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Title: ADHD Update Author: Barbara Howard Last modified by: Barbara Howard Created Date: 2/1/2010 5:19:05 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: ADHD%20Update

ADHD Update
  • Barbara J. Howard, MD

  • I have a financial relationship to disclose
  • Consultant, Total Child Health, Inc.
  • producer of CHADIS
  • Off label medication will be discussed
  • psychotropics

Characteristics of AD/HD
  • Prevalence - 3-5 of school- age children
  • Usually identified in the early elementary school
  • 41 to 91 malefemale
  • lt70 persist into adulthood
  • Often FH AD/HD

DSM-IV Criteria for ADHD
  • gt 6 months of 6 of either (1) or (2)
  • (1) Inattention
  • inattention to details trouble sustaining
  • doesnt listen doesnt finish
  • trouble organizing avoids sustained tasks
  • loses supplies easily distracted
  • forgetful

DSM-IV Criteria for ADHD
  • (2) Hyperactivity
  • fidgets leaves seat
  • excess running, climbing trouble playing quietly
  • on the go talks too much
  • Impulsivity
  • blurts out answers trouble waiting turn
  • interrupts or intrudes

DSM-IV Criteria- 2
  • Onset with impairment lt 7 years old
  • Impairment in gt 2 settings
  • Significant impairment in social, academic, or
    occupational functioning
  • Not exclusively part of PDD, schizophrenia, or
    psychotic disorder nor better accounted for by
    another mental disorder

ADD without H and ADHD -Inattentive Type
  • ?Similarity to ADHD
  • Spacey
  • Daydreamer
  • Sluggish responses - ?processing issues
  • Excessive confusion
  • Inconsistent memory retrieval
  • Shy/anxious passive
  • Deficits on measures of attention
  • Not impulsive not oppositional

Codes for Attentional Disorders
  • 314.01 AD/HD, Combined Type
  • Meets criteria of both A1 A2
  • 314.00 AD/HD, Predominantly Inattentive Type
  • Meets criteria for A1 but not A2 in last 6mos
  • 314.01 AD/HD, Predominantly Hyperactive-Impulsive
  • Meets criteria for A2 but not A1 in last 6 mos
  • 314.9 AD/HD, NOS
  • Prominent symptoms but not to criteria

Newer Conceptual Model Deficit of INHIBITION
related to Areas of Executive Functioning
  • Deficient Self-Regulation
  • Impaired Temporal Organization of Behavior
  • Impaired Goal-Directed Persistence
  • Diminished Social Effectiveness Adaptation

  • No consensus yet regarding precise transmitter
    defect or anatomic localization
  • PET study of hyperactive parents of hyperactive
    children showed decreased glucose metabolism in
    right frontal lobe
  • MRI studies showing abnormalities in corpus

Neurotransmittors in ADHD
  • Dopamine
  • Enhances signal
  • Improves attention
  • Focus
  • Vigilance
  • On-task behavior
  • On-task cognition
  • Norepinephrine
  • Dampens noise
  • Enhances executive operations
  • Increases Inhibition

  • Pattern of single dominant gene or a single major
  • 50 - 92 of monozygotic twins
  • Siblings at 2 to 3 times greater risk
  • Possible association with dopamine transporter
    gene (DAT1) and dopamine receptor (DRD4)

Differential Diagnosis- Medical/neurological
primary diagnosis
  • Endocrine- hyperthyroidism, generalized
    resistance to thyroid hormone
  • Neurological- petit mal, migraine, chorea, lead
    poisoning, ?iron deficiency
  • Sensory- mild hearing and/or vision losses
  • Arousal- day time drowsiness associated with
    obstructive sleep apnea, lack of sleep
  • Drug induced- drug side effects (e.g.
    Phenobarbital, sympathomimetics)

Treatment Implications
  • If it is not a problem of how or what then
    teaching what or how is not likely to help
  • Treatments or modifications at the site of
    performance are more likely to be effective
  • medication, seating arrangement, fm receivers,
    touching and redirecting, in class assistance
  • Immediate consequences for goal-directed and
    task-oriented behavior

Unproven Therapies
  • Dietary Management
  • Megavitamins
  • Chiropractic Manipulations
  • Ocular Motor Exercises
  • Self control training outside performance site
    (e.g., in a clinic)
  • EEG biofeedback

Empirically Proven Treatments
  • Pharmacologic (gt300 double blind published
  • Note- medication alone is usually not sufficient
  • Parent counseling about ADHD (ODD)
  • Parent training in child management
  • Teacher counseling and training in ADHD and
    classroom management
  • Special Education when indicated
  • Individual counseling as needed
  • Residential Treatment
  • Parent/Family Counseling when indicated

Components of Treatment
  • Education of parent, other caregivers
  • Psychological/behavioral therapies
  • Parent training
  • Support groups
  • Social skills training
  • Psychoeducational interventions
  • Medication
  • Regular follow up

Class Room Adaptations
  • Preferential seating
  • Cueing by teacher before instruction
  • Shorter work periods with frequent breaks
  • Visual and tactile stimuli with verbal
  • Remediation when necessary
  • FM receivers

Families as Advocates
  • 504 Plans- other health impaired with doctor
  • Individual Educational Plan for LD
  • Request complete intelligence and achievement
  • Other specific assessments as needed e.g. VMI,
    educational assessment, projective testing
  • Dont sign it unless satisfied
  • May need an educational advocate at ARD meeting
  • Especially key at change to KG, middle, high,
  • Always appeal possible for higher level of

Multisite Multimodal Treatment Study (MTA)
  • 600 children (age 7 9)
  • ADHD combined type
  • 24 month outcomes
  • Groups
  • Medical management monthly tailored
  • Behavioral Therapy 8 week summer training
    in-class aid, teacher consultation
  • Combined
  • Community standard 67 meds mostly bid

MTA Results
  • Medical management or combination therapy had
    better outcomes than behavioral therapy or
    community care
  • Combined therapy was equal to medical for ADHD sx
    but for subgroups combined may be preferable
  • Anxiety disorders high levels of socio-economic
    and/or family stressors

Medication Choice Stimulants
  • MPH and DA are approximately equivalent in
    efficacy (75) side effects
  • Some children respond better to one
  • MPH dose 0.3 - .5 mg/kg/dose DA
  • Ritalin SR is less effective and slower onset
    than short acting. Ritalin LA more reliable
  • Long acting DA is more likely to cause sleep
  • Dexedrine SR- 10-12 hours, greater anorexia,
  • Adderall- 4-6 hours, Adderall XR 10-12 smoother
  • Pemoline (Cylert) is no available because of
    liver toxicity-gtdeath

Medication - Dosing
  • Short acting lasts 3 1/2 to 4 hours
  • Children benefiting from school dosing usually
    can benefit from a 3rd dose
  • Long acting now recommended
  • Consider using a placebo trial
  • With weekly parent and teacher ratings to
    establish objectivity
  • Helps parents carefully sort out their fears from
  • Helps establish an optimal dosage early

CHADIS decision support
  • Parent takes previsit online questionnaires
    (behavior, development, health, family factors)
  • Clinician reviews questionnaire results, can
    consult linked textbook
  • Clinician may exchange findings with school or
    mental health provider online
  • Clinician finds relevant resources, handouts from
    links prints for family
  • Bill 96110

Graphic display of Vanderbilt
Other stimulants for ADHD
  • Focalin- d MPH- Short acting ½ dose same
    effectiveness and side effects
  • Focalin XR (5,10,20)- 10-12 hours, same side
  • Methylin liquid 5 or 10/5cc short acting
  • Metadate CD- MPH, 6 hours, can sprinkle
  • Ritalin LA- MPH, 8-10 hours
  • Daytrana or MTS or MethyPatch
  • Vyvanse Slow release mixed salts of amphetamine
  • Procentra Liquid Dexedrine 5 mg/5 cc

Methylphenidate Transdermal System or Daytrana or
  • Takes 2 hours for effect, remove at 9 hours,
    lasts 12
  • Signif. effective vs placebo
  • Potential for sensitization to methylphenidate
    due to topical route
  • MTS vs Concerta Insomnia 13 vs 8 anorexia 26
    vs 19
  • 12.5 cm 18 mg Concerta 18.75 cm 27 mg
    Concerta 25 cm 36 mg Concerta 37.5 cm 54 mg

Non-stimulants for ADHD
  • Atomoxetine
  • Modafinil
  • Intuniv guanfacine er
  • Clonicel long acting clonidine (pending)

Atomoxetine (Strattera)
  • Norepinephrine reuptake inhibitor- not category
  • CYP2D6 metabolized, T1/2 5.2 h
  • Signif better than placebo in child adult
  • Side effects anorexia 14, N/V/D 12-15,
    dizziness, fatigue 9, mood swings 5
  • Possible inc or dec BP, inc pulse, allergic rash
  • Recent reports liver abnormalities and failure
  • Contraindicated near MAO inhibitors
  • 0.5mg/kg-gt2.0 q 3 d max 100mg div qd-bid. Less
    with paroxetine or fluoxetine

Modafinil or Provigil
  • Indicated for sleep apnea and narcolepsy
  • 100, 200 mg
  • Dose up to 200 mg q am
  • Onset 2-4 hours, delayed by food 1 hr, T1/2 15
  • CYP inhibitor. Also interferes with OCPs
  • Transient LFT elevations, palpitations, anorexia,
    headache all lt2
  • Euphoria risk?

Intuniv FDA approved 6/07
  • Selective agonist for alpha-2A-receptors in the
    prefrontal cortex
  • Nonstimulant
  • Monotherapy
  • Once daily long acting
  • Ages 6 to 17 years
  • 1 mg to 4 mg daily
  • Better than placebo in 2 double blind trials

Other Nonstimulants
  • Imipramine 1-4 mg/kg /2-3 doses/day EKG
  • Clonidine 4-5 microgram/kg/day or Guanfacine
    (Tenex) long acting esp for aggression and when
    sedation HS needed cvs concerns
  • Bupropion

Bupropion (Wellbutrin)
  1. Antidepressant with stimulant action (beta
    noradrenergic receptors and prefrontal lobe)
  2. Significant effect on ADHD but less effect size
    than first line stimulants
  3. Better than nicotine patch for smoking cessation
  4. Dosage 3-6mg/kg (lt/300/day) 75, 100, 150mgSR
  5. Side-effects (especially if increase fast)
    Decreased seizure threshold (rate .06),
    agitation, insomnia

Stimulants and CV Risk
  • FDA reports showed
  • 25 patients (19 who were 18 years and younger)
    taking stimulants had suddenly died.
  • 54 more patients on these pills had unusual
    heartbeats, heart attacks, or strokes. Some had
    preexisting heart problems, some were taking
    other pills, including cocaine.
  • AAP advises continuing current practice
  • FDA- no black box warning
  • Prudent to avoid use in structural heart disease,
    arrythmia, ? if FH sudden cardiac death

Family Cardiac History (Crosson)
  • Has your child ever experienced any of the
  •  Unexplained seizures
  •  Passing out/fainting during exercise, when
    startled, or when highly emotional
  •  Dizziness during or after exercise
  •  Chest pain during or after exercise
  •  Racing heart or skipped heartbeats
  •  Getting extremely tired or short of breath more
    quickly than friends do during exercise
  •  High blood pressure or high cholesterol
  •  None of these
  •  Not sure

Has anyone in the family (including your child)
had any of the following serious heart
conditions? Please check all that apply.
  •  Hypertrophic or dilated cardiomyopathy
  •  Long-QT syndrome, short-QT syndrome, Brugada
    syndrome, or another ion channel disorder
  •  Other heart rhythm problems that required
  •  Marfan syndrome or ruptured aorta
  •  Born with heart malformation (e.g. hole in
    heart, bad valves, etc.)
  •  Unexplained fainting or seizures
  •  Use of pacemaker or cardiac defibrillator
  •  Primary pulmonary hypertension
  •  Ventricular tachycardia
  •  Heart attack age 50 or younger
  •  Disability due to heart problems before age 50
  •  Sudden death due to heart problems before age 50
  •  None of these
  •  Not sure

Managing Side Effects
  • Appetite - 4th meal at bedtime
  • Abdominal pain disappears in 3 wks try slow
    acting medication ?bowel urgency give with
  • Headache disappears in 3 wks try slow acting,
    use 7 days/wk
  • Growth 1 kg, 1 cm mostly nutrition related
    reversible with drug holidays if needed
  • Tics - mostly due to comorbidity, may have less
    tics with stimulants 0.5 chance of a persistent
    problem try lower dose
  • Irritability- change family of meds, use another
    dose in pm

Sleep problems in ADHD
  • 85 of children with ADHD have sleep problems
    before using meds
  • Sleep debt makes ADHD and comorbid conditions
  • Mostly trouble falling asleep but also restless
  • Consider OSA if snore, bipolar if up for hours in
    the middle of the night
  • Start with routine bedtime, back rub, milk, white
  • Meds prn evening stimulant dose, melatonin 1-8
    mg, Clonidine 0.05-0.1 mg., guanfacine up to 1 mg

ADHD Follow-Up Visits- Goals
  • To watch for and begin early intervention for
    co-morbid conditions
  • To monitor self concept of child, perception of
    parents and progress toward asset building (e.g.,
    involvement in nonschool skill building)
  • To adjust medication as needed
  • Teacher and parent check lists and work samples
    and report card data are usually needed
  • Repeat placebo trials are helpful
  • To monitor for side effects

Adult Outcomes and Need for Continued Medication
  • 1/3 have no symptoms as adults
  • Consider various work demands
  • Air traffic controller vs. salesperson
  • Accountant vs. CEO with 3 secretaries
  • Pathologist vs. pediatrician
  • May increase creativity, energy

  • Barkley, R. A. Attention Deficit Hyperactivity
    Disorder A handbook for diagnosis and treatment.
    New York Guilford Press, 72 Spring St., New
    York, NY, 1990.
  • Culbert TP, Banez, GA, Reiff, MI. Children who
    have Attentional Disorders Interventions.
    Pediatrics in Review 15 (1), 5-14. 1994
  • Diller, L. H., Running on Ritalin, Bantam Books,
    New York, NY, 1998.

  • Gorski P (Ed) 2002, Supplement, The Diagnosis and
    Treatment of ADHD in Early Childhood Evidence
    Based Controversies and Implications of Practice
    and Policy, J Dev Beh Ped 23(1S)

  • Greenhill, L. L., Attention-Deficit Hyperactivity
    Disorder The Stimulants. In Riddle, MA, (Ed),
    Pediatric Psychopharmacology I Child and
    Adolescent Psychiatric Clinics of North America,
    January. 123. 41, Saunders, Phila, PA. 1995
  • Papolos D and Papolos J The Bipolar Child.
    Broadway Books, NY, 1999

  • Reiff MI, Banez, GA, Culbert TP. Children Who
    Have Attentional Disorders Diagnosis and
    Evaluation. Pediatrics in Review. 14. 455-469.
  • Sturner RA, 2005, Attention Deficit Disorder, In
    The Child Health and Development Interactive

  • Wolraich, M (Edit.), 1996, The Classification of
    Child and Adolescent Mental Diagnoses in Primary
    care. Diagnostic and Statistical Manual for
    Primary Care (DSM-PC), Child and Adolescent
    Version, American Academy of Pediatrics
  • for Vanderbilt checklist

Pediatric Evaluation of ADHDFactors and Trigger
  • Interviewing the child
  • General information age, grade, name of school,
    name of teacher
  • Subjects, grades, favorite subject/hardest
    subject and why
  • Best friend, activities together
  • Family- members, kind of person, activities
    together, hardest part about
  • Chores, discipline, allowance, hobbies
  • Family kinetic drawing

Pediatric Evaluation of ADHDFactors and Trigger
  • Classroom Behavior
  • Parent What are your concerns about him?
  • What does/has his teacher say/said about him?
    (each grade)
  • Teacher Ratings (e.g., Conners, DSM)
  • Child Tell me about the teacher you have -- Is
    she nice or did you get one of the mean ones?
    What does she/he do that seems mean?

Pediatric Evaluation of ADHDFactors and Trigger
  • Classroom environment
  • Is the child being compassionately, and
    competently managed? Or is the teacher
    overwhelmed and confrontational?
  • Parent How many children are in the class?
  • Child Where do you sit?

Pediatric Evaluation of ADHDFactors and Trigger
  • Behavior at home
  • How is his behavior at home?
  • What is the hardest part with him?
  • How bad does it get?
  • Focus on transitions Tell me what it is like..
    getting him ready for school....bedtime,...
    turning off TV,... putting his toys away?.
  • Patience Is he able to sit through a meal and
    take turns talking?
  • Organization What is his room like?

Pediatric Evaluation of ADHDFactors and Trigger
  • Sleep
  • Settling Struggle suggests oppositionism or
  • Adequacy When does he get up on the weekends?
  • Quality Screen for sleep apnea

Differentiating ADHD from Typical-1
  • Severity- impairs daily function
  • Have you changed family routines?
  • Duration- Not just transient reaction to stress
    or environmental change
  • What else has been going on recently?
  • Pervasiveness- outside home, occurs with people
    other than pa
  • How does he do with other people?

Differentiating ADHD from Typical-2
  • Comorbidity- Presence of other mental health
  • Ask about all areas of functioning
  • Family History- of ADD/ADHD Vs. other psych
  • Genogram
  • Higher scores on scales (not validated)
  • Use some instrument eg CBCL

Pediatric Evaluation of ADHD-Performance
  • Review of report card and work samples
  • Do you have any hard work at your school?
  • Sample achievement performance (e.g. WRAT and
    standard reading comprehension paragraph,
    alphabet, writing sample)
  • Hypothesis driven performance sampling- e.g. If
    problem listening Do a standard 5 part command
    writing -VMI process related tasks from PEEX,
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