ADHD
Attention-Deficit/Hyperactivity Disorder An Introduction to Diagnosis and Treatment Scott Carroll, MD Assistant Professor Child and Adolescent Psychiatry UNM - HSC
[email protected] 505-272-4763
ADHD
Overview • What is ADHD? • Why do we diagnose and treat it? • Diagnosis in the primary care setting
• Treatment in the primary care setting • Diagnostic and treatment complications (when to refer)
ADHD
History of ADHD • Hohman (1922) - post-encephalitic disorder in children who had suffered ‘encephalitis lethargica’ following the influenza pandemic of 1917 • Strauss (1947) - minimal brain damage/minimal brain dysfunction •DSM - I (1952) - hyperactivity of childhood • ICD-9 (1965), DSM-II (1968) – hyperkinetic syndrome of childhood, hyperkinetic reaction of childhood • DSM-III (1980) – ADD with or w/o hyperactivity • DSM-IIIR (1987) – ADHD • DSM-IV (1994) – AD/HD, 50% increase in prevalence
ADHD
What is ADHD? ADHD is a genetic, neurobiological disorder that affects ones ability to regulate impulse control, motor activity, and attentiveness (i.e. a disorder of executive function). Cognitive Process of Attention: 1. Detecting a stimulus (focusing). 2. Processing the detected information. 3. Sustaining attention to the relevant stimulus. 4. Inhibiting involuntary shifting (distractibility). 5. Organizing a response to the stimulus. The core problem in ADHD seems to be with response inhibition
ADHD
ADHD – Disproven Theories • Bad parenting - still widely believed • Defiance/willfullness - also widely believed
• Moral defect - due to co-morbid CD • Poor diet - can cause ADHD-like sx and worsen sx, but actually rare in modern society • Allergies/sensitivities - mimics, doesn’t cause • Brain damage - causes small percentage • Toxic exposure (lead, etc.) - rare cause
ADHD
Epidemiology of ADHD •Prevalence Estimates • 3-5% DSM-IV estimates (APA, 1994)
• 1.7 - 17.8% (Elia et al. 1999) • 3 - 6% (Goldman et al. 1998) • 4 - 12% (Brown et al., 2001) • M to F originally 3:1, more likely 1:1 • Persists into adulthood 50-60% • Thus 5 to 10% of adults may be affected
ADHD
RESEARCH ADVANCES IN ADHD – Genetics/Genomics HEREDIBILITY – Does ADHD have a genetic component?
• Twin studies show higher concordance rates in MZ (identical) twins than in DZ (fraternal) twins (e.g., Stevenson, 1992; Gilger, Pennington, and DeFries, 1992) – Average heritability is .80 for twin studies (Faraone 1996) • Gilger, Pennington, and DeFries (1992): if one twin was diagnosed with ADHD, the concordance for ADHD was 81% in MZ twins and 29% in DZ twins – Environment accounts for 0-13% (majority 3,000) confirming medication efficacy • stimulants (methylphenidate and amphetamines)
• antidepressants (bupropion, mirtazapine and TCA’s) • alpha-adrenergic agents (clonidine and guanfacine)
• atomoxetine (Strattera) • modafinil (Provigil) – do not use due to risk of SJS • 70 – 80% of ADHD children respond positively to stimulants; 20-30% show adverse or no response (Swanson et al 1995)
ADHD
ADHD - Medication Treatment of Children • The psychostimulants are the most effective • Non-stimulants are mildly to moderately effective • Large individual differences in doses and responses
• Try methylphenidate first - no risk of sudden cardiac death (SCD), but may increase seizures • Start with Concerta 18mg qam (or Focalin XR 10mg) • Switch to amphetamine if no response or if dysphoric
ADHD
ADHD - Medication Treatment of Teens and Adults • May respond to Wellbutrin alone (300-450mg) • Only try Strattera if pt fails Wellbutrin • Try methylphenidate first (no SCD, except w/Sz)
• Start with Concerta 18mg qam (or Focalin XR 10mg) • Switch to amphetamine if no response or dysphoric • Consider Vyvanse if risk of abuse or diversion
ADHD
Psychosocial Treatments for ADHD • Generally only help if core ADHD sx treated with meds • Social and organization skills gradually develop once core ADHD sx adequately treated, coaching may help • 504 Educational plan may help, but not enforceable • Apply for special ed via ADA under “other health impaired”
• IEP legally enforceable, high levels of support in regular classes • Computer based charter schools may work for teens
• ODD responds to consistent consequences, Conduct d/o needs to be on probation and sentenced to Multisystemic therapy (MST)
ADHD
Complications and When to Refer • Confusing diagnostically or severe co-morbidity (not just ODD) • Insist upon individual/family therapy for comorbid ODD • Difficult to manage side effects or failure of both stimulants • Suspicion of Autism or Asperger’s, get neuropsych or CDD eval • Always refer if suspicion of BPAD or signs of mania or psychosis • Call PALS line (1-888-866-7257) if not sure whether to refer • Can refer to the Consultation Clinic for 3-4 visits (505-272-0371)
• Call Access at CPH (272-0053) if hospitalization is possibility