The ADHD Journey. Angelina Wiwczor, Nurse Practitioner

Transcription

1 The ADHD Journey Angelina Wiwczor, Nurse Practitioner

2 Disclosure * I do not have any conflicts of interest to declare

3 Objectives * 1. Epidemiology of ADHD * 2. Review DSM 5 diagnostic criteria for ADHD * 3. Discuss treatment options, including behavioural and medications * 4. Discuss when to refer patients with ADHD

4 Case #1: George * 8y.o. Grade 2 * Parents are requesting an assessment for George because he is always getting into trouble at school * He gets into fights on the playground and doesn t have any close friends that parents know of * He likes to do things his own way and when playing with peers is quick to interrupt or redirect them * George tends to get along better with children younger than him * George is smart and gets all A s and B s * George loves lego and can sit for hours building things, but generally he is a kid on the go and can play with a multitude of toys in an afternoon * Dad says George is just like me when I was his age!

5 Case #2: Angela * 11y.o. Grade 4 * Teachers have requested that Angela be assessed for ADHD * Parents don t have any issues with Angela at home * She has always been a bit of a day dreamer, but she is a good kid and has several good friends * However at school this year Angela s grades have dropped from mostly B s to mostly C s * She is day dreaming in class, forgetting to hand in work, and the work she does hand in is often rushed and incomplete * Angela is frustrated with her homework after school * Angela s room has always been messy at home * She is an only child and parents prompt her to get ready in the morning and stay on time * Angela is involved in karate, swimming, and girl guides

6 Epidemiology * ADHD is the most common psychiatric disorder in pediatrics affecting between 5-12% school aged children * Very well studied and widely accepted neurobiological condition * Up to 60% of children/adolescents with ADHD continue to have impairments into adulthood * Overall, ADHD is one of the best-researched disorders in medicine, and the overall data on its validity are far more compelling than for many medical conditions. (Goldman et al., 1998) Polanczyk, G., et al., The worldwide prevalence of ADHD: a systema?c review and metaregression analysis. Am J Psychiatry, (6): p Canadian ADHD Resource Alliance (CADDRA) - h"p://

7 ADHD Diagnosis * A persistent pattern of inattention and/ or hyperactivity-impulsivity that interferes with functioning or development, as characterized by inattention and/or hyperactivity * Symptoms interfere with functioning or development * Symptoms start before age 12 * Symptoms identified in 2 or more settings

8 Inattention * Six or more (children) five or more (adolescent/adult) of following symptoms for at least 6 months: * Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. * Often has trouble holding attention on tasks or play activities. * Often does not seem to listen when spoken to directly. * Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, sidetracked). * Often has trouble organizing tasks and activities. * Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). * Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). * Is often easily distracted * Is often forgetful in daily activities. Diagnostic Criteria- D SM-5

9 Hyperactivity/Impulsivity * Six or more (children), five or more (adolescent/adult) of following symptoms for at least 6 months: * Often fidgets with or taps hands or feet, or squirms in seat. * Often leaves seat in situations when remaining seated is expected. * Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). * Often unable to play or take part in leisure activities quietly. * Is often "on the go" acting as if "driven by a motor". * Often talks excessively. * Often blurts out an answer before a question has been completed. * Often has trouble waiting his/her turn. * Often interrupts or intrudes on others (e.g., butts into conversations or games Diagnostic Criteria- D SM-5

10 Diagnosis- Data gathering * Made by a combination of: 1. Medical history 2. Parent/teacher rating scales 3. Physical examination 4. Supporting documentation (IPRC, IEP, report cards etc.) * Various rating scales exist: * SNAP- IV * ADHD Checklist * Vanderbilt

11

12

13

14 Difficulties in making a diagnosis * Histories are subjective * Symptoms need to be present in 2 or more settings * In young children, there is not often consensus on whether there is a problem * Discord often between parent and teacher questionnaires (School often prompts the referral) * Office visits are too short for full assessment * Office behaviour is an insensitive measure of daily behaviour * CADDRA guidelines offer tools to help organize an ADHD assessment over multiple visits

15

16

17

18

19

20

21 Assessing dysfunction * School- poor marks, behavioural difficulties etc. * Home- poor familial relationships, ADLs, dangerous behaviours etc. * Extra-curricular activities * Social relationships- friends, teachers etc. * Emotionally- self-esteem, mood, anxiety etc.

22 Differential Diagnosis * Anything that can affect attention levels need to be considered in the differential diagnosis * Our job is to rule out other medical conditions that cause inattention * Helps with the buy in of the ADHD diagnosis * Thorough history, ROS, and physical exam will help to identify any possible conditions * Blood work or other investigations rarely ever necessary if normal assessment

23 Differential Diagnosis * Learning problems * Specific Learning Disorder, cognitive disability * Psychiatric/psychologic conditions * Autism, oppositional defiant disorder, mood disorder, anxiety, panic attacks, obsessive compulsive disorder, Tourette syndrome, substance use, bipolar disorder * Medical conditions * Genetic disease (Fragile X, Neurofibromatosis, metabolic disease) * Medical disease (anemia, thyroid, absence seizures) * Other * Fetal Alcohol Spectrum Disorder * Sleep disorder * Post-concussive * Hearing/Vision

24 Comorbidities * 50-90% of children have at least one comorbidity * ~50% have 2 or more comorbidities * Specific learning disorders occur in 40% of patients with ADHD Canadian ADHD Resource Alliance (CADDRA) - h"p://

25 Comorbidities can include * Mood Disorders * Anxiety Disorders * Behavioural Disorders * Learning Disorders * ASD * Medical * Seizures, tics, sleep-related disorders

26 Principles of Management * Education of patients and families * Behavioural/occupation interventions * Psychological assessment/treatment * Education accommodations * Medical management

27 Recognize the Impact * Child * Siblings * Parents

28 Management * Once diagnosis is made, discuss medical and non-medical options * Non-medical * Behavior therapy * Omega-fatty acids (EPA doses > 600mg) * Literature suggests no role for other nutritional interventions * However each case is different and many families are convinced that a certain food type is implicated in their child s behavior * Decide risk/benefit (ex. red dye versus gluten free) * Environmental accommodations (ex. Classroom) Bloch, M. Omega-3 Fa"y Acid Supplementa<on for the Treatment of Children with A"en<on-Deficit/Hyperac<vity Disorder Symptomatology: Systema<c Review and Meta-Analysis. Journal of the American Academy of Child and Adolescent Psychiatry October 2011, 50 (10). Millichap,G. The Diet Factor in A"en<on-Deficit/Hyperac<vity Disorder. Pediatrics 2012; 129;330.

29 Environmental accommodations * Direct instruction, repetition, and frequent clarification * Preferential seating to alleviate distractibility * Additional time for assignments and class work * Testing on computer or orally where appropriate * Quiet environment for tests/assignments * Listening to headset during individual class work time * Assignments broken down into manageable chunks * Assistance with time management * Scribes where necessary/appropriate

30 Parenting Tips * Stay positive * Establish structure and stick to it * Set clear expectations and rules * Encourage movement and sleep * Balanced nutrition * Teach social skills

31 Management- Medical Options * First line options: stimulant medications * Methylphenidate- based versus amphetamine-based * Large evidence to support the efficacy of stimulants in treating ADHD * All are marketed as long-acting, once-a-day * Second line option: Strattera (Atomoxetine) * Third line/adjunctive treatment: Intuniv XR (Guanfacine XR) Canadian ADHD Resource Alliance (CADDRA) - h"p://

32

33 Management * All stimulants have similar common side-effect symptoms: * Appetite suppression * Increased sleep latency * Abdominal pain * Headaches * Exacerbation of tics * Blood pressure changes

34 Management * Rare but severe side-effects/reactions: * Exacerbation of other psychiatric disorders (ex. bipolar) * Stimulant-induced psychosis * Lowered seizure threshold * Abuse/Dependence * Sudden cardiac death (?)

35 Sudden Cardiac Death (SCD) * In 2005, postmarketing data from the FDA indicated a small but potentially increased risk of sudden cardiac death in children taking Adderall XR * In response to this Health Canada initially removed Adderall from the market, then reinstated its sale with a black box warning similar to what was released by the FDA: * Sudden death has been reported in association with amphetamine treatment at usual doses in children with structural cardiac abnormalities. Adderall XR generally should not be used in children or adults with structural cardiac abnormalities. VeXer, V. Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Medica<ons for A"en<on Deficit/Hyperac<vity Disorder. Circula?on 2008; 117 (18).

36 Sudden Cardiac Death (SCD) * In response, the American Heart Association (2008) suggested ECG screening for all patients prior to starting stimulants * In contrast, the Canadian Pediatric Society felt the data suggesting cardiovascular risk was weak and that evidence did not exist that routine ECG screening would somehow prevent death in predisposed patients * Since then several larger studies have shown the risk of SCD in patients on stimulants to be the same as the general population * Current recommendations suggest a screening history for possible underlying cardiac disease only and avoid prescribing in patients with positive history Belanger, S. Cardiac risk assessment before the use of s?mulant medica?ons in children and youth. Paediatr Child Health 2009;14(9):579-85

37 Screening Questions for SCD (CPS) Belanger, S. Cardiac risk assessment before the use of s?mulant medica?ons in children and youth. Paediatr Child Health 2009;14(9):

38 Medication choices * Based primarily on: * Can patient swallow pills? * Onset of action and duration of coverage needed * Age/weight of patient, dosing titration * Family history of medication use * Affordability * Medication interactions * Comorbid conditions * Risk of side-effects * Physician comfort/preference

39

40 Writing prescriptions * Stimulants are controlled substances * Dispensing amount, frequency and total quantity * No substitutions for generic products

41 Medication Decisions * Always start on lowest possible dose and titrate up slowly * Explain to parents * What symptoms we are targeting * What symptoms we are NOT targeting * Goal: appropriate benefit to side-effect balance

42 Follow-up plans * Re-evaluate benefits and side-effects of medication at each visit * Use parent/teacher rating scales as objective evidence * May choose to see every 1-2 weeks, slowly titrate up dose to desired effect (go slow, no rush!) * Decision to increase/decrease dose based entirely on balance of benefits to side-effects

43 Follow-up plans * If severe side-effects, just discontinue medication * In future may consider trying another medication (preferably from a different category) * If there is either insufficient benefit or excessive S/E * Consider adjusting dose * Determine timing of symptoms and need for longer acting stimulant * Consider adding adjunctive therapy to target desired symptoms (ex. Intuniv, SSRI, etc )

44 When to Refer * Children <6y.o. * Considering using adjunctive medications * Significant side effects from medications * Comorbid diagnoses

45 Summary * ADHD is a clinical diagnosis * ADHD can cause significant impairment in all aspects of life * Don t stress about making the diagnosis right away, there is no rush! * Multimodal treatment includes: * Education * Behavioural interventions * Psychological assessment/treatment * Medication * It is our job to educate families on ADHD, but in the end it s up to the patient and parents as far as what they want to do about it * Refer: complex case, multiple drugs, comorbid dx

46 Case #1: George * 8y.o. Grade 2 * Parents are requesting an assessment for George because he is always getting into trouble at school * He gets into fights on the playground and doesn t have any close friends that parents know of * He likes to do things his own way and when playing with peers is quick to interrupt or redirect them * George tends to get along better with children younger than him * George is smart and gets all A s and B s * George loves lego and can sit for hours building things, but generally he is a kid on the go and can play with a multitude of toys in an afternoon * Dad says George is just like me when I was his age!

47 Case #1: George * SNAP questionnaires were positive for significant inattention and hyperactivity/impulsivity * Parents and teachers have already been implementing behavioural interventions for years * Parents agree to trial medication * Biphentin start at 15mg, increase to 20mg * Follow up in 6 weeks * Parents notice a big difference in George s ability to play with peers his own age

48 Case #2: Angela * 11y.o. Grade 4 * Teachers have requested that Angela be assessed for ADHD * Parents don t have any issues with Angela at home * She has always been a bit of a day dreamer, but she is a good kid and has several good friends * However at school this year Angela s grades have dropped from mostly B s to mostly C s * She is day dreaming in class, forgetting to hand in work, and the work she does hand in is often rushed and incomplete * Angela is frustrated with her homework after school * Angela s room has always been messy at home * She is an only child and parents prompt her to get ready in the morning and stay on time * Angela is involved in karate, swimming, and girl guides

49 Case #2: Angela * SNAP questionnaires were positive for inattention * Parents agree to trial medication * Concerta start at 18mg, increase to 27mg * Angela notices a big difference in her ability to concentrate and complete her homework

50 Objectives * 1. Epidemiology of ADHD * 2. Review DSM 5 diagnostic criteria for ADHD * 3. Discuss treatment options, including behavioural and medications * 4. Discuss when to refer patients with ADHD

51 Resources * Belanger, S. Cardiac risk assessment before the use of s?mulant medica?ons in children and youth. Paediatr Child Health 2009;14(9): * Bloch, M. Omega-3 Fa"y Acid Supplementa<on for the Treatment of Children with A"en<on-Deficit/Hyperac<vity Disorder Symptomatology: Systema<c Review and Meta-Analysis. Journal of the American Academy of Child and Adolescent Psychiatry October 2011, 50 (10). * Canadian ADHD Resource Alliance (CADDRA) - h"p:// * Millichap,G. The Diet Factor in A"en<on-Deficit/Hyperac<vity Disorder. Pediatrics 2012; 129;330. * Polanczyk, G., et al., The worldwide prevalence of ADHD: a systema?c review and metaregression analysis. Am J Psychiatry, (6): p