ADHD

Clinical FeaturesO Mainly:

O Attention deficitO HyperactivityO ImpulsivityO Functional impairmentO Above features must be present

before age 7 yrsO Impairment in > 1 setting

O DSM-IV criteria for ADHD

Clinical FeaturesO Salient manifestations change during

adolescenceO Hyperactivity diminishesO Academic and peer problems magnify

Clinical FeaturesO Other characteristics of adolescents

with ADHDO Often seem emotionally immature O ProcrastinateO Easily distracted and have difficulty

completing projectsO Have significant sleep disturbances

ComorbiditiesO There is a high rate of comorbidity

O Oppositional defiant disorderO Conduct disorderO Substance use disorderO Mood disorderO Antisocial personality disorder

O Ask about symptoms of these disorders also

Co-Existing DiagnosesO Children with mild to moderate

degrees of intellectual disability may have symptoms consistent with ADHD and may respond to medications

O Children with pervasive developmental disorders may also have ADHD symptoms and may benefit from medical treatment for ADHD

AssessmentO Parents and primary classroom

teacher are rich resourcesO Homework patterns O School gradesO Daily routinesO Classroom behaviorO Social relationships

O Children with ADHD tend to under-report their level of impairment dramatically

AssessmentO At increased risk of specific learning

disordersO ReadingO MathO Written expression

O Encourage parents to request (in writing) that school complete a multidisciplinary evaluation

AssessmentO In the ADHD evaluation, clinician

must also assess for co-existing conditionsO Emotional or behavioral

O Anxiety, depression, ODD, conduct disorder

O DevelopmentalO Learning or language disorder, other

neurodevelopmental disordersO Physical

O Tics, sleep apnea

ADHD Rating ScalesO Vanderbilt parent and teacher scalesO Conners’ parent and teacher rating

scalesO Swanson, Nolan and Pelham

Questionnaire IV teacher and parent rating scale (SNAP-IV)

O Disruptive Behavior Disorder ScaleO ADHD Rating Scale

O All free except Conners’

Pharmacologic ManagementO Methylphenidate

O RitalinO Ritalin LAO Ritalin SRO ConcertaO FocalinO MethylinO Methylin ERO Metadate ERO Metadate CD

O Amphetamine compoundsO AdderallO Adderall XRO DexedrineO Dexedrine

SpansuleO DextroStat

Pharmacologic ManagementO Short-term adverse effects of

stimulants:O Appetite suppressionO Sleep disturbancesO Abdominal pain

O Controversial association with stimulant use and…O Motor tic developmentO Height / weight decrement

Pharmacologic ManagementO Straterra (atomoxetine)

O Highly specific noradernergic reuptake inhibitor

O Efficacy for ADHD + anxiety/tics/depression

O Consider if:O Unresponsive to stimulantsO Family prefers nonstimulant O Concern for stimulant abuse

Pharmacologic ManagementO Atomoxetine adverse effects

O Sedation (during initial titration)O Appetite suppressionO Nausea / vomitingO Headaches

Pharmacologic ManagementO Anti-depressants are off-label and

2nd-lineO TricyclicsO Wellbutrin (buproprion)

Pharmacologic ManagementO Tricyclics

O Block the reuptake of neurotransmitters including norepinephrine

O Consider only when:O Adequate trials with both stimulant

medications have failed,O Atomoxetine is ineffective, ANDO Behavioral interventions have been

tried

Pharmacologic ManagementO Common adverse effects of tricyclics

O SedationO Weight gainO Dry mouthO ConstipationO Headache

O EKG monitoring at baseline and at therapeutic dose is suggested

Pharmacologic Management

O Clonidine (Catapres)O AntihypertensiveO 2nd line esp. with adolescents with

ADHD + tics/aggression/conduct disorder

O Commonly used as adjuvant

Pharmacologic ManagementO Clonidine short term adverse effects

O SedationO Dry mouthO DepressionO ConfusionO EKG changesO Hypertension with abrupt withdrawal

Pharmacologic ManagementO Guanfacine (Tenex)

O Alpha-2 agonistO Used to treat ADHD + tic disorders

O Venlafaxine (Effexor)O Noradrenergic reuptake inhibitorO May have mild efficacy for ADHD

Pharmacologic ManagementO Monoamine oxidase inhibitors

(Nardil, Parnate)O Limited usefulness due to:

O Potential hypertensive crises with tyramine-containing foods (most cheeses)

O Interactions with prescribed, illicit, OTC drugs

O Pressor amines, most cold medicines, amphetamines

Psychosocial Treatments

O Behavior therapyO Broad set of specific interventions that have

common goal of modifying physical and social environment to change behavior

O Academic interventionsO Services enhanced if child is eligible under:

O Section 504 of Rehabilitation ActO “Other Health Impaired” of Individuals with

Disabilities Education ActO Family therapyO Care coordination

Anticipatory GuidanceO Substance abuse

O Youths with ADHD experiment earlier than other children

O Auto accidents and traffic violationsO Parents can restrict passengers and

time of day car is usedO Parents should discuss these topics

often and follow up aggressively on any suspicions

First-Line ManagementO Preschool-aged children (4 - 5 years of age)

O Parent and/or teacher-administered behavior therapy is first line

O Methylphenidate if no significant improvement and moderate-to-severe functional impairment

O Elementary school-aged children (6 - 11 years)O Medication and/or behavior therapy, preferably

bothO Adolescents (12 – 18 years)

O Medication + behavior therapy, preferably both

EducationO Provide basic understanding of the

disorderO Destigmatize by comparing it to less

stigmatizing conditions (ex: asthma)O Remind patients it is not a reflection

of their intelligence

Factors Promoting Adherence

O Self-conceptO Family stabilityO Internal locus of controlO Increased motivationO Simplified medication regimenO Lack of adverse effectsO Characteristics of the doctor-patient

relationship

ReferencesO Subcommittee on Attention-Deficit/Hyperactivity

Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011 Nov;128(5):1007-22

O Wolraich ML, Wibbelsman CJ, Brown TE, Evans SW, Gotlieb EM, Knight JR, Ross EC, Shubiner HH, Wender EH, Wilens T. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005 Jun;115(6):1734-46.