ADHD: Diagnosis and Management

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ADHDDiagnosis and Management

• Christine L. Johnson, MD
• Maj, USAF, MC
• Assistant Professor of Pediatrics
• Education Section
• Uniformed Services University of the Health
  Sciences
• March 8 and April 12, 2001

2
ADHDOverview

• What is ADHD?
• How do you diagnose and treat ADHD?
• What do you need to consider in the differential
  diagnosis of ADHD?
• What comorbidities should you be aware of?

3
ADHDDefinition

• Attention Deficit Hyperactivity Disorder is a
  persistent pattern of inattention and/or
  hyperactivity that is more frequent and severe
  than is typically observed in individuals at a
  comparable level of development.
• DSM IV

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ADHDBackground

• First described systematically by George Still in
  1902
• There have been 25 different name changes for the
  clinical symptom complex
• A specific neuroanatomic, physiologic,
  biochemical or psychologic origin has not been
  identified, despite extensive investigation
• 5-10 prevalence in the US
• 41 boys to girls for hyperactive-impulsive and
  21 for inattentive type
• Intense public scrutiny
• Many controversial alternative treatments have
  flourished without scientific evidence of
  clinical benefit
• Basic diagnostic and treatment approaches have
  changed little over the past 20 years

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ADHDTimeline

• 1902 defect in moral control
• 1930-1950s Minimal Brain Damage- looked at
  history of toxins, injuries, etc
• 1950-1960s Minimal Brain Dysfunction- recognized
  most individuals had no evidence of damage,
  also coined hyperkinetic reaction of childhood
• 1960s Use of stimulant medications became
  widespread, although use since 1930s was
  recognized to improve symptoms
• 1970s Renamed ADD/ADHD
• 1980-1990s Investigation of processing problems

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ADHDGenetics

• ADHD has long been recognized to run in families
• 1st and 2nd degree relatives are at highest risks
• Concordance rates are higher in full siblings
  than ½ siblings and in monozygotic than dizygotic
  twins
• Research is ongoing on 3 associated genes

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ADHDEnvironmental

• Toxins lead, alcohol, cigarette smoke can
  contribute to ADHD symptoms
• A small proportion of children are affected by
  food additives and allergenic whole foods
• Studied but not proven Iron deficiency,
  deficiency in essential fatty acids, Zinc and
  other minerals

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ADHDMedical Assessment

• Detailed History, comprehensive Physical Exam,
  functional neurodevelopmental assessment
• There are no confirmatory lab tests
• Rating scales from different sources (useful as a
  normative database and useful for monitoring
  treatment)

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ADHDAssessment

• Parent and Child Interviews
• Consider using DSM-IV symptom checklist
• General Past Medical History with attention to
  Birth History and trauma
• Specific queries about Family History of ADHD,
  other psychiatric disorders, neurologic disorders
  and psychosocial adversity
• Medications ( RX, OTC, illicit substances),
  Social History, Developmental History
• Parent completed rating scales

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ADHDAssessment

• School-Related Assessment
• Obtain reports of behavior, learning, attendance,
  grades and test scores
• Psychoeducational testing is indicated to assess
  intellectual ability and to r/o learning
  disabilities
• Review IEP if applicable
• Teacher completed rating scales

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ADHDRating Scales

• Parent and teacher rating scales yield valuable
  information efficiently
• Comparison with normative groups by age and sex
  can help distinguish normal variants in level of
  attention, activity, and impulse control from
  ADHD
• The broad-spectrum scales can be used to screen
  for co-morbidities

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ADHDRating Scales

• Commonly Used and Best Validated
• Child Behavior Checklist (Achenbach)
• Conners Parent and Teacher Rating Scales
• ACTERS Teacher and Parent Rating Scales

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ADHDPhysical Exam

• Comprehensive Physical Exam
• General Observation of behavior and interactions
• Exam Growth parameters and plot on growth curves
• Vital signs to include blood pressure
• Vision and hearing screens
• Physical exam including neurologic exam

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ADHDDSM-IV

• ADHD-H ADD with predominant hyperactivity and
  impulsivity
• ADHD-I ADD with predominant inattentiveness
• ADHD-C ADD combined type with both
  hyperactivity and inattention

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ADHDDSM- IV

• In order to diagnose ADD, the clinician must
  also ascertain the following
• Onset before age 7 years
• Behaviors present for at least 6 months
• Functional impairment must be present in two or
  more settings
• The exclusion of pervasive developmental
  disorder, schizophrenia, mood and anxiety
  disorders, mental retardation, and learning
  disability

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ADHD Differential Diagnosis

• Medical
• Sleep Apnea
• Substance Use
• Developmental Disorder- Learning disability,
  cognitive dysfunction, fragile x, fetal alcohol
  syndrome etc.
• Other medications
• Seizure disorder (Absence)
• Thyroid abnormality

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ADHDDifferential Diagnosis

• Psychologic/ Psychiatric
• Mood Disorder
• Psychotic Disorder
• Adjustment Disorder
• Anxiety Disorder
• Learning and Language Deficits
• Stress

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ADHDComorbidities

• 45 of children with ADHD have 1 comorbid
  condition
• 30 have 2 comorbid conditions
• 10 have 3 comorbid conditions
• Common comorbid conditions include ODD, Anxiety,
  Learning Disability, Mood, Conduct, Smoking,
  Substance Use and Tics

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ADHDAssociated Conditions

• Cognitive Deficits
• Impaired Adaptive Function
• Motor Development Deficits
• Impaired Task Performance
• Medical Problems (h/o trauma, prematurity, sleep
  disturbances)

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ADHDClinical Management

• Fit treatment to the patient
• Educate parents and patients regarding ADHD
• Discuss behavioral treatment
• Medication management
• Ensure educational support

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ADHDMedications

• Psychostimulants
• Methylphenidate (Ritalin)
• Methylphenidate HCL (Concerta)
• Dextroamphetamine (Dexedrine)
• Dextro and Levoamphetamine (Adderall)
• Pemoline (Cylert)

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ADHDMedications

• Anti-Depressants
• Tricyclic anti-depressants- Usually a second
  line alternative treatment for 10-20 of patients
  unresponsive to any psychostimulants. Maximal
  benefits are primarily observed in depressed or
  angry patients. Potential for lethal overdose.
  Need for screening labs and EKG.
• Imipramine
• Desipramine

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ADHDMedications

• Anti-Depressants
• SSRIs May be preferred adjunctive therapy for
  depressed adolescents with ADD even though they
  have not been approved for an ADD indication.
• Sertraline (Zoloft)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)

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ADHDMedications

• Anti-depressants
• Bupropion (Wellbutrin)- an anxiolytic drug that
  blocks uptake of serotonin and norepinephrine.
  Occasionally prescribed for off-label
  non-responders. May exacerbate tics.

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ADHDMedications

• Anti-hypertensives
• Clonidine (Catapres)- alpha-adrenergic agonist of
  particular benefit in patients who are
  hyperaroused, extremely overactive and those with
  ODD or conduct disorder. Occasionally used at
  bedtime to counteract insomnia of stimulants.
  May cause hypotension and should be withdrawn
  slowly to avoid rebound hypertension.
  Transdermal patches may enhance compliance.

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ADHDStimulant Dosing

• Ritalin SR 20mg for slow release
• Dexedrine Spansule available for slow release

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ADHDStimulants

• Of 70 of children with ADHD
• 1/3 respond to Ritalin
• 1/3 respond to Adderall
• 1/3 respond to Dexedrine
• Trial of multiple psychostimulants may be
  warranted
• Idiosyncratic dosing is not dependent on weight

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ADHDStimulants

• Frequent Side Effects
• Decreased appetite
• Insomnia
• Anxiety
• Irritability
• Emotional lability
• Abdominal pain
• Headaches

• Infrequent Side Effects
• Mood disturbance
• Tics
• Nightmares
• Social withdrawal

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ADHDStimulants

• Long term use of stimulants may increase heart
  rate, blood pressure but these increases do not
  approach clinical significance
• Children treated with stimulants are at no higher
  risk for substance abuse than their untreated
  peers with ADHD
• In children for whom behavior problems are
  cross-situational, stimulants must be considered
  on a daily basis. Consider drug holidays during
  summer if height and weight is of concern
• Careful clinic follow-up is recommended every 3-4
  months
• Recommend treatment be discontinued on an annual
  basis for a short period of time during the
  school year to assess behavior and symptoms

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ADHDBehavioral Management

• The main emphases in parent training are on
  understanding the antecedents of undesirable
  behaviors, modifying the environment to alter
  those antecedents, and establishing positive
  incentives before using punishment.
• Emphasis on quality attention to positive
  behaviors.
• Teach appropriate use of time out and other
  disciplinary methods
• Enable parents to create an environment that
  maximizes the childs potential to behave
  appropriately

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ADHDBehavioral Management

• Discuss use of structure and routine and
  minimizing distractions
• Suggest the use of an assignment sheet or day
  planner to be reviewed by teachers and parents
• Consider a second set of textbooks at home
• Family psychotherapy may be indicated to address
  family dysfunction
• Consider to a parent support group if available

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ADHDEducational Placement

• Federal law PL 94-142 (1975 Education for All
  Handicapped Children Act) requires school systems
  to test any child within 30 days after a written,
  signed request has been presented to them
• Section 504 of the Rehabilitation Act requires
  that children who are underperforming relative to
  their expected level should receive classroom
  modifications to improve their academic progress

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ADHDEducation Placement

• Modifications may include appropriate classroom
  placement, resource education, additional time
  for taking tests, not penalizing for misspelling
  or neatness, and additional instruction,
  including supplemental auditory learning and
  computer time
• Under the Individual Disabilities Educational
  Act, ( PL101-476), these patients may further
  qualify for special education assistance in
  organization, work completion, listening,
  planning and following directions

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ADHDAlternative Treatments

• Publications on alternative treatments for ADHD
  are sparse in the peer-reviewed literature, but
  abound in the popular press.
• Practitioners must be prepared to provide
  accurate information and answer questions

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ADHDAlternative Treatments

• Dietary Management
• Feingold Diet- Dr. Ben Feingold, in 1975,
  contended that artificial colors, flavors and
  preservatives as well as naturally occurring
  salicylates were the primary cause of ADHD.
  Studies showed only 1 with consistent
  improvement after strict elimination diets.

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ADHDAlternative Treatments

• Sugar
• Prinz hypothesized that the positive effects of
  the Feingold diet may have been due to it higher
  protein-sugar ratio rather than to salicylates
  and additives.
• Multiple well-designed studies discounted his
  theory and showed no significant behavioral
  effects of sugar in either normal or ADHD study
  populations.

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ADHDAlternative Treatments

• Aspartame
• Aspartame appeared on the market in 1981 and was
  used as a placebo in many of the studies on the
  effects of sugar on behavior. No independent
  neurologic, metabolic, or behavioral-cognitive
  effects related to aspartame have been found.

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ADHDAlternative Treatments

• The Yeast Connection
• Dr. William Cook, an allergist and pediatrician,
  claimed a success rate in reducing hyperactive
  behavior in his patients with ADHD using strict
  elimination diets
• He maintained that frequent antibiotic treatment
  results in chronic candidiasis and candida toxin
  production. This is responsible for metabolic
  and behavioral disturbances including
  hyperactivity, irritability, and learning
  disorders
• His treatment included oral antifungal agents and
  a diet strictly eliminating sources of sugar and
  any foods made with molds and yeast
• His claims are based on experience and have not
  been scientifically validated

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ADHDAlternative Treatments

• Megavitamin therapy
• Children who initially were noted to have
  improved classroom attention while on
  megavitamins in an open trial, did not show any
  improvement in the double blind cross over
  placebo control phase
• In fact, they showed 25 more disruptive behavior
• 4 had elevation of liver enzymes
• Therefore, Megavitamins are of little benefit in
  treating ADHD, and may cause harm

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ADHDAlternative Treatments

• Iron
• Symptoms of iron deficiency anemia include
  decreased attention, arousal, and social
  responsiveness. Iron deficiency should be
  suspected on the basis of dietary history and
  then verified. There is no indication form iron
  supplementation in non-deficient individuals.

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ADHDAlternative Treatments

• Magnesium- a required co-factor of many enzyme
  systems. Only isolated reports of improvement
  with supplementation.
• Pyridoxine- essential for neurotransmitter
  synthesis and normal brain development. Some
  studies suggest behavior improvement, but no
  replication has proven link.
• Zinc- essential for normal growth, immune
  functions and neurologic development. No good
  controlled studies have been performed. Zinc is
  potentially toxic and not indicated in the
  absence of deficiency.

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ADHDAlternative Treatments

• Essential Fatty Acids- Linoleic and Linolenic
  acid are essential to brain development and
  neuronal functioning. Role in ADHD is unclear
  and still being studied.
• Anitoxidants and Herbs- Most of these agents are
  used in folk and traditional medicine. None have
  been studied systematically in ADHD. (e.g.
  Pycnogenol,melatonin, gingko biloba, chamomile,
  kava, hops, valerian, lemon balm and passion
  flower) Caution should be used because of
  possible potentiation of effects. No clinical
  trials have proven there effectiveness in ADHD

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ADHDAlternative Treatments

• Vision Therapy and Oculovestibular Treatment-
  Impairment in visual acuity, oculomotor function
  and visuospatial perception has been implicated
  in the etiology of dyslexia and secondary
  attention problems. Introduction of lenses have
  anecdotally shown improvements, but any concerns
  regarding a childs vision should prompt a
  referral to an ophthalmologist

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ADHDAlternative Treatments

• Homeopathy- based on the concept of vital
  energies and using dilutions of plant, animal
  and mineral extracts to restore those energies.
  Widespread use in Europe, but unknown mechanisms
  of action. Therefore, more studies are needed.
• Auditory Stimulation- Tomatis method of sound
  training uses high frequency modifications of
  human voice and music. Requires 75 sessions and
  no controlled studies have shown improvement.
• Biofeedback- methods of hypnotherapy, relaxation,
  and biofeedback are most effective when
  integrated into a multimodal treatment plan.

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ADHDReferences

• Conners' Rating Scales, Toronto, MultiHealth
  Systems, 1997 Tel
  800-456-3003
• Achenbach, Child Behavior Checklist, 1
  South Prospect Street, Burlington, Vt.
  05401-3456, Tel [phone]

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ADHDReferences

• American Academy of Child and Adolescent
  Psychiatry Practice parameters for the
  assessment and treatment of children, adolescents
  and adults with attention-deficit/hyperactivity
  disorder. J Am Acad Child Adolesc Psychiatry 36
  (suppl 10)085S-121S, 1997
• Pediatr Clin North Am 45, Oct 1998
• Pediatr Clin North Am 46, Oct 1999
• Pediatric in Review, Vol 21, Number 8, Aug 2000

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ADHDReferences

• www.aap.org
• www.chadd.org
• www.pedsedu.com