ADHD SIV FASCI, MD FAAP DEVELOPMENTAL-BEHAVIORAL PEDIATRICS DELL CHILDREN S MEDICAL CENTER 9TH ANNUAL PEDIATRIC CONFERENCE - MARCH 24, 2016
Objectives Epidemiology Risk Factors Diagnosis Co-morbidities Treatment When to refer
Trends
CDC data Percent of children 5-17 years of age ever diagnosed with ADHD: 10.1% (2011-2013) Percent of boys 5-17 years of age ever diagnosed with ADHD: 14.0% (2011-2013) Percent of girls 5-17 years of age ever diagnosed with ADHD: 5.9% (2011-2013) Number of ambulatory care visits (to physician offices, hospital outpatient and emergency departments) with attention deficit disorder as primary diagnosis: 9.0 million (average annual, 2009-2010)
Risk Factors Genetic +FH 80% heritability Neurodevelopmental disorders (Schizophrenia, autism and epilepsy) share genetic variants with ADHD Prematurity Perinatal stress Prenatal alcohol, drugs, smoking IUGR Environmental lead
Brain-Based Disorder Frontal lobe Parietal lobe Temporal lobe Thalamus Basal ganglia Cerebellum
Pathophysiology Catecholamines Dopamine, norepinephrine Mediate CNS functions: Motor control, Cognition, Emotion, Memory processing White Matter: axons and myelin sheath Limbic system (amygdala, hippocampus, interior parts temporal, frontal, pariental lobes primitive responses, controls our immediate, automatic responses to stimuli (reward network)
AAP 2011
Evaluation History: Rule out alternative causes and assess for co-morbidities lead toxicity, trauma, absence seizure, hearing problem, autism, developmental delay, IDD, LD, language disorder, encephalopathy, substance abuse, depression, anxiety, psychosis, sleep disorder, obstructive sleep apnea Physical exam: mental status exam, soft neurologic signs, fine motor deficits, motor tics
PCP Work-up DSM based questionnaire: Vanderbilt (Teacher/Parent) ASQ, MCHAT, PSC-Y Audio Cbc, lead
CASE STUDY
Treatment Behavior and psychotherapy Medication Stimulant Nonstimulant Special education 504 plan IEP
Treatment ADHD medication and behavior therapy among children with ADHD (ages 4-17) with special health care needs
Functional Impairments Academic performance Peer relations Adaptive skills Family functioning
Medical decision making Is there harm in delaying treatment? What's the risk of medication at 4-5 years age? behavioral therapy first line, medication if fails to improve with therapy and moderate to severe symptoms Age 6-18, medication+behavior therapy Rule out substance abuse in adolescents Low abuse meds: Nonstimulants, Vyvanse, Concerta
Medical decision making Clinical rating scales Formal assessment Communication with school Informed consent General guidelines 20% do not respond to medication Only 50% respond well to either stimulant class Children respond to medication differently at different ages Long acting formulations are not for everybody Regular follow-up visits
When to Refer Fails to respond to psychostimulants/nonstimulant Concern for other medical conditions: seizures, genetic syndrome, developmental disorder, obstructive sleep apnea Multiple co-morbidities Severe mental health concerns
Resources American Academy of Child and Adoscent Psychiatry http://www.aacap.org/aacap/families_and_youth/r esource_centers/adhd_resource_center/home.as px American Academy of Pediatrics Healthy Children AAP website for parents Caring for Children with ADHD: A Resource Toolkit for Clinicians - many useful handouts
Resources National Resource Center on ADHD - a national clearinghouse for science-based information about all aspects of attentiondeficit/hyperactivity disorder (AD/HD). Funded by the Centers for Disease Control and Prevention, NRC provides information on ADHD and has an online library of materials. CHADD: Children and Adults with Attention- Deficit/Hyperactivity Disorder is a national non-profit organization serving people with AD/HD and their families. CHADD has local chapters- there is a chapter in the Valley. The membership fee of $45 gives you access to an informationpacked website and to an online magazine named Attention. ADD Warehouse a source for books and DVD s on ADHD, Learning disabilities, and childhood mental health disorders ADD Store Products that can help organize, remind (pill boxes with alarms) and make life easier (e.g. clothing for hypersensitive skin) for people with ADHD
Resources Learning Disabilities LD OnLine - web site on learning disabilities and ADHD Learning Disabilities Association of America - the largest nonprofit group for people with learning disabilities. Over 200 local affiliates in 42 states, including Arizona. National Center for Learning Disabilities Great Schools Website with many handouts about Learning Difficulties (LD & ADHD). Can be searched by age group. Healthy Children American Academy of Pediatrics