illinois doc assist adhd presentation
DESCRIPTION
Screening, Diagnosing, and Treating ADHD in the Primary Care Setting Toya Clay, MDTRANSCRIPT
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Illinois DocAssist Program
Screening, Diagnosing, and Treating ADHD in the Primary Care Setting
Toya Clay, MD
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Disclosure Information
No financial relationships with:
pharmaceutical firms
provider of commercial services or CME credits
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Learning Objectives
1) Understand screening recommendations for ADHD and common co-morbidities
2) Identify and employ rating tools for ADHD
3) Recognize diagnostic criteria for ADHD and common co- morbidities
4) Determine if treatment in the primary care setting is feasible
5) Identify psychosocial interventions that can be integrated into PC setting
6) Formulate a plan for initiation, titration, and monitoring of ADHD medication
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Role of the Primary Care Provider
Primary Care Providers (PCPs) as the major source of mental health care
ADHD is one of the most prevalent chronic health conditions affecting school-aged children
PCPs are frequently asked by parents and teachers to evaluate a child for ADHD
Not uncommon for the PCP to be first person who has opportunity to diagnose ADHD
Early recognition, assessment, and management, can realign the educational and psychosocial development of most children with ADHD
Many patients will go undiagnosed and untreated if their clinicians are not prepared to consider the diagnosis of ADHD
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ADHD facts
Most common behavioral health problem among children
4-12% of school-aged children are diagnosed with ADHD (community samples)
65% of children diagnosed will have symptoms persisting into adolescence and more than a third will have symptoms persisting into adulthood
3 types: inattentive, hyperactive-impulsive, combined; 65% have the combined type
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More ADHD facts
Most are diagnosed in childhood but some diagnosed in adolescence, particularly with the inattentive type
Hyperactivity symptoms decline but impulsivity and inattention often persist into adulthood
Girls are more than twice as likely as boys to be diagnosed with the inattentive subtype
There is a strong genetic component
But, extent of impairment is influenced by co- morbidities and psychosocial factors
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ADHD characteristics in adolescents
Low self esteem
Accident prone
New academic problems
Problems with time management, organization, problem solving, completing tasks
Problems in peer relationships
Higher risk of substance abuse if untreated
Higher risk of traffic violations/ accidents if untreated
Frequency and type of co-morbidities in adolescents
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Presentations in the primary care setting
Presentations of ADHD vary in clinical practice
In many (but not all) cases, concerns are spontaneously mentioned by parents and
Common teacher concerns:
Academic underachievement/ failure
Disruptive classroom behavior
Inattention
Problems with peer relationships
Common parental concerns:
Similar to teachers
Poor self-esteem
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Screening recommendations in the primary care setting
Symptoms may not be present or concerns may not be reported in the primary care setting
Thus, screening during routine health supervision visits can assist in early recognition
Strategies for screening during routine health supervision
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Diagnosing ADHD
DSM-IV criteria: Inattention Symptoms
1) fails to give close attention to details;makes careless mistakes
2) difficulty sustaining attention in tasks or play activities3) does not seem to listen when spoken 4) does not follow instructions or finish school work, chores, or
duties5) has difficulty organizing tasks and activities6) avoids, dislikes tasks requiring sustained mental effort 7) loses things necessary for tasks or activities 8) easily distracted by extraneous stimuli9) forgetful in daily activities
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Diagnosing ADHD
DSM-IV criteria: Hyperactive-Impulsive Symptoms
1) Fidgets/ squirms 2) Trouble sitting still/ leaves seat3) Runs about inappropriately (in adolescents may be feelings
of restlessness/ jittery)4) Difficulty playing quietly5) ”On the go”; "driven by a motor"6) Talks excessively7) Blurts out (I)8) Difficulty awaiting turn (I)9) Interrupts or intrudes on others
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Diagnosing ADHD
DSM-IV criteria: Other criteria1) More than 6 symptoms total for more than 6 months and to a
maladaptive degree and inconsistent with developmental level2) Some symptoms present before age 73) Some impairment from symptoms in at least 2 settings (usually
school and home)4) Clear evidence of significant impairment in social or academic
functioning5) Symptoms due not exist solely secondary to PDD, a psychotic
disorder, and are not better accounted for by another physical or mental disorder
Combined type: if criteria are met from a combination of Inattention and Hyperactive-Impulsive
ADHD Not Otherwise Specified: prominent symptoms that do not meet full diagnostic criteria (ex-age of onset after 7 or symptoms of inattention such as daydreaming and hypoactivity)
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Special considerations to diagnosing ADHD in primary care setting
DSM IV diagnosis requires significant impairment/ dysfunction but no reliable/ valid measure of dysfunction applicable to primary care setting exists
Diagnosis must come from a synthesis of sources (parents, child, school etc) and DSM IV criteria must be applied in the context of clinical judgment
PCPs typically encounter children with behaviors related to activity level--inattention and impulsivity that may be less problematic or a developmental variation not meeting DSM IV criteria
The Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version provides behavioral descriptions with a developmental perspective; can guide clinicians in evaluating and managing these concerns
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ADHD Specific Rating Scales
Conners’ Rating Scales
Vanderbilt Assessment Scales
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ADHD diagnosed: Next steps
Assessing for Co-morbid conditions and distinguishing a co- morbid condition from a “masquerading” condition
The role of a careful family psychiatric history
Co-morbid or “masquerading” disorders
ODD
CD
Depressive disorders
Anxiety Disorders
Learning Disorders
Others
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ADHD diagnosed: Next steps
Medical or neurological work-up?
Neuropsychological and Academic testing?
Documentation and Monitoring
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Explaining the diagnosis
Parent/Child
Background
Importance of recognizing symptoms
Expected course of disorder
Resources
National Alliance on Mental, www.nami.org
Facts for Families, www.aacap.org
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) http://www.chad.org
Teacher/ School
Resources
School Psychiatry Program at Massachusetts General Hospital, www.schoolpsychiatry.org
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Treatment Choices for PCPs
When to refer:
Upon assessment
severe aggression
co-morbid psychiatric disorders
After initiation of treatment
failure to respond to stimulants, atomoxetine
treatment emergent psychosis, agitation
family problems persist with resolution of ADHD symptoms
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Treatment Choices for PCPs
Psychosocial interventions
Psychoeducation for patient and family members
symptoms
course of disorder
treatment options
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Treatment Choices for PCPs
Psychosocial interventions
Support groups (www.chadd.org)
Advocacy groups (www.add.org)
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Treatment Choices for PCPs
Psychosocial interventions
Educational
coordinated behavioral plan
504 Plan
Individualized Educational Plan
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Treatment Choices for PCPs
Psychosocial interventions
Behavior therapy
positive reinforcement
time-out
response cost
token economy
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Treatment Choices for PCPs
Psychosocial interventions
Parent training
1-2-3 Magic: Effective Discipline for Children 2-12 (Thomas W. Phelan)
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Treatment Choices for PCPs
Pharmacotherapy
stimulants
atomoxetine
other
2 adrenergic agonists
bupropion
tricyclic antidepressants
modafanil
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ADHD Prevalence vs. Medication Treatment
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
Ages 4-17* Ages 20+**
PrevalenceRx Treated
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Treatment Algorithm for ADHD
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Stimulant Medications
Treatment of choice
65 – 75% respond to first trial
85% respond if both classes tried
Classes
methylphenidate
amphetamines
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Stimulant Medications
Methylphenidate preparations
Immediate release
methylphenidate (generic)1
Ritalin2
Methylin2
Focalin (dexmethylphenidate)2
dexmethylphenidate (generic)1
1 – HFS Preferred Drug2 – HFS Non-Preferred Drug
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Stimulant Medications
Methylphenidate preparations
Sustained release
Ritalin SR
Ritalin LA2
Concerta1
Methylin ER
Metadate CD1
Metadate ER
Focalin XR1
1 – HFS Preferred Drug2 – HFS Non-Preferred Drug
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Stimulant Medications
Methylphenidate preparation
Other
Daytrana2
1 – HFS Preferred Drug2 – HFS Non-Preferred Drug
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Stimulant Medications
Amphetamine preparations
immediate release
d-amphetamine2
Dexedrine
Liquadd (5 mg/5ml)
mixed amphetamine salts1
Adderall
Desoxyn (methamphetamine)2
1 – HFS Preferred Drug2 – HFS Non-Preferred Drug
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Stimulant Medications
Amphetamine preparations
Sustained release
Adderall XR1
Other
Vyvanse (lisdexamfetamine)2
1 – HFS Preferred Drug2 – HFS Non-Preferred Drug
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Contraindications
CNS stimulants can cause cardiac stimulation- may cause problems for patients with angina, dysrhythmias, hypertension
Also contraindicated in anxiety disorders, glaucoma, or hyperthyroidism
Usually contraindicated in history of drug abuse
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Stimulant Medications
Methylphenidate
Dose: 0.3-2 mg/kg/day PO div bid-tid
Start: 2.5-5 mg PO bid
Increase: 5-10 mg/day q7 days
Maximum: 2 mg/kg/day up to 60 mg/day
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Stimulant Medications
Dexmethylphenidate
~ 2x as potent as d,l-methylphenidate
>6y.o.
Dose: 2.5-10 mg PO BID
Start: 2.5 mg PO BID
Increase: 5-10 mg/day q7 days
Max: 20mg/day
Focalin XR
>6 y.o.
Start: 5 mg PO QAM
Increase: 5mg/day q7 days
Max: 20mg/day
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Stimulant Medications
Concerta
6-12 y.o.
Start: 18 mg PO qd
Increase: 18 mg/day q7 days
Maximum: 54 mg/day
> 13 y.o.
Start: 18 mg PO qd
Increase: 18 mg/day q7 days
Maximum: 2 mg/kg/day or 72 mg/day
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Stimulant Medications
Metadate CD
>6 y.o.
Dose: 20-60 mg PO qam
Start: 20 mg PO qam
Increase: 10-20 mg/day q7 days
Maximum: 60 mg/day
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Stimulant Medications
Amphetamine/d-amphetamine
3-5 y.o.
Start: 2.5 mg/day qwk
Increase: 2.5 mg/d q7 days
> 6 y.o.
Start: 5 mg PO qam or bid
Increase: 5 mg/day qwk
Maximum: 40 mg/day
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Stimulant Medications
Adderall XR
6-12 y.o.
Start: 5-10 mg PO qam
Increase: 5-10 mg/day qwk
Maximum: 30 mg/day
13-17 y.o.
Start:10 mg PO qam
Increase:10 mg/day qwk
Maximum: 40 mg/day
Daytrana
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Vyvanse
Lisdexamfetamine dimesylate
Prodrug
Dosage equivalent
70 mg Vyvanse
23.7 mg Adderall XR
14.8 mg d-amphetamine
Decreased abuse potential
Decreased interpatient variability
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Stimulant Medications
Side effects
headache/jittery feeling
anorexia/weight loss
increased HR, BP
irritability
insomnia
tics
Psychosis
Effects on growth
Black box warning
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Atomoxetine
General information
Low abuse potential
May be first line treatment
tic disorder
anxiety disorder
substance use disorder
Onset of action delayed
Black box warning for suicidal thinking
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Atomoxetine
Side effects
Anorexia/weight loss
Nausea / vomiting
Sleep disturbance
Suicidal ideation
Liver damage
Black box warning
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Non-Stimulant Medications
Atomoxetine
>6 y.o., <70 kg
Start: 0.5 mg/kg PO qam x 3 days
Increase to 1.2 mg/kg PO qam
Maximum: 1.4 mg/kg/day
>6 y.o., >70 kg
Start: 40 mg PO qam x3 days
Increase to 80 mg PO qam
Maximum: 100 mg/day
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Monitoring Treatment
Symptom severity
Each visit
Parent and teacher rating scales
Worsening of behaviors
School failure
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Monitoring Treatment
Height and weight
Once or twice a year
Growth charts
changes in growth velocity
crosses 2 percentile lines
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Monitoring Treatment
BP and pulse
Several times annually
With dosage adjustment
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Monitoring Treatment
Medication side effects
Each visit
Strategies to alleviate side effects
dose adjustment
switching medication
Adjunctive
Assess for development of co-morbid
conditions
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Monitoring Treatment
Assessment to determine if ongoing medication management is necessary
Annually
At least one year symptom free
Drug holiday
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Combined Pharmacotherapy & Behavior Therapy
Decreased ratings of:
Inattention (P & T)
Hyperactivity-impulsivity (P)
Oppositional/aggressive behaviors (P)
Anxiety and depression (P)
Lower dose of medication
P – parent reportT – teacher report
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ADHD – Treatment
Adjunctive medications for comorbid features
Tics/Tourette’s
Insomnia
Aggression
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Illinois DocAssist Program
The mission of the Illinois DocAssist Program is to improve the ability of primary care providers to screen, diagnose and
treat the mental health and substance use problems of children and youth (ages 21 and under).
For more information about DocAssist call 866-986-ASST (2778) or visit our website at:
www.psych.uic.edu/DOCASSIST
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Illinois DocAssist Program
Thank You