File - Old Dominion Medical Society

Report
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??

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