Attention Deficit Hyperactivity Disorder:

Considering the diagnosis and the basics of management…

Even though management can be anything but basic!

Declaration:

I cannot identify any affiliation (financial or otherwise) with a pharmaceutical, medical device, or communications organization, or other for-profit funder for this program.

Attention Deficit Hyperactivity Disorder

Usually manifests in childhood*

Symptoms of inattention and/or hyperactivity-impulsivity

Affect on function**

Who is affected?

Est. prevalence of ADHD = 7.2% of school-aged children Meta-analysis of 175 studies, Pre-DSM V*

Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis; Thomas et al; Pediatrics. 2015;135(4):e994.

Prevalence increases with age

More common in boys 4:1 for predominantly hyperactive/Impulsive 2:1 for predominantly inattentive

Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003 - 2011 Visser et al.; J Am Child Adolesc Psychiatry. 2014 Jan;53(1):34-46.e2. Epub 2013 Nov 21

Why does it occur?

Not entirely understood: Suspected to be at least partly due to an imbalance of

catecholamine and dopamine metabolism in the cerebral cortex (prefrontal predominantly + cerebellum, caudate) Structural and functional differences in brain imaging Response to medications with noradrenergic activity

Genetic factors – twin studies* Variable environmental factors Prenatal exposure to maternal smoking Prenatal alcohol exposure Prematurity/low birth weight Diet? Conflicting evidence. Certainly not causative but

potentially some impact

When is an assessment appropriate?

Age 4 or older

Patient has identified possible symptoms in him/herself

Relative/Parent/Teacher/supervisor has identified symptoms Often people with ADHD themselves identify the symptoms

in their own relatives

Patient presents with behavioral/academic/learning difficulties and the clinician believes the symptoms may be due to ADHD

ADHD – Diagnostic Criteria

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V): Persistent Pattern of Inattention and/or hyperactivity/Impulsivity At least 6 core symptoms from either or both inattention

group of criteria and hyperactivity/impulsivity group* Several symptoms present before age 12 Several symptoms present in 2 or more settings Symptoms present for at least 6 months** Symptoms interfere with/reduce quality of functioning*** Symptoms are not better explained by another mental

disorder (ex: mood, anxiety, schizophrenia, psychotic d/o)

Changes from DSM-IV to DSM-V*

Provides examples of behaviors/symptoms**

If > 17 yrs of age, only 5 symptoms per category

Behaviors present before age 7 age 12

>1 setting: Impairment vs. presence of symptoms

No exclusion criteria for those patients with ASD

Diagnostic wording: ex: Inattentive Type Presentation

Rating of current severity; mild, moderate, severe

How do we assess?

SNAP questionnaire forms – Teacher and Parent scales Identify Inattentive, Hyperactive/Impulsive, and OD Symptoms

Interview/History/Physical Examination Can be supported with Weiss Functional Impairment Scale – Parent Report

Corroborating information from school CADDRA Teacher Assessment Form

+/-Weiss Symptom Record – to further define symptoms of possible comorbid disorders (mood, anxiety, ODD, etc.)

+/-Encourage a formal psychoeducational assessment through school or other resource

+/-Patient ADHD Medication Form - to identify preexisting somatic complaints and track possible side effects

Consider Alternative Diagnoses/Co-Morbidities

Comorbidities in up to 1/2 of children (ODD, CD, Anxiety, etc.)

Psychoeducational assessment through school or alternative resource – rule out specific learning disabilities, intellectual disabilities, etc.** Learning Disabilities Association of Saskatchewan Early Childhood Psychology

Consider other mental health diagnoses as main contributor to behaviors and learning difficulties Ex. Mood disorders, anxiety, psychosis

Consider other medical diagnoses which may also be playing a role*** Ex. FASD, ASD, OSA, Tic disorder, Seizure Disorder

Ancillary Evaluation

Guided by differential diagnosis after initial assessment: Signs of sleep apnea sleep study ?Absence epilepsy EEG/Neurology referral Suspected mood/anxiety disorder but not clear Mental

health evaluation (consider psychiatry referral) Developmental delay on screening developmental

pediatrics referral Signs of systemic illness investigations guided by specific

findings*

Why treat?

Untreated ADHD Impaired academic functioning limitation of vocational Increased injury and Self Injury Increased incidence of MVCs, license suspensions Increased risk of engaging in substance use Persistence of symptoms into adult life in 1/3-2/3

Treatment: Multimodal

Psychosocial Interventions: Education: provide reading materials/resources to help

educate the family/patient Canadian ADHD Resource Alliance (CADDRA.ca) Centre for ADHD Awareness, Canada (CADDAC.ca) ADHD information on healthychildren.org – From the AAP

Behavioral Interventions: personalized application of rewards, point systems, consequences/response cost; PBP/PEP*

Social Interventions: group interactions, parent training Cognitive behavioral therapy: in older children/adolescents

Diet, Exercise, Sleep

Pharmacotherapy

Pharmacotherapy

First Line: Long acting medications – Taken OD in am methylphenidate (Biphentin/Concerta) mixed salts amphetamine (Adderall XR) lisdexamphetamine dimesylate (Vyvanse) atomoxetine (Strattera) – non-stimulant

Second Line: dextroamphetamine (Dexedrine/Dexedrine Spansules) methylphenidate (Ritalin, Ritalin SR)

Adjunctive: guanfacine (Intuniv XR)

Concerns for poor growth?

While evidence is inconsistent, some studies have suggested treatment with stimulant medications can lead to a reduction in expected final adult height

Close monitoring of height, weight, and BMI at baseline and 1-2 times per year during treatment. If falling away from curve*, consider drug holidays or

switching to non-stimulant

Consider the drug plan

In Saskatchewan: methylphenidate (Concerta, Ritalin, Ritalin SR) and

dextroamphetamine (Dexedrine/Dexedrine Spansules) Full benefits

methylphenidate (Biphentin) – listed EDS mixed amphetamine salts (Adderall XR) – not listed lisdexamphetamine (Vyvanse) – listed EDS atomoxetine (Strattera) - restricted

Ongoing Evaluation

Periodic visits* Adherence to treatment plan Efficacy of treatments Side effects of treatments

Repeat Rating Scales for objective evidence of core symptom management

Keep open line of communication with teacher/parents

Titrate medications to achieve maximum benefit with minimum adverse effects

Indications for Referral

To Pediatrician or Child/Adolescent Psychiatry Coexisting psych conditions (mood/anxiety/substance) Coexisting medical conditions (epilepsy/autism/sleep d/o) Lack of response or poor tolerance of controlled trial of

appropriate therapy

Recap

DSM-5 - making the diagnosis somewhat clearer

Evidence of dysfunction in 2 environments

Preschool – behavioral interventions first-line Positive reinforcement, response cost; modification of environment Parental training (Classes, literature)

School age & beyond – Pharmacotherapy +/- behavioral Ideally combination, but need buy-in from parents/school

First-line medications: long-acting stimulants Once daily dosing, variety of options

It’s a process!

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition, Toronto ON; CADDRA, 2011.

AAP. ADHD Clinical Practice Guidelines. Pediatrics 2011; 128: 1007-1022

Centre for ADHD Awareness, Canada. (2016). CADDAC.ca

Thank you!