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Attention Deficit Hyperactivity Disorder

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  1. Attention Deficit Hyperactivity Disorder

  2. Kevin Leehey M.D. 1980 E. Fort Lowell Rd. Suite 150 Tucson, AZ 85719 520-296-4280 fax 520-296-3835

  3. Attention Deficit Hyperactivity Disorder • ADHD Inattentive Type • ADHD Hyperactive/Impulsive Type • ADHD Combined Type • ADHD NOS Kevin Leehey, M.D. 296-3835

  4. Differential Diagnosis • Medical or neurologic or other psychiatric conditions, such as hyperthyroidism, medication side-effects, anxiety disorders, post traumatic stress, depression, immature character, and oppositional behaviors, may look like ADHD but not actually be ADHD. Kevin Leehey, M.D. 296-3835

  5. Co-morbid • Anxiety disorders, Tourette’s Syndrome, depression, post traumatic stress difficulties, behavioral problems, learning difficulties, coordination disorders, sensory integration disorders, PDD, etc. • The most common condition associated with ADHD is a learning disorder (about 50 percent) Kevin Leehey, M.D. 296-3835

  6. Diagnostic Criteria A. • Six (or more) of the symptoms of inattention have persisted for at least six-months to a degree that is maladaptive and inconsistent with developmental level • Or six (or more) of the symptoms of hyperactivity-impulsivity have persisted for at least six-months to a degree that is maladaptive and inconsistent with developmental level Kevin Leehey, M.D. 296-3835

  7. Inattention : • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • Often has difficulty sustaining attention in tasks or play activities • Often does not seem to listen when spoken to directly • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) • Often has difficulty organizing tasks and activities • Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort (such as schoolwork or homework) • Often loses things necessary for tasks or activities (ie: toys, school assignments, pencils, books, or tools) • Is often easily distracted by extraneous stimuli • Is often forgetful in daily activities Kevin Leehey, M.D. 296-3835

  8. Often fidgets with hands or feet and squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) Often has difficulty playing or engaging in leisure activities quietly Is often “on the go” or often acts as if “driven by a motor Often talks excessively Often blurts out answers before questions have been completed Often has difficulty awaiting his/her turn Often interrupts or intrudes on others (eg: butts into conversations or games) Hyperactivity: Impulsivity: Kevin Leehey, M.D. 296-3835

  9. More Diagnostic Criteria B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age seven years C. Some impairment from the symptoms is present in two or more settings (ie: school, work, home) D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (ie: Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)

  10. Making the Diagnosis • ADHD is often diagnosed based on meeting at least the minimum criteria for ADHD from DSM-IV • Psychological testing, WISC-IV, Woodcock-Johnson-R • Rating scales such as the Connors or SNAP • Continuous Performance Task Tests • Observation of the child or adolescent’s behavior in school and non-school settings • Family history Kevin Leehey, M.D. 296-3835

  11. Making the Diagnosis • Making the diagnosis for adults and preschoolers is more difficult. Many of the diagnostic criteria are described in terms most relevant for elementary, middle school, and less so, high school age groups. For adults, past history and data regarding school experiences and testing is often crucial (along with current and past functioning and family history). Kevin Leehey, M.D. 296-3835

  12. ADHD trends • 8 years old, third grade • Sixth grade, middle school • 3X Boys - wrong • Missed - girls, minorities, ODD, inattentive only, bright, co-morbid, mild • 5-7% of school age youth Kevin Leehey, M.D. 296-3835

  13. ADHD is more difficult to diagnose in preschool • A wider range of behavior is expectable • Attention span normally increases with age, as does impulse control and a lessening of physical hyperactivity • Parenting styles and cultural norms vary markedly in this age group • Medication treatment is often less helpful and less researched • Other interventions are often worthwhile • ADHD will become more clear with time Kevin Leehey, M.D. 296-3835

  14. Executive Function Disorder • Disorganization and poor time management skills • Follow-through and carrying out plans • Getting schoolwork/homework done or turned in • Failure to complete or turn in assignments • Do (fully or partially) their assignments but fail to turn them in or lose them Kevin Leehey, M.D. 296-3835

  15. ADHD diagnosis myths • Video/computer games, television, movies • “He/she can if he/she wants to” • “He/she is fine at home”, or 1:1, or at the office • “Lazy”, underachiever, unmotivated Kevin Leehey, M.D. 296-3835

  16. Prognosis, Outcome • ADHD can be mild, moderate, or severe • Learning disorders may also be mild, moderate, or severe • Associated conditions complicate • Ability of that youngster’s family, school, and even that youngster’s ability to adjust to his/her current developmental needs and to what is expected of him/her Kevin Leehey, M.D. 296-3835

  17. ADHD prognosis • Hyperactivity resolves for 50% around puberty; 75% by age 21 • Inattention often persists • “School of hard knocks” • 25% have conduct disorders and or substance abuse • Higher risks MVA, job losses, relationship problems, depression, anxiety Kevin Leehey, M.D. 296-3835

  18. Basic Medical Principles • H&P, labs, hearing, vision • Educational assessment • Experienced and well trained clinician • 365 days, 24/7 • Individualize and fine tune treatment Kevin Leehey, M.D. 296-3835

  19. Treatment • Individual Therapy • Self esteem and impulse control • Family Therapy • It is more difficult to parent a youngster with ADHD Kevin Leehey, M.D. 296-3835

  20. Treatment 3. School/Work • Special education, 504 Accommodation • Positive home-school communication • The transition from elementary to middle school and again from middle school to high school • Environmental manipulation 4. Medication Kevin Leehey, M.D. 296-3835

  21. Treatment 5. Additional or Alternative treatments • Martial arts • Exercise/sports • Biofeedback (“Neurofeedback”) • Sensory integration treatment • Nutritious diet, sweets, “junk food”, sugar • Vitamins, herbs, and other supplements • “Dyslexia” is a language processing phonologic error in language areas of the brain, not a hearing or vision disorder Kevin Leehey, M.D. 296-3835

  22. Medications for ADHD-1 • Stimulants • Methylphenidate • Short and extended duration • Amphetamines • Short and extended duration • Pemoline (Cylert) Kevin Leehey, M.D. 296-3835

  23. Medications for ADHD-2 • Non-stimulants • Atomoxetine (Stattera) • Tricyclics (Imipramine, Desipramine) • Buproprion (Wellbutrin) • Partial alpha agonists [Guanfacine (Tenex), Clonidine] Kevin Leehey, M.D. 296-3835

  24. Medications for ADHD-3 • Combinations/polypharmacy • Avoid if possible • Stimulant and atomoxetine or other non-stimulant ADHD medication • Atomoxetine and SRI • Non psych medications • Stimulant plus SRI plus DDAVP is safer than desipramine alone Kevin Leehey, M.D. 296-3835

  25. Medications for ADHD-4 • Out of the Box • amantadine (Symmetrel) • modafinil (Provigil) • pramipexole (Mirapex) • ropinirole (Requip) Kevin Leehey, M.D. 296-3835

  26. Medications for ADHD-5 • Beads/sprinkle • Adderall XR, Ritalin LA, Metadate CD, Focalin XR • Liquid • Methylin, Amantadine (Symmetrel) • Chewable • Methylin • Patch -Catapres, MPH (soon) • Osmotic pressure release - Concerta • Compounding Kevin Leehey, M.D. 296-3835

  27. Prescribing for ADHD-1 • Co-morbidity: Depression, anxiety, tics, substances, bipolar, nicotine • Height, weight • Appetite decrease and low weight is the most common limiting stimulant side effect • Class II, no “refills”, 60 days, less on base post, out of state varies, 90 day mail order • Match side effects as well as good effects Kevin Leehey, M.D. 296-3835

  28. Prescribing for ADHD-2 • Duration • Convenience • Weight (height less of a concern) • Tics • “Meaner” • Abuse of stimulants • Truck driver, pilot Kevin Leehey, M.D. 296-3835

  29. Prescribing for ADHD-3 • Regular follow-up appointments • Not just “med checks” • Height, weight, growth curve • School, home, peers, activities, etc. • Patient and significant other input • Benefits and adverse effects Kevin Leehey, M.D. 296-3835

  30. Kevin Leehey M.D. 1980 E. Fort Lowell Rd. Suite 150 Tucson, AZ 85719 520-296-4280 fax 520-296-3835