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ADHD WORKSHOP FOR PAEDIATRICIANS. UCT Paediatric Refresher Course Feb 2010. The role of the Paediatrician in the treatment of ADHD. Diagnosis and management Increase in presentation More presentations to Paediatricians and reluctance to visit a Psychiatrist Families need from Paediatrician

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Adhd workshop for paediatricians

ADHD WORKSHOP FORPAEDIATRICIANS

UCT Paediatric Refresher Course

Feb 2010


The role of the paediatrician in the treatment of adhd
The role of the Paediatrician in the treatment of ADHD

  • Diagnosis and management

  • Increase in presentation

  • More presentations to Paediatricians and reluctance to visit a Psychiatrist

  • Families need from Paediatrician

  • Awareness of differential diagnosis

  • Awareness of co-morbidity

  • Medication cornerstone of treatment but holistic approach very NB

  • Paediatrician may be first professional to notice ADHD


General concepts of adhd
General concepts of ADHD

  • Aetiological and symptomatic understanding


Adhd workshop for paediatricians


Criteria
criteria

  • INATTENTION

  • Failure to give close attention to detail

  • Difficulty sustaining attention

  • Not listening when spoken to directly

  • Inability to finish work / follow through instructions

  • Difficulty organizing tasks or activities

  • Avoidance of tasks requiring sustained mental effort


Adhd workshop for paediatricians

  • Often looses things required for tasks

  • Easily distracted

  • Forgetful in daily activities

  • 6 symptoms required

  • HYPERACTIVITY

  • Fidgety

  • Difficulty remaining in seat

  • Excessive running about / subjective feeling of restlessness

  • Difficulty engaging in leisure activity quietly

  • On the go / “driven by motor”

  • Excessive talking


Adhd workshop for paediatricians

  • IMPULSIVITY

  • Blurting out of answers

  • Difficulty waiting turn

  • Often interrupts or intrudes on others

  • 6 criteria required


Adhd workshop for paediatricians

  • ALSO

  • Symptoms present before age 7 years

  • Impairment in 2 or more settings

  • Impaired functioning

  • Symptoms not due to other causes


Adhd workshop for paediatricians

  • Spectrum of presentation i.e.. Below threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions

  • Up to 50% of children have co morbid disorder(s)


Adhd workshop for paediatricians

  • Impairment in social, family and academic functioning threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions

  • Occurrence in at least 2 settings

  • Onset during childhood

  • Longitudinal course - 2/3 of patients progress into adulthood


Adhd workshop for paediatricians

  • Why are more children presenting now? threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions

  • “Evolutionary” concept of ADHD

  • How/why do most patients/families present?

  • Disruption (in class) probably most common reason for referral


Has modern society created a disorder from a previous strength
Has modern society created a disorder from a previous strength?

  • Genetic and adaptive factors in ADHD

  • Information overload

  • Stimulation overload

  • Academic overload

  • Outsourcing of care

  • Is it normal for a child to sit still at a desk for 6 – 8 hours

  • Societal issues vs mental health issues


Why nb to treat
Why NB to treat strength?

  • Academic potential

  • Disruption

  • Self esteem

  • Impaired functioning (academic, social, family )

  • co morbidity


Evaluation of clinical approach to the child presenting with adhd
Evaluation of/Clinical approach to the child presenting with ADHD

  • May depend on referral source e.g.. Psychologist, school, parents etc

  • N.B. to take ones time, i.e. extended consult, 2-3 consultations

  • Differential diagnosis and co morbidity always need to be born in mind


Adhd workshop for paediatricians


Interview with parents
Interview with parents child)

  • May initially be necessary to exclude the child

  • Presenting complaint

  • History of presenting complaint

  • DSM IV checklist

  • Context of symptoms

  • Resulting impairments


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Family history
Family history alternative treatments

  • History of ADHD or co morbid disorder

  • Learning difficulty

  • Family coping style, level of organisation and resources

  • Family stressors

  • Signs of abuse and neglect (especially in younger children)


Child interview
Child Interview alternative treatments

  • Note symptoms of ADHD (may however be absent during one on one consultation)

  • Note and explore:

  • Defiance

  • Aggression

  • Anxiety

  • Obsessions and compulsions


Adhd workshop for paediatricians


Family observation
Family observation alternative treatments

  • Patients behaviour with siblings and parents

  • Parental responses to child’s behaviour

  • Parental level of agreement around child rearing principles and discipline


Physical evaluation
Physical evaluation alternative treatments

  • Past medical history and medication

  • Medical record over past 12 months

  • Stability of any illnesses e.g. asthma, allergies etc (may tip the balance)

  • Visual acuity

  • Hearing

  • Height, weight and growth chart

  • Other evaluation as indicated e.g. neurological, cardiology, developmental assessment


Additional information investigations
Additional information/investigations alternative treatments

  • Forms/rating scales completed by parents, teachers and significant others

  • Conner’s forms: basic and extended, also important to complete once patient being treated

  • School reports (especially the comments)


Adhd workshop for paediatricians


Adhd workshop for paediatricians


The younger and older child
The younger and older child other carers)

  • Young child: rule out neglect, abuse and other environmental factors, mother/parent: child relationship difficulties may be important contributor

  • Older child: NB. To make patient an active participant in treatment


Treatment intervention
Treatment/Intervention other carers)

  • Non pharmacological

  • Pharmacological (cornerstone of treatment)


Non pharmacological interventions
Non pharmacological interventions other carers)

  • Psycho education: parents, child, others

  • Collaboration with/ interventions at school

  • Additional school/ remedial resources

  • Support group for parents

  • Books and other materials

  • Behavioural interventions


Behavioural interventions
Behavioural interventions other carers)

  • Should be part of overall intervention

  • May be used on own if symptoms mild or parents refusing meds

  • Attend to child’s misbehaviours and complaints (target symptoms)

  • Token systems (target symptoms)

  • Time out

  • Manage non compliant behaviour in public places PTO


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Pharmacological interventions
Pharmacological interventions children who only have ADHD/ADD

  • Methylphenidate: Ritalin IR

  • Ritalin LA

  • Concerta

  • Atomoxetine: Strattera

  • Other: Imipramine

  • Clonidine


Side effects and their management methylphenidate
Side effects and their management:Methylphenidate children who only have ADHD/ADD

  • Loss of appetite (daily quantity N.B.)

  • Weight loss (monitor)

  • Headache, abdominal pain

  • Rebound phenomena

  • Anxiety

  • Tics

  • Depression

  • Affective blunting/ emotional lability

  • insomnia


Management of stimulant s e
Management of stimulant S/E children who only have ADHD/ADD

  • loa

  • loss of wt

  • early insomnia

  • blunted affect

  • tic

  • stereotypic movement

  • growth delay


If symptoms severe change to 2nd line meds

l o a children who only have ADHD/ADD

decrease dosage

increase breakfast + supper

if early - dev of tolerance

monitor wt and ht

if symptoms severe -- change to 2nd line meds


Adhd workshop for paediatricians

loss of wt children who only have ADHD/ADD

decrease dose

increase caloric intake (breakfast and supper)

no meds over w/e and holidays

monitor wt, growth curve

hope for tolerance


Adhd workshop for paediatricians

early insomnia children who only have ADHD/ADD

if IR - no meds after 3pm

if LA - lower dosage,

give dose earlier, give before breakfast for faster absorption

ensure bedtime routine eg reading

Clonidine, anntihisamine,melatonin


Adhd workshop for paediatricians

blunted affect children who only have ADHD/ADD

decrease dosage

change preparation


Adhd workshop for paediatricians

tic children who only have ADHD/ADD

discontinue, if tic disappears restart

if tic recurs - change meds


Adhd workshop for paediatricians

  • stereotypic movement children who only have ADHD/ADD

    decrease dosage

  • growth delay

    decrease dosage

    drug holidays

    bone age monitoring on radiograph


Atomoxetine
Atomoxetine children who only have ADHD/ADD

  • Gastrointestinal disturbances

  • Sedation

  • Decreased appetite

  • Hepatic disorder

  • Black box warning: suicidality

  • “feeling ill” but unable to verbalize

  • Severe acting out behaviour


Adhd workshop for paediatricians



Adhd workshop for paediatricians

  • Ritalin vs. Strattera to use

  • Ritalin generally considered 1st line

  • Consider Strattera if: tics, anxiety, Ritalin intolerance, patient preference


Introducing medication
Introducing medication to use

  • Dosage

  • Start over weekend (parents feel in control)

  • Warn re side effects

  • Ritalin : fast onset

  • Strattera : 4-6 weeks onset (may start in holidays)

  • Drug holidays ; depends on side effects and level of functioning off meds

  • Follow up regularly including Connors form and collateral (see later)


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Role play the difficult parents
Role play : the difficult parents ago and treated for ADD. He decided to stop meds then but now realises he requires them to get a decent matric result. How would you approach this problem?


Adhd workshop for paediatricians

  • Meds around for over 30 years- no major lawsuits in USA ago and treated for ADD. He decided to stop meds then but now realises he requires them to get a decent matric result. How would you approach this problem?

  • “drug” dependency issues – the opposite is true, never come across a child addicted to Ritalin, drug dealers don’t stock Ritalin…Why not

  • Self esteem issues and marginalisation

  • Co morbidity

  • Sitting on the other side

  • Why withhold something that works e.g. other meds (asthma), spectacles

  • Consideration of trial of meds

  • In and out of system….like coffee

  • If side effects… at least you can say you tried


Adhd workshop for paediatricians

  • Empirical evidence of other interventions lacking, i.e. diet, multivitamin loading, specialized programmes etc

  • If there were a proven intervention programme say over 10-15 sessions I would certainly administer it. It would be far more remunerative for me

  • If you know of a programme show me the evidence

  • Internet myths--- you can find anything on the internet


Patient follow up
Patient follow up diet, multivitamin loading, specialized programmes etc

  • What would your follow up strategy and protocol be for a patient that you have commenced on medication?

  • What specific features would you be looking out for?


Adhd workshop for paediatricians

  • Frequency of follow up (scripts may act as a good gatekeeper)

  • Weight, height, pulse and blood pressure

  • Co morbidity check, other disorders may creep in over time

  • Assess level of functioning in all spheres

  • Repeat Connor’s form

  • Side effects

  • Dosage

  • When to discontinue?


Differential diagnosis of adhd add and co morbidity
Differential diagnosis of ADHD/ADD and co morbidity gatekeeper)

  • ADD may often go undetected until later. Why?

  • Symptoms of ADHD may often mimic other psychiatric conditions

  • In addition about 50% of individuals with ADHD meet criteria for one or more other psychiatric disorder(s)

  • The list is long and the treatment may be complex


Differential diagnosis and co morbid conditions
Differential diagnosis and Co morbid conditions gatekeeper)

  • Oppositional Defiant Disorder

  • Anxiety Disorders (incl OCD)

  • Mood Disorders (incl BMD)

  • Conduct Disorder

  • Learning Disorder

  • Tourette’s Disorder, Motor Tic Disorder

  • Substance Abuse Disorder


Adhd workshop for paediatricians

  • Pervasive Developmental Disorder gatekeeper)

  • Sleep Difficulties/Disorders

  • Accidental Injuries

  • “Personality Difficulties”, Cluster B traits

  • Family dysfunction

  • Medical illnesses/ medication

  • Actively exclude co morbidity

  • Consider when ADHD “refractory”


Adhd workshop for paediatricians

  • , gatekeeper)

Joseph Biederman and Stephen Faraone 1996


Differential diagnosis
Differential diagnosis gatekeeper)

  • How would you differentiate a child suffering from ADHD/ADD from the following condition(s):Note that these patients may be referred to you with a request to treat their “ADHD/ADD”

  • Anxiety disorder( all types)

  • Depression

  • Bipolar mood disorder

  • Learning disorder

  • Oppositional defiant disorder

  • Substance use disorder

  • Pervasive developmental disorder


Adhd workshop for paediatricians


Co morbidity and adhd add
Co morbidity and ADHD/ADD gatekeeper)

  • More complex than establishing whether another diagnosis/disorder may be responsible for an “ADHD/ADD” presentation is when one or more disorders are indeed present in addition to ADHD/ADD

  • Furthermore when these disorders present during treatment of ADHD we need to ask ourselves whether these symptoms could be as a result of medication


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Tourette s syndrome
Tourette’s Syndrome comorbidities given the fact that the child/family is receiving psychological intervention?

  • clonidine

  • atomoxetine

  • stimulants (not as problematic as initially thought)


Pervasive development disorder
Pervasive Development Disorder comorbidities given the fact that the child/family is receiving psychological intervention?

  • meds not as effective 50% vs 70%

  • S/E less well tolerated

  • can be used but monitor

  • ? other agents eg Risperidone


B m d
B M D comorbidities given the fact that the child/family is receiving psychological intervention?

  • OK to use once stable on mood stabilizer

    Substance abuse

  • avoid stimulants (however)

  • NB preventative role


Anxiety disorder
Anxiety Disorder comorbidities given the fact that the child/family is receiving psychological intervention?

  • Second line agents

  • add SSRI


Depressive disorder
Depressive disorder comorbidities given the fact that the child/family is receiving psychological intervention?

  • Consider adding a SSRI (Fluoxetine)

  • Imipramine of limited value


Challenging cases over time
Challenging cases over time comorbidities given the fact that the child/family is receiving psychological intervention?

  • Imaad, 5 yrs old at end 2007

  • Met parents at ADHD Support Group

  • Recently diagnosed with ADHD and had been commenced on Ritalin 5mg mane

  • Now presents with mood swings and irritability in afternoons

  • Changed to Concerta 18mg with good effect

  • Mid 2009 – Psychometric assessment reveals some learning difficulties and significant ADHD “break through” symptoms


Adhd workshop for paediatricians

  • Increased dose to 36mg, initially symptoms controlled comorbidities given the fact that the child/family is receiving psychological intervention?

  • Oct 2009 emergence of vocal tic (parents concerned +++)

  • changed to Atomoxetine, Clonidine and Risperidone (monotherapy)….. Mild reduction of tics but ADHD out of control

  • Recommenced on Concerta 18mg in Jan 2010, ADHD symptoms controlled, still minor vocal tics


Adhd workshop for paediatricians

  • Lara, grade 1, 2009, Referred with diagnosis of ADHD/anxiety…Aggression on Strattera, mood swings on Ritalin, dysinhibited on Fluoxetine

  • Found to have additional ODD when seen

  • Predominant symptom ADHD

  • Commenced on Concerta 18mg

  • Developed severe insomnia


Adhd workshop for paediatricians


Adhd workshop for paediatricians


Adhd workshop for paediatricians

  • Reasonable response Started on Strattera….

  • Concentration difficulties at school Sept2009

  • Addition of Concerta 18mg

  • Good response

  • RSA karate champ end 2009

  • Mini “meltdown” beginning school year 2010

  • Parental tension

  • Couple counselling

  • Keeping fingers crossd……


Adhd workshop for paediatricians


Adhd workshop for paediatricians

  • Comment of the year 2009 Started on Strattera….

  • A 17 year old boy diagnosed with ADHD in Grade 11 and commenced on Methylphenidate:

  • Marks initially improved by 20%

  • “For the first time in my life I realized that I am not STUPID!”