1. Attention Deficit Hyperactivity Disorder
Royann Mraz, MD
Clinical Associate Professor
Center for Disabilities and Development
Dec 10, 2014

2. No conflict of interest

3. Epidemiology of ADHD 8-10% of school aged children
8% 4-10yr, 14% yr.
Boys>Girls 2-4:1
High rates of Co-Morbidities –especially psychiatric and learning
33% have one co-morbidity, 16% -2,
18% - 3

4. Neurobiology of ADHD Cerebellar-prefrontal-striatal network hypothesis
Volume differences- caudate, smaller cerebrum (esp. anterior) and cerebellum

5. Genetics
Genetic imbalance in dopamine and noradrenergic systems- several genes play a role
Strong genetic influence
Concordance -92% identical twins, 33% dizygotic twins

6. Environment Increased risk with prenatal smoking exposure *
Prematurity, Brain injury, fetal alcohol, lead
Dietary factors do not play a role in the majority of children – food additives, essential fatty acids?, Fe or Zn deficiency?

7. Attention Deficit Hyperactivity Disorder- subtypes
Predominately inattentive type – 8-9 yr Pr
Predominately inattentive type
Predominately hyperactive-impulsive- start at 4yr, max 6-8 yr
Combined type- most common

8. DSM 5 ADHD
Children - 6/9 symptoms of Inattention (inconsistant with developmental level, impacts activities, and not secondary to oppositional behavior or failure to understand) and/or 6/9 symptoms of hyperactivity/impulsivity
Adolescent and adults – only require 5 symptoms from either category
Some symptoms must be present by 12 years of age (DSM-IV by 7 yrs and be impairing)

9. Diagnostic criteria - Inattention
Careless mistakes
Difficulty sustaining attention
Does not seem to listen
Does not follow through on tasks
Not organized
Avoids sustained mental effort
Loses things
Is easily distracted
If forgetful /9

10. Diagnostic criteria – Hyperactivity/Impulsivity
Fidgets or squirms
Inappropriately leaves seat
Inappropriately runs or climbs
Has difficulty playing quietly
Is “on the go”
Talks excessively
Blurts out answers
Has Difficulty waiting his or her turn
Interrupts or intrudes on others 6/9

11. DSM-5 ADHD updates
Most of changes recognize that ADHD is a chronic illness and help with diagnosis in adolescents and adults
18 symptoms remain the same (additional examples provided)
Inattentive symptom f: Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg. Schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers)

12. ADHD Updates Cross-situational symptoms rather than impairment
Symptoms interfere or reduce quality of social, academic, or occupational functioning
Present for over 6 months
Symptoms aren’t secondary to other mental disorder
Rate current severity of symptoms –mild, moderate, severe

13. Consequences of DSM-5 ADHD
Easier to diagnose in adolescents and adults
May increase the prevalence rates
Can diagnose ADHD in individuals with Autism Spectrum disorder

14. Differential Diagnosis of ADHD
Normal age appropriate behavior, Unrealistic expectations
Lack of structure/limits
Family stress and dysfunction, abuse
PTSD, RAD, and adjustment disorders
Intellectual disability/Learning disorder
Autism, fetal alcohol, seizures, lead exposure, sleep disorder, thyroid

15. COMORBIDITY Learning disorder 10-30%
Opposition defiant disorder/ Conduct disorder 50-67%
Anxiety or Mood disorder 30%
Tourette’s and tic disorders
Coordination problems
Substance abuse
Sleep problems

16. DIAGNOSTIC EVALUATION
Child’s history and functioning
Family history and functioning
School information
Rating scales – parent and teacher
Interview and physical exam of child
Consider psychological/educational evaluation

17. AAP Practice Guidelines for ADHD 2011
Initiate evaluation for ADHD in child 4-18 years of age if behavior or academic problems and ADHD symptoms
Determine if DSM criteria are met in more than one setting (teacher questionnaires) and rule out other causes

18. AAP guidelines for ADHD
Assess for co-existing conditions –
Emotional/behavioral (anxiety, depression, ODD, conduct disorders)
Developmental (learning, language, etc.)
Physical (sleep apnea, tics, etc.)

19. AAP Guidelines for ADHD
Treat ADHD as a chronic condition using principles of chronic care model and medical home
Titrate medication to achieve maximal benefit with minimal side effects

20. AAP guidelines for preschoolers
Addresses evaluation and management of 4 and 5 year olds with ADHD symptoms
Recommends behavior management counseling and placement in structured setting
Allows for stimulant treatment if above isn’t sufficient

21. AAP Guidelines ADHD 6-11 Years
Treat with FDA approved medication (strong evidence for stimulants) and/or
Parent and/or Teacher behavior management or preferably both
12-17 Years
Treat with FDA approved medication
May prescribe behavior therapy

22. Consider referring if Preschool child
Developmental delay or learning problems
ADHD, inattentive type
Family dysfunction
Moderate to severe behavior problems
Anxiety or depression

23. Medical Treatment of ADHD
Monitor or treat co-morbidities
Educate patient and family
Set goals with family and school
ADHD is a chronic disorder – 65% of children with ADHD will have symptoms as adolescents

24. Medical Management of ADHD
Medication is most effective treatment
Good behavior management program can provide additional benefit
Stimulants are first line treatment and most effective
70-80% of children will respond to a stimulant

25. Stimulants
Methylphenidate, d-amphetamine, mixed amphetamine salts are equally effective
Probably act by increasing dopamine and norepinephrine levels
Similar side effects

26. Stimulants
Individualized dosing- often have better results with higher dose
All day coverage for many/most children
Frequent follow-up with health care provider with teacher feedback
If one stimulant doesn’t work, try another

27. Stimulants Improve attention span
Decrease hyperactivity and impulsivity
Improve work completion
Often improve behavior
Often improve academic performance

28. Common stimulant side effects
Decreased appetite- give with or after meals
Difficulty falling to sleep
Tics
Stomachaches – give with food
Headaches

29. Less common side effects
Moodiness or irritability
Overly quiet “Zombie effect”
Weight loss
Small decrease in height velocity
Rebound symptoms as med wears off
Mild increase in heart rate and B/P
Rare risk of mania or hallucinations
Priapism- 15 cases reported

30. Stimulants
Methylphenidate products (Ritalin, Concerta, Metadate, Methylin, generics, patch
D-methylphenidate (Focalin, Focalin XR)
D-amphetamine (Dexedrine, Dextrostat)
Mixed amphetamine salts (Adderall, Adderall XR)

31. Methylphenidate –dose and duration of action
Short acting ( Ritalin, Methylin, etc.) 3-5 hrs (.3-.7 mg/kg/dose 2-3 times/day) D-methylphenidate Focalin( mg/kg/dose)
Intermediate acting (Ritalin SR, Metadate ER, Methylin ER) – 3-8 hr
Extended release ( Metadate CD, Ritalin LA) 6-8 hr, Concerta hr
Methylphenidate patch, wear for 9 hr
Usual maximum daily dose – 2 mg/kg

32. Methylphenidate Extended Release
Concerta – longest lasting,22% immediate release, ascending plasma level, must be swallowed whole
Ritalin LA 50% immediate release, 50% release at 4 hr, mimic bid dosing. Can open capsule
Metadate CD 30% immediate release, can open capsule

33. Methylphenidate patch
Methylphenidate patch (Daytrana)
10,15,20,30 mg patches
Takes 2 hrs to take effect, wear 9 hours, lasts 12 hours
Same side effects, patch may come off
Useful for patients unable to take pills or with fast metabolism

34. Amphetamines – dose and duration of action
Short acting (Dexedrine, Dextrostat) – 4-6 hr
Intermediate acting (Adderall, Dexedrine spansules) 5-8 hr
Extended release (Adderall XR) hr
Usual maximum daily dose – 1 mg/kg
Dose is ½ to 2/3 of methylphenidate dose

35. Other stimulant preparations.
Lisdexamfetamine (Vyvanse)
Pro-drug, which is activated when aminoacid is cleaved off
Effective for ADHD, same side effects
Aim is to provide protection against abuse and addiction
6-12 years, start at mg, can increase weekly up to 70 mg max
Lisdexamfetamine 30 mg roughly equivalent to dextroamphetamine 10 mg

36. Cardiac warnings
27 unexplained deaths in children under 18 yrs on ADHD medication reported between
11 on methylphenidate
13 on amphetamine salts (Adderall)
3 on atomoxetine (Strattera)
FDA recommends not using if heart disease, arrhythmia, or FH of arrhythmia
Concern about patients with undiagnosed heart disease and long term effects
EEG not needed if cardiac hx is negative

37. Benefits of stimulants in Adolescents
Medication reduces risk of auto accidents for ADHD patients
Medication reduces risk of substance abuse in ADHD patients

38. Other Medications for ADHD
Atomoxetine (Strattera)
Bupropion (Wellbutrin), imipramine
Alpha2 agonists -clonidine or guanfacine (Tenex) – useful for tics, sleep, and aggression

39. Atomoxetine (Strattera)
Selective norepinephrine reuptake inhibitor
Effective for ADHD, may take 3-4 weeks to see full effect
No abuse potential, not controlled substance
Unlikely to worsen tics or anxiety
Dosage – start .5 mg/kg/day for 3 days, then up to 1.2 to 1.4 mg/kg/day
10, 18, 25, 40, 60, 80, 100 mg capsules
Useful for ADHD with anxiety or depression

40. Atomoxetine (Strattera)- side effects
Somnolence – can give in evening or divide dose
Anorexia, GI upset, weight loss – give with food, divide dose
Dizziness
Rare risk of liver disease
Increased risk of suicidal ideation .4%

41. Alpha 2 Agonists Clonidine and guanfacine (Tenex) Adjuctive medication
Useful for sleep, tics, aggression, hyperarousal
Not as effective for inattention
May take 2 weeks to see
effect

42. Alpha 2 Agonists
Clonidine mg/kg/day, tid,qid, often start mg per day, also available as patch and long-acting form
Guanfacine mg/kg/day, max 4 mg/day, often start .5 mg perday (also once daily form )
Side effects – sedation, especially with clonidine, dry mouth, depression, low B/P, headache
Withdrawal symptoms if stopped suddenly –high pulse, B/P, headache, agitation

43. ADHD and Co-morbidities
ADHD and anxiety – respond to stimulants, may need to add SSRI, another option is atomoxetine
ADHD and tics – stimulants and clonidine or other meds for tics, atomoxetine
ADHD and aggression – stimulant and clonidine/guanfacine or other meds

44. Parenting and ADHD Brief clear instructions
Give immediate and frequent feedback and consequences
Use incentive more than punishment
Try to be consistent and provide structured environment
Plan for problem situations
Negotiable and non-negotiable issues

45. Special Education and ADHD
Child with ADHD may be eligible for special education, under “Other health impairment”
Child must be tested and qualify for special education
“Limited alertness” for academics, which adversely affects education, including grades, tests, behavior, social skills.

46. 504 Plan Section 504 of Rehabilitation Act
Schools receiving Federal funds and employers can not discriminate against people with disabilities (including ADHD) and must make reasonable accommodations

47. Educational Accommodations
Tailor homework assignments and tests
Structured environment, help with organization
Simplify and/or provide visual instructions
Behavior management techniques
Use of tape recorders or notes
Daily or weekly report to parents

48. Medical management for ADHD
Stimulants are first line treatment
70-80% effective
Titrate to optimal dose
All day coverage for many/most children
Set and monitor goals
Close long-term follow-up

49. References
AAP. ADHD Clinical Practice Guidelines. Pediatrics 2011;128:
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.,2013, American Psychiatric Association, Arlington, VA.

50. Resources www.chadd.org www.dbpeds.org www.aap.org www.help4adhd.org
ADHD toolkit

51. Questions