Attention Deficit Hyperactivity Disorder in Children and Adults

Transcription

1 Attention Deficit Hyperactivity Disorder in Children and Adults Steven R. Pliszka, MD Professor and Chair Department of Psychiatry The University of Texas Health Science Center at San Antonio

2 Speaker Disclosure Dr. Pliszka has disclosed that he has received research support from Ironshore and he is a consultant for Ironshore.

3 Learning Objective By the end of this activity, the participant should be better able to: 1. Implement the criteria required for a diagnosis of ADHD. 2. Develop a protocol for managing ADHD patients in the office, including medication refills. 3. Identify how comorbid diagnoses such as anxiety, depression, conduct disorder, and learning disabilities can mimic and/or confuse the diagnosis of ADHD. 4. Formulate diagnoses and develop treatment recommendations for patients presenting with ADHD.

4 Making the Diagnosis Unfounded fears An occult medical diagnosis might masquerade as ADHD Missing an underlying psychiatric disorder Depression Mania Psychosis Contributing to the overuse of medication Forgetting that common diseases occur commonly

5 Making the Diagnosis Should never take more than an hour, can be done in 3 minutes with proper preparation (not including note writing) You have the advantage of knowing the family and child (in many cases) When brought up in follow up visit, give rating scales for home and school and schedule 3 minute follow up When parent call in with complaint of ADHD, give script to office staff- send rating scales to home, when returned, schedule parent

6 Interviewing the Parent Review the rating scales from home and school. Look at report card, behavior chart if scales not available. I see there are a lot of symptoms of inattention and/or impulsivity When did they start? (DSM-5 allows onset by age 12) Nearly every day? Impairment school and home? Re-direct extensive Storytelling

7 Interviewing the Parent Academics Grades may not be impaired in early grades Learning disability vs. ADHD Psychological evaluation is NOT required for a diagnosis of ADHD Inconsistent with Learning disability He can do it (school work) when he wants to Able to do work when one on one LD does not masquerade as ADHD (particularly impulsivity) Only when ADHD is treated can true cognitive ability be assessed

8 Ruling out MAJOR Comorbidities Minor depression/anxiety are common in ADHD and are NOT a contradiction to stimulant treatment Many ADHD children discouraged about their lives, this gets better with treatment Questions to ask about depression/anxiety How often does it occur, (daily, weekly rarely)? How long does it last? What does he/she talk about? Self-esteem issues?

9 Comorbidity Major Depressive Disorder Sad/Irritable/Depression 3-5 times per week for at least an hour Chronic low self esteem Suicidal ideation/plan outside of anger outbursts Neurovegetative signs Demoralization/Emotional Lability Intermittent sadness or anger Tied to frustration Brief threats of self-harm that resolve when calm No neurovegetative signs except difficulty falling asleep

10 Interview with Child In young children, focus on depression and anxiety rather than the ADHD Ask concrete questions, quantify Sad/happy, like self/don t like self, hurt self, wish dead/suicide Rules: how parent s punish, fair/unfair, corporal punishment, abuse Psychosis screen

11 Anger Issues Anger/aggression in ADHD most often improve when ADHD is treated Aggression a rare side effect and is often related to rebound Anger/aggression not a contraindication to ADHD treatment unless: Severe, prolong rage attacks Psychotic symptoms co-occurring with anger Self injurious behavior (beyond dropping or head banging, i.e. cutting, suicidal ideation)

12 Methylphenidate (MPH)

13 Methylphenidate (MPH) Apatensio XR- 4% released immediately, 6% as extended release

14 Amphetamine

15 ADHD Medication Guide

16 Side Effects with Methylphenidate and Amphetamine Therapy Many side effects are characteristic of ADHD and improve with stimulant treatment * * Baseline Dextroamphetamine Methylphenidate Mean Severity * * * * * * * * * * 1. * * * *. Trouble Sleeping Poor Appetite Irritable Anxious Daydreams Biting Fingernails Sadness Tics Headaches Nightmares *P<.1 vs placebo, P<.1 vs methylphenidate. Efron D, et al. Pediatrics. 1997;1:

17 Stages of Medication RX for ADHD 1. Trial of a single stimulant, try different formulations for duration action 2. Trial of stimulant in alternate class MPH fail AMP AMP fail MPH 3. Trial of atomoxetine or alpha agonist XR 4. Combination of stimulant and alpha agonist

18 How fast to titrate? Titrations can be done by phone

19 Alpha Agonist Summary Clonidine Increasingly used in single dose in PM for insomnia secondary to stimulants (.5 to.1 mg q HS) Declining role for treatment of daytime ADHD due to efficacy issues as well as sedation Guanfacine Both immediate release and XR used more ADHD itself Non responders to stimulants and atomoxetine Patients with stimulant-induced tics whose ADHD responds only to stimulants

20 Dosing of Alpha Agonists Week Dosage (mg) of Alpha Agonist (Weight < 45 kg) Dosage (mg) of Alpha Agonist (Weight > 45 kg) All weights Baseline Clonidine Guanfacine Clonidine Guanfacine Guanfacine q.h.s..5 q.h.s..1 q.h.s. 1. q.h.s. 1-2 mg b.i.d..5 b.i.d..1 b.i.d. 1. b.i.d. 3 mg t.i.d..5 t.i.d..1 t.i.d. 1. t.i.d. 4 mg

21 Guanfacine XR and Stimulants No difference in somnolence rates between AM and PM administration Wilens et al. Presented at AACAP meeting, New York, 21

22 Clonidine XR and Stimulants Mean age 1.5 years ADHD >26 after 4 weeks of stimulant Kollins et al. Pediatrics 127:e146, 211

23 Rebound When medication wears off, possible that behaviors not only return to baseline, but are worse. Evening behavior- is it just the same or worse? Is it associated with irritability/outbursts not present before meds (or much worse after meds)? If school behavior much improved, but evening behavior worse, that is rebound. If irritability is worse during the peak time of the stimulant during the day, that is a mood side effect (rare)

24 How to Handle Rebound If rebound occurs at 4 PM or symptoms do not controlled after 4 PM in spite of long acting: If room for improvement in daytime ADHD, increase AM dose of long-acting stimulant If perfect at school but sxs rebound at 4 PM, add short-acting stimulant in pm If rebound occurs later in night or is associated with severe predominately irritable mood add alpha agonist

25 Sculpting the Stimulant Dose Daytime Dose Concerta 18 mg Q AM Concerta Q AM Vyvanse 3-5 mg Q AM Vyvanse 6-7 mg Q AM Focalin XR 5 mg Q AM Focalin XR 1 mg Q AM Focalin XR 15-3 mg Q AM Afternoon Dose MPH 5 q 4 pm MPH 1-2* mg q 4 PM DEX/MSA 5 mg q 4 PM DEX/MSA 5 mg q 4 PM D-MPH 2.5 mg Q 4 PM D-MPH 5 mg Q 4 PM D-MPH 7.5-1* mg Q 4 PM *Caution regarding sleep and appetite

26 Adding Alpha Agonist Add for: Hyperarousal - either baseline or stimulant induced-irritable, crying, can t settle Partial response of ADHD symptoms when stimulant has been maximized Sleep issues Tics (as discussed)

27 Adding Alpha Agonist Sleep Problems Only Clonidine.1-.2 mg q hs Avoid doses above.2 mg Irritability PM only Guanfacine IR 1-2 mg Q 4 PM Can be added to pm stimulant dose All day irritability/partial response Intuniv 1-4 mg q AM Can give Intuniv q hs Clonidine ER helpful in severe hyperarousal, watch for sedation

28 Behavior Management The Psychology of ADHD There is no Why? Everything is short-term Parental ADHD/ADHD traits a problem ADHD children do not process rewards and punishments similar to typically developing children: Always go for immediate reward Cannot delay gratification Social rewards not salient - i.e. reinforcing

29 Behavioral Approaches Mon Tues Wen Thu Fri Sat Sun Don t hit sister Do things 1st time asked Homework Total

30 ADHD in Adults

31 Age-specific Prevalence of ADHD Remission 31 Biederman et al. Am J Psychiatry 2;157:816.

32 Age of Onset Issues DSM-5 now requires onset before age 12 Spirited debate among clinicians/researchers-does age of onset matter? Avoiding ADHD, when I wanna be Prevalence of adult ADHD when childhood onset is required is 4.4% (Kendler et al)

33 Impact of ADHD in Adolescence 6 ADHD Normal Percent subjects (%) Harpin V A Arch Dis Child 25;9:i2-i7.

34 ADHD-associated Behaviors Percent subjects (%) P<.1 P<.1 P<.1 P<.1 P<.1 P=NS P<.1 ADHD, n = 23, ages 12-2 years at follow-up Normal, n = 66 P=NS P<.1 P=NS 34 Harpin VA Arch Dis Child 25;9:i2-i7.

35 Diagnostic Interview of Adult ADHD Patient Chief complaint vs. latent comorbidity Screening Were you treated for ADHD as a child? Did you have grade or behavior problems in elementary/middle school? Do you remember having focus/attention problems as child? Parents/teachers always saying, Sit still, Get back to work, I have told you a thousand times! Did this happen more to you than your siblings? 35

36 36 Type: How to fake ADHD into Google, this is but one of many websites

37 Collateral Informants Documenting age of onset Medical records School records Parent report Intellectual ability Functional impairment, information from employer? 37

38 QUESTIONS?

39 Methylphenidate and Serious Cardiovascular Events in Adults Cohort study (212) of new users of methylphenidate [MPH] based on administrative data from a five-state Medicaid database and a 14-state commercial insurance database Recent 43,999 new MPH users, 175,955 nonusers (no MPH, amphetamine [AMP] or atomoxetine [ATX]) Too few AMP, ATX users to make comparison, but results most likely apply to AMP as well Examined rates of sudden death, arrhythmia, stroke, myocardial infarction, composite endpoint Study results: next slide 39 Schelleman et al. Am J Psychiatry 169:178, 212 (Shire-funded study).

40 Methylphenidate and Cardiovascular Events 2.17/1 patient years vs..98/1 in non users * * 4

41 ADHD, Medical Outcome and Cause of Death Olazagasti et al, JAACAP 52: , year follow up of 135/27 boys with ADHD (with and without Conduct Disorder) and 136/178 matched comparison boys Interviewed blind to original diagnosis, mean age 41.4 ± 3.2 years 41

42 ADHD and Medical Outcomes 6 Percent of sample * * * * * P <.5 ADHD Controls 42 Comorbidity of CD accounted for the relationship Olazagasti et al JAACP, Jan 213.

43 ADHD and Cause of Death * * All causes Medical Suicide Drugs/Accident * * P <.5 ADHD Controls 43 Comorbidity of CD accounted for the relationship Olazagasti et al JAACP, Jan 213.

44 Maximum Doses in Adults Methylphenidate Amphetamine Immediate release 6-8 mg/day 6 mg/day Concerta 18 mg Adderall 6 mg/day Vyvanse 1 mg/day Focalin XR 5 mg/day No need for Mega doses Use Texas PMP aware

45 Accommodations Many universities may require Evidence of childhood treatment Repeat of evaluation or evidence of comprehensive evaluation High functioning person who request diagnosis in adulthood ( I always could compensate ) Many accommodations used (extra time on tests) may not provide specific benefit to ADHD and may be unfair to other students Students need to be warned about need to report self in certain occupations