ADD Update

1. ADD Update Kristi Maroni, MD Lance Feldman, MD, MBA, BSN

2. Disclosures Drs. Maroni & Feldman have no disclosures to report

3. Our Practice • Outpatient • 4 physicians & 1 nurse practitioner • 2 therapists • Inpatient • 7N (24 adult beds) • 7S (8 child / adolescent beds) • Consultation service

4. Goals & Objectives 1. Providers will be able to explain the diagnosis of ADHD 2. Providers will be able to understand the medical management of ADHD in children and adults

5. ADHD Overview – Diagnostic Criteria • Inattention: >/= 6 or more for children; >/= 5 for 17 and older and adults: • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. • Often has trouble holding attention on 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 (e.g., loses focus, side-tracked). • Often has trouble organizing tasks and activities. • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). • Is often easily distracted • Is often forgetful in daily activities. http://www.cdc.gov/ncbddd/adhd/diagnosis.html

6. Diagnostic Criteria, Cont’d • Hyperactivity and Impulsivity: >/= 6 or more for children; >/= 5 for 17 and older and adults: • Often fidgets with or taps hands or feet, or squirms in seat. • Often leaves seat in situations when remaining seated is expected. • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). • Often unable to play or take part in leisure activities quietly. • Is often "on the go" acting as if "driven by a motor". • Often talks excessively. • Often blurts out an answer before a question has been completed. • Often has trouble waiting his/her turn. • Often interrupts or intrudes on others (e.g., butts into conversations or games) http://www.cdc.gov/ncbddd/adhd/diagnosis.html

7. Diagnostic Criteria, Cont’d Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months. http://www.cdc.gov/ncbddd/adhd/diagnosis.html

8. Confirming a Diagnosis… • Forms (parent & teacher) • Vanderbilt • Connors • Testing • Connors CPT • Psycho-educational testing

11. Adult Onset vs. Child Onset • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. • Several symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities). • Keep in mind possible secondary gain (NC controlled substance database) http://www.cdc.gov/ncbddd/adhd/diagnosis.html

12. Treatment Medication Therapy Behavior Modification

13. Medications • Stimulants • Methylphenidate people • Dextroamphetamine people • Non-Stimulants • Alpha 2 agonists • Norepinephrine reuptake inhibitor

14. Methlyphenidate • Concerta • Daytrana • Focalin & Focalin XR • Metadate CD & ER • Ritalin, Ritalin LA & SR • Quillivant • >6 y/o choose long acting first • Costs vary widely • Method of administration (tab, cap, liquid, patch) • Time release differences

15. Dextroamphetamine • Adderall & Adderall XR • Procentra (3 y/o!) • Vyvanse • >6 y/o choose long acting first • Costs vary widely • Method of administration (tab, cap, liquid) • Vyvanse is a pro-drug

16. Alpha 2 Agonists • Intuniv (tenex / guanfacine) • Once daily dosing • Kapvay (clonidine) • More sedating • BID dosing (if >0.1 mg) • 6-17 y/o • Monotherapy or adjunct treatment • Costly (consider generics)

17. Strattera (Atomoxetine) Ages 6+ Weight based dosing if <70kg (start 0.5 mg/kg, max 1.4mg/kg) Increased risk of suicidality in children/adolescents Norepinephrine reuptake inhibitor Non-stimulant alternative in adults Costly

18. Therapy Pearls Interpersonal interactions Study skills Organizational improvement Playing well with others Common cognitive distortions: all-or-nothing thinking, mind reading, magnification and minimization, emotional reasoning, comparative thinking http://www.additudemag.com/adhd/article/912-2.html

19. Behavior Modification Classroom seating assignment Minimize distractions Take frequent breaks Encouragement and positive reinforcement Parent skills training Partnering with teachers / co-workers

20. General Prescribing Thoughts… • Methylphenidate v. Dextroamphetamine • Stimulant v. Non-Stimulant • Long acting first if >6 y/o • Ages (3+, seriously…) • Keep in mind dosing ranges

21. Deep Thoughts… • When to switch or add adjunct tx • 0 x 0 = 0 • How to deal with side effects… • Worsening of tics • Exacerbation of mood / anxiety • Sleep / Appetite

22. When to Refer… 3+ medication failures Untoward side effects Significant treatment contraindications Concomitant mood or anxiety concerns

23. Thanks! Any Questions?