ADHD Child to Adult Cindy Ruttan DO 2008
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ADHD Child to Adult Cindy Ruttan DO 2008

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ADHD Child to Adult Cindy Ruttan DO 2008 ADHD Child to Adult Cindy Ruttan DO 2008 Presentation Transcript

  • ADHD Child to Adult Cindy Ruttan DO 2008 Kansas Osteopathic Conference OVPK KS
  • Key points to cover
    • Symptoms/ History
    • Who it effects-ages
    • Collecting informants
    • Rule out diagnosis
    • Treatment options
      • Behavioral
      • Medications
  • ADHD is like---
    • I stopped to think, and forgot to start again.
    •  
    • I was trying to daydream, but my mind kept wandering .
  • What is ADHD ?
    • Neuro- Behavioral Disorder
      • Inattention-( executive functions)
      • Hyperactivity
      • Impulsivity
    • Speculate: Dopamine and NE dysregulation
    • Affects 7-12% of pediatric group pop.
    • High chance for Co-morbidity
    • Costly due to ER use, injury and Hospital use .
  • ADHD Review History
    • Core criteria DSM-III:
      • 3 separate symptom areas
    • DSM-III-R
      • one long list
    • DSM-IV
      • two core dimensions
  • ADHD and DSM IV criteria
    • Concerned by …may change in future DSM’s.
    • Age of onset- ? 7 years
    • Age appropriate Symptoms are needed for helping diagnose disorder from Child/ Adol/ Adults
    • Various inputs needed –they can conflict
  • MOAT ADHD Diagnosis
    • M ovement excessive (Hyperactive)
    • O rganization problems (difficulty finishing tasks)
    • A ttention problems
    • T alking impulsively
    Meet criteria of 6 of 9 symptoms, present prior to age 7yrs and present in 2 or more settings. The Psychiatric Interview 2 nd ed Carlat
  • Children's ADHD Review of past 10 years
    • Reviews in Child Adolescent Psychiatry (Williams and Wilkins) Pg 9-17. by Dennis Cantwell MD
      • Reprint from the J. of the American Academy of Child and Adolescent Psychiatry .
  • ADHD Natural Hx
    • 30% Developmental Delay
    • 40% Continual Display
      • Internalizing disorders
        • Depression
        • Anxiety
    • 30% Developmental Decay
      • Externalizing disorders
        • ODD
        • CD
  • ADHD info from 10 year review
    • Core symptoms may change over time. Consider the younger one presented the more persistent diagnosis and the older one is diagnosis the fewer symptoms that are present.
    • Examples Include:
    • Temper outbursts
    • Aggressive argumentative behavior
    • Fearless
    • Sleep disturbance
  • Diagnostic concerns…
    • Can one diagnosis contribute to all symptoms reported?
    • Can you be observing more than one disorder?
    • ADHD –diagnosis of exclusion.
    • consider : Hyper behavior and Mania/ Hypomania
    • Decreased focus/inattention with Depression
  • ADHD Co morbidities
    • CD
      • Possible reduction in Substance Abuse Disorder ( Drugs and ETOH) if treated early for ADHD with Stimulants
    • ODD
    • LD
    • Anxiety 20-40%
      • OCD increase up to 11%^
    • Tourette’s-rare (usually reverse) / Tic
      • Tic 10-15%^
    • Mood Disorder 5-40% depression
      • Bipolar 10-22%^
    • Poor interpersonal skills/demoralized
      • David Krefetz DO MBA FACN, FAPA
      • ADHD with Comorbidity in Pediatric Populations:
      • Impllications for Eval and Management ^
  • DBD (Disruptive Behavior Disorder) refers to the Comorbidity diagnosis of ODD/CD
    • Worry about aggression and delinquency
    • Academic underachievement
    • Increased risk for substance abuse
    • Increased social maladaptation
    • Note having both DBD and ADHD makes the ADHD harder to treat.
    • NO medications FDA approved for ODD/ CD
  • Learning Disorders
    • Input
      • Process of getting info into the brain
    • Integration
      • Organization and understanding
    • Memory
      • Storage of info to retrieve later
    • Output
      • Communicate from brain to others or put into action in the environment
      • ADHD and LD Booklet for Parents by Larry B Silver MD
  • Input Disability
    • Visual Perception
    • Auditory Perception
    • Auditory Lag (Auditory Processing )
    • ADHD and LD Booklet for Parents by Larry B Silver MD
  • Integration Disability
    • Sequencing
    • Abstraction
    • Organization
    • Memory
    • ADHD and LD Booklet for Parents by Larry B Silver MD
  • Output Disability
    • Language
    • Motor
      • Gross
      • Fine
      • ADHD and LD Booklet for Parents by Larry B Silver MD
  • Diagnosing ADHD
    • NO lab tests, or psychologic tests that definitely diagnose.
    • Recommend Academic Testing to establish level in school and any LD’s.
    • Obtain Conners Forms or Vanderbuilt Scales that help with defining criteria –or use the DSM IV criteria.
    • TOVA or CPT may help with identification of ADHD symptoms and how well the meds are working.
  •  
  •  
  • Early Medical intervention with Medication has shown:
    • For individuals with ADHD in childhood to decrease the risk for subsequent non-nicotine SUD in adol and early adulthood.
    • ? (Worked best for those with the milder form of ADHD)
    • A Literature Review Series Vol 1 No. 3
  • Children with ADHD at risk for ETOH problems
    • ADHD is a risk factor for ETOH problems –parental behaviors and environmental stress contribute too.
      • More likely to drink heavy and to have enough problems to diagnose ETOH Abuse or Dependency.
        • onset average age 15
        • Consider a possible subset of ADHD disorder with antisocial behavior patterns
      • ETOH and ADHD seem to run in families which thus seem to be under more “stress” situations.
      • Addiction Science Made Easy 4-8-07
      • WWW.NATTC.org
  • Young Adults –college age
    • Problems noted:
      • Harder to adjust to adult life, college life with poorer social skills and less self esteem.
      • Lower GPA, less financially, inc. school drop out
      • Less methodical, inc. procrastination, less self control/self disciplinary behaviors
    • Symptoms look different
      • Impulsive and hyper = mental restlessness or subjective feelings of such.
  • Adult ADHD
    • Nature of disorder is disorganized, forgetful and poor self regulation
    • Majority can not remember to take their medication if on IR or multi doses needed.
      • Inconvenience
      • Embarrassed
      • Safety and long term effects
      • Different feeling…
  • Adult ADHD
      • Basic same core symptoms as with Peds ADHD
      • Review HX of Ed, job and family
      • Standard rating scales/specific for ADULTS
      • Collateral info coping /stressors
      • Rule out other diagnosis
      • Review options for Treatment as they match patient goals
        • Meds/ CBT
  •  
  • Adult ADHD who had diagnosis as child
    • Many loose full diagnostic status( functional remission)10% vs Persistent ADHD at15% by 25 yrs old.
    • reality is ADHD had remitted only for a minority.
    • Inattentiveness remains when inattention and Hyperactivity decline.
    • If one put partial remission + Persistant = 65% have symptoms of ADHD.
  • Functional Impairment
    • Lower Socioeconomic
    • Relationship impaired
    • Dec. academic accomplishments
    • Employment issues
    • Driving record bad
    • Dating, vol. work, community service, socializing with friends /family, culture and educational out of school activities limited.
  • Adult ADHD cont-
    • Common Maladaptive Beliefs:
    • Self mistrust
    • Failure
    • Inadequate
    • Incompetent
    • Instability
    • Common Dysfunctional Coping Behaviors seen:
    • Avoidance
    • Procrastination
    • Pseudo efficiency low priority tasks first then high priority tasks last.
    • Busy without completion of things
  • Co morbidity is “The RULE” with Adult ADHD
    • Mood Disorders—50-60%
    • Depression- recurrent
    • BAD
    • Cyclothymia
    • Dysthymia
    • DEP NOS
    • Anxiety Disorders
    • 40-50%
    • GAD
    • Anxiety NOS
  • Co morbidity cont- Adult ADHD Various %
    • SUD
    • LD
    • IED
    • Tourette
    • Antisocial Personality Disorder
    • Borderline Personality Disorder
    • Dependent Personality Disorder
  • Behavioral Interventions
  • Treatment Options with or without medications 1
    • Praise reward positive behaviors by :
      • verbalize it
        • Speak individual / public
      • Write it
      • Reward it
        • Physical Activity -participation
        • Material - for doing good job in class
        • Dec / Jan 2008 ADDitude Magazine pg 49
  • Cont: Treatment Options with or without Medication 2
    • Follow up with teachers regarding childs Positive and Negative attributes . Keep open communication.
    • Make sure IEP/504 is being used.
      • Address LD issues and grade appropriate level of work in sink
    • Do help at home with homework or working ahead if possible/ tutor
        • Dec / Jan 2008 ADDitude Magazine pg 49
  • Cont: Treatment Options with or without Medication 3
    • Encourage routine healthy food and snacks –due to side effects form medications
      • Peanut butter / double up on Breakfast drink
    • Consider type and delivery style of medications including time frame medications given and duration of action
    • Keep structured as possible and avoid chaotic situations-you as a parent stay calm, cool and collected.
    • Give yourself time to accomplish the task/ goal desired. Keep a Daytimer/ planner if needed
    • Give an exercise break
        • Dec / Jan 2008 ADDitude Magazine pg 49
  • Cont: Treatment Options with or without Medication 4
    • Use verbal and non-verbal cues to remind or stay focused
    • Keep good sleep hygiene. Insomnia is common with ADD/ ADHD either a part of the disorder itself or exacerbated by medications
    • Try to avoid arguments and confrontations leading to poor self esteem
    • Dec / Jan 2008 ADDitude Magazine pg 49
  • Therapy Goal:
    • Sensitize the patient to and interrupt dysfunctional behaviors
      • Coping skills
      • Problem focused
      • Adaptive thinking
      • Anger management
      • Communication skills
  • RX Treatments
  • Medication Options
    • 19 meds are FDA approved
      • 18 are stimulants
        • Use Lowest Dose which addresses symptoms—as one increases dose if no improvement noted than lowest dose which provided improvement is the best dose.
        • List symptoms from patients concern then family and compare… may not agree.
  • Medication Diversion
    • Transfer of meds from one it is prescribed to one whom it is not.
    • Taking more (quantity)
    • misuse for Euphoric desire
    • Combo with other substances
    • Study of those Diagnosed with ADHD and its misuse:
    • 22% of adol and young adults in study misused in some capacity.
    • ADHD patients Sold it more than the non ADHD group. Those who sold had comorbid diagnosis of SUD and CD.
    • IR prep most often diverted
    • A Literature Review Series Vol 1 No. 3 Pg 19-21
  • Medications
    • Stimulants
      • Short
      • Intermediate
      • Long
      • Transdermal
    • Stimulant Pro Drugs
    • Non Stimulants
      • SNRI
      • Adrenergic Agents
      • Antidepressants
      • Dopaminergic Agents
  • Stimulants FDA Approved Adult FDA Approved is in BLUE
      • Amphetamine
        • Adderall
        • Dexedrine
        • Dextrostat
        • Adderall XR 2004
        • Dexedrine Spanules
    • Not recommended under age 3 yrs
  • Stimulants cont-FDA approved
      • Methylphenidate
        • Ritalin
        • Methylin chewable, Oral sol
        • Metadate ER
        • Focalin
        • Focalin XR 2005
        • Methylin ER
        • Ritalin SR
        • Metadate CD
        • Ritalin LA
        • Concerta
      • Not recommended for children under age 6
  • MethylphendateTransdermal Patch New Stimulant Delivery Option
  • Transdermal Methylphenidate Patch
    • Daytrana
      • FDA approved ages 6-12
      • 10,15, 20 and 30 mg
      • Recommended one patch daily
      • Start with the 10 mg patch if no improvement in 1 week increase-- cont to adjust dose per 1 week intervals.
      • Location hip (rotate area/ sides) may cause irritation
      • Delivered over 9 hours
      • Possibly effects initial height but minimal to not significant in adulthood
      • Much the same side effect profile as oral agents
      • Remove 2 hours prior to effects wearing off.
      • Current Psychiatry Vol 5 No.6 / June 2006
  • Stimulant Pro Drug
    • Vyvanse - Lisdexamfetamine
      • FDA approved for ages 6-12
        • 30, 50, and 70 mg capsules
      • Start with 30 mg/day. If needed titrate up with 20mg every 3-7 days as tolerated to max of 70 mg/day
        • Effect about 12 hours
        • Steady state in 2-3 days
        • Half life 9.5 hours
        • Current Psychiatry Vol.6 no.6 June 2007
  • Vyvanse – Lisdexamfetamine cont-2
    • Blocks NE and Dopamine reuptake in Presyn neuron
    • Noted improvement 2 hrs after dosing.
    • Large change in corrected QTC intervals--? Need more info about cardiac risk
    • Possibly Less risk for abuse at recommended doses—may be misused at higher than therapeutic doses.
        • Current Psychiatry Vol.6 no.6 June 2007
  • Vyvanse – Lisdexamfetamine cont-3
    • Caution in Patients:
      • Co morbid eating
      • Sleep disorder
      • HTN or cardiovascular illness
        • Monitor HR and BP
    • Do not prescribe to patients taking MAOI or who have taken one in 2 weeks of the presentation.
        • Current Psychiatry Vol.6 no.6 June 2007
  • Stimulant: side effects
    • Review Black Box Warnings regarding CV risks and Sudden Death.
    • Encourage Food prior to taking Medications
    • Understand possibility of Psychosis
    • May make Mania or Tics worse
    • Can write for 90 day RXN as of Dec 07
  • Stimulant Black Box Warnings
    • Pre-existing Cardiac abnormality, cardiomyopathy, arrythmias, or other disorders which the use of a sympathomimetic could be dangerous or increase the vulnerability of patients lives .
      • Murmurs, syncopy history, HTN
    • Consult Cardiology to be safe.
    • Current Psychiatry Vol. 5 No. 10 / Oct 2006
  • STRATTERA = Atomoxetine 2002
    • FDA approved for:
    • Child
    • Adol
    • adult
  • SNRI – Atomoxetine Non Stimulant --FDA Approved
    • Full effect 3-7 weeks peak levels 1-2 hrs or 3-4 for slow metabolizers
    • Shorter sleep latency , improved sleep
    • Increased risk of suicidal ideation in children and adolescents (see precautions)
    • Dose by Body Weight.
      • Do not exceed 1.4 mg/kg/day or 100 mg whichever is less. Start low go slow (start 0.5mg/kg/day for 10 day then 0.8 for 10 days then 1.2 in a individual or BID dose)
      • Over 70 kg start at 40 mg dose and increase after 10 days to 60 mg for 10 days then to 80mg after 2-4 weeks consider max dose at 100 mg/ day.
  • Cont:SNRI - Atomoxetine
    • Safety not established under age 6 years
    • Lower dose if a slow CYP2D6 metabolizer or go slower to increase after 4 weeks if on another drug which also uses/ inhibits 2D6
    • Modify dose by 50-25 % theraputic dose if hepatic issues
    • Monitor BP,hepatic dysfunction,CV issues always review the Adv. Effects list.
    • Monitor BP
    • Adults with more Anxiety, emotional dysregulation
  • Cont:SNRI - Atomoxetine
    • Adults start with 40 mg then in 3 days increase to 80 mg either in one AM dose or split dose 40 bid. Max is 100mg.
  • Adrenergic Options Not FDA approved in children or Adolescents
    • Clonidine
      • Helps with impulsivity, insomnia associated with Stimulant meds, hyperarousal, agitation, and tic disorder
        • Oral and transdermal patch
    • Side affects:
      • Sedation daytime if dosed in daytime.
      • Withdrawl hypertensive episodes
      • 5 reported sudden deaths when used in combo with stimulants
  • Adrenergic Options Not FDA approved in children or Adolescents
    • Guanfacine
      • Similar to Clonidine in it’s uses
      • Less sedation and hypotension than Clonidine
      • Not recommended or use with caution in patients with renal insufficiency
      • Refractory ADHD with Tic issues, may help with nightmares associated with PTSD
      • Always read Adverse Effects, contraindications and Precautions in the package inserts
  • Antidepressants : Not FDA approved in children/adolecents for ADHD treatment nor Adults for ADHD
    • Buproprion max 450 mg/ day in Divided dose unless using 300XL for Once daily dosing.
      • 50 % or adult respond
      • HA, Dry mouth, nausea, insomnia
    • Venlafaxine prelim studies suggest efficacy
    • TCA’s (Amitriptyline, desipramine, imipramine,nortriptyline)
    • MAOI’s open label suggest improved concentration in children with ADHD
  • Dopaminergic Agents: Not FDA approved in Adults or children ** Cholinergic Agents: Not FDA approved in Adults or children *
    • Modafinil**
    • Donepezil*
  • Herbal and Natural Products: Not FDA approved in Adults or children for ADHD
    • Ginko Biloba
    • Omega 3 Fatty Acids
    • Vitamins/Minerals
      • Zinc
      • Iron
  • Treatment Summary
    • RX treatment optimal and better for core symptoms than Behavioral treatment alone.
    • Combo of RX and Behavioral was superior to either alone.
  • Can meet someone, fall deeply in love, marry, fight, hate, and divorce, all in about 35 minutes or less.    
  • Clinical Practice Guidelines CPG’s
    • www.pediatrics.org/cgi/content/full/105/5/1158
    • www.aacap.org/galleries/practiceParameters/New_ADHD_Parameter.pdf
    • Valid rating scale:
    • Vanderbuilt
    • Conners Forms
    • www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp
    • www.med.nyu.edu/psych/assets/adhdscreen18.pdf
      • Vol. 6 No. 4 /April 2007
  • References
        • The Psychiatric Interview 2 nd Ed. Carlat
        • Dec/Jan2008ADDitude Magazine
        • Clinical Handbook of Psychotropic Drugs for children and adolescents 2 nd Ed. Kalyna Bezchlibnyk-Butler and Adil Virani
        • Current Psychiatry
          • Vol.5 No. 2 / Feb.2006
        • Atomoxetine package insert
    • New Perspectives on Adult ADHD
      • College Years CME Part 5 of 6
      • ADHD : A Disorder with Life time Impact CME part 3 of 6
    • Advances in ADULT ADHD CME Part 7 of 8
        • ADHD Drug Therapy: Long and short of it.
  • References
    • Primary Psychiatry
      • July 2004: Vol.11 No.7
    • NeuroPsychiatry Reviews
      • Jan 08 Vol.9 No.1 pg.21
    • Psychiatric News
      • Feb.1, 08 Vol 43 No.3 pg.23