Attention Deficit/ Hyperactivity Disorder

Dennis L. Hufford, CDR, MC, USN Faculty Development Fellowship Madigan Army Medical Center

Objectives
• Define Diagnostic Criteria • Discuss Workup and Differentiation • Discuss Therapy

ADHD: What is It? • Triad: – Inattentiveness. Hyperactivity. Impulsiveness • • • • Maladaptive and Pervasive Academic and Behavioral Problems Onset Prior to Age 7 Probable Organic Cause – Exact Etiology Unknown .

Prevalence • • • • • 3-5 % of School Age Children (1:25) 2 % of Adolescents (1:50) 0.2 % of 30 year olds (1:500) 0.05 % of 40 year olds (1:2000) .8 % of 20 year-olds (1:125) 0.

DSM IV Criteria • EITHER: 6 symptoms of – Inattention OR Hyperactivity & Impulsivity • AND – Onset before age 7 – Impairment in at least 2 Settings – Impairment in social. academic or occupational Function – No other pervasive disorder .

Pitfalls in Diagnosis • • • • DSM criteria also describe NORMAL kids! No Physical or Lab Markers Significant Overlap w/ Diff. Misinformation . Public Awareness. Dx.

Diff. Dx. and Comorbid Conditions • • • • • • Oppositional Defiant Disorder Tic Disorders Learning Disabilities Mental Retardation Family Dysfunction/Discord Other Medical and Mental Disorders .

and more History!! • Standardized Checklists/Questionaires • Exclusion of Diff. by – Physical Exam – IQ testing. eye screening – Multidiscliplinary Approach . audiometry.Keys to Accurate Diagnosis • History. Dx. History.

developmental • ROS: Neuro. meals – interactions with peers • Medical: year by year school performance. church. home. classroom. psychiatric . encopresis. GI esp.History • Behavioral – incl.

tics. psychiatric disorders • Social – Family Dysfunction – Parenting Skills • Never the root of ADHD! .History • Family – ADHD.

or plan to misbehave? – Refuse to do things or try to do things. but fails to finish? • Does the child display aggression toward people or animals.Useful Questions • Is the child more apt to: – do things without thinking ahead. destructiveness or theft? (inconsistent with ADHD) .

Checklists/ Questionnaires • “Objective” Data (?) – – – – – Achenbach Behavior Checklist ADD II (ACTeRs) Connors Rating Scale Child Behavior Rating Scale Others .

only rulesOUT other Diff Dx.Physical Exam • Directed – Hearing and Vision Screening – Developmental Milestones • PE cannot rule-IN Diagnosis. .

and psychometric testing – IQ measurement – (usually done through the school) • Social Services • Counseling Services – Individual and Family .Multidisciplinary Approach • Primary Provider • Psychoeducational Consultant – academic. aptitude.

Treatment/ Management • Education – – – – Patient Parent Teachers and Caregivers Physician .

. – Bain. A Parent’s Guide to Attention Deficit Disorders.Education Resources • Books: – Barkley RA. New York. 1991. New York. Taking Charge of ADHD: The Complete Authoritative Guide For Parents. 1995.: Delta Books. LJ. Guilford Press.

adults. parents. Ph. Suite 109.chadd.org/ . (800) 233-4050 – Website: www. Plantation FL 33317. schools – 499 70th Ave NW.Education Resources • Support Organization: – CHADD: “Children and Adults with Attention Deficit Disorder” – local chapters – materials for children.

Education Resources • Special Education – child may qualify for special services under Federal Law. (Individuals with Disabilities Education Act and section 504 of Rehabilitation Act of 1973) – Schools responsible for determining eligiblility (they may need info from YOU) .

Medical Therapy • Medications – Stimulants: • methylphenidate (Ritalin) • dextroamphetamine (Dexadrine) • pemoline (Cylert) – Others • TCA’s. beta-blockers. venlafaxine . bupropion.

5 mg/kg per dose – administered bid or tid – start low.3-0.Medication Doses: • Methylphenidate: 0. titrate 5mg increments – max 60 mg qd • Dextroamphetamine – 1/2 the methylphenidate dose • Both meds have SR formulations .

25-75 mg/day – Maximum 112.75 mg at weekly intervals to response (1/2 pill) – Usual effective range: 56.5 mg/day (1 pill) – Increase by 18.Medication Doses • Pemoline – Start 37.5 mg/day (3 pills) – Check LFTs at 6 month intervals .

etc.Stimulants • Expected benefit – Improved CONCENTRATION • evidence: better grades. – All other benefits are secondary .

Stimulants • Problems – Misinformation. Unrealistic Expectations – Controlled Substance – Adverse Effects • • • • Sleep disturbance Appetite Suppression Tics Anemias (rare) .

Supportive Therapy • Counseling/ Psychotherapy – Behavior Modification • Structured Schedule and Environment • Regular Followups – (not necessarily in person!) • Social Services – on-base support programs. training .

however… • LOTS of Media Attention Lately! • Comorbidity with Major Depression – 12% of Adult MDD patients who had ADHD as children manifest ADHD symptoms – May benefit from ADHD therapy .Adult ADHD • Relatively Rare.

Adult ADHD • Therapy – Education – Support – Medication • Stimulants • TCA’s incl desipramine .

Summary • ADHD diagnosis and therapy is complex and labor intensive • There are NO short-cuts in gathering necessary history and data! • Emphasis on – Diagnostic Accuracy by HISTORY – Realistic Expectations of Therapies – Multidisciplinary Approach .

• Hill. . Mayo Clinic Proc. Grace. 1996 Sep. Age-Dependent Decline of Attention Deficit Hyperactivity Disorder. EP.. 1143-6. – The best overview I found on the subject. 101:4. 153:9. Steven and Tan. Postgraduate Medicine. – Good picture of natural course of the disorder. • Schneider. – Concentrates on diagnostic features. JC and Schoener.References • Barbaresi. 71:5. Primary Care Approach to the Diagnosis and Management of Attention-Deficit Hyperactivity Disorder. WJ. Attention-Deficit Hyperactivity Disorder: In Pursuit of Diagnostic Accuracy. 463-71. 1997 Apr. Am J Psychiatry. 1996 May. 231-40.

– A middle of the road. Am J Psychiatry.References (cont. – Criteria attached to handout. Evaluating the Hyperactive Child in Your Office: Is It ADHD? AFP. Adult Psychiatric Status of Hyperactive Boys Grown Up. 1997 July.) • Mannuzza. . 493-8. 155:4. S et al. • DSM IV. – Abstract’s worth reading for what ADHD kids turn into! • Johnson. 155-60. 56:1. Descriptive. TM. 1998 Apr. 78-85. pp. “Here’s how I do it”.

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