Attention deficit hyperactivity disorder

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What is Attention-Deficit/Hyperactivity Disorder? Inattentive, hyperactive & impulsive to excessive degree compared with their peers.For more info, download the presentation.Babatunde Idowu Ogundipe M.D. M.P.H.Comprehensive Clinical Services P.C.October 7 2011


<ul><li> 1. Attention-Deficit/HyperactivityDisorderBabatunde Idowu Ogundipe M.D. M.P.H.Comprehensive Clinical Services P.C.October 7 2011</li></ul> <p> 2. What is Attention-Deficit/Hyperactivity Disorder? Inattentive, hyperactive &amp; impulsive toexcessive degree compared with theirpeers. Prevalence as high as 3%-10% of children&amp; 1%-6% adults in the U.S. High prevalence, global impairment, &amp;chronicity has lead CDC to identify it asserious public health problem since1999. Areas impairment children: Academic dysfunction. Social dysfunction &amp; skills deficits. Areas impairment adults: Occupational &amp; vocational Social impairment. High rates of motor vehicle accidents. 3. 4. Etiology Attention-Deficit/Hyperactivity Disorder Validity ADHD been established byresearch on neurobiological features: Functional MRI studies- activity infrontal striatal networks in ADHD vsactivity in anterior cingulate gyrusthose without ADHD. Positron Emission tomography decreased frontal cortical activityaffected adults + indicatedmethylphenidate increasesextracellular dopamine levels bymedscape.orgblocking dopamine transporter(DAT), particularly in striatum. Adultswith ADHD been found to have two-fold increase in DAT-binding potential. 5. Attention-Deficit/Hyperactivity Disorder Developmental Course Preschool: Children have difficulty with quiet, focused activities.Trouble cooperating with other children, engage in less play than peers&amp; have difficulty managing transitions. More noncompliant with adultrequests + are less socially skilled than children of same age. Elementary School: Continued conflict with peers. Trouble organizingschool-related tasks (i.e. doing homework &amp; keeping desk in order) +underachieve in school even when with intellectual potential to dowell. Adolescence: At school inattentive, hyperactive &amp; impulsive behaviors difficulties completing projects &amp; homework thus do not achieveacademic potential. At home have more conflict with parents than dothose without ADHD. Tend to be immature, get into trouble whenunsupervised, have poor social skills &amp; engage in high-risk activities(i.e. reckless driving, cigarette smoking, unprotected sex, marijuanause). 6. Attention-Deficit/Hyperactivity Disorder DiagnosisSteps in the diagnosis of attention-deficithyperactivity disorder (ADHD) in adults1. Assess current ADHD symptoms (within the last 6 months) using rating scaleswith adult norms.2. Establish a childhood history of ADHD.3. Assess functional impairment at home, work and school and in relationships.4. Obtain developmental history, including during prenatal, childhood and schoolyears.5. Obtain psychiatric history: rule out other psychiatric disorders or establishcomorbid diagnoses (e.g., learning disabilities, mood and anxietydisorders, personality disorders and substance abuse, especially marijuanaabuse).6. Obtain family psychiatric history, especially concerning learningproblems, attention and behavior problems, ADHD and tics. Enquire about allfirst-degree relatives (parents, siblings and offspring).7. Perform physical examination: rule out medical causes of symptoms(e.g., serious head injury, seizures, heart problems, thyroid problems) orcontraindications to medical therapy (e.g., hypertension, glaucoma). Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. 7. Attention-Deficit/Hyperactivity Disorder Diagnosis: AssessmentAsk the patient to indicate how often, using a 4-point scale (0 = never or not at all,1 = sometimes orsomewhat, 2 = often or pretty much or 3 = very often or very much), he or she has experienced thefollowing symptoms of ADHD in the past 6 months and whether they have persisted for at least 6 months:(1) Inattention Does not pay close attention to what he or she is doing and makes careless mistakes Has trouble paying attention to tasks Has trouble following verbal instructions Starts things but does not finish them Has trouble getting organized Tries to avoid doing things that require a lot of concentration Misplaces things Is easily distracted by other things going on Is forgetful(2) Hyperactivityimpulsivity Fidgets with hands or feet Has trouble sitting still Feels restless and jittery Has trouble doing things quietly Is a person who is on the go Talks too much Acts before thinking things through Gets frustrated when having to wait for things Interrupts other peoples conversations Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. 8. Attention-Deficit/Hyperactivity Disorder Diagnosis: AssessmentDiagnosisAll of the following criteria must be met for a diagnosis of ADHD:A. Six or more of the symptoms of either (1) or (2) above are rated as often orpretty much or very often or very much and have persisted for at least 6months. (For adults over the age of 50 years, only 3 or more symptoms ratedoften or very often are required to meet diagnostic thresholds.)B. Some symptoms of inattention or hyperactivityimpulsivity that causedimpairment were present in childhood.C. Some impairment from the symptoms is present in 2 or more settings (e.g., atwork, at school, at home, during leisure activities, when driving a car).D. There must be clear evidence of clinically significant impairment insocial, academic or occupational functioning.E. The symptoms do not occur exclusively during the course of a pervasivedevelopmental disorder, schizophrenia or other psychotic disorder and are notbetter accounted for by another mental disorder (e.g., mood disorder, anxietydisorder, dissociative disorder or personality disorder).The symptoms and diagnostic criteria are modified from the DSM-IV. Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. 9. A single 36-year-old woman is referred for a psychiatric evaluation to exploreoccupational and personal problems in her life. She reports that she has always hadproblems concentrating on her work, felt restless and acted impulsively (e.g., madecomments to people that she later regretted). She describes herself as chronicallydisorganized. She currently works as a computer technician and says that her workevaluations have indicated that she has often been late for meetings, made carelesserrors and disrupted her coworkers with her constant chatter. As for personalrelationships, she reports having had few friends. She suspects that she burnt outher friends with her high energy level and admits that her mind wanders duringserious conversations, leaving her friends feeling that she is selfish or does not care.Beyond these difficulties, the woman is in good physical health, with no history ofserious childhood illnesses. When asked about her childhood, she admits that shefrequently got into trouble for acting before thinking. Her report cards indicatedthat she was working below potential and that she had atrocious handwriting. Shewas eventually placed in a special class because she talked constantly and would notsit in her seat.Weiss, Margaret. Assessment and Management of Attention-DeficitHyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. 10. The patient reports that she has experienced 6 of the inattention symptoms and 7 of thehyperactivityimpulsivity symptoms of ADHD often or very often over the past 6 months.She reports having experienced all 18 symptoms in her childhood. Her roommate is asked torate her current behavior using the Adult Inventory4; this collateral information indicates thatthe patients behaviors are consistent with ADHD. No collateral informant is available to assessthe patients behavior in childhood; however, teachers comments on her report cards clearlyindicate a long-standing history of attention problems and disruptive behavior in school. Thepatient had a prior history of depression, although she is not depressed at the time ofassessment. Her presenting problems associated with ADHD existed before and after the onsetof her depression. Given the results of the assessment, her physician diagnoses ADHDcombined type (symptoms of both inattention and hyperactivityimpulsivity) and chooses acombination of medication and support to manage her symptoms. A trial of methylphenidate(15 mg orally, every 4 hours, 4 times during waking hours) is effective in reducing the severityof her symptoms, with mild appetite suppression and irritability as each dose wanes. Thepatient is switched to dextroamphetamine (15 mg orally twice daily) to improve compliance. Atwork, the patient requests assignments that are interesting but challenging, instead of rotetasks that she finds boring and tedious. Socially, she monitors the physical distance betweenherself and others so that she can behave more appropriately. To improve her organizationalskills, she learns how to use an electronic planner. Two years after the diagnosis, the patient isproud that she is still employed with the same company and is better able to form and maintainfriendships. Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. 11. Assessment of patients developmental historyPrenatal Did your mother use drugs, nicotine or alcohol when she was pregnant with you? Do you know if there was difficulty during pregnancy or childbirth such as diabetes, eclampsia, cord around the neck, breech delivery or lack ofoxygen?Childhood Were you described as a very active or impulsive child? Did your parents complain that you were difficult? Did you have any accidents requiring hospital treatment as a child? Were you exposed to any physical, verbal or emotional abuse? Were you neglected? Did you have any serious trauma, exposure to violence or losses as a child? Did you have any medical illnesses as a child? Did you ever lose consciousness?School How did you do academically in elementary school? In high school? Were you ever enrolled in college or university? Did you drop out? Why? Did you ever fail a grade? Did you ever have psychological testing or were told you had a learning disability? Did you receive learning assistance or were you ever placed in a special class? Were you ever suspended or expelled from school? Did you have any special problems with reading? Arithmetic? Writing? Did teachers complain that you were not achieving your potential or were not trying your best? Was your performance at school variable or unpredictable?Family psychiatric historyHave your parents, siblings or children had any of the following problems? ADHD Depression Anxiety (worrying, fears, extreme embarrassment in front of people, repetitive behaviors that do not make sense) Psychosis (hearing voices, seeing things, or having fixed, wrong ideas) Tics (involuntary and repetitive movements or sounds) Substance abuse or alcoholism Learning disability Behavior problems or problems with the law Suicide attempt or self-destructive behaviorWeiss, Margaret. Assessment and Management of Attention-DeficitHyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. 12. Attention-Deficit/Hyperactivity Disorder Management Treatment c/o 3 parts: (1)Education on ADHD +psychological support to the patient&amp; family. (2) Medication. (3) Follow up and continued support. Medication 1st line for ADHD &amp;effective &amp; safe in adults &amp; children: First Line: Stimulants Second Line: Tricyclic Antidepressants Bupropion Atomoxetine 13. MedicationDose Durati Schedule Rate Adverse Events ADR management on (h)titrationFirst Line: Start at 5-3.53-4 x/day0.5- Decreased appetite,Discuss dietary needsMethylphenidate 10mg PO BID, 1.0mg/kg insomnia,Decrease late day dosing;switch tomax 80mg/d daily long acting medication;discuss sleep hygiene.Headache (few wks only)If headache severe consider change of dose or switch to anotherDextroamphetamStart at 5mg 52-3x/day 0.5mg/kgstimulant/medine PO oncedaily or 5mg nervousness/dysphoriaConsider use of antidepressant; r/odaily BID,qweek.comorbid disordermax 40mg/dSecond Line:Start at 24 Every25-50mgConstipation High-fiber dietDesipramine or50mg/d, max nightevery week Dry mouthAdvise no drinks sweetened with sugarImipramine200mg/d+ get regular dental check ups.(response after 4weeks)Postural hypotension Advise to get up slowlyTachycardia /arrhythmiaLower doseDrowsiness(1st few days)Bupropion SRStart at 12 2x daily 50mg every Seizures Keep doses within recommended max,(response after 5 100mg in am,(8h apart) weekensure max 8h between doses; avoidweeks)max 15om use in patients at risk seizures i.e.BIDeating disorder, alcohol abuse, h/o seizureInsomnia Take earlier in day/ single dose in amHeadache Adjust doseAtomoxetine daily Decreased appetite/wgtloss (early only) 14. References FIRST AID for the USMLE 3, Tao Le, Vikas Bhushan, Robert W.Grow, Veronique Tache. Psychiatry History Taking. Third Edition. A Current ClinicalStrategies medical book. Alex Kolevzon, Craig L.Katz. Barkley, Russell. A. Adolescents with Attention-Deficit/Hyperactivity Disorder: An Overview of Empirically BasedTreatments (2004). Journal of Psychiatric Practice, 10:1, 39-56. Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722. Spencer, Thomas al. Overview and Neurobiology of Attention-Deficit/Hyperactivity Disorder (2002). Journal of ClinicalPsychiatry, 63, 3-9. Brown, Ronald T. et al. Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the Evidence (2005).Pediatrics, 115, 749-757.</p>


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