ADHD Review for UCAYA Wiki

1. ADHD
Mike Guyton, MD
Assistant Clinical Professor/Academic
Faculty in General Pediatrics

3. Objectives
• What is ADHD
– Definition and Criteria
– Evaluation
• How is ADHD Treated?
-Stimulants vs Non-stimulants vs Adjunctive
-Side effects of therapy
• The culture of ADHD
– Public perceptions vs medical perceptions
• Abuse of ADHD Medications
– Populations at Risk
– Medications commonly abused
– Co-morbid conditions
• Management of ADHD
– Alternative options

4. ADHD: Setting the
Record Straight

5. ADHD
• A neuropsychiatric disorder of inattention,
impulsivity and/or hyperactivity
– Affecting cognitive, academic, behavioral,
emotional, and social functioning
• Commonly manifests in childhood
• Wide spectrum of presentation

6. Criteria for ADHD
• <17yo
– ≥6 symptoms of hyperactivity/impulsivity or ≥6
symptoms of inattention
• >17yo
– ≥5 symptoms of hyperactivity/impulsivity or ≥5
symptoms of inattention
• Exclusion of other physical, mental, or
situational conditions that could account for
the symptoms

7. Adult Symptoms of ADHD
Adult
ADHD
Hyperactivity:
Restlessness
Verbosity
Constant Activity
Impulsivity:
Ending
Relationships/Jobs
Overreaction to
Frustrations
Inattention:
Procrastination
Difficulty making
decisions/organization
Poor Time Management

8. Evaluation of ADHD
• Several rating scales out there
– Conners’ Adult ADHD Rating Scale (CAARS)
– Adult ADHD Self-Report Scale (ASRS)
• Should be used as supplements rather than
substitutes for the clinical exam/impression
– Not diagnostic, but supportive
• Need to see deficit in at least 2 separate
areas
– Home, school, personal/professional life,
economics

9. Differential Diagnosis
• Medical Conditions
– Anemia, sleep disorder, substance abuse, endocrine disorders
• Psychosocial/Environmental Conditions
– Parental psychopathology, stressful home environment
• Emotional/Behavioral Disorders
– Depression, Anxiety, ODD, OCD, PTSD, Adjustment Disorder
• Developmental Variations
– ID, normal variation, giftedness
• Neurologic/Developmental Disorders
– LD, Autism Spectrum Disorder, Seizure Disorder

11. Medical Treatment for ADHD
• Stimulant vs non-stimulant medication
– Stimulants are gold standard
– Non-stimulant meds not recommended less than 6yo
• Based on evidence, experience/comfort, and
insurance
– Guides initial choice as well as when switching
• Monitoring is just as important as medication
• Are Medications Safe

12. Pre-Treatment Counseling
• Aim to is improve IMPULSIVITY and FOCUS
– Not to curb bad behavior
• Explain benefits and potential risks
– Some risks not well understood (i.e. causal association
between serious cardiovascular events and stimulant use)
• Explain the expected length of management
– 1-3 months to find appropriate medication/dosing regimen

14. Stimulant Medication
• First line agent
– Consider risk of substance abuse by patient or
family
• Several blinded randomized trials showed
efficacy of stimulants over non-stimulants
– Response rate to specific stimulants range 70-80%
• Some long term studies also exist
– Safe and effective for years-decades
– Appetite suppression most common long term SE

15. Non-stimulant Medication
• Used in various settings
– History of substance abuse
– Concern over side effects
of stimulants
– Unable to tolerate
stimulant medication
• Found to be more
effective than placebo in
multiple studies
• Some used in conjunction
with stimulant
medication
– Clonidine, Guanfacine

16. Side Effects
• Common
– Anorexia, Insomnia, Tics
– Dizziness
– Mood Labiality
– Mild Cardiovascular
changes (dose dependent)
• Not so common
– Priaprism
– Psychosis
– Diversion and Misuse
– Poor Growth Trajectory

17. Effects on those without ADHD
• Mechanism of action of stimulants is not well
known
– Dopamine and Norepinephrine concentrations
• In general, there is increased ability to focus
and some increase in hyperactivity in those
without ADHD
• Side effects happen in both ADHD and non-
ADHD population

19. The Culture of ADHD: Public
Perceptions
• Many myths and misconceptions regarding
ADHD
– Not a real medical diagnosis
– Only seen in children if seen at all
– ADHD is over diagnosed
– Poor parenting causes ADHD
– ADHD is worse in men vs women
– Children with ADHD are “troublemakers”

20. ADHD Myths

21. Public Perceptions: Is this an American
Disease?
• In 2003 it was found that 1:20 children had
ADHD in America
– Due to certain cultural and societal factors
inherent to American life
• 50 studies were looked at retrospectively
– Prevalence of ADHD in non-US children just as
high if not higher in other countries
• Ukraine
– In others, rates were lower
• Sweden, Iceland, Australia, Italy

22. Medical Perspective: The risk of not
treating
• Increased risk of poor
social/financial/educational attainment
– ~32% drop out of school
– ~47% of youth in juvenile detention have ADHD
• Increased risk of injury to self/others
– 4X the accidents; 3X the speeding tickets; more likely
overall for bodily harm
• Involvement in high risk behaviors
– Onset of substance use disorders (SUD) at a younger
age than peers
– More likely to participate in high risk sexual behavior

23. Abuse of ADHD Meds
• Most abuse involves short acting medications
• Adults with ADHD and history of substance abuse
are at highest risk
– Also, those with FH of drug abuse
• Treatment of ADHD with stimulants does not
seem to induce substance abuse
– ? Protective against SUD if ADHD treated properly
• Other co-morbid conditions could promote
misuse as well and need to be taken into account
with treatment
– Anxiety and depression

24. Specific Co-Morbid Disorders in Adult
ADHD
• Specific Phobias
– 29.3%
• Bipolar Disorder
– 19.4%
• Major Depressive
Disorder
– 18.6%
• Dysthymia
– 12.8%
• Generalized Anxiety
Disorder
– 8.0%

26. ADHD and Substance Abuse
• Youth with ADHD are:
– ~2X as likely to have
lifetime nicotine use
– ~3X more likely to report
nicotine dependence in
adolescence and young
adult hood
– ~2x more likely to meet
criteria of alcohol
dependence or abuse
– ~1.5X more likely to meet
criteria for MJ dependence
– More than 2.5X more likely
to develop a SUD overall

27. Theories on the relationship of ADHD
and SUD
• Inherent impulsivity/poor
judgment and insight
• Biological factors and
similarities
– Dopamine Stimulation and
routing of motivation
– ADHD + Stimulants 
routed to executive
functioning  task
oriented rewards
– Illicit drugs of abuse 
routed to mainly reward
centers  euphoria and
eventual dependence

29. Misuse, Diversion, and Abuse of
Stimulants
• Misuse (5-35% in college aged students)
– Use of meds not prescribed or used in non-prescribed
ways
• Taking larger doses than prescribed to improve studying or
to “get high”
• Diversion (occurring as often as 16-23%)
– Transfer of meds from a person whom it is prescribed
for to one it is not prescribed for
• Abuse (as high as 6% in ages 18-25)
– Use of meds associated with problems or risks that
impair functioning

30. ADHD vs non-ADHD Patient
• Abuse of stimulant medication strongly linked
to subjective effect
– How much one likes a drug, experiences euphoria
• Those with ADHD less likely to experience the
subjective effect than those without ADHD
– 1970’s, reported no changes in mood but definite
changes in productivity
• Short acting agents much more likely to be
abused than long acting agents

31. Alternative Strategies
• Many have been proposed; unfortunately not
many studies to support
– Nutritional Supplementation
• Various vitamins, minerals, and herbal supplements
– Yoga and Meditation
– Special Diets
• Elimination of sugar, caffeine, allergens (milk, wheat)
– Biofeedback Sessions
• Use of EEG to promote brainwave awareness/theoretical
– Psychotherapy
• Cognitive Behavioral Therapy

35. Take Home Points
• ADHD is a complex condition
– Biological/Medical/Psychiatric/Neurological
• Pharmacologic therapy is tried and true, but that
doesn’t mean its for everyone
• Proper identification and screening for co-morbidities
needs to be the focus of healthcare practitioners
– Multidisciplinary approach
• Doctors need to partner with their patients (and vice
versa)
– Plan only therapeutic if there is buy-in from both parties

36. Questions?