Attention-Deficit / Hyperactivity Disorder

1. Attention-Deficit / Hyperactivity Disorder Ross Andelman, M.D. Contra Costa Children’s Mental Health CCRMC Noon Lecture Series September 8th 2009

2. ADHD Diagnosis “A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at comparable level of development.” DSM IV, APA 1994

3. ADHD: Current Perspective • Highly prevalent in community studies • Extremely prevalent in clinical samples • Developmental disorder • Presents in childhood (before age 7) • Persists into adolescence and into adulthood • Neurobiological disorder • Disorder of executive function • Spectrum ‘heterogeneous’ disorder • Highly inheritable • Responsive to appropriate treatment

4. ADHD Etiology -Genetics • Up to 92% concordance in monozygotic twins • Heritability - .75 (twin studies) • Comparable to schizophrenia • Panic - .48; Height - .92 • Siblings - 26-50% in full; 9% in half • First degree family members – 20-25% • Dopamine transporter gene (DAT1), chr 5 • Dopamine receptor D4 (DRD4*7), chr 11

5. ADHD: D/O of Executive Fxn • Shifting from one mindset to another - flexibility • Organization - anticipating needs & problems • Planning - goal setting • Working memory (short-term) - receiving, storing, retrieving information • Separating affect from cognition - detaching emotions from reason • Inhibiting and regulating verbal and motoric action - jumping to conclusions too quickly, difficulty waiting in line in an appropriate fashion

6. ADHD, DSM IV Diagnosis 6 of 9 Sxs of inattention and/or 6 of 9 Sxs of hyperactivity-impulsivity Sxs present for more than 6 months Presence of some Sxsbefore age 7 Impairment in 2 or more settings Clear evidence of significant social, academic, or occupation impairment Symptoms not secondary to other Dx

7. ADHD, DSM IV –Inattentive Symptoms • Fails to give close attention; makes careless mistakes • Has difficulty sustaining attention • Does not seem to be listening when spoken to • Does not follow through; fails to finish tasks • Difficulty organizing tasks • Avoids tasks requiring sustained mental effort • Often loses things • Easily distracted by extraneous stimuli • Forgetful in daily activities

8. ADHD, DSM IV -Hyperactivity-Impulsivity Symptoms Fidgets or squirms Unable to stay in seat Runs and climbs excessively Difficulty playing quietly On the go (driven by a motor) Talks excessively Blurts out answers Difficulty waiting turn Interrupts or intrudes on others

9. ADHD, Presentation -Preschool • Hyperactivity the rule • Frequent temper tantrums • Impulsive aggression toward peers • Fearlessness with frequent injuries • Noncompliance with preschool rules & decorum • Demanding and argumentative with parents • Sleep disturbance • Delays in motor-language development

10. ADHD, Presentation-Elementary Age • Difficulty, especially with challenging work • Homework disorganized, messy, with careless errors • Easily distracted, unable to sustain attention • Difficulty forming & keeping peer relationships • Denny Cantwell's 'lack of social savoir-faire' • Perceived as poorly controlled, disrespectful, disruptive, class clown, immature, bad • Impulsivity and noncompliance now result in trips to the principal's office

11. ADHD, Presentation -Adolescence • From 'on the go' to fidgety and restless • School performance inconsistent • If not yet diagnosed, likely to be intelligent • Poor organization & poor follow through • Persistent high risk behavior • Bike and auto accidents • Drug and alcohol use • Lack of social skills now impacts on both same-sex and opposite-sex relationships

12. ADHD, Presentation -Adults • Failure to meet educational and career goals • Poor organization, time management, and Procrastination • Interpersonal instability at home and at work • Poor social skills 'grown up‘ • Short fuse, irritability • Inability to maintain long-term relationships • May still be restless or fidgety • May be drawn to high risk activities & substance abuse • May have legal problems • May have low self-esteem

13. ADHD - Assessment • Diagnostic Bottom Line • Diagnostic interviews with parents & child or adult +/- spouse/ co-worker • Rating scales – e.g. SNAP, Vanderbilt, Conners, & Adult ADHD checklists • Frills and Extras • Observation of behavior in natural contexts • Medical and / or neurological evaluation • Cognitive, psycholinguistic, and psycho-educational testing

14. ADHD, Initial Assessment -Goals Determine presence of core symptoms (Sxs) Rule out alternate explanations for symptoms Assess for co-morbid conditions Obtain baseline ratings of symptom severity and functional impairment Educate family about disorder Dispel myths and normalize condition

15. ADHD, Initial Assessment -Interview and History • Symptom & impairment history • How long / how bad / where / when • Family’s understanding of problem • What has helped? What has not? • Past mental health history • Birth, development, and medical history • Social and educational history • Family and home environment • Family psychiatric history • Individual and family strengths and resources

17. ADHD, Treatment -Goals • Reduce core symptoms of ADHD • Establish individual target symptoms • Improve functioning in all areas of impairment • Assess for and attend to co-occurring conditions • Minimize adverse effects of therapy

18. ADHD, TreatmentTreatment is Multimodal! • Psycho-Education • Psycho-Pharmacology • Psycho-Social • Educational Interventions • Parent Training and Support • Social Skills Training • Recreational Mainstreaming • Individual and Group Psychotherapies

19. ADHD Psychopharmacology

20. ADHD, Treatment -Psychopharmacology • Symptoms likely to respond to medication • Inattention • Impulsivity • Hyperactivity • Non-compliance with authority • Impulsive aggression • Social deficits • Academic performance

21. ADHD, Treatment -Psychopharmacology

22. ADHD, Treatment -Psychopharmacology • Psychostimulants • MPH, dextroamphetamine, mixed amphetamines • >200 double-blind random controlled trials (RCTs) • Typical investigations of efficacy usually quite brief • Other medications found effective in RCTs • Tricyclic Antidepressants (>18 trials) • Atomoxetine • Buproprion • alpha-2 agonists • Promising, efficacy not yet fully established • Venlafaxine, Nicotine, modafinil, donepezil

23. ADHD, Psychopharmacology -? Adverse effects of stimulants • Weight loss; Sleep disturbance; Mood lability • ? Risk of sudden death • ? Induce tics • ? Height suppression • ? Dependence • ? Drug abuse

24. ADHD, Psychopharmacology -Stimulants • The Andelman (Cantwell-UCLA) Algorithm • Trial of one of the long-acting formulations, titrating dose weekly, and monitoring benefits and side effects through parent and child interviews, and teacher serial checklists • Concerta 18mg – 36 mg – 54 mg qAM; • Metadate CD 20mg – 40 mg - 60mg qAM; • Dexadrine Spansule 10 mg – 20 mg - 30mg qAM; • Adderall XR 10 mg – 20 mg -30mg qAM • Vyvance 20mg – 30 mg – 40 mg – 50 mg qAM

25. ADHD, Psychopharmacology -Beyond Stimulants • Atomoxetine (Strattera) • Initiate 0.5mg/kg/D qAM or 10mg • Titrate alt weekly to 1.2mg/kg or 80mg Max • Bupropion (Wellbutrin [SR]) • Initiate 3mg/kg/D qAM to TID [BID for SR] • Titrate weekly to 7mg/kg/D or 400mg Max • Clonidine (Catapres) or Guanfacine (Tenex) • Initiate 0.05mg qHS (.5mg Guanfacine) • Titrate weekly to .05mg TID (.5mg Guanfacine), then to .1mg TID Max (1mg TID Guanfacine)

26. ADHD, Treatment -Psychosocial interventions • Behavioral parent support & training • Bibliotherapy / Organizational support • Behavioral classroom interventions • Social skills group therapy • Individual psychotherapy • Unfortunately not all that useful

27. ADHD, Treatment -Parent training

28. ADHD, Psychosocial Treatment -Parent Training • Normalize hygiene – food and sleep • Consistency in expectations / discipline • Positive reinforcement • Homework & Chores • Provide structure and predictability • Modeling good organizational skills • Home-school-clinician communication • Exercise & relaxation

29. ADHD, Psychosocial Treatment -Parent Training –Behavioral Mod • Positive attending • Catch the child doing good: Be specific! • Contingency contracting • Identifying “target behaviors” • Establishing behavioral baseline • Ignoring low-level negative behaviors • Creating positive reward systems • Selected use of “punishment” • Shaping, cueing, modeling

30. Parent Training-Creating positive rewards

31. Parent Training-Creating positive rewards

32. -Parent Training Selective ignoring

33. ADHD, Psychosocial Treatment -School-based interventions

34. ADHD, Psychosocial Treatment- Self Discipline (Adult) • Normalize hygiene • Food and sleep • Exercise & relaxation • Structure and predictability • Developing good organizational skills • Attention to schedule, deadlines, & priorities

35. ADHD, Treatment -Psycho-Education: Bibliotherapy • Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood, Hallowell and Ratey, 1995. • Attention Deficit Hyperactivity Disorder: What Every Parent Wants To Know, Wodrich, 1994. • ADHD 102: Practical Strategies for Reducing the Deficit, Frank and Smith, 2001. • Getting a Grip on ADD: A Kids Guide to Understanding and Coping With Attention Disorders, Frank and Smith, 1994. • I Would If I Could : a Teenagers Guide ADHD Hyperactivity, Gordon, 1992.

36. ADHD Treatment QUESTIONS?