Transcript ADHD Child to Adult Cindy Ruttan DO 2008

ADHD Child to Adult
Cindy Ruttan DO
2008
Kansas Osteopathic Conference
OVPK KS
Key points to cover
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Symptoms/ History
Who it effects-ages
Collecting informants
Rule out diagnosis
Treatment options
Behavioral
 Medications
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ADHD is like--I stopped to think, and forgot to
start again.
I was trying to daydream, but my
mind kept wandering.
What is ADHD ?
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Neuro- Behavioral Disorder
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Inattention-( executive functions)
Hyperactivity
Impulsivity
Speculate: Dopamine and NE
dysregulation
Affects 7-12% of pediatric
group pop.
High chance for Co-morbidity
Costly due to ER use, injury
and Hospital use.
ADHD Review History
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Core criteria DSM-III:
 3 separate symptom
areas
DSM-III-R
 one long list
DSM-IV
 two core dimensions
ADHD and DSM IV criteria
Concerned by …may change in
future DSM’s.
1.
2.
3.
Age of onset- ? 7 years
Age appropriate Symptoms are
needed for helping diagnose
disorder from Child/ Adol/
Adults
Various inputs needed –they
can conflict
MOAT
ADHD Diagnosis
Movement excessive
(Hyperactive)
 Organization problems
(difficulty finishing
tasks)
 Attention problems
 Talking impulsively
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Meet criteria of 6 of 9 symptoms, present prior to age 7yrs and
present in 2 or more settings.
The Psychiatric Interview 2nd ed Carlat
Children's ADHD
Review of past 10 years
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Reviews in Child Adolescent
Psychiatry (Williams and
Wilkins) Pg 9-17.
by
Dennis Cantwell MD
 Reprint from the J. of
the American Academy of
Child and Adolescent
Psychiatry.
ADHD Natural Hx
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30% Developmental Delay
40% Continual Display
 Internalizing disorders
 Depression
 Anxiety
30% Developmental Decay
 Externalizing disorders
 ODD
 CD
ADHD info from 10 year
review
Core symptoms may change over
time. Consider the younger one
presented the more persistent
diagnosis and the older one is
diagnosis the fewer symptoms
that are present.
Examples Include:
 Temper outbursts
 Aggressive argumentative
behavior
 Fearless
 Sleep disturbance
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Diagnostic concerns…
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Can one diagnosis contribute to all
symptoms reported?
Can you be observing more than one
disorder?
ADHD –diagnosis of exclusion.
consider: Hyper behavior and Mania/
Hypomania
Decreased focus/inattention
with Depression
ADHD Co morbidities
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CD
Possible reduction in Substance Abuse Disorder
( Drugs and ETOH) if treated early for ADHD
with Stimulants
ODD
LD
Anxiety 20-40%
 OCD increase up to 11%^
Tourette’s-rare (usually reverse) / Tic
 Tic 10-15%^
Mood Disorder 5-40% depression
 Bipolar 10-22%^
Poor interpersonal skills/demoralized
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David Krefetz DO MBA FACN, FAPA
ADHD with Comorbidity in Pediatric Populations:
Impllications for Eval and Management ^
DBD (Disruptive Behavior Disorder)
refers to the
Comorbidity diagnosis of ODD/CD
Worry about aggression and
delinquency
Academic underachievement
Increased risk for substance abuse
Increased social maladaptation
Note having both DBD and ADHD
makes the ADHD harder to treat.
NO medications FDA approved
for ODD/ CD
Learning Disorders
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Input
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Integration
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Organization and understanding
Memory
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Process of getting info into the brain
Storage of info to retrieve later
Output
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Communicate from brain to others or put
into action in the environment
ADHD and LD Booklet for Parents by Larry B Silver MD
Input Disability
 Visual
Perception
 Auditory Perception
 Auditory Lag
(Auditory
Processing )
ADHD and LD Booklet for Parents by Larry B Silver MD
Integration Disability
 Sequencing
 Abstraction
 Organization
 Memory
ADHD and LD Booklet for Parents by Larry B Silver MD
Output Disability
Language
Motor
Gross
Fine
ADHD and LD Booklet for Parents by Larry B Silver MD
Diagnosing ADHD
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NO lab tests, or psychologic tests
that definitely diagnose.
Recommend Academic Testing to
establish level in school and any
LD’s.
Obtain Conners Forms or
Vanderbuilt Scales that help with
defining criteria –or use the DSM IV
criteria.
TOVA or CPT may help with
identification of ADHD symptoms
and how well the meds are working.
Early Medical intervention
with Medication has shown:
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For individuals with ADHD in
childhood to decrease the risk for
subsequent non-nicotine SUD in
adol and early adulthood.
? (Worked best for those with the milder
form of ADHD)
A Literature Review Series Vol 1 No. 3
Children with ADHD at risk for
ETOH problems
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ADHD is a risk factor for ETOH
problems –parental behaviors and
environmental stress contribute too.
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More likely to drink heavy and to have
enough problems to diagnose ETOH
Abuse or Dependency.
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onset average age 15
Consider a possible subset of ADHD
disorder with antisocial behavior patterns
ETOH and ADHD seem to run in
families which thus seem to be under
more “stress” situations.
Addiction Science Made Easy 4-8-07
WWW.NATTC.org
Young Adults –college age
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Problems noted:
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Harder to adjust to adult life, college life with
poorer social skills and less self esteem.
Lower GPA, less financially, inc. school drop out
Less methodical, inc. procrastination, less self
control/self disciplinary behaviors
Symptoms look different
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Impulsive and hyper = mental restlessness or
subjective feelings of such.
Adult ADHD
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Nature of disorder is disorganized,
forgetful and poor self regulation
Majority can not remember to take
their medication if on IR or multi
doses needed.
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Inconvenience
Embarrassed
Safety and long term effects
Different feeling…
Adult ADHD
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Basic same core symptoms as
with Peds ADHD
Review HX of Ed, job and
family
Standard rating
scales/specific for ADULTS
Collateral info coping
/stressors
Rule out other diagnosis
Review options for Treatment
as they match patient goals
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Meds/ CBT
Adult ADHD who had
diagnosis as child
Many loose full diagnostic status(
functional remission)10% vs
Persistent ADHD at15% by 25 yrs
old.
reality is ADHD had remitted only for
a minority.
Inattentiveness remains when
inattention and Hyperactivity decline.
If one put partial remission + Persistant
= 65% have symptoms of ADHD.
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Functional Impairment
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Lower Socioeconomic
Relationship impaired
Dec. academic accomplishments
Employment issues
Driving record bad
Dating, vol. work, community
service, socializing with friends
/family, culture and educational out
of school activities limited.
Adult ADHD contCommon
Maladaptive
Beliefs:
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Self mistrust
Failure
Inadequate
Incompetent
Instability
Common
Dysfunctional
Coping Behaviors
seen:
 Avoidance
 Procrastination
 Pseudo efficiency
low priority tasks
first then high
priority tasks last.
 Busy without
completion of
things
Co morbidity is “The RULE”
with Adult ADHD
Mood Disorders—
50-60%
Depressionrecurrent
BAD
Cyclothymia
Dysthymia
DEP NOS
Anxiety Disorders
40-50%
GAD
Anxiety NOS
Co morbidity contAdult ADHD
Various %
 SUD
 LD
 IED
 Tourette
 Antisocial Personality Disorder
 Borderline Personality Disorder
 Dependent Personality Disorder
Behavioral
Interventions
Treatment Options with or
without medications 1
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Praise reward positive
behaviors by :
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verbalize it
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Speak individual / public
Write it
 Reward it
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Physical Activity -participation
 Material - for doing good job in class
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Dec / Jan 2008 ADDitude Magazine pg 49
Cont: Treatment Options with
or without Medication 2
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Follow up with teachers regarding childs
Positive and Negative attributes. Keep
open communication.
Make sure IEP/504 is being used.
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Address LD issues and grade
appropriate level of work in sink
Do help at home with homework or
working ahead if possible/ tutor
Dec / Jan 2008 ADDitude Magazine pg 49
Cont: Treatment Options with
or without Medication 3
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Encourage routine healthy food and snacks –due to
side effects form medications
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Peanut butter / double up on Breakfast drink
Consider type and delivery style of medications
including time frame medications given and duration
of action
Keep structured as possible and avoid chaotic
situations-you as a parent stay calm, cool and
collected.
Give yourself time to accomplish the task/ goal
desired. Keep a Daytimer/ planner if needed
Give an exercise break
Dec / Jan 2008 ADDitude
Magazine pg 49
Cont: Treatment Options with
or without Medication 4
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Use verbal and non-verbal cues to
remind or stay focused
Keep good sleep hygiene. Insomnia
is common with ADD/ ADHD either a
part of the disorder itself or
exacerbated by medications
Try to avoid arguments and
confrontations leading to poor self
esteem
Dec / Jan 2008 ADDitude Magazine pg 49
Therapy Goal:
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Sensitize the patient to and
interrupt dysfunctional behaviors
Coping skills
 Problem focused
 Adaptive thinking
 Anger management
 Communication skills
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RX Treatments
Medication Options
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19 meds are FDA approved
 18 are stimulants
Use Lowest Dose which addresses
symptoms—as one increases dose if
no improvement noted than lowest
dose which provided improvement is
the best dose.
 List symptoms from patients concern
then family and compare… may not
agree.
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Medication Diversion
Transfer of meds from one it is prescribed to
one whom it is not.
 Taking more (quantity)
 misuse for Euphoric desire
 Combo with other substances
Study of those Diagnosed with ADHD and its
misuse:
22% of adol and young adults in study
misused in some capacity.
ADHD patients Sold it more than the non
ADHD group. Those who sold had comorbid
diagnosis of SUD and CD.
IR prep most often diverted
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A Literature Review Series Vol 1 No. 3 Pg 19-21
Medications
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Stimulants
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Short
Intermediate
Long
Transdermal
Stimulant Pro Drugs
Non Stimulants
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SNRI
Adrenergic Agents
Antidepressants
Dopaminergic Agents
Stimulants FDA Approved
Adult FDA Approved is in BLUE
 Amphetamine
Adderall
 Dexedrine
 Dextrostat
 Adderall XR 2004
 Dexedrine Spanules
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Not recommended under age 3 yrs
Stimulants contFDA approved
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Methylphenidate
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Ritalin
Methylin chewable, Oral sol
Metadate ER
Focalin
Focalin XR 2005
Methylin ER
Ritalin SR
Metadate CD
Ritalin LA
Concerta
Not recommended for children under age 6
MethylphendateTransdermal Patch
New Stimulant Delivery
Option
Transdermal Methylphenidate Patch
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Daytrana
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FDA approved ages 6-12
10,15, 20 and 30 mg
Recommended one patch daily
Start with the 10 mg patch if no improvement in 1
week increase-- cont to adjust dose per 1 week
intervals.
Location hip (rotate area/ sides) may cause irritation
Delivered over 9 hours
Possibly effects initial height but minimal to not
significant in adulthood
Much the same side effect profile as oral agents
Remove 2 hours prior to effects wearing off.
Current Psychiatry Vol 5 No.6 / June 2006
Stimulant Pro Drug
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Vyvanse - Lisdexamfetamine
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FDA approved for ages 6-12
30, 50, and 70 mg capsules
Start with 30 mg/day. If needed titrate up with
20mg every 3-7 days as tolerated to max of 70
mg/day
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3.
Effect about 12 hours
Steady state in 2-3 days
Half life 9.5 hours
Current Psychiatry Vol.6 no.6 June 2007
Vyvanse –
Lisdexamfetamine cont-2
Blocks NE and Dopamine reuptake in Presyn
neuron
Noted improvement 2 hrs after dosing.
Large change in corrected QTC intervals--?
Need more info about cardiac risk
Possibly Less risk for abuse at
recommended doses—may be misused at
higher than therapeutic doses.
Current Psychiatry Vol.6 no.6 June 2007
Vyvanse –
Lisdexamfetamine cont-3
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Caution in Patients:
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Co morbid eating
Sleep disorder
HTN or cardiovascular illness
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Monitor HR and BP
Do not prescribe to patients taking
MAOI or who have taken one in 2
weeks of the presentation.
Current Psychiatry Vol.6 no.6 June 2007
Stimulant: side effects
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Review Black Box Warnings
regarding CV risks and Sudden
Death.
Encourage Food prior to taking
Medications
Understand possibility of Psychosis
May make Mania or Tics worse
Can write for 90 day RXN as of Dec
07
Stimulant Black Box Warnings
Pre-existing Cardiac
abnormality,
cardiomyopathy, arrythmias,
or other disorders which
the use of a
sympathomimetic could be
dangerous or increase the
vulnerability of patients
lives.
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Murmurs, syncopy history, HTN
Consult Cardiology to be safe.
Current Psychiatry Vol. 5 No. 10 / Oct 2006
STRATTERA =
Atomoxetine 2002
 FDA
approved for:
 Child
 Adol
 adult
SNRI –Atomoxetine
Non Stimulant --FDA Approved
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Full effect 3-7 weeks peak levels 1-2 hrs or
3-4 for slow metabolizers
Shorter sleep latency , improved sleep
Increased risk of suicidal ideation in
children and adolescents (see precautions)
Dose by Body Weight.
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Do not exceed 1.4 mg/kg/day or 100 mg
whichever is less. Start low go slow (start
0.5mg/kg/day for 10 day then 0.8 for 10 days
then 1.2 in a individual or BID dose)
Over 70 kg start at 40 mg dose and increase
after 10 days to 60 mg for 10 days then to 80mg
after 2-4 weeks consider max dose at 100 mg/
day.
Cont:SNRI -Atomoxetine
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Safety not established under age 6 years
Lower dose if a slow CYP2D6 metabolizer
or go slower to increase after 4 weeks if on
another drug which also uses/ inhibits 2D6
Modify dose by 50-25 % theraputic dose if
hepatic issues
Monitor BP,hepatic dysfunction,CV issues
always review the Adv. Effects list.
Monitor BP
Adults with more Anxiety, emotional
dysregulation
Cont:SNRI -Atomoxetine
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Adults start with 40 mg then in 3
days increase to 80 mg either in
one AM dose or split dose 40
bid. Max is 100mg.
Adrenergic Options
Not FDA approved in children
or Adolescents
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Clonidine
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Helps with impulsivity, insomnia associated with
Stimulant meds, hyperarousal, agitation, and tic
disorder
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Oral and transdermal patch
Side affects:
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Sedation daytime if dosed in daytime.
Withdrawl hypertensive episodes
5 reported sudden deaths when used in
combo with stimulants
Adrenergic Options
Not FDA approved in children
or Adolescents
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Guanfacine
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Similar to Clonidine in it’s uses
Less sedation and hypotension than
Clonidine
Not recommended or use with caution in
patients with renal insufficiency
Refractory ADHD with Tic issues, may
help with nightmares associated with
PTSD
Always read Adverse Effects,
contraindications and Precautions in
the package inserts
Antidepressants: Not FDA
approved in children/adolecents for
ADHD treatment nor Adults for ADHD
 Buproprion max 450 mg/ day in
Divided dose unless using 300XL for
Once daily dosing.
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50 % or adult respond
HA, Dry mouth, nausea, insomnia
Venlafaxine prelim studies suggest
efficacy
TCA’s (Amitriptyline, desipramine,
imipramine,nortriptyline)
MAOI’s open label suggest improved
concentration in children with ADHD
Dopaminergic Agents: Not FDA
approved in Adults or children **
Cholinergic Agents:Not FDA
approved in Adults or children *
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Modafinil**
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Donepezil*
Herbal and Natural Products:
Not FDA approved in Adults or
children for ADHD
 Ginko
Biloba
 Omega 3 Fatty Acids
 Vitamins/Minerals
 Zinc
 Iron
Treatment Summary
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RX treatment optimal and better
for core symptoms than
Behavioral treatment alone.
Combo of RX and Behavioral
was superior to either alone.
Can meet someone,
fall deeply in love,
marry, fight, hate, and
divorce,
all in about 35 minutes
or less.
Clinical Practice Guidelines
CPG’s
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www.pediatrics.org/cgi/content/full/105/5/11
58
www.aacap.org/galleries/practiceParamete
rs/New_ADHD_Parameter.pdf
Valid rating scale:
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Vanderbuilt
Conners Forms
www.massgeneral.org/schoolpsychiatry/screenin
gtools_table.asp
www.med.nyu.edu/psych/assets/adhdscreen18.p
df
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Vol. 6 No. 4 /April 2007
References
The Psychiatric Interview 2nd Ed.
Carlat
 Dec/Jan2008ADDitude Magazine
 Clinical Handbook of Psychotropic Drugs for
children and adolescents 2nd Ed. Kalyna
Bezchlibnyk-Butler and Adil Virani
 Current Psychiatry
 Vol.5 No. 2 / Feb.2006
 Atomoxetine package insert
New Perspectives on Adult ADHD
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College Years CME Part 5 of 6
ADHD : A Disorder with Life time Impact CME part 3 of
6
Advances in ADULT ADHD CME Part 7 of 8
 ADHD Drug Therapy: Long and short of it.
References
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Primary Psychiatry
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NeuroPsychiatry Reviews
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July 2004: Vol.11 No.7
Jan 08 Vol.9 No.1 pg.21
Psychiatric News
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Feb.1, 08 Vol 43 No.3 pg.23