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ADHD Treatment Objectives 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 Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition Strong evidence Strong recommendation CONTINUITY CLINIC Recommendation 1: Management Program Prevalence 4-12% of school-age children 60-80% persist into adolescence Inform, educate, counsel, demystify family, child Resources local, national (CHADD, ADDA) CONTINUITY CLINIC Recommendation 1: Management Program 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 The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management. Strong evidence Strong recommendation CONTINUITY CLINIC Recommendation 2: Outcomes- maximize function Relationships Disruptive behaviors Academic performance work volume, efficiency, completion, accuracy Individual parents, siblings, peers self-care, self-esteem Safety in the community CONTINUITY CLINIC Objectives of the Literature Review 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 Agency for Healthcare Research & Quality McMaster Univ. Evidence-based Practice Center Canadian Office for Health Technology Assessment Study (CCOHTA) Multimodal Treatment Study (MTA Study) Pelham et al. review of psychosocial therapies CONTINUITY CLINIC Recommendation 2: developing target outcomes Input parents, children (patient), teachers 3-6 key targets realistic, attainable, measurable methods will change over time CONTINUITY CLINIC School Interventions Individual Education Plan IDEA = Individuals with Disabilities Education Act ADHD under “Other Health Impaired” Educational Disability Services CONTINUITY CLINIC 504 Plan Section 504 of the Rehabilitation Act ADHD medical diagnosis Medical Disability with educational impact Accommodations Recommendation 3: make some recommendations 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 Short-term benefits well established Core symptoms: attention, hyperactivity, and impulsivity observable social and classroom behaviors IQ and achievement testing- less effect CONTINUITY CLINIC Recommendation 3: MTA Study 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 CONTINUITY CLINIC Recommendation 3: MTA Study 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 CONTINUITY CLINIC Non-stimulants Second rate-only 2 Tricyclic antidepressants 9 studies alone 4 studies =/< methylphenidate Bupropion (Wellbutrin, Zyban) Clonidine limited studies > placebo CONTINUITY CLINIC Stimulants Dose determination NOT weight dependent Optimal effects with minimal side effects nothing ventured, nothing gained Match target outcomes and timing crucial step prior to starting CONTINUITY CLINIC Stimulants Side effects appetite suppression stomachache, headache delayed sleep onset jitteriness overfocused, dull demeanor mood disturbances CONTINUITY CLINIC Stimulants Side effects- NOT 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 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 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... 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 Small samples: dizziness 9% vs 1% placebo vomiting 6% vs 7% Weight loss dose dependent 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 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 ADHD Rating Scale- Parent Conners’ Parent RS-Revised No Teacher ratings Clinical Global Impressions of ADHD SeverityClinician Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002 CONTINUITY CLINIC Side Effects 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 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 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 Comparable improvement between the two mean dose 1.4 mg/kg/d extensive mtb, 0.5mg/kg/d slow mtb mph 0.85 mg/kg/d, (31mg/d) High rate of dropouts Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label JAACAP 41:7, 2002 CONTINUITY CLINIC Trial Findings 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 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 No abuse potential adolescent usage adult usage 24/7 coverage No tic relationship Novel class of med and Little data head to head vs stimulants Weight loss/vomiting Takes week(s) to effects Tolerance use with stimulants, too CONTINUITY CLINIC Cons “starter kit” issue adjust if SSRI added Cost Behavior Therapy accept no substitutes Behavior therapy Emotions-based therapy e.g. play therapy-NOT efficacious in ADHD Thought patterns directed cognitive, cognitive-behavioral therapy NOT efficacious in ADHD CONTINUITY CLINIC Behavior Therapy Parent Training 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 Positive reinforcement Time-out removing positive reinforcement Response cost reward for performance losing advance rewards Token economy combination CONTINUITY CLINIC Behavior Therapy Meta-analyses difficult and few 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 Schools can implement 504 Plan IEP CONTINUITY CLINIC Recommendation 4: When to re-evaluate 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 unrealistic target symptoms poor information regarding child’s behavior incorrect diagnosis and/or coexisting condition interfering ODD, conduct disorder, mood, anxiety, LD poor adherence/compliance treatment failure CONTINUITY CLINIC Recommendation 4: Steps in re-evaluation Re-establish target symptoms “team” communication Gather further information, other sources Consider consultation Consider psycho-educational testing CONTINUITY CLINIC Recommendation 4: True treatment failure Lack of response to 2-3 stimulants maximum dose without side effects any dose with intolerable side effects Inability to control child’s behavior Interference of coexisting condition Refer to mental health CONTINUITY CLINIC Recommendation 5: follow-up guidelines 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 Team management plan Recording clinical data 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 NO controlled trials document the appropriate frequency MTA study: more frequent did better, BUT Once stable, visit every 3-6 months CONTINUITY CLINIC Conclusion nuggets ADHD is a chronic condition Explicit negotiations regarding target outcomes are key Stimulant and behavior therapy use are the mainstay of therapy CONTINUITY CLINIC