Beyond ADHD: Treating Children with Co-occurring Conditions

1
Beyond ADHDTreating Children with Co-occurring
Conditions

• S. Steve Snow. MD
• Doug Emch MD
• Child Psychiatrists- Nashville, TN

2
Professional Affiliations

• Private Practice, Child/Adolescent/Adult
  Psychiatry.
• Belle Meade Office Park, 4535 Harding RD
• Nashville TN 37205 (Emch and Snow).
• Clinical Professor of Psychiatry, Vanderbilt
  University (Snow)
• Child/Adolescent Psychiatrist, Centerstone Mental
  Health Centers (Emch)
• Child/Adolescent Psychiatrist, Namaste, Inc.
  (Emch)
• Child Adolescent Psychiatrist, Teambuilders
  Counseling Services, Inc. (Emch)

3
Disclosures

• Speakers Bureaus Eli Lilly and Novartis
  Pharmaceutical Companies (Snow)
• Preparation of the presentation received no
  commercial support
• Off-label uses of medications, such as lack of
  approval for specific diagnosis or certain ages,
  as frequently used by psychiatrists, will be
  included.

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Learning Objectives

• Review diagnostic guidelines for Attention
  Deficit Hyperactivity Disorders (DSM-IV-TR)
• Identify common co-occurring conditions with
  ADHD, and disorders which mimic ADHD
• Update pharmacotherapy for ADHD and its
  co-occurring disorders

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Presentation Outline

• ADHD
• Mimicry
• Comorbid Conditions
• Pharmacotherapy
• Questions?

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ADHD

• Inattention

• Careless
• Inattentive
• Not listening
• Poor instructions

• Disorganized
• Avoids
• Loses things
• Distracted
• Forgetful

Hyperactivity

• Fidgets
• Out of seat
• Climbs/runs

• Loud
• On the go
• Talkative

Impulsivity

• Blurts out
• Impatient
• Interrupts

7
ADHD Subtypes

• Predominantly Inattentive (20-30)
• Predominantly Hyperactive/Impulsive (lt15)
• Combined hyperactive-impulsive and inattentive
  (50-75)

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Etiology

• Genetic
• Heritability about 76
• Complex - Chromosomes 4,5,6,8,11,16,17
• Non-Genetic
• Perinatal stress and low birth-weight
• Traumatic brain injury
• In utero substance exposure
• Trauma
• Society?

Farone, Molecular Genetics of ADHD, Biol
Psychiatry 571313-1323 (2005)
9

FCC All Programming To Be Broadcast in ADHDTV
by 2007

• in accordance with the ADHDTV standard, that all
  shows be no more than six minutes in length, and
  that they contain jarring and unpredictable
  camera cuts to shiny props and detailed
  background sets

10
Prevalence

• 1-20 of child/adolescent population (5-8)
• Account for 30-50 of child referrals to mental
  health services
• 4-5 of adult population
• MalesFemales 91 ? 41 ? 21

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Mimicry

• Learning disorders
• Hypoglycemia/Diabetes
• Hypo/hyperthyroidism
• Allergies
• Hearing/vision problems
• Toxicity (lead, mercury)
• Epilepsy
• Nutrient deficiencies
• Anemia
• Sensory integration dysfunction

• Anxiety disorders
• Bipolar/depression
• Trauma/PTSD
• Attachment disorders
• Sleep disorders
• Infections
• Pain
• Traumatic Brain Injuries
• Fetal Alcohol Syndrome
• Substance abuse
• Family problems

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Comorbidity

• Almost 3/4s of individuals with ADHD have a
  psychiatric comorbidity
• Conduct Disorder (10-20)
• ODD (54-84)
• Substance Abuse (40)
• Anxiety Disorders (30-40)
• Affective Disorders (20-30)
• Learning Disorders (_at_ 33-60)
• Tic Disorders (34)
• Developmental Disorders (?)
• Sleep disorders (25-50)

13
Academic Impairment

• Very well documented
• Failure to perform academically is the single
  most common source of referral for children and
  adolescents
• Children with ADHD
• Perform poorly on achievement tests and fail
  grades / courses significantly more often than
  children without ADHD
• Complete 3 fewer years of education than matched
  controls
• More likely not to graduate from high school
  (35)
• Academic impairment more profound when learning
  disabilities are present

Weiss Hechtman Hyperactive Children Grown Up
1993 Manuzza Klein The Economics of
Neuroscience, 200147-53
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Social Function

• Social problems begin in childhood, persist into
  adolescence
• Fewer friends, more limited social skills
• Lower self esteem on assessment scores
• 3Xs as likely to have trouble getting along with
  peers
• ½ as likely to have good friends
• 2Xs as likely to get picked on by peers
• 3Xs as likely to have problems that limit after
  school activities

Suppl. JAACAP Practice Parameters for Use of
Stimulant Medications 20024126S-49S I.M.P.A.C.T.
SurveyNYU Child Study Center2001
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Sexual Behaviors

• Longitudinal follow-up of cohort of 160 children
  with ADHD shows
• More unprotected sex gt50 tested for HIV
• 0 in the control group
• Of 43 children born to study participants, 42
  were born to those in the ADHD group
• Limiting their academic and occupational
  attainment
• 54 of these had lost custody of the children

Barkley. Attention 19968-11
16
Criminality

• ADHD has high comorbidity with ODD and CD
• Coupled with an impulsive, high risk lifestyle
• increases risk for legal problems
• Patients with ADHD more likely to be
• Arrested (39 vs. 20)
• Convicted (28 vs. 11)
• Jailed (9 vs. 1)

Biederman et. al. Arch Gen Psychiatry
199653,437 Manuzza et. al. Arch Gen Psychiatry
198946,1073
17
Oppositional Defiant DisorderODD

• Pattern of negative/hostile/defiant behavior
• Loses temper
• Argues with adults
• Defies adults requests/rules
• Deliberately annoys others
• Blames others
• Touchy/annoyed easily
• Angry/resentful
• Spiteful/vindictive

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Conduct Disorder

• Aggression to people and animals
• Destruction of Property
• Deceitfulness, lying, stealing
• Serious violation of rules

19
TICs

• Transient Tic
• Chronic Motor or Vocal Tic
• Tourettes (Motor and Vocal)

20
Sleep Requirementsper 24 hours

• Infant to 6 months 16-20 hours
• 6mo to 2 yrs roughly 15 hours
• 2 to 6 yrs 10-12 hours
• Grade School (7 to 13 yrs) 9 to 11 hours
• High School (14 to 18 yrs) roughly 9 to 10
  hours (may vary greatly day by day)

Dr. Scott Shannon Please Dont Label My Child
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Anxiety Disorders

• Generalized
• Separation
• Obsessive-Compulsive
• Specific Social Phobia
• Panic
• Stress Disorders/PTSD

22
Affective Disorders

• Depression
• Dysthymia
• Cyclothymia
• Bipolar

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Depression

• Prevalence
• 2 Children
• 4-8 Adolescents
• Malefemale 11 ? 12
• 20 cumulative incidence by 18
• 5-10 children/adolescents subsyndromal

JAACAP Practice Parameter 4611, Nov 2007
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Depression

• 2 weeks of (5)
• Depressed mood or irritability, or
• Loss of interest/pleasure
• Wt change (failure to thrive)
• Sleep changes
• Psychomotor agitation/retardation
• Fatigue
• Feeling worthless/guilty
• Poor concentration/indecisiveness
• Recurrent thoughts of death or suicide

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Dysthymia

• Depressed mood or irritability on most days for
  most of the day for 1 year
• Plus
• Changes in appetite or weight
• Changes in Sleep
• Problems with decision making or concentration
• Low self-esteem, energy, hope

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Juvenile Bipolar Disorder

• Adult criteria in DSM none for youngsters
• Severe type of mood disorder manic-depressive
  illness
• Episodes of mania, major depression, or both,
  often with psychosis
• Mania includes hyperactivity, which can mimic
  ADHD, but also elation, grandiosity, and flight
  of ideas may not sleep for days
• Irritability and rapid speech seen with both
• Depression often very severe, sometimes mixed
  with mania can be suicidal, psychotic, even look
  catatonic
• Key is an up and down course, with children and
  teens often cycling very rapidly, unlike most
  adults

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Developmental Problems and Substance Abuse

• Many types of underlying developmental disorder,
  as well as external factors such as illicit
  substance use, and complicate or mimic ADHD
• Autistic Spectrum Disorder overrides and
  presumably includes ADHD, under current DSM
  guidelines, although frequently ADHD sx are
  marked in these pts and the target of Tx
• Cocaine, methamphetamine and other stimulant
  abuse can mimic ADHD sx, but even marijuana and
  other CNS-depressant substances can result in
  dreamy, off-task school performance

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Developmental Disorders

• Co-occurring developmental disorders are the rule
  with ADHD, but may not be medication targets and
  require specialized learning approaches
• Mental Retardation, of varying degrees of
  severity, may be changed to Intellectual
  Disability or similar term in DSM-V.
• Learning Disorder include Reading, Math and
  Written Language disabilities
• Developmental Coordination Disorder may produce
  problems in sports, predispose to minor injuries,
  but also be a target of teasing or hazing

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Developmental Disorders (cont)

• Communication Disorders include both expressive
  and receptive language disabilities, as well as
  Phonological (Articulation) disorders and
  Stuttering
• Elimination Disorders include enuresis or
  encopresis and may require both medical and
  behavioral intervention
• Tic Disorder are specified as transient, chronic
  motor or vocal and Tourettes Syndrome most
  individuals with Tourettes have parallel ADHD sx
  and often OCD, as well stimulants may exacerbate
  tics and RX may be complex
• Haloperidol (Haldol) and pimozide (Orap) are
  problematic older drugs, age 12 and older for
  pimoxide, but atypical agents as will be
  discussed for bipolar disorders are used
  off-label for severe T.S.

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Treatment
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Medications for ADHD

• Stimulants
• methylphenidates, amphetamines
• Alpha-agonists
• Clonidine, Tenex, Intuniv, Kapvay
• NE/DA Active Antidepressants
• Wellbutrin
• Strattera
• Provigil/Nuvigil
• Tricyclic Antidepressants

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Duration of Action

• 2-5 hours
• methylphenidate (MPH) (Ritalin) (1-4 hrs)
• d-MPH (Focalin) (1-4 hrs)
• d-amphetamine (Dexedrine) (1-6 hrs)
• Amphetamine-dextroamphetamine (Adderall) (4-6hrs)
• 5-8 hours
• methylphenidate SR (Ritalin SR) (3-8 hrs)
• methylphenidate ER (Metadate ER, Methylin ER)
  (3-8 hrs)
• d-amphetamine (Dexedrine Spansules) (6-8 hrs)
• extended release MPH (Ritalin LA Metadate CD)
  (6-8 hrs)
• 10-12 hours
• methylphenidate (Concerta) (10-12 hrs)
• dexmethylphenidate (Focalin XR) (10-12hrs)
• Methylphenidate transdermal (Daytrana) (9-12)
• amphetamine-dextroamphetamine (Adderall XR)
  (10-12 hrs)
• lisdexamfetamine (Vyvanse)- (12-14hrs)

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Stimulant Side Effects

• Delay of sleep onset
• Reduced appetite
• Weight loss
• Tics
• Stomach ache
• Headache
• Jitteriness

• But not necessarily
• Staring
• Daydreaming
• Irritability
• Anxiety
• Nail biting

Suppl. JAACAP Practice Parameters for Use of
Stimulant Medications 200241,229S
34
Diet

• Issues with sugars and dyes
• Citric Acid and Ascorbic Acid
• Citrus fruits, juices
• Coke, Diet Coke, Dr. Pepper, AW Root Beer
• Not the clear, yellow, or red drinks
• Cereals, MVI
• Anything in foil wrappers
• High fat diets

35
Medications for ADHD

• Stimulants
• methylphenidates, amphetamines
• Alpha-agonists
• Clonidine, Tenex, Intuniv, Kapvay
• NE/DA Active Antidepressants
• Wellbutrin
• Strattera
• Provigil/Nuvigil
• Tricyclic Antidepressants

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Antidepresants

• SSRIs
• Fluxoetine (Prozac), Sertraline (Zoloft),
  Citalopram (Celexa), Escitalopram (Lexapro),
  Paroxetine (Paxil), Fluvoxamine (Luvox)
• SNRIs
• Venlafaxine (Effexor), Desvenlafaxine (Pristiq),
  Duloxetine (Cymbalta)
• NE/DA
• Buproprion (Wellbutrin)

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Antidepressants (cont)

• Tricyclics
• Imipramine (Tofranil), Amitriptyline (Elavil),
  Clomipramine (Anafranil)
• Other
• Trazodone, Remeron

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SSRI Side Effects

• Common
• sleep changes
• restlessness
• headaches
• akathisia
• appetite changes
• sexual dysfunction

• 3-8 youths
• impulsivity
• agitation
• irritability
• silliness
• behavioral activation

Black Box Warning Suicidality
JAACAP Practice Parameter 4611, Nov 2007
39
Anxiolytics

• SSRIs
• Prozac, Zoloft, Celexa
• Buspar
• Neurontin
• Strattera?
• Benzodiazepines
• Valium, Klonopin, Ativan

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Pharmacotherapy of Bipolar Disorder

• Lithium carbonate, typically from 150 mg to
  450mg, one to two tabs or caps, up to BID often
  in controlled-release form
• FDA approval ages 12-17 many side effects,
  including tremor, thirst and somnolence lab
  needed to monitor Li levels, electrolytes, renal
  and thyroid studies
• Calms mania and helps prevent mood excursions,
  but not very effective for depression
• Less likely now to be the first agent prescribed

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Bipolar TreatmentAnticonvulsants

• Anticonvulsant mood stabilizers
• Commonly prescribed, approvals for pediatric
  epilepsy, but not for mood problems
• Valproic Acid (Depakote) has adult bipolar
  indication dose range 125mg BID to as much as
  750mg BID, or more may cause drowsiness or
  ataxia lab monitoring for serious liver,
  pancreatic or heme A.E.s
• Lamotrigine (Lamictal) also has adult bipolar
  indication dose range 25mg BID to 150mg BID, or
  more usually well-tolerated and no blood
  monitoring, but rare toxic rashes, and very slow
  acclimation

42
Anticonvulsants (cont)

• Oxcarbamazepine (Trileptal) does not have an
  indication for mood disorders, adult or children,
  but has had considerable clinical use, and
  largely replaced carbamazepine (Tegetol) usually
  tolerated except for sedation and hyponatremia,
  though not usually a problem dosed 150mg BID up
  to 600mg BID or more
• Topiramate (Topamax) also used off label in doses
  of 50-100mg BID, up to 200mg BID or more, but may
  cause some cognitive difficulties, such as
  anomia, and predispose to renal stone formation
• Gabapentine (Neurontin) used off label in doses
  of 100mg BID or TID, to as much as 600mg TID or
  more some initial fatigue, like other agents,
  but generally well-tolerated and does not
  interact much with other drugs

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Bipolar TreatmentAtypicals

• Atypical neuroleptics, such as Risperidone,
  Aripiprazole, and Olanzepine have mostly replaced
  older agents, such as Haloperidol and
  Thioridazine, so-called typical neuroleptics
• Risperidone (Risperdal) in doses from 0.25mg BID,
  all the way to 4mg BID, or more, treat mania and
  stabilize bipolar episodes approved in children
  and adolescents ages 10 and up for mania can
  cause significant weight gain, sedation,
  prolactin stimulation and other adverse effects
• Aripiprazole (Abilify) approved ages 10-17 and
  used in doses of 2mg daily up to a maximum of
  30mg per day, often in divided doses generally
  not as much weight increase, but may cause
  restlessness and dystonias does not elevate
  prolactin

44
Atypical Antipsychotics (cont)

• Olanzepine (Zyprexa) is a potent anti-psychotic,
  with concerns of weight gain and subsequent
  metabolic problems, but does have an approval for
  bipolar 1 disorder, ages 13-17 dose ranges from
  2.5 to 30mg, or more
• Quiatepine (Seroquel) is not approved in children
  or adolescents, but used for insomnia of bipolar
  disorders, and for psychosis and mood stability
  in higher doses, range from 25 to 800mg or more,
  off label. Sedation and wt gain as S.E.s
• Ziprasidone (Geodon), also non-approved in kids,
  but sometimes used because of wt. gain from other
  agents, or sedation from other agents more
  concern in children of QT prolongation on EKG
  more EPS and akathisia does not raise prolactin
  levels

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Parent Medication Guide

• Newly revised guide for Depression in children
  and adolescents
• Comprehensive guide to ADHD Rx nice discussion
  of conditions that accompany and/or show the
  same type of sx
• Joint project of American Psychiatric Association
  and American Academy of Child and Adolescent
  Psychiatry
• Available at ParentsMedGuide.org
• Slides available at www.emchpsychiatry.com

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?
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Dopamine

• Enhances signal
• Improves attention
• Focus
• Vigilance
• Acquisition
• On-task behavior
• On-task cognition

Nigrostriatal Pathway
Mesolimbic Pathway
Substantia nigra
Mesocortical Pathway
Ventral tegmental area
Solanto. Stimulant Drugs and ADHD. Oxford 2001.
48
Norepinephrine

• Dampens noise
• Decreases shifting
• Executive operations
• Increases inhibition
• Behavioral
• Cognitive
• Motoric

Locus ceruleus
Solanto. Stimulant Drugs and ADHD. Oxford 2001.