ADHD: Diagnosis and Management

ADHD:Diagnosis and Management Christine L. Johnson, MD Maj, USAF, MC Assistant Professor of Pediatrics Education Section Uniformed Services University of the Health Sciences March 8 and April 12, 2001

ADHDOverview • What is ADHD? • How do you diagnose and treat ADHD? • What do you need to consider in the differential diagnosis of ADHD? • What comorbidities should you be aware of?

ADHDDefinition • Attention Deficit Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. • DSM IV

ADHDBackground • First described systematically by George Still in 1902 • There have been 25 different name changes for the clinical symptom complex • A specific neuroanatomic, physiologic, biochemical or psychologic origin has not been identified, despite extensive investigation • 5-10 % prevalence in the US • 4:1 boys to girls for hyperactive-impulsive and 2:1 for inattentive type • Intense public scrutiny • Many controversial alternative treatments have flourished without scientific evidence of clinical benefit • Basic diagnostic and treatment approaches have changed little over the past 20 years

ADHDTimeline • 1902 “defect in moral control” • 1930-1950’s Minimal Brain Damage- looked at history of toxins, injuries, etc • 1950-1960’s Minimal Brain Dysfunction- recognized most individuals had no evidence of “damage”, also coined “hyperkinetic reaction of childhood” • 1960’s Use of stimulant medications became widespread, although use since 1930’s was recognized to improve symptoms • 1970’s Renamed ADD/ADHD • 1980-1990’s Investigation of processing problems

ADHDGenetics • ADHD has long been recognized to run in families • 1st and 2nd degree relatives are at highest risks • Concordance rates are higher in full siblings than ½ siblings and in monozygotic than dizygotic twins • Research is ongoing on 3 associated genes

ADHDEnvironmental • Toxins: lead, alcohol, cigarette smoke can contribute to ADHD symptoms • A small proportion of children are affected by food additives and allergenic whole foods • Studied but not proven: Iron deficiency, deficiency in essential fatty acids, Zinc and other minerals

ADHDMedical Assessment • Detailed History, comprehensive Physical Exam, functional neurodevelopmental assessment • There are no confirmatory lab tests • Rating scales from different sources (useful as a normative database and useful for monitoring treatment)

ADHDAssessment • Parent and Child Interviews • Consider using DSM-IV symptom checklist • General Past Medical History with attention to Birth History and trauma • Specific queries about Family History of ADHD, other psychiatric disorders, neurologic disorders and psychosocial adversity • Medications ( RX, OTC, illicit substances), Social History, Developmental History • Parent completed rating scales

ADHDAssessment • School-Related Assessment • Obtain reports of behavior, learning, attendance, grades and test scores • Psychoeducational testing is indicated to assess intellectual ability and to r/o learning disabilities • Review IEP if applicable • Teacher completed rating scales

ADHDRating Scales • Parent and teacher rating scales yield valuable information efficiently • Comparison with normative groups by age and sex can help distinguish normal variants in level of attention, activity, and impulse control from ADHD • The broad-spectrum scales can be used to screen for co-morbidities

ADHDRating Scales • Commonly Used and Best Validated • Child Behavior Checklist (Achenbach) • Conners’ Parent and Teacher Rating Scales • ACTERS Teacher and Parent Rating Scales

ADHDPhysical Exam • Comprehensive Physical Exam • General Observation of behavior and interactions • Exam Growth parameters and plot on growth curves • Vital signs to include blood pressure • Vision and hearing screens • Physical exam including neurologic exam

ADHDDSM-IV • ADHD-H = ADD with predominant hyperactivity and impulsivity • ADHD-I = ADD with predominant inattentiveness • ADHD-C = ADD combined type with both hyperactivity and inattention

ADHDDSM- IV • In order to diagnose ADD, the clinician must also ascertain the following: • Onset before age 7 years • Behaviors present for at least 6 months • Functional impairment must be present in two or more settings • The exclusion of pervasive developmental disorder, schizophrenia, mood and anxiety disorders, mental retardation, and learning disability

ADHD Differential Diagnosis • Medical • Sleep Apnea • Substance Use • Developmental Disorder- Learning disability, cognitive dysfunction, fragile x, fetal alcohol syndrome etc. • Other medications • Seizure disorder (Absence) • Thyroid abnormality

ADHDDifferential Diagnosis • Psychologic/ Psychiatric • Mood Disorder • Psychotic Disorder • Adjustment Disorder • Anxiety Disorder • Learning and Language Deficits • Stress

ADHDComorbidities • 45% of children with ADHD have 1 comorbid condition • 30% have 2 comorbid conditions • 10% have 3 comorbid conditions • Common comorbid conditions include ODD, Anxiety, Learning Disability, Mood, Conduct, Smoking, Substance Use and Tics

ADHDAssociated Conditions • Cognitive Deficits • Impaired Adaptive Function • Motor Development Deficits • Impaired Task Performance • Medical Problems (h/o trauma, prematurity, sleep disturbances)

ADHDClinical Management • Fit treatment to the patient • Educate parents and patients regarding ADHD • Discuss behavioral treatment • Medication management • Ensure educational support

ADHDMedications • Psychostimulants • Methylphenidate (Ritalin) • Methylphenidate HCL (Concerta) • Dextroamphetamine (Dexedrine) • Dextro and Levoamphetamine (Adderall) • Pemoline (Cylert)

ADHDMedications • Anti-Depressants • Tricyclic anti-depressants- Usually a second line alternative treatment for 10-20% of patients unresponsive to any psychostimulants. Maximal benefits are primarily observed in depressed or angry patients. Potential for lethal overdose. Need for screening labs and EKG. • Imipramine • Desipramine

ADHDMedications • Anti-Depressants • SSRI’s – May be preferred adjunctive therapy for depressed adolescents with ADD even though they have not been approved for an ADD indication. • Sertraline (Zoloft) • Fluoxetine (Prozac) • Paroxetine (Paxil)

ADHDMedications • Anti-depressants • Bupropion (Wellbutrin)- an anxiolytic drug that blocks uptake of serotonin and norepinephrine. Occasionally prescribed for off-label non-responders. May exacerbate tics.

ADHDMedications • Anti-hypertensives • Clonidine (Catapres)- alpha-adrenergic agonist of particular benefit in patients who are hyperaroused, extremely overactive and those with ODD or conduct disorder. Occasionally used at bedtime to counteract insomnia of stimulants. May cause hypotension and should be withdrawn slowly to avoid rebound hypertension. Transdermal patches may enhance compliance.

ADHDStimulant Dosing • Ritalin SR 20mg for slow release • Dexedrine Spansule available for slow release

ADHDStimulants • Of 70% of children with ADHD • 1/3 respond to Ritalin • 1/3 respond to Adderall • 1/3 respond to Dexedrine • Trial of multiple psychostimulants may be warranted • Idiosyncratic dosing is not dependent on weight

Frequent Side Effects Decreased appetite Insomnia Anxiety Irritability Emotional lability Abdominal pain Headaches Infrequent Side Effects Mood disturbance Tics Nightmares Social withdrawal ADHDStimulants

ADHDStimulants • Long term use of stimulants may increase heart rate, blood pressure but these increases do not approach clinical significance • Children treated with stimulants are at no higher risk for substance abuse than their untreated peers with ADHD • In children for whom behavior problems are cross-situational, stimulants must be considered on a daily basis. Consider drug holidays during summer if height and weight is of concern • Careful clinic follow-up is recommended every 3-4 months • Recommend treatment be discontinued on an annual basis for a short period of time during the school year to assess behavior and symptoms

ADHDBehavioral Management • The main emphases in parent training are on understanding the antecedents of undesirable behaviors, modifying the environment to alter those antecedents, and establishing positive incentives before using punishment. • Emphasis on quality attention to positive behaviors. • Teach appropriate use of time out and other disciplinary methods • Enable parents to create an environment that maximizes the child’s potential to behave appropriately

ADHDBehavioral Management • Discuss use of structure and routine and minimizing distractions • Suggest the use of an assignment sheet or day planner to be reviewed by teachers and parents • Consider a second set of textbooks at home • Family psychotherapy may be indicated to address family dysfunction • Consider to a parent support group if available

ADHDEducational Placement • Federal law PL 94-142 (1975 Education for All Handicapped Children Act) requires school systems to test any child within 30 days after a written, signed request has been presented to them • Section 504 of the Rehabilitation Act requires that children who are underperforming relative to their expected level should receive classroom modifications to improve their academic progress

ADHDEducation Placement • Modifications may include appropriate classroom placement, resource education, additional time for taking tests, not penalizing for misspelling or neatness, and additional instruction, including supplemental auditory learning and computer time • Under the Individual Disabilities Educational Act, ( PL101-476), these patients may further qualify for special education assistance in organization, work completion, listening, planning and following directions

ADHDAlternative Treatments • Publications on alternative treatments for ADHD are sparse in the peer-reviewed literature, but abound in the popular press. • Practitioners must be prepared to provide accurate information and answer questions

ADHDAlternative Treatments • Dietary Management • Feingold Diet- Dr. Ben Feingold, in 1975, contended that artificial colors, flavors and preservatives as well as naturally occurring salicylates were the primary cause of ADHD. Studies showed only 1% with consistent improvement after strict elimination diets.

ADHDAlternative Treatments • Sugar • Prinz hypothesized that the positive effects of the Feingold diet may have been due to it higher protein-sugar ratio rather than to salicylates and additives. • Multiple well-designed studies discounted his theory and showed no significant behavioral effects of sugar in either normal or ADHD study populations.

ADHDAlternative Treatments • Aspartame • Aspartame appeared on the market in 1981 and was used as a placebo in many of the studies on the effects of sugar on behavior. No independent neurologic, metabolic, or behavioral-cognitive effects related to aspartame have been found.

ADHDAlternative Treatments • The Yeast Connection • Dr. William Cook, an allergist and pediatrician, claimed a success rate in reducing hyperactive behavior in his patients with ADHD using strict elimination diets • He maintained that frequent antibiotic treatment results in chronic candidiasis and candida toxin production. This is responsible for metabolic and behavioral disturbances including hyperactivity, irritability, and learning disorders • His treatment included oral antifungal agents and a diet strictly eliminating sources of sugar and any foods made with molds and yeast • His claims are based on experience and have not been scientifically validated

ADHDAlternative Treatments • Megavitamin therapy • Children who initially were noted to have improved classroom attention while on megavitamins in an open trial, did not show any improvement in the double blind cross over placebo control phase • In fact, they showed 25% more disruptive behavior • 4% had elevation of liver enzymes • Therefore, Megavitamins are of little benefit in treating ADHD, and may cause harm

ADHDAlternative Treatments • Iron • Symptoms of iron deficiency anemia include decreased attention, arousal, and social responsiveness. Iron deficiency should be suspected on the basis of dietary history and then verified. There is no indication form iron supplementation in non-deficient individuals.

ADHDAlternative Treatments • Magnesium- a required co-factor of many enzyme systems. Only isolated reports of improvement with supplementation. • Pyridoxine- essential for neurotransmitter synthesis and normal brain development. Some studies suggest behavior improvement, but no replication has proven link. • Zinc- essential for normal growth, immune functions and neurologic development. No good controlled studies have been performed. Zinc is potentially toxic and not indicated in the absence of deficiency.

ADHDAlternative Treatments • Essential Fatty Acids- Linoleic and Linolenic acid are essential to brain development and neuronal functioning. Role in ADHD is unclear and still being studied. • Anitoxidants and Herbs- Most of these agents are used in folk and traditional medicine. None have been studied systematically in ADHD. (e.g. Pycnogenol,melatonin, gingko biloba, chamomile, kava, hops, valerian, lemon balm and passion flower) Caution should be used because of possible potentiation of effects. No clinical trials have proven there effectiveness in ADHD

ADHDAlternative Treatments • Vision Therapy and Oculovestibular Treatment- Impairment in visual acuity, oculomotor function and visuospatial perception has been implicated in the etiology of dyslexia and secondary attention problems. Introduction of lenses have anecdotally shown improvements, but any concerns regarding a child’s vision should prompt a referral to an ophthalmologist

ADHDAlternative Treatments • Homeopathy- based on the concept of “vital energies” and using dilutions of plant, animal and mineral extracts to restore those energies. Widespread use in Europe, but unknown mechanisms of action. Therefore, more studies are needed. • Auditory Stimulation- Tomatis method of sound training uses high frequency modifications of human voice and music. Requires 75 sessions and no controlled studies have shown improvement. • Biofeedback- methods of hypnotherapy, relaxation, and biofeedback are most effective when integrated into a multimodal treatment plan.

ADHDReferences • Conners' Rating Scales, Toronto, MultiHealth Systems, 1997 Tel 800-456-3003 • Achenbach, Child Behavior Checklist, 1 South Prospect Street, Burlington, Vt. 05401-3456, Tel 802-656-8313

ADHDReferences • American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 36 (suppl 10):085S-121S, 1997 • Pediatr Clin North Am 45, Oct 1998 • Pediatr Clin North Am 46, Oct1999 • Pediatric in Review, Vol 21, Number 8, Aug 2000

ADHDReferences • www.aap.org • www.chadd.org • www.pedsedu.com

ADHD: Diagnosis and Management