Attention Deficit Hyperactivity Disorder

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Attention Deficit/ Hyperactivity Disorder

• Dennis L. Hufford, CDR, MC, USN
• Faculty Development Fellowship
• Madigan Army Medical Center

2
Objectives

• Define Diagnostic Criteria
• Discuss Workup and Differentiation
• Discuss Therapy

3
ADHD What is It?

• Triad
• Inattentiveness, Hyperactivity, Impulsiveness
• Maladaptive and Pervasive
• Academic and Behavioral Problems
• Onset Prior to Age 7
• Probable Organic Cause
• Exact Etiology Unknown

4
Prevalence

• 3-5 of School Age Children (125)
• 2 of Adolescents (150)
• 0.8 of 20 year-olds (1125)
• 0.2 of 30 year olds (1500)
• 0.05 of 40 year olds (12000)

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DSM IV Criteria

• EITHER 6 symptoms of
• Inattention OR Hyperactivity Impulsivity
• AND
• Onset before age 7
• Impairment in at least 2 Settings
• Impairment in social, academic or occupational
  Function
• No other pervasive disorder

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Pitfalls in Diagnosis

• DSM criteria also describe NORMAL kids!
• No Physical or Lab Markers
• Significant Overlap w/ Diff. Dx.
• Public Awareness, Misinformation

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Diff. Dx. and Comorbid Conditions

• Oppositional Defiant Disorder
• Tic Disorders
• Learning Disabilities
• Mental Retardation
• Family Dysfunction/Discord
• Other Medical and Mental Disorders

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Keys to Accurate Diagnosis

• History, History, and more History!!
• Standardized Checklists/Questionaires
• Exclusion of Diff. Dx. by
• Physical Exam
• IQ testing, audiometry, eye screening
• Multidiscliplinary Approach

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History

• Behavioral
• incl. classroom, home, church, meals
• interactions with peers
• Medical year by year school performance,
  developmental
• ROS Neuro, GI esp. encopresis, psychiatric

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History

• Family
• ADHD, tics, psychiatric disorders
• Social
• Family Dysfunction
• Parenting Skills
• Never the root of ADHD!

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Useful Questions

• Is the child more apt to
• do things without thinking ahead, or plan to
  misbehave?
• Refuse to do things or try to do things, but
  fails to finish?
• Does the child display aggression toward people
  or animals, destructiveness or theft?
  (inconsistent with ADHD)

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Checklists/ Questionnaires

• Objective Data (?)
• Achenbach Behavior Checklist
• ADD II (ACTeRs)
• Connors Rating Scale
• Child Behavior Rating Scale
• Others

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Physical Exam

• Directed
• Hearing and Vision Screening
• Developmental Milestones
• PE cannot rule-IN Diagnosis, only rules- OUT
  other Diff Dx.

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Multidisciplinary Approach

• Primary Provider
• Psychoeducational Consultant
• academic, aptitude, and psychometric testing
• IQ measurement
• (usually done through the school)
• Social Services
• Counseling Services
• Individual and Family

15
Treatment/ Management

• Education
• Patient
• Parent
• Teachers and Caregivers
• Physician

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Education Resources

• Books
• Barkley RA. Taking Charge of ADHD The Complete
  Authoritative Guide For Parents. New York,
  Guilford Press, 1995.
• Bain, LJ. A Parents Guide to Attention Deficit
  Disorders. New York, Delta Books, 1991.

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Education Resources

• Support Organization
• CHADD Children and Adults with Attention
  Deficit Disorder
• local chapters
• materials for children, adults, parents, schools
• 499 70th Ave NW, Suite 109, Plantation FL 33317.
  Ph. [phone]
• Website www.chadd.org/

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Education Resources

• Special Education
• child may qualify for special services under
  Federal Law. (Individuals with Disabilities
  Education Act and section 504 of Rehabilitation
  Act of 1973)
• Schools responsible for determining eligiblility
  (they may need info from YOU)

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Medical Therapy

• Medications
• Stimulants
• methylphenidate (Ritalin)
• dextroamphetamine (Dexadrine)
• pemoline (Cylert)
• Others
• TCAs, beta-blockers, bupropion, venlafaxine

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Medication Doses

• Methylphenidate 0.3-0.5 mg/kg per dose
• administered bid or tid
• start low, titrate 5mg increments
• max 60 mg qd
• Dextroamphetamine
• 1/2 the methylphenidate dose
• Both meds have SR formulations

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Medication Doses

• Pemoline
• Start 37.5 mg/day (1 pill)
• Increase by 18.75 mg at weekly intervals to
  response (1/2 pill)
• Usual effective range 56.25-75 mg/day
• Maximum 112.5 mg/day (3 pills)
• Check LFTs at 6 month intervals

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Stimulants

• Expected benefit
• Improved CONCENTRATION
• evidence better grades, etc.
• All other benefits are secondary

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Stimulants

• Problems
• Misinformation, Unrealistic Expectations
• Controlled Substance
• Adverse Effects
• Sleep disturbance
• Appetite Suppression
• Tics
• Anemias (rare)

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Supportive Therapy

• Counseling/ Psychotherapy
• Behavior Modification
• Structured Schedule and Environment
• Regular Followups
• (not necessarily in person!)
• Social Services
• on-base support programs, training

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Adult ADHD

• Relatively Rare, however
• LOTS of Media Attention Lately!
• Comorbidity with Major Depression
• 12 of Adult MDD patients who had ADHD as
  children manifest ADHD symptoms
• May benefit from ADHD therapy

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Adult ADHD

• Therapy
• Education
• Support
• Medication
• Stimulants
• TCAs incl desipramine

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Summary

• ADHD diagnosis and therapy is complex and labor
  intensive
• There are NO short-cuts in gathering necessary
  history and data!
• Emphasis on
• Diagnostic Accuracy by HISTORY
• Realistic Expectations of Therapies
• Multidisciplinary Approach

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References

• Barbaresi, WJ. Primary Care Approach to the
  Diagnosis and Management of Attention-Deficit
  Hyperactivity Disorder. Mayo Clinic Proc, 1996
  May, 715, 463-71.
• The best overview I found on the subject.
• Schneider, Steven and Tan, Grace.
  Attention-Deficit Hyperactivity Disorder In
  Pursuit of Diagnostic Accuracy. Postgraduate
  Medicine, 1997 Apr., 1014, 231-40.
• Concentrates on diagnostic features.
• Hill, JC and Schoener, EP. Age-Dependent Decline
  of Attention Deficit Hyperactivity Disorder. Am
  J Psychiatry, 1996 Sep, 1539, 1143-6.
• Good picture of natural course of the disorder.

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References (cont.)

• Mannuzza, S et al. Adult Psychiatric Status of
  Hyperactive Boys Grown Up. Am J Psychiatry, 1998
  Apr, 1554, 493-8.
• Abstracts worth reading for what ADHD kids turn
  into!
• Johnson, TM. Evaluating the Hyperactive Child in
  Your Office Is It ADHD? AFP, 1997 July, 561,
  155-60.
• A middle of the road, Heres how I do it.
• DSM IV, pp. 78-85.
• Criteria attached to handout. Descriptive.