ADD Update

Kristi Maroni, MDLance Feldman, MD, MBA, BSN

Drs. Maroni & Feldman have no disclosures to report

Disclosures

Outpatient 4 physicians & 1 nurse practitioner 2 therapists

Inpatient 7N (24 adult beds) 7S (8 child / adolescent beds) Consultation service

Our Practice

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

Goals & Objectives

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.

ADHD Overview – Diagnostic Criteria

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

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)

Diagnostic Criteria, Cont’d

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

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.

Diagnostic Criteria, Cont’d

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

Forms (parent & teacher) Vanderbilt Connors

Testing Connors CPT Psycho-educational testing

Confirming a Diagnosis…

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)

Adult Onset vs. Child Onset

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

Medication Therapy Behavior Modification

Treatment

Stimulants Methylphenidate people Dextroamphetamine people

Non-Stimulants Alpha 2 agonists Norepinephrine reuptake inhibitor

Medications

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

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

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)

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

Strattera (Atomoxetine)

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

Therapy Pearls

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

Classroom seating assignment Minimize distractions Take frequent breaks Encouragement and positive reinforcement Parent skills training Partnering with teachers / co-workers

Behavior Modification

Methylphenidate v. Dextroamphetamine Stimulant v. Non-Stimulant Long acting first if >6 y/o Ages (3+, seriously…) Keep in mind dosing ranges

General Prescribing 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

Deep Thoughts…

3+ medication failures Untoward side effects Significant treatment contraindications Concomitant mood or anxiety concerns

When to Refer…

Thanks!

Any Questions?