AFP Journal Review

1. AFP Journal Review Lianne Beck, MD Assistant Professor Emory Family Medicine April 15, 2009

2. Articles • Current Strategies in the Diagnosis and Treatment of Childhood Attention-Deficit/Hyperactivity Disorder • Risks and Benefits of Pacifiers

3. Childhood ADD/ADHD • Most commonly diagnosed neurodevelopmental disorder in children and adolescents. • Estimated 2 to 16% of school-aged children are affected • Symptoms affect cognitive, academic, behavioral, emotional, social, and developmental functioning

4. Etiology • Many theories, no single etiology • Neurotransmitters: dopamine, norepinephrine and serotonin • PET scans show reduced global and local activation in basal ganglia and anterior frontal lobe • Risk factors • genetic factors • behavioral disorders • medical conditions • environmental influences • Both sexes equally affected

5. Combined AAP and AACAP Recommendations for the Evaluation of Children with Suspected ADHD • Recommendation 1: The primary care physician should initiate an evaluation for ADHD in a child six to 12 years of age who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavioral problems. The initial evaluation should include the following: (1) standard H & P, with the AACAP recommending assessment of the child's developmental history, hearing and vision, any learning difficulties or psychiatric illness, and family history of ADHD; (2) neurologic examination; (3) family assessment, with the AACAP recommending review of family stressors and family coping style; and (4) school assessment

6. Recommendation 2: The diagnosis of ADHD requires that a child meet DSM-IV diagnostic criteria for the disorder • Recommendation 3: The assessment of ADHD requires evidence obtained directly from parents or caregivers regarding the core symptoms of ADHD in various settings, age at onset of symptoms, duration of symptoms, and degree of functional impairment

7. Recommendation 4: The assessment of ADHD requires evidence obtained directly from the classroom teacher (or other school-based professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and coexisting conditions. A physician should review any reports from a school-based multidisciplinary evaluation, including assessments from the child's teacher or other school-based professional.

8. Recommendation 5: The evaluation of a child with ADHD should include an assessment for coexisting conditions (e.g., learning and language disabilities, oppositional defiant disorder, conduct disorder, anxiety and depression). • Recommendation 6: Diagnostic testing (e.g., measurement of lead and thyroid hormone levels; neuroimaging; EEG) is not routinely recommended.

9. DSM-IV Criteria A. Either 1 or 2: 1. Six (or more) of the following symptoms of inattentionhave persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities b. Often has difficulty sustaining attention in tasks or play activities c. Often does not seem to listen when spoken to directly d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) e. Often has difficulties organizing tasks and activities f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) g. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, tools) h. Is often easily distracted by extraneous stimuli i. Is often forgetful in daily activities

10. 2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity a. Often fidgets with hands or feet, or squirms in seat b. Often leaves seat in classroom or in other situations in which remaining seated is expected c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) d. Often has difficulty playing or engaging in leisure activities quietly e. Is often "on the go" or acts as if "driven by a motor" f. Often talks excessively Impulsivity a. Often blurts out answers before questions have been completed b. Often has difficulty awaiting turn c. Often interrupts or intrudes on others

11. B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before seven years of age C. Some impairment from the symptoms is present in two or more settings (e.g., at school or work and at home) D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychiatric disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, a personality disorder)

12. ADHD and Adolescence • Antisocial behavior • Cognitive fatigue • Difficulties at school or work • Ineffective self-monitoring • Legal trouble • Low self-esteem • Impulsivity • Risk taking • Substance abuse

14. Differential Diagnosis of ADHD • General medical conditions • Adverse effects from medication use • Allergic rhinitis • Asthma • Hypothyroidism • Infection or trauma • Lead toxicity • Malnutrition • Sensory impairment (vision, hearing) • Sequelae of the central nervous system

15. Differential Diagnosis of ADHD • Neurologic conditions • Brain injury • Developmental delays • Learning disability • Mental retardation (e.g., fetal alcohol syndrome, fragile X syndrome, phenylketonuria) • Seizure disorder • Sleep disorders, such as obstructive sleep apnea • Speech or language problems (e.g., expressive/receptive and phonologic disorders, dysfluency, apraxia)

16. Differential Diagnosis of ADHD • Psychiatric conditions • Anxiety • Conduct disorder • Depression • Obsessive-compulsive disorder • Oppositional defiant disorder • Posttraumatic stress disorder • Substance abuse

17. Differential Diagnosis of ADHD • Environmental conditions (family psychosocial problems) • Child neglect, physical or sexual abuse • Dysfunctional parenting (e.g., inappropriate, inconsistent, punitive) • History of bullying, victim of bullying • Improper learning environment (e.g., unsafe, disruptive) • Parental psychopathology or substance abuse • Social skills deficits • Sociocultural factors

19. Treatment • Pharmacologic • First-line agents (stimulants) • Methylphenidate (Ritalin, Methylin, Metadate, Concerta) • Immediate release, extended release and long active • Adverse affects: appetite suppression, weight loss, abdominal pain, headache, irritability, growth effects, tics, cardiovascular effects, insomnia • Dexmethylphenidate (Focalin) • Dextroamphetamine (Dexedrine Spansule, Adderall) • Short, intermediate and long acting • Similar adverse affects

20. Treatment • No evidence supporting the use of one stimulant over another. • Short-, intermediate-, and long-acting preparations have similar effectiveness. • Administration of short-acting preparations can be timed to correspond with certain activities. • Long-acting formulations eliminate the burden of medication administration during the school day, improve compliance, and decrease opportunity for abuse.

21. Treatment • Second line agents • Atomoxetine (Strattera) • Selective norepinephrine-reuptake inhibitor • Consider if child is unresponsive to stimulants, the parents prefer a nonstimulant medication, or there is concern about abuse • Comparable effectiveness to stimulant medications when compared to placebo • Adverse affects: Similar to methylphenidate; nausea, vomiting, fatigue, mild increase in blood pressure and pulse • Black box warning about the rare association with suicidal ideation in children

22. Treatment • Third-line agents • Bupropion (Wellbutrin) – sustained and extended release • Adverse affects: weight loss, insomnia, agitation, anxiety, dry mouth, seizures • Imipramine (Tofranil) • Anticholinergic effects, dry mouth, constipation, tachycardia, changes on electrocardiography, sudden death, arrhythmias • Desipramine (Norpramin) • Same anticholinergic effects • Clonidine (Catapres) • Drowsiness, dizziness, dry mouth, orthostatic hypotension • Guanfacine (Tenex) • Adverse affects same as clonidine, but lower incidence and severity

23. Behavioral Therapy • Focus on rewarding and consequences to gradually reshape the child's thinking and behavior • Parental support groups and skills training • No high-quality studies to show effectiveness of psychotherapy, including CBT in the treatment of ADHD

24. Combined Therapy • A 14-month, multicenter, RCT compared effectiveness of combined behavioral interventions and pharmacotherapy with either treatment alone • Combination treatment and pharmacotherapy alone yielded similar results and were more effective than behavioral treatment alone or standard care in reducing core ADHD symptoms. • Combining behavioral modifications and pharmacotherapy may reduce the need for higher medication dosages and may provide modest advantages for non-ADHD symptoms and positive functioning outcomes.

25. Combined Therapy • A more recent study by Molina and colleagues showed that there were no significant differences among pharmacologic, behavioral, and combined therapy groups after six to eight years, and that all children in the study had significant impairment compared with unaffected peers. Molina BS, Hinshaw SP, Swanson JM, et al., for the MTA Cooperative Group. MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009

26. Childhood ADD/ADHD

27. Resources • A free tool kit developed by the AAP and the National Initiative for Children's Healthcare Quality to help physicians improve the management of ADHD. • www.nichq.org/adhd.html

28. Risks and Benefits of Pacifiers

29. SOR:B

30. Quiz • A 10-year-old girl presents to her family physician because of behavioral problems. Which one of the following most strongly suggests attention-deficit/hyperactivity disorder (ADHD)? A. Her symptoms began three months ago, at the beginning of the school. B. She only misbehaves at school. C. She has been inattentive and impulsive for as long as her parents can remember. D. Her symptoms began two years ago, when she was eight years of age.

31. The patient in the previous question meets the diagnostic criteria for ADHD. Her history and physical examination are unremarkable. To establish the diagnosis of ADHD, which one of the following should be recommended? A. Measurement of thyroid hormone levels. B. Measurement of lead levels. C. Neuroimaging. D. No further diagnostic testing is needed.

32. A child is prescribed methylphenidate (Ritalin) for ADHD. After appropriate dosage adjustments, no change in behavior is noted. Which one of the following is a reasonable treatment option? A. Switching the patient to another stimulant medication. B. Adding a bedtime dose of atomoxetine (Strattera). C. Prescribing a trial of psychotherapy. D. Titrating the dosage of methylphenidate until an adequate response is noted.

33. Which one of the following is appropriate advice for the parents of a four-year-old child who uses a pacifier? A. Pacifier use has no known risks, and children may be weaned anytime they are ready. B. Because of the increased risk of dental malocclusion with pacifier use, the child should be weaned from pacifiers after four years of age. C. Pacifier use reduces the risk of otitis media and should be continued as long as possible. D. Latex pacifiers are less likely to be colonized with Candida and Staphylococcus than silicone pacifiers.

34. When providing hospital discharge instructions to the parents of a healthy, full-term newborn, which one of the following recommendations is appropriate? A. A pacifier should be introduced immediately to help establish healthy sucking. B. Infants should be weaned from pacifiers after six months of age to reduce the risk of otitis media. C. Pacifiers should be avoided to reduce the risk of sudden infant death syndrome. D. Pacifiers should be used to reduce the risk of otitis media in the first three months of life.

35. Which of the following is/are benefits of pacifier use in preterm infants? A. Shorter hospital stay. B. Improved bottle feeding performance. C. Improved behavior. D. Fewer tube feedings.

36. Case Study E.R., a 23-year-old Mexican-American woman, presents for her first prenatal visit after a positive home pregnancy test. Her last menstrual cycle was 12 weeks ago. E.R.'s medical history includes outpatient treatment for an episode of pelvic inflammatory disease. She has a two-year-old child who was born at 34 weeks' gestation. Her physical examination is normal.

37. 1. Which one of the following approaches would be most consistent with the U.S. Preventive Services Task Force (USPSTF) recommendation on screening for bacterial vaginosis? A. Do not screen E.R. for bacterial vaginosis because the harms of screening pregnant women outweigh the benefits. B. Screen E.R. for bacterial vaginosis because she is at high risk of preterm delivery. C. Screen E.R. for bacterial vaginosis because all pregnant women should be screened routinely. D. Explain to E.R. that testing for bacterial vaginosis is an option because of her high risk of preterm delivery, but that the evidence is insufficient to recommend routine screening.

38. 2. If E.R. had a vaginal discharge, which one of the following findings or combinations of findings would fulfill the Amsel criteria for diagnosis of bacterial vaginosis? A. Vaginal pH less than 4.7 and clue cells on wet mount. B. Vaginal pH greater than 4.7 and "fishy odor" when potassium hydroxide is added to discharge. C. Clue cells on wet mount, with no other findings. D. "Fishy odor" when potassium hydroxide is added to discharge, with no other findings.

39. 3. Which of the following patients is/are considered to be at increased risk of preterm delivery? A. A 25-year-old black woman who is an attorney. B. A 25-year-old unemployed white woman receiving welfare benefits. C. A 25-year-old Hispanic woman whose first child was born at 32 weeks' gestation. D. A 25-year-old Asian woman with a history of pelvic inflammatory disease.

40. References • Rader R, Callen E. Current Strategies in the Diagnosis and Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. American Family Physician. April 15, 2009 • Sexton S, Natale R. Risks and Benefits of Pacifiers. American Family Physician. April 15, 2009.