Pharmacological management of adhd and associated comorbidities
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Pharmacological Management of ADHD and Associated Comorbidities. Regina Bussing, M.D., M.S.H.S. Professor, Division of Child and Adolescent Psychiatry. ADHD: Etiology and Prevalence. Etiology No single cause Many possible etiologies Genetic causation increasingly implicated Prevalence

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Pharmacological Management of ADHD and Associated Comorbidities

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Pharmacological Management of ADHD and Associated Comorbidities

Regina Bussing, M.D., M.S.H.S.

Professor, Division of Child and Adolescent Psychiatry


ADHD: Etiology and Prevalence

Etiology

  • No single cause

  • Many possible etiologies

  • Genetic causation increasingly implicated

    Prevalence

  • Estimates in school-age children: 3% to 9%

  • More commonly diagnosed in boys (4:1 to 9:1)

  • Girls were under-represented in clinical populations, but increasing numbers of girls receiving ADHD treatment

  • More prevalent in 1st degree biologic relatives

    Ref: Greenhill 1993; Biederman 1989; Safer 1988; Lambert 1981


National Survey of Children's Health, 2003: Attention-Deficit/Hyperactivity Disorder

Percent of Youth (4-17y) ever diagnosed and currently medicated

Percent of Youth (4-17y) ever diagnosed

Source: http://www.cdc.gov/ncbddd/adhd/default.htm


ADHD: Core Symptoms

Varying degrees of:

  • Inattention

  • Hyperactivity

  • Impulsivity

    Symptoms also vary in:

  • Degree of impairment

  • Frequency of occurrence

  • Pervasiveness

    Ref: Greenhill 1993; Swanson 1992; Cantwell 1985


DSM-IV ADHD Criteria:Inattention Symptoms

Behaviors manifested often:

  • Careless mistakes

  • Difficulty sustaining attention

  • Seems not to listen

  • Fails to finish tasks

  • Difficulty organizing

  • Avoids tasks requiring sustained attention

  • Loses things

  • Easily distracted

  • Forgetful

    Ref: APA 1994


DSM-IV ADHD Criteria:Hyperactivity/Impulsivity Symptoms

Hyperactivity behaviors manifested often:

  • Difficulty engaging in leisure activities quietly

  • Fidgeting

  • Unable to stay seated

  • Moving excessively (restlessness)

  • “On the go”

  • Talking excessively

    Impulsivity behaviors manifested often:

  • Blurting out answer before question is completed

  • Difficulty waiting turn

  • Interrupting/intruding upon others

    Ref: APA 1994


ADHD: DSM-IV General Criteria and Subtypes

Inattention and hyperactivity-impulsivity symptoms:

  • Onset before age 7

  • Present for > 6 months

  • Present in  2 settings (e.g., home, school, work)

    Subtypes:

  • AD/HD, combined type: criteria from both dimensions

    • 6 of 9 from both symptom lists

  • AD/HD, predominantly inattentive type: inattentive criteria

    • 6 of 9 inattentive symptoms

  • AD/HD, predominantly hyperactive-impulsive type: hyperactive-impulsive criteria

    • 6 of 9 hyperactive-impulsive symptoms

      Ref: APA 1994


ADHD: Context for Pharmacological Treatment - Overview of Assessment Process

  • What is the child’s developmental level?

  • Does the child meet criteria for ADHD?

  • What are the areas of functional impairment?

  • What comorbidities are present?

  • What is family history of mental disorders?

  • What are the strengths of the child, family, school setting and social environment?

  • What treatment plan is indicated?


ADHD: Patient Evaluation Procedures

  • Parent/child interviews

  • Parent-child observation

  • Behavior rating scales

  • Physical examination (including neurologic)

  • Cognitive testing (as indicated)

  • Other studies

    • Check on audiology/vision testing

    • Laboratory studies are not pathognomonic

      Ref: Reiff 1993


Differential diagnosis and possible comorbidities of childhood ADHD

Ref: Reiff 1993; Barkley 1990


ADHD: Comorbidities in Children/Adolescents

  • Learning disorders

  • Language and communication disorders

  • Oppositional defiant disorder

  • Conduct disorders

  • Anxiety disorders

  • Mood disorders

  • Tourette’s syndrome; chronic tics

    Ref: Biederman 1991; Hinshaw 1987


Historical Context

1998 NIH Consensus Conference

2000 -2005

Concerta, Metadate CD, Ritalin LA, Strattera, Focalin XR

1937 Amphetamine reduces disruptive behavior

Period of Increasing Access and Medication Use:

1987–96 Medicaid/HMO prescription studies

1989–99 NAMCS studies

1987-97 NMES/MEPS studies

1956 Ritalin introduced

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2011

DSM-IV 1994 AD/HD

Post-encephalitic Behavior Disorder

DSM-III 1980 ADD/+-Hyper

Minimal Brain Dysfunction

1902 G. F. Still “Defect in Moral Control”

Period of “Use Attenuation”:

1997-02 MEPS

2001-04 NHANES

2003 NCHS

2006 NHIS

DSM-II 1968 Hyperkinetic Reaction of Childhood


MMWR, September 2, 2005 / 54(34);842-847 United States 2003 (NCHS)

Reflects variations in prevalence, parental help seeking, provider practice patterns and other factors


ADHDPharmacotherapy

Stimulants

  • Methylphenidate-based

  • Dextroamphetamine-based

  • Mixed Amphetamine Salts

    Non-Stimulant

  • Atomoxetine

    Other (Off-label, but with EB)

  • Antidepressants

  • Antihypertensives


Long-Acting Stimulant Agents


Begin ADHD algorithm


ADHD and Other Disruptive Disorders

  • ODD

    • Diagnosis:

      • Similar age of onset, course

      • Likely the most frequent comorbidity encountered

      • Prompts specialty mental health referral (over-represented)

    • Treatment implications

      • Family and patient education

      • Raises caregiver stress more than ADHD or CD

      • Psychotherapy choices (PCIT; parenting interventions)

      • Medication implications (stimulants; non-stimulant ADHD treatments; alpha agonists)


ADHD and Other Disruptive Disorders

  • CD

    • Diagnosis:

      • Variations in age of onset, course

      • Comorbidity with significant prognostic impact (increased risk of drug abuse; antisocial behaviors)

    • Treatment implications

      • Family likely has significant other risk factors

      • Psychotherapy choices (PCIT; parenting interventions; MST)

      • Medication implications (stimulants; non-stimulant ADHD treatments; atypical neuroleptics; possibly mood stabilizers for anti-aggressive effects)


ADHD and Anxiety Disorders

  • GAD and SAD

    • Diagnosis:

      • Tease out age of onset and course of symptoms

      • “Shared” symptoms (inattention, hyperactivity; academic performance problems; sleep problems)

      • Unique features (worry; fears; significant somatic complaints)

    • Treatment implications

      • Families may be reinforcing avoidances and fears

      • Psychotherapy choices (CBT)

      • Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)


ADHD and Anxiety Disorders

  • PTSD

    • Diagnosis:

      • Identify stressor event

      • Tease out age of onset and course of symptoms

      • “Shared” symptoms (inattention, hyperactivity; academic performance problems; sleep problems)

    • Treatment implications

      • Families often have significant other stressors

      • Psychotherapy choices

      • Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)


ADHD and Mood Disorders

  • Major Depression/Dysthymia

    • Diagnosis:

      • Differentiate age of onset, course

      • “Shared” symptoms (inattention, academic performance problems; sleep problems)

    • Treatment implications

      • Family and patient education

      • Psychotherapy choices (CBT; IPT; DBT)

      • Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)


ADHD and Mood Disorders

  • Bipolar Disorder

    • Diagnosis:

      • Differentiate age of onset, course (issues of mixed presentation and of rapid cycling)

      • “Shared” symptoms (attention problems; hyperactivity; increased speech output; loud; sleep problems; academic performance problems)

      • Unique symptoms (grandiosity; psychotic symptoms; severe mood lability; severe aggression)

    • Treatment implications

      • Family and patient education

      • Medication implications (mood stabilizers; atypical neuroleptic medications; issue of stimulants; non-stimulant ADHD treatments; antidepressant options)


ADHD and Tic Disorders

  • Chronic Tics or Tourette’s Disorder

    • Onset of ADHD often precedes onset of Tics or TS

    • Important to inquire about family history and educate parents about stimulants and tics/TS

  • Treatment

    • Stimulants were considered “contraindicated” in past

    • Focus now on improving functioning – ADHD may be more impairing than tics

    • Complex regimens may be used, combining ADHD medications with alpha-agonists and/or atypical neuroleptic medications


Case Example

  • Bob presented to child psychiatrist for ADHD, SLD, expressive language disorder

  • Family history + ADHD, depression

  • Treated with stimulants, school interventions as preadolescent

  • Developed severe aggression, mood instability, some seasonal variations in mood in early adolescence

  • Repeated inpatient crisis stabilization, family therapy, medication adjustments

  • Developed psychotic symptoms with hypomanic component

  • Residential treatment pursued


Bob follow-up

  • Temporarily stopped ADHD medication treatment, used antipsychotic medications

  • Moved into mood stabilization, resumed ADHD medications once Bob had remained free of psychotic symptoms for 3 months

  • Continued family intervention (“the explosive child”)

  • Able to resume regular school attendance, with partial special education services, continued ADHD treatment, ongoing mood stabilization, off all antipsychotic medications

  • Continued to experience social isolation, but markedly improved overall functioning

  • Young adult outcome: subclinical ADHD symptoms without further mood disturbance; completed high school; dropped out of community college; works successfully as cook; terminated outpatient therapy and medication therapy age 22.


Questions/Discussion


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