is it adhd? · new pt: sara • after demystification with mom, she realized the degree of anxiety...
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Is It ADHD?
James H. Beard, Jr., M.D, FAAP Developmental-Behavioral Pediatrician
Department of Developmental-Behavioral Pediatrics Greenville Health System
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Lecture Goals
• Understand ADHD in children and adolescents
• Familiarity with Co morbid conditions associated with ADHD and how they relate to successful treatment
• Accommodations and strategies for success in ADHD
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New Pt: Sara
• Initial visit for this well kempt 8 yo female, oldest of 4 siblings
• Gr 2, regular classes, lowest 5 in reading and math. No behavioral concerns. Teacher questions attention problems or learning difficulty.
• VTRS: 4/9 for Attention Sx, 1/9 for Hyperactive-Impulsive Sx and 2/7 Anxiety. VPRS: 4/9 for inattention, 3/9 for Hyperactive-Impulsive Sx and 3/8 for oppositional Sx
• Fx Hx positive for Internalizing conditions on Mom’s side and Learning difficulties on Dad’s
• Both parents graduated from high school. Mom stays at home with the children. Dad works construction and has a side job in landscaping.
• PE is normal except for moist palms. Developmental evaluation close to age-normal, but performance anxiety noted and fine motor control is less than expected
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ADHD is a group of neurobehavioral disorders
resulting in developmentally inappropriate self-regulation of attention, impulsivity,
and hyperactivity.
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DSM V Criteria for Inattention
• Careless • Difficulty sustaining attention • Seems not listen • Fails to finish things • Avoids/dislikes tasks requiring sustained mental
effort • Difficulty organizing • Loses things • Easily distracted • Forgetful in daily activities
6 or more often manifested
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DSM V Criteria for Impulsivity/Hyperactivity
• Hyperactivity • Squirms and fidgets • Unable to stay seated • Runs/climbs excessively • Can’t play/work quietly • On the go/”driven by a motor” • Talks excessively
• Impulsivity • Blurts out answers • Difficulty waiting turn • Interrupts or intrudes on others
6 or more often manifested
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Attention Deficit / Hyperactivity Disorder
• Interest Driven, Not Task Driven
• Immature Executive Function • Easily Distracted
• Excitable / Impulsive
• Poor Frustration Tolerance
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Executive Function • The ability to plan, organize, initiate, maintain
and complete tasks, with the ability to monitor and shift priorities, as needed
• A collection of processes responsible for directing and managing cognitive, behavioral, psychosocial and emotional functions
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Executive Skills • Initiation – Getting started • Working Memory – Holding and using
information actively • Inhibition – Not react to impulse, stop activity • Flexibility/ Shifting – Move from one task to
another • Planning – Anticipation of future events and
developing strategies • Organizing – Establish and maintain order • Self-Monitoring – Attention to behavior and
output with ability to revise • Emotional/Behavioral Control – Regulate
emotional response
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Clinical Course • Hyperactivity and impulsivity diminish over
time. • Diminished executive functions persist. • Accommodations and strategies develop • 80% of patients maintain some Sx into
adulthood • 55-65% maintain clinically significant Sx • Heavy burden of losses (career, family,
marriage, social )
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Comorbidity in Children • ODD 50% • Conduct Disorder 10% • Language Based LD 30% • Specific Learning Disorder 25% • Anxiety/OCD 25% • Depressive Disorders 35% • Smoking 3 Xs • SUD 3 Xs
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New Pt: Sara
• After demystification with Mom, she realized the degree of anxiety in Sara’s life.
• Mom agreed that the anxiety was more limiting than the attention.
• Dx was Generalized Anxiety Disorder (300.01), ADHD-I (314.00), and Academic Underachievement (313.83)
• Treatment options addressed and CBT encouraged and Rx for Prozac®, with handout, supplied. Followed by phone q week and 1 month re-evaluation showed improved anxiety, but continued struggle in school. Focalin XR® started and titrated with academic improvements and IQ/ Psycho-Educational testing put on hold
• 3 month F/U revealed continued academic improvements and improved self-confidence. VTRS scores fell into the normal range
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Adolescent Issues with ADHD • ADHD teens have 3-4 Xs the number of auto
accidents, 4-6 Xs the speeding tickets, and 3 Xs the ER visits than control group
• Inattention and distractions as the cause • Dr Daniel Cox has shown protection if stimulant
taken properly • Parents of teens often distracted by crisis with
their own parents, leaving supervision of ADHD to the adolescent
• Unplanned pregnancy 4 Xs as likely • Smoking and SUD
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Adults
• 30%-60% of children with ADHD continue having symptoms when they grow up.
• In adults, the inability to stay focused derail careers, ambitions, and relationships. Many don't realize they have the disorder, leaving them mystified.
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Symptoms • Adults may be continually late to work or
events. • They may be disorganized, restless, and have
difficulty relaxing. • Trouble concentrating while reading. • Mood swings, low self-esteem, make impulsive
decisions and have poor anger management.
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On the Job • They often have trouble breaking down
tasks and following directions, and making deadlines.
• They're also prone to tardiness and careless mistakes.
• According to a national survey, only half of adults with ADHD when compared to 72% of normal adults were able to maintain a full-time position.
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Marriage
• The condition makes it difficult to remember social commitments, birthdays or anniversaries, pay bills on time, etc.
• Adults with ADHD may lose their tempers easily or engage in reckless behavior. This increases the chances of divorce.
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Treatment of ADHD
ADHD medications ameliorate (not eliminate) symptoms of ADHD, so treatment is much
more than just medications!
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Treatment Plan • Demystification
• Behavioral modification
• Environmental modification
• Psychopharmacology
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Demystification
• Resources for Families – Websites
• Children and Adults with AD/HD (CHADD): www.chadd.org
• National Resource Center on AD/HD: www.help4adhd.org
• National Center on Gender Issues and ADHD (website for girls/women with ADHD): www.ncgiadd.org
• Wrights Law (website with information on educational law): www.wrightslaw.com
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Demystification: Education • Resources for Families
– Books • ADHD: What Every Parent Needs to Know by AAP • Taking Charge of ADHD: The Complete, Authoritative Guide for
Parents by Russell Barkley • The ADHD Book of Lists by Sandra Rief • Understanding Girls with ADHD by Patricia Quinn and Kathleen
Nadeau • Straight Talk and Psychiatric Medications for Kids by Tim Wilens,
MD • Cory Stories: A Kid’s Book About Living with ADHD by Jeanne
Kraus and Whitney Martin • Joey Pigza Swallowed the Key by Jack Gantos
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Environment: Home • Fun and Organized • Study Aides / Tutoring/ Coach • Rou:ne / Time Management • Encouragement / Challenge • Involved / Suppor:ve Parents • Efficient environment • Consistent medica:on usage • Sleep (www.kidzzzsleep.org)
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Environment: School • Efficient and Organized • Inclusive, Not Exclusive • Preferential Seating • Psycho-educational testing (if indicated) • 504 / IEP (www.Wrightslaw.com) • Silent Signal • No Loss of Recess • Peer mentor/tutor • Teacher/student match
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Environment: Work
• Efficient Environment/ Avoid Distractions • Avoid traps (Games, Social Networking) • Life/ Career Coach • Organization aides (Apps, Smart Phone) • Reminders (Sticky Notes) • Planner/ Lists…Scheduled Checks • Accountability Partner
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Treatment: Medica3ons
• Stimulants – Methylphenidate-based medications – Amphetamine-based medications
• Non-stimulants – Atomoxetine – Extended release alpha-2 agonists
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Treatment: Medica3ons • General Principles
• Some patients need dose of immediate release medication in the afternoon to help with evening coverage, rebound hyperactivity, and/or evening dysphoria
• Do not use Rx as a test for ADHD; do full evaluation on all patents
• Treat mood disorder first, intrinsic anxiety second, and then ADHD
• Treat ADHD first when dealing with mild anxiety • Middle school onward should be treated 365 days per
year to protect from substance use/abuse, auto injuries, unplanned pregnancy, etc
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Treatment: Medications • MPH-based Stimulants
– Immediate Release MPH – Extended Release®
• OROS Delivery System (Concerta®) – Longest acting oral MPH medication – Must be swallowed – Available in generic – 72 mg indication for adolescents/ adults
• Bead Delivery System – Designed to mimic BID dosing – May be sprinkled and then swallowed (not chewed!) – 30/70 Release (Metadate CD®) – 50/50 Release (Ritalin LA®)
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Treatment: Medications
• MPH-based Stimulants – Extended Release (cont)
• Wax Matrix Delivery System – Rarely used due to inconsistent delivery of medication even
in same patient – Must be swallowed – Available in generic which is relatively inexpensive [brand
names: Ritalin SR®, Metadate ER®, Methylin ER®]
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Treatment: Medications
• MPH-based Stimulants Dexmethylphenidate
• Immediate Release (Focalin®) • Extended Release (Focalin XR®) • Bead Delivery System • May be sprinkled • Fewer side effects?
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Treatment: Medications
• MPH-based Stimulants – Extended Release (cont)
• Transdermal (Daytrana®) – Start everyone on 10 mg q am (regardless of
prior MPH dose) and titrate to effect – Patch should be worn for 9 hours, and then
removed to get full 12 hour effect – Patch may be removed in less than 9 hours if
shorter duration wanted – MPH is a skin irritant! Rotate application site
through 4 positions on hip
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Treatment: Medications • Amphetamine-based Stimulants
– Dextroamphetamine • Short acting
– Generic Tablet (Brand Name: Dexedrine®) – Brand Name Liquid (Procentra®)
• Extended Release (Dexedrine Spansule®) – May be sprinkled – Available in generic
– Lisdexamfetamine Dimesylate (Vyvanse®) • May be sprinkled OR dissolved in water
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Treatment: Medications
• Amphetamine-based Stimulants – Mixed amphetamine salts
• Immediate Release (Adderall®) • Extended Release (Adderall XR®)
• Bead Delivery System • May be sprinkled
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Treatment: Medications • Non Stimulants
– Atomoxetine (Strattera® ) • Provides 24 hour coverage of ADHD symptoms • May be given in the evening® or in the morning
(with food!) • Must be swallowed per package insert because
drug is an esophageal irritant • Dosed by weight: target dose of 1.2 – 1.4 mg/kg
daily • Side effects: similar to stimulants • Rare side effects: jaundice/liver injury, suicidal
ideation, activation, disinhibition. Adults with ED
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Treatment: Medications
• Stimulants • Side Effects: decreased appetite, weight loss,
headache, stomachache (give after food!), emotion/mood changes, rebound hyperactivity, sleep difficulties, emergence of tics
• Rare Side Effects: psychotic episode, sudden cardiac death
• “Risks/benefits discussed, including psychiatric and cardiac risks”
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Treatment: Medications • Non-stimulants
• Alpha-2 Agonists • Extended release guanfacine (Intuniv®)
• Once daily • May be given at night or in the morning • Start everyone at 1 mg daily • May increase dose by 1 mg each week to max of 0.12 mg/kg/day
(but no more than 4 mg daily) • MAXIMUM DOSE: 4 mg
• Side Effects: fatigue, somnolence, headache, decreased blood pressure, syncope
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Treatment: Medications • Non-stimulants
• Alpha-2 Agonists • Extended release clonidine (Kapvay®)
• Start with 0.1 mg bedtime dose; increase by 0.1 mg each week to desired effect (if SEs tolerated)
• Doses higher than 0.1 mg should be given in 2 divided doses • If reach 0.3 mg, give 0.2 mg at night and 0.1 mg in the morning • Max dose 0.4 mg/day
• Side Effects: fatigue, somnolence, headache, decreased blood pressure, syncope
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Pearls for Managing ADHD
• Monitor growth and vital signs with each visit • Re-evaluate diagnosis and continued need
for therapy • Watch for emergence of co-morbid disabilities • Re-examine patient q 3 months • Discourage drug holidays • Monitor flow of Rx (freq of use) and be aware
of risks for diversion. • Immediate release>>delayed release
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Pearls for Managing ADHD
• Use specific target symptoms and monitor efficacy • Start low and titrate dose until maximum
improvement or side effect(SE) • Change to different class of stimulant if SE persist • Treat SUD first, Mood Disorder second, intrinsic
Anxiety third, then ADHD • Treat ADHD first when dealing with mild anxiety/
chronic underachievement • Middle school onward should be treated 7/365 to
protect from SUD, smoking, auto injuries, unplanned preg.,ect.
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Suggested Reading • Adler, L. (2006). Scattered Minds. GP Putnams, NY • Barkley, R. ADHD Report. Guilford Press • Dawson, P et al. (2009). Smart but Scattered. Guildford Press • Dulcan, M. (2003). Concise Guide to Child and Adolescent
Psychiatry. 3rd ed. American Psychiatric Press. DC • Kelly, D et al. Pediatric Annals, 34(4), 259-329 • Plizka, S et al. (1999). ADHD with Comorbid Disorders. Quilford
Press. NY • Quinn, P et al. (1999). Understanding Girls with ADHD.
Advantage Books. MD • Stahl, S. (2005). Essential Psychopharmacology, the
Prescriber’s Guide. Cambridge U. Press. NY • Wilens, T. (2004). Straight Talk About Psychiatric Medications
for Kids. Guilford Press.
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Is It ADHD?
James H. Beard, Jr., M.D, FAAP Developmental-Behavioral Pediatrician
Department of Developmental-Behavioral Pediatrics Greenville Health System