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ADD Update. Kristi Maroni, MD Lance Feldman, MD, MBA, BSN. Disclosures. Drs. Maroni & Feldman have no disclosures to report. Our Practice. Outpatient 4 physicians & 1 nurse practitioner 2 therapists Inpatient 7N (24 adult beds) 7S (8 child / adolescent beds) Consultation service.

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add update

ADD Update

Kristi Maroni, MD

Lance Feldman, MD, MBA, BSN

disclosures
Disclosures

Drs. Maroni & Feldman have no disclosures to report

our practice
Our Practice
  • Outpatient
    • 4 physicians & 1 nurse practitioner
    • 2 therapists
  • Inpatient
    • 7N (24 adult beds)
    • 7S (8 child / adolescent beds)
    • Consultation service
goals objectives
Goals & Objectives

1. Providers will be able to explain the diagnosis of ADHD

2. Providers will be able to understand the medical management of ADHD in children and adults

adhd overview diagnostic criteria
ADHD Overview – Diagnostic Criteria
  • Inattention: >/= 6 or more for children; >/= 5 for 17 and older and adults:
    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
    • Often has trouble holding attention on 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 (e.g., loses focus, side-tracked).
    • Often has trouble organizing tasks and activities.
    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
    • Is often easily distracted
    • Is often forgetful in daily activities.

http://www.cdc.gov/ncbddd/adhd/diagnosis.html

diagnostic criteria cont d
Diagnostic Criteria, Cont’d
  • Hyperactivity and Impulsivity: >/= 6 or more for children; >/= 5 for 17 and older and adults:
    • Often fidgets with or taps hands or feet, or squirms in seat.
    • Often leaves seat in situations when remaining seated is expected.
    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
    • Often unable to play or take part in leisure activities quietly.
    • Is often "on the go" acting as if "driven by a motor".
    • Often talks excessively.
    • Often blurts out an answer before a question has been completed.
    • Often has trouble waiting his/her turn.
    • Often interrupts or intrudes on others (e.g., butts into conversations or games)

http://www.cdc.gov/ncbddd/adhd/diagnosis.html

diagnostic criteria cont d1
Diagnostic Criteria, Cont’d

Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

http://www.cdc.gov/ncbddd/adhd/diagnosis.html

confirming a diagnosis
Confirming a Diagnosis…
  • Forms (parent & teacher)
    • Vanderbilt
    • Connors
  • Testing
    • Connors CPT
    • Psycho-educational testing
adult onset vs child onset
Adult Onset vs. Child Onset
  • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
  • Several symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).
  • Keep in mind possible secondary gain

(NC controlled substance database)

http://www.cdc.gov/ncbddd/adhd/diagnosis.html

treatment
Treatment

Medication

Therapy

Behavior Modification

medications
Medications
  • Stimulants
    • Methylphenidate people
    • Dextroamphetamine people
  • Non-Stimulants
    • Alpha 2 agonists
    • Norepinephrine reuptake inhibitor
methlyphenidate
Methlyphenidate
  • Concerta
  • Daytrana
  • Focalin & Focalin XR
  • Metadate CD & ER
  • Ritalin, Ritalin LA & SR
  • Quillivant
  • >6 y/o choose long acting first
  • Costs vary widely
  • Method of administration (tab, cap, liquid, patch)
  • Time release differences
dextroamphetamine
Dextroamphetamine
  • Adderall & Adderall XR
  • Procentra (3 y/o!)
  • Vyvanse
  • >6 y/o choose long acting first
  • Costs vary widely
  • Method of administration (tab, cap, liquid)
  • Vyvanse is a pro-drug
alpha 2 agonists
Alpha 2 Agonists
  • Intuniv (tenex / guanfacine)
    • Once daily dosing
  • Kapvay (clonidine)
    • More sedating
    • BID dosing (if >0.1 mg)
  • 6-17 y/o
  • Monotherapy or adjunct treatment
  • Costly (consider generics)
strattera atomoxetine
Strattera (Atomoxetine)

Ages 6+

Weight based dosing if <70kg (start 0.5 mg/kg, max 1.4mg/kg)

Increased risk of suicidality in children/adolescents

Norepinephrine reuptake inhibitor

Non-stimulant alternative in adults

Costly

therapy pearls
Therapy Pearls

Interpersonal interactions

Study skills

Organizational improvement

Playing well with others

Common cognitive distortions: all-or-nothing thinking, mind reading, magnification and minimization, emotional reasoning, comparative thinking

http://www.additudemag.com/adhd/article/912-2.html

behavior modification
Behavior Modification

Classroom seating assignment

Minimize distractions

Take frequent breaks

Encouragement and positive reinforcement

Parent skills training

Partnering with teachers / co-workers

general prescribing thoughts
General Prescribing Thoughts…
  • Methylphenidate v. Dextroamphetamine
  • Stimulant v. Non-Stimulant
  • Long acting first if >6 y/o
  • Ages (3+, seriously…)
  • Keep in mind dosing ranges
deep thoughts
Deep Thoughts…
  • When to switch or add adjunct tx
    • 0 x 0 = 0
  • How to deal with side effects…
    • Worsening of tics
    • Exacerbation of mood / anxiety
    • Sleep / Appetite
when to refer
When to Refer…

3+ medication failures

Untoward side effects

Significant treatment contraindications

Concomitant mood or anxiety concerns

thanks
Thanks!

Any Questions?