Update - AAP 2011 Guidelines on ADHD

Karen Pierce MD FAPA, FAACAPNorthwestern University

January 28, 2012

Disclosure

• No conflict of interests• Off label use of medication will be indicated • Only Dexedrine is approved for children ages 3

to 4 years, all other stimulants are off-label

Objectives

• To review the update of diagnosis and treatment of ADHD new AAP 2011 guidelines

• To review the importance of diagnosing comorbidity in a child with ADHD

• To talk about the importance of behavior treatment and learning skills for the pre-schooler that presents with behavior problems

AAP ADHD 2011 Guidelines - Rational

• Updates and replaces two previous guidelines• Uses new information and evidence • Expanded age ranges from 4 to 18 years• Expanded scope-behavior interventions may

help families without full ADHD diagnosed• A process of care for diagnosis and treatment• Integration with Task Force on Mental Health

AAP 2011 Guidelines 1

• Primary Care Clinicians should evaluate children 4 -18 years of age for ADHD who present with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity

• Quality of the Evidence- B:strong recommendation

Portrait of a child with ADHD

Normal Development

A. Active: Characteristics of Active Baby Syndrome:

1. Highly active2. Poorly adaptive3. Intensely reactive4. Unpredictable with routines

Normal Development

B. Short Attention Span: Preschoolers and Time on Task:

3 years old = 9 or 10 minutes4 years old = 13 minutes5 years old = 20 minutes

Normal Development

C. Impulsive vs.. Normal Preschool

1. Excessive activity in structured situations2. Poor attention sustaining attention3. Trouble inhibiting behavior

Clinical Picture

Attention deficit disorder is a developmentaldisorder characterized by defects in theregulation and maintenance of behavior.

ADHD has an onset before age seven, but determining how early to diagnose it is a challenge.

ADHD and the Brain

ADHD Facts

– ADHD not caused by poor parenting skills or a stressful family environment

– Environmental factors can exacerbate the symptoms

– Parenting techniques appropriately in tune with the ADHD child can improve symptoms and increase the child’s self-esteem

ADHD Practice Parameters. JAACAP 1997;36:85S.

AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S.Barkley RA. J Am Acad Child Adolesc Psychiatry. 1991;30:752-761.

ADHD Affects Socialization• Children are stigmatized by their behavior

– Disruptive behavior• Troublemakers • Bad sportsmanship• Excessive talking • Cannot sit still• Unfocused, not responsive to others • Impulsive aggression

– Immaturity and impulsiveness• Center of attention • Breaks the rules• Blurting out answers • Peer rejection

• Adolescents continue to demonstrate social problems

- Poor participation in group activities– Few friends– Vulnerable to antisocial groups, drug abuse

• Adults– More marriages and divorces– Lower level of occupation/fewer advancements

Peer Perception of ADHD Children

Those who: (%name)• Try to get other people in

trouble• Play the clown• Tell other children what to

do• Are usually chosen last• Start a fight over nothing

ADHD Boys Controls• 51 17

• 40 19• 41 16

• 27 13• 48 19

Murphy D, Barkley B. Am J Orthopsychiatry. 1996;66:93-102.

How ADHD Affects Parents

• Increased stress– Worry — Anxiety– Frustration — Anger

• Lower self-esteem– Self-blame — Depression– Social isolation

• Increased employment disruption• Increased marital disruption• Increased alcohol/substance abuse

Why is it important to identify & treat ADHD?

• Interferes with the child’s learning• Interferes with the learning of others• Disrupts social development• Reduces instructional time• Adds to stress for all involved• Drains resources• Not having an effective strategy can

maintain or exacerbate ADHD behaviors

Why is it important to identify & treat ADHD?

• Less schooling & poorer grades• Higher expulsion rates• Fewer friends• Lower self-esteem• Higher arrest rates• Lower occupational rank• Higher job termination rates• Driving differences: 3x• Accident proneness

Developmental Trendsof ADHD Symptoms

before 17 yo

Impa

irmen

t

Inattention

Hyper/Imp

Age

AAP 2011 Guideline- 2

• To make a diagnosis of ADHD, determine that DSM-IV criteria have been met including impairment in more than one major setting with information obtained from parents, school or guardians. All alternative causes should be ruled out

• (Quality of the evidence: B/Strong Recommendation)

Inattention Hyperactivity

Impulsivity

What Is ADHD?

Hyperactive/Impulsive Symptoms

1. Fidgety & squirmy2. Often gets up out of seat3. Runs or climbs excessively4. Has trouble playing quietly5. “On the go” or “driven by a motor”6. Talks excessively7. Blurts out answers8. Has trouble waiting for a turn9. Interrupts or intrudes

Inattentive Symptoms

1. Makes careless mistakes2. Has trouble paying attention to a task3. Does not seem to listen when spoken to directly4. Does not follow instructions5. Has trouble organizing6. Avoids or dislikes sustained effort7. Loses things8. Easily distracted9. Forgetful

DSM IV Criteria (1)

• At least 6 of the 9 behaviors described in the inattentive domain occur often and to a degree inconsistent with child’s developmental age, and/or

• At least 6 of the 9 behaviors described in the hyperactive/impulsive domain occur often and to a degree inconsistent with child’s developmental age

• Presence of some impairment in two or more major settings (e.g., home and school) for at least six months

DSM IV Criteria (2)

• Presence of some symptoms of ADHD that caused impairment (by history) prior to 7 years of age

• Symptoms have persisted for at least six months• Evidence for significant clinical impairment in

social, academic or occupational functioning due to the behaviors.

• Symptoms are not attributable to another physical, situational or mental health condition

3 DSM IV Subtypes

• ADHD primarily of the inattentive type (ADHD/I, having the inappropriately often occurrence of at least 6 of 9 inattention behaviors and less than 6 hyperactive-impulsive behaviors)

• ADHD primarily of the hyperactive-impulsive type (ADHD/HI, having the inappropriately often occurrence of at least 6 of 9 hyperactive-impulsive behaviors and less than 6 inattention behaviors)

• ADHD combined type (ADHD/C, having the inappropriately often occurrence of at least 6 of 9 behaviors in both the inattention and hyperactive-impulsive dimensions) , most common

Special Circumstances-Preschool

• Evidence for ADHD diagnosis in Preschool• Need a check list but only the Connors is

validated in preschool children• Need poor functioning in two or more setting,

so a valid rater outside the home is important to obtain

• Egger HL et al, The epidemiology and diagnostic issues in preschool ADHD, Infants and Young Children 2006;19(2);109-122

Steps for Preschool pre-treatment

• Parents should consider completing a parent-training program prior to confirming an ADHD diagnosis

• Consider placement in a qualified preschool program such as Head Start

• Learn age-appropriate developmental expectations

• May qualify for Early Childhood Special Education through their local public school

AAP 2011 Guideline-3

• In the Evaluation of a child for ADHD, an assessment for other conditions that might coexist with ADHD including emotional, behavioral (e.g. anxiety, depression, oppositional defiant, and conduct disorders), developmental (e.g. learning and language disorders, or other neurodevelopmental disorders) and physical(e.g. tics, sleep apnea)

• Quality of Evidence: B/Strong Recommendation

ADHD—Childhood Common Comorbid Diagnoses

Biederman et al. JAACAP 1996;35:343. Pliszka. J Clin Psychiatry 1998:59(suppl 7):50.Biederman et al. JAACAP 1999;38:966. Spencer et al. Pediatric Clin N Am 1999:46:915.

Approximate Prevalence Rate in Children with ADHD (%)

0 10 20 30 40 50 60

Oppositional defiant disorder

Conduct disorder

Mood disorder

Anxiety disorder

Learning disorderMaleFemale

Overlap of Symptoms and Diagnoses

ADHD Anxiety LD ODD

Attention Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep

Co-occurring Disorders

Oppositional defiant disorder…………….…………..40%Anxiety or mood disorder…………………...........25-30%Learning disability………………………………..…....20%Conduct disorder………………………………...….…10%Language disorder………………………..….…....10-60%Tics…………………..………………………………10-15%

½ of ADHD patients have two or more diagnoses

½ of ADHD patients have > 2 diagnoses

Comorbidity

60% of children with ADHD have a learning disability

1. Language-Based Disorders2. Non-verbal Disorders

Externalizing Disorders• Oppositional Defiant Disorder (ODD)

– Negativistic, hostile, and defiant behavior– Unwilling to conform to demands of others– Less severe than conduct disorder– Nationally: 30-40% of children with ADHD have ODD

• Conduct Disorder (CD)– Aggression toward people and/or animals– Destruction of property– Deceitfulness– Breaking the law– Lack of remorse– Nationally: 15-20% of children with ADHD have CD

Oppositional Defiant Disorder IV

• A pattern lasting 6 months, need 4 Often loses temper Often argues with adults Often actively defies or refuses to comply Often deliberately annoys people Often blames others for his/her mistakes Often is touchy or easily annoyed by others Often is angry and resentful Often is spiteful and vindictive

AAP 2011 Guideline-4

• ADHD is a chronic condition and therefore consider children and adolescents with ADHD as children with Special Health Care Needs (CYSHCN) and follow the principles of the chronic care model and the medical home

• Quality of evidence: B/Strong Recommendation

AAP 2011 Guidelines-5

• Recommendations for treatment of children and youth with ADHD varies depending on age

• Preschool-(4-5) –evidence based parent and/or teacher administrated behavior therapy first

• Quality of Evidence: A/Strong Recommendation• May prescribe methylphenidate if behavior

treatment fails and there is moderate to severe impairment

AAP 2011 Guidelines- 5 (cont)

• For Elementary school age children (6 to 11)Consider both FDA-approved mediations for

ADHD (quality of evidence A:/Strong) and/or evidence based parent and/or behavior treatment (quality of evidence B:/strong). The evidence is strong for stimulant medications and sufficient but less strong on Atomoxetine, extended release guanfacine and extended release clonidine

Preschool Recommendations

• Studies of ADHD treatment in preschool was limited to children with moderate to severe dysfunction

• Research shows that up to 1/3 of young children (age 4-5) experience improvements in symptoms with behavior therapy alone

• There is limited information and experience about the effects of stimulant medication between ages 4 to 5- off label

Management-1

– Set rules– Set clear expectations – Ignore mild inappropriate behaviors – Praise positive behavior– Utilize contingency management with positive

reinforcement (eg,stickers) and prudent negative consequences (eg, privilege loss)

Contingency Management

• Explain clearly the behavior that is desired: ‘Sit quietly in the chair’ ‘ don’t bite my finger’

• Practice the behavior and reward immediately with a sticker, small point sheet to a larger ‘prize’

• Take breaks and reinforce with praise• Use visual charts to reinforce behavior

Contingency Management

• Be consistent, • Be Predictable• Praise liberally• Have empathy• TALK TO THE CHILD DIRECTLY, not to the

parent

Troubleshooting

• If rewards not working, examine the program and change the reward

• Ask the parent or get permission to call the PCP (children over 12 years need to sign mental health consent) for suggestions

• Ask what is reinforcing at home and use home rewards, too

Components of Evidenced-Based

Child Intervention -Behavioral and developmental approach -Focus on teaching academic, recreational, and

social/behavioral competencies, decreasing aggression, increasing compliance, developing close friendships, improve adult relations,

-Paraprofessional or teacher-based -Summer treatment programs

Components of Evidence-based Treatment for ADHD

School Intervention• Behavioral approach – teachers are trained and implement

treatment with the child, modifying interventions as necessary using ongoing functional analysis

• Focus on classroom behavior, academic performance, and peer relationships

• Widely available in schools• Teacher training: (1) Inservice training and follow-up or (2)

consultant model – initial weekly sessions as needed, then contact faded – Daily Report Card.

Why Is It Important to Use Behavioral Interventions for ADHD in Schools?

(Kent et al, 2011; Loe & Feldman, 2007; Molina et al, 2009; Robb et al, 2011)

• 33% of ADHD have academic problems (special ed., academic probation, dropped out, or held back) every year, vs.. 2% of controls.

• 48% of ADHD children have at least one year of special education placement vs.. 3% of controls (bulk of cost).

• 12% of ADHD vs.. 5% of controls have been held back a grade.• 9% of ADHD adolescents drop out of school vs.. 1% of

controls.• ADHD adolescents score a full letter grade lower than

controls, with twice the rate of absences.• Medication does not improve these outcomes.

Components of Evidence-based Treatment for ADHD

School Intervention• Don’t expect instant changes in child – improvement

(learning) often gradual• Continued support and contact for as long as necessary –

typically multiple school years and/or if deterioration• Program for maintenance and relapse prevention (e.g.,

school-wide programs, train all school staff, including administrators; train parent to implement and monitor).

• Reestablish contact for major developmental transitions (e.g., adolescence).

Components of Evidence-based Treatment for ADHD

Parent Training• Behavioral approach • Focus on parenting skills, child’s behavior, and family

relationships• Parents learn skills and implement treatment with child,

modifying interventions as necessary using ongoing functional analysis

• Group-based or individual weekly sessions with therapist initially (8-16 sessions), then contact faded

• Don’t expect instant changes in child – improvement (learning) often gradual

Why Is It Important to Include Behavioral Parent Training in ADHD Treatment?

• No one is taught how to be a parent.• Parents of ADHD children have significant stress,

psychopathology, and poor parenting skills.• ADHD children contribute greatly to parental stress and

disturbed parent-child relationships.• Parenting styles characteristic of ADHD parents predict and

mediate long-term negative outcomes for children.• Medication for the child has not been shown to improve these

domains.

Daily Report Card (DRC)

• An integral part of all school interventions• Effective in changing ADHD children’s behavior• Cost little and takes little teacher time• Provide daily communication between

teachers and parents• Provide positive reinforcement for a child that

has been singled out by peers• Downloads free at http://ccf.flu.edu

Daily Report Cards (2)

• Reduce the need for notes and phone calls • Once set up, reduce the time that a teacher

spends with a child• Provide a tool for ongoing monitoring of the

child’s progress• Can be used to titrate medications• Help give specific feedback and

rewards/consequences for behavior

Daily Report Card

Daily Report Card

Pharmacology

Swanson et al. Except Child 1993;60:154.

Symptoms Likely to Respond to Medication

• Inattention• Impulsivity• Hyperactivity

• Noncompliance• Impulsive aggression• Social interactions• Academic productivity and

accuracy

ANDCore Symptoms

Preschool medication use

• Must assess severity with rating scales, interfering with function (expelled from multiple pre-schools etc), hospitalization, multiple home placements

• Symptoms have persisted for at least nine months

• Must asses development impairment, safety risk, or consequences for school or home

Preschool Methylphenidate Study

• 165 children• Multi-site study• Increased risk of side effects at low doses• Doses start at methylphenidate 2.5 mg bid and

titrated in smaller increments.• Maximum doses have not been studied.

ADHD Preschool Medication

• Dextro –amphetamine in the only FDA medication approved for children 4 to 6 but the approval was based on less stringent criteria when approved

• Most evidence about the safety and efficacy of treating preschool children with stimulant medication is limited to methylphenidate

Stimulant Medications

• Medication choices depend on:– Targeted symptoms (ADHD symptoms, co-existing

conditions, areas of significant impairment)– Availability on formularies– Child’s individual response: efficacy vs.. side effects

• Research: McMaster report showed no differences comparing methylphenidate with dextroamphetamine or among different forms of each of these stimulants. Each stimulant improved core symptoms equally.

ADHDStimulants

• Amphetamine mixed salts (Adderall®) (Adderall XR)– contains equal parts d-amphetamine sulfate, d,l-amphetamine sulfate,

d,l-amphetamine aspartate, and d-amphetamine saccharate. (Vyvanse)

• Dextroamphetamine (Dexedrine®; DextroStat®)

• Methylphenidate (Ritalin®; Methylin®; Metadate®; Concerta®,

Ritalin LA, Metadate CD, Focalin, Focalin XR)

Stimulant Effects

• Stimulants last from 3 to 12 hours, with the best concentration at peak dose

• Rank order of duration of effect- Ritalin < Focalin < Dexedrine < Adderall < Ritalin LA < Adderall XR < Concerta

• If a child is taking medication, ask what time was there last dose

Stimulant Adverse Effects

• AEs are similar for all stimulants:– Decreased appetite– Insomnia– Headache– Stomachache– Irritability/rebound phenomena

• Rates of these AEs may be high prior to any medical intervention so baseline levels should always be obtained

Medication Titration Part I• Dosage amount:

– Begin with average starting dose (counsel family to expect no response)

– Should see result with first dose if working; allow child to stay on that dose for q3-7 days to track side effects

– Increase dose q3-7 days until significant decrease in symptoms & side effects minimal

– Ideal dose likely to be several mgs higher than 1st dose that makes a noticeable change

– Dosing is NOT related to child’s weight– NO laboratory tests are available to monitor dosage– Goal: highest possible dose which increases performance

and minimizes side-effects

Medication Titration Part II

• Dosage interval: – Interval should be based on the specific target outcomes– Goal is smooth control: give 2nd dose before 1st wears off– REMEMBER: Children vary in metabolism rate so will vary

in appropriate interval

Rationale for Non-stimulant Treatment of ADHD

• Stimulants and extremely effective, but:– Poor response or tolerability in some patients– Suboptimal response is not uncommon– Relative or labeled contraindications for some

comorbid conditions (e.g., tics, anxiety, substance abuse)

– Some patients will not take stimulants– Risk for diversion or abuse of Schedule II drugs

• Predominance of noradrenergic mechanisms among non-stimulant treatments

Unproved or untested treatmentsPlay therapy or talking psychotherapy

BiofeedbackDietary changes, elimination diets

Gingko biloba & other supplementsMeditation

ExerciseKarate/martial arts

CaffeineMetronome

Vision trainingSensory integration therapy

Summary- Evidence Treatment

• Use DSM IV criteria with functional impairment in two settings

• Parent training- Use always• School Interventions- Use always• Child interventions-Use when indicated• Medication-Use when needed

Where to find help

• AAP and pediatricians• AACAP• CHADD.ORG – a great website for

information and up to date research

Thank you

Questions???