Attention Deficit/Hyperactivity Disorder (ADHD)

Transcription

1 Disclaimers Attention Deficit/Hyperactivity Disorder (ADHD) Paul Glasier, Ph.D. Licensed Psychologist I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation ADHD (Per DSM IV TR) Inattention, hyperactivity, impulsivity, seen more frequently than typical for age/development (Criterion A) Symptoms present before age 7 years (Criterion B) May change in DSM V to before age 12 years symptoms evident in many by 4 5 years DSM implies that symptoms can be evident by 2 3 years Impairment present in at least two settings (Criterion C) Must interfere with social, academic, or occupational functioning (Criterion D) Not accounted for by Pervasive Developmental Disorder (PDD), Schizophrenia, other Psychotic Disorder, or other mental disorder (Criterion E) Most common neurobehavioral disorder in children and adolescents Approximately 8% according to CDC estimates ADHD Subtypes Predominantly Inattentive (ADHD I) Most common subtype More commonly diagnosed in boys Did not exist in DSM III R Combined (ADHD C) More commonly diagnosed in girls Second most common subtype Predominantly Hyperactive Impulsive (ADHD HI) Least frequently diagnosed Only 25% of ADHD in large sample (Froehlich et al., 2007) Did not exist in DSM III R ADHD Not Otherwise Specified (ADHD NOS) ADHD I with age of onset after 7 years Inattention marked by sluggishness, daydreaming, and hypoactivity ADHD I Symptoms Six or more in six months of the following: Poor attention to details or careless mistakes in activities Poor sustained attention Not listening when spoke to directly Not related to hearing impairment Not following instructions to completion or failure to finish tasks Organizational difficulties Avoiding or complaining about effortful tasks Losing needed materials Easily distracted by irrelevant stimuli Forgetfulness Often manifest in academics and workplace ADHD HI Symptoms Six or more in six months of the following: Fidgets with hands, feet, or squirms in seat Leaves seat at inappropriate times Runs or climbs excessively Difficulty playing quietly On the go or acts driven by a motor Vague symptoms Talks excessively Blurts answers to questions Difficulty waiting for turn Interrupts or intrudes on others Often manifest in early life with difficult peer relations, educator complaints, and risk for physical injury

2 Clinical Features More commonly diagnosed in Western countries Symptoms can exist as young as 2 or 3 years E.g., distractible when looking at picture books Difficult to diagnose in very young Much higher incidence of ADHD in males 2:1 to 9:1 according to DSM IV TR Clinic referred ADHD more likely to be male Less pronounced gender disparity in ADHD I Very heritable disorder Epigenetic factors are also important Biological Substrates Strong implication of dopaminergic systems Frontal striatal circuits Stimulant impact Noradrenergic systems implicated Right hemisphere role in attention Strong evidence from injury research Cerebellum Genetic factors Specific region of chromosome 16 consistently linked to ADHD Risk possibly linked to specific dopamine receptor genes (e.g., DRD4 and DRD5) Associated Symptoms Bossiness Tantrums Stubbornness Irritability Need for demands to be quickly met Quick mood changes Social rejection Low self esteem Comorbidities Comorbid conditions: Oppositional Defiant Disorder or Conduct Disorder 50% of clinic referred children Highest in ADHD HI and ADHD C Mood Disorders Anxiety Disorders Learning Disorders Communication Disorders Tourette s Disorder 50% of clinic referred Tourette s with ADHD Neurological injury/medical conditions High familial prevalence of: Mood Disorder Anxiety Disorders Learning Disorders Substance Related Disorders Antisocial Personality Disorder Clinical Course Initial presentation with excessive motor activity Emerging evidence for diagnosing as young as age 4 years Most commonly diagnosed in elementary school ADHD I may exist for several years prior to diagnosis Must have some evidence of impairment in early life when diagnosing in adults Symptoms can remain evident throughout lifespan Some mitigation of hyperactivity/impulsivity with age Remission of symptoms may depend on definition With age, syndromal symptoms decline more than functional symptoms (Biederman, Mick, & Faraone, 2000) Clinical Course Symptoms of ADHD must be present over last 6 months Can result in fluctuations among subtype diagnosis E.g., shifting from ADHD C to ADHD I diagnosis with age Symptoms can linger in adulthood Possibly 4% of adult population with ADHD Attention symptoms more likely to linger or present initially Possibly more evenly distributed gender ratio In Partial Remission specifier often applicable

3 Clinical ADHD Diagnosis: Rating Forms Ratings from two or more sources using DSM criteria is ideal Usually parents and teachers No gold standard rating form exists Few rating forms validated in preschool children (American Academy of Pediatrics [AAP] Subcommittee on ADHD, 2011) Attention problems hard to separate from comorbid diagnoses Anxiety, Mood Disorder, etc. Rater bias Particularly with retrospective nature of ratings from adults undergoing evaluation for ADHD Clinical ADHD Diagnosis: Psychological Measures Psychological evaluation (sensitive but not specific) No definitive psychological clinical measure of ADHD Discrepancies between clinical findings and parental ratings of concepts such as sustained attention and inhibitory control Questions of ecological validity Attention difficulties on clinical measures not specific to ADHD Continuous performance tests with high false negative rate Many neuropsychological measures developed for adults extended to children without developmental rationale Differences in clinical presentation vs. environment One on one testing Minimal distractions in examination room Lack of environmental contextual triggers in clinic Performance in clinic may or may not generalize to environment Emerging evidence for structured observation and behavioral tracking during analogous academic tasks AAP ADHD Guidelines ADHD subcommittee of AAP commented on best practices in 2011 article ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents First AAP recommendations for diagnosis of ADHD published in 2000 AAP recommendations for ADHD treatment followed in article improves replaces the earlier two with: Expanded age range: Diagnosis and treatment recs expanded from 6 12 to 4 18 years Expanded scope: Expansion of ADHD recommendations provided in Diagnostic and Statistical Manual for Primary Care (DSM PC) Child and Adolescent Version published in 1996 Provision of algorithm to guide diagnosis and treatment Integration with the AAP Task Force on Mental Health Multidisciplinary recommendations to assist primary care physicians who are at the forefront of treatment, particularly in rural areas AAP Guidelines: Evaluation of Extant Research Extensive literature review guided by content area experts Experts from several disciplines Review also included reference to a prior review completed by the Agency for Healthcare Research and Quality (AHRQ) Effective Healthcare Program Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At Risk Preschoolers; Long term effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment Utilized algorithm to denote recommendations as strong recommendation or recommendation Based on strong scientific evidence Also based on minimization of harm AAP Action Statement 1 Primary care clinician (PCP) should initiate ADHD evaluation for child 4 18 years with significant academic and behavioral problems possibly related to ADHD Benefits: Minimize missed diagnosis Risks: Inappropriate diagnosis leads to misallocated intervention Benefits vs. harm: Good evidence of treatment efficacy vs. lack of treatment resulting in impaired outcome AAP Action Statement 2 To diagnose ADHD, PCP should determine that DSM IV TR criteria are met. Information is obtained from more than 1 setting preferably from guardians, teachers, school personnel, and mental health clinicians. Also, rule out any alternative cause Benefits: DSM IV TR leads to uniform categorization Risks: DSM IV TR does not account for developmental differences leading to misdiagnosis DSM PC addresses this Challenges to this method: Difficult to find alternate raters for preschoolers (e.g., teachers) Adolescents underreport symptoms Comorbid substance use, depression, and anxiety in adolescents may account for symptoms

4 AAP Action Statement 3 PCP should assess comorbid psychiatric, medical, learning, or developmental condition that might exist with ADHD Benefits: Assists treatment plan Risks: Misdiagnosis Follow AAP recommendations for assessing and treating childhood disorders with awareness of financial costs Treat adolescent substance abuse prior to ADHD treatment AAP Action Statement 4 PCP should consider ADHD as a chronic condition and follow principals of chronic care model and the medical home Benefits: Described coordinated services needed for management Risks: Potentially increased financial cost Children with ADHD at greater risk for significant problems if discontinue treatment Parents of ADHD children often have ADHD themselves and need these additional supports Consistent communication needed with schools and other care providers, etc. Action Statement 5a PCP should consider behavior therapy for preschool ADHD (4 5 years of age) as first line of treatment PCP should consider methylphenidate if behavioral interventions are insufficient Benefits: Both interventions demonstrated to reduce ADHD symptoms and improve function Risks: Cost of care, family involvement, potential adverse medication effects Family preference essential in determining treatment plan Action Statement 5b PCP should consider FDA approved medications for elementary school children (6 11 years of age) as first line of treatment PCP should consider behavior therapy from parents and teachers, preferably in combination with medication Strong evidence for stimulant medications and less strong for atomoxetine, extended release guanfacine, and extended release clonidine (listed in order of strongest to weakest efficacy) Benefits: Both medication and behavior therapy demonstrated to reduce ADHD symptoms and improve function Risks: Cost, family involvement, potential adverse medication effects Benefits vs. harm: Benefits outweigh harm Combination of medication and behavior therapy may allow for lower dose of stimulants (Pelham & Gnagy, 1999) Behavior therapy appropriate for co occurring conditions resistant to meds Behavior Therapy Components of successful behavior therapy for ADHD: Implementation of contingency management strategies across multiple settings, including: Parent training Predictable, immediate contingencies for behavior Classroom interventions Contingencies implemented by educators, coordinated with strategies used at home May include use of token economy Academic interventions Organizational devices Study skills training Peer tutoring Environmental modifications Preferential seating Emerging evidence for group based social skills interventions Action Statement 6 PCP should titrate doses of ADHD meds to achieve maximum efficacy with minimal side effects Benefits: Optimal dose of meds reduces core ADHD symptoms to level close to typically developing child Risks: Higher doses increase risk of adverse effects Growth deceleration only in first two years and only 1 2 cm Benefits vs. harm: Benefits of treating ADHD outweigh risk of adverse events Education of parents and patients needed to enhance cooperation and reach appropriate titration Often takes several months of adjustment and close monitoring to achieve maximal efficacy

5 Summary Adverse effects of ADHD noted as early as the preschool years Inattention symptoms often linger into adulthood No gold standard instrument for diagnosis of ADHD through behavioral rating forms and/or psychological assessment Both inform treatment but are not perfect systems Diagnosis and treatment requires careful monitoring and input from caregivers in multiple settings AAP subcommittee on ADHD 2011 article supports the strong role that PCPs and behavioral clinicians provide in treatment and interventions Medications show strongest efficacy Behavioral interventions may augment these The close monitoring and consistent feedback regarding interventions is time consuming PCPs, but very beneficial Particularly for patients in underserved populations Behavioral therapists can assist with monitoring and interventions References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). 2000; Washington, DC: Author. Biederman J, Mick E, Faraone SV. Age dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry May;157(5): Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At risk Preschoolers; Long term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Rockville, MD: Agency for Healthcare Research and Quality. Comparative Effectiveness Review. October Froehlich TE, Lanphear BP, Epstein JN, Barbaresi WJ, Katusic SK, Kahn RS. Prevalence, Recognition, and Treatment of Attention Deficit/Hyperactivity Disorder in a National Sample of US Children. Arch Pediatr Adolesc Med. 2007;161(9): Pelham, W. E., Gnagy, E. M. Psychosocial and combined treatments for ADHD. Ment. Retard. Dev. Disabil. Res. Rev. 1999; 5: Subcommittee on Attention Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention deficit/hyperactivity disorder in children and adolescents. Pediatrics Nov;128(5):