Download Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity
Disorder
Kevin Leehey M.D.
1980 E. Fort Lowell Rd. Suite 150
Tucson, AZ 85719
520-296-4280 fax 520-296-3835
http://leeheymd.com
[email protected]
Attention Deficit Hyperactivity
Disorder
1.
2.
3.
4.
ADHD Inattentive Type
ADHD Hyperactive/Impulsive Type
ADHD Combined Type
ADHD NOS
Kevin Leehey, M.D.
296-3835
Differential Diagnosis

Medical or neurologic or other
psychiatric conditions, such as
hyperthyroidism, medication sideeffects, anxiety disorders, post
traumatic stress, depression, immature
character, and oppositional behaviors,
may look like ADHD but not actually be
ADHD.
Kevin Leehey, M.D.
296-3835
Co-morbid
Anxiety disorders, Tourette’s
Syndrome, depression, post traumatic
stress difficulties, behavioral problems,
learning difficulties, coordination
disorders, sensory integration
disorders, PDD, etc.
 The most common condition
associated with ADHD is a learning
disorder (about 50 percent)
Kevin Leehey, M.D.

296-3835
Diagnostic Criteria
A.

Six (or more) of the symptoms of inattention
have persisted for at least six-months to a
degree that is maladaptive and inconsistent
with developmental level
 Or six (or more) of the symptoms of
hyperactivity-impulsivity have persisted for at
least six-months to a degree that is
maladaptive and inconsistent with
developmental level
Kevin Leehey, M.D.
296-3835
Inattention :
a)
b)
c)
d)
e)
f)
g)
h)
i)
Often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions)
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks
requiring sustained mental effort (such as schoolwork or
homework)
Often loses things necessary for tasks or activities (ie: toys,
school assignments, pencils, books, or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Kevin Leehey, M.D.
296-3835
Hyperactivity:






Often fidgets with hands or
feet and squirms in seat
Often leaves seat in
classroom or in other
situations in which
remaining seated is
expected
Often runs about or climbs
excessively in situations in
which it is inappropriate (in
adolescents or adults, may
be limited to subjective
feelings of restlessness)
Often has difficulty playing
or engaging in leisure
activities quietly
Is often “on the go” or often
acts as if “driven by a motor
Often talks excessively
Impulsivity:



Often blurts out
answers before
questions have been
completed
Often has difficulty
awaiting his/her turn
Often interrupts or
intrudes on others (eg:
butts into conversations
or games)
Kevin Leehey, M.D.
296-3835
More Diagnostic Criteria
B. Some hyperactive-impulsive or inattentive
C.
D.
E.
symptoms that caused impairment were present
before age seven years
Some impairment from the symptoms is present in
two or more settings (ie: school, work, home)
There must be clear evidence of clinically
significant impairment in social, academic, or
occupational functioning
The symptoms do not occur exclusively during the
course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder and
are not better accounted for by another mental
disorder (ie: Mood Disorder, Anxiety Disorder,
Dissociative Disorder, or a Personality Disorder)
Making the Diagnosis






ADHD is often diagnosed based on meeting
at least the minimum criteria for ADHD from
DSM-IV
Psychological testing, WISC-IV, WoodcockJohnson-R
Rating scales such as the Connors or SNAP
Continuous Performance Task Tests
Observation of the child or adolescent’s
behavior in school and non-school settings
Family history
Kevin Leehey, M.D.
296-3835
Making the Diagnosis

Making the diagnosis for adults and
preschoolers is more difficult. Many of
the diagnostic criteria are described in
terms most relevant for elementary,
middle school, and less so, high school
age groups. For adults, past history
and data regarding school experiences
and testing is often crucial (along with
current and past functioning and family
history).
Kevin Leehey, M.D.
296-3835
ADHD trends
8 years old, third grade
 Sixth grade, middle school
 3X Boys - wrong
 Missed - girls, minorities, ODD,
inattentive only, bright, co-morbid, mild
 5-7% of school age youth

Kevin Leehey, M.D.
296-3835
ADHD is more difficult to
diagnose in preschool



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A wider range of behavior is expectable
Attention span normally increases with age,
as does impulse control and a lessening of
physical hyperactivity
Parenting styles and cultural norms vary
markedly in this age group
Medication treatment is often less helpful
and less researched
Other interventions are often worthwhile
ADHD will become more clear with time
Kevin Leehey, M.D.
296-3835
Executive Function Disorder


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Disorganization and poor time management
skills
Follow-through and carrying out plans
Getting schoolwork/homework done or
turned in
Failure to complete or turn in assignments
Do (fully or partially) their assignments but
fail to turn them in or lose them
Kevin Leehey, M.D.
296-3835
ADHD diagnosis myths
Video/computer games, television,
movies
 “He/she can if he/she wants to”
 “He/she is fine at home”, or 1:1, or at
the office
 “Lazy”, underachiever, unmotivated

Kevin Leehey, M.D.
296-3835
Prognosis, Outcome

ADHD can be mild, moderate, or severe
 Learning disorders may also be mild,
moderate, or severe
 Associated conditions complicate
 Ability of that youngster’s family, school, and
even that youngster’s ability to adjust to
his/her current developmental needs and to
what is expected of him/her
Kevin Leehey, M.D.
296-3835
ADHD prognosis
Hyperactivity resolves for 50% around
puberty; 75% by age 21
 Inattention often persists
 “School of hard knocks”
 25% have conduct disorders and or
substance abuse
 Higher risks MVA, job losses,
relationship problems, depression,
anxiety

Kevin Leehey, M.D.
296-3835
Basic Medical Principles
H&P, labs, hearing, vision
 Educational assessment
 Experienced and well trained clinician
 365 days, 24/7
 Individualize and fine tune treatment

Kevin Leehey, M.D.
296-3835
Treatment
Individual Therapy
1.
•
Self esteem and impulse control
Family Therapy
2.
•
It is more difficult to parent a youngster
with ADHD
Kevin Leehey, M.D.
296-3835
Treatment
3. School/Work
•
•
•
•
Special education, 504 Accommodation
Positive home-school communication
The transition from elementary to middle
school and again from middle school to
high school
Environmental manipulation
4. Medication
Kevin Leehey, M.D.
296-3835
Treatment
5. Additional or Alternative treatments
• Martial arts
• Exercise/sports
• Biofeedback (“Neurofeedback”)
• Sensory integration treatment
• Nutritious diet, sweets, “junk food”, sugar
• Vitamins, herbs, and other supplements
• “Dyslexia” is a language processing
phonologic error in language areas of the
brain, not a hearing or vision disorder
Kevin Leehey, M.D.
296-3835
Medications for ADHD-1

Stimulants
–
Methylphenidate
 Short
–
Amphetamines
 Short
–
and extended duration
and extended duration
Pemoline (Cylert)
Kevin Leehey, M.D.
296-3835
Medications for ADHD-2

Non-stimulants
–
Atomoxetine (Stattera)
– Tricyclics (Imipramine, Desipramine)
– Buproprion (Wellbutrin)
– Partial alpha agonists [Guanfacine
(Tenex), Clonidine]
Kevin Leehey, M.D.
296-3835
Medications for ADHD-3

Combinations/polypharmacy
–
–
–
–
–
Avoid if possible
Stimulant and atomoxetine or other nonstimulant ADHD medication
Atomoxetine and SRI
Non psych medications
Stimulant plus SRI plus DDAVP is safer
than desipramine alone
Kevin Leehey, M.D.
296-3835
Medications for ADHD-4

Out of the Box
–
amantadine (Symmetrel)
– modafinil (Provigil)
– pramipexole (Mirapex)
– ropinirole (Requip)
Kevin Leehey, M.D.
296-3835
Medications for ADHD-5

Beads/sprinkle
–

Liquid
–

Methylin, Amantadine (Symmetrel)
Chewable
–

Adderall XR, Ritalin LA, Metadate CD, Focalin XR
Methylin
Patch
- Catapres, MPH (soon)

Osmotic pressure release
- Concerta
 Compounding
Kevin Leehey, M.D.
296-3835
Prescribing for ADHD-1
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Co-morbidity: Depression, anxiety, tics,
substances, bipolar, nicotine
Height, weight
Appetite decrease and low weight is the
most common limiting stimulant side effect
Class II, no “refills”, 60 days, less on base
post, out of state varies, 90 day mail order
Match side effects as well as good effects
Kevin Leehey, M.D.
296-3835
Prescribing for ADHD-2
Duration
 Convenience
 Weight (height less of a concern)
 Tics
 “Meaner”
 Abuse of stimulants
 Truck driver, pilot

Kevin Leehey, M.D.
296-3835
Prescribing for ADHD-3
Regular follow-up appointments
 Not just “med checks”
 Height, weight, growth curve
 School, home, peers, activities, etc.
 Patient and significant other input
 Benefits and adverse effects

Kevin Leehey, M.D.
296-3835
Kevin Leehey M.D.
1980 E. Fort Lowell Rd. Suite 150
Tucson, AZ 85719
520-296-4280 fax 520-296-3835
http://leeheymd.com
[email protected]