ADHD Assessment and Treatment in Primary Care

Transcription

1 ADHD Assessment and Treatment in Primary Care Matthew Tolliver, Ph.D., Assistant Professor, ETSU Pediatrics Dr. David Wood, Professor and Chair, ETSU Pediatrics

2 ADHD in Teenagers We have no financial disclosures. 13 November 2018 David L. Wood, MD, MPH

3 What is Attention Deficit Hyperactivity Disorder? The term ADHD refers to Attention Deficit Hyperactivity Disorder, a condition that makes it difficult for children to pay attention and/or control their behavior.

4 AAP: Youth should meet DSM-5 criteria before making a dx A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development Not just oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. Sx prior to age 12 years and occur in 2+ settings Interfere with social, academic, or occupational functioning

5 Diagnose cont. Based on the these criteria, three types of ADHD are identified: 1. ADHD, Combined Type: if both criteria A and B are met for the past 6 months. Tigger type-hyperactive, restlessness, disorganized, inattention, impulsivity

6 Diagnose cont. 2. ADHD, Predominantly Inattentive Type: if criterion A is met but criterion B is not met for the past six months Pooh type- Inattentive, sluggish, slow-moving, unmotivated, daydreamer

7 Diagnose cont. 3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion B is met but Criterion A is not met for the past six months. Rabbit Type- over focused, obsessive, argumentative

8 What ADHD is not Laziness Lack of Intelligence Bad attitude The parents fault Irresponsibility

9 Specific culture, age, gender features ADHD is known to occur in various cultures, with variations in reported prevalence among Western countries probably arising from different diagnostic practices than from differences in clinical presentation

10 Epidemiology CDC estimates 4.4 million youth ages 4-17 have been diagnosed with ADHD In 2003, 2.5 million youth ages 4-17 are currently receiving medication treatment for the disorder.

11 Difference in diagnoses between boys and girls ADHD Boys Girls (Pastor & Reuben, 2008)

12 ADHD by Race ADHD Hispanic White (not H) Black (not H) (Pastor & Reuben, 2008)

13 Percent of Youth 4-17 ever or currently diagnosed with Attention- Deficit/Hyperactivity Disorder: National Survey of Children's Health, Currently Diagnosed Ever Diagnosed

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16 Lifetime Impairments of ADHD Disruptive behavior Low self-esteem Smoking Substance use Crime Car accidents Anxiety Depression ODD, CD Relationship failures Poor work history Chronic substance abuse and dependence Incarceration Pre-school School-age Adolescence College-age Adult Academic failure Poor socialization Self-esteem issues Injuries Academic failure Occupational failure Substance abuse Slide courtesy of Joseph Biederman, MD.

17 AAP Rec s for Assessment 1. Youth who present with inattention/hyperactivity should be evaluated 2. Youth should meet DSM-5 criteria before making a dx 3. Assessment requires direct evidence from parents and teachers regarding core symptoms, duration, and degree of impairment. 4. Assess for comorbid conditions. 5. Other diagnostic tests not indicated to establish diagnosis (evidence: strong, recommendation: strong). (AAP, PEDIATRICS Volume 128, Number 5, November 2011)

18 Inattention Scale Impulsivity Scale

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20 AAP: Assess for comorbid conditions (Chankalal & Daily, 2014)

21 Prevalence of Comorbid Conditions (Larson, Russ, Kahn, & Halfon, 2011)

22 NIMH Multimodal Treatment Study of Children with ADHD Study Groups Med Management Behavior Therapy Combined TAU (medicated in community) -large 14 month RCT 7-9 y/o kids -19 outcome measures -all 4 groups improved (MTA Comparative Group, 1999) 22

23 NIMH Multimodal Treatment Study of Children with ADHD F/U Time Finding 14 months Meds > BT; combined brought no advantages 24 months -Med & Combined groups lost up to 50% of their effect (smaller differences between groups) 36 months -groups did not differ significantly on any measure 8 years -type/intensity of original tx did not predict current functioning -early ADHD sx trajectory most predictive Young adulthood -Extended use of medication associated with suppression of adult height, but not with reduction of symptom severity compared to other groups (Jensen et al., 2007; MTA Cooperative Group, 2004; Swanson et al., 2017)

24 Medication: Stimulants Most well-researched, effective, and commonly used medication treatment for ADHD. Methylphenidate (Ritalin, Concerta, and Metadate) Dextroamphetamine (Adderall) These medications reduce ADHD symptoms by: Blocking the reuptake of norepinephrine (NOR) and dopamine (DOP) and facilitating their release Enhances NOR and DOP availability in in certain brain regions: PFC and basal ganglia

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26 Additional Medications Used Clonidine (Catapress and Kapvay) and Guanfacine (Tenex and Intuniv) Alpha-2 agonists Can help with sleep and aggression and attention/impulsivity Side effects Sleepiness, fatigue, Hypotension Constipation, Dry Mouth

27 Acupuncture Meditation Homeopathy Physical exercise Chiropractic care St. John s wort Music or play therapy Bach flower remedies Elimination diets Hypericum perforatum St. John s Wort

28 Treatment of ADHD in Primary Care

29 Active Ingredients in Behavioral Interventions Predictability/ consistency Practice/ repetition Differential reinforcement Proximity of consequences to bx

30 Preschool Elementary Adolescent Well Established Behavioral Parent Training Bx Classroom Management Combined Bx Mgt Intervent. Behavioral Parent Training Bx Classroom Management Bx Peer Intervention Organization Training Combined Bx Mgt Intervent. Organization Training Probably Efficacious Combined training treatments with relevant skills and extensive practice and feedback Possibly Efficacious Neurofeedback Training Behavioral Parent Training Experimental Cognitive Training Combined training treatments: skills relevant to daily functioning but with limited practice/feedback. CBT techniques & brief behavioral parent training Questionable Efficacy Social Skills Training Physical Activity Omega 3/6 supplements (Evans, Owens, Wymbs, & Ray, 2018)

31 Framework for Brief Bx Parent Training Psychoed about ADHD regular parenting approach vs. advanced ADHD parenting skills Message: Child behaviors are not caregivers fault, but they can play a special role to help

32 Behavioral Interventions to Address Home Behaviors Point/token systems Visual supports timers/clocks, posted rules/routines Reinforcement of + behavior Effective commands Planned ignoring Time out/loss of privileges Organizational skills, HW plan Establish house rules/structure When then contingencies

33 Interventions to Address School Problems Daily Report Card (home-school note) Request FBA Advocacy for IEP/504 plan Organizational skills Class-wide interventions (Good Bx Game) Encourage parent-teacher communication

34 Bibliography AAP. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents. Pediatrics CDC Resources: Cowan, D. (2007), The ADHD information library. Retrieved from Evans, S. W., Owens, J. S., Wymbs, B. T., & Ray, A. R. (2018). Evidence-Based Psychosocial Treatments for Children and Adolescents With Attention Deficit/Hyperactivity Disorder. Journal of Clinical Child and Adolescent Psychology, 47(2), doi: / Jensen, P. S., Arnold, L. E., Swanson, J. M., Vitiello, B., Abikoff, H. B., Greenhill, L. L.,... Hur, K. (2007). 3-Year follow-up of the NIMH MTA study. Journal of the American Academy of Child and Adolescent Psychiatry, (8), Key Findings: Trends in the Parent-Report of Health Care Provider-Diagnosis and Medication Treatment for ADHD: United States, See: Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD, Pediatrics, 127(3), doi: /peds M. T. A. Cooperative Group. (2004). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder. Pediatrics, 2004(4), Molina, B. S. G., Hinshaw, S. P., Swanson, J. M., Arnold, L. E., Vitiello, B., Jensen, P. S.,... Houck, P. R. (2009). The MTA at 8 years: Prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child and Adolescent Psychiatry, 48(5), doi: /chi.0b013e31819c23d0 Russell Barkley Resources: Swanson, J., Arnold, L. E., Kraemer, H., Hechtman, L., Molina, B., Hinshaw, S.,... Wigal, T. (2008). Evidence, interpretation, and qualification from multiple reports of long-term outcomes in the Multimodal Treatment Study of Children with ADHD (MTA): Part II: Supporting details. Journal of Attention Disorders, 12(1), doi: / Swanson, J. M., Arnold, L. E., Molina, B. S. G., Sibley, M. H., Hechtman, L. T., Hinshaw, S. P.,... Kraemer, H. C. (2017). Young adult outcomes in the follow up of the multimodal treatment study of attention deficit/hyperactivity disorder: Symptom persistence, source discrepancy, and height suppression. Journal of Child Psychology and Psychiatry, 58(6), doi: /jcpp.12684