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

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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

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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

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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

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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 childs parents, including
  marital problems, increased stress, and poor
  relationships with their child

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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

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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.

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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

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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

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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

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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

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Treatment

• Currently no cure for ADHD
• Three types of treatment
• Medication management
• Behavioral therapy
• Combination of medication behavioral therapy

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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

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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

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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

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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

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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

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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

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Conclusion

• ADHD is a disorder in which research must
  continue in order to determine its 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.

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References

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References (Continued)

• Leslie, L. et al. Implementing the American
  Academy of Pediatrics attention-deficit/hyperactiv
  ity disorder diagnostic guidelines in primary
  care settings. Pediatrics 2004 July 114(1)
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• Mental health in the United States. Prevalence
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• Olfson, M. New options in the pharmacological
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• Am J Manag Care 2004 10 s117-s124.
• Steer, C.R. Managing attention
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• www.cdc.gov
• www.nimh.nih.gov
• www.shire.com
• www.webcenter.health.webmd.netscape.com
• www.wellmark.com

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Questions?