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ADHD: ChildGail A. Mattox, MD,FAACAPMorehouse Schoolof Medicine
Russell E. Scheffer, MDUniversity of KansasSchool of Medicine-Wichita
LearningObjectiveImplement assessmenttools for accuratediagnosis and developan evidence-basedtreatment strategy tooptimize themanagement of ADHDin children andadolescents
RecognizingADHD in Childrenand AdolescentsGail A. Mattox, MD,FAACAPMorehouse Schoolof Medicine
Gail A. Mattox, MD, FAACAPDisclosures
Research/Grants: None
Speakers Bureau: None
Consultant: None
Stockholder: None
Other Financial Interest: None
Advisory Board: None
LearningObjectiveRecognize the importanceof early identification ofsymptoms for improveddiagnosis and treatment ofchildren and adolescentswith ADHD
ADHDA Common Disorder
ADHD
One of the most common psychiatricdisorders of childhood
A neurobiological disorder Results in significant impairment Most will continue to meet criteria during
adolescence Frequently associated with comorbid
disorders
http://www.cdc.gov/ncbddd/adhd/data.html. Accessed July 8, 2009.
Prevalence and Impact
Common disorder, long-lasting 5–10% of children in United States 2.5x more frequently reported in males Disparities in access and treatment Cost of illness $36–52 billion More likely to have major injuries Greater risk for accidents
http://www.cdc.gov/ncbddd/adhd/data.html. Accessed July 8, 2009.
Core Symptoms
Inattention
Impulsivity
Hyperactivity
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
ADHD Types
ADHD Combined Type
ADHD Predominantly Inattentive Type
ADHD PredominantlyHyperactive/Impulsive Type
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
ADHD Core Symptoms
Difficulty sustaining attention Does not seem to listen Makes careless mistakes Difficulty organizing tasks Easily distracted Often forgetful Often loses things Often does not follow through
Difficulty playing quietly Fidgets, squirms Leaves seat Runs about Often “on the go” Often talks excessively Blurts out Often interrupts Can’t wait turn
Greenhill L. J Clin Psychiatry 1998;5(suppl 7):31-41.
ADHD Presentation DuringAdolescence
Risky, impulsive behavior– Driving, drugs/alcohol, sex, risk-taking
Gives up easily Difficulty organizing tasks, poor time management, and
easily distracted– Email, IM/texting, jobs, sports
Interrupts Fooling around behavior Annoys others Often in trouble, difficulty with authority
ADHD Diagnostic CriteriaDSM-IV-TR
Usually appears earlybetween 3–6 musthave impairmentbefore age 7
Impairment in two ormore settings
Clinically significantimpairment x 6 mos
Must exclude otherdisorders
6 or more symptoms ofinattention or
6 or more symptoms ofhyperactivity orimpulsivity
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
http://www.cdc.gov/ncbddd/adhd/data.html. Accessed July 8, 2009.
State-Based Prevalence ofADHD Diagnosis
Correlates of ADHD
Low self-esteem
Impaired peer relationships
Lower academic achievement
School failure
Family difficulties
Parent InterviewADHD symptoms
ImpairmentComorbidity
Academic functionFamily historyMedical and
developmental history
Behavior RatingScalesParent
Teacher
Child InterviewADHD symptoms?
InconsistenciesMental status exam
NeuropsychologicalTesting
Academic impairmentLearning disabilitiesExecutive function
optional
Laboratory/Neurological TestingOnly if strong evidence in
medical history
Pliszka S, et al. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
ADHD Assessment
AACAP Practice GuidelinesRecommendations
Unremarkable medical history laboratoryand neurological testing is not indicated
Psychological and neuropsychological arenot mandatory
Neuroimaging a research tool
Pliszka S, et al. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
Behavior Rating Scales forADHD Recommended
AcademicPerformance RatingScale
ADHD Rating ScaleIV
Child BehaviorChecklist
Conners ParentRating Scale
Conners TeacherRating Scale
Conners WellsAdolescent SelfReport Scale
Vanderbilt ADHDDiagnostic Parentand Teacher Scales
Resources for Rating Scales
National Resource Center on ADHDwww.help4adhd.org
American Academy of Pediatricswww.aap.org
American Academy of Child and Adolescent Psychiatrywww.aacap.org
Bright Futureswww.brightfutures.orgwww.brightfutures.org/mentalhealth/pdf/professionals/bridges/adhd.pdf
www.adhd.net
ADHD and Comorbidity
Look for comorbidities in patients withADHD
Offer appropriate treatment options for bothADHD and comorbidities
MTA Cooperative Group. Arch Gen Psychiatry 1999;56:1073-1086.
Affective DisorderAnxietyDisorders
Disruptive BehaviorDisordersODD, CD
Mania/Hypomania
ADHD33.5%
2.2%ODD, 39.9%
CD, 14.3%
22%
Common ComorbiditiesPrevalence with ADHD
Summary
ADHD is a common childhood disorder withnegative impact on multiple areas offunction
High prevalence of continuation of disorderinto adolescence with varying presentations
Assessment and diagnosis requires multi-pronged approach
Psychiatric comorbidities prevalent
Intervention StrategiesAre Effective
TreatmentStrategies forChildhood ADHDRussell E. Scheffer, MDUniversity of KansasSchool of Medicine-Wichita
Russell E. Scheffer, MDDisclosures
Research/Grants: Wyeth Pharmaceuticals
Speakers Bureau: None
Consultant: AstraZeneca Pharmaceuticals LP
Stockholder: None
Other Financial Interest: None
Advisory Board: None
LearningObjectiveCompare and contrastthe current treatmentoptions for ADHD anddevelop individualizedmanagementstrategies for eachpatient
Treatment Overview
Why Treat It? Myths and Legends Mechanisms of Action Drug Delivery System Treatment Choices Optimizing Treatment—Sculpting Side Effects Concurrent Conditions
ADHD: Impact of Untreated &Under-Treated ADHD
Patient
Society Substance use disorders:
2x risk8
Earlier onset8
Less likely to quit smokingin adulthood9
Health Care System50% ↑ in bike accidents1
33% ↑ in ER visits2
2-4x moremotor vehicle crashes3-5
School & Occupation
46% expelled6
35% drop out6Lower occupational
status7
Employer↑ parental
absenteeism13
and ↓ productivity13
Family3-5x ↑ parental divorce
or separation10,11 2-4x ↑ sibling fights12
See supplemental bibliography for a complete list of references.
Concerns About Drug Abuse
Stimulants are Schedule II and should be takenseriously and monitored closely
You do not get sued less because you did not see thepatient
Addictive potential is based upon rapid onset(absorption) and euphoric effects
Diversion—mostly for amateurs and college students Tactics to change schedule
– Prodrug– Getting rid of the L isomer (early peak onset)
Odds Ratio = 6.3; p < .001Biederman J, et al. Pediatrics 1999;104:e20.
Substance Abuse in ADHDYouth Growing UpOverall Rate of Substance Abuse
(n = 19) (n = 56) (n = 137)
Presynaptic vesicle+ release
NE Reuptake
DA Reuptake
Synaptic Actions of ADHDMedications
Blocks reuptake of DA Blocks reuptake ofDA and NE
Increases recirculatingpools
Blocks NE reuptake Some DA reuptake
MethylphenidateD-AmphetamineAtomoxetine
Drug Delivery SystemsIt’s Really What Differentiates the Meds
Immediate-release
Sustained-release– Beads (bid dosing in one capsule)– OROS (ascending profile—sipping studies)
Methylphenidate transdermal patches
Prodrug lisdexamfetamine dimesylateeffective 13 hours post-dose
-1
0
1
2
3
Effe
ct S
ize
Non-Stimulant Immediate-ReleaseStimulants
Long-ActingStimulants
Represents the meaneffect size for each classof medication
p < .05 for stimulants vs. non-stimulantsFaraone SV, et al. Medscape General Medicine 2006;8:4. Available at:www.medscape.com/viewarticle/543952.
Effect Sizes for FDA-ApprovedADHD Medications
Recommended Medicationsfor ADHD
110-30Daytrana2-32.5-102.5-5Focalin‡
120-4020Ritalin LA
110-2010Metadate ER, MetadateCD, Methylin ER
127-5418-27ConcertaMarked anxiety,tension, agitation,glaucoma, use ofmonoamine oxidaseinhibitors, seizures,tics
Appetite suppression,stomachaches,headaches, irritability,weight loss, decelerationin rate of growth,exacerbation of psychosis,exacerbation of tics, mildincrease in blood pressureand pulse
2-310-205-10Ritalin, MethylinMethylphenidate†
mg
ContraindicationsSide EffectsDosesper Day
UsualDose
InitialDoseMedication*
* For each category the generic drug is given and dosing information for each named marketed drug.† The manufacturer states that seizures and tic disorder are contraindications; research supports the use
of stimulants in children with seizures that have stabilized with the use of anticonvulsants and in childrenwith tic disorder or Tourette’s disorder. With use of long-acting methylphenidate or dextroamphetamineproduct, a short-acting product may be added at 4 p.m. to 6 p.m. for homework or special activities;appetite and sleep onset are then carefully monitored.
‡ Focalin is a dextro isomer of methylphenidate that is given at a lower level.
Recommended Medicationsfor ADHD
110-305-10Addreall XR
1-25-305-10Adderall
1-25-155-10Dexedrine Spansule
Cardiovasculardisease,hypertension,hyperthyroidism,glaucoma, drugdependence, use ofmonoamine oxidaseinhibitors
Appetite suppression,stomachaches,headaches, irritability,weight loss, possiblegrowth inhibition,exacerbation of psychosis,exacerbation of tics, mildincrease in blood pressureand pulse
2-35-205Dexedrine
Dextroamphetamine (sulfate alone and in combination with amphetamine salts)†
mg
ContraindicationsSide EffectsDosesper Day
UsualDose
InitialDoseMedication*
* For each category the generic drug is given and dosing information for each namedmarketed drug.
† The manufacturer states that seizures and tic disorder are contraindications; researchsupports the use of stimulants in children with seizures that have stabilized with the use ofanticonvulsants and in children with tic disorder or Tourette’s disorder. With use of long-acting methylphenidate or dextroamphetamine product, a short-acting product may beadded at 4 p.m. to 6 p.m. for homework or special activities; appetite and sleep onset arethen carefully monitored.
Recommended Medicationsfor ADHD
Advancedarteriosclerosis,symptomaticcardiovasculardisease, moderate toserve hypertension,hyperthyroidism,knownhypersensitivity oridiosyncratic reactionto sympathomimeticamines, glaucoma,history of drugabuse, use ofmonoamine oxidaseinhibitors
Vomiting, nausea, drymouth, upper abdominalpain, pyrexia, Insomnia,irritability, appetitesuppression, irritability,weight loss, possiblegrowth inhibition,exacerbation of psychosis,dizziness, somnolence,exacerbation of tics, mildincrease in blood pressureand pulse
130-7030Vyvanse
Lisdexamfetamine dimesylate (LDX)mg
ContraindicationsSide EffectsDosesper Day
UsualDose
InitialDoseMedication*
• For each category the generic drug is given and dosing information for each namedmarketed drug.
www.fda.gov
Recommended Medicationsfor ADHD
1150-300150Wellbutrin XL
Seizures, bulimia, anorexianervosa, abruptdiscontinuation of alcoholor benzodiazepines, use ofmonoamine oxidaseinhibitors or otherbupropion products (e.g.,Zyban)
Weight loss, insomnia,agitation, anxiety, drymouth, seizures, others1-2150100-150Wellbutrin SR
Bupropion∫
Jaundice or other clinical orlaboratory evidence of liverinjury, use of monoamineoxidase inhibitors, narrow-angle glaucoma
Appetite suppression,nausea, vomiting,fatigue, weight loss,deceleration in rate ofgrowth, mild increase inblood pressure and pulse
118-6010-25Strattera
Atomoxetineƒ
mg
ContraindicationsSide EffectsDosesper Day
UsualDose
InitialDoseMedication
* For each category the generic drug is given and dosing information for each named marketed drug.ƒ Younger children may need two doses a day.∫ Bupropion has not been approved by the FDA for pediatric use. Only sustained release (twice daily) or extended release
(once daily) are recommended for adolescents. There is a higher incidence of side effects with the immediate-releasepreparation.
Percent “Normalized” at 14-MonthEndpoint Across the Four MTA Groups
The classroom controls were drawn from the same classroom cohorts as MTA children wereoriginally, and were age- and gender-matched to assure comparability with MTA subjects. The“normalization” indicator was based on a composite of parent and teacher ratings, with the overallsymptom cutoff required to be indicative of “little or no” symptoms).Swanson JM, et al. J Am Acad Child Adolesc Psychiatry 2001;40:168-179.
88%
68%56%
34%25%
NS
NS
SculptingOptimizing Treatments
Goals: Good coverage throughout the day(or when needed)
Avoid or fill excessive troughs How do you know if this is the best they can be?
Switches can improve or worsen MPH vs. dAMPH Optimal dosing—frequently we stop when they
are better with little idea of what they could be Other treatments
Sculpting Solutions
Problem Solution 1 Solution 2
Lack of early morningefficacy
Add an IR dose to theXR Possibly atomoxetine
Can not get readyin the a.m.
Take meds 1 hourbefore desired wake
up time
Take an IR doseupon awakening
Does not last long enough Add an IR dose later Add a second XR doseor atomoxetine
Trouble settling for bed Clonidine orguanfacine HS dose of IR stimulant
Wakes up late onweekends Consider a patch Use IR instead
Side Effects
GI distress
Vomiting
Nausea
Dry mouth
Irritability
Tics
Insomnia
Affective lability
Decreased appetite(anorexia)
Increased pulse
Increased bloodpressure
Wear Off and Rebound
Stimulants are “out” of the blood streamevery day
Irritability and moodiness can occur as themeds are wearing off
Poor “settling” for bed is frequently acharacteristic of patients with ADHD evenbefore treatment—it becomes a focus wheneverything else is better
Alpha2 adrenergic agonists can improve this
Non-Stimulants
Atomoxetine
Alpha2 adrenergic agonists
Bupropion
Tricyclic antidepressant
ADHD Comorbidity
Conduct disorder
Oppositional defiantdisorder
Tic disorders
Sleep problems:Failure to settle—accelerate atbedtime
Depression
Anxiety disorders
Bipolar disorder
Tourette’s disorder
Learning disorders
Behavioral interventions should be considered at each step for disruptive behavior disorders.
Treatment of ConcurrentConditions
Condition Solution 1 Solution 2
Aggression Alpha2 adrenergic agonist Antipsychotic or moodstabilizer
Anxiety disorder Start low and go slow withstimulant
Treat the anxiety disorder oratomoxetine
Depression Treat ADHD first,if still present SSRI Consider bupropion
Tic disorder Lower dose Alpha2 adrenergic agonist
Bipolar disorder Treat BPD first Consider over stabilization
Learning disorder Treat ADHD Refer to learning specialist
Conduct/ODD Treat ADHD Consider Alpha2 agonist,antipsychotic later
1. Loe IM, Feldman HM. Ambul Pediatr 2007:82-90.2. MTA Cooperative Group. Arch Gen Psychiatry 1999;56:1073-1086.3. Jensen PS, et al. J Am Acad Child Adolesc Psychiatry 2007;46:989-1002.
Why Consider Non-PharmacologicalTreatment for ADHD?
Medication does not ameliorate existing skillsdeficits1
– Deficits in prosocial skills remain– Academic achievement does not improve
Some children only partial responders2
Poor maintenance effects after withdrawal ofmedication3
No appreciable impact on long-term outcome3
1. Conners CK, et al. J Am Acad Child Adolesc Psychiatry 2001;40:159-167.2. MTA Cooperative Group. Arch Gen Psychiatry 1999;56:1073-1086.3. Vitielo B, et al. J Am Acad Child Adolesc Psychiatry 2001;40:188-196.
Why Consider Non-PharmacologicalTreatment for ADHD?
Patient preferences and satisfaction Some individuals unable to tolerate side effects of
medications Added benefits of combining pharmacologic and
psychosocial treatments1,2,3
– May improve broader outcomes– May be necessary for some individuals to achieve
significant improvement– May lower the acute and lifetime dosages of medication
Summary
Individualize treatment strategies for eachpatient based on safety, efficacy, andtolerability of treatment options
Drug delivery systems matter Sculpting is an important option for
optimizing treatment Consider comorbid psychiatric disorders
in management strategy
an educational series offered byCME Outfitters, LLC
This CME/CE activity isco-sponsored by
Recognizing ADHD in Children and Adolescents Gail A. Mattox, MD, FAACAP
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
Greenhill LL. Diagnosing attention-deficit/hyperactivity disorder in children. J Clin Psychiatry 1998;59(Suppl 7):31-41.
http://www.cdc.gov/ncbddd/adhd/data.html. Accessed July 8, 2009.
MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group multimodal treatment study of children with ADHD. Arch Gen Psychiatry 1999;56:1073-1086.
Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
Treatment Strategies for Childhood ADHD Russell E. Scheffer, MD Barkley R, Fischer M, Edelbrock C, et al. The adolescent outcome of hyperactive children diagnosed by research criteria--III. Mother-child interactions, family conflicts and maternal psychopathology. J Child Psychol Psychiatry 1991;32:233-255.
Barkley R, Guevremont DC, Anastopoulos AD, et al. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Pediatrics 1993;92:212-218.
Barkley R, Murphy KR, Kwasnik D. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics 1996;98:1089-1095.
Biederman J, Wilens T, Mick E, et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104:e20.
Brown RT, Pacin JN. Perceived family functioning, marital status, and depression in parents of boys with attention deficit disorder. J Learn Disabil 1989;22:581-587.
Conners CK, Epstein JN, March JS, et al. Multimodal treatment of ADHD in the MTA: an alternative outcome analysis. J Am Acad Child Adolesc Psychiatry 2001;40:159-167.
DiScala C, Lescohier I, Barthel M, Li G. Injuries to children with attention deficit hyperactivity disorder. Pediatrics 1998;102:14,15-21.
Faraone SV, Biederman J, Spencer TJ, Aleardi M. Comparing the efficacy of medications for ADHD using meta-analysis. MedGenMed 2006;8:4.
Fischer M, Barkley R, Edelbrock CS, et al. The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status. J Consult Clin Psychol 1990;58:580-588.
Jensen PS, Arnold LE, Swanson JM, et al. 3-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry 2007;46:989-1002.
Leibson CL, Barbaresi WJ, Ransom J, et al. Emergency department use and costs for youth with attention-deficit/hyperactivity disorder: associations with stimulant treatment. Ambul Pediatr. 2006;6:45-53.
Loe IM, Feldman HM. Academic and educational outcomes of children with ADHD. Ambul Pediatr 2007;7(Suppl 1):82-90.
Mannuzza S, Klein RG, Bessler A, et al. Educational and occupational outcome of hyperactive boys grown up. J Am Acad Child Adolesc Psychiatry 1997;36:1222-1227.
Mash EJ, Johnston C. Parental perceptions of child behavior problems, parenting self-esteem, and mothers' reported stress in younger and older hyperactive and normal children. J Consult Clin Psychol 1983;51:86-99.
MTA Cooperative Group. Multimodal treatment study of children with ADHD. Arch Gen Psychiatry 1999;56:1073-1086.
Noe L, Hankin CS. Health outcomes of childhood attention-deficit/hyperactivity disorder (ADHD): health care use and work status of caregivers. Value in Health 2001;4:142-143.
NHTSA. Available at: http://www.nhtsa.dot.gov/.
Pomerleau OF, Downey KK, Stelson FW, et al. Cigarette smoking in adult patients diagnosed with attention deficit hyperactivity disorder. J Subst Abuse 1995;7:373-378.
Swanson JM, Kraemer HC, Hinshaw SP, et al. Clinical relevance of the primary findings of the MTA: success rates based on severity of ADH and ODD symptoms at the end of treatment. J Am Acad Child Adolesc Psychiatry 2001;40:168-179.
Vitiello B, Severe JB, Greenhill LL, et al. Methylphenidate dosage for children with ADHD over time under controlled conditions: lessons from the MTA. J Am Acad Child Adolesc Psychiatry 2001;40:188-196.
Wilens T, Biederman J, Mick E, et al. Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders. J Nerv Ment Dis 1997;185:475-482.
Supplemental Bibliography for: Treatment Strategies for Childhood ADHD Russell E. Scheffer, MD Slide Title: ADHD: Impact of Untreated & Under-Treated ADHD 1. DiScala C, Lescohier I, Barthel M, Li G. Injuries to children with attention deficit hyperactivity disorder. Pediatrics 1998;102:14,15-21.
2. Leibson CL, Barbaresi WJ, Ransom J, et al. Emergency department use and costs for youth with attention-deficit/hyperactivity disorder: associations with stimulant treatment. Ambul Pediatr 2006;6:45-53.
3. NHTSA. Available at: http://www.nhtsa.dot.gov/.
4. Barkley R, Guevremont DC, Anastopoulos AD, et al. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Pediatrics 1993;92:212-218.
5. Barkely R, Murphy KR, Kwasnik D. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics 1996;98:1089-1095.
6. Fischer M, Barkley R, Edelbrock CS, et al. The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status. J Consult Clin Psychol 1990;58:580-588.
7. Mannuzza S, Klein RG, Bessler A, et al. Educational and occupational outcome of hyperactive boys grown up. J Am Acad Child Adolesc Psychiatry 1997;36:1222-1227.
8. Wilens T, Biederman J, Mick E, et al. Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders. J Nerv Ment Dis 1997;185:475-482.
9. Pomerleau OF, Downey KK, Stelson FW, et al. Cigarette smoking in adult patients diagnosed with attention deficit hyperactivity disorder. J Subst Abuse 1995;7:373-378.
10. Barkley R, Fischer M, Edelbrock C, et al. The adolescent outcome of hyperactive children diagnosed by research criteria--III. Mother-child interactions, family conflicts and maternal psychopathology. J Child Psychol Psychiatry 1991;32:233-255.
11. Brown RT, Pacin JN. Perceived family functioning, marital status, and depression in parents of boys with attention deficit disorder. J Learn Disabil 1989;22:581-587.
12. Mash EJ, Johnston C. Parental perceptions of child behavior problems, parenting self-esteem, and mothers' reported stress in younger and older hyperactive and normal children. J Consult Clin Psychol 1983;51:86-99.
13. Noe L, Hankin CS. Health outcomes of childhood attention-deficit/hyperactivity disorder (ADHD): health care use and work status of caregivers. Value in Health 2001;4:142-143.
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