ADHD Update. Kim C. Brownell, M.D. Hub Medical Director, ACCESS-Mental Health CT Hartford Hospital/Institute of Living Mental Health Network

Transcription

1 ADHD Update Kim C. Brownell, M.D. Hub Medical Director, ACCESS-Mental Health CT Hartford Hospital/Institute of Living Mental Health Network Lisa B. Namerow, M.D. Child and Adolescent Psychiatry Director of Consultation-Liaison Service, CCMC Hartford Hospital/Institute Of Living Mental Health Network

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3 How To Start? Develop your office flow and forms that will be used so that the following chief complaint initiates a consistent evaluation process. Example chief complaint: Johnny is not doing well in school PE should be current/review last PE: hearing, vision normal? No suspected genetic abnormalities? Not in psychiatric care? Brief school review-what grade, what kind of grades? Did patient receive Birth to 3? Special Education preschool? Currently receiving Special Ed services? Does child have IEP? Complete Cardiac Health and Family History Form Consider completing Child And Family Mental Health History form

4 Cardiac Health and Family History Form (To be completed by Patient, parent or guardian prior to examination) Patient History Has your child ever had any of the following conditions or symptoms: 1. History of any kind of heart problem? Yes No 2. Palpitations, fast heart rate or extra skipped beats? Yes No 3. Syncope(fainting) or dizziness with exercise? Yes No 4. Seizures Yes No 5. Is your child taking any supplements(non-prescription drugs)? Yes No 6. Congenital deafness Yes No (a person born without the ability to hear and never improved)? 7. Is your child taking any medications (prescription and over the counter) Yes No If yes, please list them:

5 Family History 1. Has anyone in your family had a heart attack before the age of 40? Yes No 2.Has anyone in your family died from sudden death? Yes No 3.Does anyone in your family have a cardiac arrthymia? Yes No (This is when the heart has an irregular heart beat, skipped or extra beats? 4.Congenital Deafness Yes No (a person born without the ability to hear and never improved)? 5. Does anyone in your family have these cardiac conditions: * Hypertrophic cardiomyopathy (HCM)? Yes No *Prolonged QT Syndrome? Yes No *Wolf Parkinson White or other specific condition Yes No

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8 The Initial Packet to Give to Family: Letter For School 3-5 Early Childhood Assessment Team (this is via school board of town child resides in) 5+ request psycho-educational testing Vanderbilt screens for home and school with your fax number on for teacher Get consent form signed to speak to school staff and teacher

9 Letter For School DATE: RE: DOB: I have met with the above named child and family to evaluate the patient for school problems. The child s physical exam, including a neurological assessment, is completely normal. Therefore, we are requesting that the school system conduct the following, or forward the results if already conducted. Comprehensive Psycho-Educational Testing Teacher Vanderbilt and Teacher Assessment Forms PPT Please fax or mail a copy of these results to the Primary Care Center [Insert your clinic name here]. Our contact information is listed below. Thank you for your assistance in this matter. Please feel free to contact me with any questions. Sincerely, Health Care Provider Parent or Guardian

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14 AAP Resources to consider : Caring for Children with ADHD: A Resource Toolkit for Clinicians American Academy of Pediatrics PRICE MEMBER PRICE Format:CD/DVD Description This toolkit was developed to bring the latest updates and guidance for pediatric health care professionals who provide care for children and adolescents with ADHD in the medical home. Caring for Children With ADHD: A Resource Toolkit for Clinicians, provides more than 40 tools to help deliver these services to patients and family members. Published in November 2011, the ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Caring for Children With ADHD: A Resource Toolkit for Clinicians, bring these updated AAP recommendations to your practice. It provides a full set of ready-to-use tools many in Spanish and English for

15 AAP Resources Continued: Assessment and Diagnosis including the Vanderbilt Assessment Scales Treatment and Medication Monitoring and Follow-up Parent Education and Support Coding and Payment The ADHD toolkit components have been evaluated and refined based on input from the AAP Quality Improvement Innovation Network (QuIIN). For institution or practice-wide site licenses, contact

16 Toolkit scoop Go to this web site Click learn more: You can download entire first edition toolkit for free

17 Follow Up Visit in 1-2 weeks Review screens Use the card (ADHD Medication Guide)if you make the decision that a medication trial should begin If yes to meds, give letter about how ADHD is managed in your office(picking up paper prescription every month, how parents will call the office to obtain this paper Rx, how often follow up is needed etc.) Keep practice parameters and algorithms handy

18 Practice parameters AAP

19 Practice Parameters AACAP

20 ADHD Algorithms: The Texas Children s Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder STEVEN R. PLISZKA, M.D., M. LYNN CRISMON, PHARM.D., CARROLL W. HUGHES, PH.D., C. KEITH CONNERS, PH.D., GRAHAM J. EMSLIE, M.D., PETER S. JENSEN, M.D., JAMES T. McCRACKEN, M.D., JAMES M. SWANSON, PH.D., MOLLY LOPEZ, PH.D., AND THE TEXAS CONSENSUS CONFERENCE PANEL ON PHARMACOTHERAPY OF CHILDHOOD ATTENTION-DEFICIT/HYPERACTIVITY J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:6, JUNE 2006

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22 Amphetamine derivatives

23 Updated versions may be viewed at To order laminated cards:

24 Sample letter clarifying Office ADHD policy Dear Parents: We would like to take this opportunity to share the office policy regarding follow up/medication refills for ADD/ADHD. The treatment plan for your child requires close follow up. You can expect that your child will have regularly Scheduled follow up appointments with the doctor. We may not be able to refill a prescription if your child has not had a follow up appointment. Medication refills will only be written by the prescribing doctor. To allow time for the prescribing doctor to write your prescription, requests should be called to our office 5-7 days before you expect to run out of medication. ADD/ADHD medications are considered controlled substances and cannot be called in or faxed to a pharmacy. Each prescription may only be written for a 30 day supply. The prescription must be picked up at the office, we are unable to mail them. To assist with planning our doctors are available in the office on the following days: Dr. Smith :Monday through Friday Dr. Jones: Wednesday, Thursday, Friday Dr. Percy: Monday Tuesday Thank you! Your Health Care Team

25 More About Follow Up Visits: Monitor Child s Blood Pressure, Weight, Heart Rate Vanderbilt follow up/connors follow up from teachers Meds are not an emergency-develop a policy and follow it for prescriptions A Sample letter given out at the start of medication trial will work

26 Kaylee is a 9yo female who has been seen in your practice a couple of times previously. Family calls to make an appointment. Your schedule reads school concerns Admin booked this into a 15 minute acute care slot As you are reviewing the chart, you realize Kaylee has not had a routine physical exam in 2-3 years You turn visit into a physical Family receives routine screens PSC17 is within normal limits

27 Height/weight/BMI=50 th percentile Hemoglobin =WNL Blood pressure=100/60 Heart rate=65 Hearing Test=pass Vision Test= 20/200 bilaterally

28 Does Kaylee have ADHD?

29 Alan is an 11yoMale followed closely in your practice since birth. His family is well known to you. Mom calls for an appointment to discuss Eric s school progress. School is complaining that Eric is fidgety, does not pay attention or follow directions. Otherwise he is socially successful, has friends and is polite and respectful to teachers. His physical is up to date, no concerns about hearing or vision You activate your ADHD protocol and send your letter and teacher Vanderbilt screen to school as well as home to parents. You make an appointment with Allan and his mother in 2 weeks to review information Teacher s score on Vanderbilt=9 Parent s score on Vanderbilt=2 =7 =3 =39 =11 Your observation of Alan s behavior: Coloring quietly, completes word find, follows directions, able to sit still and attend to tasks

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32 Does Alan have ADHD? Should you engage in stimulant trial? What else might be going on here?

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34 DSM 5 Updates: DSM IV DSM V Symptoms present before age 7 Symptoms present before age 12 Subtypes: No specification Impairment in more than one setting Presentations: Inattentive,Hyperactive- Impulsive, Combined Inattentive and Hyperactive Must specify: mild, moderate, severe Several symptoms should be present in more than one setting If you are 17 or older, only 5 symptoms are needed instead of 6

35 If Vanderbilt screens do not agree- And your clinical observation does not agree- Remember that ultimately ADHD is a clinical diagnosisreconsider the diagnosis. Is it possible Alan s behavior can be explained by an undiagnosed learning disability? Is it possible his behavior is so different at school because he feels stupid and slow compared to other peers and at home his parents teach him 1:1?

36 Billy Billy is an 8 year male old comes in for a well child visit. In your review of systems, mom notes a drop in academic performance for 3 rd grade and wonders about a learning problem. Teachers states he just needs to show more effort. He is too easily distracted by his peers. What do you do?

37 You activate your well established ADHD protocol Physical exam is up to date-no medical or neurological concerns Send Vanderbilt screens to home and school Have a parent complete the Family Mental History form and Cardiac History Form Arrange for follow up in 2 weeks Billy returns-you review the date Teacher s Vanderbilt =39 Parent s Vanderbilt=38 Reports consistent with ADHD Should you consult your ADHD Medication Guide and choose a stimulant?

38 How Many say Yes?? How Many say no?

39 What did we forget to review first? Billy s brother had a radiofrequency ablation last year for WPW Billy s father had one too What is the most prudent course of action at this point?

40 Consider EKG Consider Pediatric Cardiology clearance before proceeding

41 If family history screen was very strongly + for Bipolar Disorder, how would this change your plans?

42 Family History Positive for Bipolar Disorder If very concerned or patient has an atypical presentation, you may consider referral to child psychiatry for further evaluation Or you may choose to proceed with caution and have a low threshold for discontinuing stimulant trial and referring to child psychiatry for evaluation

43 Johnny is an 8yo boy who you first saw in the newborn nursery You follow his 2 other siblings and have known the family for years Mom calls you and leaves a message that Johnny is struggling in 3 rd grade

44 You hand them the Vanderbilt screens You have them sign the release for school The medical assistant in your office who is assigned to coordinate ADHD issues books an appointment with you in 2 weeks The ADHD medical assistant obtains copies of patient s psychoeducational testing which showed: IQ=102 Achievement Tests=Normal for age

45 You are ready now Your office knows to schedule the patient in a 30minute slot at the end of the day You review your physical exam from this summer and everything was WNL You meet with the parents and Johnny Johnny School is too hard this year! I like football better. Parents: It is like he is driven by a motor. When we sit down to supervise his homework it takes 3 hours because he needs constant re-direction and he is so distracted by everything!

46 Family History Screen shows: Father, Uncle Ted and 1 sibling were diagnosed and treated for childhood onset ADHD Cardiac History is WNL

47 Now it is time You choose Ritalin 5mg daily You make another appointment for 2 weeks You pull out your ADHD medication guide After 1 month, you send the teacher either the Vanderbilt follow up or the Connors. They fax it directly to the ADHD medical assistant You sit back and enjoy the teacher s comments that Johnny is like a new boy

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50 In Summary: Obtain clinical information From family From school Consider alternative etiologies (other medical conditions: sleep apnea, hypothyroidism, anemia)

51 In Summary continued: consider comorbidities Anxiety Mood disorders Trauma-based disorders (PTSD) Rarely: Psychotic Disorders Tourette s

52 In Summary Final: Recognize as a chronic condition Maintain ongoing follow up PCP office should become a medical home Use a chronic care model for treatment This can involve a Chronic Disease Registry in your office which could look like: -a cardex -an excel spread sheet Some offices will designate one person (medical assistant or nurse)to be in charge of all matters involving ADHD diagnosis and follow up This person can help you with efficiency by making sure parents complete all relevant paperwork and that you have the results of Vanderbilt screening in a timely fashion. They can also obtain copies of any formal psycho educational testing done by school

53 ADHD DSM-V People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

54 Inattention Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. Often has trouble keeping 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 (loses focus, gets sidetracked). Often has trouble organizing activities. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). Is often easily distracted. Is often forgetful in daily activities.

55 Hyperactive-impulsive Presentation Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level Often fidgets with hands or feet or squirms in seat when sitting still is expected. Often gets up from seat when remaining in seat is expected. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). Often has trouble playing or doing leisure activities quietly. Is often "on the go" or often acts as if "driven by a motor". Often talks excessively. Often blurts out answers before questions have been finished. Often has trouble waiting one's turn. Often interrupts or intrudes on others (e.g., butts into conversations or games).

56 Female Vs. Male ADHD Females tend to be more inattentive, less disruptive overall but social impact can still be significant On CPT testing, girls show less impulsivity (MTA, 2001) More associated with LD issues, but less ODD even impulsivity can look different associated with more social butterfly chatter rather than aggression or disruptive behaviors girls with ADHD have higher levels of anxiety, somatic sxs; boys have higher ODD/Conduct Disorders

57 Nonpharmacologic Interventions family psycho-education a must behavior therapy should be considered Social skills training if social competency are significant issues Regular and routine follow up Anticipatory guidance re: accidents, substance use, and conduct disorder

58 ADHD and School Impact on learning is quite variable depending on symptom impact full psycho-educational evaluation if learning below grade level neuropsychological evaluation if resources are present 504 plan considered vs. IDEA designation

59 PATS Study (2006): Preschool ADHD Treatment Study Designed to assess methylphenidate efficacy in preschool children Effect size in MTA % Effect size in PATS ( ) in PATS, more side effects & intolerance (11% discontinued) and impact on growth rates All of which suggests a higher threshold for pharmacotherapy

60 MTA Study 10-m Followup After up After 22-m Follow- Treatment Treatment 0 14-m Treatment Stage Recruitment Screening Diagnosis Random Assignment 579 ADHD Subjects Medication Only 144 Subjects Psychosocial (Behavioral) Treatment Only 144 Subjects Combined Medication & Behavioral Treatment 145 Subjects Community Controls No Treatment from Study Assessed for 24 mo. 146 Subjects Baseline Early Mid- Treatment End Treatmenttreatment (3 m) (9 m) (14 m) Assessment Points Follow-up (24 m) Recruitment of LNCG Cohort Follow-up (36 m)

61 Average Score 14-Month Outcomes Teacher SNAP-Inattention Time x Tx: F=10.6, p<.0001 Site x Tx: F=0.9, ns Site: F=2.7, p<.02 CC Beh MedMgt Comb Comb, MedMgt > Beh, CC Assessment Point (Days) days

62 Teacher-Rated Inattention (CC Children Separated By Med Use) Key Differences, 2.5 MedMgt vs. CC: Initial Titration Dose Dose Frequency #Visits/year Length of Visits Average Score CC-NO MEDS CC-MEDS BEH MED COMB Contact w/schools Assessment Point (Days)

63 MTA: 8 year followup After 14 months treatment, no arm did better than any other re: outcomes Only 17% remained on medications At 36months, the more responsive to treatment group, the better the outcome Take home: Monitor both responders and non-responders carefully and even if not on meds, maintain regular followup

64 ADHD alone

65 A few general guidelines If a patient has not been exposed to stimulants before, begin with the short acting version of either class Although efficacy high, side effects are not uncommon Its worth determining tolerance first, then efficacy, then switch to long-acting prep Same goes for the alpha agonists

66 STAGE 1: METHYLPHENADATE AGENTS

67 Ritalin LA: Extended-release Delivery via SODAS Technology SODAS is a trademark of Elan Corporation, PLC

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69 Long-acting Methylphenidate Medications Products Concerta Metadate CD Ritalin LA Formulation Technology OROS Diffucaps SODAS Dose 18 mg 27 mg 36 mg 54 mg 20 mg 20 mg 30 mg 40 mg Immediate 22% 30% 50% release 4 mg 6 mg 8 mg 12 mg 6 mg 10 mg 15 mg 20 mg Sustained/ 78% 70% 50% 2nd release 14 mg 21 mg 28 mg 42 mg 14 mg 10 mg15 mg 20 mg Concerta [package insert]. Moutain View, CA: Alza Corporation; OROS is a registered trademark of ALZA Corporation. Metadate CD [package insert]. Rochester, NY: Celltech Pharmaceuticals, Inc; Diffucaps is a registered trademark of Eurand. Ritalin LA [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; SODAS is a trademark of Elan Corporation, Plc.

70 Mean d,l-methylphenidate plasma levels (ng/ml) Comparison of Extended-release Methylphenidate Dosage Forms Ritalin 20 mg BID Concerta 54 mg Metadate CD 60 mg (3 x 20 mg) Ritalin LA 40 mg Time (h) Gonzalez MA, et al. Int J Clin Pharmacol Ther. 2002;40: Data on file, Novartis Pharmaceuticals.

71 Daytrana Transdermal absorption Lasts 9 hours Needs to be placed and removed every day alternating sites Less ups and downs? More autonomy for college use, less change of college abuse?

72 Newest once-a-day: Quillivant XR 25mg/5cc Only liquid long-acting 20% immediate-release, 80% extended release FDA-approved for age 6 and older Unclear mechanism of release

73 Quillivant XR pharmacokinetics

74 Quillivant XR: Mechanism of Action

75 Stage 2: Amphetamine class Concept is the same Short-acting can determine tolerance Choice of which long-acting has to do with dispensing system

76 General choices Dexadrine Adderall Dexedrine spansule Adderall XR Vyvanse

77 Adderall XR First came off the shelf after Adderall had been developed to be a diet medication but FDA felt that the addictive qualities do not outweigh the benefits. ADHD researchers felt that it had the components for adhd treatment Made up of 4 amphetamine salts Hence had some intrinsic long acting properties

78 Vyvanse Not biologically active until cleaved during absorption by the proximal small bowel absorption is rate limited by enzyme within the villi which creates a continuous duration of action Can be swallowed whole or sprinkled in water Less rebound? Active compound is dextroamphetamine

79 Long-Acting Stimulants: The Bad News May have greater potential for weight loss May have greater potential for agitation:? More potent May have greater chance for sleep disturbance Take home: tolerance of short-acting stimulants does not assure tolerance of longacting preparations but the long-acting agents offer some clear advantages if well-tolerated

80 Stage 3:The nonstimulants

81 Strattera: The first NRI A completely different class of medication for ADHD, a norepinephrine reuptake inhibiter Not a controlled medication The first nonstimulant approved by the FDA for age 6 and over for ADHD Works by establishing a steady state, so needs to be taken daily rather than as needed Yet, seems to have a rapid onset of action

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84 Atomoxetine (Strattera ) CYP2D6 Metabolism Drug class Selective norepinephrine reuptake inhibitor Indication Attention deficit hyperactivity disorder (ADHD) Reason for HILOmet Typing Poor metabolizers may be overdosed with standard dose Clinical complications Appetite suppression, rebound hyperactivity, insomnia, tremor Package insert Laboratory tests are available to identify CYP2D6 poor metabolizers 84

85 New considerations:genomic Testing P450 analysis on 3 isoenzymes has been developed As a review, the P450 system is a series of enzymes in the liver which break down toxins The analysis is based on genomic technology and using whole blood, determines the presence or absence of the allelles that promote the formation of these 3 enzymes In doing so, enzymes can be categorized as normal, deficient, null or ultrarapid in their activity It has been determined by very smart pharmacologists which medications are substrates for which enzymes-- -some medications can even induce or inhibit the activity of an enzyme

86 Frequency of Polymorphisms Double and Triple Gene Alterations 45% 2C19 2D6 2C9 2C19 2D6 None 2C9 No Gene Alterations 9% 2C19 N=577 LPH Patient Referrals Nov C9 2D6 2C9 2C19 2D6 Single Gene Alterations 46%

87 DNA-Guided Psychotropic Selection

88 Stage 4/5:Alpha 2 Agonists Mechanism: alpha 2 stimulants cause the presynaptic noradrenergic receptor to decrease sympathetic output over time, this is a brake on the release of norepinephrine. Originally approved for HTN in adults but then used in children for treatment of tics, ADHD, and aggression.

89 Guanfacine ER (Intuniv) A long acting version of Tenex May have less sedation FDA approved for ADHD in children over 6 Would assess tolerance by using shortacting first, then converting Comes in 1mg, 2mg, 3mg, 4mg

90 Kapvay (clonidine) FDA approved as an adjuvant to stimulant meds Dosed twice per day Possibly less sedation than its short acting version, clonidine Comes as 0.1mg, 0.2mg

91 Combinations that make sense Methylphenidate/amphetamine salt plus guanfacine Methylphenidate/amphetamine salt plus kapvay Methylphenidate/amphetamine salt plus strattera Long-acting methylphenidate or amphetamine salt with short-acting of the same kind

92 Combinations that do not make sense Amphetamine with methylphenidate Strattera with guafacine Guanfacine with clonidine

93 A word about comorbidities The norm rather than the exception Look for anxiety, mood If they exist consider combined treatment

94 Consideration of comorbidities in the treatment of ADHD (Texas Algorithms, July, 2005) ADHD with MDD ADHD with Anxiety ADHD with tics ADHD with aggression

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96 ADHD with tics

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98 ADHD with Aggression

99 Risperidone in ADHD ONLY if with significant aggression and or tics which do not respond to alphaagonist Will need to be aware of all potential side effects: weight gain, dyskinesias, prolactinemia FDA support from research on autism Can safely be used in primary care but only at low-dose and with careful

100 Summary of Treatment Planning: Consider family psycho-education Consider behavioral therapy Consider a 504 plan Consider medications Choose either methylphenidate or dexedrine to start Use short acting preps first, then based on tolerance and efficacy choose Long-acting version of same Above all maintain follow up, remember the MTA

101 Take Home points : Literature supports that the natural untreated course of ADHD places a child or adolescent at high risk for comorbidities such as substance use disorders, Anxiety, Depression, ODD/Conduct Disorder or a sense of failure

102 Take Home Points continued: Adults can often find a role that works for their individual strengths/weaknesses (NY times, A natural cure for ADHD November, 2014) But the first years of life can be a real challenge The push for identification and treatment of ADHD is NOT meant to simply pathologize normal variants of behavior but rather to promote an at-risk child s developmental trajectory

103 And finally- Take home points continued Medication management alone is never enough (see MTA, community sample, and follow up studies) Regular follow up and check-ins with school Individualize therapies based on nature of difficulties (PMT, CBT, social skills training, educational/ remediation or therapy)

104 If any of this seems baffling, remember you are never alone

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109 Questions?