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ADHD Treatment

ADHD Treatment. Objectives. Be familiar with the evidence supporting particular forms of management for ADHD, including medication Know the different classes of stimulant medications and their potential side effects Be familiar with Atomoxetine and its potential side effects.

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ADHD Treatment

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  1. ADHDTreatment

  2. Objectives • Be familiar with the evidence supporting particular forms of management for ADHD, including medication • Know the different classes of stimulant medications and their potential side effects • Be familiar with Atomoxetine and its potential side effects

  3. Recommendation 1:Management Program • Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition • Strong evidence • Strong recommendation

  4. Recommendation 1:Management Program • Prevalence 4-12% of school-age children • 60-80% persist into adolescence • Inform, educate, counsel, demystify • family, child • Resources • local, national (CHADD, ADDA)

  5. Recommendation 1:Management Program • What distinguishes this condition from most other conditions managed by primary care clinicians is the important role that the educational system plays in the treatment and monitoring of children with ADHD.

  6. Recommendation 2:Target Outcomes by Team • The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management. • Strong evidence • Strong recommendation

  7. Recommendation 2:Outcomes- maximize function • Relationships • parents, siblings, peers • Disruptive behaviors • Academic performance • work volume, efficiency, completion, accuracy • Individual • self-care, self-esteem • Safety in the community

  8. Objectives of the Literature Review • Effectiveness (short and long-term) and safety of therapies • Medication and non-medication therapies • Single therapy vs combination • 6-12 year olds

  9. Sources for Review • Agency for Healthcare Research & Quality • McMaster Univ. Evidence-based Practice Center • Canadian Office for Health Technology Assessment Study (CCOHTA) • Multimodal Treatment Study (MTA Study) • Pelham et al. review of psychosocial therapies

  10. Recommendation 2:developing target outcomes • Input • parents, children (patient), teachers • 3-6 key targets • realistic, attainable, measurable • methods will change over time

  11. IDEA = Individuals with Disabilities Education Act ADHD under “Other Health Impaired” Educational Disability Services Section 504 of the Rehabilitation Act ADHD medical diagnosis Medical Disability with educational impact Accommodations School InterventionsIndividual Education Plan 504 Plan

  12. Recommendation 3:make some recommendations • The clinician should recommend stimulant medication and/or behavior therapy as appropriate, to improve target outcomes in children with ADHD • Strong evidence (medication), Fair evidence (behavior therapy) • Strong recommendation

  13. Recommendation 3:Efficacy of Stimulants • Short-term benefits well established • Core symptoms: attention, hyperactivity, and impulsivity • observable social and classroom behaviors • IQ and achievement testing- less effect

  14. Recommendation 3:MTA Study • Effects over 14 months • 579 children 7-9.9 years old • 4 randomized groups • medication alone • medication and behavior management • behavior management • standard community care

  15. Recommendation 3:MTA Study • Medication management alone • Medication + behavior therapy • > Community management • > Behavior management alone

  16. The StimulantsNobody does it better • Short, intermediate (the “old” long-lasting), truly long acting • 22 studies show NO difference between methylphenidate, dextroamphetamine, or mixed amphetamine salts (Adderall) • Individual’s response may vary • NO serologic, hematologic tests needed **EKG – based on history and risk

  17. Non-stimulantsSecond rate-only 2 • Tricyclic antidepressants • 9 studies alone • 4 studies =/< methylphenidate • Bupropion (Wellbutrin, Zyban) • Clonidine • limited studies • > placebo

  18. StimulantsDose determination • NOT weight dependent • Optimal effects with minimal side effects • nothing ventured, nothing gained • Match target outcomes and timing • crucial step prior to starting

  19. StimulantsSide effects • appetite suppression • stomachache, headache • delayed sleep onset • jitteriness • overfocused, dull demeanor • mood disturbances

  20. StimulantsSide effects- NOT • seizures- NO increased frequency with mph • growth delay- at least one negative study • Tourette syndrome • 15-20% of patients have motor tics • 50% of TS have ADHD • 7 studies comparing stimulants vs placebo/other show NO increase in tics with stimulants

  21. Short Intermediate Extended 3-4 hours 5-6 hours 8-10 (12)hours

  22. Atomoxetine Strattera • Selective norepinephrine uptake inhibitor • Little effect on dopamine or serotonin uptake • Little effect on Ach, H1, alpha-2, DA receptors • Well-tolerated in adult and pediatric studies

  23. Atomoxetine...Randomized, Placebo-Controlled, Dose-Response... • 297 children and adolescents • 8-18 years old; 71 % male • 70% had prior stimulant therapy • Combined/Inattentive/Hyper-impulsive • 63/33/2 % • 37 % Oppositional-defiant disorder • 1 depression, 1 anxiety disorder Atomoxetine…AD/HD…Study. Pediatrics 108:e83, 2001

  24. Side Effects • Small samples: • dizziness 9% vs 1% placebo • vomiting 6% vs 7% • Weight loss dose dependent • mean 0.4kg at 1.2 mg/kg/d • small pulse, BP changes • no EKG changes • <5% dropout rate atmx and placebo Atomoxetine…AD/HD…Study. Pediatrics 108:e83, 2001

  25. Efficacy of Atomoxetine vs Placebo in School-Age Girls with AD/HD • 52 children and adolescents • 7-13 years old • Combined/Inattentive/Hyper-impulsive • 79/21/0 % • 38.5 % Oppositional-defiant disorder • 13.5% phobias Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002

  26. Measures • ADHD Rating Scale- Parent • Conners’ Parent RS-Revised • No Teacher ratings • Clinical Global Impressions of ADHD Severity- Clinician Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002

  27. Side Effects • Small sample size subset here (279 total); so no significant differences • Vomiting 19% vs 0% • Abdominal pain 29% vs 14% • Nausea 6.5% vs 14% • ?Weight, cardiac... • Increased cough 16% vs 4.8% Efficacy…Girls...AD/HD. Pediatrics 110:e75, 2002

  28. Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial • 228 children and adolescents • 184 atomoxetine, 44 mph; 10 weeks • 7-15 year old boys; 7-9 year old girls • Most/all had prior stimulant therapy • Combined/Inattentive/Hyper-impulsive • 76/23/1 % • 53% ODD, 7% major depression Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

  29. Measures • ADHD Rating Scale- Parent Completed • ADHD Rating Scale- Parent Interview • Conners’ Parent RS-Revised • No Teacher ratings • Clinical Global Impressions of ADHD Severity- Clinician Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

  30. Findings • Comparable improvement between the two • mean dose 1.4 mg/kg/d extensive mtb, 0.5mg/kg/d slow mtb • mph 0.85 mg/kg/d, (31mg/d) • High rate of dropouts Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

  31. Findings • 43% of mph, 36 % atmx dropped out! • 11%; 5 % because of adverse effects comparable • atomoxetine wt loss avg 0.6 kg; (mph 0.1) • small changes both in pulse, BP • EKG, labs no problems, no differences Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

  32. Side Effects • Generally comparable • Vomiting 12% vs 0% • Abdominal pain 23% vs 17.5% (NS) • Nausea 10% vs 5% (NS) • ?Weight, cardiac... • Cough 5% same • “Thinking abnormal” 0% vs 5% (N=2) Atomoxetine and Methylphenidate... Prospective Randomized, Open-Label Trial JAACAP 41:7, 2002

  33. No abuse potential adolescent usage adult usage 24/7 coverage No tic relationship Novel class of med use with stimulants, too Little data head to head vs stimulants Weight loss/vomiting Takes week(s) to effects Tolerance “starter kit” issue adjust if SSRI added Cost Pros and Cons

  34. Behavior Therapyaccept no substitutes • Behavior therapy • Emotions-based therapy • e.g. play therapy-NOT efficacious in ADHD • Thought patterns directed • cognitive, cognitive-behavioral therapy • NOT efficacious in ADHD

  35. Behavior TherapyParent Training • 8-12 weeks with trained therapist • teaches parent skills • incorporates maintenance and relapses • improves child’s functioning and behavior • not necessarily achieves normal behavior

  36. Behavior Therapy Examples of Techniques • Positive reinforcement • reward for performance • Time-out • removing positive reinforcement • Response cost • losing advance rewards • Token economy • combination

  37. Behavior Therapy Meta-analyses difficult and few • Must be maintained to be effective • Stimulant effects much > behavioral therapy • MTA study: combination > med alone, but not a statistically significant difference • However, parents and teachers more satisfied • Schools can implement • 504 Plan • IEP

  38. Recommendation 4:When to re-evaluate • When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions • Weak evidence • Strong recommendation

  39. Recommendation 4:Ddx in re-evaluation • unrealistic target symptoms • poor information regarding child’s behavior • incorrect diagnosis and/or • coexisting condition interfering • ODD, conduct disorder, mood, anxiety, LD • poor adherence/compliance • treatment failure

  40. Recommendation 4:Steps in re-evaluation • Re-establish target symptoms • “team” communication • Gather further information, other sources • Consider consultation • Consider psycho-educational testing

  41. Recommendation 4:True treatment failure • Lack of response to 2-3 stimulants • maximum dose without side effects • any dose with intolerable side effects • Inability to control child’s behavior • Interference of coexisting condition • Refer to mental health

  42. Recommendation 5:follow-up guidelines • The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child. • Fair evidence • Strong recommendation

  43. Recommendation 5:follow-up guidelines • Team management plan • not just : “What does the doctor recommend?” • Recording clinical data • flow sheet, progress note • Interview, T-Con, teacher reports, report cards, checklists

  44. Recommendation 5:frequency of follow-up • NO controlled trials document the appropriate frequency • MTA study: more frequent did better, BUT • Once stable, visit every 3-6 months

  45. Conclusion nuggets • ADHD is a chronic condition • Explicit negotiations regarding target outcomes are key • Stimulant and behavior therapy use are the mainstay of therapy

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