AD/HDAD/HDGeneral Medical InformationGeneral Medical Information

Mary Margaret Dagen, M.D.Mary Margaret Dagen, M.D. Westshore Family MedicineWestshore Family Medicine

April 24, 2013April 24, 2013

AD/HD- DefinitionAD/HD- Definition

6 or more symptoms of inattention for at least 6 or more symptoms of inattention for at least 6mos to a degree that is inconsistent 6mos to a degree that is inconsistent w/developmental levelw/developmental level

6 or more symptoms of hyperactivity-impulsivity 6 or more symptoms of hyperactivity-impulsivity for at least 6mos that is inconsistent for at least 6mos that is inconsistent w/developmental levelw/developmental level

Symptoms present before age 7Symptoms present before age 7 Impairment from symptoms present in 2 or Impairment from symptoms present in 2 or

more settingsmore settings Clinically significant impairment in social, Clinically significant impairment in social,

academic, or occupational functioningacademic, or occupational functioning Symptoms do not occur exclusively in another Symptoms do not occur exclusively in another

mental disordermental disorder

AD/HD- DefinitionAD/HD- Definition

InattentionInattention

Fails to give close attention to details or makes Fails to give close attention to details or makes careless mistakescareless mistakes

Difficulty sustaining tasks/activitiesDifficulty sustaining tasks/activities Does not listen when spoken to directlyDoes not listen when spoken to directly Does not follow through on instructions or complete Does not follow through on instructions or complete

taskstasks Difficulty organizing tasks/activitiesDifficulty organizing tasks/activities Avoids, dislikes, reluctant to engage in tasks that Avoids, dislikes, reluctant to engage in tasks that

require sustained mental effortrequire sustained mental effort Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli Forgetful in daily activitiesForgetful in daily activities

AD/HD- DefinitionAD/HD- Definition

HyperactivityHyperactivity

Fidgets with hands/feet or squirms in seatFidgets with hands/feet or squirms in seat Leaves seat in classroom or other situations in which Leaves seat in classroom or other situations in which

remaining seated is expectedremaining seated is expected Runs about or climbs excessively in situations in which Runs about or climbs excessively in situations in which

it’s inappropriateit’s inappropriate Difficulty playing or engaging in leisure activities Difficulty playing or engaging in leisure activities

quietlyquietly Talks excessivelyTalks excessively Often ‘on the go’ or acts as if ‘driven by a motor’Often ‘on the go’ or acts as if ‘driven by a motor’

AD/HD- DefinitionAD/HD- Definition

ImpulsivityImpulsivity

Difficulty awaiting turn in games or Difficulty awaiting turn in games or group situationsgroup situations

Blurts out answers to questions before Blurts out answers to questions before they have been completedthey have been completed

Interrupts or intrudes on othersInterrupts or intrudes on others

AD/HD- EpidemiologyAD/HD- Epidemiology

16% increase in diagnosis since 200716% increase in diagnosis since 2007 3.7% children in U.S. have been 3.7% children in U.S. have been

diagnoseddiagnosed Boys are more likely to be diagnosed Boys are more likely to be diagnosed

(13.2% boys vs 5.6% girls)(13.2% boys vs 5.6% girls) Rates are increasing in teens Rates are increasing in teens

compared to young childrencompared to young children

AD/HD- DiagnosisAD/HD- Diagnosis

Learning disordersLearning disorders 50% those 50% those diagnosed with ADHD have co-morbid diagnosed with ADHD have co-morbid learning disabilitieslearning disabilities

Oppositional defiant disorderOppositional defiant disorder starts starts before age 8. lose temper, argue, refuse before age 8. lose temper, argue, refuse to follow rules, deliberately annoyto follow rules, deliberately annoy

Conduct disorderConduct disorder aggression towards aggression towards others, violations of rules/lawsothers, violations of rules/laws

Mental disordersMental disorders anxiety, depression anxiety, depression

AD/HD- DiagnosisAD/HD- Diagnosis

Medical examMedical exam Evaluate hearing & visionEvaluate hearing & vision

Ratings scales & checklistsRatings scales & checklists Conner’s Parent & Teacher rating scaleConner’s Parent & Teacher rating scale

AD/HD- DiagnosisAD/HD- Diagnosis

Conner’s rating scaleConner’s rating scale

AD/HD- TreatmentAD/HD- Treatment

StimulantsStimulants (Ritalin, Adderall, Concerta, (Ritalin, Adderall, Concerta, Daytrana, Focalin, Vyvanse, etc)Daytrana, Focalin, Vyvanse, etc)

Stimulates CNS (brain) activity by blocking Stimulates CNS (brain) activity by blocking reuptake & increases release of reuptake & increases release of norepinephrine & dopaminenorepinephrine & dopamine

Side effectsSide effects decreased appetite, insomnia, decreased appetite, insomnia, anxietyanxiety

70-80% children respond positively to these70-80% children respond positively to these

AD/HD- TreatmentAD/HD- Treatment

Non-stimulantsNon-stimulants (Strattera, Intuniv, (Strattera, Intuniv, Tenex, Kapvay, Wellbutrin, etc)Tenex, Kapvay, Wellbutrin, etc) Most still affect norepinephrine system, Most still affect norepinephrine system,

but at a different level so they are not but at a different level so they are not directly stimulatingdirectly stimulating

Less side effect profileLess side effect profile

AD/HD- Treatment AD/HD- Treatment GuidelinesGuidelines

Preschool (4-5yo): behavioral Preschool (4-5yo): behavioral therapy is 1therapy is 1stst line. If this doesn’t line. If this doesn’t provide significant improvement, provide significant improvement, trial of stimulanttrial of stimulant

Elementary (6-11yo): stimulants are Elementary (6-11yo): stimulants are 11stst line, + behavioral therapy line, + behavioral therapy

Adolescents (12-18yo): medications Adolescents (12-18yo): medications + behavioral therapy + behavioral therapy

AD/HD- Behavioral TherapyAD/HD- Behavioral Therapy

Create routineCreate routine OrganizationOrganization Avoid distractionsAvoid distractions Limit choicesLimit choices Change interactions to brief explanationsChange interactions to brief explanations Use goals w/rewardsUse goals w/rewards DisciplineDiscipline Help child discover a talentHelp child discover a talent

AD/HD- Alternative AD/HD- Alternative TherapiesTherapies

Screen time & dietScreen time & diet no direct relation no direct relation Feingold diet- sensitivity to dietary salicylates & Feingold diet- sensitivity to dietary salicylates &

artificially added colors/flavors/preservativesartificially added colors/flavors/preservatives no relationno relation

SupplementsSupplements essential fatty acids, essential fatty acids, glyconutritional supplements, vitamins, amino glyconutritional supplements, vitamins, amino acids, Ginko biloba, herbalsacids, Ginko biloba, herbals

Sensory integrationSensory integration not specific to AD/HD not specific to AD/HD Interactive Metronome trainingInteractive Metronome training promising promising Cerebellar training, anti-motion sickness, yeast Cerebellar training, anti-motion sickness, yeast

infections, neurofeedback, chiropractic, thyroid, infections, neurofeedback, chiropractic, thyroid, leadlead no direct relation to improvement no direct relation to improvement

AD/HDAD/HD

www.cdc.gov www.help4adhd.org American Psychiatric AssociationAmerican Psychiatric Association American Academy of Family American Academy of Family

PhysiciansPhysicians American Academy of PediatricsAmerican Academy of Pediatrics

AD/HDAD/HD

QUESTIONS??QUESTIONS??