ADHD

Mike Guyton, MDAssistant Clinical Professor/Academic

Faculty in General Pediatrics

Objectives

• What is ADHD– Definition and Criteria– Evaluation

• How is ADHD Treated?-Stimulants vs Non-stimulants vs Adjunctive-Side effects of therapy

• The culture of ADHD– Public perceptions vs medical perceptions

• Abuse of ADHD Medications– Populations at Risk– Medications commonly abused– Co-morbid conditions

• Management of ADHD– Alternative options

ADHD: Setting the Record Straight

ADHD

• A neuropsychiatric disorder of inattention, impulsivity and/or hyperactivity– Affecting cognitive, academic, behavioral,

emotional, and social functioning

• Commonly manifests in childhood• Wide spectrum of presentation

Criteria for ADHD

• <17yo– ≥6 symptoms of hyperactivity/impulsivity or ≥6

symptoms of inattention• >17yo

– ≥5 symptoms of hyperactivity/impulsivity or ≥5 symptoms of inattention

• Exclusion of other physical, mental, or situational conditions that could account for the symptoms

Adult Symptoms of ADHD

Adult ADHD

Hyperactivity:Restlessness

VerbosityConstant Activity

Impulsivity:Ending

Relationships/JobsOverreaction to

Frustrations

Inattention:Procrastination

Difficulty making decisions/organization

Poor Time Management

Evaluation of ADHD

• Several rating scales out there– Conners’ Adult ADHD Rating Scale (CAARS)– Adult ADHD Self-Report Scale (ASRS)

• Should be used as supplements rather than substitutes for the clinical exam/impression– Not diagnostic, but supportive

• Need to see deficit in at least 2 separate areas– Home, school, personal/professional life,

economics

Differential Diagnosis

• Medical Conditions– Anemia, sleep disorder, substance abuse, endocrine disorders

• Psychosocial/Environmental Conditions– Parental psychopathology, stressful home environment

• Emotional/Behavioral Disorders– Depression, Anxiety, ODD, OCD, PTSD, Adjustment Disorder

• Developmental Variations– ID, normal variation, giftedness

• Neurologic/Developmental Disorders– LD, Autism Spectrum Disorder, Seizure Disorder

Medical Treatment for ADHD

• Stimulant vs non-stimulant medication– Stimulants are gold standard– Non-stimulant meds not recommended less than 6yo

• Based on evidence, experience/comfort, and insurance– Guides initial choice as well as when switching

• Monitoring is just as important as medication• Are Medications Safe

Pre-Treatment Counseling

• Aim to is improve IMPULSIVITY and FOCUS– Not to curb bad behavior

• Explain benefits and potential risks– Some risks not well understood (i.e. causal association

between serious cardiovascular events and stimulant use)

• Explain the expected length of management– 1-3 months to find appropriate medication/dosing regimen

Stimulant Medication

• First line agent– Consider risk of substance abuse by patient or

family• Several blinded randomized trials showed

efficacy of stimulants over non-stimulants– Response rate to specific stimulants range 70-80%

• Some long term studies also exist– Safe and effective for years-decades– Appetite suppression most common long term SE

Non-stimulant Medication

• Used in various settings– History of substance abuse– Concern over side effects of

stimulants– Unable to tolerate stimulant

medication

• Found to be more effective than placebo in multiple studies

• Some used in conjunction with stimulant medication– Clonidine, Guanfacine

Side Effects

• Common– Anorexia, Insomnia, Tics– Dizziness– Mood Labiality– Mild Cardiovascular

changes (dose dependent)

• Not so common– Priaprism– Psychosis– Diversion and Misuse– Poor Growth Trajectory

Effects on those without ADHD

• Mechanism of action of stimulants is not well known– Dopamine and Norepinephrine concentrations

• In general, there is increased ability to focus and some increase in hyperactivity in those without ADHD

• Side effects happen in both ADHD and non-ADHD population

The Culture of ADHD: Public Perceptions

• Many myths and misconceptions regarding ADHD– Not a real medical diagnosis– Only seen in children if seen at all– ADHD is over diagnosed– Poor parenting causes ADHD– ADHD is worse in men vs women– Children with ADHD are “troublemakers”

ADHD Myths

Public Perceptions: Is this an American Disease?

• In 2003 it was found that 1:20 children had ADHD in America– Due to certain cultural and societal factors inherent

to American life• 50 studies were looked at retrospectively

– Prevalence of ADHD in non-US children just as high if not higher in other countries

• Ukraine

– In others, rates were lower• Sweden, Iceland, Australia, Italy

Medical Perspective: The risk of not treating

• Increased risk of poor social/financial/educational attainment– ~32% drop out of school– ~47% of youth in juvenile detention have ADHD

• Increased risk of injury to self/others– 4X the accidents; 3X the speeding tickets; more likely overall

for bodily harm• Involvement in high risk behaviors

– Onset of substance use disorders (SUD) at a younger age than peers

– More likely to participate in high risk sexual behavior

Abuse of ADHD Meds

• Most abuse involves short acting medications• Adults with ADHD and history of substance abuse are

at highest risk– Also, those with FH of drug abuse

• Treatment of ADHD with stimulants does not seem to induce substance abuse– ? Protective against SUD if ADHD treated properly

• Other co-morbid conditions could promote misuse as well and need to be taken into account with treatment– Anxiety and depression

Specific Co-Morbid Disorders in Adult ADHD

• Specific Phobias– 29.3%

• Bipolar Disorder– 19.4%

• Major Depressive Disorder– 18.6%

• Dysthymia– 12.8%

• Generalized Anxiety Disorder– 8.0%

ADHD and Substance Abuse• Youth with ADHD are:

– ~2X as likely to have lifetime nicotine use

– ~3X more likely to report nicotine dependence in adolescence and young adult hood

– ~2x more likely to meet criteria of alcohol dependence or abuse

– ~1.5X more likely to meet criteria for MJ dependence

– More than 2.5X more likely to develop a SUD overall

Theories on the relationship of ADHD and SUD

• Inherent impulsivity/poor judgment and insight

• Biological factors and similarities– Dopamine Stimulation and

routing of motivation– ADHD + Stimulants routed

to executive functioning task oriented rewards

– Illicit drugs of abuse routed to mainly reward centers euphoria and eventual dependence

Misuse, Diversion, and Abuse of Stimulants

• Misuse (5-35% in college aged students)– Use of meds not prescribed or used in non-prescribed

ways• Taking larger doses than prescribed to improve studying or to

“get high”

• Diversion (occurring as often as 16-23%)– Transfer of meds from a person whom it is prescribed for

to one it is not prescribed for• Abuse (as high as 6% in ages 18-25)

– Use of meds associated with problems or risks that impair functioning

ADHD vs non-ADHD Patient

• Abuse of stimulant medication strongly linked to subjective effect– How much one likes a drug, experiences euphoria

• Those with ADHD less likely to experience the subjective effect than those without ADHD– 1970’s, reported no changes in mood but definite

changes in productivity• Short acting agents much more likely to be

abused than long acting agents

Alternative Strategies

• Many have been proposed; unfortunately not many studies to support– Nutritional Supplementation

• Various vitamins, minerals, and herbal supplements

– Yoga and Meditation– Special Diets

• Elimination of sugar, caffeine, allergens (milk, wheat)– Biofeedback Sessions

• Use of EEG to promote brainwave awareness/theoretical– Psychotherapy

• Cognitive Behavioral Therapy

Take Home Points

• ADHD is a complex condition– Biological/Medical/Psychiatric/Neurological

• Pharmacologic therapy is tried and true, but that doesn’t mean its for everyone

• Proper identification and screening for co-morbidities needs to be the focus of healthcare practitioners– Multidisciplinary approach

• Doctors need to partner with their patients (and vice versa) – Plan only therapeutic if there is buy-in from both parties

Questions?