Evaluation and Treatment of AD/HD in the Primary Pediatric

Transcription

1 Evaluation and Treatment of AD/HD in the Primary Pediatric Clinic Carolyn Lentzsch-Parcells, MD Assistant Professor University of Kentucky, Department of Pediatrics April 9, 2009 GOALS The learners will gain a better understanding of what AD/HD is. The learners will understand how to initiate and conduct an appropriate evaluation for AD/HD in the primary pediatric setting. The learners will better understand how to initiate and manage an AD/HD treatment plan. 1

2 Objectives The audience will be able to: List key diagnostic criteria. List at least 5 conditions included in differential diagnosis of AD/HD. Discuss the steps involved in evaluation of AD/HD in the child or adolescent. Know where to find the resources for evaluation of AD/HD. List the situations in which referral for further testing or evaluation should be made. List the key components to treatment. Background Estimated 5-10% of school age children Symptoms affect all areas of life academic, social, cognitive and behavioral performance. Symptoms persist to adulthood in 60-70% Children, adolescents, and adults with ADHD are at greater risk for experimentation with and abuse of alcohol and drugs, school and job failure, and accidental injuries. Differential Diagnosis is extremely broad and improper diagnosis can have serious consequences 2

3 Background NIMH Multimodal Treatment Study of AD/HD showed that children receiving closely monitored medication with or without behavioral management showed improvements at home and school and in relationships more so than seen with behavioral treatment alone or typically community management. Proper and early treatment leads to improved life long prognosis. Differential Diagnosis of ADHD 2004 UpToDate Contact Us 3

4 Differential Diagnosis of AD/HD Normal variation Gifted Learning disability (20-60%) Depression (33%) Bipolar Anxiety (33%) OCD ODD Child abuse/neglect Neurodegenerative disorder Diabetes Mellitus Sensory deficit Substance abuse Medication effects Sleep disorder Undernourished WHAT IS AD/HD? 4

5 Brief Review There are 3 basic subtypes of symptoms: Hyperactivity it Inattention Impulsivity Manifestations Hyperactivity Fidgeting Over talkative Difficulty sitting still Problems playing quietly Restless, agitated, or always on the go 5

6 Manifestations Inattention Losing / misplacing things Disorganization Poor academic performance Absent minded / forgetful Poor completion of tasks Decreased attention to detail Distractible Manifestations Impulsivity Interrupting others or talking out of turn Difficulty waiting turns Accidental trauma Disruptive behavior Ready, Fire, Aim. Don t forget overly focused!! 6

7 DSM-IV Criteria Key features of DSM-IV Criteria for ADHD: Symptoms present in at least 2 settings Symptoms for > 6 months Onset of symptoms before 7 y.o. Impaired occupational, academic, or social functioning Symptoms inappropriate for stage of development NO OTHER DISORDER ACCOUNTS FOR SYMPTOMS Classifications of AD/HD Inattentive type (ADHD I) Hyperactive-Impulsive type (ADHD-HI) Combined type (ADHD-C) Proper nomenclature: AD/HD Proper nomenclature: AD/HD, Inattentive Type. 7

8 What Causes AD/HD? (we re not really sure) What we do know It is a brain-based disorder the basis of which is largely genetic likely due to multiple interacting genes Some cases may be caused by external factors such as prenatal or perinatal complications or exposures Dietary factors continuing area of research 8

9 What we do Know Several differences in structure and function of prefrontal and frontal cortices and basal ganglia have been shown. Possible increase of norepinephrine with decrease of inhibition by dopamine But what is AD/HD, really? (What is it like?) (What does this mean for our Patients?) 9

10 Please Read the Following: Next Step p HOW DO WE DIAGNOSE AD/HD? 10

11 AAP Guidelines: STEP 1 In a child 6-12 year old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate i i an evaluation for ADHD. STEP 2 To Assess for DSM-IV criteria (may take multiple office visits): History Developmental onset/course of symptoms, developmental milestones, days of school missed, life stressors, observe interaction between parent and child Medical prenatal environmental exposures, prenatal trauma/infections, chronic illnesses, head trauma, CNS infections, recurrent otitis media, medications Family History ADHD, learning disabilities, problems in school? Heritability = about 80%. 11

12 Step 2 Social History Sleep, diet, mood, bullying Changes at home or school Stressors Talk to the child alone if possible Actively look for other diagnosis STEP 2 Full Physical with attention to: Height, weight, FOC, vitals Neurologic exam Look for neurocutaneous or dysmorphic features 12

13 AAP Guidelines: Step 3 the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and ddegree of ffunctional limpairment i Step 3 May be accomplished by interview or by using Rating scales. Narrowband scales focus on ADHD specific symptoms are used for diagnosis. Sensitivity and specificity of > 90% In Adolescents: Have patient rate self!! Note: a significant other or close friends may be a candidate to complete rating scale if the adolescent is no longer living with a care taker. 13

14 AAP Guidelines: Step 4 the assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions Step 4 Evaluating teacher should have at least 6 months of close contact with the patient. Teacher evaluation should include: Teacher rating scale Narrative describing class room behavior, functional impairment, learning patterns, and classroom interventions Report cards and samples of school work 14

15 Rating Scales Conner s Scales Parent scale Teacher scale NICHQ Vanderbilt Assessment Scale Parent scale Teacher scale Follow up scales Other resources AAP Guidelines: Step 5 evaluation of the child with ADHD should include assessment for associated (coexisting) conditions Typically screened for in History with yp y y referrals, lab tests, and further evaluation conducted as needed. 15

16 AAP Guidelines: Step 6 other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions (e.g., learning disabilities and mental retardation). Including blood lead levels, psychometric testing, thyroid hormone levels, and neuro imaging NOTE Always reevaluate when symptoms Always reevaluate when symptoms change or get worse you may have the wrong diagnosis or there may be a co morbid condition lurking. 16

17 When to Refer Refer to psychiatrist, developmental pediatrician, neurologist, educational specialist, Nero psychologist or other when: Child is <6 y.o. (debatable) Or there is concern of: Developmental disorder Visual or hearing impairment Learning disability Mental retardation History of abuse Co morbid behavioral or emotional problems Chronic illness Seizure disorder Sever aggression Treatment failure KNOW YOUR OWN LIMITATIONS!! Case 1 First visit, New Patient CC: Mother of this 7 yo female states My Daughter bounces off the walls. What do you want to know? 17

18 Case 1 First visit, New Patient HPI: 7yo y.o. girl, bounces off the walls, " cannot have a conversation without getting distracted. Has to have one-on-one help at school to stay on task. Currently in special reading class at school, but mom is unsure of the extent of the evaluation the school has done. Reports auditory sensitivity. Gets overly focused on projects. ROS: Wakes at night. Snores some. No asthma, some seasonal allergies. Case 1 First Visit PMHX/FamHX: No chronic problems, hospitalization or surgeries, normal development and birth hx Family history: no diabetes, allergies or asthma. Dad is diagnosed with ADHD and on Concerta. Child has done some counseling. No family history of psychiatric disorder 18

19 Case 1 First Visit Child Social History: Parent information: Divorced parents-single mom; lives with mom. Parents divorced when she was 5 y.o. Starting to have more contact with dad. Home occupants: Immediate family Parents smokers: Yes Child-parent bonding/ interaction: Good per mom School performance: Good (as reported by mother). Case 1 First Visit PE: very busy, happy child. Otherwise negative including neurological exam. 19

20 Vanderbilt forms brought to this visits: Parent Teacher Inattention 9 Inattention 6 Hyperactivity 6 Hyperactivity 6 Oppositional 3 Oppositional 2 Anxiety/Depression 3 Anxiety/depression 3 Average Performance Average Performance Score = 0.5 Score = 0.67 Assessment and Plan: Tentative diagnosis of ADHD combined type made. Started on Vyvanse 20 mg q am Referred to ENT/sleep study Recommended family counseling Instructed mom to talk to the school regarding testing that had been done, and have results sent to me. Follow up in one month 20

21 Case 1 Second Visit What do you want to know? Case 1 Second Visit School performance is improving, but still difficult for her. Sleep is the same, appetite fine, no stomach ache or head ache. Having difficulty with discipline but better on medication. Seems to wear off after school. Hearing and vision screens normal. Weight good. BP normal. PE unchanged 21

22 Assessment/Plan After discussing the options with Mom and patient, we chose to continue Vyvanse 20 mg q am. Mom and teachers to do follow up Vanderbilt forms Continue to pursue ENT/sleep evaluation, counseling, and information on testing from school. Follow up in one month. Case 1 - Third visit What do you want to know? 22

23 Third Visit Irritable after school - possibly slightly more than before the medicine. She says she feels tired on the medicine. No other side effects. Working on getting sleep study done financial difficulties. School has already done LD evaluation - apparently no LD but getting special help in reading. Math and other grades have come up. Has found counseling - getting ready to start. Wt and BP good. PE unchanged. Assessment and Plan Change to Focalin 5 mg po qam. Increase to 10 mg q am after about 3 days if no side effects and still with poor symptom control. After 3 days call to discuss. Start counseling. Follow up with sleep study. Appears that school had conducted LD evaluation. Mom to call with school number so I can talk to learning specialist. Follow up in 1 month. 23

24 Follow up Visits Follow up side effects and efficacy of medication. Changes made at school and home how are they working? How is the echild ddoing goverall. ea Follow-up visits Always reevaluate when symptoms Always reevaluate when symptoms change or get worse you may have the wrong diagnosis or there may be a co morbid condition lurking. 24

25 Case 2 Established Patient CC:15 yo female presents with wanting to change her contraception and concerns that she has ADD. Case 2 Why does she think she has ADD? She watched a movie in which one of the characters had ADD and she thinks she similar symptoms. 25

26 Case 2 HPI: Difficulty concentrating in school Difficulty completing tasks at home Grades are F s and a B Started 2 years ago. Before that she had no difficulty with concentration and got A s and B s in school Case 2 ROS: Difficulty getting to sleep and staying asleep Mood is ok most days Easily irritable and angered 26

27 Case 2 PMHX: None reported. On review of the chart, another physician was concerned for depression 1 year ago. FamHX: Mom has history of depression requiring hospitalization SocHX: She moved from out of state 2 years ago Case 2 PE: Normal exam including neurological exam. Alert and oriented. Affect appropriate. Cooperative. 27

28 Case 2 Assessment and Plan: Depression NOS Counseling and start antidepressant THIS IS NOT ADHD!! Case 3 Established Patient 12 yo male with difficulty in school Gets in trouble at 12 yo male with difficulty in school. Gets in trouble at school for talking out of turn, being rude to teachers, angry verbal outbursts, difficulty completing tasks. At home, does not do chores sometimes because he forgets, and at times because he just doesn t want to. The family doesn t know what to do anymore. 28

29 Case 3 ROS negative PMHX: Diagnosed with ADHD for years. Previously Concerta helped, but he had side effects. Mom concerned about using any medication. No other medical problems. Famhx: NC SocHX: Parents are together. Current financial stress. PE unremarkable fairly closed off during visit Case 3 Assessment and Plan: Repeat Vanderbilts Gather information from teachers Discussed various medications Start family counseling ASAP! Follow up in 1 month 29

30 Case 3 Over several visits and with a lot of feed back from teachers Vanderbilts ADHD inattentive type, some ODD components. Through report cards and teacher comments worst grades were in math and science this is also when he got in trouble Case 3 After chart diving School testing did not show an LD in math but independent testing by SS did and mom was never told. 30

31 Case 3 With class accommodations in math and Vyvanse, he is now getting good grades, teachers state he is a pleasure to have in class, and he s doing the dishes without arguing. CASE 4 7 y.o. boy presents with a history of inattention, difficulty sitting still, interrupting people, and emotional labiality and home and school. Mother reports these behaviors have been a problem since about 4 y.o. According to the mother, the boys 1 st grade teacher has noticed similar problems since the beginning of school. What would you do? 31

32 CASE 4 The boy is diagnosed with ADHD and placed on Ritalin. The mother comes back very concerned because the boy is now throwing fits and often seems out of control. He has increased emotional labiality li and irrational i behavior during these episodes. Now what? Long Story Short After being taken off Ritalin. After 5 years of being diagnosed with everything from ADHD to OCD At age 13, he was finally diagnosed correctly with bipolar disorder and placed on Lithium which was then changed to Valproic Acid. He went on to graduate 2 nd in his high school class and National Honor Society. 32

33 Treatment Plan Multimodal Treatment Plan Education and participation of parent and child. Behavioral management School interventions Medication (or not) Possible family therapy* Sleep hygiene and nutrition* 33

34 Education This takes time and often repetition over several visits. Discuss what AD/HD is and treatment options. Address myths and preconceived notions Refer to National Resource Center on ADHD and CHADD. Don t forget the child!! Behavioral Management Consists of teaching children, parents, and teachers specific skills that will improve child s behavior. By consistently altering the parents and teachers response to the child s behavior, the child is taught new behaviors. Ideally to be carried out by a mental health professional specializing in AD/HD. 34

35 Behavioral Modification The only non-medical intervention for AD/HD with substantial supportive data. Positive prognostic indicators for those with AD/HD: effective parenting skills relationships with other children success in school. All of which can be addressed with behavioral modification Behavioral Management Basic Principles: The ABC s Antecedent, Behavior, Consequences Parents and teachers can intervene in the antecedent event and set consequences to change behavior. Baby steps: Pick one behavior or habit at a time to work on and build up. 35

36 Behavioral Modification Starts with parent training Often met with resistance Techniques to help them work with, not against, the child Most successful with professional help Behavioral Modification Topics addressed in Parent Training as taken directly from NRC What We Know handout 7: Establishing house rules and structure Learning to praise appropriate behaviors and ignoring mild inappropriate behaviors (choosing your battles) Using appropriate commands Using when then contingencies (withdrawing rewards or privileges in response to inappropriate behavior) 36

37 Behavioral Modification Planning ahead and working with children in public places Time out from positive reinforcement (using time outs as a consequence for inappropriate behavior) Daily charts and point/token systems with rewards and consequences School-home note system for rewarding behavior at school and tracking homework Behavioral Modification School Interventions Is the teacher trained in developing a plan for AD/HD students? Encourage parents to work closely with teachers With permission i from parents, confer with teacher and/or learning specialist directly See Appendix A from NRC #7. 37

38 Behavioral Modification Peer relationships Key interventions ti Social skills training Teaching Social problem solving Improving any antisocial behaviors Teaching other skills important for social activities (sports, games, ) One best friend is a protective factor foster this relationship. Behavioral Modification May teach these skills in individual or May teach these skills in individual or group setting including camps. 38

39 Behavioral Management Key Points: Change starts with the parents and Teachers. CONSISTANCY, CONSISTANCY, CONSISTANCY!! This is different from counseling/therapy Behavioral Modification For more information See NRC AD/HD What We Know #7: Psychosocial Treatment for Children and Adolescents with AD/HD. Includes suggested reading for professionals and parents. 39

40 School Interventions Behavioral Modification as above. Identify specific problems and help student develop and implement solution Example: looses home work assignments. Solution: Get one binder with color coded folders for each subject, color coded teacher plan book, extra paper for brain dump. School Interventions IDEA VS Section 504 Individuals id with Disabilities Educational Act (IDEA) For more impaired students Eligibility determined by team of professionals which may include psychologists, teachers, principle, p etc Psychoeductional testing, reports from teachers and doctors and other data may be used Provides for Individualized Education Program (IEP) which states specific goals, accommodations and services for student 40

41 School Intervention To initiate IDEA or Section 504 School may initiate evaluation on their own Physician can write letter requesting evaluation for accommodations Parents may request evaluation Process varies by school district, but the school MUST adequately evaluate the child with in 90 days. Encourage parents to call school every few weeks or more to follow up - A phone call from the primary practitioner can go a long way School Interventions Section 504 of Rehabilitation Act Disability must interfere with a major life activity Provides for accommodations such as tape recording lectures, note taking assistance, testing accommodations Less formal evaluation, but must includes data from multiple sources 504 Plan includes specific accommodations and interventions Child must be reevaluated before any changes are made. 41

42 Medications Considerations Severity of impairment Needs of patient and family Compliance Medical history (seizures, tics, co-morbid disorders) Family history What has worked or not worked Other disorders (i.e. bipolar) that may affect medication choice Medications Stimulants - Have been used since % of AD/HD patients will show improvement with stimulants Exact mechanism of action unknown but believed to block dopamine and norepinephrine reuptake. Common Side effects: headache, decreased appetite, difficulty sleeping, stomach upset, stimulant rebound, elevated blood pressure (less common), short term weight changes. 42

43 Medications Stimulants Methylphenidates: Short Acting: Ritalin, Methylin Long acting: Daytrana (transdermal), Ritalin LA, Ritalin SR, Concerta, Medidate ER, Medidate CD, Methylin ER Dexmethylphenidate (Focalin XR and Focalin SR) more active enantiomer of racemic methylphenidate. Concentration peaks twice about 4 hours apart. Medications - Stimulants Amphetamines Dextroamphetamine (Dexedrine and DextroStat) short acting Dextroamphetamine/amphetamine (Adderall and Adderall XR) Intermediate and long acting respectively. Blocks reuptake of dopamine and norepinephrine. Lisdexamfetamine Dimesylate (Vyvanse) prodrug that is converted to active drug dextroamphetamine by first-pass intestinal/hepatic metabolism. Less risk of abuse. More consistent metabolism. Long acting. 43

44 Medications - Stimulants Management Start t with low dose and adjust every 3-7d days (if possible) until lowest effective dose reached with few to no side effects. Dosage does not necessarily correlate to weight or severity Mild side effects may resolve over about 1 week* Follow up every 1-2 weeks until medication and dosage established, then in about 1 month, then every 3 months. Continue to re-evaluate effectiveness with data from teachers, parents and patient Monitor closely for side effects at every visit including BP, Ht, wt. Medications Non-stimulants Primarily used when stimulants are not effective, intolerable side effects with stimulants, unable to use stimulants, or as adjuvant to stimulants. Most were developed at Most were developed at antidepressants and effect norepinephrine and/or dopamine 44

45 Medications Non-stimulants Atomoxetine (Straterra) inhibits norepinephrine uptake. Must be taken every day. Bupropion Hydrochloride (Wellbutrin) weakly inhibits reuptake of serotonin, dopamine, and norepinephrine. Must be taken every day. Clonidine (Catapres) and Guanfacine (Tenex) central alpha-adrenergic agonists. Some positive effect on hyperactivity, insomnia, anger. No effect on inattention. Management Non-stimulants Varies by drug. Many take 3-4 weeks for full effect Monitor closely for side effects and efficacy. Adjust follow up timing and formal reevaluation based on profile of individual drug. 45

46 Medication - Stimulants Management Trouble shooting: What medication issues have you run into in your practice? Nutrition Conduct thorough nutrition history High protein breakfast before taking morning meds Protein containing snacks timing to be determined e ed by history Reevaluate at each visit as may be affected by meds 46

47 Sleep Sleep disturbance is very common in AD/HD (2-3 times higher than general population) Which came first, the AD/HD or the sleep disturbance? Poor sleep mimics/worsens symptoms of AD/HD Diagnostic challenge Stimulants can worsen sleep issues Sleep Through history and physical to determine cause Other disorder (i.e. OSA) Outside factors Medications Intrinsic associated with AD/HD 47

48 Sleep Solutions (depending on cause) Good sleep hygiene Realistic and consistent bedtime and wake time Avoid caffeine Address sleep environment noise, light, temperature Regular exercise Eliminate all technology (TV, cell, text) except for music minutes prior to bed time Establish bed time routine Summary 48

49 Resources References Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. American Academy of Pediatrics: Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. PEDIATRICS Vol. 105 No. 5 May 2000, pp Krull, Kevin R. Evaluation and diagnosis of attention deficit hyperactivity disorder in children. March 3, 2004 Krull, Kevin R. Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. March 25, NICHQ ADHD Practitioners' Toolkit

50 References What We Know 1: The Disorder Named AD/HD. National Resource Center on AD/HD, A program of CHADD, What We Know 2: Parenting a Child with AD/HD. National Resource Center on AD/HD, A program of CHADD, What We Know 3: Managing Medication for Children and Adolescents with AD/HD. National Resource Center on AD/HD, A program of CHADD, What We Know 4: Educational Rights for Children with AD/HD in Public Schools.National Resource Center on AD/HD, A program of CHADD, What We Know 5D: AD/HD, Sleep, and Sleep Disorders. National Resource Center on AD/HD, A program of CHADD, What We Know 7: Psychosocial Treatment t for Children and Adolescents with AD/HD. National Resource Center on AD/HD, A program of CHADD, What We Know 11: Time Management:Learning to Use a Day Planner. National Resource Center on AD/HD, A program of CHADD,