ADHD Child to Adult Cindy Ruttan DO 2009

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ADHD Child to Adult Cindy Ruttan DO 2009

• KCUMB Homecoming 2009
• Class of 89

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Key points to cover

• Symptoms/ History
• Who it effects-ages
• Collecting informants
• Rule out diagnosis
• Treatment options
• Behavioral
• Medications

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ADHD is like---

• I stopped to think, and forgot to start again.
•  
• I was trying to daydream, but my mind kept
  wandering.

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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.

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ADHD Review History

• Core criteria DSM-III
• 3 separate symptom areas
• DSM-III-R
• one long list
• DSM-IV
• two core dimensions
• Inattention
• Hyperactivity / Impulsivity

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ADHD and DSM IV criteria

• Concerned by may change in future DSMs.
• Age of onset- ? 7 years
• Age appropriate Symptoms are needed for helping
  diagnose disorder from Child/ Adol/ Adults
• Various inputs needed they can conflict

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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
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Children's ADHD Review 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.

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ADHD Natural Hx

• 30 Developmental Delay
• 40 Continual Display
• Internalizing disorders
• Depression
• Anxiety
• 30 Developmental Decay
• Externalizing disorders
• ODD
• CD

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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

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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

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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
• Tourettes-rare (usually reverse) / Tic
• Tic 10-15
• Mood Disorder 5-40 depression
• Bipolar 10-22
• Poor interpersonal skills/demoralized
• Possible sleep disorder and ocular disorders

David Krefetz DO MBA FACN, FAPA ADHD with
Comorbidity in Pediatric Populations
Impllications for Eval and Management
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DBD (Disruptive Behavior Disorder) 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

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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

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Input Disability

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

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Integration Disability

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

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Output Disability

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

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Diagnosing ADHD

• NO lab tests, or psychologic tests that
  definitely diagnose.
• Recommend Academic Testing to establish level in
  school and any LDs.
• 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.

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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

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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

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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.

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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

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Adult ADHD

• Basic same core symptoms as with Peds ADHD
• Review HX of Ed, job and family
• Standard rating scales/specific for ADULTS
• 18 item and 6 item screener (highly specific)
• www.med.nyu.edu/psych/psychiatrist/adhd.html
• Collateral info coping /stressors
• Rule out other diagnosis
• Review options for Treatment as they match
  patient goals
• Meds/ CBT

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Adult ADHD who had diagnosis as child

• Many lose 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 Impulsivity and
  Hyperactivity decline.
• If one put partial remission Persistant 65
  have symptoms of ADHD.

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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.

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Adult ADHD cont-

• 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

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Co morbidity is The RULE with Adult ADHD

• Mood Disorders50-60
• Depression- recurrent
• BAD
• Cyclothymia
• Dysthymia
• DEP NOS

• Anxiety Disorders
• 40-50
• GAD
• Anxiety NOS

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Co morbidity cont-Adult ADHDVarious

• SUD
• LD
• IED
• Tourette
• Antisocial Personality Disorder
• Borderline Personality Disorder
• Dependent Personality Disorder

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Behavioral Interventions
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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

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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
• Consider eye exam
• Dec / Jan 2008 ADDitude Magazine pg 49
• Science Daily April 17,2000

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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

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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

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Therapy Goal

• Sensitize the patient to and interrupt
  dysfunctional behaviors
• Coping skills
• Problem focused
• Adaptive thinking
• Anger management
• Communication skills

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RX Treatments
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Medication Options

• 19 meds are FDA approved
• 18 are stimulants
• Use Lowest Dose which addresses symptomsas 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.

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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

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Medications

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

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Stimulants FDA Approved Adult FDA Approved is
in BLUE

• Amphetamine
• Adderall
• Dexedrine
• Dextrostat
• Adderall XR 2004
• Dexedrine Spanules
• Not recommended under age 3 yrs

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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

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MethylphendateTransdermal Patch

• New Stimulant Delivery
• Option

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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 effects wearing off.
• Current Psychiatry Vol 5 No.6 / June 2006

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Stimulant Pro Drug

• Vyvanse - Lisdexamfetamine
• FDA approved for ages 6-12
• 20, 30,40,50,60 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

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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
  dosesmay be misused at higher than therapeutic
  doses.
• Current Psychiatry Vol.6 no.6 June 2007

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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

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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

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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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STRATTERA Atomoxetine 2002

• FDA approved for
• Child
• Adol
• adult

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SNRI Atomoxetine Non Stimulant --FDA Approved

• Full effect 3-7 weeks peak levels 1-2 hrs or 3-4
  for slow metabolizers
• Shorter sleep latency , improved sleep
• Increased risk of suicidal ideation in children
  and adolescents (see precautions)
• Dose by Body Weight.
• Do not exceed 1.4 mg/kg/day or 100 mg whichever
  is less. Start low go slow (start 0.5mg/kg/day
  for 10 day then 0.8 for 10 days then 1.2 in a
  individual or BID dose)
• Over 70 kg start at 40 mg dose and increase after
  10 days to 60 mg for 10 days then to 80mg after
  2-4 weeks consider max dose at 100 mg/ day.

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ContSNRI -Atomoxetine

• Safety not established under age 6 years
• Lower dose if a slow CYP2D6 metabolizer or go
  slower to increase after 4 weeks if on another
  drug which also uses/ inhibits 2D6
• Modify dose by 50-25 theraputic dose if hepatic
  issues
• Monitor BP,hepatic dysfunction,CV issues always
  review the Adv. Effects list.
• Monitor BP
• Adults with more Anxiety, emotional dysregulation

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ContSNRI -Atomoxetine

• Adults start with 40 mg then in 3 days increase
  to 80 mg either in one AM dose or split dose 40
  bid. Max is 100mg.

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Adrenergic Options Not FDA approved in children
or Adolescents

• Clonidine
• Helps with impulsivity, insomnia associated with
  Stimulant meds, hyperarousal, agitation, and tic
  disorder
• Oral and transdermal patch
• ? Future extended release
• Side affects
• Sedation daytime if dosed in daytime.
• Withdrawl hypertensive episodes
• 5 reported sudden deaths when used in combo with
  stimulants

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Adrenergic Options Not FDA approved in children
or Adolescents

• Guanfacine
• Similar to Clonidine in its uses
• Less sedation and hypotension than Clonidine
• Not recommended or use with caution in patients
  with renal insufficiency
• Refractory ADHD with Tic issues, may help with
  nightmares associated with PTSD
• Always read Adverse Effects, contraindications
  and Precautions in the package inserts
• ? Future an extended release

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Antidepressants Not FDA approved in
children/adolecents for ADHD treatment nor Adults
for ADHD

• Buproprion max 450 mg/ day in Divided dose unless
  using 300XL for Once daily dosing.
• 50 or adult respond
• HA, Dry mouth, nausea, insomnia
• Venlafaxine prelim studies suggest efficacy
• TCAs (Amitriptyline, desipramine,
  imipramine,nortriptyline)
• MAOIs open label suggest improved concentration
  in children with ADHD

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Dopaminergic Agents Not FDA approved in Adults
or children Cholinergic AgentsNot FDA
approved in Adults or children

• Donepezil

• Modafinil

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Herbal and Natural ProductsNot FDA approved in
Adults or children for ADHD

• Ginko Biloba
• Omega 3 Fatty Acids
• Vitamins/Minerals
• Zinc
• Iron

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Treatment Summary

• RX treatment optimal and better for core symptoms
  than Behavioral treatment alone.
• Combo of RX and Behavioral was superior to either
  alone.

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Can meet someone, fall deeply in love, marry,
fight, hate, and divorce, all in about 35
minutes or less.    
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Clinical Practice Guidelines CPGs

• www.pediatrics.org/cgi/content/full/105/5/1158
• www.aacap.org/galleries/practiceParameters/New_ADH
  D_Parameter.pdf

• Valid rating scale
• Vanderbuilt parent and teacher scales
• Conners Forms
• www.massgeneral.org/schoolpsychiatry/screeningtool
  s_table.asp
• www.med.nyu.edu/psych/assets/adhdscreen18.pdf
• Vol. 6 No. 4 /April 2007

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References

• The Psychiatric Interview 2nd Ed. Carlat
• Dec/Jan2008ADDitude Magazine
• Clinical Handbook of Psychotropic Drugs for
  children and adolescents 2nd Ed. Kalyna
  Bezchlibnyk-Butler and Adil Virani
• Current Psychiatry
• Vol.5 No. 2 / Feb.2006
• Atomoxetine package insert
• New Perspectives on Adult ADHD
• College Years CME Part 5 of 6
• ADHD A Disorder with Life time Impact CME part
  3 of 6
• Advances in ADULT ADHD CME Part 7 of 8
• ADHD Drug Therapy Long and short of it.

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References

• Primary Psychiatry
• July 2004 Vol.11 No.7
• NeuroPsychiatry Reviews
• Jan 08 Vol.9 No.1 pg.21
• Psychiatric News
• Feb.1, 08 Vol 43 No.3 pg.23
• Current Psychiatry
• Vol 4 no.5 May 2005
• Vol. 7 no.11 Nov 2008
• Vol. 6 no.6 June 2007
• Vol. 1 No.10 Oct 2002
• Vol. 7 No. 9 Sept 2008
• Psychiatric Times
• March 18, 2009 Cognitive Impairment with ADHD
• Dec 1 2008 Vol. 25 no. 14 Update on
  Pharmacotherapy for ADHD