Attention Deficit Hyperactivity Disorder (ADHD)Justin A. Glass, MD21 February 2008Emory Family Medicine

Attention Deficit Hyperactivity Disorder (ADHD)What is the role of the primary care physician in diagnosis and treatment of ADHD?

ADHD Talk ObjectivesYou will understand ADHD diagnostic criteriaYou will will know where to find and how to use assessment tools for diagnosing ADHDYou will know when to refer a patient w/ ADHD for specialty careYou will understand tx options for ADHDYou will want to see a child with ADHD in your clinic in the near future

ADHD EpidemiologyPrevalence Survey average: 8-10% in children of school ageParent reported prevalence age 4-17Boys 11%Girls 4.4%

Male: Female ratio 2:1 - 4:1

ADHD PathogenesisMultiple theoriesImbalance of catecholamine metabolism in cerebral cortexImpaired executive functionsImpaired response inhibition

Diagnosis of ADHDInattentionHyperactivityImpulsivity

Diagnosis of ADHDInattentionForgetful outside of schoolIncomplete performance on school tasksMissing detailsMissing homeworkPoor performance on schoolwork

Diagnosis of ADHDHyperactivity Always in motionDifficulty during quiet timesConstant talking

Diagnosis of ADHDImpulsivityUnable to wait turnAnswers for othersUnsafe behavior

DSM IV Criteria ADHD (Inattention)Often fails to give close attention to detail or makes careless mistakes in schoolwork, work or other activities.Often has difficulty sustaining attention in tasks of play activitiesOften does not seem to listen when spoken to directlyOften does not follow through on instructions and fails to finish homework, chores or other dutiesOften has difficulty organizing tasks and activitiesOften avoids, dislikes or is reluctant to engage in tasks that require sustained mental effortOften loses things required to complete tasksIs often easily distractedIs often forgetful in daily activitiesSix (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

DSM IV Criteria ADHD (Hyperactivity)Often fidgets with hands or feet or squirms in seatOften leaves seat in situations in which remaining seated is expectedOften runs about or climbs excessively in situations in which it is inappropriateOften has difficulty in playing quietlyIs often on the go or acts as if driven by a motorOften talks excessivelyOften blurts out answers before questions are completedOften has difficulty waiting turnOften interrupts of intrudes on othersSix (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

Diagnosis of ADHDAdditional Criteria:Some inattentive or hyperactive/impulsive symptoms were present before the age of seven.Some impairment from the symptoms is present in two or more settings (e.g. at school and at home)Clear evidence of clinically significant impairment in social, academic or occupational functioning

DSM IV Criteria - ADHDThree typesInattention predominant (ADHD-IA) (30-40%)Hyperactivity predominant (ADHD-H/I) (10%)Combined type (ADHD-C) (50-60%)

Diagnosis of ADHDScreening questionsHow is your child doing in school this year?Is your child happy to go to school?Have you heard from the teacher(s) regarding any concerns about behavior or performance in school?How does your child do with chores around the house?How does your child do with homework?

Diagnosis of ADHDObjective approachData needs to be collected from more than one sourceParentsTeachersOthers

Diagnosis of ADHDWhat kind of data?Standardized formsConners Rating Scale (CATRS)ACTeRS FormVanderbilt ADHD Diagnostic Rating Scale

Diagnosis ADHD Need to develop a differential diagnosis

Diagnosis of ADHD

Oppositional Defiant DisorderConduct DisorderDepressionAnxietyLearning disabilitySpecial senses disabilitySubstance AbusePervasive Developmental Delay NOS

Oppositional Defiant DisorderA pattern of negativistic, hostile and defiant behavior lasting at least six months, during which four or more of the following are present:Often loses temperOften argues with adultsOften actively defies or refuses to follow adults rulesOften deliberately annoys peopleOften blames others for his/her mistakesOften is touchy / easily annoyed by othersOften is resentfulOften is spiteful / vindictiveThe disturbance in behavior causes significant impairment in social, academic or occupational functioning. The symptoms are not due to a mood disorder or conduct d/o.

Conduct DisorderRepetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate norms or rules of society are violated.Aggression to people or animalsDestruction of propertyDeceitfulness or theftSerious violation of rules

DepressionDepressed moodChange in sleep (S)Loss of interest / pleasure in activities (I)Thoughts of worthlessness or guilt (G)Loss of energy (E)Trouble concentrating (C)Change in appetite or weight (A)Change in psychomotor activity (P)Thoughts of suicide or death (S)

5 of the 9 symptoms present frequently for at least two weeks. One of the 5 symptoms must be depressed mood or loss of interest in usual activities. Symptoms can not be due to substance use of another psychiatric diagnosis.

Learning DisabilitySchoolwork performance issuesReadingWritingMathematics

Special Senses DisabilityVisual disturbanceHearing loss

Substance AbuseHigh index of suspicion in teens

Pervasive Developmental Delay NOSAutistic spectrum, but not meeting autism criteria

When should I refer a child I suspect has ADHD?Age younger than sixCo-existent psychiatric conditionsCo-existent neurologic conditions

Lets go to Vanderbilt

ADHD Management PlanClear communication with parents and teachersPhone callsEmailProgress notesDaily School-Home Report Card

ADHD Management PlanParenting skillsHomework rulesSleep rulesT.V. / Videogame rules

ADHD Management PlanStimulant MedicationsDextroamphetamine / LevoamphetamineAdderallAdderall XRDextramphetamineDexedrineDexedrine SpansuleDextrostatMethyphenidateRitalinRitalin LARitalin SRConcertaMethylinMetadate ERMetadate CDFocalinDaytrana

ADHD Management PlanStimulant MedicationsAdverse effectsAnorexiaWeight lossSleep disturbanceTicsTachycardiaHypertension

ADHD ManagementStimulant MedicationUse the least amount neededUse extended release preparations when possibleGive drug holidays if appropriateReassess regularly as to response

ADHD ManagementStimulant Medications are Schedule 2 drugs30 day supply with written prescriptionRule change 2007 allows up to 90 day supplyThree 30 day scriptsEach dated sequentially for fill dateAtomoxetine is not a restricted medication

ADHD Management PlanNon stimulant medicationAtomoxetine (Strattera)Norepinephrine reuptake inhibitorStarting dose 0.5 mg/kgMaximum dose 1.4 mg/kg or 100 mg /dayADHD scores improve with atomoxetine vs placeboADHD scores are equal to / slightly worse than stimulant medications

ADHD ManagementNon-stimulant MedicationAtomoxetine side effectsAnorexiaWeight lossAbdominal painNausea / VomitingSleep disturbanceSuicidal ideation (0.4% vs 0% placebo)Liver injury (VERY RARE -- 2 cases!)

When else should I refer a child I suspect has ADHD?Failure to respond to a reasonable trial of stimulant / non-stimulant medications and behavior interventions

Conclusions: ADHDPerforming an ADHD evaluation is within the spectrum of practice of a family doctorObserver data is needed from at least two settings in the childs lifeCo-morbid / alternate diagnoses should be ruled outA comprehensive management plan offers the patient the best chance for success in school

ADHD ResourcesCaring for Children with ADHD: A Resource Toolkit for Clinicians, AAP, 2008.

http://www.nichq.org/NICHQ/Topics/ChronicConditions/ADHD/Tools/Individual forms are available here for download

http://www.nichq.org/resources/toolkit A compressed folder of all ADHD forms is available for download.

Additional ReferencesChanges and Challenges: Managing ADHD in a Fast-Paced World, Michael J Manos, et al, Manag Care Pharm. 2007;13(9)(suppl S-b):S2-S13Obtaining Systematic Teacher Reports of Disruptive Behavior Utilizing DM-IV, Mark L. Woraich, et al, Journal of Abnormal Child Psychology, Vol 26(2), 1998: 141-152.

Adult ADHDChildhood ADHD commonly persists:22-85% of adolescents 4-50% of adults

Adult ADHDSymptom complex can differ from childhoodInattention and impulsivity > hyperactivity

Adult ADHDWender (Utah) CriteriaHyperactivity and inattention plus (2) of belowLabile emotionsHot temperInability to complete tasksInability to tolerate stresssImpulsivity

Adult ADHDTreatmentStimulants Response rate decreased versus childhood ADHDAtomoxetineLower cadiovascular risk profileMinimal abuse potential

Management of ADHDStimulant Misuse (22%) / Diversion (11%)Continuously escalating dosageRepeated lost prescriptions / dispensing errorsDemand for immediate release preparationInfrequent user PsychosisPalpatations

70% of children with ADHD will respond to a stimulant medication. If used sequentially looking for response, greater than 80% will respond.*HR increase 3-10 beats/min SBP 3-8 mm Hg DBP 1.5 14 mm Hg*Suicidality risk is excess 0.4% versus placebo. Family needs to watch child for any evidence of this.*