Transcript ADHD and Teenagers An Appraoch

ADHD and Teenagers
An Approach
Henry Maguire MD
Director Pediatric Neurology
Geisinger Medical Center
ADHD – DO YOU BELIEVE?
• Is this real or just a big pharma marketing tool
for their medications?
• Cross cultural studies support the idea that
ADHD this is not an American phenomena
• Medication does work
ADHD Do You Believe?
• Neuroimaging- ADHD patients have smaller
prefrontal and basal ganglia structures along with
smaller posterior inferior cerebellar vermis
• Neuropsychological studies- frontal cortical and
basal ganglia circuits key for executive
function/attention/inhibition
• fMRI- abnormal activation in striatum/prefrontal
cortex/anterior cingulate cortex
ADHD Do You Believe?
• We have known that effective pharmacologic
treatment has existed for ADHD syndrome for
years
• 1937 Charles Bradley, working at Bradley
Children’s hospital in Rhode Island, treats 30
behaviorally disturbed children with benzedrine
and in 14 notes spectacular results
• Benzedrine had been used to treat post
pneumoencephalogram headaches
ADHD Do You Believe?
• “To see a single daily dose of benzedrine
produce a greater improvement in school
performance than the combined efforts of a
capable staff working in a most favorable
setting, would have been all but demoralizing
to the teachers, had not the improvement
been so gratifying from a practical viewpoint”
ADHD Do you Believe?
Medication for Attention Deficit–Hyperactivity Disorder and
Criminality
Paul Lichtenstein, Ph.D., Linda Halldner, M.D., Ph.D., Johan
Zetterqvist, M.Ed., Arvid Sjölander, Ph.D., Eva Serlachius, M.D.,
Ph.D., Seena Fazel, M.B., Ch.B., M.D., Niklas Långström, M.D.,
Ph.D., and Henrik Larsson, M.D., Ph.D.
N Engl J Med 2012; 367:2006-2014November 22, 2012DOI:
10.1056/NEJMoa1203241
Using Swedish national registers, we gathered information on 25,656
patients with a diagnosis of ADHD, their pharmacologic treatment, and
subsequent criminal convictions in Sweden from 2006 through 2009. We
used stratified Cox regression analyses to compare the rate of criminality
while the patients were receiving ADHD medication, as compared with the
rate for the same patients while not receiving medication.
Results
As compared with nonmedication periods,
among patients receiving ADHD medication,
there was a significant reduction of 32% in the
criminality rate for men (adjusted hazard ratio,
0.68; 95% confidence interval [CI], 0.63 to
0.73) and 41% for women (hazard ratio, 0.59;
95% CI, 0.50 to 0.70). The rate reduction
remained between 17% and 46% in sensitivity
analyses among men, with factors that
included different types of drugs (e.g.,
stimulant vs. nonstimulant) and outcomes
(e.g., type of crime).
Conclusions
Among patients with ADHD, rates of criminality
were lower during periods when they were
receiving ADHD medication. These findings
raise the possibility that the use of medication
reduces the risk of criminality among patients
with ADHD.
ADHD Do You Believe?
• If you don’t then not much to say
• If you do then the question is how do we
diagnose
• KISS- Keep It Simple Stupid
ADHD Defined
• DSM V- 2 symptom domains hyperactivity and
inattention
• INATTENTION-poor attention to
detail/difficulty sustaining attention/does not
follow through on instructions/difficulty
organizing tasks/avoids sustained mental
effort (except video games)/loses things/easily
distracted/forgetful
ADHD DEFINED
• HYPERACTIVITY-fidgets/leaves seat when
expected to sit/runs about, climbs excessively,
feels restless/ difficulty playing quietly/always
on the go (Energizer Bunny)/ talks excessively
• Hyperactivity/Inattention-18 symptoms, 6 in
each domain- that’s your diagnosis
ADHD Defined
• DSM V
• Small change- used to be symptoms are
present before age 7
• Now several of these symptoms were present
before age 12
• I feel this is a key point
• NOT AN ACQUIRED ILLNESS
ADHD Defined-Office Tools
• Conners Scale/Vanderbilt Scale- Good for
picking up hyperactive and inattentive sx- can
miss comorbid psychiatric morbidities
• Google “ ADHD rating scales children”
• http://www2.massgeneral.org/schoolpsychiat
ry/screeningtools_table.asp
Teenage ADHD
What Is The Concern
With Making a New Diagnosis of
ADHD?
• Excuse for poor performance
• Not addressing other issues
• The need for pharmacologic treatment
ADHD- Differential Diagnosis
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Depression- not helped by stimulants
Anxiety- worsened with stimulants
Sleep Disorder- worsened with stimulants
Substance Abuse-not a great idea to give
stimulants
• Nutritional Deficiency- not helped
• Hypomania/Mania – worsened with
stimulants
What is the Concern with making the
Diagnosis? –Excuses For Performance
• Is performance a
problem? Need to
review report cards
• If the patient is
suddenly not doing well
after previously being a
good student this
requires some looking
into (ADHD a life long
condition)
• Family strife
• School strife
• Switching school
• More challenging
curriculum
What is the Concern with making the
Diagnosis?- Excuses for Performance
• New medical problem,
seizures, concussion,
pregnancy
• Learning to read (1st
through 3rd grade) vs
reading to learn (4th
grade and beyond)
• How much time is spent
on homework- for the
college bound 10
minutes per grade per
night and doing it in
school does not count
(homework log)
How Do I Treat ADHD
• Stimulants are the best- methylphenidate and
methamphetamine (Ritalin and Adderall)
• Rapid onset and offset
• Side effect profiles identical but individuals
may tolerate one and not the other
• One can work and the other may not
• Chevy vs Ford
How Do I Treat ADHD/ Stimulants
• Irritability /nausea/headache/ sleep
disturbance/tics
• Need to monitor height/ weight/ blood
pressure
• I do not get baseline EKG
• Do get a cardiac history (preexisting heart
disease/family hx of heart disease below age
25?)
• What about seizure history?
How Do I Treat ADHD-Stimulants
• Go low go slow
• Methylphenidate 0.5 to 1.5 mg/kg/day –to a
point
• Adderall 0.25 to 0.75 mg/kg/day –to a point
• Consider rx for homework only (early session)
• Start with long acting form Adderall XR or
Concerta to avoid afternoon crash and /or need
to give med in school
• Reassess after ~ 2 weeks on med
How Do I Treat ADHD
Strattera/Atomoxetine
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Selective norepinephrine reuptake inhibitor
More effective for inattention than hyperactivity
Effect not immediate
Need to monitor LFT’s
Not the same punch as stimulants but a good
second line - ~70% response rate for stimulant
failures
• BID dosing more effective
How Do I Treat ADHD/Other
• Bupropion
• Guanfacine (Tenex)
• Modafinal
ADHD Adolescents- Important Points
• It could be undiagnosed (particularly ADD
girls) or blamed/not recognized as part of
learning disability syndrome
• However it is a preexisting condition- not
acquired
• High response rate to stimulants (80%)
• Define “response”
How Do You Know It is Helping?
• Teacher Assessments- blinded?
• Grades
• Parent observations