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ADHD Evaluation & Treatment

ADHD Evaluation & Treatment. Edward J. Coll, M.D. COL, MC Chief, Developmental Pediatrics Walter Reed Army Medical Center. Practice Guidelines. Primary care clinicians Children 6-12 years old Framework for diagnostic decisionmaking Evidence based review. Review and Recommendations.

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ADHD Evaluation & Treatment

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  1. ADHD Evaluation & Treatment Edward J. Coll, M.D. COL, MC Chief, Developmental Pediatrics Walter Reed Army Medical Center

  2. Practice Guidelines • Primary care clinicians • Children 6-12 years old • Framework for diagnostic decisionmaking • Evidence based review

  3. Review and Recommendations • Strong recommendation: high-quality scientific evidence or strong expert consensus • Fair/weak: lesser quality, limited data, or expert consensus • Clinical Options: reasonable provider

  4. Recommendation #1 • If inattention, hyperactivity, impulsivity, academic underachievement, behavior problems • Primary care clinician needs to initiate the evaluation • Good evidence Strong recommendation

  5. Screening Questions • How is __ doing in school? • Are there any problems with learning that you/teacher see? • Is your child happy in school? • Are you concerned…behaviors at home/school/play with friends? • Is your child having problems completing classwork or homework

  6. Recommendation #2 • ADHD diagnosis must meet DSM-IV criteria • Symptoms and functional impairment • Criteria remain subjective and no reliable measures in primary care • Good evidence Strong recommendation

  7. DSM-IV Criteria • 6 of 9 symptoms often • Inattentive • Hyperactive/Impulsive • Combined (both) • causes distress or impairment • inconsistent with developmental level

  8. DSM-IV Criteria • starts before 7 years old • lasts over 6 months • two or more situations • not due to: • Autism, Pervasive Dev Disorder • Mood or Anxiety Disorder • Psychotic Disorder • Dissociative or Personality Disorder

  9. DSM-IV CriteriaInattention • fails to give close attention to details, makes careless mistakes in schoolwork or other activities • has difficulty sustaining attention to task or play activities • does not seem to listen what is said to him/her

  10. DSM-IV CriteriaInattention • not follows through on instructions; fail to finish schoolwork, chores, duties in workplace (not due to oppositional behavior or failure to understand) • difficulty organizing tasks/activities • avoids/dislikes tasks that require sustained mental effort

  11. DSM-IV CriteriaInattention • loses things necessary for tasks or activities (school assignments, pencils, books, tools, toys) • easily distracted by extraneous stimuli • forgetful in daily activities

  12. DSM-IV CriteriaHyperactivity/Impulsivity • often fidgets with hands/feet or squirms in seat • leaves seat in classroom or in other situations in which remaining seated is expected • runs about or climbs excessively where inappropriate (teens or adults may be limited to subjective feelings of restlessness

  13. DSM-IV CriteriaHyperactivity/Impulsivity • difficulty playing or engaging in leisure activities quietly • talks excessively • acts as if “driven by a motor” and cannot remain still

  14. DSM-IV CriteriaHyperactivity/Impulsivity • blurts out answers before questions completed • difficulty waiting in lines or for turn in games or group situations • interrupts or intrudes on others

  15. Dr. Barkley’s ADHD Graph * “Normal” ADHD Work X Level of Interest

  16. Recommendation #3 • Evidence of core symptoms from parents and caregivers • various settings • age onset; duration of symptoms • degree of functional impairment • Good evidence Strong recommendation

  17. Recommendation #3A • Rating scales are an option • Questions subjective and subject to bias • ? If additional benefit • Strong evidence; strong recommendation

  18. Recommendation #3B • Broad-band scales/questionnaires not recommended • May be useful for other purposes • Strong evidence Strong recommendation

  19. Recommendation #4 • School evidence required • Core symptoms, duration • Functional impairment • Coexisting conditions • Good evidence Strong recommendation

  20. Recommendation #4A • Rating scales a clinical option • sensitivity/specificity >94% • ? If any added benefit • Strong evidence Strong recommendation

  21. Recommendation #4B • Global scales not recommended • May be useful for other purposes • Frequent discrepancies • Can use other informants • Strong evidence Strong recommendation

  22. Recommendation #5 • Assess for coexisting conditions • ODD 35 % • Conduct Disorder 26% • Anxiety Disorder 26 % • Depressive Disorder 18% • Strong evidence Strong recommendation

  23. Recommendation #6 • Other diagnostic tests not routinely indicated • Pb; resistance to thyroid hormone • Brain imaging; EEG • Continuous performance testing • sensitivity/specificity <70% • Strong evidence Strong recommendation

  24. Diagnosis Guidelines Conclusions • Use explicit DSM-IVcriteria • Symptoms in >1 setting • Search for coexisting conditions

  25. 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

  26. 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

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

  28. 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)

  29. 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.

  30. 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

  31. 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

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

  33. 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

  34. 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

  35. 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

  36. 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

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

  38. 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 (Adderal) • Individual’s response may vary • NO serologic, hematologic, EKG needed

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

  40. 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

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

  42. 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

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

  44. 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

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