1. ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

2. Outline  Define ADHD  Highlight common co- morbid & confounding conditions  Discuss assessment & treatment considerations

3. 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)

4. Attention-Deficit/Hyperactivity Disorder

5. Criteria: DSM-5  At least 6 symptoms of Inattention AND/OR  At least 6 symptoms of Hyperactivity- Impulsivity  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

6. 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

7. Hyperactivity  Fidgets, squirms  Difficulty remaining seated  Runs & climbs excessively  Difficulty playing quietly  Acts as if “driven by a motor”  Talks excessively

8. Impulsivity  Blurts out answers  Interrupts others  Can be intrusive  Limited patience

9. Types  Combined Presentation  Predominantly Inattentive Presentation  Predominantly Hyperactive/Impulsive Presentation  Mild/Moderate/Severe  Other Specified ADHD  Unspecified ADHD

10. 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

11. 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%)

12. Rule of 3 rd’s By adulthood:  1/3 rd will continue to need medications  1/3 rd will have mild/residual symptoms but functional without medications  1/3 rd will no longer meet clinical criteria

13. Confounding & Co-Morbid Conditions

14. Medical Conditions  Hearing impairment  Hyperthyroidism  Metals or toxins  In -utero exposure

15. Medical Conditions  Seizures (Absence, Complex Partial)  Severe head injuries  Sensory Integration Disorders  Sleep Apnea

16. Disruptive, Impulse Control & Conduct Disorders  Oppositional-Defiant Disorder  Conduct Disorder  Intermittent Explosive Disorder

17. Substance Related Disorders  Alcohol  Amphetamines  Cannabis  Caffeine  Cocaine  Hallucinogens  Inhalants  Nicotine  Opiate  Sedative or Hypnotic  Abuse  Dependence  Intoxication  Withdrawal

18. Neurodevelopmental Disorders  Communication Disorders  Autism Spectrum Disorders  Intellectual Disabilities  Specific Learning Disorders  Motor Disorders

19. Anxiety Disorders  Separation Anxiety Disorder  Generalized Anxiety Disorder  Specific Phobia  Social Anxiety Disorder  Adjustment Disorder with Anxiety  Panic Disorder

20. Obsessive Compulsive Disorders  Obsessive Compulsive Disorder  Trichotillomania  Excoriation

21. Depressive Disorders  Major Depressive Disorder  Persistent Depressive Disorder  Disruptive Mood Dysregulation Disorder  Adjustment Disorder with depressed mood

22. Manic Disorders  Bipolar I Disorder  Bipolar II Disorder  Cyclothymic Disorder

23. Trauma – Related Disorders  Reactive Attachment Disorder  Disinhibited Social Engagement Disorder  Posttraumatic Stress Disorder  Acute Stress Disorder

24. Evaluation  Presenting symptoms  Perinatal & developmental histories  Medical history  Family history  Educational history  Social history  Patient & parent interviews  Physical examination  Collateral information

25. Assessment Considerations  Onset, frequency & duration  Setting  Context  Level of disruption  Stressors or trauma  Intensity  Level of impairment  Ability to self-regulate  Insight

26. Scales  Conner’s Parent’s Rating Scale  Conner’s Teacher’s Rating Scale  Brown ADD  Vanderbilt ADHD  Child Behavior Checklist

27. Treatment

28. Psychoeducation  Clarify diagnosis  Give contextual framework  Be honest & sincere about your opinion  Anticipate developmental challenges  Provide or recommend resources: fact sheets, books, websites etc.

29. 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

30. 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

31. 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

32. Pharmacotherapy  First Line Approved by FDA for ADHD  Stimulants  Atomoxetine  Second Line  Buproprion  α Agonists  Tricyclic Antidepressants

33. 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

34. Stimulants Side Effects  Decreased appetite, weight loss  Insomnia, headaches  Tics, emotional lability, irritability  Visual & tactile hallucinations  Contra-indicated in pre-existing heart condition

35. 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 co- morbid anxiety Side Effects  Nausea, decreased appetite  Headaches  Sedation (can give as single night dose)  Suicidality

36. 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

37. 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

38. 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

39. 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

40. 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

41. Questions??