Attention Deficit Hyperactivity
Disorder – ADHD: The Essentials
This AAPA Chapter Lecture Series program is
supported by an educational grant from McNeil
Pediatrics, Division of Ortho-McNeil-Janssen
Pharmaceuticals, Inc., administered by OrthoMcNeil Janssen Scientific Affairs, LLC.
• Daniel Wood
• Email: woodx27@gmail.com
• Cell: 210-386-7882
The Story of Fidgety Phillip by
Heinrich Hoffmann
• "Let me see if Philip can
Be a little gentleman;
Let me see if he is able
To sit still for once at
table."
Thus spoke, in earnest
tone,
The father to his son;
(cont…….)
Faculty Disclosure Statement
1. In the past 12 months, I have not had a significant
financial interest or other relationship with the
manufacturer(s) of the product(s) or provider(s) of
the service(s) that will be discussed in my
presentation.
2. This presentation will not include discussion of
pharmaceuticals or devices that have not been
approved by the FDA and I will not be discussing
unapproved or “off-label” uses of pharmaceuticals or
devices.
Learning Objectives
1. List the criteria for diagnosis of ADHD.
2. Discuss the prevalence of ADHD and its impact
on society.
3. Discuss one screening tool used to diagnose and
assess control of ADHD.
4. Review all FDA-approved medications for
treatment of ADHD.
5. Describe the risks and benefits of using stimulant
medications to treat ADHD.
Pre-test Question #1
1. According to the DSM IV, how long must
symptoms of inattention/ hyperactivity be
present before considering a diagnosis of
ADHD?
a. 2 months
b. 6 months
c. 12 moths
d. 24 months
Pre-test Question #2
2. What is the estimated prevalence of ADHD
among school-aged children in the United
States?
a. 1-3%
b. 4-8%
c. 11-14%
d. 15-18%
Pre-test Question #3
3. Which of the following is considered a
Broadband Screening tool useful in screening
for ADHD?
a. BASC Monitor Rating Scale
b. Connors Rating Scale (long form)
c. ACTeRS Boys and Girls Form
d. Vanderbilt Assessment Scales
Pre-test Question #4
4. Which of the following is NOT a criterion
for initiation of pharmacotherapy?
a. Diagnostic tools confirm diagnosis
b. Age 6 or older
c. Blood chemistries within normal range for age
d. Normal cardiac examination
Pre-test Question #5
5. Of the following drugs used to treat ADHD,
which drug does NOT carry the option of a
“drug holiday”?
a. Lisdexamphetamine(Vyvanse)
b. Methylphenidate(Concerta, Ritalin, etc.)
c. Dextroamphetamine(Dexedrine)
d. Atomoxetine(Strattera)
Epidemiology of ADHD
• Affects 4-6% of children
• Persists into adolescence and adulthood
– 4.4% estimated current adult ADHD
• Stimulant Usage
– 1.5 – 2 million American children
– 2-3 fold increase over last 30 years
– Greater use in females and adolescents
• The total excess cost of ADHD in the US in 2000 was
$31.6 billion
Case Study
• DC is a 10 y.o. male that is being seen in your
office for evaluation of ADHD. His mother is
concerned because his grades have started
slipping, and he seems to have a hard time
completing his assignments. She also notes that
he fidgets a lot and can’t seem to sit still, unless
he is playing a video game. DC’s father thinks
that he is just “a typical boy”, and needs to apply
himself better.
Core Symptoms
INATTENTION
HYPERACTIVITY/IMPULSTIVITY
Core Symptoms
• Hyperactivity
– Hyperactivity symptoms peak at age 4
• Impulsivity
– Peak at age 4, but remain throughout life
• Inattention
– Generally appear at 8-9 yo and tend to be
lifelong
• DSM IV criteria: Symptoms must be present for at
least 6 months to make ADHD diagnosis
Eur Child Adolesc Psychiatry. 2004;13 Suppl 1:I7-30
INATTENTION: CORE SYMPTOM AREAS
1. Often fails to give close attention to details
2. Difficulty sustaining attention in tasks or play activities.
3. Does not seem to listen when spoken to directly.
4. Does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace.
5. Difficulty organizing tasks
6. Avoids tasks that require sustained attention.
7. Loses necessary things
8. Distracted by external stimuli
9. Is forgetful
American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th ed.
Washington, D.C., 1994. Copyright © 1994 American Psychiatric Association
HYPERACTIVITY/IMPULSTIVITY
1. Fidgets with hands or feet or squirms in seat.
2. Leaves seat in classroom.
3. Runs about or climbs excessively in situations in which it is
inappropriate.
4. Difficulty playing or engaging in leisure activities quietly.
5. “On the go" or often acts as if "driven by a motor."
6. Talks excessively.
7. Blurts out answers
8. Difficulty awaiting turn.
9. Interrupts or intrudes on others
American Psychiatric Association, Diagnostic and statistical manual of
mental disorders, 4th ed. Washington, D.C., 1994
ADHD: Course of the Disorder
INATTENTION
AGE
Diagnosis: Questions to ask
•
•
•
•
How is your child doing in school?
Has you child had any learning difficulties?
Does your child seem happy in school?
Do you think your child has any behavioral
problems?
• Does your child have difficulty completing
assignments?
www.uptodate.com accessed on 3/18/10
ADHD Subtypes
ADHD,
Inattentive Type
ADHD,
HyperactiveImpulsive Type
ADHD,
Combined Type
40%
Academic
impairments
10%
Behavioral
impairments
50%
Academic/
behavioral
impairments
Noah welcomes his sister Juliette
Prevalance
Physical/Medical Risk
Comorbid psych disorder
ADHD Prevalence And Its Impact
On Society
Prevalence
• School-age children: 8-10%
– One the most common childhood disorders
• Male: female ratio is 2:1 - 4:1
– Higher ratio for hyperactive subtype
• Whites, males, those with older teachers are more likely to be
diagnosed
• Lower rates on West coast
• Declines with age??
Prevalence, Recognition, and Treatment of Attention-Deficit/Hyperactivity Disorder in a National Sample of US Children. Arch Pediatr
Adolesc Med. 2007 Sep;161(9):857-64.
Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of
Pediatrics. Pediatrics 2000; 105:1158.
Green, M, Wong, M, Atkins, D, et al. Diagnosis of Attention Deficit/Hyperactivity Disorder: Technical Review 3. US Department of Health
and Human Services, Agency for Health Care Policy and Research; Rockville, MD, 1999.
Taylor, E, Sergeant, J, Doepfner, M, Gunning, B. Clinical guidelines for hyperkinetic disorder. European Society for Child and
Adolescent Psychiatry. Eur Child Adolesc Psychiatry 1998; 7:184.
ADHD Physical/Medical Risk
•
•
•
•
•
•
Seizures – 2.5X greater
Sleep problems(39%-56%)
Developmental coordination disorder(50%+)
Reduced Physical fitness, Strength, Stamina
Accident proness(57%+)
2x-3x the medical cost of a normal child
Comorbid Psychiatric Conditions
• 50% of children with ADHD have one or more
comorbid condition.
– Oppositional defiant disorder (40%)
– Conduct disorder (20%)
– Depression & mood disorders (15%)
– Anxiety disorder (25%)
– Learning disabilities (25%)
J Am Acad Child Adolesc Psychiatry 2001 Feb;40(2):147-58.
Prognosis
•
•
•
•
•
•
Education
Employment
Peer relationships
Substance Use
Injuries
Driving
Prognosis
• Education
– Impaired academic functioning
– Persist into adulthood
• Employment
– Lower status jobs
– Poorer performance
• Peer relationships
Prognosis
• Substance Use
– Increased prevalence?
• Injuries
– Greater risk for intentional or unintentional
injury
• Driving
– Twice as likely to be involved in a MVC
Broadband/Narrow Screening
Genetics
Neuroanatomy
Cathecholamine Imbalance
Pathogenesis and Screening in
ADHD.
Case Study
• MA is a 7 year old
male in your clinic
whose mother
suspects that her son
has ADHD. How
would you evaluate if
this child has ADHD?
Screening
Broadband screening
• Rely on parent- , teacher-, or child-completed
questionnaires
• Rule out a broad range of possible diagnoses.
Narrow screening
• Directed toward a specific diagnosis
• >90% accuracy in diagnosing ADHD
Arch Dis Child. 2005 Oct;90(10):1010-5
Pathogenesis
• Disorder of multiple
causes
• Causes may compound
each other
• Genetics
• Neuroanatomy
– Frontalstriatial cerebellar
cicuit
• Catecholamine
imbalance
ADHD Risk Factors
• PRENATAL
– Maternal smoking
– Maternal Etoh
– Cocaine user – polydrug
– Pesticides?
• POSTNATAL
– Head trauma, tumors
– Lead posioining – affinitiy for dopamine receptors
– ALL – Inattentive type
Case Study
RW has the diagnosis of ADHD. Her mother
wonders about the treatment options, and is
concerned about the side effects of ADHD
medications. What can you tell her about
the medications available and the side
effects of the stimulant medication you are
about to prescribe?
Medication
Behavioral therapy
Treatment of ADHD
Treatment
• Behavioral
• Pharmacological
Behavioral Therapy
• Maintaining a daily schedule
• Provide logical choices for schoolwork and
toys
• Setting small reasonable goals
• Rewarding positive behavior
• Using charts
• Limit choices
• Cognitive therapy??
Criteria for Initiation of Pharmacotherapy
• Diagnostic assessment confirms ADHD.
• Child age is greater than 6?
• Parents accept pharmacotherapy as contribution to
management
• Child has a normal cardiac exam
• Administration of medication will be reliable
• Consider a specialist:
– Child with Tourette syndrome
– Child with a pervasive developmental delay
– Child with seizures
– Caridiac question
An auditable protocol for treating attention deficit/hyperactivity disorder.
Arch Dis Child 2001; 84:404.
Prior to Commencement
•
•
•
•
Discuss: fears/questions
Discuss: risk/benefit of treatment
Discuss: trial and error period
Medication delivery: 5 P’s
– Patch, pump, pellet, pill, prodrug
Stimulant Medications
• Generally thought of as first line treatment
• Methylphenidate
– Short acting: Ritalin, Methylin, Focalin
– Intermediate: Metadate, Methylin ER
– Long acting: Concerta, Daytrana(patch)
• Amphetamines
– Short acting: Dextroamphetamine/amphetamine
(Adderall), Dextroamphetamine sulfate (Dextrostat,
Dexedrine)
– Long acting: Lisdexamfetamine (Vyvanase),
Adderall XR
Stimulant Medication: Side Effects
•
•
•
•
•
•
•
Monitor blood pressure, heart rate
Appetite Reduction/Weight Loss
Final height ?
Insomnia
Tics
Rare: Headache/abdominal pain
Rare: Depression/withdrawn behavior
Initial CV Risk Assessment
• Personal history, focusing
on cardiovascular events
• Family history of cardiac
problems
• Physical exam
• Cardiac consultation if
irregularities
are suspected
• EKG ?
Non-Stimulant Therapy
• Atomoxetine (Strattera)
• Alpha-adrenergic agents
– Guanfacine (Tenex)
– Clonidine (Catapres)
• Anti-depressant (non-SSRI, non-tricyclic)
– Buproprion (Wellbutrin)
Atomoxetine (Strattera)
• Selective norepinephrine reuptake inhibitor
• May work via norepinephrine transporter
• In randomized studies: as effective as
methylphenidate
• May be given as single daily dose or bid
• Currently recommended as second-line only
Adverse Side Effects: Atomoxetine
•
•
•
•
•
•
Nausea
Sedation
Tics
Liver Injury
Suicidal Thinking
Cardiovascular
Other Medications
• Antidepressants
– TCA
– Bupropion
• Alpha 2 adrenergic agonist
– Clonidine
– Guanfacine hydrochloride
Alpha-2-adrenergic agonists
• Not routinely prescribed
• Clonidine
– Not as effective as stimulants
– Patient profile
– Side effects
• Guanfacine hydrochloride
– Patient profile
– Side effects
J Am Acad Child Adolesc Psychiatry 1999 Dec;38(12):1551-9.
Alpha-2 Agonist
•
•
•
•
Drowsiness may occur
Rare: depression
Rare: hypotension, cardiac arrhythmia
Aggression
Antidepressants
• TCA
– Inhibit the reuptake of norepinephrine and serotonin
– Second line therapy
– Cardiac side effects
• Bupropion
– Blocks the reuptake of norepinephrine and dopamine
– More stimulant properties than TCAs
– Side effects- lowers seizure threshold
J Am Acad Child Adolesc Psychiatry 1996 Oct;35(10):1314-21.
Low-dose Antidepressants
• Bupropion, Desipramine, and imipramine
• Limited evidence base
• Not as frequently used
• Side-effects: rare with low-dose
• Risk of idiosyncratic effect such as arrhythmia
Titration
Maintenance
Drug Holidays
Termination
MEDICATION MANAGEMENT
Medication Monitoring
• For stimulant-naïve patient
– Initially every 1-2 weeks
– Titrate medication dosage as needed based
on efficacy and side effects
• Routinely every 4-6 months (at least twice
a year)
– Evaluate medication efficacy, side effects
– Physical examination
Titration
• Optimal dose and frequency are determined
• The timing of dose administration in relationship to
meals and expectations is important.
• Medication should be started on a weekend day.
• Dosing history varies on clinical picture
• During titration, have a standardized assessment of
effect.
• Monitor at least 2-4 weeks
• Monitor the child's height, weight, blood pressure,
and pulse.
• Switching medication classes
JAMA 1998 Apr 8;279(14):1100-7
Maintenance
• Begins once optimal dose achieved.
• Regular monitoring
– Vitals
– Adjust dose
– Monitor for side effects
J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894
Drug Holidays
• Definition
• Not an option for children who are taking
atomoxetine.
• Inattentive type
Termination of Medication
• Duration of pharmacologic therapy is highly
individualized
• Ongoing evaluation of the risk-benefit analysis
• Long-term side effects and drug dependence
do not occur with stimulant medications or
atomoxetine
• Other medications, follow prescribing
guidelines
J Clin Psychopharmacol 2004 Feb;24(1):30-5.
Things you may have heard…
•
•
•
•
•
Food additives
Refined sugar
Essential fatty acids
Iron deficiency
Pesticides
Resources for Families
• CHADD: Children and Adults with ADD
– www.chadd.org
• NAMI: National Alliance for the Mentally Ill
– www.nami.org
• ADDA: National Attention Deficit Disorder
Association
– www.add.org
• NIMH: National Institute of Mental Health
– www.nimh.nih.gov/publicat/adhd.cfm
More Resources for Families
• United States Department of Education
– www.ed.gov/offices/OSERS
• Society for Developmental and Behavioral
Pediatrics
– www.dbpeds.org/handouts
• American Academy of Child and Adolescent
Psychiatry (AACAP)
– www.aacap.org/publications/factsfam/noattent.htm
Post-test Question #1
1. According to the DSM IV, how long must
symptoms of inattention/ hyperactivity be
present before considering a diagnosis of
ADHD?
a. 2 months
b. 6 months
c. 12 moths
d. 24 months
Post-test Question #2
2. What is the estimated prevalence of ADHD
among school-aged children in the United
States?
a. 1-3%
b. 4-6%
c. 11-14%
d. 15-18%
Post-test Question #3
3. Which of the following is considered a
Broadband Screening tool useful in screening
for ADHD?
a. BASC Monitor Rating Scale
b. Connors Rating Scale (long form)
c. ACTeRS Boys and Girls Form
d. Vanderbilt Assessment Scales
Post-test Question #4
4. Which of the following is NOT a criterion
for initiation of pharmacotherapy?
a. Diagnostic tools confirm diagnosis
b. Age 6 or older
c. Blood chemistries within normal range for age
d. Normal cardiac examination
Post-test Question #5
5. Of the following drugs used to treat ADHD,
which drug does NOT carry the option of a
“drug holiday”?
a. Lisdexamphetamine(Vyvanse)
b. Methylphenidate(Concerta, Ritalin, etc.)
c. Dextroamphetamine(Dexedrine)
d. Atomoxetine(Strattera)
Thank you for attending this
AAPA Chapter Lecture Series program
supported by an educational grant from
McNeil Pediatrics,
Division of
Ortho-McNeil-Janssen Pharmaceuticals, Inc.,
administered by
Ortho-McNeil Janssen Scientific Affairs, LLC