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ADHD: AN UPDATE AND PRACTICAL APPROACHES FOR PRIMARY CARE

ADHD: AN UPDATE AND PRACTICAL APPROACHES FOR PRIMARY CARE. Matthew Biel, MD, MSc Associate Professor of Psychiatry and Pediatrics Division Chief, Child and Adolescent Psychiatry Georgetown University Medical Center. Learning Objectives. Listeners will be able to:

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ADHD: AN UPDATE AND PRACTICAL APPROACHES FOR PRIMARY CARE

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  1. ADHD:AN UPDATE AND PRACTICAL APPROACHES FOR PRIMARY CARE Matthew Biel, MD, MSc Associate Professor of Psychiatry and Pediatrics Division Chief, Child and Adolescent Psychiatry Georgetown University Medical Center

  2. Learning Objectives Listeners will be able to: • Review symptom criteria for ADHD. • Review the differential diagnosis for ADHD. • Note recent neurobiological findings in ADHD. • Consider approaches to diagnosis in outpatient primary care setting. • Choose between various treatment options based upon their risk/benefit profiles. • How best to utilize DC MAP for ADHD patients?

  3. ADHD: Why do pediatric primary care providers care about ADHD? • Most common neuro-developmental disorder • Highly impairing throughout childhood (and into adulthood for many) • Most treatment occurs in primary care • Treatment works and is not onerous to provide! • Good treatment can change your patients’ life trajectories

  4. Epidemiology of ADHD • 3 – 7% of school-aged children affected in U.S. • Males>Females • Girls typically show less hyperactivity, fewer conduct problems– as a result, often missed

  5. Epidemiology (3) • At least 30 – 50% maintain diagnosis ≥ 15 yrs • Strongest predictor of poor prognosis is pre-pubertal aggression • Approx 80% of ADHD meds prescribed to kids are prescribed by PCPs

  6. Who “Gets” ADHD? • Children without insurance receive less mental health assessment and treatment • Latino and African-American children are less likely to be diagnosed with ADHD • Once diagnosed, they are equally likely to be prescribed and to take stimulants • Access to care? • Caregiver bias? • Cultural factors

  7. Potential Areas of Impairment Academic limitations Children Relationships Occupational/ vocational Adults ADHD Low self esteem Legal difficulties Motor vehicle accidents Injuries Smoking and substance abuse Adolescents

  8. Comorbidities in 2/3 of ADHD kids • Anxiety disorders: 10-30% • Oppositional defiant disorder: 40-65% • Conduct disorder: 10-25% • Mood disorders: 15-75% • Tic disorder: 10-35% • Learning/academic problems: up to 90% Biederman et al 1996 Spencer et al 2000

  9. Comorbidities (2) • ≥ 80% of children with ADHD demonstrate psychiatric difficulties as adults • What about substance abuse? • Higher rates than non-ADHD kids • Treatment with stimulants: protective effect • Educational impairments • Employment problems • Greater sexual-reproductive risks • Greater motor vehicle risks

  10. Parent Problems Related to ADHD • Parents of children w/ADHD: • 3-5x more likely to become separated or divorced • higher incidence of depression & family discord • Majority report changes in work status due to child’s difficulties • Up to 35% risk that a parent has ADHD • Biggest factor in which kids are diagnosed and treated: how burdened are parents by child’s difficulties?

  11. Natural History • Rule of “thirds”: • 1/3  complete resolution • 1/3  continued inattention, impulsivity • 1/3  early ODD/CD, poor academic achievement, substance abuse, social difficulties as adults • Age related changes: • Preschool (3-5 y/o) – hyperactive/impulsive • School age (6-12 y/o) – combination symptoms • Adolescence (13-18 y/o) – inattention, restlessness • Adult (18+) – largely inattention w/periodic impulsivity

  12. —Age— ADHD: Course of the Disorder Inattention Hyperactivity Impulsivity

  13. Neurobiology of ADHD • Smaller brain volumes in all regions regardless of medication status (cortical white & gray matter) • Most implicated region: prefrontal cortex • Volumetric abnormalities persist with age • No gender differences • Volumetric findings correlate w/ ADHD severity • Delayed maturation of PFC • Castellanos et al, 2002 and Shaw et al, 2007

  14. The age of attaining peak cortical thickness in children with ADHD compared with typically developing children. Shaw P et al. PNAS 2007;104:19649-19654

  15. Kaplan–Meier curves illustrating the proportion of cortical points that had attained peak thickness at each age for all cerebral cortical points (Left) and the prefrontal cortex (Right).

  16. ADHD is a dimensional condition • Longitudinal structural MRIs of: • 197 kids with ADHD • Smaller brain volumes, thinner cortical gray matter • Delayed maturational process (rate of thinning) • 193 kids with typical development (no ADHD) • Assessed symptoms of hyperactivity, impulsivity • Those with more symptoms had relatively smaller brains, thinner cortical ribbons, slower maturation (delayed thinning) Shaw et al, 2011

  17. Genetic and Non-Genetic Causes of ADHD • Over a dozen implicated genes • Tend to relate to dopamine system in CNS • Non-genetic causes are also neurobiological • Perinatal stress • Low birth weight • Traumatic brain injury • Maternal smoking during pregnancy • Maternal ETOH use during pregnancy • Severe early deprivation

  18. How to establish the diagnosis? • There is no single test to identify ADHD • Diagnosis must be multi-factorial • Take a good history • Rule out medical causes • Consider other psychiatric diagnoses • Obtain information from parents & teachers

  19. DSM-V Criteria (Inattention) • Fails to give close attention to details or makes careless mistakes • Has difficulty sustaining attention. • Does not appear to listen. • Struggles to follow through on instructions. • Has difficulty with organization. • Avoids or dislikes tasks requiring a lot of thinking. • Loses things. • Is easily distracted. • Is forgetful in daily activities.

  20. DSM-V Criteria (Hyperactive/Impulsive) • Fidgets with hands or feet or squirms in chair. • Has difficulty remaining seated. • Runs or climbs excessively in children; extreme restlessness in adults. • Acts as if driven by a motor; adults will often feel inside like they were driven by a motor. • Talks excessively. • Blurts out answers before questions have been completed. • Difficulty waiting or taking turns. • Interrupts or intrudes upon others.

  21. Executive Functioning • Most children with ADHD have impairments in executive functioning, including problems with: • Planning • Organizing • Response inhibition • Vigilance • Working memory

  22. DSM-V Functional Criteria • 6 of 9 symptoms in either or both categories • Persisting for at least 6 months • Mild, moderate, or severe • Symptoms present before 12 y/o • Social/academic/occupational impairment • Two or more settings

  23. Differential Diagnosis (Psychiatric) • Mood Disorder • Anxiety Disorder • Learning Disorder • Intellectual Disability • Autism Spectrum Disorder • Substance Abuse • Psychosocial Cause (abuse, parenting, etc.)

  24. Differential Diagnosis (Medical) • Seizure Disorder • Chronic Otitis Media • Hyperthyroidism • Primary Sleep Disorder (OSA, Narcolepsy) • Drug-Induced • TBI/Concussion • Hepatic Illness • Toxic Exposure (e.g., lead)

  25. Making the Diagnosis • Review of Current Psychiatric Systems • attention, hyperactivity/impulsivity, disruptive behavior, mood, anxiety, trauma, tics, substances • Medical, Psychiatric, & Developmental History • Educational History • repeating grades, particular problems in one area • Family History • school and behavioral problems • Social History • Major disruptions, traumas

  26. Making the Diagnosis (2) • Symptoms in ≥ 1 setting (school, home, sports, etc.) • Symptoms in group settings are a must! • Don’t diagnose (or rule out) ADHD based on 1:1 interview • Individuals with ADHD often have no signs of symptoms when they are interested, such as… • Engaging conversation with interested adult • Playing video games or watching TV

  27. Rating Scales for Teachers and Parents • SNAP – IV • 18- and 104-item versions • Free • Conners (for teachers, parents, and affected adults) • 30- and 60-item versions • Not free • Vanderbilt (for teachers, parents) • Free • Screens for functioning as well as symptoms

  28. Practical issues of diagnosis of ADHD in primary care: when, how, where? • Use formal general screening (such as SDQ) or use brief ADHD-specific screening questions with parents of school-age kids • SDQ has 5 items in hyperactivity/inattention subscale • When concerns are raised, use rating scales • Bring child and parent back (ideally with longer appointment slot) to complete assessment • Use of ancillary medical staff to collect rating scales • Regular follow-up once treatment starts

  29. What do you not need to do? • Labs, neuroimaging, cardiac workup not indicated with routine medical history/exam • Formal psychological/neuropsychological testing not mandatory; pursue if: • history suggests low cognitive ability or LD • diagnostically complex issues

  30. Three Cornerstones of Treatment • Medication • Behavioral Therapy • Parent Management Training • Organizational Skills Training • Social Skills Training • Educational Support • 504 • Individual Educational Plan (IEP)

  31. Treatment: The MTA Study of 1999 • Over 550 school-aged children with ADHD were followed for 14 months: • Community Treatment • Rigorous Medication Protocol • Rigorous Behavioral Protocol • Combined Behavioral and Medication Protocols

  32. Treatment • The MTA Study demonstrated: • Stimulant treatment effective in short-term • Behavioral treatment not effective for core ADHD symptoms in short-term • More frequent & higher dosing led to greater responses • Increased physician contact improved outcome • 2-, 4-, 6-, 8-year follow-ups: those who responded early did well long-term; those who didn’t respond early didn’t tend to get a lot better • Long-term follow-up also supports behavioral tx

  33. Are Stimulants Protective? • 10-year prospective study of 112 males with ADHD ages 6 -17 • 82 (73%) received stimulants, mean duration of six years • Those tx with stimulants were significantly less likely to subsequently develop • MDD (24% versus 69% for those who were stimulant naïve) • conduct disorder (22% versus 67%) • oppositional defiant disorder (40% versus 88%) • anxiety disorders (7% versus 60%) • Children tx with stimulants had significantly lower rates of grade retention compared to those who never received stimulants (26% versus 63%) Biederman et al, 2009

  34. Methylphenidates Short-acting Methylphenidate Ritalin Long-acting Concerta Ritalin LA Metadate CD Daytrana Quillivant Dexmethylphenidate Focalin Focalin XR Amphetamines Short-acting Dexedrine Adderall Long-acting Dexedrine Spansules Adderall XR Vyvanse Name those stimulants…

  35. Stimulants: Response Rates • 70% response rate w/a single stimulant (DEX/MPH); 90% respond if both tried • Large effect size (0.8-1.2) • No significant differences between amphetamines and MPH • Only MPH has established efficacy with kids<6yo

  36. Stimulants: Dosage & Administration • Long-acting treatments are good options given: • Concerns about tachyphylaxis • Hassle of multiple doses/day • Weight based dosing (not generally utilized) • Methylphenidate @ 1 mg/kg • Adderall @ 0.6 mg/kg • Dose to clinical response • Dosing averages: 30 mg/d MPH, 20 mg/d AD

  37. Stimulants: Side Effects • Side Effects: • Common: Nausea, headache, early insomnia, decreased appetite, tics, anxiety, mildly elevated BP/HR, mood changes • Rare: psychosis, arrhythmias • Long-term: minimal effects on growth

  38. Contraindications to stimulant use • HTN • symptomatic cardiovascular disease • Glaucoma • Hyperthyroidism • tics/Tourette’s (relative) • drug abuse (relative) • psychosis • Risk of sudden cardiac death under 1/1,000,000  no more than expected in an untreated population

  39. Stimulants: Standard Medical Care • Prior to treatment • Height, weight, BP, HR • Cardiac Exam • Family history of sudden cardiac death and/or personal history of syncope, CP, SOB, or exercise intolerance  ECG and pediatric cardiology referral for an echo • During Treatment • Annual height & weight • BP and HR 2x/year and with dosage increase

  40. Why consider other meds? • Can’t tolerate stimulants • Side effects • Medical co-morbidities • Psychiatric co-morbidities • Substance abusing/dependent patients • Lack of response to stimulants

  41. AtomoxetineHCl (Strattera): • Well-established efficacy • Effect size 0.7 • Norepinephrine reuptake inhibitor; acts at presynaptic neuron • Useful alternative to stimulants

  42. Atomoxetine: Side Effects • Decreased appetite (15%) • Avg wt loss 2 – 4 LB in first 3 months, then resume nl growth • Dizziness (5%) • Dyspepsia (5%) • Sedation • Increased BP/HR

  43. Effect Sizes

  44. When to think atomoxetine? • History of adverse effect to stimulants • Comorbid anxiety, depression, tics, enuresis • Require 24 hour symptom relief • Personal or family history of substance abuse • Concern about insomnia or appetite suppression • Patients who don’t respond to stimulants may respond favorably to atomoxetine (40%)

  45. A third option: -2 Agonists • Several DBPC trials showing efficacy • Mechanism of action: reduce central noradrenergic activity via presynapticagonism • Clonidine (0.1 – 0.3 mg/d) & Guanfacine (1 – 3 mg/d) • Contraindications: CAD, impaired liver/renal function • Side Effects: Rebound HTN/tachycardia, HOTN, sedation, dizziness, constipation, H/A, fatigue • Smaller effect size than stimulants/atomoxetine (0.4 vs. 0.7-1.2)

  46. When to think of -2 Agonists? • More helpful with hyperactivity/impulsivity • Can be adjunctive with stimulants • Less helpful with attention • Younger kids>adolescents • Problematic degrees of sedation common • Can be helpful with tics

  47. What about behavioral therapies? • Parent management training • Education about what kids with ADHD need • Behavior modification techniques • Use of rewards and reinforcement • Positive attention • Organizational skills training for kids • Study skills • Personal habits and routines • Social skills training for kids

  48. When to refer to child psychiatry? • Diagnostic complexity • Problematic comorbidity • Not responding to 1st, 2nd line treatments

  49. When to consult with DC MAP? • Whenever, wherever! • Please bring your questions to us: • Is the diagnosis correct? • Is additional workup necessary? • Is the medication appropriate? • What is the next medication to try? • What is the role for behavioral therapy? • What other services might help this child and family? • And many more terrific questions

  50. DC MAP • Call 844-30 DC MAP • Visit http://www.dcmap.org/ • Monday-Friday from 9am-5pm • Prompt (within 30min) consultation with child psychiatrist and/or therapist • Care coordination support for MH services • Prompt (within 48hrs) clinical documentation • Face-to-face consultation for highly complex cases

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