Download The Role of the Primary Care Provider in the Diagnosis and

The Role of the Primary Care Provider
in the Diagnosis and Treatment of
Attention Deficit / Hyperactivity
Disorder
Carla M. Thacker
PAS 646
March 22, 2007
Basic ADHD Information
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Most common neurological and behavioral
disorder in childhood
One of the most frequently identified chronic
childhood disorders seen in the primary care
setting
Core symptoms are inattentiveness,
hyperactivity, and impulsiveness
Statistics
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In 2003, the CDC reported that
approximately 4.4 million children ages 4-17
in the US had a diagnosis of ADHD
An estimated 4-12% of children in the
community are affected by ADHD
There is a significant difference in the
prevalence of ADHD in boys and girls, with
estimates of 10% and 4%, respectively
ADHD often results in the following:
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Difficulties in school
Poor relationships with parents and peers
Low self-esteem
Various other behavioral, learning, and
emotional problems
Difficulties for the child’s parents, including
marital problems, increased stress, and poor
relationships with their child
Etiology
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Exact etiology of ADHD is unknown
Thought to be a complex interaction between
neurological, biological, & environmental
factors
Genetics and biological factors play the
major roles
Variation in genes regulating dopamine,
norepinephrine, & serotonin in the brain
Predisposing Factors
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Low birth weight
Low social status
Severe conflicts among parents
Being placed in foster care
Mother who smoked, consumed alcohol
and/or drugs while pregnant.
Symptoms Suggestive of ADHD:
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Easily distracted by sights and sounds in
their environment
Difficulty concentrating for long periods of
time
Becomes restless easily
Excessive impulsiveness
Frequent daydreaming
Slow to complete tasks
Diagnosis
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Use of AAP guidelines:
Evaluate children 6-12 yrs. presenting with core
symptoms of ADHD
 Must meet DSM-IV criteria
 Gather information about symptoms from various
settings from the parents & school system
 Assess for coexisting mental health & learning
problems
 Order diagnostic tests as indicated by findings
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Diagnosis
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Need a detailed patient & family history
Interview with patient & family
Obtain report cards & teacher reports
Obtain a thorough physical examination
including visual & auditory screening
Refer patient to mental health specialist if
coexisting mental disorders or learning
disabilities suspected
Subtypes of ADHD (Based on DSM-IV
Criteria)
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Predominantly hyperactive-impulsive type –
no significant inattention
Predominantly inattentive type – no
significant hyperactive-impulsive behavior
(previously known as ADD)
Combined type- both inattentive &
hyperactive-impulsive behaviors
Treatment
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Currently no cure for ADHD
Three types of treatment:
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Medication management
Behavioral therapy
Combination of medication & behavioral therapy
Medications for ADHD
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Stimulants – shown to improve core
symptoms by increasing & maintaining
balance of dopamine & serotonin in brain
Non-stimulants (atomoxetine) – enhances
noradrenergic function through presynaptic
reuptake of norepinephrine
Stimulants
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Some available in short-acting, long-acting, and
extended release forms.
Produce relatively quick response in patient
Schedule II controlled substance – potential for
abuse
Side effects – loss of appetite, insomnia, HA,
dizziness, abdominal pain
Begin with lowest dosage & titrate up as necessary
Commonly Used Stimulants
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Methylphenidate (Ritalin) – long-acting form
is Concerta, extended-release forms are
Ritalin SR, Metadate ER, & Metadate CD
Amphetamine (Adderall)
Dextroamphetamine (Dexedrine, Dextrostat,
and Focalin)
Pemoline (Cylert) – no longer considered
first-line due to risk of hepatotoxicity
Non-Stimulants (atomoxetine)
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Slower response times than stimulants
Non-scheduled drug – no potential for abuse
Side effects similar to those of stimulants
Atomoxetine (Straterra) is the only non-stimulant
approved by the FDA to treat childhood ADHD
More expensive than stimulants
Others sometimes used are antidepressants;
including bupropion (Wellbutrin) & despiramine, &
antihypertensives; including clonidine & guanfacine
Methylphenidate (Ritalin) vs.
Atomoxetine (Straterra)
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Recent study analyzed all clinical trials which
compared the two drugs
More patients responded to Ritalin than Straterra &
responses were quicker with Ritalin
Study confirmed that stimulants are the most
efficacious treatment for childhood ADHD
Straterra is a good alternative treatment when
stimulants are not well tolerated or when drug abuse
is a potential problem
New ADHD Treatment Option
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The 1st and only stimulant prodrug,
lisdexamphetamine (Vyvanse) was granted market
approval by FDA in Feb. 2007
Therapeutically inactive until contact is made with GI
tract – only active if swallowed
May prevent abuse of drug by those who snort or
inject crushed pills
Recent study showed that 95% of children taking
Vyvanse produced “much improved” or “very much
improved” rating on Clinical Global Impressions
rating scale
Conclusion
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ADHD is a disorder in which research must
continue in order to determine it’s etiology &
to obtain more information regarding safety
of treatments.
Due to increasing numbers of children with
ADHD, it is very important for primary care
physicians to become skilled at diagnosing
and treating the disorder.
References
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Adesman, A. The diagnosis and management of attention-deficit/hyperactivity disorder in pediatric
patients. Primary Care Companion J Clin Psychiatry 2001; 3: 66-77.
Foy, J., Earls, M. A process for developing community consensus regarding the diagnosis and
management of attention-deficit/hyperactivity disorder. Pediatrics 2005; 115: e97-e104.
Furman, L. What is attention-deficit hyperactivity disorder (ADHD)? J Child Neurol 2005; 20(12): 9941003.
Gibson, A.P., Bettinger T.L., Patel, N.C., Crismon, M.L. Atomoxetine versus stimulants for treatment of
attention deficit/hyperactivity disorder. Ann Pharmacother 2006 Jun; 40(6): 1134-42.
Greydanus, D.E. Pharmacologic treatment of attention-deficit hyperactivity disorder. Indian J Pediatr
2005; 72: 953-960.
Harpin, V.A. The effect of ADHD on the life of an individual, their family, and community from preschool to
adult life. Arch Dis Child 2005; 90: i2-i7.
Karande, S. Attention deficit hyperactivity disorder: A review for family physicians. Indian J Med Sci
2005; 59: 547-556.
Kuntsi, J., McLoughlin, G., Asherson, P. Attention deficit hyperactivity disorder. Neuromolecular Med.
2006; 8(4): 461-84.
Leslie, L. The role of primary care physicians in attention deficit hyperactivity disorder (ADHD). Pediatr
Ann 2002 August; 31(8): 475-484.
References (Continued)
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Leslie, L. et al. Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder
diagnostic guidelines in primary care settings. Pediatrics 2004 July; 114(1): 129-140.
Mental health in the United States. Prevalence of diagnosis and medication treatment for attentiondeficit/hyperactivity disorder—United States, 2003. MMWR Morb Mortal Wkly Rep 2005; 54(34):
842-7.
Olfson, M. New options in the pharmacological management of attention-deficit/hyperactivity disorder.
Am J Manag Care 2004; 10: s117-s124.
Steer, C.R. Managing attention deficit/hyperactivity disorder: unmet needs and future directions.
Arch Dis Child 2005; 90: i19-i25.
Wolraich, M.L. et al. Attention-deficit/hyperactivity disorder among adolescents: A review of the
diagnosis, treatment, and clinical implications. Pediatrics 2005; 115(6): 1734-46.
www.cdc.gov
www.nimh.nih.gov
www.shire.com
www.webcenter.health.webmd.netscape.com
www.wellmark.com
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