Download Cari’s presentation - Richard Adler, M.D

RICHARD S. ADLER, M.D.
Staff Psychiatrist
Children’s Hospital & Regional Medical Center
&
Private Practice
Forensic & Clinical Psychiatry
Seattle, WA
WHICH IS IT?
ADHD,
BIPOLAR DISORDER OR
ASPERGER’S DISORDER?
New York Area
Florida
April – May 2003
Overview
 Interactive Case – Participant Centered
Learning
 What differentiates these disorders?
 Clinical Management +/- comorbidity?
 Clinical strategies when the diagnosis is
uncertain
 Q &A
ADHD: Comorbidity In Majority
60
55
50
45
40%
40
30-35%
35
(%)
30
20-25%
25
15-20%
20
15-20%
15-20%
19%
15%
15
10
5
0
Oppositional
Defiant
Disorder1
Language
disorder
Anxiety
disorders1
Learning
difficulties1
1NIMH
2Milberger
S et al. J Am Acad Child Adolesc Psychiatry 1997;36:37-44.
et al. J Am Acad Child Adolesc Psychiatry 1997;36:21-29.
3Biederman
Mood
disorders1
Conduct
disorder1
Smoking2
Substance
Use
Disorder3
ALISSA CHAVARONE
Alissa is a youngster transferred to your care. Her
prior attending is no longer on her parents’ insurance
panel.
In the fall of 1st grade Alissa was noted to have
problems with inattention and impulsivity that
interfered with her school achievement and behavior.
In the home, she was difficult to manage, irritable,
highly demanding and had tantrums that at times
seemed entirely unprovoked. She was rough with,
and sometimes completely mean to her 3-year old
sister. By the spring of first grade the teacher
suggested that her parents obtain an evaluation for
the attention deficit.
Have you ever thought, or has anyone ever told you, that
they suspected that your child might have Attention
Deficit Hyperactivity Disorder (ADHD)?
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Have you ever thought, or has anyone ever told you, that
they suspected that your child might have Attention
Deficit Hyperactivity Disorder (ADHD)?
Total
3346
%
Yes
No
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Have you ever thought, or has anyone ever told you, that
they suspected that your child might have Attention
Deficit Hyperactivity Disorder (ADHD)?
Total
3346
%
Yes
35
No
65
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Who was it that suspected that your child might have
Attention Deficit Hyperactivity Disorder (ADHD)?
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Who was it that suspected that your child might have
Attention Deficit Hyperactivity Disorder (ADHD)?
Total
1143
%
Me
Doctor or other medical
professional
School professional (i.e. teacher,
nurse, guidance counselor)
Social worker
Friend or family member
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Who was it that suspected that your child might have
Attention Deficit Hyperactivity Disorder (ADHD)?
Total
1143
%
Me
45
Doctor or other medical
professional
School professional (i.e. teacher,
nurse, guidance counselor)
Social worker
Friend or family member
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Who was it that suspected that your child might have
Attention Deficit Hyperactivity Disorder (ADHD)?
Total
1143
%
Me
45
Doctor or other medical
professional
School professional (i.e. teacher,
nurse, guidance counselor)
62
Social worker
Friend or family member
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Who was it that suspected that your child might have
Attention Deficit Hyperactivity Disorder (ADHD)?
Total
1143
%
Me
45
Doctor or other medical
professional
30
School professional (i.e. teacher,
nurse, guidance counselor)
62
Social worker
15
Friend or family member
25
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, McNeil Consumer Healthcare, 2002, p. 38
Did you seek help for your child after this
possibility was raised?
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, Harris Interactive, 2002, p. 39
Did you seek help for your child after this
possibility was raised?
Total
1143
%
Yes
No
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, Harris Interactive, 2002, p. 39
Did you seek help for your child after this
possibility was raised?
Total
1143
%
Yes
79
No
21
Cultural Attitudes & Perceptions About Attention Deficit Hyperactivity Disorder, Harris Interactive, 2002, p. 39
Alyssa's pediatrician started her on Ritalin at
a low dose daily. It was remarkably helpful
in all areas of Alissa’s schoolwork and
behavior, but tended to wear off by midafternoon. Alissa’s mother went to a
CHADD meeting and was urged to get a
Health Impairment Form filled out by the
doctor. Alissa was placed close to the
teacher and had frequent breaks during the
day. A parent at CHADD also told Mrs.
Chavarone about Ritalin SR. Upon mother’s
request the doctor switched Alissa to Ritalin
SR which was somewhat less effective
overall but seemed to last for more of the
school day.
Representative Behavioral
Half-lives
of the Stimulant Medications for ADHD
Response
MPH IR/D-AMPH
MPH SR
Mixed AMPH salts
OROS® MPH
0
2
4
6
Hours
Wilens, Spencer. Child Adolesc Psychiatr Clin N Am. In press
10
Alissa’s 2nd and 3rd grades progressed with numerous
suspensions for misbehavior, including a number of
fights, one of which involved biting another student.
The Chavarone’s prior insurance did not cover
mental health treatment. The pediatrician referred
Alissa to the local mental health clinic, but she
remained on a wait list for two years. Occasional
pastoral counseling reassured Mrs. Chavarone that it
was OK to have Alissa on medication. Alissa
appeared to be socially immature and she had only
one friend who shared her fascination with Pokeman
cards. Alissa insisted that other children call her
Pikachu and gave all the other children in the class
names of characters from the cards. She would giggle
and laugh when they expressed dislike for this habit
of hers.
DSM IV Diagnostic Criteria for Asperger’s Disorder
 Qualitative impairment in social interaction, as manifested by at least two
of the following:
 Marked impairment in the use of multiple nonverbal behaviors such
as eye-to-eye gaze, facial expression, body postures, and gestures to
regulate social interaction
 Failure to develop peer relationships appropriate to development
level
 A lack of spontaneous seeking to share enjoyment, interests, and
activities with other people (e.g., by a lack of showing, bringing, or
pointing out of objects of interest to other people)
 Lack of social or emotional reciprocity
DSM IV Diagnostic Criteria for Asperger’s Disorder
 Restricted repetitive and sterotyped patterns of behavior, interests, and
activities, as manifested by at least one of the following:
 Encompassing preoccupation with one or more sterotyped and
restricted patterns of interest that is abnormal either in intensity or
focus
 Apparently inflexible adherence to specific, nonfunctional routines or
rituals
 Stereotyped and repetitive motor mannerisms (e.g., hand or finger
flapping or twisting, or complex whole-body movements)
 Persistent preoccupation with parts of objects
DSM IV Diagnostic Criteria for Asperger’s Disorder
 The disturbance causes clinically significant impairment in social,
occupational, or other important areas of functioning.
 There is no clinically significant general delay in language (e.g., single
words used by age 2 years, communicative phrases used by age 3 years).
 There is no clinically significant delay in cognitive development or in the
development of age-appropriate self-help skills, adaptive behavior (other
than in social interaction), and curiosity about the environment in
childhood.
 Criteria are not met for another specific Pervasive Developmental
Disorder or Schizophrenia.
In 4th grade Alissa appeared to be
sad, withdrawn and angry. She did not
sleep well, and reported that she
feared the devil would take her soul if
she slept too deeply. She appeared
drawn, tired and would ask staff and
students, even those she did not
know: “I don’t need to sleep, do
you?”
Survey of NDMDA Members
• N = 500
• 59% endorsed onset during childhood or
adolescence
• 48% did not get dx until consulting at least
3 professionals
• 10% did not get dx until consulting at least
7 professionals
Lish JD, Dime-Meenan J, Whybrow PC. J Affective Disorders, 1994, 31(4), 281-94
“Akiskal described the profile of a child at
risk to develop bipolar illness as one who
experienced emotions, whether they be
positive or negative, passionately and
intensely and whose mood and behavior was
dysregulated and disinhibited. Predictors of
bipolar outcome in adolescents with major
depression have been identified as a family
history of bipolar disorder, sudden onset of
symptoms, delusions, psychomotor retardation
and hypersomnia, pharmacologically induced
hypomania/mania (Akiskal and coworkers;
Strober and Carlson)”.
Cogan MB. Psychiatric Times, 13 (5), 1996
DSM IV Diagnostic Criteria for Manic Episode
 A distinct period of abnormally and persistently elevated, expansive, or irritable mood,
lasting at least 1 week (or any duration if hospitalization is necessary).
 During the period of mood disturbance, three (or more) of the following symptoms have
persisted (four if the mood is only irritable) and have been present to a significant degree:
 Inflated self-esteem or grandiosity
 Decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
 More talkative than usual or pressure to keep talking
 Flight of ideas or subjective experience that thoughts are racing distractibility (i.e.,
attention too easily drawn to unimportant or irrelevant external stimuli)
 Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)
 Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
 Excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).
Bipolar Disorder in Youth:
•
•
•
•

M>F
Mixed>manic or depressed, esp.
prepubertal [DeLong &
Aldershof 1987]
Mixed phase: dysphoria,
hypomania and agitation
intermixed
Incr. freq. of psychotic sxs,
grandiosity, bizarre
delusions
Of those with MDD prepubertally, 20-33% incidence of
Bipolar Disorder
The pediatrician increased the Ritalin
SR to address Alissa’s worsening
behavior but it was assumed that this
was causing insomnia. Mrs.
Chavarone urged the pediatrician to
give Alissa something to help her
sleep. The pediatrician prescribed
imipramine for sleep. Initially it was
helpful. Alissa’s mood improved. She
began to play with her sister, even if
the sister forgot to call her Pikachu.
In 5th grade Alissa had worsening difficulties. In
September it was attributed to transitioning back to
school, and a change in teachers due to an
unexpected illness in teaching staff. By October,
Alissa frequently left class and the playground on a
whim. She seemed to be in constant motion, almost
frantic. At times she would shriek at the top of her
lungs, or sing “Happy Birthday” in the middle of
class. Her mother initiated a referral for Special
Education services after chatting with another mother
on the MSN ADHD chat room. When the examining
School Psychologist asked Alissa why she insisted
that he call her Pikachu, she turned over his laptop
and threw a vase out his window. The vase hit a child
in a wheelchair below.
The school called the police, who took
Alissa in handcuffs to the Emergency
Room. The psychiatrist on duty told Alissa
that she was misbehaving terribly and would
not likely get many toys for Christmas if she
persisted in this way. She told him: “My
father spanks me everyday with a belt and I
still won’t behave, so kiss my ass doctor.”
Mrs. Chavarone confirmed that her husband
often used this form of discipline. The
Emergency Room social worker insisted on
reporting the family to CPS. The
psychiatrist wrote a 10-day prescription for
Mellaril to help Alissa “calm down.”
The new medication was initially
helpful and the pediatrician continued
the Mellaril. Alissa appeared a bit
sluggish and cognitively less sharp,
but her aggression decreased. The
pediatrician discontinued the
imipramine because the Mellaril had
been helpful for sleep. Alissa told a
classmate: “OK, I’m not really
Pikachu, I just like Pikachu.”
After your initial visit with
the patient, the parents tell
you that Alissa is starting to
“outgrow her ADD”, they
have limited funds and would
like to discontinue her
medications.
Discussion Issue 1:
What is the most likely
diagnosis?
Telling one from the other:
Why isn’t it easier?
 Many symptoms in common
 Some illnesses develop over time (like a
Polaroid picture – fuzzy at first, obvious
after the fact)
 Denial & minimization, lack of clinician
expertise, patient access to care
How does the clinician differentiate one
disorder from the other?





Inclusion and exclusion criterion (DSM-IV)
Pattern recognition (experience)
Family history
Progression of illness
? Response to interventions
 Positive and negative
 “Pharmacological dissection”
Differential Diagnosis
INCIDENCE
MEDIAN AGE FOR
CLINICAL
PRESENTATION
ADHD
MDI
ASP
5-7%
M:F::1-3:1
< 1%
M>F
< 0.5%
M>F
9 M
11 F
?
11
PSYCHOSIS NOT
UNCOMMON
EXACERBATION IN
ADOLESCENCE
COURSE OF ILLNESS
HYPERACTIVITY
DECREASES,
COMORBIDITY
INCREASES,
RESPONSE TO ADD
MEDS PERSIST
FH & GENETICS
HERED = 0.75
ASSOCIATED
FEATURES
LD, ODD, CD, MOOD,
ANX, SUBST AB
SUBST ABUSE
ADD SXS, OCD SXS.
MOOD 50%
TREATMENT
STIM, NON-STIM
ADD
MOOD STABIL,ANTI
PSYCHOTICS, APS
(COMPLEX
REGIMENS)
SSRIs,
ANTIPSYCHOTICS,
STIMS
HERED =
0.4-0.75
MZ CONCORD FOR
PDD SPECTRUM IS
90%, INCR FH MDI
Differential Diagnosis
PROGNOSIS
PSYCHOSOCIAL
TREATMENT
ADHD
MDI
ASP
FAIRLY GOOD
WITH TX
GUARDED
MINIMAL
CHANGE WITH
TX
ROLE OF
DECREASED
EE
FOCUS ON
STRUCTURE,
DECREASED
EE
Discussion Issue 2:
What further workup
is indicated?
Diagnostic Options for
Asperger’s Disorder













Hearing Evaluation
Vision Evaluation
IQ Testing
Speech and Language Evaluation
Chemistries, CBC, Thyroid Function Tests
Lead Level
Fragile X Testing
Amino Acids/Organic Acids
Chromosome karyotype
EEG
Brain MRI
Neurology Consultation
Genetics Consultation
Source: Posey, DJ, McDougle CJ.Autism:A Three-step Practical Approach to making the Diagnosis. Current
Psychiatry 2002;1:20-28.
Discussion Issue 3:
What would an ideal
treatment plan look
like for Alyssa?
Strategies for managing when
the diagnosis is uncertain
 Educate and engage parents re: uncertainty
 Develop a cascade of interventions (e.g. Plan A, Plan B,
Plan C)
 Assess level of parental support (e.g. respite, NAMI, CHADD)
 Address parental psychopathology
 Visit and re-visit FH of psychiatric illness
Set reasonable goals and timelines for interventions,
target specific symptoms, then follow closely
 Involve multiple informants
 Get consultation, especially peer-to-peer
EDUCATIONAL
INTERVENTIONS
Classroom Strategy and Effectiveness Rating [ADHD]
STRATEGY
FREQUENCY
EFFECTIVENESS
% OF TEACHERS
USING ON REGULAR
STUDENTS
Preferential Seating
4.2
3.9
53%
Routine and Structure
4.1
4.3
76%
Frequent Contact
4.0
4.1
76%
Use of Motor Breaks
3.6
3.7
61%
Curriculum Modifications
3.6
3.6
54%
Assignment Modifications
3.6
3.5
42%
Teach Self-Monitoring of
Behavior
3.5
3.7
70%
Individual Behavior Program
3.5
3.6
40%
Alternative Evaluations
3.4
3.5
55%
Environmental Modifications
3.3
3.6
59%
Use of Quiet Work Area
3.2
3.5
56%
Assistance During
Transitions
3.2
3.5
42%
Peer Tutoring
3.0
3.0
65%
Time Out
3.0
2.5
31%
Sensory Modulation
Techniques
2.6
2.3
26%
Source: Mulligan, S. Classroom Strategies Used by Teachers of Students with Attention Deficit Hyperactivity Disorder.
Physical & Occupational Therapy in Pediatrics, Vol. 20(4) 2001, 25-44.
Classroom Accommodations To Consider In ADHD
INSTRUCTION
 Adjust reading level
 Allow student to tape lectures
 Permit child to submit typed or word-processed
homework
 Provide a written outline for work when feasible
 Use peer tutoring
 Preprint chalkboard and oral instructions so that
students may refer to them later
Source: A Guide to the Educational Rights of Children with ADHD [pamphlet]. Shire US Inc. Florence, Kentucky, July 2002.
Classroom Accommodations To Consider In ADHD
TESTING
 Allow open-book tests
 Provide practice questions for study
 Give multiple-choice instead of short-answer
questions
 Permit the use of a dictionary or calculator
during test
 Provide extra time to complete work
Source: A Guide to the Educational Rights of Children with ADHD [pamphlet]. Shire US
Inc. Florence, Kentucky, July 2002.
Classroom Accommodations To Consider In
ADHD
COMMUNICATION
 Create a daily/weekly journal
 Schedule periodic parent/teacher meetings
 Provide parents and students with a duplicate set of
texts that they can use at home for the school year
 Develop weekly progress reports
 Mail a schedule of classroom and homework
assignments to student’s parents
Source: A Guide to the Educational Rights of Children with ADHD [pamphlet]. Shire US Inc. Florence, Kentucky, July 2002
Classroom Accommodations to Consider in
Asperger's Disorder
CONSIDERATIONS
 Visual Schedules
 Oral Presentations provided in written form
 Routine Predictable Schedule
 Sensory Outlet Breaks
 Placement in classroom offering least sensory
distraction
 Facilitate Social Relationships
A SIDE-BY SIDE COMPARISON OF
SECTION 504 AND IDEA
SECTION 504
IDEA
•A child is considered eligible for Section 504 if
ADHD substantially limits a major life activity
•In order to receive special education services,
ADHD must result in a child’s heightened
alertness to stimuli in the classroom that limits
his or her alertness in academic tasks
•A child not eligible for special education may still
receive related services if he or she meets the
eligibility requirements
•The effects of ADHD must be long lasting
(chronic) or have a substantial impact (acute)
Since learning is considered a major life activity,
a child is eligible under Section 504 if ADHD
substantially limits his or her ability to learn
ADHD must result in an adverse effect on
academic performance, and the student must
require special education services in order to
address his or her ADHD and its impact
Source: A Guide to the Educational Rights of Children with ADHD [pamphlet]. Shire US Inc. Florence, Kentucky,
July 2002.
A SIDE-BY SIDE COMPARISON OF
SECTION 504 AND IDEA
SUMMARY OF LEGAL REQUIREMENTS
SECTION 504
IDEA
•Prohibits discrimination on the basis of disability by
recipients of federal funds
•Requires that state and local districts make a free
appropriate public education available to all eligible
children with disabilities
Requires that a free appropriate public education
(FAPE) be provided to each qualified child who is
disabled, but does not require special education services
under IDEA. FAPE includes regular or special
education and related aids and services that are designed
to meet an individual student’s needs and are based on
adherence to the regulatory requirements for education
setting, evaluation, placement, and procedural
safeguards
Requires that the rights and protections provided by
IDEA are extended to children with ADHD and their
parents
Requires a local district to make an individualized
determination of child’s educational needs for regular or
special education, or related aids and services, if the
child is found eligible under Section 504
Requires that an evaluation be performed, without
undue delay, to determine if a child requires special
education services
Source: A Guide to the Educational Rights of Children with ADHD [pamphlet]. Shire US Inc. Florence, Kentucky, July,
2002.
A SIDE-BY SIDE COMPARISON OF SECTION 504
AND IDEA
SUMMARY OF LEGAL REQUIREMENTS
SECTION 504
IDEA
•Prohibits discrimination on the basis of disability by
recipients of federal funds
•Requires that state and local districts make a free
appropriate public education available to all eligible
children with disabilities
Requires that a free appropriate public education
(FAPE) be provided to each qualified child who is
disabled, but does not require special education services
under IDEA. FAPE includes regular or special
education and related aids and services that are designed
to meet an individual student’s needs and are based on
adherence to the regulatory requirements for education
setting, evaluation, placement, and procedural
safeguards
Requires that the rights and protections provided by
IDEA are extended to children with ADHD and their
parents
Requires a local district to make an individualized
determination of child’s educational needs for regular or
special education, or related aids and services, if the
child is found eligible under Section 504
Requires that an evaluation be performed, without
undue delay, to determine if a child requires special
education services
Source: A Guide to the Educational Rights of Children with ADHD [pamphlet]. Shire US Inc. Florence, Kentucky, July,
2002.
Treating ADD Symptoms
• PDDs:
– Expect less robust results with stimulants
– Anticipate lower mg/kg/d dosing for stimulants than in
ADHD
– Be alert for worsening of anxiety with stimulants
• Bipolar Disorder:
– Mood stabilization is #1 priority.
– ADD meds are added later.
OROS® Methylphenidate HCI qd (ConcertaTM)
Versus Methylphenidate HCI tid (Ritalin®)
OROS MPH 1x/d
MPH 3x/d
N = 61 ADHD children
6
5
4
Plasma
Concentration
3
(ng/mL)
2
1
0
0
1
2
3
4
5
6
7
8
9
10 11 12
Time (h)
Swamson JM et al. Comparison of efficacy and safety of ConcertaTM (methylphenidate HCL) with Riralin® and placebo
in children with ADHD. Presented at Region IX and X Annual Meeting of the Ambulatory Pediatric Association: February
12-13, 2000: Carmel, CA.
CONCERTA®: Dosing
The 27mg tablet
is now available
for increased
dosing flexibility
®
CONCERTA :
Dosing
• Results from a pivotal initiation study showed that
84% of patients titrated to their optimal dose required
doses above 18 mg:1
– 16% of patients were titrated to 18 mg
– 40% of patients were titrated to 36 mg
– 44% of patients were titrated to 54 mg
• Appropriate to initiate therapy with CONCERTA®1
– In truly naïve patients
– In patients who have previously used other therapies
– 96% of treated patients were successfully dose titrated
1
Swanson J et al. J Clin Res 2000;3:59-76.
METADATE CD:
ADDERALL XR
ADDERALL XR COMPONENTS
ATOMOXETINE
(Strattera)
 Highly selective noradrenergic reuptake inhibitor
 FDA approval 12/02 for children, adolescents & adults
 Non-stimulant
 2/3 as impactful as suggested by Connors rating
 No significant insomnia, tics, minimal appetite impact
 Sexual side effects, somnolence, dyspepsia, urinary retention
 Metabolized via CYP450 2D6
 Inhibited strongly by fluoxetine, paroxetine
 Buproprion and St. John’s Wort are weaker inhibitors
 Dose initiated at 0.5 mg/kg/d x 3d, then 1.4 mg/kg/d
 Deepening effect over the course of weeks
 May need to cross taper or augment with stimulants
The Medical Letter
On Drugs and Therapeutics
 Strattera
‘may be worth trying in patients who
 Have not responded to stimulants
 Cannot tolerate stimulants
 Do not want to take a controlled substance.’
 The Medical Letter, V45, February 3, 2003, pp. 11 – 13.
Monthly Retail Cost
AGENT
COST
DOSE
(MG)
COMMENT
ATOMOXETINE
$ 90
ANY ONE 10, 18, 25, 40,
CAP
60 MGS
ADDERALL XR
$ 73.20
20
CONCERTA
$ 74.70
36
 The Medical Letter, V45, February 3, 2003, p. 11.
Strategies for Managing
Asperger's Disorder
 Behavioral Treatment: Parent Education,
Structure, Decreased EE
 Psychopharmacologic Treatment
 Speech and Occupational Therapy
 Social skills training
 Assist Parents in obtaining “guaranteed”
appropriate education (i.e. Special Education)
either within district or elsewhere
COMMENTS?
QUESTIONS?
Richard S. Adler, M.D.
2910 E. Madison St., Suite #202
Seattle, WA 98112
(206) 621-9325
[email protected]
www.RichardAdlerMD.com
THANK YOU !
www.citizen.org/hrg
www.fda.gov
http://jama.ama-assn.org