Download ADHD Treatment

ADHD
Treatment
Objectives
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Be familiar with the evidence supporting
particular forms of management for ADHD,
including medication
Know the different classes of stimulant
medications and their potential side effects
Be familiar with Atomoxetine and its potential
side effects
CONTINUITY CLINIC
Recommendation 1:
Management Program
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Primary care clinicians should establish a
management program that recognizes
ADHD as a chronic condition
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Strong evidence
Strong recommendation
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CONTINUITY CLINIC
Recommendation 1:
Management Program
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Prevalence 4-12% of school-age children
60-80% persist into adolescence
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Inform, educate, counsel, demystify
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family, child
Resources
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local, national (CHADD, ADDA)
CONTINUITY CLINIC
Recommendation 1:
Management Program
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What distinguishes this condition from most
other conditions managed by primary care
clinicians is the important role that the
educational system plays in the treatment and
monitoring of children with ADHD.
CONTINUITY CLINIC
Recommendation 2:
Target Outcomes by Team
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The treating clinician, parents, and the
child, in collaboration with school personnel,
should specify appropriate target outcomes to
guide management.
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Strong evidence
Strong recommendation
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CONTINUITY CLINIC
Recommendation 2:
Outcomes- maximize function
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Relationships
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Disruptive behaviors
Academic performance
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work volume, efficiency, completion, accuracy
Individual
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parents, siblings, peers
self-care, self-esteem
Safety in the community
CONTINUITY CLINIC
Objectives of the Literature Review
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Effectiveness (short and long-term) and safety
of therapies
Medication and non-medication therapies
Single therapy vs combination
6-12 year olds
CONTINUITY CLINIC
Sources for Review
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Agency for Healthcare Research & Quality
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McMaster Univ. Evidence-based Practice Center
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Canadian Office for Health Technology
Assessment Study (CCOHTA)
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Multimodal Treatment Study (MTA Study)
Pelham et al. review of psychosocial therapies
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CONTINUITY CLINIC
Recommendation 2:
developing target outcomes
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Input
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parents, children (patient), teachers
3-6 key targets
realistic, attainable, measurable
methods will change over time
CONTINUITY CLINIC
School Interventions
Individual Education Plan
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IDEA = Individuals with
Disabilities Education Act
ADHD under “Other
Health Impaired”
Educational Disability
Services
CONTINUITY CLINIC
504 Plan
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Section 504 of the
Rehabilitation Act
ADHD medical diagnosis
Medical Disability with
educational impact
Accommodations
Recommendation 3:
make some recommendations
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The clinician should recommend stimulant
medication and/or behavior therapy as
appropriate, to improve target outcomes in
children with ADHD
Strong evidence (medication),
Fair evidence (behavior therapy)
Strong recommendation
CONTINUITY CLINIC
Recommendation 3:
Efficacy of Stimulants
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Short-term benefits well established
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Core symptoms: attention, hyperactivity, and
impulsivity
observable social and classroom behaviors
IQ and achievement testing- less effect
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CONTINUITY CLINIC
Recommendation 3:
MTA Study
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Effects over 14 months
579 children 7-9.9 years old
4 randomized groups
medication alone
 medication and behavior management
 behavior management
 standard community care
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CONTINUITY CLINIC
Recommendation 3:
MTA Study
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Medication management alone
Medication + behavior therapy
> Community management
> Behavior management alone
CONTINUITY CLINIC
The Stimulants
Nobody does it better
Short, intermediate (the “old” long-lasting),
truly long acting
 22 studies show NO difference between
methylphenidate, dextroamphetamine, or
mixed amphetamine salts (Adderall)
 Individual’s response may vary
 NO serologic, hematologic tests needed
**EKG – based on history and risk
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CONTINUITY CLINIC
Non-stimulants
Second rate-only 2
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Tricyclic antidepressants
9 studies alone
 4 studies =/< methylphenidate
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Bupropion (Wellbutrin, Zyban)
Clonidine
limited studies
 > placebo
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CONTINUITY CLINIC
Stimulants
Dose determination
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NOT weight dependent
Optimal effects with minimal side effects
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nothing ventured, nothing gained
Match target outcomes and timing
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crucial step prior to starting
CONTINUITY CLINIC
Stimulants
Side effects
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appetite suppression
stomachache, headache
delayed sleep onset
jitteriness
overfocused, dull demeanor
mood disturbances
CONTINUITY CLINIC
Stimulants
Side effects- NOT
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seizures- NO increased frequency with mph
growth delay- at least one negative study
Tourette syndrome
15-20% of patients have motor tics
 50% of TS have ADHD
 7 studies comparing stimulants vs placebo/other
show NO increase in tics with stimulants
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CONTINUITY CLINIC
Short
Intermediate Extended
3-4 hours
Methylphenidate
Ritalin
Focalin
5-6 hours
Ritalin 20 SR
Metadate ER
8-10 (12)hours
Concerta
Metadate CD
Ritalin LA
Dextroamphetamine Dexedrine
Dexedrine
spansule
Dextrostat
Adderall
CONTINUITY CLINIC
Adderall XR
CONTINUITY CLINIC
Atomoxetine Strattera
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Selective norepinephrine uptake inhibitor
Little effect on dopamine or serotonin uptake
Little effect on Ach, H1, alpha-2, DA receptors
Well-tolerated in adult and pediatric studies
CONTINUITY CLINIC
Atomoxetine...Randomized, PlaceboControlled, Dose-Response...
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297 children and adolescents
8-18 years old; 71 % male
70% had prior stimulant therapy
Combined/Inattentive/Hyper-impulsive
63/33/2 %
37 % Oppositional-defiant disorder
1 depression, 1 anxiety disorder
Atomoxetine…AD/HD…Study. Pediatrics 108:e83, 2001
CONTINUITY CLINIC
Side Effects
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Small samples:
dizziness 9% vs 1% placebo
 vomiting 6% vs 7%
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Weight loss dose dependent
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mean 0.4kg at 1.2 mg/kg/d
small pulse, BP changes
no EKG changes
<5% dropout rate atmx and placebo
Atomoxetine…AD/HD…Study. Pediatrics 108:e83, 2001
CONTINUITY CLINIC
Efficacy of Atomoxetine vs Placebo in
School-Age Girls with AD/HD
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52 children and adolescents
7-13 years old
Combined/Inattentive/Hyper-impulsive
79/21/0 %
38.5 % Oppositional-defiant disorder
13.5% phobias
Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002
CONTINUITY CLINIC
Measures
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ADHD Rating Scale- Parent
Conners’ Parent RS-Revised
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No Teacher ratings
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Clinical Global Impressions of ADHD SeverityClinician
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Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002
CONTINUITY CLINIC
Side Effects
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Small sample size subset here (279 total); so
no significant differences
Vomiting 19% vs 0%
Abdominal pain 29% vs 14%
Nausea 6.5% vs 14%
?Weight, cardiac...
Increased cough 16% vs 4.8%
Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002
CONTINUITY CLINIC
Atomoxetine and Methylphenidate...
Prospective Randomized, Open-Label Trial
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228 children and adolescents
184 atomoxetine, 44 mph; 10 weeks
7-15 year old boys; 7-9 year old girls
Most/all had prior stimulant therapy
Combined/Inattentive/Hyper-impulsive
76/23/1 %
53% ODD, 7% major depression
Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label
JAACAP 41:7, 2002
CONTINUITY CLINIC
Trial
Measures
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ADHD Rating Scale- Parent Completed
ADHD Rating Scale- Parent Interview
Conners’ Parent RS-Revised
No Teacher ratings
Clinical Global Impressions of ADHD
Severity- Clinician
Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label
JAACAP 41:7, 2002
CONTINUITY CLINIC
Trial
Findings
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Comparable improvement between the two
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mean dose 1.4 mg/kg/d extensive mtb,
0.5mg/kg/d slow mtb
mph
0.85 mg/kg/d, (31mg/d)
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High rate of dropouts
Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label
JAACAP 41:7, 2002
CONTINUITY CLINIC
Trial
Findings
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43% of mph, 36 % atmx dropped out!
11%; 5 % because of adverse effects comparable
atomoxetine wt loss avg 0.6 kg; (mph 0.1)
small changes both in pulse, BP
EKG, labs no problems, no differences
Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label
JAACAP 41:7, 2002
CONTINUITY CLINIC
Trial
Side Effects
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Generally comparable
Vomiting 12% vs 0%
Abdominal pain 23% vs 17.5% (NS)
Nausea 10% vs 5% (NS)
?Weight, cardiac...
Cough 5% same
“Thinking abnormal” 0% vs 5% (N=2)
Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label
JAACAP 41:7, 2002
CONTINUITY CLINIC
Trial
Pros
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No abuse potential
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adolescent usage
adult usage
24/7 coverage
No tic relationship
Novel class of med
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and
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Little data head to head vs
stimulants
Weight loss/vomiting
Takes week(s) to effects
Tolerance
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use with stimulants, too
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CONTINUITY CLINIC
Cons
“starter kit” issue
adjust if SSRI added
Cost
Behavior Therapy
accept no substitutes
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Behavior therapy
Emotions-based therapy
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e.g. play therapy-NOT efficacious in ADHD
Thought patterns directed
cognitive, cognitive-behavioral therapy
 NOT efficacious in ADHD
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CONTINUITY CLINIC
Behavior Therapy
Parent Training
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8-12 weeks with trained therapist
teaches parent skills
incorporates maintenance and relapses
improves child’s functioning and behavior
not necessarily achieves normal behavior
CONTINUITY CLINIC
Behavior Therapy
Examples of Techniques
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Positive reinforcement
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Time-out
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removing positive reinforcement
Response cost
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reward for performance
losing advance rewards
Token economy
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combination
CONTINUITY CLINIC
Behavior Therapy
Meta-analyses difficult and few
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Must be maintained to be effective
Stimulant effects much > behavioral therapy
MTA study: combination > med alone, but not a
statistically significant difference
 However, parents and teachers more satisfied
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Schools can implement
504 Plan
 IEP
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CONTINUITY CLINIC
Recommendation 4:
When to re-evaluate
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When the selected management for a child
with ADHD has not met target outcomes,
clinicians should evaluate the original
diagnosis, use of all appropriate treatments,
adherence to the treatment plan, and
presence of coexisting conditions
Weak evidence
Strong recommendation
CONTINUITY CLINIC
Recommendation 4:
Ddx in re-evaluation
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unrealistic target symptoms
poor information regarding child’s behavior
incorrect diagnosis and/or
coexisting condition interfering
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ODD, conduct disorder, mood, anxiety, LD
poor adherence/compliance
treatment failure
CONTINUITY CLINIC
Recommendation 4:
Steps in re-evaluation
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Re-establish target symptoms
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“team” communication
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Gather further information, other sources
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Consider consultation
Consider psycho-educational testing
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CONTINUITY CLINIC
Recommendation 4:
True treatment failure
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Lack of response to 2-3 stimulants
maximum dose without side effects
 any dose with intolerable side effects
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Inability to control child’s behavior
Interference of coexisting condition
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Refer to mental health
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CONTINUITY CLINIC
Recommendation 5:
follow-up guidelines
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The clinician should periodically provide a
systematic follow-up for the child with
ADHD. Monitoring should be directed to
target outcomes and adverse effects by
obtaining specific information from parents,
teachers, and the child.
Fair evidence
Strong recommendation
CONTINUITY CLINIC
Recommendation 5:
follow-up guidelines
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Team management plan
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Recording clinical data
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not just : “What does the doctor recommend?”
flow sheet, progress note
Interview, T-Con, teacher reports, report
cards, checklists
CONTINUITY CLINIC
Recommendation 5:
frequency of follow-up
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NO controlled trials document the
appropriate frequency
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MTA study: more frequent did better, BUT
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Once stable, visit every 3-6 months
CONTINUITY CLINIC
Conclusion nuggets
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ADHD is a chronic condition
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Explicit negotiations regarding target
outcomes are key
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Stimulant and behavior therapy use are the
mainstay of therapy
CONTINUITY CLINIC