ADHD Diagnosis, Treatment & DSM-5 Considerations

ADHDDiagnosis, Treatment & DSM-5 Considerations

Sala S.N. Webb, MDOld Dominion Medical Society

June 8, 2013

Outline Define ADHD

Highlight common co-morbid & confounding conditions

Discuss assessment & treatment considerations

The Diagnostic & Statistical Manual of

Mental DisordersMinimal Brain DysfunctionHyperkinetic Reaction of Childhood (DSM-II, 1968)Attention Deficit Disorder: With & Without Hyperactivity (DSM-III, 1980)Attention Deficit Hyperactivity Disorder (DSM-IV, 1994)Attention Deficit/Hyperactivity Disorder (DSM-5, 2013)

Attention-Deficit/Hyperactivity Disorder

Criteria: DSM-5 At least 6 symptoms of

InattentionAND/OR

At least 6 symptoms of Hyperactivity-Impulsivity

Persistent for at least 6 months

Maladaptive Inconsistent with

developmental level

Present before age 12 years

Problems in two or more settings

Impairment in social, academic or occupational functioning

Not due to other condition

Inattention• Makes careless mistakes• Difficulty with sustained

focus• Does not follow through

on instructions• Unable to organize• Avoids tasks requiring

sustained attention• Loses things needed for

tasks• Easily distracted• Often forgetful

Hyperactivity

Fidgets, squirms Difficulty remaining seated Runs & climbs excessively Difficulty playing quietly Acts as if “driven by a motor” Talks excessively

Impulsivity

Blurts out answers

Interrupts others

Can be intrusive Limited patience

Types

Combined Presentation Predominantly Inattentive Presentation Predominantly Hyperactive/Impulsive

Presentation Mild/Moderate/Severe Other Specified ADHD Unspecified ADHD

Etiology Deficits in executive functioning Genetic & Neurobiological contributors:

perinatal stress, low birth weight, TBI, maternal smoking, severe early deprivation

Decreased frontal & temporal lobe volumes

Decreased activation of frontal lobes, caudate and anterior cingulate

Epidemiology

6%-12% prevalence 4%-10% treated with medications 60%-85% will continue to meet criteria

through teenage years Adult prevalence varies: by self report (2%-

8%), parent report (46%), developmentally modified criteria (67%)

Rule of 3rd’s

By adulthood: 1/3rd will continue to need medications 1/3rd will have mild/residual symptoms but functional without medications 1/3rd will no longer meet clinical criteria

Confounding & Co-Morbid Conditions

Medical Conditions

Hearing impairment Hyperthyroidism Metals or toxins In -utero exposure

Medical Conditions Seizures

(Absence, Complex Partial)

Severe head injuries Sensory Integration

Disorders Sleep Apnea

Disruptive, Impulse Control & Conduct Disorders

Oppositional-Defiant Disorder

Conduct Disorder Intermittent Explosive

Disorder

Substance Related Disorders Alcohol Amphetamines Cannabis Caffeine Cocaine Hallucinogens Inhalants Nicotine Opiate Sedative or Hypnotic

Abuse Dependence Intoxication Withdrawal

Neurodevelopmental Disorders Communication

Disorders

Autism Spectrum Disorders

Intellectual Disabilities

Specific Learning Disorders

Motor Disorders

Anxiety Disorders

Separation Anxiety Disorder Generalized Anxiety Disorder Specific Phobia Social Anxiety Disorder Adjustment Disorder with

Anxiety Panic Disorder

Obsessive Compulsive Disorders

Obsessive Compulsive Disorder Trichotillomania Excoriation

Depressive Disorders Major Depressive Disorder Persistent Depressive Disorder Disruptive Mood

Dysregulation Disorder Adjustment Disorder

with depressed mood

Manic Disorders

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

Trauma – Related Disorders

Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder

Evaluation Presenting symptoms Perinatal & developmental

histories Medical history Family history Educational history Social history Patient & parent interviews Physical examination Collateral information

Assessment Considerations Onset , frequency &

duration Setting Context Level of disruption Stressors or trauma

Intensity Level of impairment Ability to self-regulate Insight

Scales

Conner’s Parent’s Rating Scale Conner’s Teacher’s Rating Scale Brown ADD Vanderbilt ADHD Child Behavior Checklist

Treatment

Psychoeducation Clarify diagnosis Give contextual framework Be honest & sincere about your opinion Anticipate developmental challenges Provide or recommend resources: fact sheets,

books, websites etc.

School Resources Talk with child’s main teacher Talk with guidance counselor If applicable, encourage parents to request in writing testing

or Child Study Suggest accommodations, if solicited

Behavioral Therapies

Initial therapy for mild symptoms and uncertain diagnosis

Per parental preference Focuses in parental management and molding

of behaviors Can be in-home or outpatient

Behavioral Therapies

Cognitive Behavioral Therapy (CBT) more efficacious in adolescents & adults than younger children

Metacognitive Therapy (MCT) combines CBT with training on improving executive functioning

Pharmacotherapy

First Line Approved by FDA for ADHD Stimulants Atomoxetine

Second Line Buproprion α Agonists Tricyclic Antidepressants

Stimulants

Methylphenidate Short acting (2-6 hrs):

Focalin, Ritalin, Methylin Intermediate acting (4-8

hrs): Metadate CD, Methylin ER, Ritalin SR, Ritalin LA

Long acting (8-12 hrs): Concerta, Focalin XR, Daytrana Patch

Amphetamine Short acting: Dexedrine,

Dextrostat, Adderall Intermediate acting:

Dexedrine Spansules Long acting: Adderall XR,

Vyvanse

Stimulants

Side Effects Decreased appetite, weight loss Insomnia, headaches Tics, emotional lability, irritability Visual & tactile hallucinations Contra-indicated in pre-existing heart

condition

Atomoxetine Selective Norepinephrine

Reuptake Inhibitor (SNRI) Strattera Not as effective as stimulants Can use if negative side

effects experienced on stimulants

Requires 6 weeks to see full effect

Effective in treating co-morbid anxiety

Side Effects Nausea, decreased

appetite Headaches Sedation (can give as

single night dose) Suicidality

Buproprion Dopamine Norepinephrine

Reuptake Inhibitor (DNRI) Wellbutrin, Wellbutrin SR,

Wellbutrin XL Helpful in co-occurring

depression Less effective for

inattention, no effect on hyperactivity

Delayed onset of action

Side Effects Insomnia Headaches Nausea Contraindicated in

seizure disorders Use with caution in

eating disorders Can induce seizures in

overdose

α 2 Adrenergic Agonists Guanfacine (Tenex,

Intuniv) Clonidine (Catapres,

Kapvay) Effective for impulsivity

and hyperactivity; not inattention

Helpful in co-occurring traumatic flashbacks, aggression, insomnia & tics

Side Effects Sedation Dizziness Hypotension Rebound hypertension

with rapid discontinuation

Tricyclic Antidepressants Imipramine,

Nortriptyline, Desipramine

Inhibits reuptake of NE EKG at baseline and

each dose increase Once symptom control

achieved, check serum level for toxicity

Side Effects Dry mouth, constipation Vision changes,

sedation Tachycardia Cases of sudden death

reported in children & adolescents with desipramine

When to Refer… For evaluation & treatment For consultation with

resumption of treatment Concerns for safety Significant impairment in

functioning No improvement after 6-8

weeks of first-line intervention

Diagnostic conundrum History suggestive of

trauma with current impact Difficulty coping with

chronic medical illness

Can always seek collegial consultation without face-to-face evaluation of patient

References

Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition American Psychiatric Association, 2013

Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit-Hyperactivity Disorder J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46 (7): 894-921

Questions??