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Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder. Puja Patel PGY5 Pediatric Neurology Nov 6, 2013. Epidemiology. Overall prevalence 2-18% School age children 8-10%  most common neurobehavioral disorder of childhood More common in boys than girls Male to female ratios:

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Attention-deficit/hyperactivity disorder

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  1. Attention-deficit/hyperactivity disorder Puja Patel PGY5 Pediatric Neurology Nov 6, 2013

  2. Epidemiology • Overall prevalence 2-18% • School age children 8-10%most common neurobehavioral disorder of childhood • More common in boys than girls • Male to female ratios: • 4:1 for predominantly hyperactive type • 2:1 for predominantly inattentive type

  3. Clinical Features 2 categories of core symptoms: • Hyperactive and impulsive behaviors occur together • Inability to sit still or inhibit behavior • Observed by age 4, peaks age 7-8, then hyperactive symptoms decline but impulsive symptoms persist • Inattention • Reduced ability to focus attention, reduced speed of cognitive processing and responding • Apparent at 8-9 years old, usually lifelong

  4. Diagnostic Criteria DSM-5 • Age <17 years: ≥6 symptoms in 1 or both categories • Age ≥17 years, ≥5 symptoms of in 1 or both categories • Present > 1 setting • Persist > 6mo • Present before age 12 • Inconsistent with developmental level child • Impair functioning • Exclude psychiatric disorders

  5. DSM-4 vs DSM-5 • New overall diagnostic category • Neurodevelopmental disorders(DSM-5) vsDisorders usually first diagnosed in infancy, childhood and adolescence (DSM-4) • ADHD across lifespan • Not only a disorder of childhood • Adding new examples to apply criteria across lifespan • Lower age cutoff for diagnosis in adults • Age of onset changed from 7 to 12 • Removal of PDD/ASD from exclusion criteria • Allows for diagnosis of ADHD with comorbid PDD/ASD

  6. Changes from subtypes to presentations: DSM-4 vs DSM-5 DSM-4 DSM-5 • Combined subtype • Inattention + hyperactive-impulsivity • Predominantly inattentive type • Predominantly hyperactive-impulsive type • Combined presentation • Predominantly inattentive • 6 inattentive and 3-5 hyperactive/impulsive symptoms • Inattentive (restrictive) • 6 inattentive and no more than 2 hyperactive/impulsive symptoms • Predominantly hyperactive/impulsive

  7. Prevalence distribution of DSM-4 subtypes

  8. Etiologies Genetic factors account for ~80% of etiology • Twin studies demonstrate concordance as high as 92% in monozygotic twins and 33% in dizygotic twins • 5-6x higher risk of first degree relatives affected • Genes that may play a role: • DA and serotonin-Rs and transporters • DA beta-hyroxylase • Glutamate-R

  9. Etiologies Mixed reviews on environmental factors: • Maternal factors • Smoking, prenatal alcohol, lead, viral infections • Perinatal/early life risk factors • Premature infants with BW<1500gm • Striatum and cingulate-cortical loop vulnerable to ischemia induced release of glutamate • Post-natal risk factors • Cerebral trauma/infections, thyroid dysfunction, toxins, nutritional deficiencies • Genetic factor likely basic cause;environmental factor probably secondary, acting as a trigger

  10. Comorbid disorders Prevalence of comorbid disorders for children with ADHD vs those without • Primary vs secondary • ADHD subtype specific comorbidities Larson et al, 2007

  11. Evaluation • Keep in mind diagnostic criteria for ADHD • Evaluate medical/neurologic/developmental disorders • Hearing/visual impairment, genetic/metabolic, sleep d/o, seizures, med effects, learning disabilities, language d/o • FHx similar behaviors • Evaluate for emotional/social stressors • Screen for psychiatric conditions • Substance abuse in adolescents

  12. Evaluation • Behavior rating scales to be completed > 2 informants • ADHD specific (narrow-band): focus directly on core symptoms • Sensitivity and specificity>90% • Conners and the ADHD Rating Scale IV for preschoolers • Vanderbilt for children ≥4 years • Broadband scales: Assess variety of behavioral symptoms • Less sensitive and specific • Can help identify coexisting conditions • Educational evaluation mandated by schools in US • Core symptoms in classroom • Neuropsych testing (IQ and academic) to eval learning d/o

  13. Treatment • Preschool children (4-5yo) • Behavior therapy administered by parent or teacher • Addition of medication (stimulant) if fails behavioral therapy • School age children (6-11yo) and adolescents (12-18yo) • Medication + behavioral therapy • Treat coexisting conditions concurrently with ADHD

  14. Behavior therapy • Modifications in physical and social environment using rewards and nonpunitiveconsequences • Positive reinforcement, time-out, token economy • Small reachable goals • Keep organized: maintaining daily schedule, charts/checklists • Keep on task: minimum distractions, limiting choices • School based interventions • Qualifications for special ed/IEP/accommodations under section 504 • Tutoring/resource room support • Classroom modifications • Extended time to complete tasks

  15. Pharmacologic Treatments Stimulants first line • Methylphenidate (Ritalin), dexmethylphenidate (focalin), amphetamine (adderall) • NE and DA reuptake inhibitor/releasing agent • Advantages: rapid onset of action, safe, long and short-acting forms approved in children<6 • SEs: appetite suppression, retard growth trajectory, insomnia, mood lability, rebound, tics, psychosis, abuse potential, sudden cardiac death (rare)

  16. Pharmacologic Treatments Non-stimulants • Atomoxetine (straterra) • NE reuptake inhibitor • Adv: no abuse potential • Disadv: less effective than stimulants, decrease dose if use with P450 inhibitors • SEs: somnolence, GI symptoms, decreased appetite, SI (rare), hepatitis (rare) • Alpha-2 adrenergic agonists (not FDA approved) • Guanfacine(tenex), clonidine (catapres) • Adv: no abuse potential, helpful if coexisting sleep or tic disorders • Disadv: less effective than stimulants • SEs: somnolence, dry mouth, hypotension, orthostasis

  17. Treatment considerations • Monitor treatment response • Drug holidays not routinely recommended • Consider if aberrant growth trajectory, excessive SEs • Stopping medications • Consider if stable symptoms • Time appropriately • Stimulant medications and atomoxetine do not need taper • Taper alpha-2-adrenergic agonists

  18. Prognosis 30-60% continue to manifest appreciable symptoms into adult life • Impaired academic functioning • especially for inattentive or combined types • Some data suggests decreased rate of employment, lower job status and poor job performance • Increased risk for incurring intentional or unintentional injury • Increased risk for antisocial personality disorder in adulthood

  19. References • Dalsgaard S. Attention-deficit/hyperactivity disorder (ADHD). Eur Child Adolesc Psychiatry. 2013 Feb;22 Suppl1:S43-8 • DaughtonJM, Kratochvil CJ. Review of ADHD pharmocotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry 2009;48(3):240-8 • Klein RG et al. Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Arch Gen Psychiatry 2012;69(12):1295-303 • Larson K et al. Patterns of Comorbidity, Functioning, and Service Use for US children with ADHD, 2007. Pediatrics 2011; 127(3):462-70 • MillichapJG. Etiological Classification of Attention-Deficit/Hyperactivity Disorder. Pediatrics 2008;121(2): 358-65 • WolraichM et al. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatmentof Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011 Nov;128(5):1007-22 • UpToDate, “ADHD in children and adolescents,” 2013 • Clinical Features and Evaluation; Epidemiology and Pathogenesis; Overview of treatment and Prognosis; Treatment with Medications

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