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ADHDSIV FASCI, MD FAAPDEVELOPMENTAL-BEHAVIORAL PEDIATRICSDELL CHILDREN’S MEDICAL CENTER 9TH ANNUAL PEDIATRIC CONFERENCE - MARCH 24, 2016
Objectives
Epidemiology Risk Factors Diagnosis Co-morbidities Treatment When to refer
Trends
CDC data
Percent of children 5-17 years of age ever diagnosed with ADHD: 10.1% (2011-2013)
Percent of boys 5-17 years of age ever diagnosed with ADHD: 14.0% (2011-2013)
Percent of girls 5-17 years of age ever diagnosed with ADHD: 5.9% (2011-2013)
Number of ambulatory care visits (to physician offices, hospital outpatient and emergency departments) with attention deficit disorder as primary diagnosis: 9.0 million (average annual, 2009-2010)
Risk Factors Genetic
+FH 80% heritability
Neurodevelopmental disorders (Schizophrenia, autism and epilepsy) share genetic variants with ADHD
Prematurity Perinatal stress Prenatal alcohol, drugs, smoking IUGR Environmental lead
Brain-Based Disorder
Frontal lobe Parietal lobe Temporal lobe Thalamus Basal ganglia Cerebellum
Pathophysiology Catecholamines
Dopamine, norepinephrine
Mediate CNS functions: Motor control, Cognition, Emotion, Memory processing
White Matter: axons and myelin sheath Limbic system (amygdala,
hippocampus, interior parts temporal, frontal, pariental lobes – “primitive” responses, controls our immediate, automatic responses to stimuli (reward network)
AAP 2011
Evaluation
History: Rule out alternative causes and assess for co-morbidities lead toxicity, trauma, absence seizure, hearing
problem, autism, developmental delay, IDD, LD, language disorder, encephalopathy, substance abuse, depression, anxiety, psychosis, sleep disorder, obstructive sleep apnea
Physical exam: mental status exam, soft neurologic signs, fine motor deficits, motor tics
PCP Work-up
DSM – based questionnaire: Vanderbilt(Teacher/Parent)
ASQ, MCHAT, PSC-Y Audio Cbc, lead
CASE STUDY
Treatment
Behavior and psychotherapy Medication
Stimulant
Nonstimulant
Special education 504 plan
IEP
Treatment ADHD medication and behavior therapy among
children with ADHD (ages 4-17) with special health care needs
Functional Impairments
Academic performance Peer relations Adaptive skills Family functioning
Medical decision making
Is there harm in delaying treatment? What's the risk of medication at 4-5 years age?
behavioral therapy first line, medication if fails to improve with therapy and moderate to severe symptoms
Age 6-18, medication+behavior therapy Rule out substance abuse in adolescents
Low abuse meds: Nonstimulants, Vyvanse, Concerta
Medical decision making
Clinical rating scales Formal assessment
Communication with school
Informed consent General guidelines
20% do not respond to medication Only 50% respond well to either stimulant class Children respond to medication differently at
different ages Long acting formulations are not for everybody
Regular follow-up visits
When to Refer
Fails to respond to psychostimulants/nonstimulant Concern for other medical conditions: seizures,
genetic syndrome, developmental disorder, obstructive sleep apnea
Multiple co-morbidities Severe mental health concerns
Resources
American Academy of Child and AdoscentPsychiatry http://www.aacap.org/aacap/families_and_youth/r
esource_centers/ADHD_Resource_Center/Home.aspx
American Academy of Pediatrics Healthy Children – AAP website for parents
Caring for Children with ADHD: A Resource Toolkit for Clinicians - many useful handouts
ResourcesNational Resource Center on ADHD - a national clearinghouse for science-based information about all aspects of attention-deficit/hyperactivity disorder (AD/HD). Funded by the Centers for Disease Control and Prevention, NRC provides information on ADHD and has an online library of materials.
CHADD: Children and Adults with Attention-Deficit/Hyperactivity Disorder is a national non-profit organization serving people with AD/HD and their families. CHADD has local chapters- there is a chapter in the Valley. The membership fee of $45 gives you access to an information-packed website and to an online magazine named “Attention”.
ADD Warehouse – a source for books and DVD’s on ADHD, Learning disabilities, and childhood mental health disorders
ADD Store – Products that can help organize, remind (pill boxes with alarms) and make life easier (e.g. clothing for hypersensitive skin) for people with ADHD
Resources
Learning Disabilities
LD OnLine - web site on learning disabilities and ADHD
Learning Disabilities Association of America - the largest non-profit group for people with learning disabilities. Over 200 local affiliates in 42 states, including Arizona.
National Center for Learning Disabilities
Great Schools – Website with many handouts about Learning Difficulties (LD & ADHD). Can be searched by age group.
Healthy Children – American Academy of Pediatrics