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ADHD and the School Age Child

ADHD and the School Age Child. James Hedrick, MD Assisant Professor of Clinical Pediatrics University of Louisville . Objectives. Participants will improve their professional competence by being able to: Describe the diagnostic tools and evaluation of children who may have ADHD.

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ADHD and the School Age Child

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  1. ADHD and the School Age Child James Hedrick, MDAssisant Professor of Clinical Pediatrics University of Louisville

  2. Objectives Participants will improve their professional competence by being able to: • Describe the diagnostic tools and evaluation of children who may have ADHD. • Discuss the multitude of older and newer pharmacologic medications available for ADHD, including titrating medications to an appropriate dose, adverse effect profiles, duration, drug abuse potential and subpopulations where non-stimulant drugs are less likely to be effective. • Indicate selection of medication taking into account side effects, risks of abuse, need for 24 medication coverage, comorbid conditions, and potential for combination therapies using stimulant and non-stimulant drugs.

  3. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  4. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  5. The ProblemBabies change into children

  6. ADHD Hyperactivity Increase activity compared to others same age and in same situation Attention Deficient Disorder Ability to scan your enviroment and notice every little thing

  7. Causes of ADHD • Neurotransmitter function • ADHD -Imbalance of 2 neurotransmitters • dopamine (DA) • norepinephrine (NE), • Believed to play important role in ability to focus and pay attention to tasks. 8

  8. Causes of ADHD Unknown!!! Biologic disorder FH often positive (up to 80%) Other causes Prematurity Very Rare causes: Prenatal cocaine, alcohol, tobacco Head injuries Lead or other toxins Not caused by: sugar, food additives, allergies, immunizations 9

  9. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  10. ADHD: Prevalence in U.S. • 3%-7% of school-aged children • Estimated 7 million children • Male to female ratio is 4:1 in children and adolescents • Females are over-represented in inattentive subtype, may lead to under-diagnosis and under-treatment • Prevalence is similar across cultures Goldman et al. JAMA. 1998;279:1100-1107. Barkley RA. Attention-deficit hyperactivity disorder. In: Mash EJ, Barkley RA, eds. Child Psychopathology. 1996:63-112.

  11. Over Diagnosing? • (Jensen, JAACAP, 1999) study of stimulant use in 4 communities (total of 1,285 children studied): only 12% of children with ADHD had received stimulant medication during the preceding year. • (Jensen, 2000): only 1.2 - 1.5 of the 3.0 million US children with ADHD received stimulant medication.

  12. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  13. Diagnostic criteria No test for ADHD

  14. Diagnostic criteria

  15. Three cardinal features of ADHD Inattention Impulsivity Plus/Minus Hyperactivity In addition Occur in more than one setting Symptoms more than 6 months Significant impairments!!! Should be present before age 7— 17

  16. Inattention- often or very often Daydreams Poor listening Easily distracted Careless mistakes, poor at details Poor follow through Disorganized Loses things Forgetful Avoids mental effort 18

  17. Hyperactivity- often or very often Constant motion Cannot stay seated Fidgety; squirmy Too talkative Overactive—runs, jumps, climbs inappropriately Cannot play quietly 19

  18. Impulsivity- often or very often Acts and speaks without thinking Trouble taking turns Accident prone Cannot wait Blurts out answers Interrupts or intrudes 20

  19. Children and Adults With ADHD Frequently Have Coexisting Disorders MTA Study National Comorbidity Study Children1 Adults2 (Ages 7.0-9.9; N=579) (Age ≥ 18; N=3199) 40% 47% ADHD & Oppositional Defiant Disorder (ODD) ADHD & Any Anxiety Disorder 39% ADHD & Anxiety 38% 32% ADHD & Any Mood Disorder ADHD Alone 14% 20% ADHD & IntermittentExplosive Disorder ADHD & Conduct 11% ADHD & Tic 15% 4% ADHD & Any Substance Use Disorder ADHD & Mood 1. Jensen PS, et al. J Dev Behav Pediatr. 2001;22:60-67 2. Kessler RC, et al. Am J Psychiatry. 2006; 163(4);716-723.

  20. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  21. ADHD Workup: Who May Need One? Behavior problem-uncontrolled or discipline issues Hyperactive School failure or struggles Check grades! (“OK” is not acceptable) Learning disability Child labeled as “lazy” Angry or depressed school age child or teen 23

  22. ADHD workup: how? Parent input Teacher input Child/teenager input Psychological issues PMH, SH, FH The “poor man’s” IQ testing and LD testing: Grades and achievement scores (after 3rd grade) Exclude MR, severe LD B 24

  23. Pre-visit requirements ADHD checklists—both teacher and parent Report cards Achievement scores (after 3rd grade) IQ tests if available Primary care giver, preferably BOTH parents 25

  24. ADHD workup: how?Mainstay: teacher and parent checklists SNAP* Vanderbilt* Iowa* Connors ASRS * Available for FREE online 26

  25. History & Physical examination 27

  26. History & Physical examination Chronic illness Visual or auditory problems (hearing and vision) Seizures Sleep disorder? R/O severe anxiety, depression, social/family stress, abuse Cardiac problems or history: Must document normal cardiac exam Ask: syncope/dizzy/CP w/exercise; H/T, heart murmur, palpitations, cardiac issues, FH of sudden death 28

  27. Initial tests NOT needed (routinely) Lead Thyroid EEG CPT (performance tests) CT or MRI scan of head Sleep studies ECG 29

  28. Should we perform an ECG? AHA suggest “yes,” but backed down (Vetter-Circulation 2008:117:1161) At physician discretion Use meds w/ caution if known CHD or arrhythmia AAP/AACAP says “no” (Perrin- Pediatrics 2008;122:451) Impractical No evidence Costly Sudden death very rare, no higher than general pop. Rather use careful history, FH, and physical 30

  29. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  30. Why treat ADHD? To prevent... Social problems: Peers, teachers and family Behavioral problems (hyperactive): Always hear “NO”, negatives, constant discipline problem Academic problems (inattentive): Underachievers, poor grades Overall: poor self esteem, frustration Higher risk for accidents, drugs, work and academic failure

  31. Unmanaged ADHD Can Give Rise toIncreasing Complications Antisocial behavior School exclusion Substance abuse Conduct disorder Lack of motivation Complex LD Oppositional defiant disorder Mood Disorder Challenging behavior Disruptive behavior Poor social skills Learning delay Low self esteem ADHD only Age 6 1014-16

  32. ADHD Affects Socialization • Children are stigmatized by their behavior • Disruptive behavior • Troublemakers • Bad sportsmanship • Excessive talking and cannot sit still • Unfocused, not responsive to others • Impulsive - aggression

  33. ADHD Affects Socialization • Children are stigmatized by their behavior continued • Immaturity and impulsiveness • Center of attention • Breaks the rules • Peer rejection • Blurting out answers

  34. ADHD Affects Socialization • Adolescents continue to demonstrate social problems • Poor participation in group activities • Few friends • Vulnerable to antisocial groups, drug abuse

  35. How ADHD Affects Parents • Increased stress • Worry — Anxiety • Frustration — Anger • Lower self-esteem • Self-blame — Depression • Social isolation • Increased employment disruption • Increased marital disruption • Increased alcohol/substance abuse

  36. Agenda The problem Prevalence Diagnostic criteria Evaluation Consequences Treatment

  37. Adhd Treatment • Change environment to eliminate distraction • Home, not school • Simplify life • One step commands

  38. Adhd Treatment

  39. Behavior Modification in the MTA Study.

  40. MTA Study for ADHD 579 children with combined ADHD F/U 14 months 4 groups: Meds alone (MPH TID titration + monthly visits) Intense behavior treatment Meds + behavior treatment Standard community care (2/3 medicated by office MDs) Arch Gen Psych 99; 56:1073

  41. MTA Study for ADHD All 4 groups showed response Meds alone group and combined meds + intense behavior mod group were most effective These two equally effective for Core sx’s Combined more beneficial for ODD, internalization, social skills, reading Study meds strategy (MPH tid) superior to routine community care Arch Gen Psych 99; 56:1073

  42. Parent and Clinician Concerns • Early morning coverage • Rapid onset of action • Optimal medication management for school day • Extended coverage for evening hours • Least amount of side effects

  43. ADHD medications:Critical Points Only meds show effectiveness for core sx’s Long term treatment Usually meds needed daily Allow child/teen decision making to some degree Check for compliance if prior good response wanes Give meds at school in a.m. if adherence issues Be alert for diversion and dealing

  44. Classes of Medication Used to Treat ADHD AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl):85S-121S.

  45. Classes of Medication Used to Treat ADHD • Insurance view • Only two types ADHD meds • Cheap • All other • Patient view AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl):85S-121S.

  46. Classes of Medication Used to Treat ADHD • FDA-approved • Stimulants (methylphenidate, amphetamine) • Atomoxetine (Strattera®) • -adrenergic agonists (clonidine, guanfacine) • Off-label • Antidepressants (tricyclics, bupropion) AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl):85S-121S.

  47. Stimulants • Caffeine • Most popular drug in world • 80% of world adult population every day • Very similar to ritalin

  48. Most effective and safest Reduction Hyperactivity Impulsivity ─Negative behaviors Inattention ─ Negative comments Quick onset All short term (effects, good and bad, gone by next day) Overall aggressive acts tend to decline Effects of Stimulants 50

  49. Effects of Stimulants Often need titration 70% respond to 1st choice, 90% by 2nd or 3RD choice More severe ADHD requires 7/365 therapy: Tachyphylaxis is common Increase dose reasonably Drug holidays only for less severe: Reduces tachyphylaxis and weight issues Problematic for severe cases I-ADHD requires ~50% dose of hyperactive 51

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