Transcript ADHD

ADHD, ODD or CD
A Practical Approach to Treatment
David Shadid, D.O.
Attention-Deficit
Hyperactivity Disorder
(ADHD)
Prevalence of ADHD in Children and
Adolescents
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The prevalence of ADHD is underestimated2,3
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ADHD affects approximately 3% to 6% of children and
adolescents, with some estimates as high as 16.1%1
Comorbidities may mask diagnosis
Girls with inattentive symptoms are under-recognized
and undertreated
Difficult primary diagnosis in the adolescent
A high proportion of youngsters with ADHD grow into
adulthood with persistent ADHD symptoms4
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Leads to problems with social function, poor occupational
achievement, and driving
ADHD = attention deficit hyperactivity disorder.
1. Goldman LS et al. JAMA. 1998;279:1100-1107; 2. Datamonitor report DMHC2008, published 9/2004; 3. Biederman J et al. J
Am Acad Child Adolesc Psychiatry. 1999;38:966-975; 4. Barkley RA. J Clin Psychiatry. 2002;63:10-15.
Lifetime Course of ADHD Symptoms:
Inattention Domain
Childhood
Difficulty sustaining attention
Doesn’t listen
Adult
Difficulty sustaining attention
(meetings, reading, paperwork)
Paralyzing procrastination
Slow, inefficient
No follow through
Can’t organize
Poor time management
Loses important items
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.
Disorganized
Lifetime Course of ADHD Symptoms:
Hyperactivity/Impulsivity Domain
Childhood
Squirming, fidgeting
Can’t stay seated
Can’t wait turn
Runs/climbs excessively
Can’t play/work quietly
On the go/driven by motor
Talks excessively
Blurts out answers
Intrudes/interrupts others
Adult
Inefficiencies at work
Can’t sit through meetings
Can’t wait in line
Drives too fast
Self-selects very active job
Can’t tolerate frustration
Talks excessively
Makes inappropriate comments
Interrupts others
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.
Potential Impact of Untreated ADHD Across the Lifespan
Low selfesteem
Childhood
Injuries
Academic
limitations
Smoking and
substance abuse
Adolescence
Impaired family and
peer relationships
Motor vehicle
accidents
Legal
problems
Adulthood
Occupational/
vocational
difficulties
American Academy of Pediatrics. Pediatrics. 2000;105:1158-1170; Kelly PC et al. Pediatrics. 1989;83:211-217; Murphy K
et al. Compr Psychiatry. 1996;37:393-401; Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7; Barkley RA et al.
Pediatrics. 1996;98:1089-1095; Swensen A et al. J Adolesc Health. 2004;35:346.e1-9.
Outcomes From the Wisconsin Longitudinal
Study of People with ADHD
Longitudinal study following a sample of children with hyperactivity and
community controls for at least 13 years
70
Outcomes of People Diagnosed With “Hyperactivity”
(ADHD) as a Child and Controls
60
55
Participants (%)
60
50
38
40
32
30
20
23
18
10
17
4
0
4
0
Suspended
during high
school
Failed high
school
Fired from job
Pregnancy
Had sexually
transmitted
disease
Hyperactive (n=149) Community Controls (n=76)
Barkley RA et al. J Am Acad Child Adolesc Psychiatry. 2006;45:192-202.
Annual Costs of Healthcare for Children and
Adolescents with ADHD*
Annual costs of healthcare were 31% higher for children and
adolescents with ADHD than for those without
ADHD care accounted for >5% of all pediatric health expenditures
in the state
Extrapolated nationwide annual cost of caring for children and
adolescents with ADHD was
$2.15 billion
*Population-based study conducted in North Dakota, case population = 7745 children and adolescents.
Burd L et al. J Child Neurol. 2003;18:555-561.
The Pathophysiology of ADHD Involves
DA and NE Neurotransmission
ADHD is associated with abnormal DA and NE
neurotransmission in frontal/striatal areas1,2
Corticostriatal circuits play an important role in
ADHD1,3,4
Efficacy of ADHD medications with pharmacologic
activity affecting DA and NE lends support to the
theory of monoamine dysfunction in ADHD3
DA = dopamine; NE = norepinephrine.
1. Mercugliano M. Ment Retard Dev Disabil Res Rev. 1995;1:220-226; 2. Krause K-H et al. Neurosci Let.
2000;285:107-110; 3. Markowitz JS et al. Pharmacotherapy. 2003;23:1281-1299; 4. Zametkin AJ et al. J Clin
Psychiatry. 1998;59(suppl 7):17-23.
Stimulant Effects on DA and NE
 MPH
and AMPH both block DA and NE
transporters1
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Increases DA and NE in the synapse
 Clinical
efficacy of MPH and AMPH is likely
driven by synaptic DA and NE concentrations1,2
AMPH = amphetamine; MPH = methylphenidate; EPH = epinephrine.
1. Biederman J et al. Biol Psychiatry. 1999;46:1234-1242; 2. Schiffer WK et al. Synapse. 2006;59:243-251;
Comorbidities Add to Personal and
Economic Costs of ADHD
Females without ADHD
Males without ADHD
Lifetime prevalence (%)
70
60
50
40
30
20
14
11
10
0
3
4
1
2
5
0
4
6
0
0
Conduct
disorder
Oppositional
defiant
disorder
Severe
depression
Pediatric population with ADHD and controls by gender.
Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7.
Bipolar
disorder
>2 Anxiety
disorders
Enuresis
Comorbidities Add to Personal and
Economic Costs of ADHD
Females with ADHD
Lifetime prevalence (%)
70
Males with ADHD
66
60
50
40
35
33
29
30
32
28
25
21
20
10
15
11
8
11
0
Conduct
disorder
Oppositional
defiant
disorder
Severe
depression
Pediatric population with ADHD and controls by gender.
Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7.
Bipolar
disorder
>2 Anxiety
disorders
Enuresis
Treatment Options in ADHD
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Psychoeducation for patient and family members
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Psychosocial/behavioral interventions
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Psychotherapy
Cognitive behavioral therapy
Pharmacotherapeutic interventions
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Support groups (www.chadd.org)
Coaching (www.coaching.com)
Stimulants
Non-stimulants
Stimulant therapy is first-line treatment1 and behavioral therapy may
be offered to improve target outcomes1,2
1. Greenhill L et al. J Atten Disord. 2002;6:S89-S100. 2. American Academy of Pediatrics. Pediatrics.
2001;108:1133-1044.
Improvement at 14 months (%)
Long-Term Outcomes of Therapies for ADHD in
the MTA Study
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Hyperactive Impulsive Symptoms
(Teacher Reports)
56%
60%
45%
36%
Medication
Management
Combination
Therapy
(medication +
behavior therapy)
MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
Behavior
Therapy
Community-based
Therapy
FDA-Approved Medications Indicated for ADHD
in Children or Adolescents*
Stimulants
Brand Names
d,l-methylphenidate
Ritalin®, Ritalin-SR®, Ritalin LA®,
Concerta®, Metadate® CD, Methylin® ER,
Daytrana™
d-methylphenidate
Focalin®, Focalin® XR
Mixed amphetamine salts
Adderall®, Adderall XR®
d-amphetamine
Dexedrine®, Dexedrine Spansule®
Nonstimulant
Atomoxetine
Strattera®
*As of May 2006.
Ritalin®, Ritalin SR®, and Ritalin LA® are trademarks of Novartis Pharmaceuticals Corporation; Concerta® is a trademark
of ALZA Corporation; Metadate® CD is a trademark of Celltech Pharma Limited; Methylin® ER is a trademark of
Mallinckrodt Inc; Daytrana™ is a trademark of Shire Pharmaceuticals Ireland Limited; Adderall®, and Adderall XR® are
trademarks of Shire US Inc.; Dexedrine® and Dexedrine Spansule® are trademarks of GlaxoSmithKline; Strattera® is a
trademark of Eli Lilly and Company.
Vyvanse
(lisdexamfetamine dimesylate)
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Prodrug- inactive molecule
 FDA approved
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Ages 6-12
Lower abuse- related effects
 Provides 12 hour symptom control
 95% of children show overall improvement
Vyvanse
(lisdexamfetamine dimesylate)
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Inactive
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Vyvanse (lisdexamfetamine dimesylate) is a
therapeutically inactive molecule
Activated
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Following ingestion, Vyvanse is rapidly absorbed in
the GI tract and converted to l-lysine and active
d-amphetamine
Vyvanse adverse event profile
SOCIAL IMPAIRMENT IN CHILDREN
WITH ADHD
50
40
30
ADHD
NORM
20
10
0
THEFT
LIES
DESTROYS
PROPERT Y
CRUELTY TO
ANIM ALS
CRUELTY TO CARRIES/USES
WEAPONS
PEOPLE
SETS FIRES
Oppositional Defiant Disorder (ODD)
Oppositional Defiant Disorder
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Associated with ODD:
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Negativity
Defiance
Disobedience
Hostility directed toward authority figures
Uncooperative
Symptoms
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Frequent temper tantrums
Excessive arguing with adults
Active defiance and refusal to comply with adult
requests and rules
Deliberate attempts to annoy or upset people
Blaming others for his or her mistakes or
misbehavior
Symptoms Continued
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Often being touchy or easily annoyed by others
 Frequent anger and resentment
 Mean and hateful talking when upset
 Seeking revenge
ODD
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Occurs in 5-15% of all school-age children
Multiple settings, more noticeable at home and
school
Persist 6 months
Disruptive to family at home
Oppositional behavior is part of normal
development for 2-3 year olds and early
adolescents
Possible Causes of ODD
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Child’s inherent temperament
Family’s response to the child’s style
A genetic component that when coupled with
certain environmental conditions, such as lack of
supervision, poor quality daycare and instability
Biochemical or neurological factor
Child’s perception that he of she isn’t getting
enough of the parents time and attention
Risk Factors
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Having a parent with a mood or substance abuse disorder
Being abused or neglected
Harsh or inconsistent discipline
Lack of supervision
Poor relationship with one or both parents
Family instability such as multiple moves, changing schools
Parents with a history of ADHD, oppositional defiant disorder and
conduct problems
Financial problems in the family
Peer rejection
Exposure to violence
Frequent changes in daycare providers
Parents who have a troubled marriage of are divorced
Co-morbidity
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Oppositional Defiant Disorder usually does not
occur alone
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50-65% of ODD children also have ADHD
35% of these children develop some form of affective
disorder
20% have some form of mood disorder, such as
Bipolar Disorder or anxiety
15% develop some form of personality disorder
Many of these children have learning disorders
Screening and Diagnosis
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Comprehensive evaluation
 Information for parents, teachers, and other
caregivers
 ODD symptom screening checklist
 Look for co-morbidity including ADHD, learning
disabilities, mood and anxiety disorders
Treatment ODD
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Parent training programs
 Individual psychotherapy
 Family psychotherapy
 Cognitive Behavioral Therapy
Techniques
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Effective time-outs
Avoid proven stressors
Remain calm
Praise good behavior
Offer choices
Build on positives
Good modeling
Don’t walk on eggshells
Use respite care
Self Care
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Praise your childs positive behaviors
 Model the behavior
 Pick your battles
 Set limits and enforce consistent reasonable
consequences
 Develop a consistent daily schedule
 Work with your spouse to assure consistent and
appropriate discipline procedures
 Assign your child a household chore that is essential and
won’t get done unless the child does it
Coping Skills
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Learn ways to calm yourself
 Take time for yourself
 Be forgiving
Conduct Disorder (CD)
Symptoms of Conduct Disorder
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Aggression to people and animals
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Bullies, threatens or intimidates others
Often initiates physical fights
Has used a weapon that could cause serious physical harm to
others
Is physically cruel to people of animals
Steals from a victim while confronting them
Forces someone into sexual activity
Destruction of property
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Deliberately engaging in fire setting with the intention to cause
damage
Deliberately destroys others property
Symptoms of Conduct Disorder
Continued
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Deceitfulness, lying, or stealing
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Has broken into someone else’s building, house, or
car
Lies to obtain goods, or favors or to avoid obligations
Steals items without confronting the victim
Serious violations of the rules
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Often stays out all night despite parental objections
Runs away from home
Often truant from school
Conduct Disorder Features
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1-4% of 9-17 year olds
 Greater in boys
 Higher rates of depression, suicidal thoughts, and
suicide
 Academic difficulties
 Poor relationships with peers or adults
 Sexually transmitted diseases
 Difficulty staying in adoptive, foster, or group homes
 Higher rates or injuries, school expulsions, and problems
with the law
Risk Factors
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Early maternal rejection
Separation from parents, without an adequate alternative
caregiver
Early institutionalization
Family neglect
Abuse or violence
Parental mental illness
Parental marital discord
Large family size
Crowding
Poverty
Genetic/ neuropsychological
Treatment
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Your child’s age, overall health, and medical
history
Extent of your child’s symptoms
Your child’s tolerance for specific medications,
procedure or therapies
Expectations for the course of the condition
Your opinion or preference
Treatment May Include
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Cognitive-behavioral approaches
Family therapy
Peer group therapy
Medication
Structural environments:
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military school, group home, inpatient residential
treatment
Internal State
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Experiencing internal distress
Anger
Frustration
Disappointment
Anxiety
Sorrow
Autonomy issues
Superego deficits
Conclusion
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Every child’s mental health is important
Many children have mental health problems
These problems are real and painful and can be
severe
Mental health problems can be recognized and
treated
Caring families and communities working
together can help