ADHD



 
ADHD
General comments • Male to female ratio-10:1
• Overtreatment is common; differentiate from child who is simply "overactive"
Clinical signs 6 symptoms present
• Causes impairment in 2 or more settings:
  – School, work, or home/personal life
  – Frequently comorbid with other childhood disorders
 
Inattentive:
  • Makes careless mistakes
  • Difficulty sustaining attention
  • Does not listen
  • Fails to finish tasks
  • Poor organization
  • Loses important belongings
  • Distractible
  • Forgetful
  • Avoids jobs that require sustained mental effort
Difficulty sustaining attention: difficulty with organization, easily distracted, often does not listen when spoken to, doesn't complete tasks
Hyperactivity:
 • Fidgets
 • Difficulty sitting still
 • Constantly restless
 • Constantly driven
 • Talks excessively
 • Interrupts conversations
 • Can’t wait turn
lmpulsivity: interrupts others, blurts out answers, difficulty waiting turn
Treatment • Behavior therapy
Drug therapy: methylphenidate, dextroamphetamine, atomoxetine

 

Adult ADHD

  • Strong genetic basis
    – 70% heritability (among highest for mental health disorders)
  • Is more likely to be inattentive type (hyperactive type is picked up in childhood)
  • Can be comorbid with impulse disorders (gambling, substance abuse)

Adult Symptoms of ADHD

  • Poor job performance
  • Frequent changing of jobs
  • Career/academic underachievement
  • Poor daily management
    – Paying bills, completing chores
  • Chronic stress from failures
  • Relationship difficulties from inattention and forgetfulness

Diagnosis of ADHD

  • Meets DSM-5 criteria
  • Various checklists
    – Conners Comprehensive Behavior Rating Scales
    – Vanderbilt Rating Scale
    – Wender Utah Rating Scale (for adults)
    – Brown ADD Rating Scales
     
  • Formal psychological testing for ADHD
  • Therapeutic trials don’t work

Differential Diagnosis & Comorbidity

  • Newer estimates of comorbidity rates:
    • Non-comorbid ADHD: 30%
    • ODD: 60% males, 30% females
    • Conduct disorder: boys > girls
    • Depression: 30-40%
    • Bipolar disorder: 20%
    • Anxiety: up to 25%
    • Learning disabilities: up to 30%

Treating ADHD:
Evidence-based Medicine

Stimulants

  • Greater than 80% response rate
  • Stimulants improve ADHD by:
    – Blocking reuptake of dopamine and norepinephrine at the presynaptic neuron
    – Amphetamines directly release catecholamines
    – Inhibiting monoamine oxidase
  • Goal is to decrease inattention, impulsivity, hyperactivity
  • FDA indication for ADHD

Use of Stimulants for ADHD

  • Schedule II controlled substance
  • Also used for narcolepsy
  • Need psychological evaluation to confirm ADHD and rule out learning disorder prior to use
  • Side effects include insomnia, weight loss, and tics
Drugs
Methylphenidate
  • Short-acting
    – Methylphenidate
    – Ritalin
    – Focalin
     
  • Long-acting
    – Concerta
    – Ritalin LA, Ritalin SR
    – Metadate CD
     
  • Transdermal form available
Amphetamines
  • Short-acting
    – Dextroamphetamine
    – Adderall (mixture of amphetamine salts)
     
  • Long-acting
    – Dexedrine Spansule
    – Adderall XR
    – Lisdexamfetamine (Vyvanse)
Nonstimulant Drugs for ADHD
  • Bupropion (not with seizures)
  • Atomoxetine (Strattera)
    – Not a controlled substance
    – Is a norepinephrine reuptake inhibitor
    – Good for patients who find stimulants too activating, or patients with substance abuse history
    – FDA indication for ADHD
     
  • Alpha 2 agonists
    • Clonidine
    • Guanfacine
       
  • Imipramine
Nonpharmacologic Treatment for ADHD
  • Schedule — Keep same routine
  • Organize home and office items
  • Use notebook organizers
  • For adults, the book Driven to Distraction
  • For children, clear and consistent guidance, rewards for following rules and successes
 
Side Effects of Stimulants
  • Anorexia
  • Insomnia
  • Weight loss, probably no effect on growth
  • Irritability, dysphoria, “withdrawal”
  • Headaches
  • Abdominal pain
  • Tics (4% incidence per year is baseline for this population)
 

 

Cardiac Recommendations
  • AAP did not support the AHA recommendation that ECG be performed in ALL patients in advance of ADHD medication use
  • Risk of sudden cardiac death
    – ADHD medication greater than general population
  • Testing (ECG, echo) should be performed:
    – Family history of sudden cardiac death
    – Patient report of chest pain, shortness of breath, syncope/dizziness before/after medication use
    – Abnormal examination findings (initial and f/u)
    – Laboratory testing: at physician’s discretion
 

 

 

Differentiating Bipolar & ADHD

Bipolar Disorder ADHD
  • Bipolar disorder is more common after the age of 12
  • Bipolar disorder is usually episodic
  • Relatives of children with ADHD rarely have bipolar disorder
  • Relatives of children with bipolar disorder frequently have bipolar disorder
  • Bipolar disorder is not a label to use casually, especially when criteria are not clear in children
  • Get a good history, including family history
  • ADHD is known to be developmental, and symptoms can be seen in infancy
  • ADHD is known to be continual, not episodic
  • Mood symptoms can be secondary to frustration from ADHD, with short-lived tantrums
  • Grandiosity needs to be seen in the context of development