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ADHD Update
Barbara J. Howard, MD
[email protected]
www.childhealthcare.org
Disclosures
I have a financial relationship to disclose:
Consultant, Total Child Health, Inc.
producer of CHADIS
Off label medication will be discussed:
psychotropics
Characteristics of AD/HD
Prevalence - 3-5% of school- age children
 Usually identified in the early elementary
school years
 4:1 to 9:1 male:female
 <70% persist into adulthood
 Often FH+ AD/HD
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DSM-IV Criteria for ADHD
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>= 6 months of 6 of either (1) or (2)
 (1) Inattention
inattention to details
trouble sustaining attention
doesn’t listen
doesn’t finish
trouble organizing
avoids sustained tasks
loses supplies
easily distracted
forgetful
DSM-IV Criteria for ADHD
 (2)
Hyperactivity
fidgets
excess running, climbing
on the go
Impulsivity
blurts out answers
interrupts or intrudes
leaves seat
trouble playing quietly
talks too much
trouble waiting turn
DSM-IV Criteria- 2
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Onset with impairment < 7 years old
Impairment in >= 2 settings
Significant impairment in social, academic, or
occupational functioning
Not exclusively part of PDD, schizophrenia, or
psychotic disorder nor better accounted for by
another mental disorder
ADD without H and ADHD -Inattentive
Type
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?Similarity to ADHD
“Spacey”
Daydreamer
Sluggish responses - ?processing issues
Excessive confusion
Inconsistent memory retrieval
Shy/anxious passive
Deficits on measures of attention
Not impulsive & not oppositional
Codes for Attentional Disorders
314.01 AD/HD, Combined Type
Meets criteria of both A1 & A2
314.00 AD/HD, Predominantly Inattentive Type
Meets criteria for A1 but not A2 in last 6mos
314.01 AD/HD, Predominantly HyperactiveImpulsive Type
Meets criteria for A2 but not A1 in last 6 mos
314.9 AD/HD, NOS
Prominent symptoms but not to criteria
Newer Conceptual Model: Deficit of INHIBITION
related to “Areas of Executive Functioning”
Deficient Self-Regulation
 Impaired Temporal Organization of
Behavior
 Impaired Goal-Directed Persistence
 Diminished Social Effectiveness &
Adaptation
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Etiology
 No consensus yet regarding precise
transmitter defect or anatomic localization
 PET study of hyperactive parents of
hyperactive children showed decreased
glucose metabolism in right frontal lobe
 MRI studies showing abnormalities in
corpus callosum
Neurotransmittors in ADHD
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Dopamine
 Enhances
signal
 Improves attention
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Focus
Vigilance
On-task behavior
On-task cognition
Norepinephrine
 Dampens
noise
 Enhances executive operations
 Increases Inhibition
Genetics
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Pattern of single dominant gene or a
single major gene
 50
- 92% of monozygotic twins
 Siblings at 2 to 3 times greater risk
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Possible association with dopamine
transporter gene (DAT1) and dopamine
receptor (DRD4)
Differential DiagnosisMedical/neurological primary diagnosis
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Endocrine- hyperthyroidism, generalized
resistance to thyroid hormone
Neurological- petit mal, migraine, chorea, lead
poisoning, ?iron deficiency
Sensory- mild hearing and/or vision losses
Arousal- day time drowsiness associated with
obstructive sleep apnea, lack of sleep
Drug induced- drug side effects (e.g.
Phenobarbital, sympathomimetics)
Treatment Implications
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If it is not a problem of how or what then
teaching what or how is not likely to help
Treatments or modifications at the site of
performance are more likely to be effective
 medication, seating arrangement, fm
receivers, touching and redirecting, in class
assistance
Immediate consequences for goal-directed and
task-oriented behavior
Unproven Therapies
Dietary Management
 Megavitamins
 Chiropractic Manipulations
 Ocular Motor Exercises
 Self control training outside performance
site (e.g., in a clinic)
 EEG biofeedback
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Empirically Proven Treatments
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Pharmacologic (>300 double blind published
studies)
 Note- medication alone is usually not
sufficient treatment
Parent counseling about ADHD (&ODD)
Parent training in child management
Teacher counseling and training in ADHD and
classroom management
Special Education when indicated
Individual counseling as needed
Residential Treatment
Parent/Family Counseling when indicated
Components of Treatment
Education of parent, other caregivers
 Psychological/behavioral therapies
 Parent training
 Support groups
 Social skills training
 Psychoeducational interventions
 Medication
 Regular follow up
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Class Room Adaptations
Preferential seating
 Cueing by teacher before instruction
 Shorter work periods with frequent breaks
 Visual and tactile stimuli with verbal
instructions
 Remediation when necessary
 FM receivers
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Families as Advocates
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504 Plans- “other health impaired” with doctor
note
Individual Educational Plan for LD
 Request
complete intelligence and achievement testing
 Other specific assessments as needed e.g. VMI,
educational assessment, projective testing
 Don’t sign it unless satisfied
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May need an educational advocate at ARD
meeting
Especially key at change to KG, middle, high,
graduation
Always appeal possible for higher level of service
Multisite Multimodal Treatment
Study (MTA)
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600 children (age 7 – 9)
ADHD combined type
24 month outcomes
Groups
 Medical
management: monthly tailored
 Behavioral Therapy: 8 week summer; training; inclass aid, teacher consultation
 Combined
 Community standard: 67% meds mostly bid
MTA Results
Medical management or combination
therapy had better outcomes than
behavioral therapy or community care
 Combined therapy was equal to medical
for ADHD sx but for subgroups combined
may be preferable
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 Anxiety
disorders; high levels of socioeconomic and/or family stressors
Medication Choice: Stimulants
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MPH and DA are approximately equivalent in efficacy
(75%) & side effects
 Some children respond better to one
 MPH dose = 0.3 - .5 mg/kg/dose; DA = 0.150.25mg/kg/dose
Ritalin SR is less effective and slower onset than short
acting. Ritalin LA more reliable
Long acting DA is more likely to cause sleep problems
Dexedrine SR- 10-12 hours, greater anorexia, irritability?
Adderall- 4-6 hours, Adderall XR 10-12 smoother
Pemoline (Cylert) is no available because of liver
toxicity->death
Medication - Dosing
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Short acting lasts 3 1/2 to 4 hours
Children benefiting from school dosing usually
can benefit from a 3rd dose
Long acting now recommended
Consider using a placebo trial
 With
weekly parent and teacher ratings to establish
objectivity
 Helps parents carefully sort out their fears from fact
 Helps establish an optimal dosage early
CHADIS decision support:
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Parent takes previsit online
questionnaires (behavior,
development, health,
family factors)
Clinician reviews
questionnaire results, can
consult linked textbook
Clinician may exchange
findings with school or
mental health provider
online
Clinician finds relevant
resources, handouts from
links & prints for family
Bill 96110
Graphic display of Vanderbilt
Other stimulants for ADHD
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Focalin- d MPH- Short acting; ½ dose; same
effectiveness and side effects
Focalin XR (5,10,20)- 10-12 hours, same side effects
Methylin liquid 5 or 10/5cc short acting
Metadate CD- MPH, 6 hours, can sprinkle
Ritalin LA- MPH, 8-10 hours
Daytrana or MTS or MethyPatch
Vyvanse = Slow release mixed salts of amphetamine
Procentra = Liquid Dexedrine 5 mg/5 cc
Methylphenidate Transdermal
System or Daytrana or MethyPatch
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Takes 2 hours for effect, remove at 9 hours, lasts
12
Signif. effective vs placebo
Potential for sensitization to methylphenidate due
to topical route
MTS vs Concerta: Insomnia 13% vs 8%;
anorexia 26% vs 19%
12.5 cm = 18 mg Concerta 18.75 cm = 27 mg
Concerta 25 cm = 36 mg Concerta 37.5 cm = 54
mg Concerta
Non-stimulants for ADHD
Atomoxetine
 Modafinil
 Intuniv = guanfacine er
 Clonicel = long acting clonidine (pending)
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Atomoxetine (Strattera)
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Norepinephrine reuptake inhibitor- not category
II
CYP2D6 metabolized, T1/2 5.2 h
Signif better than placebo in child & adult
Side effects: anorexia 14%, N/V/D 12-15%,
dizziness, fatigue 9%, mood swings 5%
Possible inc or dec BP, inc pulse, allergic rash
Recent reports liver abnormalities and failure
Contraindicated near MAO inhibitors
0.5mg/kg->2.0 q 3 d max 100mg div qd-bid.
Less with paroxetine or fluoxetine
Modafinil or Provigil
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Indicated for sleep apnea and narcolepsy
100, 200 mg
Dose up to 200 mg q am
Onset 2-4 hours, delayed by food 1 hr, T1/2 15
hrs
CYP inhibitor. Also interferes with OCPs
Transient LFT elevations, palpitations, anorexia,
headache all <2%
“Euphoria” risk?
Intuniv
FDA approved 6/07
Selective agonist for alpha-2A-receptors in
the prefrontal cortex
 Nonstimulant
 Monotherapy
 Once daily long acting
 Ages 6 to 17 years
 1 mg to 4 mg daily
 Better than placebo in 2 double blind trials
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Other Nonstimulants
Imipramine: 1-4 mg/kg /2-3 doses/day;
EKG monitoring
 Clonidine: 4-5 microgram/kg/day or
Guanfacine (Tenex) long acting; esp for
aggression and when sedation HS
needed; cvs concerns
 Bupropion
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Bupropion (Wellbutrin)
1.
2.
3.
4.
5.
Antidepressant with stimulant action (beta
noradrenergic receptors and prefrontal lobe)
Significant effect on ADHD but less effect size
than first line stimulants
Better than nicotine patch for smoking cessation
("Zyban")
Dosage: 3-6mg/kg (</=300/day); 75, 100, &
150mgSR
Side-effects (especially if increase fast):
Decreased seizure threshold (rate = .06%),
agitation, insomnia
Stimulants and CV Risk
FDA reports showed:
25 patients (19 who were 18 years and younger)
taking stimulants had suddenly died.
54 more patients on these pills had unusual
heartbeats, heart attacks, or strokes. Some had
preexisting heart problems, some were taking
other pills, including cocaine.
AAP advises continuing current practice
FDA- no black box warning
Prudent to avoid use in structural heart disease,
arrythmia, ? if FH sudden cardiac death
Family Cardiac History (Crosson)
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Has your child ever experienced any of the
following?
 Unexplained seizures
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Passing out/fainting during exercise, when startled, or when
highly emotional
Dizziness during or after exercise
Chest pain during or after exercise
Racing heart or skipped heartbeats
Getting extremely tired or short of breath more quickly than
friends do during exercise
High blood pressure or high cholesterol
None of these
Not sure
Has anyone in the family (including your child) had any of the
following serious heart conditions? Please check all that apply.
 Hypertrophic or dilated cardiomyopathy
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Long-QT syndrome, short-QT syndrome, Brugada syndrome, or
another ion channel disorder
Other heart rhythm problems that required treatment
Marfan syndrome or ruptured aorta
Born with heart malformation (e.g. hole in heart, bad valves, etc.)
Unexplained fainting or seizures
Use of pacemaker or cardiac defibrillator
Primary pulmonary hypertension
Ventricular tachycardia
Heart attack age 50 or younger
Disability due to heart problems before age 50
Sudden death due to heart problems before age 50
None of these
Not sure
Managing Side Effects
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Appetite - “4th meal” at bedtime
Abdominal pain – disappears in 3 wks; try slow
acting medication; ?bowel urgency; give with
food
Headache – disappears in 3 wks; try slow acting,
use 7 days/wk
Growth – 1 kg, 1 cm; mostly nutrition related;
reversible with drug holidays if needed
Tics - mostly due to comorbidity, may have less
tics with stimulants; 0.5% chance of a persistent
problem; try lower dose
Irritability- change family of meds, use another
dose in pm
Sleep problems in ADHD
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85% of children with ADHD have sleep problems
before using meds
Sleep debt makes ADHD and comorbid
conditions worse
Mostly trouble falling asleep but also restless
Consider OSA if snore, bipolar if up for hours in
the middle of the night
Start with routine bedtime, back rub, milk, white
noise
Meds prn: evening stimulant dose, melatonin 1-8
mg, Clonidine 0.05-0.1 mg., guanfacine up to 1
mg
ADHD Follow-Up Visits- Goals
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To watch for and begin early intervention for
co-morbid conditions
To monitor self concept of child, perception of
parents and progress toward asset building
(e.g., involvement in nonschool skill building)
To adjust medication as needed
 Teacher and parent check lists and work
samples and report card data are usually
needed
 Repeat placebo trials are helpful
To monitor for side effects
Adult Outcomes and Need for
Continued Medication
1/3 have “no symptoms” as adults
 Consider various work demands:
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 Air
traffic controller vs. salesperson
 Accountant vs. CEO with 3 secretaries
 Pathologist vs. pediatrician
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May increase creativity, energy
References:
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Barkley, R. A. Attention Deficit Hyperactivity
Disorder: A handbook for diagnosis and
treatment. New York: Guilford Press, 72 Spring
St., New York, NY, 1990.
Culbert TP, Banez, GA, Reiff, MI. Children who
have Attentional Disorders: Interventions.
Pediatrics in Review 15 (1), 5-14. 1994
Diller, L. H., Running on Ritalin, Bantam Books,
New York, NY, 1998.
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Gorski P (Ed) 2002, Supplement, The
Diagnosis and Treatment of ADHD in
Early Childhood: Evidence –Based
Controversies and Implications of Practice
and Policy, J Dev Beh Ped 23(1S)
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Greenhill, L. L., Attention-Deficit Hyperactivity
Disorder: The Stimulants. In Riddle, MA, (Ed),
Pediatric Psychopharmacology I Child and
Adolescent Psychiatric Clinics of North America,
January. 123. 4:1, Saunders, Phila, PA. 1995
Papolos D and Papolos J: The Bipolar Child.
Broadway Books, NY, 1999
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Reiff MI, Banez, GA, Culbert TP. Children Who
Have Attentional Disorders: Diagnosis and
Evaluation. Pediatrics in Review. 14. 455-469.
1993.
Sturner RA, 2005, Attention Deficit Disorder, In
The Child Health and Development Interactive
System, www.childhealthcare.org
Wolraich, M (Edit.), 1996, The
Classification of Child and Adolescent
Mental Diagnoses in Primary care.
Diagnostic and Statistical Manual for
Primary Care (DSM-PC), Child and
Adolescent Version, American Academy of
Pediatrics
 www.nichq.org for Vanderbilt checklist
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Appendix
Pediatric Evaluation of ADHD
“Factors and Trigger Questions”
Interviewing the child
 General information: age, grade, name of
school, name of teacher
 Subjects, grades, favorite subject/hardest
subject and why
 Best friend, activities together
 Family- members, kind of person, activities
together, hardest part about
 Chores, discipline, allowance, hobbies
 Family kinetic drawing
Pediatric Evaluation of ADHD
“Factors and Trigger Questions”
Classroom Behavior
 Parent: What are your concerns about him?
What does/has his teacher say/said about him?
(each grade)
 Teacher: Ratings (e.g., Conners, DSM)
 Child: Tell me about the teacher you have -- Is
she nice or did you get one of the mean ones?
What does she/he do that seems mean?
Pediatric Evaluation of ADHD
“Factors and Trigger Questions”
Classroom environment
Is the child being compassionately, and
competently managed? Or is the teacher
overwhelmed and confrontational?
 Parent: How many children are in the
class?
 Child: Where do you sit?
Pediatric Evaluation of ADHD
“Factors and Trigger Questions”
Behavior at home
 How is his behavior at home?
 What is the hardest part with him?
 How bad does it get?
 Focus on transitions: Tell me what it is like..
getting him ready for school....bedtime,...
turning off TV,... putting his toys away?.
 Patience: Is he able to sit through a meal and
take turns talking?
 Organization: What is his room like?
Pediatric Evaluation of ADHD
“Factors and Trigger Questions”
Sleep
 Settling: Struggle suggests oppositionism
or anxiety
 Adequacy: When does he get up on the
weekends?
 Quality: Screen for sleep apnea
Differentiating ADHD from
Typical-1
Severity- impairs daily function
“Have you changed family routines?”
 Duration- Not just transient reaction to stress or
environmental change
“What else has been going on recently?”
 Pervasiveness- outside home, occurs with
people other than pa
“How does he do with other people?”
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Differentiating ADHD from
Typical-2
Comorbidity- Presence of other mental health
problems
Ask about all areas of functioning
 Family History- of ADD/ADHD Vs. other psych
Genogram
 Higher scores on scales (not validated)
Use some instrument eg CBCL
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Pediatric Evaluation of ADHD“Performance Sampling”
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Review of report card and work samples
Do you have any hard work at your school?
Sample achievement performance (e.g.
WRAT and standard reading &
comprehension paragraph, alphabet, writing
sample)
Hypothesis driven performance sampling- e.g.
If problem listening: Do a standard 5 part
command; writing -VMI; process related tasks
from PEEX, etc.