ADHD Update Barbara J. Howard, MD [email protected] .

ADHD Update

Barbara J. Howard, MD [email protected]

www.childhealthcare.org

Disclosures

I have a financial relationship to disclose:

Consultant, Total Child Health, Inc.

producer of CHADIS

Off label medication will be discussed:

psychotropics

Characteristics of AD/HD Prevalence - 3-5% of school- age children Usually identified in the early elementary

school years 4:1 to 9:1 male:female <70% persist into adulthood Often FH+ AD/HD

DSM-IV Criteria for ADHD >= 6 months of 6 of either (1) or (2)

(1) Inattention

inattention to details trouble sustaining attention

doesn’t listen doesn’t finish

trouble organizing avoids sustained tasks

loses supplies easily distracted

forgetful

DSM-IV Criteria for ADHD (2) Hyperactivity

fidgets leaves seat

excess running, climbing trouble playing quietly

on the go talks too much

Impulsivity

blurts out answers trouble waiting turn

interrupts or intrudes

DSM-IV Criteria- 2 Onset with impairment < 7 years old Impairment in >= 2 settings Significant impairment in social, academic, or

occupational functioning Not exclusively part of PDD, schizophrenia, or

psychotic disorder nor better accounted for by another mental disorder

ADD without H and ADHD -Inattentive Type ?Similarity to ADHD “Spacey” Daydreamer Sluggish responses - ?processing issues Excessive confusion Inconsistent memory retrieval Shy/anxious passive Deficits on measures of attention Not impulsive & not oppositional

Codes for Attentional Disorders314.01 AD/HD, Combined Type Meets criteria of both A1 & A2314.00 AD/HD, Predominantly Inattentive Type Meets criteria for A1 but not A2 in last 6mos314.01 AD/HD, Predominantly Hyperactive-

Impulsive Type Meets criteria for A2 but not A1 in last 6 mos 314.9 AD/HD, NOS Prominent symptoms but not to criteria

Newer Conceptual Model: Deficit of INHIBITION related to “Areas of Executive Functioning”

Deficient Self-Regulation Impaired Temporal Organization of

Behavior Impaired Goal-Directed Persistence Diminished Social Effectiveness &

Adaptation

EtiologyNo consensus yet regarding precise

transmitter defect or anatomic localization PET study of hyperactive parents of

hyperactive children showed decreased glucose metabolism in right frontal lobe

MRI studies showing abnormalities in corpus callosum

Neurotransmittors in ADHD Dopamine

Enhances signal Improves attention

Focus Vigilance On-task behavior On-task cognition

Norepinephrine Dampens noise Enhances executive operations Increases Inhibition

Genetics

Pattern of single dominant gene or a single major gene50 - 92% of monozygotic twinsSiblings at 2 to 3 times greater risk

Possible association with dopamine transporter gene (DAT1) and dopamine receptor (DRD4)

Differential Diagnosis- Medical/neurological primary diagnosis Endocrine- hyperthyroidism, generalized resistance to

thyroid hormone Neurological- petit mal, migraine, chorea, lead

poisoning, ?iron deficiency Sensory- mild hearing and/or vision losses Arousal- day time drowsiness associated with obstructive

sleep apnea, lack of sleep Drug induced- drug side effects (e.g. Phenobarbital,

sympathomimetics)

Treatment Implications If it is not a problem of how or what then

teaching what or how is not likely to help Treatments or modifications at the site of

performance are more likely to be effectivemedication, seating arrangement, fm

receivers, touching and redirecting, in class assistance

Immediate consequences for goal-directed and task-oriented behavior

Unproven Therapies Dietary Management Megavitamins Chiropractic Manipulations Ocular Motor Exercises Self control training outside performance

site (e.g., in a clinic) EEG biofeedback

Empirically Proven Treatments Pharmacologic (>300 double blind published

studies)Note- medication alone is usually not

sufficient treatment Parent counseling about ADHD (&ODD) Parent training in child management Teacher counseling and training in ADHD and

classroom management Special Education when indicated Individual counseling as needed Residential Treatment Parent/Family Counseling when indicated

Components of Treatment Education of parent, other caregivers Psychological/behavioral therapies Parent training Support groups Social skills training Psychoeducational interventions Medication Regular follow up

Class Room Adaptations Preferential seating Cueing by teacher before instruction Shorter work periods with frequent breaks Visual and tactile stimuli with verbal

instructions Remediation when necessary FM receivers

Families as Advocates 504 Plans- “other health impaired” with doctor

note Individual Educational Plan for LD

Request complete intelligence and achievement testing Other specific assessments as needed e.g. VMI,

educational assessment, projective testing Don’t sign it unless satisfied

May need an educational advocate at ARD meeting

Especially key at change to KG, middle, high, graduation

Always appeal possible for higher level of service

Multisite Multimodal Treatment Study (MTA) 600 children (age 7 – 9) ADHD combined type 24 month outcomes Groups

Medical management: monthly tailored Behavioral Therapy: 8 week summer; training; in-

class aid, teacher consultation Combined Community standard: 67% meds mostly bid

MTA Results

Medical management or combination therapy had better outcomes than behavioral therapy or community care

Combined therapy was equal to medical for ADHD sx but for subgroups combined may be preferableAnxiety disorders; high levels of socio-

economic and/or family stressors

Medication Choice: Stimulants

MPH and DA are approximately equivalent in efficacy (75%) & side effects Some children respond better to one MPH dose = 0.3 - .5 mg/kg/dose; DA = 0.15-0.25mg/kg/dose

Ritalin SR is less effective and slower onset than short acting. Ritalin LA more reliable

Long acting DA is more likely to cause sleep problems Dexedrine SR- 10-12 hours, greater anorexia, irritability? Adderall- 4-6 hours, Adderall XR 10-12 smoother Pemoline (Cylert) is no available because of liver toxicity-

>death

Medication - Dosing

Short acting lasts 3 1/2 to 4 hours Children benefiting from school dosing usually

can benefit from a 3rd dose Long acting now recommended Consider using a placebo trial

With weekly parent and teacher ratings to establish objectivity

Helps parents carefully sort out their fears from fact Helps establish an optimal dosage early

CHADIS decision support: Parent takes previsit online

questionnaires (behavior, development, health, family factors)

Clinician reviews questionnaire results, can consult linked textbook

Clinician may exchange findings with school or mental health provider online

Clinician finds relevant resources, handouts from links & prints for family

Bill 96110

Graphic display of Vanderbilt

Other stimulants for ADHD

Focalin- d MPH- Short acting; ½ dose; same effectiveness and side effects

Focalin XR (5,10,20)- 10-12 hours, same side effects Methylin liquid 5 or 10/5cc short acting Metadate CD- MPH, 6 hours, can sprinkle Ritalin LA- MPH, 8-10 hours Daytrana or MTS or MethyPatch Vyvanse = Slow release mixed salts of amphetamine Procentra = Liquid Dexedrine 5 mg/5 cc

Methylphenidate Transdermal System or Daytrana or MethyPatch Takes 2 hours for effect, remove at 9 hours, lasts

12 Signif. effective vs placebo Potential for sensitization to methylphenidate due

to topical route MTS vs Concerta: Insomnia 13% vs 8%;

anorexia 26% vs 19% 12.5 cm = 18 mg Concerta 18.75 cm = 27 mg

Concerta 25 cm = 36 mg Concerta 37.5 cm = 54 mg Concerta

Non-stimulants for ADHD Atomoxetine Modafinil Intuniv = guanfacine er Clonicel = long acting clonidine (pending)

Atomoxetine (Strattera) Norepinephrine reuptake inhibitor- not category

II CYP2D6 metabolized, T1/2 5.2 h Signif better than placebo in child & adult Side effects: anorexia 14%, N/V/D 12-15%,

dizziness, fatigue 9%, mood swings 5% Possible inc or dec BP, inc pulse, allergic rash Recent reports liver abnormalities and failure Contraindicated near MAO inhibitors 0.5mg/kg->2.0 q 3 d max 100mg div qd-bid.

Less with paroxetine or fluoxetine

Modafinil or Provigil

Indicated for sleep apnea and narcolepsy 100, 200 mg Dose up to 200 mg q am Onset 2-4 hours, delayed by food 1 hr, T1/2 15

hrs CYP inhibitor. Also interferes with OCPs Transient LFT elevations, palpitations, anorexia,

headache all <2% “Euphoria” risk?

Intuniv FDA approved 6/07

Selective agonist for alpha-2A-receptors in the prefrontal cortex

Nonstimulant Monotherapy Once daily long acting Ages 6 to 17 years 1 mg to 4 mg daily Better than placebo in 2 double blind trials

Other Nonstimulants

Imipramine: 1-4 mg/kg /2-3 doses/day; EKG monitoring

Clonidine: 4-5 microgram/kg/day or Guanfacine (Tenex) long acting; esp for aggression and when sedation HS needed; cvs concerns

Bupropion

Bupropion (Wellbutrin) 1. Antidepressant with stimulant action (beta

noradrenergic receptors and prefrontal lobe)2. Significant effect on ADHD but less effect size

than first line stimulants3. Better than nicotine patch for smoking cessation

("Zyban")4. Dosage: 3-6mg/kg (</=300/day); 75, 100, &

150mgSR5. Side-effects (especially if increase fast):

Decreased seizure threshold (rate = .06%), agitation, insomnia

Stimulants and CV Risk

FDA reports showed:25 patients (19 who were 18 years and younger)

taking stimulants had suddenly died. 54 more patients on these pills had unusual

heartbeats, heart attacks, or strokes. Some had preexisting heart problems, some were taking other pills, including cocaine.

AAP advises continuing current practiceFDA- no black box warningPrudent to avoid use in structural heart disease,

arrythmia, ? if FH sudden cardiac death

Family Cardiac History (Crosson)

Has your child ever experienced any of the following? Unexplained seizures Passing out/fainting during exercise, when startled, or when highly emotional Dizziness during or after exercise Chest pain during or after exercise Racing heart or skipped heartbeats Getting extremely tired or short of breath more quickly than friends do during

exercise High blood pressure or high cholesterol None of these Not sure

Has anyone in the family (including your child) had any of the following serious heart conditions? Please check all that apply.

Hypertrophic or dilated cardiomyopathy Long-QT syndrome, short-QT syndrome, Brugada syndrome, or

another ion channel disorder Other heart rhythm problems that required treatment Marfan syndrome or ruptured aorta Born with heart malformation (e.g. hole in heart, bad valves, etc.) Unexplained fainting or seizures Use of pacemaker or cardiac defibrillator Primary pulmonary hypertension Ventricular tachycardia Heart attack age 50 or younger Disability due to heart problems before age 50 Sudden death due to heart problems before age 50 None of these Not sure

Managing Side Effects Appetite - “4th meal” at bedtime Abdominal pain – disappears in 3 wks; try slow

acting medication; ?bowel urgency; give with food

Headache – disappears in 3 wks; try slow acting, use 7 days/wk

Growth – 1 kg, 1 cm; mostly nutrition related; reversible with drug holidays if needed

Tics - mostly due to comorbidity, may have less tics with stimulants; 0.5% chance of a persistent problem; try lower dose

Irritability- change family of meds, use another dose in pm

Sleep problems in ADHD 85% of children with ADHD have sleep problems

before using meds Sleep debt makes ADHD and comorbid

conditions worse Mostly trouble falling asleep but also restless Consider OSA if snore, bipolar if up for hours in

the middle of the night Start with routine bedtime, back rub, milk, white

noise Meds prn: evening stimulant dose, melatonin 1-8

mg, Clonidine 0.05-0.1 mg., guanfacine up to 1 mg

ADHD Follow-Up Visits- Goals

To watch for and begin early intervention for co-morbid conditions

To monitor self concept of child, perception of parents and progress toward asset building (e.g., involvement in nonschool skill building)

To adjust medication as neededTeacher and parent check lists and work samples

and report card data are usually neededRepeat placebo trials are helpful

To monitor for side effects

Adult Outcomes and Need for Continued Medication

1/3 have “no symptoms” as adults Consider various work demands:

Air traffic controller vs. salespersonAccountant vs. CEO with 3 secretariesPathologist vs. pediatrician

May increase creativity, energy

References:

Barkley, R. A. Attention Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. New York: Guilford Press, 72 Spring St., New York, NY, 1990.

Culbert TP, Banez, GA, Reiff, MI. Children who have Attentional Disorders: Interventions. Pediatrics in Review 15 (1), 5-14. 1994

Diller, L. H., Running on Ritalin, Bantam Books, New York, NY, 1998.

Gorski P (Ed) 2002, Supplement, The Diagnosis and Treatment of ADHD in Early Childhood: Evidence –Based Controversies and Implications of Practice and Policy, J Dev Beh Ped 23(1S)

Greenhill, L. L., Attention-Deficit Hyperactivity Disorder: The Stimulants. In Riddle, MA, (Ed), Pediatric Psychopharmacology I Child and Adolescent Psychiatric Clinics of North America, January. 123. 4:1, Saunders, Phila, PA. 1995

Papolos D and Papolos J: The Bipolar Child. Broadway Books, NY, 1999

Reiff MI, Banez, GA, Culbert TP. Children Who Have Attentional Disorders: Diagnosis and Evaluation. Pediatrics in Review. 14. 455-469. 1993.

Sturner RA, 2005, Attention Deficit Disorder, In The Child Health and Development Interactive System, www.childhealthcare.org

Wolraich, M (Edit.), 1996, The Classification of Child and Adolescent Mental Diagnoses in Primary care. Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version, American Academy of Pediatrics

www.nichq.org for Vanderbilt checklist

Appendix

Pediatric Evaluation of ADHD“Factors and Trigger Questions”

Interviewing the child General information: age, grade, name of school,

name of teacher Subjects, grades, favorite subject/hardest subject

and why Best friend, activities together Family- members, kind of person, activities

together, hardest part about Chores, discipline, allowance, hobbies Family kinetic drawing


Classroom Behavior Parent: What are your concerns about him?

What does/has his teacher say/said about him? (each grade)

Teacher: Ratings (e.g., Conners, DSM) Child: Tell me about the teacher you have -- Is

she nice or did you get one of the mean ones? What does she/he do that seems mean?


Classroom environment

Is the child being compassionately, and competently managed? Or is the teacher overwhelmed and confrontational?

Parent: How many children are in the class?

Child: Where do you sit?


Behavior at home How is his behavior at home? What is the hardest part with him? How bad does it get? Focus on transitions: Tell me what it is like.. getting him

ready for school....bedtime,... turning off TV,... putting his toys away?.

Patience: Is he able to sit through a meal and take turns talking?

Organization: What is his room like?


Sleep Settling: Struggle suggests oppositionism

or anxiety Adequacy: When does he get up on the

weekends? Quality: Screen for sleep apnea

Differentiating ADHD from Typical-1 Severity- impairs daily function“Have you changed family routines?” Duration- Not just transient reaction to stress or

environmental change“What else has been going on recently?” Pervasiveness- outside home, occurs with

people other than pa“How does he do with other people?”

Differentiating ADHD from Typical-2 Comorbidity- Presence of other mental health

problems

Ask about all areas of functioning Family History- of ADD/ADHD Vs. other psych

Genogram Higher scores on scales (not validated)

Use some instrument eg CBCL

Pediatric Evaluation of ADHD-“Performance Sampling”

Review of report card and work samples Do you have any hard work at your school? Sample achievement performance (e.g.

WRAT and standard reading & comprehension paragraph, alphabet, writing sample)

Hypothesis driven performance sampling- e.g. If problem listening: Do a standard 5 part command; writing -VMI; process related tasks from PEEX, etc.

ADHD Update Barbara J. Howard, MD [email protected] .

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