What are the most common signs of ADHD? And what are the most common medication interventions?

Transcription

1 What are the most common signs of ADHD? And what are the most common medication interventions? Bennett Gertz, MD, FAAP Developmental Behavioral Pediatrician Children s Developmental Health Services Albertina Kerr Disclosure Nothing to disclose 1

2 Overview Basics of ADHD Common presentations Medications Treatment Strategy Basics of ADHD Executive Functioning Attention Impulse Control Monitoring Planning and Sequencing Working Memory Emotional Regulation 2

3 Basics of ADHD Executive Functioning We are not born with it Arises in early childhood (3-4y) Maturation through early adulthood (mid-20s) Varies with level of arousal Basics of ADHD Symptoms Inattentiveness Hyperactivity Impulsivity 3

4 Basics of ADHD Symptoms Inattentiveness poor regulation, motivation dependent Difficulty sustaining attention (and shifting) Easily distracted Fails to finish tasks Careless mistakes Avoids tasks that require sustained attention Seems not to listen Difficulty organizing Loses things Forgetful Basics of ADHD Symptoms Hyperactivity poor body control Fidgety Unable to stay seated Moves excessively Difficulty engaging in leisure activities quietly On the go Talks excessively 4

5 Basics of ADHD Symptoms Impulsivity lack of cognitive brakes Blurts answers before questions are finished Difficulty awaiting turn Interrupts/intrudes on others Basics of ADHD Subtypes Predominantly Inattentive (Previously known as ADD) 6/9 Inattentive Symptoms Predominantly Hyperactive-Impulsive 6/9 Hyperactive-Impulsive Symptoms Combined Type All of the above Most common 5

6 Basics of ADHD Criteria Symptoms present in at least 2 settings (home and school) Persistent for at least 6 months Present prior to age 12 (was age 7 in DSM-IV) Symptoms cause problems Symptoms are not better described by another disorder Not mutually exclusive with Autism (new in DSM-5) Basics of ADHD Statistics About 10% of school children 60-85% of children with ADHD continue to meet criteria as teens Less than half outgrow the diagnosis as adults More than 70% positive response to stimulant medication Heritability estimated at about 75% 6

7 Common Presentations Disobedience Aggressive behavior Conflict with peers Daydreamer Performance not matching abilities Autism? Bipolar? Basics of ADHD Comorbidities 54-84% with Oppositional Defiant Disorder 25-35% with language or learning problem Up to 33% with anxiety Up to 33% with mood disorder 50-60% experience peer rejection Large overlap with ASD 7

8 Medications Stimulant Medications Methylphenidates (Ritalin, Concerta, Metadate CD, Daytrana, Quillivant, Focalin XR, etc.) Amphetamines (Adderall, Adderall XR, Vyvanse, Dexedrine) Strattera Alpha-2 Agonists Guanfacine (Tenex and Intuniv) Clonidine (Kapvay) Treatment Strategy Start with a stimulant Try the other one Try Strattera Consider Alpha-2 Consider combination Balancing side effects Managing duration of effect 8

9 Adverse Reactions: Stimulants Decreased appetite in about 30% Weight loss in about 10% Skipping lunch may be associated with nutritional defficiencies Sleep problems Also common with untreated ADHD (delayed sleep onset, increased night wakings) May be secondary via rebound Irritability Direct vs. rebound vs. low blood sugar Adverse Reactions: Stimulants Tics (exacerbation) Common in the general population (up to 4% of children) Often arise in early school age Typically wax and wane Cardiac Increased heart rate Increased blood pressure Depression/Social withdrawal 9

10 Adverse Reactions: Strattera See above Less likely to interfere with sleep Less likely to exacerbate anxiety More likely to have GI side effects Adverse Reactions: Alpha-2 Agonists Somnolence Hypotension/bradycardia/AV block Irritability/depression Withdrawal/rebound hypertension with abrupt withdrawal 10

11 Treatment Goals Eradicate all signs of ADHD? Help performance meet abilities Improve compliance with behavioral approaches Increase independence Improve safety Minimize side effects Manage comorbidities Treatment Duration Not a lifetime commitment Need to re-evaluate periodically Consider time off over the summer if doing well Keeping the child part of conversation so they can eventually participate in the decision making 11

12 Resources AAP ADHD Toolkit, 2 nd Edition CHADD.org ParentsMedGuide.org Russell Barkley, PhD: Taking Charge of ADHD Edward Hallowell, MD: Driven to Distraction Peg Dawson, EdD: Smart but Scattered Ellen Galinsky: Mind in the Making CME Topic for the next Project ECHO tele-clinic: Behavioral Interventions for ADHD: Important Resources for Parents Jennifer Simon-Thomas, PhD Pediatric Clinical Psychologist Children s Developmental Health Services Albertina Kerr 12