ADHD: Overcome misconceptions and treat with confidence

Transcription

1 ADHD: Overcome misconceptions and treat with confidence Dr. Joan Flood Family Physician, The Shoniker Clinic, Scarborough Board Member, The Canadian ADHD Resource Alliance (CADDRA) Chair, Advocacy Committee, CADDRA Dr. Doron Almagor Child, Adolescent and Adult Psychiatrist, The Possibilities Clinic, Toronto Chair, The Canadian ADHD Resource Alliance (CADDRA)

2 Disclosures Dr. Doron Almagor Research support, honoraria, speaker fees, and unrestricted educational grants from the following companies: Purdue, Janssen Ortho, Shire, Ironshore Pharmaceuticals, and Avir Pharma. Dr. Joan Flood Honoraria, speaker fees, and unrestricted educational grants from the following companies: Purdue, Janssen Ortho, and Shire. *No financial or in-kind support has been received for this workshop

3 Learning Objectives At the conclusion of this activity, participants will be able to: 1. Identify the many presentations of ADHD and co-morbid disorders. 2. Apply 2018 Canadian ADHD Practice Guidelines to the assessment and management of ADHD in primary care. 3. Implement treatment strategies that address the executive function deficits of ADHD and manage comorbid disorders.

4 Canadian ADHD Practice Guidelines Fourth Edition

5 CADDRA: The Guidelines, 4 th Edition Provides standardized and practical approach Accessible across specialties and expertise levels Provides and promotes public domain diagnostic and follow-up tools Across the lifespan coverage Reviewed by multidisciplinary experts Bilingual translation (French/English) Evidence-based focus on practical clinical application 5 Doron Almagor MD FRCPC

6 Diagnostic and Statistical Manual (DSM-5) Presentations *Total number of symptoms are less in adults (17+): 5 of 9 instead of 6 of 9

7 What does ADHD look like in real life? The child that daydreams in the classroom causing no trouble for peers or teachers The patient who chronically misses or is late for appointments then makes a fuss when kept waiting The adult who has multiple driving infractions The woman who has had 2 abortions and still forgets her contraception The pre-schooler who gets kicked out of daycare for aggression The child who can t read and write and is behind his/her peers The person who can t stop talking at a dinner party

8 The person who drinks too much alcohol or caffeine, self-medicates with marijuana or cocaine The patient who is depressed and anxious The patient who appears to have a personality disorder The patient who runs a superbly successful business The young person on the Honour Roll but feels he/she is underachieving

9 Be Open to the Diagnosis of ADHD ADHD presents in many ways and if you limit your definition to the idea that it is the boy who misbehaves and underachieves in school then you will miss many in your practice. If you think you can pick up ADHD by how a person appears in a single session, you will miss it more times than not.

10 What is ADHD? A neurodevelopmental disorder with diverse symptomatology around the key factors of inattention, impulsivity, hyperactivity and emotional dysregulation. Affects 5-9% of children and 3-5% of adults worldwide

11 Adapted from: Bhat V, Hechtman L. Clinical Pharmacist. 2016;8(2). Developmental Impact

12 ADHD in Canada 2016 ADHD (ages 5 19) ADHD Adults (ages 20 64) Total Population (estimates) 5,915,466 22,222,004 Prevalence [%] 6% 4.4% Patients with ADHD 354, ,768 % Diagnosed & Treated 33% 7% Patients Diagnosed & Treated 117,126 68,444 How many adults are left untreated? 909,324 How many Children? 237,801 Kessler RC et al. Am J Psychiatry 2006; Statistics Canada, % diagnosed calculated based on estimate of treated patients in Canada 12

13 Why treat ADHD? ADHD is a medical disorder with serious impairments just as in diabetes and cardiovascular disease As primary care physicians, we treat Depression, Bipolar illness, Anxiety why aren t we treating ADHD? Don t underestimate the cost of NOT TREATING!

14 Functional Impacts of ADHD Repeat a grade Education-high school or less ADHD Normal Teen pregnancy STD Substance abuse Accident prone Serious car accident Arrested Incarcerated Fired from job Dalsgaard, S., et al., Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet, (9983): p % 10% 20% 30% 40% 50% 60% Subjects (%)

15 Impact of Inadequately Treated ADHD 1. DiScala et al., Liebson et al., NHTSA, Barkley et al., 1993; Barkley, et al., Manuzza et al., Biederman et al., Pomerleau et al., Wilens et al., Barkley, Fischer et al., Brown & Pacini, Mash & Johnston, Noe et al., 1999 Health Care System 50% in bike accidents 1 School & Occupation 46% Expelled 6 35% Drop Out 6 Lower Occupational Status 7 33% in ER visits x more motor vehicle crashes 3-5 Individual with ADHD Society Substance Use Disorders (SUD) 2 X Risk 8, Earlier Onset 9 Less Likely to Quit SUD in Adulthood 10 Employer Absenteeism 14 and Productivity 14 Family 3-5x Parental Divorce or Separation 11, x Sibling Fights 13

16 ADHD and Comorbidity Kessler RC, et al. Am J Psychiatry. 2006;163: Cumyn L et al. Can J Psychiatry. 2009;54(10): % of children with ADHD have at least one other comorbid disorder (e.g. ODD, anxiety, depression, autism, learning disabilities) 85% of adults meet the criteria for a comorbid disorder (e.g. anxiety, depression, bipolar disorder, conduct disorder, substance abuse, borderline personality disorder) Some comorbidities are more impairing than ADHD and should be treated first (for example: active substance dependence, depression, panic disorder)

17 DIAGNOSIS OF ADHD Step 1 Initial Information Gathering Step 2 Medical Review Step 3 ADHD-Specific Interview Step 4 Feedback & Treatment Recommendations

18 Resources CADDRA Canadian ADHD Practice Guidelines CADDRA Toolkit 2018

19 Essentials of Diagnosis Clinical interview that identifies not only current challenges but also examines past functioning, developmental history, academic/vocational history, social functioning, medical history and family history Attention to presence of co-morbid disorders: Oppositional Defiant Disorder, Anxiety, Dysthymia, Depression, Autism

20 Screening Tools The CADDRA Toolkit provides several assessment forms to screen for general mental health challenges as well as the specific impairments associated with ADHD. Children Adolescents SNAP-IV, WFIRS-P, CADDRA Teacher Assessment form ASRS, WFIRS-S, WFIRS-P, Teacher Assessment form Adults ASRS, WFIRS-S

21 Educate Dispel Myths ADHD isn t a real disorder People with ADHD are just lazy and looking for an excuse He s a boy It s a phase Everyone has ADHD I was hyperactive as a child and I turned out alright ADHD medications are dangerous and cause drug abuse Smart people can t have ADHD ADHD results from bad parenting, too many video games, too much sugar, red food dye Medication alone can manage ADHD

22 Essentials of Treatment Educate and understand ADHD Advocate for support at school/home/work Provide hope and encouragement ADHD is very manageable and with consistent treatment, patients with ADHD can excel Medication to management impairments and prevent future consequences

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25 Medication Management First-line treatments: methylphenidate or dexamphetamine Use long acting NOT short acting meds Start at a low dose and titrate upwards at biweekly intervals Different preparations are available on the market place that vary in length of duration, whether they can be sprinkled or swallowed Short acting stimulants and generic copies are less effective and more prone to abuse beware the patient who requests them Second-line treatments: atomoxetine, guanfacine, clonidine Option for patients who do not tolerate or respond to first-line treatment often an add-on to the stimulant Be sure that you have optimized first-line agents before commencing second-line treatments

26 Potential Side Effects Loss of appetite ensure a healthy, calorie dense breakfast and fluids through the day Insomnia usually settles with good sleep hygiene and avoidance of screens in the hour before bed Headaches usually transient when starting on meds if at all simple analgesics and hydration are helpful Occasional mood changes will respond to a change in medication Contrary to general belief, cardiac effects are minimal equivalent to running up a flight of stairs there is no need for an EKG or cardiac workup unless there is a family history of sudden cardiac death in the young or known serious heart disease

27 Take-home Messages Despite common belief, ADHD is underdiagnosed Effective management of ADHD includes: Education Parent/patient counseling Behavioural, psychosocial, and pharmacological treatments Long-acting stimulants are recommended as first-line therapy Monitoring and optimization of medication is important throughout the lifespan Remain vigilant for the presence of co-morbidities which may emerge over time, and consider referral to a specialist

28 You can manage ADHD in Primary Care and markedly improve the lives of your patients with ADHD

29 Please fill out your session evaluation now! Complete a session evaluation one of two ways: FMF app Fmf.cfpc.ca Session: (#W752) ADHD Overcome Misconceptions and Treat with Confidence YOUR FEEDBACK IS IMPORTANT TO US!