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ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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Page 1: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

ADHDDiagnosis, Treatment & DSM-5 Considerations

Sala S.N. Webb, MDOld Dominion Medical Society

June 8, 2013

Page 2: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Outline Define ADHD

Highlight common co-morbid & confounding conditions

Discuss assessment & treatment considerations

Page 3: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

The Diagnostic & Statistical Manual of

Mental Disorders

Minimal 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)

Page 4: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Attention-Deficit/Hyperactivity Disorder

Page 5: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 6: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 7: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Hyperactivity

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

Page 8: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Impulsivity

Blurts out answers

Interrupts others

Can be intrusive Limited patience

Page 9: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Types

Combined Presentation Predominantly Inattentive Presentation Predominantly Hyperactive/Impulsive

Presentation Mild/Moderate/Severe Other Specified ADHD Unspecified ADHD

Page 10: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 11: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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%)

Page 12: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 13: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Confounding & Co-Morbid Conditions

Page 14: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Medical Conditions

Hearing impairment Hyperthyroidism Metals or toxins In -utero exposure

Page 15: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Medical Conditions

Seizures(Absence, Complex Partial)

Severe head injuries Sensory Integration

Disorders Sleep Apnea

Page 16: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Disruptive, Impulse Control & Conduct Disorders Oppositional-Defiant

Disorder Conduct Disorder Intermittent Explosive

Disorder

Page 17: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Abuse Dependence Intoxication Withdrawal

Page 18: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Neurodevelopmental Disorders Communication

Disorders

Autism Spectrum Disorders

Intellectual Disabilities

Specific Learning Disorders

Motor Disorders

Page 19: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Anxiety Disorders

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

Anxiety Panic Disorder

Page 20: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Obsessive Compulsive Disorders

Obsessive Compulsive Disorder Trichotillomania Excoriation

Page 21: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Depressive Disorders Major Depressive Disorder Persistent Depressive Disorder Disruptive Mood

Dysregulation Disorder Adjustment Disorder

with depressed mood

Page 22: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Manic Disorders

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

Page 23: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Trauma – Related Disorders

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

Page 24: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Evaluation Presenting symptoms Perinatal & developmental

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

Page 25: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Assessment Considerations

Onset , frequency & duration

Setting Context Level of disruption Stressors or trauma

Intensity Level of impairment Ability to self-regulate Insight

Page 26: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Scales

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

Page 27: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Treatment

Page 28: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

books, websites etc.

Page 29: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 30: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 31: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 32: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Pharmacotherapy

First Line Approved by FDA for ADHD Stimulants Atomoxetine

Second Line Buproprion α Agonists Tricyclic Antidepressants

Page 33: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 34: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Stimulants

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

condition

Page 35: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 36: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 37: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 38: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 39: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 40: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

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

Page 41: ADHD Diagnosis, Treatment & DSM-5 Considerations Sala S.N. Webb, MD Old Dominion Medical Society June 8, 2013

Questions??