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Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder. Royann Mraz, MD Clinical Associate Professor Center for Disabilities and Development Dec 10, 2014. No conflict of interest. Epidemiology of ADHD. 8-10% of school aged children 8% 4-10yr, 14% 11-17 yr. Boys>Girls 2-4:1

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Attention Deficit Hyperactivity Disorder

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  1. Attention Deficit Hyperactivity Disorder Royann Mraz, MD Clinical Associate Professor Center for Disabilities and Development Dec 10, 2014

  2. No conflict of interest

  3. Epidemiology of ADHD • 8-10% of school aged children • 8% 4-10yr, 14% 11-17 yr. • Boys>Girls 2-4:1 • High rates of Co-Morbidities –especially psychiatric and learning • 33% have one co-morbidity, 16% -2, 18% - 3

  4. Neurobiology of ADHD • Cerebellar-prefrontal-striatal network hypothesis • Volume differences- caudate, smaller cerebrum (esp. anterior) and cerebellum

  5. Genetics • Genetic imbalance in dopamine and noradrenergic systems- several genes play a role • Strong genetic influence • Concordance -92% identical twins, 33% dizygotic twins

  6. Environment • Increased risk with prenatal smoking exposure * • Prematurity, Brain injury, fetal alcohol, lead • Dietary factors do not play a role in the majority of children – food additives, essential fatty acids?, Fe or Zn deficiency?

  7. Attention Deficit Hyperactivity Disorder- subtypes • Predominately inattentive type – 8-9 yr • Pr • Predominately inattentive type • Predominately hyperactive-impulsive- start at 4yr, max 6-8 yr • Combined type- most common

  8. DSM 5 ADHD • Children - 6/9 symptoms of Inattention (inconsistant with developmental level, impacts activities, and not secondary to oppositional behavior or failure to understand) and/or 6/9 symptoms of hyperactivity/impulsivity • Adolescent and adults – only require 5 symptoms from either category • Some symptoms must be present by 12 years of age (DSM-IV by 7 yrs and be impairing)

  9. Diagnostic criteria - Inattention • Careless mistakes • Difficulty sustaining attention • Does not seem to listen • Does not follow through on tasks • Not organized • Avoids sustained mental effort • Loses things • Is easily distracted • If forgetful 6/9

  10. Diagnostic criteria – Hyperactivity/Impulsivity • Fidgets or squirms • Inappropriately leaves seat • Inappropriately runs or climbs • Has difficulty playing quietly • Is “on the go” • Talks excessively • Blurts out answers • Has Difficulty waiting his or her turn • Interrupts or intrudes on others 6/9

  11. DSM-5 ADHD updates • Most of changes recognize that ADHD is a chronic illness and help with diagnosis in adolescents and adults • 18 symptoms remain the same (additional examples provided) • Inattentive symptom f: Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg. Schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers)

  12. ADHD Updates • Cross-situational symptoms rather than impairment • Symptoms interfere or reduce quality of social, academic, or occupational functioning • Present for over 6 months • Symptoms aren’t secondary to other mental disorder • Rate current severity of symptoms –mild, moderate, severe

  13. Consequences of DSM-5 ADHD • Easier to diagnose in adolescents and adults • May increase the prevalence rates • Can diagnose ADHD in individuals with Autism Spectrum disorder

  14. Differential Diagnosis of ADHD • Normal age appropriate behavior, Unrealistic expectations • Lack of structure/limits • Family stress and dysfunction, abuse • PTSD, RAD, and adjustment disorders • Intellectual disability/Learning disorder • Autism, fetal alcohol, seizures, lead exposure, sleep disorder, thyroid

  15. COMORBIDITY • Learning disorder 10-30% • Opposition defiant disorder/ Conduct disorder 50-67% • Anxiety or Mood disorder 30% • Tourette’s and tic disorders • Coordination problems • Substance abuse • Sleep problems

  16. DIAGNOSTIC EVALUATION • Child’s history and functioning • Family history and functioning • School information • Rating scales – parent and teacher • Interview and physical exam of child • Consider psychological/educational evaluation

  17. AAP Practice Guidelines for ADHD 2011 • Initiate evaluation for ADHD in child 4-18 years of age if behavior or academic problems and ADHD symptoms • Determine if DSM criteria are met in more than one setting (teacher questionnaires) and rule out other causes

  18. AAP guidelines for ADHD • Assess for co-existing conditions – • Emotional/behavioral (anxiety, depression, ODD, conduct disorders) • Developmental (learning, language, etc.) • Physical (sleep apnea, tics, etc.)

  19. AAP Guidelines for ADHD • Treat ADHD as a chronic condition using principles of chronic care model and medical home • Titrate medication to achieve maximal benefit with minimal side effects

  20. AAP guidelines for preschoolers • Addresses evaluation and management of 4 and 5 year olds with ADHD symptoms • Recommends behavior management counseling and placement in structured setting • Allows for stimulant treatment if above isn’t sufficient

  21. AAP Guidelines ADHD • 6-11 Years • Treat with FDA approved medication (strong evidence for stimulants) and/or • Parent and/or Teacher behavior management or preferably both • 12-17 Years • Treat with FDA approved medication • May prescribe behavior therapy

  22. Consider referring if • Preschool child • Developmental delay or learning problems • ADHD, inattentive type • Family dysfunction • Moderate to severe behavior problems • Anxiety or depression

  23. Medical Treatment of ADHD • Monitor or treat co-morbidities • Educate patient and family • Set goals with family and school • ADHD is a chronic disorder – 65% of children with ADHD will have symptoms as adolescents

  24. Medical Management of ADHD • Medication is most effective treatment • Good behavior management program can provide additional benefit • Stimulants are first line treatment and most effective • 70-80% of children will respond to a stimulant

  25. Stimulants • Methylphenidate, d-amphetamine, mixed amphetamine salts are equally effective • Probably act by increasing dopamine and norepinephrine levels • Similar side effects

  26. Stimulants • Individualized dosing- often have better results with higher dose • All day coverage for many/most children • Frequent follow-up with health care provider with teacher feedback • If one stimulant doesn’t work, try another

  27. Stimulants • Improve attention span • Decrease hyperactivity and impulsivity • Improve work completion • Often improve behavior • Often improve academic performance

  28. Common stimulant side effects • Decreased appetite- give with or after meals • Difficulty falling to sleep • Tics • Stomachaches – give with food • Headaches

  29. Less common side effects • Moodiness or irritability • Overly quiet “Zombie effect” • Weight loss • Small decrease in height velocity • Rebound symptoms as med wears off • Mild increase in heart rate and B/P • Rare risk of mania or hallucinations • Priapism- 15 cases reported

  30. Stimulants • Methylphenidate products (Ritalin, Concerta, Metadate, Methylin, generics, patch • D-methylphenidate (Focalin, Focalin XR) • D-amphetamine (Dexedrine, Dextrostat) • Mixed amphetamine salts (Adderall, Adderall XR)

  31. Methylphenidate –dose and duration of action • Short acting ( Ritalin, Methylin, etc.) 3-5 hrs (.3-.7 mg/kg/dose 2-3 times/day) D-methylphenidate Focalin(.15-.3 mg/kg/dose) • Intermediate acting (Ritalin SR, Metadate ER, Methylin ER) – 3-8 hr • Extended release ( Metadate CD, Ritalin LA) 6-8 hr, Concerta-10-12 hr • Methylphenidate patch, wear for 9 hr • Usual maximum daily dose – 2 mg/kg

  32. Methylphenidate Extended Release • Concerta – longest lasting,22% immediate release, ascending plasma level, must be swallowed whole • Ritalin LA 50% immediate release, 50% release at 4 hr, mimic bid dosing. Can open capsule • Metadate CD 30% immediate release, can open capsule

  33. Methylphenidate patch • Methylphenidate patch (Daytrana) • 10,15,20,30 mg patches • Takes 2 hrs to take effect, wear 9 hours, lasts 12 hours • Same side effects, patch may come off • Useful for patients unable to take pills or with fast metabolism

  34. Amphetamines – dose and duration of action • Short acting (Dexedrine, Dextrostat) – 4-6 hr • Intermediate acting (Adderall, Dexedrine spansules) 5-8 hr • Extended release (Adderall XR) 10-12 hr • Usual maximum daily dose – 1 mg/kg • Dose is ½ to 2/3 of methylphenidate dose

  35. Other stimulant preparations. • Lisdexamfetamine (Vyvanse) • Pro-drug, which is activated when aminoacid is cleaved off • Effective for ADHD, same side effects • Aim is to provide protection against abuse and addiction • 6-12 years, start at 20-30 mg, can increase weekly up to 70 mg max • Lisdexamfetamine 30 mg roughly equivalent to dextroamphetamine 10 mg

  36. Cardiac warnings • 27 unexplained deaths in children under 18 yrs on ADHD medication reported between 1992-2004 • 11 on methylphenidate • 13 on amphetamine salts (Adderall) • 3 on atomoxetine (Strattera) • FDA recommends not using if heart disease, arrhythmia, or FH of arrhythmia • Concern about patients with undiagnosed heart disease and long term effects • EEG not needed if cardiac hx is negative

  37. Benefits of stimulants in Adolescents • Medication reduces risk of auto accidents for ADHD patients • Medication reduces risk of substance abuse in ADHD patients

  38. Other Medications for ADHD • Atomoxetine (Strattera) • Bupropion (Wellbutrin), imipramine • Alpha2 agonists -clonidine or guanfacine (Tenex) – useful for tics, sleep, and aggression

  39. Atomoxetine (Strattera) • Selective norepinephrine reuptake inhibitor • Effective for ADHD, may take 3-4 weeks to see full effect • No abuse potential, not controlled substance • Unlikely to worsen tics or anxiety • Dosage – start .5 mg/kg/day for 3 days, then up to 1.2 to 1.4 mg/kg/day • 10, 18, 25, 40, 60, 80, 100 mg capsules • Useful for ADHD with anxiety or depression

  40. Atomoxetine (Strattera)- side effects • Somnolence – can give in evening or divide dose • Anorexia, GI upset, weight loss – give with food, divide dose • Dizziness • Rare risk of liver disease • Increased risk of suicidal ideation .4%

  41. Alpha 2 Agonists • Clonidine and guanfacine (Tenex) • Adjuctivemedication • Usefulforsleep, tics, aggression, hyperarousal • Not as effectiveforinattention • Maytake 2 weeks to see effect

  42. Alpha 2 Agonists • Clonidine .003-.01 mg/kg/day, tid,qid, often start .025 - .05 mg per day, also available as patch and long-acting form • Guanfacine .04-.08 mg/kg/day, max 4 mg/day, often start .5 mg perday (also once daily form ) • Side effects – sedation, especially with clonidine, dry mouth, depression, low B/P, headache • Withdrawal symptoms if stopped suddenly –high pulse, B/P, headache, agitation

  43. ADHD and Co-morbidities • ADHD and anxiety – respond to stimulants, may need to add SSRI, another option is atomoxetine • ADHD and tics – stimulants and clonidine or other meds for tics, atomoxetine • ADHD and aggression – stimulant and clonidine/guanfacine or other meds

  44. Parenting and ADHD • Brief clear instructions • Give immediate and frequent feedback and consequences • Use incentive more than punishment • Try to be consistent and provide structured environment • Plan for problem situations • Negotiable and non-negotiable issues

  45. Special Education and ADHD • Child with ADHD may be eligible for special education, under “Other health impairment” • Child must be tested and qualify for special education • “Limited alertness” for academics, which adversely affects education, including grades, tests, behavior, social skills.

  46. 504 Plan • Section 504 of Rehabilitation Act • Schools receiving Federal funds and employers can not discriminate against people with disabilities (including ADHD) and must make reasonable accommodations

  47. Educational Accommodations • Tailor homework assignments and tests • Structured environment, help with organization • Simplify and/or provide visual instructions • Behavior management techniques • Use of tape recorders or notes • Daily or weekly report to parents

  48. Medical management for ADHD • Stimulants are first line treatment • 70-80% effective • Titrate to optimal dose • All day coverage for many/most children • Set and monitor goals • Close long-term follow-up

  49. References • AAP. ADHD Clinical Practice Guidelines. Pediatrics 2011;128: 1007-1022. • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.,2013, American Psychiatric Association, Arlington, VA.

  50. Resources • www.chadd.org • www.dbpeds.orgwww.aap.org • www.help4adhd.org • www.ParentsMedGuide.org • www.aacap.org • www.nichq.org ADHD toolkit

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