1. Pediatric ADHD and behavioral challenges Howard Uman, M.D. Director, ADD clinic, Swedish Family Medicine First Hill Regional TSC and LAM conference, 6/11/16

2. Howard Uman, M.D. Pediatrician Pediatric residency, University of Michigan Child development Project, University of Michigan behavioral pediatrics fellow, UW, Seattle children’s Hospital 22 years in practice 16 years--Faculty, Swedish family medicine residency training program

3. ADD is common  8% of children  5% of adults

4. ADD is a neuro developmental disorder  Genetics: 25% of children with ADD have at least one parent with ADD  Symptoms are evident before the age of 5 in children  Before the age of 12 in adults.

5. ADD: 3 key symptoms  INATTENTION  Overactivity  Impulsivity (verbal and behavioral)  Symptoms are significant when they cause functional impairment

6. Inattention is the key symptom  Difficulty focusing  Distractibility  Difficulty completing tasks  May be learning despite “lack of attention”  Inattention interferes with classroom function  May be “silent”: gradually unmasked by increased demands

7. overactivity  “overrated”  Characteristic of younger child  Symptoms subside with age  or symptom is sublimated

8. impulsivity  verbal  Behavioral

9. How to assess: Objectivity and reliability  Confirmation that symptoms are significant (compared to peers)  Talk to the student and family  Functional impairment: Inability to complete assigned work  Extraordinary effort to complete tasks (6hrs to complete 3hr assignment)

10. Confirm with standard questionnaires: --Vanderbilt --Conners  Multiple questions, various perspectives; Multiple observers  “Often or very often”  Attention to details, careless mistakes  Difficulty sustaining attention  Doesn’t seem to listen  Doesn’t follow through on instructions (not oppositional or misunderstanding)  Difficulty organizing  Can’t sustain effort  Loses necessary items  Easily distracted  “Forgetful in daily activities”

11. Comprehensive approach: medical  Hearing, vision  Medical conditions interfering: Symptoms, medications, limitations  Sleep disturbance, snoring, obstructive sleep apnea  seizures  Genetic predisposition: Parent or sibling  Genetic predisposition: Associated disorder

12. Comprehensive approach: Educational  Does the classroom situation support or provoke?  Best with increased structure  Individual assistance/support  Learning disabilities, cognitive abilities  Establish systems: Example—homework assignments; “fail safe system”

13. Comprehensive approach: Educational Accommodations  Increase time allotment ( slow processing speed): Tests, extended assignments  Reduce requirements: Recognize tolerance  “Productive effort”: Reduce frustration, discouragement  Provide individual assistance, tutoring  Collaboration with the school:  Student intervention team  504 plan  IEP: Individualized educational plan

14. Comprehensive approach: Psychological  Create a positive environment  “Job of the student is to love school”  “if you were in charge of your school…”  Promote success: Music, art, sports, groups, Legos, computers, karate  (make sure it’s the right coach)  Discouragement  Frustration  Low self-esteem  Depression  Anxiety: situational vs generalized

15. Comprehensive approach: Psychological Do not embarrass Do not pressure Do not punish/restrict (blame the victim) Promote positive experiences

16. Comprehensive approach: Neurologic  Educate the patient and family: A neuro developmental disorder  Not “inadequate effort… lazy”

17. ADD treatment  Behavior first for child less than 5yo  Medication 80–90 % success  Medication is the single most powerful component  A comprehensive approach including psychological support is best  No proven benefit from fish oil, elimination diet, allergy treatment

18. Stimulant medications  Long record of safety (1950s to present)  Individual response  Individual tolerance (dosage not by age, weight, puberty…)  Must titrate: close observation, confirm individual response  Immediate response if sufficient challenge (no build-up)  “Is the benefit significant?”  Benefit is not “subliminal”

19. Stimulant medication: continuing benefit?  Is benefit waning? ( development of tolerance)  Individual patient may not perceive benefit  Need good observers  Does benefit persist long enough to meet individual needs  Tailoring medication use: 5d/wk; 7d/wk  academic, social, family?

20. Stimulant medication: Side effects  Insomnia  Headache  Decreased appetite  Abdominal pain  Weight loss (?Silent)  Increased seizures?  Emotional suppression  Emotional lability, anger

21. Stimulant medication: Cardiac risk?  Recognized condition: need cardiology clearance  Increased blood pressure: Insignificant  Increased pulse: Insignificant  Myocardial irritability: Cardiomyopathy  Family history: Early stroke, early heart attack, or sudden death before 40  No evaluation required (EKG, echocardiogram) per American Academy of pediatrics

22. Additional treatment options  Adjunctive or individual benefit: Guanfacine, clonidine  Non stimulant alternative: Strattera  ??antidepressant: bupropion ( Wellbutrin)  “If no response to stimulants, reassess diagnosis.”  Bob Hilt, psychiatric consultant, Seattle Children’s Hospital, 2/2016

23. TSC and ADD  Even individuals with no intellectual difficulties may have difficulty  2/3 individuals: Difficulties in executive function  Affected individuals with TSC: difficulties with  selective attention, sustained attention, dual tasking  Incidence of ADD is 30–50% in children; uncertain re adults  Increased associations: ADD–ASD–MR-TSC

24. Associations of brain regions and support of attention  Right frontal, right parietal  vigilance  Left lateral frontal, anterior cingulate  Executive function  Parietal, midbrain, thalamic  Orienting

25. Additional factors  All epilepsy conditions have increased incidence of ADD  TSC 2 gene: greater association with ADD than TSC 2  Lamotrigine: ?improved attention, improved behavior in epilepsy with ADD

26. Proposed approach to ADD in patients with TSC  Close coordination with neurologist  If seizure frequency is less than 1/month and ADHD is moderately severe: Careful trial of methylphenidate (stimulant) or Strattera or alpha-agonist  As always, use a comprehensive approach: Medical, educational, and psychological support as needed

27. ADD and TSC: references  Jeste, S, “neurodevelopmental, behavioral, and cognitive disorders,” Continuum Journal 2015; 21(3): 690– 714.  D’Agati, E, “attention deficit hyperactivity disorder and tuberous sclerosis complex,” Journal of child neurology 2009; 24 (10), 1282–1287.  AAP News, “behavior therapy underused in 2–5-year-olds with ADHD,” 5/3/2016.  Tierney, K, “neuropsychological attention skills and related behaviors in adults with tuberous sclerosis complex,” Behavioral Genetics 2011;41: 437–444.  Visser, S, “vital signs: National and state specific patterns of attention deficit hyperactivity disorder treatment among insured children aged 2–5 years, United States, 2008–2014,” MMWR 5/6/16; 65 (17): 443– 450.  Hanson, E, “brief report: Prevalence of attention deficit hyperactivity disorder among individuals with an autistic spectrum disorder,” Journal of autism and developmental disorders 2013; 43: 1459–1464.  Visser, S, “treatment of attention deficit hyperactivity disorder among children with special healthcare needs,” Journal of pediatrics 2015:166 (6): 1423–1430.  Murray, D, “clinical review of outcomes of the multimodal treatment study of children with attention deficit hyperactivity disorder,” current psychiatry reports 2008; 10:424–431.