Attention Deficit Hyperactivity

Disorder (ADHD)
 Attention Deficit Hyperactivity Disorder
(ADHD)

• What is the role of the primary care physician

in diagnosis and treatment of ADHD?
 ADHD Talk Objectives
• You will understand ADHD diagnostic criteria
• You will will know where to find and how to
use assessment tools for diagnosing ADHD
• You will know when to refer a patient w/
ADHD for specialty care
• You will understand tx options for ADHD
• You will want to see a child with ADHD in your
clinic in the near future
 ADHD Epidemiology
• Prevalence
– Survey average: 8-10% in children of school age
– Parent reported prevalence age 4-17
• Boys 11%
• Girls 4.4%

• Male: Female ratio 2:1 - 4:1

 ADHD Pathogenesis
• Multiple theories
– Imbalance of catecholamine metabolism in
cerebral cortex
– Impaired executive functions
– Impaired response inhibition
 Diagnosis of ADHD
• Inattention
• Hyperactivity
• Impulsivity
 Diagnosis of ADHD
• Inattention
– Forgetful outside of school
– Incomplete performance on school tasks
• Missing details
• Missing homework
• Poor performance on schoolwork
 Diagnosis of ADHD
• Hyperactivity
– Always in motion
– Difficulty during “quiet times”
– Constant talking
 Diagnosis of ADHD
• Impulsivity
– Unable to “wait turn”
– Answers for others
– Unsafe behavior
 DSM IV Criteria – ADHD (Inattention)
• Often fails to give close attention to detail or makes careless mistakes
in schoolwork, work or other activities.
• Often has difficulty sustaining attention in tasks of play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish
homework, chores or other duties
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes or is reluctant to engage in tasks that require
sustained mental effort
• Often loses things required to complete tasks
• Is often easily distracted
• Is often forgetful in daily activities
Six (or more) of the following symptoms have persisted for at least six months to a
degree that is maladaptive or not consistent with development level.
 DSM IV Criteria – ADHD (Hyperactivity)
• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in situations in which remaining seated is
expected
• Often runs about or climbs excessively in situations in which it is
inappropriate
• Often has difficulty in playing quietly
• Is often “on the go” or acts as if “driven by a motor”
• Often talks excessively
• Often blurts out answers before questions are completed
• Often has difficulty waiting turn
• Often interrupts of intrudes on others
Six (or more) of the following symptoms have persisted for at least six months to a degree
that is maladaptive or not consistent with development level.
 Diagnosis of ADHD
• Additional Criteria:
– Some inattentive or hyperactive/impulsive
symptoms were present before the age of seven.
– Some impairment from the symptoms is present in
two or more settings (e.g. at school and at home)
– Clear evidence of clinically significant impairment
in social, academic or occupational functioning
 DSM IV Criteria - ADHD
• Three types
– Inattention predominant (ADHD-IA) (30-40%)
– Hyperactivity predominant (ADHD-H/I) (10%)
– Combined type (ADHD-C) (50-60%)
 Diagnosis of ADHD
• Screening questions
– How is your child doing in school this year?
– Is your child happy to go to school?
– Have you heard from the teacher(s) regarding any
concerns about behavior or performance in
school?
– How does your child do with chores around the
house?
– How does your child do with homework?
 Diagnosis of ADHD
• Objective approach
– Data needs to be collected from more than one
source
• Parents
• Teachers
• Others
 Diagnosis of ADHD
• What kind of data?
– Standardized forms
• Conners Rating Scale (CATRS)
• ACTeRS Form
• Vanderbilt ADHD Diagnostic Rating Scale
 Diagnosis ADHD
• Need to develop a differential diagnosis
 Diagnosis of ADHD

• Oppositional Defiant Disorder

• Conduct Disorder
• Depression
• Anxiety
• Learning disability
• Special senses disability
• Substance Abuse
• Pervasive Developmental Delay NOS
 Oppositional Defiant Disorder
• A pattern of negativistic, hostile and defiant behavior
lasting at least six months, during which four or more of
the following are present:
– Often loses temper
– Often argues with adults
– Often actively defies or refuses to follow adults rules
– Often deliberately annoys people
– Often blames others for his/her mistakes
– Often is touchy / easily annoyed by others
– Often is resentful
– Often is spiteful / vindictive
The disturbance in behavior causes significant impairment in social, academic or
occupational functioning. The symptoms are not due to a mood disorder or conduct d/o.
 Conduct Disorder
• Repetitive and persistent pattern of behavior
in which the basic rights of others or major
age appropriate norms or rules of society are
violated.
– Aggression to people or animals
– Destruction of property
– Deceitfulness or theft
– Serious violation of rules
 Depression
• Depressed mood
• Change in sleep (S)
• Loss of interest / pleasure in activities (I)
• Thoughts of worthlessness or guilt (G)
• Loss of energy (E)
• Trouble concentrating (C)
• Change in appetite or weight (A)
• Change in psychomotor activity (P)
• Thoughts of suicide or death (S)

5 of the 9 symptoms present frequently for at least two weeks. One of the 5
symptoms must be depressed mood or loss of interest in usual activities.
Symptoms can not be due to substance use of another psychiatric diagnosis.
 Learning Disability
• Schoolwork performance issues
– Reading
– Writing
– Mathematics
 Special Senses Disability
• Visual disturbance
• Hearing loss
 Substance Abuse
• High index of suspicion in teens
 Pervasive Developmental Delay NOS

• Autistic spectrum, but not meeting autism

criteria
 When should I refer a child I suspect has
ADHD?
• Age younger than six
• Co-existent psychiatric conditions
• Co-existent neurologic conditions
Let’s go to Vanderbilt
 ADHD Management Plan
• Clear communication with parents and
teachers
– Phone calls
– Email
– Progress notes
– Daily School-Home Report Card
 ADHD Management Plan
• Parenting skills
– Homework rules
– Sleep rules
– T.V. / Videogame rules
 ADHD Management Plan
• Stimulant Medications
– Dextroamphetamine / Levoamphetamine
• Adderall
• Adderall XR
– Dextramphetamine
• Dexedrine
• Dexedrine Spansule
• Dextrostat
– Methyphenidate
• Ritalin
• Ritalin LA
• Ritalin SR
• Concerta
• Methylin
• Metadate ER
• Metadate CD
• Focalin
• Daytrana
 ADHD Management Plan
• Stimulant Medications
– Adverse effects
• Anorexia
• Weight loss
• Sleep disturbance
• Tics
• Tachycardia
• Hypertension
 ADHD Management
• Stimulant Medication
– Use the least amount needed
– Use extended release preparations when possible
– Give drug holidays if appropriate
– Reassess regularly as to response
 ADHD Management
• Stimulant Medications are Schedule 2 drugs
– 30 day supply with written prescription
– Rule change 2007 allows up to 90 day supply
• Three 30 day scripts
• Each dated sequentially for fill date
• Atomoxetine is not a restricted medication
 ADHD Management Plan
• Non – stimulant medication
– Atomoxetine (Strattera)
• Norepinephrine reuptake inhibitor
• Starting dose 0.5 mg/kg
• Maximum dose 1.4 mg/kg or 100 mg /day
• ADHD scores improve with atomoxetine vs placebo
• ADHD scores are equal to / slightly worse than
stimulant medications
 ADHD Management
• Non-stimulant Medication
– Atomoxetine side effects
• Anorexia
• Weight loss
• Abdominal pain
• Nausea / Vomiting
• Sleep disturbance
• Suicidal ideation (0.4% vs 0% placebo)
• Liver injury (VERY RARE -- 2 cases!)
When else should I refer a child I suspect has
ADHD?
• Failure to respond to a reasonable trial of
stimulant / non-stimulant medications and
behavior interventions
 Conclusions: ADHD
• Performing an ADHD evaluation is within the
spectrum of practice of a family doctor
• Observer data is needed from at least two
settings in the child’s life
• Co-morbid / alternate diagnoses should be
ruled out
• A comprehensive management plan offers the
patient the best chance for success in school
 ADHD Resources
• Caring for Children with ADHD: A Resource Toolkit
for Clinicians, AAP, 2008.

http://www.nichq.org/NICHQ/Topics/ChronicConditions/
ADHD/Tools/
Individual forms are available here for download

http://www.nichq.org/resources/toolkit
A compressed folder of all ADHD forms is available for
download.
 Additional References
• Changes and Challenges: Managing ADHD in a
Fast-Paced World, Michael J Manos, et al,
Manag Care Pharm. 2007;13(9)(suppl S-b):S2-
S13
• Obtaining Systematic Teacher Reports of
Disruptive Behavior Utilizing DM-IV, Mark L.
Woraich, et al, Journal of Abnormal Child
Psychology, Vol 26(2), 1998: 141-152.
 Adult ADHD
• Childhood ADHD commonly persists:
– 22-85% of adolescents
– 4-50% of adults
 Adult ADHD
• Symptom complex can differ from childhood
– Inattention and impulsivity > hyperactivity
 Adult ADHD
• Wender (Utah) Criteria
– Hyperactivity and inattention plus (2) of below
• Labile emotions
• Hot temper
• Inability to complete tasks
• Inability to tolerate stresss
• Impulsivity
 Adult ADHD
• Treatment
– Stimulants
• Response rate decreased versus childhood ADHD
– Atomoxetine
• Lower cadiovascular risk profile
• Minimal abuse potential
 Management of ADHD
• Stimulant Misuse (22%) / Diversion (11%)
– Continuously escalating dosage
– Repeated lost prescriptions / “dispensing errors”
– Demand for immediate release preparation
– Infrequent user
– Psychosis
– Palpatations