ADHD Diagnosis, Treatment & DSM-5 Considerations

1. ADHDDiagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

2. Outline • Define ADHD • Highlight common co-morbid & confounding conditions • Discuss assessment & treatment considerations

3. The Diagnostic & Statistical Manual of Mental Disorders • Minimal Brain Dysfunction • Hyperkinetic Reaction of Childhood (DSM-II, 1968) • Attention Deficit Disorder: With & Without Hyperactivity (DSM-III, 1980) • Attention Deficit Hyperactivity Disorder (DSM-IV, 1994) • Attention Deficit/Hyperactivity Disorder (DSM-5, 2013)

4. Attention-Deficit/Hyperactivity Disorder

5. Criteria: DSM-5 • At least 6 symptoms of Inattention AND/OR • At least 6 symptoms of Hyperactivity-Impulsivity • Persistent for at least 6 months • Maladaptive • Inconsistent with developmental level • Present before age 12 years • Problems in two or more settings • Impairment in social, academic or occupational functioning • Not due to other condition

6. Inattention • Makes careless mistakes • Difficulty with sustained focus • Does not follow through on instructions • Unable to organize • Avoids tasks requiring sustained attention • Loses things needed for tasks • Easily distracted • Often forgetful

7. Hyperactivity Fidgets, squirms Difficulty remaining seated Runs & climbs excessively Difficulty playing quietly Acts as if “driven by a motor” Talks excessively

8. Impulsivity • Blurts out answers • Limited patience • Can be intrusive • Interrupts others

9. Types • Combined Presentation • Predominantly Inattentive Presentation • Predominantly Hyperactive/Impulsive Presentation • Mild/Moderate/Severe • Other Specified ADHD • Unspecified ADHD

10. Etiology • Deficits in executive functioning • Genetic & Neurobiological contributors: perinatal stress, low birth weight, TBI, maternal smoking, severe early deprivation • Decreased frontal & temporal lobe volumes • Decreased activation of frontal lobes, caudate and anterior cingulate

11. Epidemiology • 6%-12% prevalence • 4%-10% treated with medications • 60%-85% will continue to meet criteria through teenage years • Adult prevalence varies: by self report (2%-8%), parent report (46%), developmentally modified criteria (67%)

12. Rule of 3rd’s • By adulthood: • 1/3rd will continue to need medications • 1/3rd will have mild/residual symptoms but functional without medications • 1/3rd will no longer meet clinical criteria

13. Confounding & Co-Morbid Conditions

14. Medical Conditions • Hearing impairment • Hyperthyroidism • Metals or toxins • In -utero exposure

15. Medical Conditions • Seizures (Absence, Complex Partial) • Severe head injuries • Sensory Integration Disorders • Sleep Apnea

16. Disruptive, Impulse Control & Conduct Disorders • Oppositional-Defiant Disorder • Conduct Disorder • Intermittent Explosive Disorder

17. Substance Related Disorders • Alcohol • Amphetamines • Cannabis • Caffeine • Cocaine • Hallucinogens • Inhalants • Nicotine • Opiate • Sedative or Hypnotic • Abuse • Dependence • Intoxication • Withdrawal

18. NeurodevelopmentalDisorders • Communication Disorders • Autism Spectrum Disorders • Intellectual Disabilities • Specific Learning Disorders • Motor Disorders

19. Anxiety Disorders • Separation Anxiety Disorder • Generalized Anxiety Disorder • Specific Phobia • Social Anxiety Disorder • Adjustment Disorder with Anxiety • Panic Disorder

20. Obsessive Compulsive Disorders • Obsessive Compulsive Disorder • Trichotillomania • Excoriation

21. Depressive Disorders • Major Depressive Disorder • Persistent Depressive Disorder • Disruptive Mood Dysregulation Disorder • Adjustment Disorder with depressed mood

22. Manic Disorders • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

23. Trauma – Related Disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder

24. Evaluation • Presenting symptoms • Perinatal & developmental histories • Medical history • Family history • Educational history • Social history • Patient & parent interviews • Physical examination • Collateral information

25. Assessment Considerations • Onset , frequency & duration • Setting • Context • Level of disruption • Stressors or trauma • Intensity • Level of impairment • Ability to self-regulate • Insight

26. Scales • Conner’s Parent’s Rating Scale • Conner’s Teacher’s Rating Scale • Brown ADD • Vanderbilt ADHD • Child Behavior Checklist

27. Treatment

28. Psychoeducation • Clarify diagnosis • Give contextual framework • Be honest & sincere about your opinion • Anticipate developmental challenges • Provide or recommend resources: fact sheets, books, websites etc.

29. School Resources • Talk with child’s main teacher • Talk with guidance counselor • If applicable, encourage parents to request in writing testing or Child Study • Suggest accommodations, if solicited

30. Behavioral Therapies • Initial therapy for mild symptoms and uncertain diagnosis • Per parental preference • Focuses in parental management and molding of behaviors • Can be in-home or outpatient

31. Behavioral Therapies • Cognitive Behavioral Therapy (CBT) more efficacious in adolescents & adults than younger children • Metacognitive Therapy (MCT) combines CBT with training on improving executive functioning

32. Pharmacotherapy • First Line Approved by FDA for ADHD • Stimulants • Atomoxetine • Second Line • Buproprion • αAgonists • Tricyclic Antidepressants

33. Stimulants Methylphenidate Amphetamine Short acting: Dexedrine, Dextrostat, Adderall Intermediate acting: Dexedrine Spansules Long acting: Adderall XR, Vyvanse • Short acting (2-6 hrs): Focalin, Ritalin, Methylin • Intermediate acting (4-8 hrs): Metadate CD, Methylin ER, Ritalin SR, Ritalin LA • Long acting (8-12 hrs): Concerta, Focalin XR, Daytrana Patch

34. Stimulants Side Effects • Decreased appetite, weight loss • Insomnia, headaches • Tics, emotional lability, irritability • Visual & tactile hallucinations • Contra-indicated in pre-existing heart condition

35. Atomoxetine • Selective Norepinephrine Reuptake Inhibitor (SNRI) • Strattera • Not as effective as stimulants • Can use if negative side effects experienced on stimulants • Requires 6 weeks to see full effect • Effective in treating co-morbid anxiety Side Effects • Nausea, decreased appetite • Headaches • Sedation (can give as single night dose) • Suicidality

36. Buproprion • Dopamine Norepinephrine Reuptake Inhibitor (DNRI) • Wellbutrin, Wellbutrin SR, Wellbutrin XL • Helpful in co-occurring depression • Less effective for inattention, no effect on hyperactivity • Delayed onset of action Side Effects • Insomnia • Headaches • Nausea • Contraindicated in seizure disorders • Use with caution in eating disorders • Can induce seizures in overdose

37. α 2 Adrenergic Agonists • Guanfacine (Tenex, Intuniv) • Clonidine (Catapres, Kapvay) • Effective for impulsivity and hyperactivity; not inattention • Helpful in co-occurring traumatic flashbacks, aggression, insomnia & tics Side Effects • Sedation • Dizziness • Hypotension • Rebound hypertension with rapid discontinuation

38. Tricyclic Antidepressants • Imipramine, Nortriptyline, Desipramine • Inhibits reuptake of NE • EKG at baseline and each dose increase • Once symptom control achieved, check serum level for toxicity Side Effects • Dry mouth, constipation • Vision changes, sedation • Tachycardia • Cases of sudden death reported in children & adolescents with desipramine

39. When to Refer… • For evaluation & treatment • For consultation with resumption of treatment • Concerns for safety • Significant impairment in functioning • No improvement after 6-8 weeks of first-line intervention • Diagnostic conundrum • History suggestive of trauma with current impact • Difficulty coping with chronic medical illness • Can always seek collegial consultation without face-to-face evaluation of patient

40. References • Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition American Psychiatric Association, 2013 • Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit-Hyperactivity Disorder J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46 (7): 894-921

41. Questions??