Attention Deficit

1. Attention Deficit/Hyperactivity Disorder Tracy Hardwick, Capt, USAF, MC Grand Forks AFB, ND March 2007

4. ADHD statistics 2 million American children 3-5% of school aged children Male>Female by 2-4:1 60-70% persist into adolescence

5. What causes ADHD? Genetics/familial Norepinephrine/dopamine imbalances Maternal smoking Disordered breathing during sleep

6. Differential diagnosis General medical conditions Hearing/vision impairment Medication effect Malnutrition Hypothyroidism Lead toxicity Sleep disordered breathing

7. Differential diagnosis Neurologic conditions Learning disability Seizure disorder Mental retardation Tic disorder Other neurologic conditions

8. Differential diagnosis Psychiatric Oppositional defiant disorder Conduct disorder Substance abuse Anxiety Depression Bipolar disorder

9. Differential diagnosis Environmental Abuse/neglect Poor parenting Mismatch of school curriculum with child�s ability Stressful home environment

11. Diagnosis of ADHD Inattention Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Often loses things necessary for tasks or activities Is often easily distracted by extraneous stimuli Is often forgetful in daily activities

12. Diagnosis of ADHD Hyperactivity Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate Often has difficulty playing or engaging in leisure activities quietly Is often "on the go" or often acts as if "driven by a motor" Often talks excessively Impulsivity Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on others

13. Physical exam General appearance Neurologic exam Mental status exam Cardiac exam

16. Co-morbidities frequently seen with ADHD ODD � 35% CD � 26% Anxiety � 26% Depression � 18% Learning disabilities � 20-60%

19. Medications for ADHD Stimulants Rapid onset Methylphenidate Dextroamphetamine Dexmethylphenidate Mixed amphetamine salts

20. Medications for ADHD Stimulants Slower onset, Longer duration Methylphenidate Dextroamphetamine Dexmethylphenidate

21. Medications for ADHD Stimulants Rapid onset and long duration Mixed amphetamine salts (Adderall XR) Methylphenidate

22. Medications for ADHD Second line medications Atomoxetine Clonidine (not approved by the FDA) Modafanil (not yet approved by the FDA) Antidepressants (especially TCAs)

23. Other therapies for ADHD Behavior therapy Family counseling Educational modification Unproven and not recommended therapies Cognative, cognative-behavioral therapy, or play therapy Modifications of diet No TV time

24. Summary Complex disorder Rule out other causes of symptoms Stimulants are the primary treatment

25. References Abramowicz, Mark (ed.). Drugs for Treatment of ADHD. Treatment guidelines from The Medical Letter. Nov 2006; 4 (51). Barkley RA, et al. Does the treatment of attention-deficit/hyperactivity disorder with stimulants contribute to drug use/abuse? A 13 year prospective study, Pediatrics. Jan 2003; 111:97-109. Chervin RD et al. Inattention, hyperactivity, and symptoms of sleep disordered breathing. Pediatrics, Mar 2002; 109:449-56. Cincinnati Children�s Hospital Medical Center. Evidence based clinical practice guideline for outpatient evaluation and management of attention deficit/hyperactivity disorder. Apr 2004. Herrerias, Carla T et al. The Child with ADHD: Using the AAP Clinical Practice Guideline. Am Fam Phys, May 1, 2001; 63(9). Johnson EO, Roth T. An epidemiologic study of sleep-disordered breathing symptoms among adolescents. Sleep, Sep 1, 2006; 29:1135-42. Kahn RS et al. Role of dopamine transporter genotype and maternal prenatal smoking in childhood hyperactive-impulsive, inattentive, and oppositional behaviors. J Pediatr, Jul 2003; 143:104-10. Krull, Kevin R. Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents. UpToDate. 2006 Krull, Kevin R. Evaluation and diagnosis of attention deficit hyperactivity disorder in children and adolescents. UpToDate. 2006. Krull, Kevin R. Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents. UpToDate. 2006

26. References Middleton, Donald B, Wolraich, Mark L. Diagnosis and Management of Childhood ADHD in the Family Practice Setting. AAFP CME program. Released Mar 2003. Millichap JG et al. Serum ferritin in children with Attention-deficit hyperactivity disorder. Pediatr Neruol Mar 2006; 34:200-3. Molina BS and Pelham WE Jr. Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. J Abnorm Psychol. Aug 2003;112:497-507. New Drug: Daytrana (methylphenidate transdermal system). Pharmacist�sLetter/Prescriber�s Letter 2006; 22(6):220606. Schab DW and Trinh NH. Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind placebo-controlled trials. J Dev Behav Pediatr Dec 2004; 25:423-34. Smucker, William D and Hedayat Marjaneh. Evaluation and Treatment of ADHD, Am Fam Phys. Sept 1, 2001; 64(5). Stein, Martin T. Diversion and Misuse of Stimulant Medications Prescribed for ADHD. J Am Acad Child Adolesc. Psychiatry. Apr 2006; 45:408-14. Stevens T and Mulsow M. There is no meaningful relationship between television exposure and symptoms of attention-deficit/hyperactivity disorder. Pediatrics Mar 2006; 117:665-72. Wilens, TE et al. Does stimulant therapy of attention deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. Jan 2003:111:179-85.