ADHD%20Update

1
ADHD Update

• Barbara J. Howard, MD
• Bjhoward_at_jhmi.edu
• www.childhealthcare.org

2
Disclosures

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

3
Characteristics of AD/HD

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

4
DSM-IV Criteria for ADHD

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

5
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

6
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

7
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

8
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
  Type
• Meets criteria for A2 but not A1 in last 6 mos
  
• 314.9 AD/HD, NOS
• Prominent symptoms but not to criteria

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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

10
Etiology

• 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
  callosum

11
Neurotransmittors in ADHD

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

12
Genetics

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

13
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)
  
  
  
  

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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

15
Unproven Therapies

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

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Empirically Proven Treatments

• Pharmacologic (gt300 double blind published
  studies)
• Note- medication alone is usually not sufficient
  treatment
• 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

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Components of Treatment

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

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Class Room Adaptations

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

19
Families as Advocates

• 504 Plans- other health impaired with doctor
  note
• Individual Educational Plan for LD
• Request complete intelligence and achievement
  testing
• 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,
  graduation
• Always appeal possible for higher level of
  service

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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

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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

22
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
  0.15-0.25mg/kg/dose
• Ritalin SR is less effective and slower onset
  than short acting. Ritalin LA more reliable
• Long acting DA is more likely to cause sleep
  problems
• Dexedrine SR- 10-12 hours, greater anorexia,
  irritability?
• Adderall- 4-6 hours, Adderall XR 10-12 smoother
• Pemoline (Cylert) is no available because of
  liver toxicity-gtdeath

23
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
  fact
• Helps establish an optimal dosage early

24
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

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Graphic display of Vanderbilt
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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
  effects
• 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

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Methylphenidate Transdermal System or Daytrana or
MethyPatch

• 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
  Concerta

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Non-stimulants for ADHD

• Atomoxetine
• Modafinil
• Intuniv guanfacine er
• Clonicel long acting clonidine (pending)

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Atomoxetine (Strattera)

• Norepinephrine reuptake inhibitor- not category
  II
• 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

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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
  hrs
• CYP inhibitor. Also interferes with OCPs
• Transient LFT elevations, palpitations, anorexia,
  headache all lt2
• Euphoria risk?

31
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

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Other Nonstimulants

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

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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
   ("Zyban")
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

34
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

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Family Cardiac History (Crosson)

• Has your child ever experienced any of the
  following?
•  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

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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
  treatment
•  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

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Managing Side Effects

• Appetite - 4th meal at bedtime
• Abdominal pain disappears in 3 wks try slow
  acting medication ?bowel urgency give with
  food
• 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

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Sleep problems in ADHD

• 85 of children with ADHD have sleep problems
  before using meds
• Sleep debt makes ADHD and comorbid conditions
  worse
• 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
  noise
• Meds prn evening stimulant dose, melatonin 1-8
  mg, Clonidine 0.05-0.1 mg., guanfacine up to 1 mg

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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

40
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

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References

• 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.

42

• 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)

43

• 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

44

• Reiff MI, Banez, GA, Culbert TP. Children Who
  Have Attentional Disorders Diagnosis and
  Evaluation. Pediatrics in Review. 14. 455-469.
  1993.
• Sturner RA, 2005, Attention Deficit Disorder, In
  The Child Health and Development Interactive
  System, www.childhealthcare.org

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• 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
• www.nichq.org for Vanderbilt checklist

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Appendix
47
Pediatric Evaluation of ADHDFactors and Trigger
Questions

• 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

48
Pediatric Evaluation of ADHDFactors and Trigger
Questions

• 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?

49
Pediatric Evaluation of ADHDFactors and Trigger
Questions

• 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?

50
Pediatric Evaluation of ADHDFactors and Trigger
Questions

• 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?

51
Pediatric Evaluation of ADHDFactors and Trigger
Questions

• Sleep
• Settling Struggle suggests oppositionism or
  anxiety
• Adequacy When does he get up on the weekends?
• Quality Screen for sleep apnea

52
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?

53
Differentiating ADHD from Typical-2

• Comorbidity- Presence of other mental health
  problems
• 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

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Pediatric Evaluation of ADHD-Performance
Sampling

• 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,
  etc.