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ADHD Child to Adult Cindy Ruttan DO 2008

ADHD Child to Adult Cindy Ruttan DO 2008. Kansas Osteopathic Conference OVPK KS . Key points to cover. Symptoms/ History Who it effects-ages Collecting informants Rule out diagnosis Treatment options Behavioral Medications. ADHD is like---.

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ADHD Child to Adult Cindy Ruttan DO 2008

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  1. ADHD Child to AdultCindy Ruttan DO 2008 Kansas Osteopathic Conference OVPK KS

  2. Key points to cover • Symptoms/ History • Who it effects-ages • Collecting informants • Rule out diagnosis • Treatment options • Behavioral • Medications

  3. ADHD is like--- I stopped to think, and forgot to start again. I was trying to daydream, but my mind kept wandering.

  4. What is ADHD ? • Neuro- Behavioral Disorder • Inattention-( executive functions) • Hyperactivity • Impulsivity • Speculate: Dopamine and NE dysregulation • Affects 7-12% of pediatric group pop. • High chance for Co-morbidity • Costly due to ER use, injury and Hospital use.

  5. ADHD Review History • Core criteria DSM-III: • 3 separate symptom areas • DSM-III-R • one long list • DSM-IV • two core dimensions

  6. ADHD and DSM IV criteria Concerned by …may change in future DSM’s. • Age of onset- ? 7 years • Age appropriate Symptoms are needed for helping diagnose disorder from Child/ Adol/ Adults • Various inputs needed –they can conflict

  7. MOATADHD Diagnosis • Movement excessive (Hyperactive) • Organization problems (difficulty finishing tasks) • Attention problems • Talking impulsively Meet criteria of 6 of 9 symptoms, present prior to age 7yrs and present in 2 or more settings. The Psychiatric Interview 2nd ed Carlat

  8. Children's ADHDReview of past 10 years • Reviews in Child Adolescent Psychiatry (Williams and Wilkins) Pg 9-17. by Dennis Cantwell MD • Reprint from the J. of the American Academy of Child and Adolescent Psychiatry.

  9. ADHD Natural Hx • 30% Developmental Delay • 40% Continual Display • Internalizing disorders • Depression • Anxiety • 30% Developmental Decay • Externalizing disorders • ODD • CD

  10. ADHD info from 10 year review • Core symptoms may change over time. Consider the younger one presented the more persistent diagnosis and the older one is diagnosis the fewer symptoms that are present. Examples Include: • Temper outbursts • Aggressive argumentative behavior • Fearless • Sleep disturbance

  11. Diagnostic concerns… • Can one diagnosis contribute to all symptoms reported? • Can you be observing more than one disorder? • ADHD –diagnosis of exclusion. consider: Hyper behavior and Mania/ Hypomania Decreased focus/inattention with Depression

  12. ADHD Co morbidities • CD • Possible reduction in Substance Abuse Disorder ( Drugs and ETOH) if treated early for ADHD with Stimulants • ODD • LD • Anxiety 20-40% • OCD increase up to 11%^ • Tourette’s-rare (usually reverse) / Tic • Tic 10-15%^ • Mood Disorder 5-40% depression • Bipolar 10-22%^ • Poor interpersonal skills/demoralized David Krefetz DO MBA FACN, FAPA ADHD with Comorbidity in Pediatric Populations: Impllications for Eval and Management ^

  13. DBD (Disruptive BehaviorDisorder) refers to the Comorbidity diagnosis of ODD/CD Worry about aggression and delinquency Academic underachievement Increased risk for substance abuse Increased social maladaptation Note having both DBD and ADHD makes the ADHD harder to treat. NO medications FDA approved for ODD/ CD

  14. Learning Disorders • Input • Process of getting info into the brain • Integration • Organization and understanding • Memory • Storage of info to retrieve later • Output • Communicate from brain to others or put into action in the environment ADHD and LD Booklet for Parents by Larry B Silver MD

  15. Input Disability • Visual Perception • Auditory Perception • Auditory Lag (Auditory Processing ) ADHD and LD Booklet for Parents by Larry B Silver MD

  16. Integration Disability • Sequencing • Abstraction • Organization • Memory ADHD and LD Booklet for Parents by Larry B Silver MD

  17. Output Disability • Language • Motor • Gross • Fine ADHD and LD Booklet for Parents by Larry B Silver MD

  18. DiagnosingADHD • NO lab tests, or psychologic tests that definitely diagnose. • Recommend Academic Testing to establish level in school and any LD’s. • Obtain Conners Forms or Vanderbuilt Scales that help with defining criteria –or use the DSM IV criteria. • TOVA or CPT may help with identification of ADHD symptoms and how well the meds are working.

  19. Early Medical interventionwith Medication has shown: • For individuals with ADHD in childhood to decrease the risk for subsequent non-nicotine SUD in adol and early adulthood. ? (Worked best for those with the milder form of ADHD) A Literature Review Series Vol 1 No. 3

  20. Children with ADHD at risk for ETOH problems • ADHD is a risk factor for ETOH problems –parental behaviors and environmental stress contribute too. • More likely to drink heavy and to have enough problems to diagnose ETOH Abuse or Dependency. • onset average age 15 • Consider a possible subset of ADHD disorder with antisocial behavior patterns • ETOH and ADHD seem to run in families which thus seem to be under more “stress” situations. Addiction Science Made Easy 4-8-07 WWW.NATTC.org

  21. Young Adults –college age • Problems noted: • Harder to adjust to adult life, college life with poorer social skills and less self esteem. • Lower GPA, less financially, inc. school drop out • Less methodical, inc. procrastination, less self control/self disciplinary behaviors • Symptoms look different • Impulsive and hyper = mental restlessness or subjective feelings of such.

  22. Adult ADHD • Nature of disorder is disorganized, forgetful and poor self regulation • Majority can not remember to take their medication if on IR or multi doses needed. • Inconvenience • Embarrassed • Safety and long term effects • Different feeling…

  23. Adult ADHD • Basic same core symptoms as with Peds ADHD • Review HX of Ed, job and family • Standard rating scales/specific for ADULTS • Collateral info coping /stressors • Rule out other diagnosis • Review options for Treatment as they match patient goals • Meds/ CBT

  24. Adult ADHD who had diagnosis as child • Many loose full diagnostic status( functional remission)10% vs Persistent ADHD at15% by 25 yrs old. reality is ADHD had remitted only for a minority. Inattentiveness remains when inattention and Hyperactivity decline. If one put partial remission + Persistant = 65% have symptoms of ADHD.

  25. Functional Impairment • Lower Socioeconomic • Relationship impaired • Dec. academic accomplishments • Employment issues • Driving record bad • Dating, vol. work, community service, socializing with friends /family, culture and educational out of school activities limited.

  26. Common Maladaptive Beliefs: Self mistrust Failure Inadequate Incompetent Instability Common Dysfunctional Coping Behaviors seen: Avoidance Procrastination Pseudo efficiency low priority tasks first then high priority tasks last. Busy without completion of things Adult ADHD cont-

  27. Mood Disorders—50-60% Depression- recurrent BAD Cyclothymia Dysthymia DEP NOS Anxiety Disorders 40-50% GAD Anxiety NOS Co morbidity is “The RULE” with Adult ADHD

  28. Co morbidity cont-Adult ADHDVarious % • SUD • LD • IED • Tourette • Antisocial Personality Disorder • Borderline Personality Disorder • Dependent Personality Disorder

  29. Behavioral Interventions

  30. Treatment Options with or without medications 1 • Praise reward positive behaviors by : • verbalize it • Speak individual / public • Write it • Reward it • Physical Activity -participation • Material - for doing good job in class Dec / Jan 2008 ADDitude Magazine pg 49

  31. Cont: Treatment Options with or without Medication 2 • Follow up with teachers regarding childs Positive and Negative attributes. Keep open communication. • Make sure IEP/504 is being used. • Address LD issues and grade appropriate level of work in sink • Do help at home with homework or working ahead if possible/ tutor Dec / Jan 2008 ADDitude Magazine pg 49

  32. Cont: Treatment Options with or without Medication 3 • Encourage routine healthy food and snacks –due to side effects form medications • Peanut butter / double up on Breakfast drink • Consider type and delivery style of medications including time frame medications given and duration of action • Keep structured as possible and avoid chaotic situations-you as a parent stay calm, cool and collected. • Give yourself time to accomplish the task/ goal desired. Keep a Daytimer/ planner if needed • Give an exercise break • Dec / Jan 2008 ADDitude Magazine pg 49

  33. Cont: Treatment Options with or without Medication 4 • Use verbal and non-verbal cues to remind or stay focused • Keep good sleep hygiene. Insomnia is common with ADD/ ADHD either a part of the disorder itself or exacerbated by medications • Try to avoid arguments and confrontations leading to poor self esteem Dec / Jan 2008 ADDitude Magazine pg 49

  34. Therapy Goal: • Sensitize the patient to and interrupt dysfunctional behaviors • Coping skills • Problem focused • Adaptive thinking • Anger management • Communication skills

  35. RX Treatments

  36. Medication Options • 19 meds are FDA approved • 18 are stimulants • Use Lowest Dose which addresses symptoms—as one increases dose if no improvement noted than lowest dose which provided improvement is the best dose. • List symptoms from patients concern then family and compare… may not agree.

  37. Medication Diversion • Transfer of meds from one it is prescribed to one whom it is not. • Taking more (quantity) • misuse for Euphoric desire • Combo with other substances Study of those Diagnosed with ADHD and its misuse: 22% of adol and young adults in study misused in some capacity. ADHD patients Sold it more than the non ADHD group. Those who sold had comorbid diagnosis of SUD and CD. IR prep most often diverted A Literature Review Series Vol 1 No. 3 Pg 19-21

  38. Medications • Stimulants • Short • Intermediate • Long • Transdermal • Stimulant Pro Drugs • Non Stimulants • SNRI • Adrenergic Agents • Antidepressants • Dopaminergic Agents

  39. Stimulants FDA ApprovedAdult FDA Approved is in BLUE • Amphetamine • Adderall • Dexedrine • Dextrostat • Adderall XR 2004 • Dexedrine Spanules Not recommended under age 3 yrs

  40. Stimulants cont-FDA approved • Methylphenidate • Ritalin • Methylin chewable, Oral sol • Metadate ER • Focalin • Focalin XR 2005 • Methylin ER • Ritalin SR • Metadate CD • Ritalin LA • Concerta Not recommended for children under age 6

  41. MethylphendateTransdermal Patch New Stimulant Delivery Option

  42. Transdermal Methylphenidate Patch • Daytrana • FDA approved ages 6-12 • 10,15, 20 and 30 mg • Recommended one patch daily • Start with the 10 mg patch if no improvement in 1 week increase-- cont to adjust dose per 1 week intervals. • Location hip (rotate area/ sides) may cause irritation • Delivered over 9 hours • Possibly effects initial height but minimal to not significant in adulthood • Much the same side effect profile as oral agents • Remove 2 hours prior to effectswearing off. Current Psychiatry Vol 5 No.6 / June 2006

  43. Stimulant Pro Drug • Vyvanse - Lisdexamfetamine • FDA approved for ages 6-12 30, 50, and 70 mg capsules Start with 30 mg/day. If needed titrate up with 20mg every 3-7 days as tolerated to max of 70 mg/day • Effect about 12 hours • Steady state in 2-3 days • Half life 9.5 hours Current Psychiatry Vol.6 no.6 June 2007

  44. Vyvanse – Lisdexamfetamine cont-2 Blocks NE and Dopamine reuptake in Presyn neuron Noted improvement 2 hrs after dosing. Large change in corrected QTC intervals--? Need more info about cardiac risk Possibly Less risk for abuse at recommended doses—may be misused at higher than therapeutic doses. Current Psychiatry Vol.6 no.6 June 2007

  45. Vyvanse – Lisdexamfetamine cont-3 • Caution in Patients: • Co morbid eating • Sleep disorder • HTN or cardiovascular illness • Monitor HR and BP • Do not prescribe to patients taking MAOI or who have taken one in 2 weeks of the presentation. Current Psychiatry Vol.6 no.6 June 2007

  46. Stimulant: side effects • Review Black Box Warnings regarding CV risks and Sudden Death. • Encourage Food prior to taking Medications • Understand possibility of Psychosis • May make Mania or Tics worse • Can write for 90 day RXN as of Dec 07

  47. Stimulant Black Box Warnings Pre-existing Cardiac abnormality, cardiomyopathy, arrythmias, or other disorders which the use of a sympathomimetic could be dangerous or increase the vulnerability of patients lives. • Murmurs, syncopy history, HTN • Consult Cardiology to be safe. Current Psychiatry Vol. 5 No. 10 / Oct 2006

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