ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013 Outline Define ADHD Highlight common comorbid & confounding conditions Discuss assessment & treatment considerations The Diagnostic & Statistical Manual of Mental Disorders Minimal Brain Dysfunction Hyperkinetic Reaction of Childhood (DSM-II, 1968) Attention Deficit Disorder: With & Without Hyperactivity (DSM-III, 1980) Attention Deficit Hyperactivity Disorder (DSM-IV, 1994) Attention Deficit/Hyperactivity Disorder (DSM-5, 2013) Attention-Deficit/Hyperactivity Disorder Criteria: DSM-5 At least 6 symptoms of Inattention AND/OR At least 6 symptoms of HyperactivityImpulsivity Persistent for at least 6 months Maladaptive Inconsistent with developmental level Present before age 12 years Problems in two or more settings Impairment in social, academic or occupational functioning Not due to other condition Inattention • Makes careless mistakes • Difficulty with sustained focus • Does not follow through on instructions • Unable to organize • Avoids tasks requiring sustained attention • Loses things needed for tasks • Easily distracted • Often forgetful Hyperactivity Fidgets, squirms Difficulty remaining seated Runs & climbs excessively Difficulty playing quietly Acts as if “driven by a motor” Talks excessively Impulsivity Blurts out answers Can be intrusive Limited Interrupts patience others Types Combined Presentation Predominantly Inattentive Presentation Predominantly Hyperactive/Impulsive Presentation Mild/Moderate/Severe Other Specified ADHD Unspecified ADHD Etiology Deficits in executive functioning Genetic & Neurobiological contributors: perinatal stress, low birth weight, TBI, maternal smoking, severe early deprivation Decreased frontal & temporal lobe volumes Decreased activation of frontal lobes, caudate and anterior cingulate Epidemiology 6%-12% prevalence 4%-10% treated with medications 60%-85% will continue to meet criteria through teenage years Adult prevalence varies: by self report (2%8%), parent report (46%), developmentally modified criteria (67%) Rule of 3rd’s By adulthood: 1/3rd will continue to need medications 1/3rd will have mild/residual symptoms but functional without medications 1/3rd will no longer meet clinical criteria Confounding & Co-Morbid Conditions Medical Conditions Hearing impairment Hyperthyroidism Metals or toxins In -utero exposure Medical Conditions Seizures (Absence, Complex Partial) Severe head injuries Sensory Integration Disorders Sleep Apnea Disruptive, Impulse Control & Conduct Disorders Oppositional-Defiant Disorder Conduct Disorder Intermittent Explosive Disorder Substance Related Disorders Alcohol Amphetamines Cannabis Caffeine Cocaine Hallucinogens Inhalants Nicotine Opiate Sedative or Hypnotic Abuse Dependence Intoxication Withdrawal Neurodevelopmental Disorders Communication Disorders Autism Spectrum Disorders Intellectual Disabilities Specific Learning Disorders Motor Disorders Anxiety Disorders Separation Anxiety Disorder Generalized Anxiety Disorder Specific Phobia Social Anxiety Disorder Adjustment Disorder with Anxiety Panic Disorder Obsessive Compulsive Disorders Obsessive Compulsive Disorder Trichotillomania Excoriation Depressive Disorders Major Depressive Disorder Persistent Depressive Disorder Disruptive Mood Dysregulation Disorder Adjustment Disorder with depressed mood Manic Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Trauma – Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Evaluation Presenting symptoms Perinatal & developmental histories Medical history Family history Educational history Social history Patient & parent interviews Physical examination Collateral information Assessment Considerations Onset , frequency & duration Setting Context Level of disruption Stressors or trauma Intensity Level of impairment Ability to self-regulate Insight Scales Conner’s Parent’s Rating Scale Conner’s Teacher’s Rating Scale Brown ADD Vanderbilt ADHD Child Behavior Checklist Treatment Psychoeducation Clarify diagnosis Give contextual framework Be honest & sincere about your opinion Anticipate developmental challenges Provide or recommend resources: fact sheets, books, websites etc. School Resources Talk with child’s main teacher Talk with guidance counselor If applicable, encourage parents to request in writing testing or Child Study Suggest accommodations, if solicited Behavioral Therapies Initial therapy for mild symptoms and uncertain diagnosis Per parental preference Focuses in parental management and molding of behaviors Can be in-home or outpatient Behavioral Therapies Cognitive Behavioral Therapy (CBT) more efficacious in adolescents & adults than younger children Metacognitive Therapy (MCT) combines CBT with training on improving executive functioning Pharmacotherapy First Line Approved by FDA for ADHD Stimulants Atomoxetine Second Line Buproprion α Agonists Tricyclic Antidepressants Stimulants Methylphenidate Short acting (2-6 hrs): Focalin, Ritalin, Methylin Intermediate acting (4-8 hrs): Metadate CD, Methylin ER, Ritalin SR, Ritalin LA Long acting (8-12 hrs): Concerta, Focalin XR, Daytrana Patch Amphetamine Short acting: Dexedrine, Dextrostat, Adderall Intermediate acting: Dexedrine Spansules Long acting: Adderall XR, Vyvanse Stimulants Side Effects Decreased appetite, weight loss Insomnia, headaches Tics, emotional lability, irritability Visual & tactile hallucinations Contra-indicated in pre-existing heart condition Atomoxetine Selective Norepinephrine Reuptake Inhibitor (SNRI) Strattera Not as effective as stimulants Can use if negative side effects experienced on stimulants Requires 6 weeks to see full effect Effective in treating comorbid anxiety Side Effects Nausea, decreased appetite Headaches Sedation (can give as single night dose) Suicidality Buproprion Dopamine Norepinephrine Reuptake Inhibitor (DNRI) Wellbutrin, Wellbutrin SR, Wellbutrin XL Helpful in co-occurring depression Less effective for inattention, no effect on hyperactivity Delayed onset of action Side Effects Insomnia Headaches Nausea Contraindicated in seizure disorders Use with caution in eating disorders Can induce seizures in overdose α 2 Adrenergic Agonists Guanfacine (Tenex, Intuniv) Clonidine (Catapres, Kapvay) Effective for impulsivity and hyperactivity; not inattention Helpful in co-occurring traumatic flashbacks, aggression, insomnia & tics Side Effects Sedation Dizziness Hypotension Rebound hypertension with rapid discontinuation Tricyclic Antidepressants Imipramine, Nortriptyline, Desipramine Inhibits reuptake of NE EKG at baseline and each dose increase Once symptom control achieved, check serum level for toxicity Side Effects Dry mouth, constipation Vision changes, sedation Tachycardia Cases of sudden death reported in children & adolescents with desipramine When to Refer… For evaluation & treatment For consultation with resumption of treatment Concerns for safety Significant impairment in functioning No improvement after 6-8 weeks of first-line intervention Diagnostic conundrum History suggestive of trauma with current impact Difficulty coping with chronic medical illness Can always seek collegial consultation without face-to-face evaluation of patient References Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition American Psychiatric Association, 2013 Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit-Hyperactivity Disorder J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46 (7): 894-921 Questions??