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ADHD: A Guide to Diagnosis, Treatment and Common Misconceptions

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Attention Deficit Hyperactivity Disorder: A Guide to diagnosis, treatment and common misconceptions

Elizabeth A. Montagnese, M.D.

Child and Adult Psychiatrist

Quittie Glen Center for Mental Health

Annville, PennsylvaniaPharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education

Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.

Attention Deficit Hyperactivity Disorder: A Guide to Diagnosis, Treatment and Common Misconceptions

Accreditation:Pharmacists: 0798-0000-11-007-L01-PPharmacy Technicians: 0798-0000-11-007-L01-TNurses: N-646

CE Credits: 1.0 contact hour

Target Audience: Pharmacists, Technicians & Nurses

Program Overview:Attention deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity). The American Psychiatric

Association states in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) that 3%-7% of school-aged children have ADHD. This knowledge based program will enhance the understanding of ADHD and it's causes, symptoms, treatment, and medications. The program will include an in-depth comparison of the available medications to include dosages, metabolism, side-effect profile and reasons practitioners select specific medications for individual patients

Objectives: • Describe the diagnostic criteria and casual theories of ADHD• Outline common presentations of the disorder during different periods of development through the use of case studies

• Compare the current evidence-based treatments available for the disorder, both pharmacologic and non-pharmacologic treatments.• Identify current misconceptions about the disorder and the impact of these misconceptions on patients and families

Attention Deficit Hyperactivity Disorder: A Guide to Diagnosis, Treatment and Common Misconceptions

Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.

PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education

Speaker: Dr. Montagnese is board certified in adult, child, and adolescent psychiatry by the American

Board of Psychiatry and Neurology. Dr. Montagnese provides comprehensive psychiatric evaluation

and treatment for individuals, couples and families. Her primary area of focus is working with children

and adolescents but she also treats adults.Dr. Montagnese received her medical degree at Wayne

State University in Detroit, Michigan. She completed her general psychiatry and child psychiatry

training at the Penn State University Milton S. Hershey Medical Center.Dr. Montagnese is the medical

director at Family and Children Services of Central Pennsylvania. This is a United Way funded

nonprofit agency that serves the greater Harrisburg, York and Lancaster areas. To contact her at this

agency please call 717-238-8118.

Speaker Disclosure: Dr. Montagnese has no actual or potential conflicts of interest in relation to

this program

Learning Objectives

1. Review the diagnostic criteria and causal theories of ADHD.

2. Review common presentations of the disorder during different periods of development through the use of case studies.

3. Compare the current evidence-based treatments available for the disorder, both pharmacologic and non-pharmacologic.

4. An in-depth comparison of the available medications will be presented and will include dosages, metabolism, side-effect profile and reasons practitioners select specific medications for individual patients.

5. Current misconceptions about the disorder and the impact of these misconceptions on individuals and families will be discussed.




Top 10 Myths about ADHD

1. ADHD is not a real disorder.2. ADHD is an American disorder.3. ADHD is over-diagnosed.4. Kids with ADHD are over-medicated.5. Kids with ADHD will outgrow it.6. ADHD is due to poor parenting.7. ADHD kids are just lazy and ill-behaved.8. ADHD kids that take stimulants will abuse drugs.9. If kids can play video games, watch TV or concentrate

on some things, they can’t have ADHD10. ADHD medications make kids zombies.

ADHD: A Historical Perspective

Fidgety Phil by Dr. Heinrich Hoffman, 1845

Sir Alexander Crichton, published in The Lancet, 1902:

“I would point out that a notable feature in many of these cases of moral defect without general impairment of intellect is a quite abnormal incapacity for sustained attention. He concluded: “there is a defect of moral consciousness which cannot be accounted for by any fault of environment”

Two Cases

Robert, 16 yo: combined type Amy,8 yo: inattentive type

• Diagnosed at age 7

• Multiple med trials over the years

• Moderate response

• Needs high doses-hates meds

• Hates school

• Bored easily, restless

• Excels at sports

• High parent conflict

• Wants to drive

• Wants to go to college-doesn’t think he can

• Quiet, shy

• Not hyperactive

• Bright but average grades

• LD in Mathematics

• Parents concerned-teachers less so

• Can be sluggish

• Low dose stimulants made big difference

• Only uses meds during school

More Current Terms

• Minimal Brain Dysfunction

• Hyperkinetic Disorder of Childhood

• Attention Deficit Disorder

• Attention Deficit Hyperactivity Disorder




Cost of ADHD

• $32 to $52 billion annually in U.S. (CDC, ADHD homepage)

• Diagnosis rates have increase 3%/year from 1997-2006

• 56% of those with diagnosis receive medication

Epidemiology of ADHD

• ~20% of children and adolescents have a mental health diagnosis

• ADHD is by far, the most common (3 to 8%)

• 75% are treated by the PCP

• Half of all pediatric office visits are for behavioral, psychosocial, or academic concerns.

Prim Care Corp Jclin Psych 2008: 10(3): 211-221

Epidemiology of ADHD

• Across all cultures when same diagnostic criteria applied

• M:F is 3-4:1

• Monozygotic twins: 81% concordance rate

• Parent with ADHD: 50% will have a child with ADHD

• Females: more likely to have inattentive type, less likely to get dx and tx

Why so prevalent?• Evolutionary advantage in early environments • One theory-not all inclusive

• Can possibly explain high prevalence rate• Hyperactivity: helps with foraging, spotting food, predators,

danger, moving to better climates

• Impulsivity: helps with reflexive or automatic responses• Pounce or be pounced on

• Overly focused/contemplative individuals would be at a disadvantage

• Rapidly shifting attention: helps with vigilance, scanning

Jensen, et al, Journal of the American Academy of Child and Adolescent Psychiatry, 1997




Once an asset, Now a deficit

• Environment changed rapidly

• Genes haven’t caught up (?)

Modern day environment

• School/workplace demands

• Attentional focus

• Motor passivity

• Many distractions-ADHD brain is wired to pay attention to distractions

• Passive listening

• Delayed response

School and the ADHD childWhy is this important?

• Steering child toward more adaptive environments/pursuits

• Changing environments to fit the child

• Strengths vs weaknesses assessment

• Providing treatment early on when brain is pliable




Theories of Causation

• Multifactorial

• Genetics

• Neurotransmitter deficits: dopamine, norepinephrine

• Perinatal complications

• Toxins: drugs, smoking, alcohol in pregnancy, lead exposure

• Trauma, neurological disorders

• Early severe deprivation

Technology and ADHD

• "You prime the mind to accept a fast pace. Real life doesn’t happen fast enough to keep your attention.” ~Dimitri Christakis, MD PHD, Univ of Washington

• AAP: Limit tech/screen time, no TV <2 yrs old

Either (1) inattention (6 or more for >6 months)

Or (2) hyperactivity-impulsivity (6 or more for >6 months)

Inattention to detail/careless mistakes

Difficulty with sustained attention to tasks or play

Doesn’t listen

Doesn’t follow through with tasks

Disorganized

Avoids tasks requiring sustained effort

Loses things necessary for tasks

Easily distracted by extraneous stimuli

Forgetful in daily activities

Fidgets, squirms

Leaves seat inappropriately in

classroom

Runs around or climbs excessively

Doesn’t play quietly when expected

“on the go” as if “driven by a motor”

Talks excessively

Blurts out answers inappropriately

Difficulty with awaiting turn

Interrupts or intrudes on others

DSM-IV ADHD Diagnostic Criteria Core symptoms

• Present in multiple settings

• Prior to age 7

• Symptoms must cause significant impairment must be present in social, academic and/or occupational functioning

• Symptoms must be present for 6 months

• Symptoms not better explained by PDD, psychotic d/o, and are not secondary to mood/anxiety disorders, dissociative disorder or personality disorder




Diagnosis

• No single test, no imaging study to confirm diagnosis• Clinical diagnosis• Synthesis of info from multiple sources: parents,

teachers, caregivers• Structured interviews-in depth• Rating scales: Conners, ADHD Rating Scale IV, CBCL:

become familiar with one brief, standardized checklist.

• Observation and interview of child• Psychoeducational testing is helpful

Remember: The acorn doesn’t fall far from the tree.

You might need to treat the parent(s) too!

Comorbid conditions

• ODD and Conduct Disorder-most common

• Learning Disorders

• Substance Abuse

• Anxiety

• Depression

• Bipolar Disorder

Mood lability: elation/irritability

Grandiosity/flight of ideas

“affective storms”

Decreased need for sleep

Age-inappropriate sexual interest

Mania is not just severe ADHD, it includes….

Treatment Approaches

• THERAPEUTIC ALLIANCE!!!!

• Behavior therapy

• Parent and teacher training

• Psychoeducation

• Educational accommodations

• Treat comorbid conditions

• Psychotherapy

• Pharmacotherapy: effective in 85%




Diet, Exercise and ADHD

Dietary modifications generally not supported (except in food allergic individuals)-current area of research

Diet: always emphasize good diet/sleep habits Exercise: growing evidence that it releases dopamine, NE!

An ADHD Med Without Side Effects:"Think of exercise as medication: "For a very small handful of

people with attention deficit/hyperactivity disorder (ADHD ADD), it may actually be a replacement for stimulants, but, for most, it's complementary — something they should absolutely do, along with taking meds, to help increase attention and improve mood,”

says John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School

Success can happen!!

Treat ‘em when they need it!

Some persons need the medication just in school

Some need it 24/7

Remember, there’s social learning, too!

MTA study• 1999

• Compared 4 groups

▫ Medication only

▫ Behavior Tx only

▫ Combo Tx

▫ Community Tx

• Initial results▫ Medication and Combo were significantly improved

▫ Lead field to feel meds were defining factor

MTA study

• JAACAP, May 2009-2008 year follow up

• Differences between treatment groups were not sustained at follow up

• Growth retardation was documented

• Protective effect on later substance abuse not evident

• Very heated debate currently




MTA study

• Treat the individual

• Assess carefully for comorbid conditions

• Periodically assess efficacy of medications

• Not everyone needs long term medications

• Monitor physical parameters and alter dose or medication if necessary

“More research is needed to test whether successful control of symptoms in the short term translates into better prognosis in the long term.” -BenedettoVitiello, M.D., Chief, Child and Adolescent Treatment and Preventive Intervention Research Branch, NIMH

Risks of Treating ADHD

• All medications have side effects.

• Stimulants have decades of research behind them.

Risks of Not Treating ADHD

• Increase risk of accidents

• Poor school performance/drop out

• Marital strife/divorce

• Work issues: decreased productivity, job loss

• Legal problems

• Poor relationships

• Poor self-concept, depression

Medication Success

• Inquire about patient’s/family’s feelings about using medication

• Educate about disorder and treatment options

• Opportunity to ask questions

• Prepare them for potential side effects

• Validate fears/concerns




Core Principles in Pediatric Psychopharmacology I: Pharmacokinetics

Do not extrapolate dosages from adult dosages:Children have:

• greater liver/kidney parenchyma per weight.• greater water and less fat and albumin content.

• larger volume of distribution, • greater first-pass metabolism, • a shorter half-life (T ½) more likely• more rapid elimination of medications.

• Less end-organ availability per unit dose!

Core Principles in Pediatric Psychopharmacology I: Pharmacokinetics

Shorter T1/2 in children Can sometimes require more frequent dosing (e.g. b.i.d. instead of q

D).

Can increase the possibility of withdrawal symptoms.

Dose-duration effect T1/2 can increase with dosage increase.

Therefore, more frequent dosing intervals may be necessary at lower doses.

In general, there is low correlation between serum/plasma levels of psychotropic medications and clinical effect.

Core Principles in Pediatric Psychopharmacology II: Pharmacodynamics

Receptor density peaks in the preschool years, then gradually declines.

Stimulants are more likely to cause euphoria in adults than in children.

Pharmacogenomics: someday we might be able to choose medications based on the patient’s allelic array of transporter, receptor and enzyme genes.

Using Stimulants

No need to start with immediate-release stimulant unless very small child

See weekly during initial titration, and adjust dose weekly

Baseline BP, pulse rate, height and weight, then follow

No EKG unless personal or family history of cardiac disease, especially dysrhythmia

Options for the child who can’t swallow a pill Sprinkles: onto applesauce, pudding, Go-gurts.

Patch: onto the hip




Stimulants

• Methylphenidate

• Amphetamine

• Lisdexamphetamine

• Equally effective

• 65-75% response rate

• Decades of research

Methylphenidates

Short acting: BID or TID Intermediate acting: QD or BID

FDA Max/day

Starting dose

Focalin(2.5,5,5,10mg)

Methylin(5,10,20mg, chew tabs, solution)

Ritalin(5,10,20 mg)

20mg

60mg

60mg

2.5-5 mg

5mg

5mg

FDA Max/day

Starting dose

MetadateER (10, 20mg)

MethylinER (10, 20mg)

Ritalin SR(20mg)

Metadate

CD(10,20,30,

40,50,60mg)

Ritalin LA (20,30,40mg)

60mg

60mg

60mg

60mg

60mg

10mg

10mg

10mg

20mg

20mg

Methylphenidates

Long acting: QD

FDA Max/day

Starting Dose

Concerta(18

, 27,36,54mg)

DaytranaPatch (10,

15,20,30mg)

Focalin XR (5,10,15,20mg)

72mg

30mg

30mg

18mg

10mg

5 mg

Amphetamines

Short acting: BID or TID Long acting: QD

FDA Max/day

StartingDose

Dexedrine(2.5, 5mg)

Dextro-stat (5, 10mg)

Adderall(5,

7.5,10,15,20,30mg)

40 mg Start 5mg/dose

Half for pre-schoolers

FDA Max/day

StartingDose

Dexedrine Spansules(

5,10,15mg)

Adderall XR(5,10,15,20,25,30mg)

Lisdexam-

phetamine (Vyvanse) (20,30,40,50,60,70mg)

40mg

30mg

70mg

5-10mg

10mg

20-30mg




Stimulant side effects

• Ask specific, rather than general, questions regarding side effects.

• Weight loss, decreased appetite

• Insomnia

• Headache

• Tics

• Emotional irritability

• Less common: psychosis, severe aggression

• Growth retardation (debated)

• Methylphenidate may cause relatively greater side effects in preschoolers.

• Stimulants may cause increased irritability in children with autism spectrum disorders.

What About Growth Suppression?

Best evidence is that many children using stimulants will experience a slight tailing off in growth rate, around a centimeter or so in height and a kilogram or two in weight over 2 years

Long-term significance of this is unclear, as there is some evidence that final adult height is not affected

Encourage high-nutrient diets in patients with ADHD

Stimulant use Precautions

• Glaucoma

• Hyperthyroidism

• Hypertension

• Don’t use with MAO-I• Drug and alcohol abuse

• No evidence stimulant use causes increased risk of substance abuse in teens

• Known cardiac defects

Dosing: How high is too high?

• “The AACAP has also issued specific parameters for the use of stimulant medications (American Academy of Child and Adolescent Psychiatry, 2002). These doses represent guidelines; with careful clinical monitoring, these doses may be exceeded in individual cases.”

• “There is a linear relationship between dose and clinical response.”

• “There is no evidence of a global therapeutic window in ADHD patients. Each patient, however, has a unique dose-response curve.”

AACAP Practice Parameters for ADHD, 2007




Dosing: How high is too high?

• Titrate stimulants until you get a positive response or untoward side effect

• In select cases, we go above FDA-recommended max doses

• These case require close monitoring

Non-stimulants: Atomoxetine

Long acting: QD or BID

• First non-stimulant FDA approved for ADHD

• Not schedule II

• Not immediately effective and not as effective as stimulants

• Monitor for SI

• MAY have less effect on sleep, appetite, tics

• Common side effects: sedation, nausea, dizziness

FDA Max/day

Starting Dose

Atomoxe-tine (Strattera)

10,18,25,40,60, 80,100mg tabs

available

100mg or 1.8mg/kg

0.5-1.2 mg/kg/day

Special Considerations with Atomoxetine

• Adolescents who drive cars-24 hour coverage

• When switching from stimulant to atomoxetine, overlap stimulant use for first week of atomoxetineadministration.

• Increase dose weekly until effective or side effects

• Use if anxiety or D&A issues are present

• Use if can’t tolerate stimulant

2nd line medications

• Buproprion-use with comorbid depression

• Tricyclic antidepressants: blood levels, ECGs

• Alpha agonists: help with tics, hyperactivity and impulsivity most

• Use care in combining these with stimulants




Side Effects of Alpha AgonistsClonidine and Guanfacine

• Headache

• Nausea

• Dizziness

• Decreased heart rate

• Decreased blood pressure

• Sedation/somnolence

• Fainting

• Must taper

Extended Release Alpha Agonists

Intuniv (guanfacine) Kapvay(clonidine)

FDA Max/day

Starting Dose

1-4 mg tabs

Start with 1mg/day.

Increase weekly by

1mg/day until reach

4mg/day.

0.12mg/kg/day

0.05mg-0.08mg/kg

/day

FDA Max/day

Starting Dose

0.1, 0.2 mg tabs

Start with

0.1mg/day.Increase

weekly by 0.1mg until

reach 0.4mg/day

0.4mg/day 0.1mg/day

How Long to Treat?

“Patients should be assessed periodically to determine whether there is continued need for treatment or if symptoms have remitted. Treatment of ADHD should continue as long as symptoms remain present and cause impairment.”

Drug-free trials of 1-2 weeks with monitoring and feedback from home and school

I don’t begin or stop ADHD medicationWithin 4 weeks in either direction of the holidaysWithin 4 weeks of the end of the school year

Educational Considerations

• Identify needs

• Individualized approach

• Strengths-based

• Match child to environment and teacher

• Identify learning disorders

• Classroom behavioral plans

• Team approach: support each other

• Involve the child




Top 10 Myths about ADHD

1. ADHD is not a real disorder.2. ADHD is an American disorder.3. ADHD is over-diagnosed.4. Kids with ADHD are over-medicated.5. Kids with ADHD will outgrow it.6. ADHD is due to poor parenting.7. ADHD kids are just lazy and ill-behaved.8. ADHD kids that take stimulants will abuse drugs.9. If kids can play video games, watch TV or concentrate

on some things, they can’t have ADHD10. ADHD medications make kids zombies.

References• JAACAP, Practice Parameter for the Assessment and Treatment of Children and Adolescents with ADHD,46:7, July 2007,894-

917

• IntJ of Clinical Practice, Clinical Assessment and Treatment of ADHD in Children, 2007; 61(10) 1730-1738.

• www.nimh.hin/gov/health/publications/attention-deficit-hyperactivity-disorder/adhd_booklet.pdf.

• www.surgeongeneral.gov/library/mentalhealth/chapter3/sect6.

• Reiff, Michael, “ADHD A Complete and Authoritative Guide”, AAP, 2004

• Jensen, P. et al, Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation, JAACAP, 36(12:1572-1679), 1997.

• Biederman, J., “Practical Considerations in Stimulant Drug Selection for the ADHD Patient-Efficacy, Potency and Titration, Today’s Therapeutic Trends, 20(4):311/238, 2002.

• http://www.additudemag.com/adhd/article/print/3142.html-Exercise: A Med Without Side Effects, Ratey, J.

• Faraone, S. et al “ The worldwide prevalence of ADHD: is it an American condition?” World Psychiatry, June 2003; 2(2), 104-113.

Resources• CHADD: www.chadd.org

• American Academy of Child and Adolescent Psychiatry: www.aacap.org

• National Institute of Mental Health: www.nimh.nih.gov/

• American Academy of Pediatrics: www.aap.org

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