ADHD Evaluation & Treatment Edward J. Coll, M.D. COL, MC Chief, Developmental Pediatrics Walter...

ADHD Evaluation & Treatment

Edward J. Coll, M.D.COL, MCChief, Developmental PediatricsWalter Reed Army Medical Center

Practice Guidelines

• Primary care clinicians

• Children 6-12 years old

• Framework for diagnostic decisionmaking

• Evidence based review

Review and Recommendations

• Strong recommendation: high-quality scientific evidence or strong expert consensus

• Fair/weak: lesser quality, limited data, or expert consensus

• Clinical Options: reasonable provider

Recommendation #1

• If inattention, hyperactivity, impulsivity, academic underachievement, behavior problems

• Primary care clinician needs to initiate the evaluation

• Good evidence Strong recommendation

Screening Questions

• How is __ doing in school?

• Are there any problems with learning that you/teacher see?

• Is your child happy in school?

• Are you concerned…behaviors at home/school/play with friends?

• Is your child having problems completing classwork or homework

Recommendation #2

• ADHD diagnosis must meet DSM-IV criteria

• Symptoms and functional impairment

• Criteria remain subjective and no reliable measures in primary care

• Good evidence Strong recommendation

DSM-IV Criteria

• 6 of 9 symptoms often – Inattentive– Hyperactive/Impulsive– Combined (both)

• causes distress or impairment

• inconsistent with developmental level

DSM-IV Criteria

• starts before 7 years old• lasts over 6 months• two or more situations• not due to:

– Autism, Pervasive Dev Disorder– Mood or Anxiety Disorder– Psychotic Disorder– Dissociative or Personality Disorder

DSM-IV CriteriaInattention

• fails to give close attention to details, makes careless mistakes in schoolwork or other activities

• has difficulty sustaining attention to task or play activities

• does not seem to listen what is said to him/her

DSM-IV CriteriaInattention

• not follows through on instructions; fail to finish schoolwork, chores, duties in workplace (not due to oppositional behavior or failure to understand)

• difficulty organizing tasks/activities

• avoids/dislikes tasks that require sustained mental effort

DSM-IV CriteriaInattention

• loses things necessary for tasks or activities (school assignments, pencils, books, tools, toys)

• easily distracted by extraneous stimuli

• forgetful in daily activities

DSM-IV CriteriaHyperactivity/Impulsivity

• often fidgets with hands/feet or squirms in seat

• leaves seat in classroom or in other situations in which remaining seated is expected

• runs about or climbs excessively where inappropriate (teens or adults may be limited to subjective feelings of restlessness

DSM-IV CriteriaHyperactivity/Impulsivity

• difficulty playing or engaging in leisure activities quietly

• talks excessively

• acts as if “driven by a motor” and cannot remain still

DSM-IV CriteriaHyperactivity/Impulsivity

• blurts out answers before questions completed

• difficulty waiting in lines or for turn in games or group situations

• interrupts or intrudes on others

Dr. Barkley’s ADHD Graph *

Level of Interest

Work

X

“Normal”

ADHD

Recommendation #3

• Evidence of core symptoms from parents and caregivers

• various settings

• age onset; duration of symptoms

• degree of functional impairment

• Good evidence Strong recommendation

Recommendation #3A

• Rating scales are an option– Questions subjective and subject to bias– ? If additional benefit

• Strong evidence; strong recommendation

Recommendation #3B

• Broad-band scales/questionnaires not recommended

• May be useful for other purposes

• Strong evidence Strong recommendation

Recommendation #4

• School evidence required

• Core symptoms, duration• Functional impairment• Coexisting conditions

• Good evidence Strong recommendation

Recommendation #4A

• Rating scales a clinical option

• sensitivity/specificity >94%

• ? If any added benefit

• Strong evidence Strong recommendation

Recommendation #4B

• Global scales not recommended• May be useful for other purposes

• Frequent discrepancies

• Can use other informants

• Strong evidence Strong recommendation

Recommendation #5

• Assess for coexisting conditions– ODD 35 %– Conduct Disorder 26%– Anxiety Disorder 26 %– Depressive Disorder 18%

• Strong evidence Strong recommendation

Recommendation #6

• Other diagnostic tests not routinely indicated– Pb; resistance to thyroid hormone– Brain imaging; EEG– Continuous performance testing

• sensitivity/specificity <70%

• Strong evidence Strong recommendation

Diagnosis Guidelines Conclusions

• Use explicit DSM-IV criteria

• Symptoms in >1 setting

• Search for coexisting conditions

Objectives of the Literature Review

• Effectiveness (short and long-term) and safety of therapies

• Medication and non-medication therapies

• Single therapy vs combination

• 6-12 year olds

Sources for Review

• Agency for Healthcare Research & Quality– McMaster Univ. Evidence-based Practice Center

• Canadian Office for Health Technology Assessment Study (CCOHTA)

• Multimodal Treatment Study (MTA Study)

• Pelham et al. review of psychosocial therapies

Recommendation 1:Management Program

• Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition

• Strong evidence

• Strong recommendation

Recommendation 1:Management Program

• Prevalence 4-12% of school-age children

• 60-80% persist into adolescence

• Inform, educate, counsel, demystify– family, child

• Resources– local, national (CHADD, ADDA)

Recommendation 1:Management Program

• What distinguishes this condition from most other conditions managed by primary care clinicians is the important role that the educational system plays in the treatment and monitoring of children with ADHD.

Recommendation 2:Target Outcomes by Team

• The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management.

• Strong evidence

• Strong recommendation

Recommendation 2:Outcomes- maximize function• Relationships

– parents, siblings, peers

• Disruptive behaviors• Academic performance

– work volume, efficiency, completion, accuracy

• Individual– self-care, self-esteem

• Safety in the community

Recommendation 2:developing target outcomes

• Input– parents, children (patient), teachers

• 3-6 key targets

• realistic, attainable, measurable

• methods will change over time

School InterventionsIndividual Education Plan 504 Plan

• IDEA = Individuals with Disabilities Education Act

• ADHD under “Other Health Impaired”

• Educational Disability

• Services

• Section 504 of the Rehabilitation Act

• ADHD medical diagnosis

• Medical Disability with educational impact

• Accommodations

Recommendation 3:make some recommendations

• The clinician should recommend stimulant medication and/or behavior therapy as appropriate, to improve target outcomes in children with ADHD

• Strong evidence (medication), Fair evidence (behavior therapy)

• Strong recommendation

Recommendation 3:Efficacy of Stimulants

• Short-term benefits well established

• Core symptoms: attention, hyperactivity, and impulsivity

• observable social and classroom behaviors

• IQ and achievement testing- less effect

Recommendation 3:MTA Study

• Effects over 14 months

• 579 children 7-9.9 years old

• 4 randomized groups– medication alone– medication and behavior management– behavior management– standard community care

Recommendation 3:MTA Study

• Medication management alone

• == Medication + behavior therapy*

• > Community management

• > Behavior management alone

The StimulantsNobody does it better

• Short, intermediate (the “old” long-lasting), truly long acting

• 22 studies show NO difference between methylphenidate, dextroamphetamine, or mixed amphetamine salts (Adderal)

• Individual’s response may vary

• NO serologic, hematologic, EKG needed

Non-stimulantsSecond rate-only 2

• Tricyclic antidepressants– 9 studies alone– 4 studies =/< methylphenidate

• Bupropion (Wellbutrin, Zyban)

• Clonidine – limited studies– > placebo

StimulantsDose determination

• NOT weight dependent

• Optimal effects with minimal side effects– nothing ventured, nothing gained

• Match target outcomes and timing– crucial step prior to starting

StimulantsSide effects

• appetite suppression

• stomachache, headache

• delayed sleep onset

• jitteriness

• overfocused, dull demeanor

• mood disturbances

StimulantsSide effects- NOT

• seizures- NO increased frequency with mph

• growth delay- at least one negative study

• Tourette syndrome– 15-20% of patients have motor tics– 50% of TS have ADHD– 7 studies comparing stimulants vs placebo/other

show NO increase in tics with stimulants

Short Intermediate Extended

MethylphenidateRitalinFocalin

Ritalin 20 SRMetadate ER

ConcertaMetadate CDRitalin LA

DextroamphetamineDexedrineDextrostat

Dexedrinespansule

Adderal Adderal XR

3-4 hours 5-6 hours 8-10 (12)hours

Atomoxetine Strattera

• Selective norepinephrine uptake inhibitor

• Little effect on dopamine or serotonin uptake

• Little effect on Ach, H1, alpha-2, DA receptors

• Well-tolerated in adult and pediatric studies

Atomoxetine...Randomized, Placebo-Controlled, Dose-

Response...• 297 children and adolescents

• 8-18 years old; 71 % male

• 70% had prior stimulant therapy

• Combined/Inattentive/Hyper-impulsive

• 63/33/2 %

• 37 % Oppositional-defiant disorder

• 1 depression, 1 anxiety disorderAtomoxetine…AD/HD…Study. Pediatrics 108:e83, 2001

Side Effects

• Small samples:– dizziness 9% vs 1% placebo– vomiting 6% vs 7%

• Weight loss dose dependent– mean 0.4kg at 1.2 mg/kg/d

• small pulse, BP changes• no EKG changes• <5% dropout rate atmx and placebo

Atomoxetine…AD/HD…Study. Pediatrics 108:e83, 2001

Efficacy of Atomoxetine vs Placebo in School-Age Girls with

AD/HD• 52 children and adolescents

• 7-13 years old

• Combined/Inattentive/Hyper-impulsive

• 79/21/0 %

• 38.5 % Oppositional-defiant disorder

• 13.5% phobias

Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002

Measures

• ADHD Rating Scale- Parent

• Conners’ Parent RS-Revised

• No Teacher ratings

• Clinical Global Impressions of ADHD Severity- Clinician

Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002

Side Effects

• Small sample size subset here (279 total); so no significant differences

• Vomiting 19% vs 0%

• Abdominal pain 29% vs 14%

• Nausea 6.5% vs 14%

• ?Weight, cardiac...

• Increased cough 16% vs 4.8%

Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002

Atomoxetine and Methylphenidate... Prospective

Randomized, Open-Label Trial• 228 children and adolescents

• 184 atomoxetine, 44 mph; 10 weeks

• 7-15 year old boys; 7-9 year old girls

• Most/all had prior stimulant therapy

• Combined/Inattentive/Hyper-impulsive

• 76/23/1 %

• 53% ODD, 7% major depression Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

Measures

• ADHD Rating Scale- Parent Completed

• ADHD Rating Scale- Parent Interview

• Conners’ Parent RS-Revised

• No Teacher ratings

• Clinical Global Impressions of ADHD Severity- Clinician

Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

Findings

• Comparable improvement between the two

• mean dose 1.4 mg/kg/d extensive mtb, 0.5mg/kg/d slow mtb

• mph 0.85 mg/kg/d, (31mg/d)

• High rate of dropouts

Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

Findings

• 43% of mph, 36 % atmx dropped out!

• 11%; 5 % because of adverse effects comparable

• atomoxetine wt loss avg 0.6 kg; (mph 0.1)

• small changes both in pulse, BP

• EKG, labs no problems, no differences

Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

Side Effects

• Generally comparable

• Vomiting 12% vs 0%

• Abdominal pain 23% vs 17.5% (NS)

• Nausea 10% vs 5% (NS)

• ?Weight, cardiac...

• Cough 5% same

• “Thinking abnormal” 0% vs 5% (N=2) Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

Pros and Cons

• No abuse potential– adolescent usage

– adult usage

• 24/7 coverage• (No tic relationship)• Novel class of med

– use with stimulants, too

• Little data head to head vs stimulants

• Weight loss/vomiting• Takes week(s) to effects• Tolerance

– “starter kit” issue

– adjust if SSRI added

• Cost $3 vs 1/2 that

Modafinil

• ProVigil in ProAthletes

Modafinil (ProVigil)• A non-stimulant stimulant• Narcolepsy, daytime drowsiness in...• Mechanism ?

– Alter balance of GABA and glutamate which activates the hypothalamus

– Increases metabolic rate of amygdala and hippocampus

– activates hypocretin(orexin)-containing neurons, (which are disrupted in narcolepsy)

Modafinil in AD/HDOpen-label study

• Once daily dosing

• Start 100 mg titrated to maximum 400 mg

• Length of time avg 4.6 weeks (range 2-7 wks)

J of Am Acad of Child and Adol Psychiatry 2001; 40:230-235

Modafinil in AD/HDOpen-label study

• 11 5-15 years old, M:F = 9:6 started

• Combined/inattentive/hyper-impulsive

• 12/2/1 started – 2 noncompliant with protocol– 1 hand-foot-mouth disease– 1 adverse rxn: episodic hand tremor + MS change

• very mixed bag of comorbidities: PDD, TS...

J of Am Acad of Child and Adol Psychiatry 2001; 40:230-235

Modafinil in AD/HDOpen-label study

• AD/HD measures– Conners’ Parent and Teacher– ADHD Rating Scale IV for Parent and Teacher– Test of Variables of Attention (TOVA)

• Side effects

• Vital signs, weight

J of Am Acad of Child and Adol Psychiatry 2001; 40:230-235

Modafinil in AD/HDOpen-label study

• AM dose effect into afternoon

• Improved Conners’ and ADHD Rating Scales

• Improved TOVA impulsivity scores– but not inattention scores

• Delayed sleep (3), stomachache, headache, lightheadedness, tremors, finger-biting (1)

J of Am Acad of Child and Adol Psychiatry 2001; 40:230-235

Modafinil BE AWAKE all you can be!

• WRAIR

• 3 doses of modafinil vs 600 mg caffeine

• Performance testing in sleep deprivation

• Enhances performance and alertness

• No advantages over caffeine

Psychopharmacology (Berl) 2002 Jan;159(3):238-47

Modafinil BE AWAKE all you can be!

• Aeromedical Research Lab., Ft. Rucker, AL

• Aviator alertness and performance

• 6 pilots, 40 hour wakeful periods compared

• Placebo vs 3 x 200 mg modafinil

• 4/6 performance measures improved, reduced slow wave EEG, better mood, alertness

• side effects: vertigo, nausea, dizziness

Psychopharmacology (Berl) 2000 Jun;150(3):272-82

Behavior Therapyaccept no substitutes

• Behavior therapy

• Emotions-based therapy – e.g. play therapy-NOT efficacious in ADHD

• Thought patterns directed– cognitive, cognitive-behavioral therapy– NOT efficacious in ADHD

Behavior TherapyParent Training

• 8-12 weeks with trained therapist

• teaches parent skills

• incorporates maintenance and relapses

• improves child’s functioning and behavior

• not necessarily achieves normal behavior

Behavior Therapy Examples of Techniques

• Positive reinforcement– reward for performance

• Time-out– removing positive reinforcement

• Response cost– losing advance rewards

• Token economy– combination

Behavior Therapy Meta-analyses difficult and few

• Must be maintained to be effective• Stimulant effects much > behavioral therapy

– MTA study: combination > med alone, but not a statistically significant difference

– However, parents and teachers more satisfied

• Schools can implement– 504 Plan– IEP

Recommendation 4:When to re-evaluate

• When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions

• Weak evidence

• Strong recommendation

Recommendation 4:Ddx in re-evaluation

• unrealistic target symptoms

• poor information regarding child’s behavior

• incorrect diagnosis and/or

• coexisting condition interfering– ODD, conduct disorder, mood, anxiety, LD

• poor adherence/compliance

• treatment failure

Recommendation 4:Steps in re-evaluation

• Re-establish target symptoms– “team” communication

• Gather further information, other sources

• Consider consultation

• Consider psycho-educational testing

Recommendation 4:True treatment failure

• Lack of response to 2-3 stimulants– maximum dose without side effects– any dose with intolerable side effects

• Inability to control child’s behavior

• Interference of coexisting condition

• Engage vs refer to mental health

Recommendation 5:follow-up guidelines

• The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child.

• Fair evidence

• Strong recommendation

Recommendation 5:follow-up guidelines

• Team management plan– not just : “What does the doctor recommend?”

• Recording clinical data– flow sheet, progress note

• Interview, T-Con, teacher reports, report cards, checklists

Recommendation 5:frequency of follow-up

• NO controlled trials document the appropriate frequency

• MTA study: more frequent did better, BUT

• Once stable, visit every 3-6 months

Conclusion nuggets

• ADHD as a chronic condition

• Explicit negotiations re target outcomes

• Stimulant and behavior therapy use

• Close – treatment outcomes– failures