADHD • Childhood ADHD commonly persists: • 22-85% of adolescents • 4-50% of adults

44. Adult ADHD • Symptom complex can differ from childhood • Inattention and impulsivity > hyperactivity

45. Adult ADHD • Wender (Utah) Criteria • Hyperactivity and inattention plus (2) of below • Labile emotions • Hot temper • Inability to complete tasks • Inability to tolerate stresss • Impulsivity

46. Adult ADHD • Treatment • Stimulants • Response rate decreased versus childhood ADHD • Atomoxetine • Lower cadiovascular risk profile • Minimal abuse potential

47. Management of ADHD • Stimulant Misuse (22%) / Diversion (11%) • Continuously escalating dosage • Repeated lost prescriptions / “dispensing errors” • Demand for immediate release preparation • Infrequent user • Psychosis • Palpatations