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The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder Carla M...
Basic ADHD Information <ul><li>Most common neurological and behavioral disorder in childhood </li></ul><ul><li>One of the ...
Statistics <ul><li>In 2003, the CDC reported that approximately 4.4 million children ages 4-17 in the US had a diagnosis o...
ADHD often results in the following: <ul><li>Difficulties in school </li></ul><ul><li>Poor relationships with parents and ...
Etiology <ul><li>Exact etiology of ADHD is unknown </li></ul><ul><li>Thought to be a complex interaction between neurologi...
Predisposing Factors <ul><li>Low birth weight </li></ul><ul><li>Low social status </li></ul><ul><li>Severe conflicts among...
Symptoms Suggestive of ADHD: <ul><li>Easily distracted by sights and sounds in their environment </li></ul><ul><li>Difficu...
Diagnosis <ul><li>Use of AAP guidelines: </li></ul><ul><ul><li>Evaluate children 6-12 yrs. presenting with core symptoms o...
Diagnosis <ul><li>Need a detailed patient & family history </li></ul><ul><li>Interview with patient & family </li></ul><ul...
Subtypes of ADHD (Based on DSM-IV Criteria) <ul><li>Predominantly hyperactive-impulsive type – no significant inattention ...
 
Treatment <ul><li>Currently no cure for ADHD </li></ul><ul><li>Three types of treatment: </li></ul><ul><ul><li>Medication ...
Medications for ADHD <ul><li>Stimulants – shown to improve core symptoms by increasing & maintaining balance of dopamine &...
Stimulants <ul><li>Some available in short-acting, long-acting, and extended release forms. </li></ul><ul><li>Produce rela...
Commonly Used Stimulants <ul><li>Methylphenidate (Ritalin) – long-acting form is Concerta, extended-release forms are Rita...
Non-Stimulants (atomoxetine) <ul><li>Slower response times than stimulants </li></ul><ul><li>Non-scheduled drug – no poten...
Methylphenidate (Ritalin) vs. Atomoxetine (Straterra) <ul><li>Recent study analyzed all clinical trials which compared the...
New ADHD Treatment Option <ul><li>The 1 st  and only stimulant prodrug, lisdexamphetamine (Vyvanse) was granted market app...
Conclusion <ul><li>ADHD is a disorder in which research must continue in order to determine it’s etiology & to obtain more...
References <ul><li>Adesman, A.  The diagnosis and management of attention-deficit/hyperactivity disorder in pediatric  pat...
References (Continued) <ul><li>Leslie, L. et al.  Implementing the American Academy of Pediatrics attention-deficit/hypera...
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ADHD diagnosis/misdiagnosis and treatment options

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ADHD diagnosis/misdiagnosis and treatment options

  1. 1. The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder Carla M. Thacker PAS 646 March 22, 2007
  2. 2. Basic ADHD Information <ul><li>Most common neurological and behavioral disorder in childhood </li></ul><ul><li>One of the most frequently identified chronic childhood disorders seen in the primary care setting </li></ul><ul><li>Core symptoms are inattentiveness, hyperactivity, and impulsiveness </li></ul>
  3. 3. Statistics <ul><li>In 2003, the CDC reported that approximately 4.4 million children ages 4-17 in the US had a diagnosis of ADHD </li></ul><ul><li>An estimated 4-12% of children in the community are affected by ADHD </li></ul><ul><li>There is a significant difference in the prevalence of ADHD in boys and girls, with estimates of 10% and 4%, respectively </li></ul>
  4. 4. ADHD often results in the following: <ul><li>Difficulties in school </li></ul><ul><li>Poor relationships with parents and peers </li></ul><ul><li>Low self-esteem </li></ul><ul><li>Various other behavioral, learning, and emotional problems </li></ul><ul><li>Difficulties for the child’s parents, including marital problems, increased stress, and poor relationships with their child </li></ul>
  5. 5. Etiology <ul><li>Exact etiology of ADHD is unknown </li></ul><ul><li>Thought to be a complex interaction between neurological, biological, & environmental factors </li></ul><ul><li>Genetics and biological factors play the major roles </li></ul><ul><li>Variation in genes regulating dopamine, norepinephrine, & serotonin in the brain </li></ul>
  6. 6. Predisposing Factors <ul><li>Low birth weight </li></ul><ul><li>Low social status </li></ul><ul><li>Severe conflicts among parents </li></ul><ul><li>Being placed in foster care </li></ul><ul><li>Mother who smoked, consumed alcohol and/or drugs while pregnant. </li></ul>
  7. 7. Symptoms Suggestive of ADHD: <ul><li>Easily distracted by sights and sounds in their environment </li></ul><ul><li>Difficulty concentrating for long periods of time </li></ul><ul><li>Becomes restless easily </li></ul><ul><li>Excessive impulsiveness </li></ul><ul><li>Frequent daydreaming </li></ul><ul><li>Slow to complete tasks </li></ul>
  8. 8. Diagnosis <ul><li>Use of AAP guidelines: </li></ul><ul><ul><li>Evaluate children 6-12 yrs. presenting with core symptoms of ADHD </li></ul></ul><ul><ul><li>Must meet DSM-IV criteria </li></ul></ul><ul><ul><li>Gather information about symptoms from various settings from the parents & school system </li></ul></ul><ul><ul><li>Assess for coexisting mental health & learning problems </li></ul></ul><ul><ul><li>Order diagnostic tests as indicated by findings </li></ul></ul>
  9. 9. Diagnosis <ul><li>Need a detailed patient & family history </li></ul><ul><li>Interview with patient & family </li></ul><ul><li>Obtain report cards & teacher reports </li></ul><ul><li>Obtain a thorough physical examination including visual & auditory screening </li></ul><ul><li>Refer patient to mental health specialist if coexisting mental disorders or learning disabilities suspected </li></ul>
  10. 10. Subtypes of ADHD (Based on DSM-IV Criteria) <ul><li>Predominantly hyperactive-impulsive type – no significant inattention </li></ul><ul><li>Predominantly inattentive type – no significant hyperactive-impulsive behavior (previously known as ADD) </li></ul><ul><li>Combined type- both inattentive & hyperactive-impulsive behaviors </li></ul>
  11. 12. Treatment <ul><li>Currently no cure for ADHD </li></ul><ul><li>Three types of treatment: </li></ul><ul><ul><li>Medication management </li></ul></ul><ul><ul><li>Behavioral therapy </li></ul></ul><ul><ul><li>Combination of medication & behavioral therapy </li></ul></ul>
  12. 13. Medications for ADHD <ul><li>Stimulants – shown to improve core symptoms by increasing & maintaining balance of dopamine & serotonin in brain </li></ul><ul><li>Non-stimulants (atomoxetine) – enhances noradrenergic function through presynaptic reuptake of norepinephrine </li></ul>
  13. 14. Stimulants <ul><li>Some available in short-acting, long-acting, and extended release forms. </li></ul><ul><li>Produce relatively quick response in patient </li></ul><ul><li>Schedule II controlled substance – potential for abuse </li></ul><ul><li>Side effects – loss of appetite, insomnia, HA, dizziness, abdominal pain </li></ul><ul><li>Begin with lowest dosage & titrate up as necessary </li></ul>
  14. 15. Commonly Used Stimulants <ul><li>Methylphenidate (Ritalin) – long-acting form is Concerta, extended-release forms are Ritalin SR, Metadate ER, & Metadate CD </li></ul><ul><li>Amphetamine (Adderall) </li></ul><ul><li>Dextroamphetamine (Dexedrine, Dextrostat, and Focalin) </li></ul><ul><li>Pemoline (Cylert) – no longer considered first-line due to risk of hepatotoxicity </li></ul>
  15. 16. Non-Stimulants (atomoxetine) <ul><li>Slower response times than stimulants </li></ul><ul><li>Non-scheduled drug – no potential for abuse </li></ul><ul><li>Side effects similar to those of stimulants </li></ul><ul><li>Atomoxetine (Straterra) is the only non-stimulant approved by the FDA to treat childhood ADHD </li></ul><ul><li>More expensive than stimulants </li></ul><ul><li>Others sometimes used are antidepressants; including bupropion (Wellbutrin) & despiramine, & antihypertensives; including clonidine & guanfacine </li></ul>
  16. 17. Methylphenidate (Ritalin) vs. Atomoxetine (Straterra) <ul><li>Recent study analyzed all clinical trials which compared the two drugs </li></ul><ul><li>More patients responded to Ritalin than Straterra & responses were quicker with Ritalin </li></ul><ul><li>Study confirmed that stimulants are the most efficacious treatment for childhood ADHD </li></ul><ul><li>Straterra is a good alternative treatment when stimulants are not well tolerated or when drug abuse is a potential problem </li></ul>
  17. 18. New ADHD Treatment Option <ul><li>The 1 st and only stimulant prodrug, lisdexamphetamine (Vyvanse) was granted market approval by FDA in Feb. 2007 </li></ul><ul><li>Therapeutically inactive until contact is made with GI tract – only active if swallowed </li></ul><ul><li>May prevent abuse of drug by those who snort or inject crushed pills </li></ul><ul><li>Recent study showed that 95% of children taking Vyvanse produced “much improved” or “very much improved” rating on Clinical Global Impressions rating scale </li></ul>
  18. 19. Conclusion <ul><li>ADHD is a disorder in which research must continue in order to determine it’s etiology & to obtain more information regarding safety of treatments. </li></ul><ul><li>Due to increasing numbers of children with ADHD, it is very important for primary care physicians to become skilled at diagnosing and treating the disorder. </li></ul>
  19. 20. References <ul><li>Adesman, A. The diagnosis and management of attention-deficit/hyperactivity disorder in pediatric patients. Primary Care Companion J Clin Psychiatry 2001; 3: 66-77. </li></ul><ul><li>Foy, J., Earls, M. A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics 2005; 115: e97-e104. </li></ul><ul><li>Furman, L. What is attention-deficit hyperactivity disorder (ADHD)? J Child Neurol 2005; 20(12): 994- 1003. </li></ul><ul><li>Gibson, A.P., Bettinger T.L., Patel, N.C., Crismon, M.L. Atomoxetine versus stimulants for treatment of attention deficit/hyperactivity disorder. Ann Pharmacother 2006 Jun; 40(6): 1134-42. </li></ul><ul><li>Greydanus, D.E. Pharmacologic treatment of attention-deficit hyperactivity disorder. Indian J Pediatr 2005; 72: 953-960. </li></ul><ul><li>Harpin, V.A. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Child 2005; 90: i2-i7. </li></ul><ul><li>Karande, S. Attention deficit hyperactivity disorder: A review for family physicians. Indian J Med Sci 2005; 59: 547-556. </li></ul><ul><li>Kuntsi, J., McLoughlin, G., Asherson, P. Attention deficit hyperactivity disorder. Neuromolecular Med. 2006; 8(4): 461-84. </li></ul><ul><li>Leslie, L. The role of primary care physicians in attention deficit hyperactivity disorder (ADHD). Pediatr Ann 2002 August; 31(8): 475-484. </li></ul>
  20. 21. References (Continued) <ul><li>Leslie, L. et al. Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings. Pediatrics 2004 July; 114(1): 129-140. </li></ul><ul><li>Mental health in the United States. Prevalence of diagnosis and medication treatment for attention- deficit/hyperactivity disorder—United States, 2003. MMWR Morb Mortal Wkly Rep 2005; 54(34): 842-7. </li></ul><ul><li>Olfson, M. New options in the pharmacological management of attention-deficit/hyperactivity disorder. </li></ul><ul><li>Am J Manag Care 2004; 10: s117-s124. </li></ul><ul><li>Steer, C.R. Managing attention deficit/hyperactivity disorder: unmet needs and future directions. </li></ul><ul><li>Arch Dis Child 2005; 90: i19-i25. </li></ul><ul><li>Wolraich, M.L. et al. Attention-deficit/hyperactivity disorder among adolescents: A review of the diagnosis, treatment, and clinical implications. Pediatrics 2005; 115(6): 1734-46. </li></ul><ul><li>www.cdc.gov </li></ul><ul><li>www.nimh.nih.gov </li></ul><ul><li>www.shire.com </li></ul><ul><li>www.webcenter.health.webmd.netscape.com </li></ul><ul><li>www.wellmark.com </li></ul>
  21. 22. Questions?

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