Download Guidelines and Treatment Updates in the Diagnosis and

Guidelines and Treatment
Updates in the Diagnosis and
Management of Attention Deficit
Hyperactivity Disorder (ADHD)
MNPA Fall Conference
Freeport, ME
November 15, 2015
Jennifer Parks, MSN, PMHNP-BC
Disclosures
• None
Objectives
1. To provide an update on diagnostic criteria for
ADHD.
2. To provide updates on current medication
management of ADHD.
3. To review other modalities of treatment, outside
of medication management, for ADHD.
4. To briefly review insurance
implications/requirements for ADHD
medications
ADHD
• One of the most common
neurodevelopmental disorders in children,
affecting anywhere between 5%-8% of
children
• Also affects 1%-6% of adults
• Males are more affected than females
• Primary neurotransmitters involved are
dopamine and norepinephrine
Diagnosis of ADHD
•
•
•
•
•
Changes from DSM-IV to DSM-5
Must occur in two settings
Must impair functioning
Symptoms not attributable to another illness
Rating scales, observations, histories
ADHD Symptoms
Hyperactive/Impulsive
• Fidgets or taps hands/feet
• Often leaves seat when staying
seated is expected
• Runs or climbs in inappropriate
situations
• Unable to play quietly
• Unable to sit still for any notable
period of time
• Talks excessively
• Blurts out answers
• Has difficulty waiting for turn
• Interrupts often
Inattentive
•
•
•
•
•
•
Failure to pay attention to details
Difficulty sustaining attention
Does not seem to listen
Does not follow instructions well
Difficulty organizing tasks
Reluctance to engage in tasks
requiring mental effort
• Loses things often
• Easily distracted by external
stimuli
• Forgetful in daily activities
Pharmacology for ADHD
• Psychostimulants
• Non-stimulants
– Strattera
– Antidepressants
– Alpha-2 agonists
Stimulants
• First line treatment
• 70-80% response rate
• Work by increasing dopamine and norepinephrine signals to the
brain by acting on dopamine and norepinephrine transporters and
changing tonic and phasic dopamine releases
– Increased dopamine signal leads to decrease extraneous noise
– Increase norepinephrine signal leads to increased strength of signals
to the prefrontal cortex
• Two classes
– Methylphenidates
– Amphetamine salts
• Immediate-release and extended-release formulations
• Fast acting
Stimulants
•
•
•
•
Methylphenidates
Ritalin (5-60 mg daily)
Concerta (18-72 mg daily)
Daytrana (10-30 mg daily)
Focalin (5-20 mg daily)
Amphetamines
• Vyvanse (10-70 mg daily)
• Adderall (5-40 mg daily)
Side Effects of Stimulants
•
•
•
•
•
•
•
•
Common
Headaches
Insomnia
Induction or exacerbation of
tics
Irritability
Tremor
Anorexia
Growth suppression
Skin reactions
Rare but Serious
• Seizures
• Hallucinations/psychosis
• Activation of hypomania or
mania
Monitor height/weight, blood pressure, and heart rate throughout treatment
Atomoxetine (Strattera)
• May be monotherapy or adjunct to stimulant
• Non-stimulant medication that acts by enhancing
norepinephrine and dopamine in PFC
• Preferred medication if substance use is present or if
stimulant side effects are intolerable
• Slower acting (may take several weeks to see full
effectiveness)
• May have some bonus antidepressant/anxiolytic effects
• 0.5-1.2 mg/kg (max 1.4 mg/kg or 100 mg daily)
• Side effects
– Black Box Warning
Bupropion (Wellbutrin)
• NDRI (Norepinephrine Dopamine Reuptake
Inhibitor)
– Boosts dopamine and norepinephrine
• 150-450 mg (XL), 225-450 mg (IR)
• Do not prescribe if there is a history of
seizures or eating disorder
• Side effects
Tricyclic Antidepressants
• May lessen hyperactive and impulsive
behaviors by affecting norepinephrine
• Evidence is mixed
• Risk of side effects may outweigh benefits of
use
– Cardiac arrhythmias
– Anticholinergic
– Seizures
Alpha-2 Agonists
• Frequently used as adjuncts
• Increase strength of NE signals to PFC, where there are many alpha-2
receptors
• May be particularly effective for impulsive symptoms
• Guanfacine (Tenex and Intuniv)
– Start with 0.5 or 1 mg QD or BID, then increase to no more than 2 mg (IR) or 4
mg (ER) total daily dose
– May be useful if tics are present
– Sedation (less than Clonidine), dry mouth, hypotension
• Clonidine/Kapvay
– Start with 0.05 or 0.1 mg QD, then increase to no more than 0.4 mg total daily
dose
– May cause sedation; dose initially only at night
– Sedation, dry mouth, hypotension, syncope
• Be mindful of rebound hypertension with discontinuation
• Must monitor pulse and BP daily!
Non-pharmacological
Interventions for ADHD
• Behavioral Interventions
– Identifying antecedents and setting consequences
– Operant conditioning and reinforcement
– Modeling
• Behavioral Parent Training
• Behavioral Classroom Training
• Child Skills Training
Treatment Recommendations
• NIMH Multimodal Treatment of ADHD Study
– Multiple research sites across the U.S.
– Included 600 children who were treated with
medications alone, therapy alone, or a
combination
– Results showed combination of medication and
therapy to be superior to either as monotherapy
– Drug doses were lower in subjects who received
concomitant therapy
– Medication alone is superior to therapy alone
Treatment Recommendations (cont.)
• American Psychological Association, American
Academy of Pediatrics, and American
Academy of Family Physicians’ most recent
stance regarding treatment is:
– Behavioral therapy alone for preschool children
initially
– Behavioral therapy plus medication for school
aged children and adolescents
Treatment of ADHD
and Comorbid Disorders
• Comorbid conditions may lead to further
cognitive, social, and psychological impairments
• General consensus is to treat mood first and
ADHD second; however, it some cases it is
possible to treat both
– Texas Algorithm for depression says to treat whichever
is more severe
• General consensus is to avoid stimulant in bipolar
disorders
• General consensus is to treat substance use
disorders before ADHD
Untreated ADHD
• Academic problems
• Interpersonal problems
• Unemployment/occupational
underachievement
• Mood instability/depression
• Substance Use
• Increased suicide/risk taking behaviors
• Family disruption
Insurance Guidelines
• Stimulants must be tried first, unless there is a
documented substance use disorder
– Ritalin is preferred methylphenidate
– Vyvanse is preferred amphetamine
• Strattera may be used after failures with both
classes of stimulants as well as failure of
guanfacine if patient is under 17 years old
• Guanfacine and clonidine are preferred
• Long acting guanfacine and clonidine require trial
with stimulants, Strattera, and short acting alpha
agonists
Questions?
References
'AAP Releases Guideline On Diagnosis, Evaluation, And Treatment Of ADHD'. American Family Physician
87.1 (2013): 61-62. Print.
Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of adults
with attention-deficit/hyperactivity disorder. Neuropsychiatric disease and treatment, 4(1),
107.
Nathan, P. E., & Gorman, J. M. (Eds.). (2015). A guide to treatments that work. Oxford University Press.
'New Guidelines For ADHD Among Children'. Monitor on Psychology 43.3 (2012): 65. Print.
Pliszka, S., & AACAP Work Group on Quality Issues. (2007). Practice parameter for the assessment and
treatment of children and adolescents with attention- deficit/hyperactivity disorder. Journal
of the American Academy of Child & Adolescent Psychiatry, 46(7), 894-921.
Pliszka, Steven R., et al. "The Texas Children's Medication Algorithm Project: revision of the algorithm
for pharmacotherapy of attention-deficit/hyperactivity disorder." Journal of the American
Academy of Child & Adolescent Psychiatry 43.3 (2006): 642-657.
Stahl, S. M. (2011). The prescriber's guide. Cambridge University Press.