Since this is a school based audience, we’ll start some of the academic repercussions: When you run some of the specifcs: 56% may require academic tutoring. 30-50% may be retained in a grade at least once 35% may fail to complete high school altogether. 30-40% may be placed in one or more special education programs. 46% may be suspended from school. 10-35% may drop out entirely and fail to complete high school. Learning disabilities occur in roughly 30-60% of ADHD kids. Learning Disorders: 8-39% are likely to have a L.D. in Reading, 12-30% have a L.D. in Math, and 12-27% have a L.D. in Spelling.
Suppl. JAACAP Practice Parameters for Use of Stimulant Medications 2002 ;41:26S-49S I.M.P.A.C.T. Survey ;NYU Child Study Center;2001 Being bullied and picked on is also a major factor in childhood depression- in both victim and perpetrator. But you can see how these social aspects of ADHD might lead towards depression. My thought is that ADHD kids have very little ability to self-monitor, so they do annoying things and are consequently ostracized. But b/c they don’t pay attention, they don’t really pick up on what they’re doing as annoying or miss the social cue, like the look of disgust, that says “stop.”
Your Faculty: Gabriel Kaplan, M.D.• President, New Alliance Academy• Medical Director, Bergen Regional Medical Center• Board Certified Psychiatrist▫ Kaplan G., Ivanov I., and Newcorn J.H. PharmacologicalManagement of ADHD in Children and Adolescents. Int J ChildAdolesc Health 2010; 3(2):143–61▫ Ivanov I., Pearson A., Kaplan G., and Newcorn J.H.Management of Comorbid ADHD and SUD Int J Child AdolescHealth 2010; 3(2):163-177▫ Kaplan G. and Newcorn J.H. Pharmacological Management ofADHD Ped Clinics North Am. 2011; 58:99–120▫ Kaplan G. “Attention deficit hyperactivity disorder inadolescence.” in Child Health and Human DevelopmentYearbook 2012 Greydanus DE, Merrick J, eds Nova BiomedicalBooks, New York 2012
Your Faculty: Bennett Silver, M.D.• Board Member, New Alliance Academy• Medical Director, Adolescent PHP andConsultation Liaison, St. Mary Hospital• Board Certified Psychiatrist• Editor Nationwide Newsletters▫ Psychiatry Drug Alerts▫ Child Psychiatry Drug Alerts▫ Psychiatry NOS▫ Readership over 22,000 psychiatrists
Conference AgendaDr. Gabriel Kaplan• ADHD Epidemiologic and DiagnosticConsiderationsDr. Bennett Silver• StimulantsDr. Gabriel Kaplan• Non Stimulants and New ApproachesDr. Bennett Silver• Non Medication Approaches
Epidemiological and DiagnosticConsiderationsGabriel Kaplan, M.D.
Perceptions of ADHD: “Then” and “Now”Then (20thCentury) Now (21stCentury)Hill, Schoener. Am J Psychiatry. 1996;153(9):1143-1146. Klorman et al. J Am Acad Child Adolesc Psychiatry.1987;26(3):363-367. J Am Acad Child Adolesc Psychiatry. 1991;30(3):I-III. Adler et al. J Atten Disord.2008;11(6):720-727. Rostain. Postgrad Med. 2008;120(3):27-38. Weiss, J Clin Psychiatry. 2004;65(suppl3):27-37. Barkley et al. J Abnorm Psychol. 2002;111(2):279-289.Childhood disorder, remits inadolescenceFunctional impairment situational andintermittent70% persistence into adulthoodCore features• Impairment of executive function• Neurologically mediated (DA andNE circuits)Functional impairment continuousacross situations and throughout the dayCore features• Impulsivity• Hyperkinesis (restlessness)• Attentional difficulties
ADHD DSM-IV-TR CriteriaAdapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC,American Psychiatric Association, 2000.A Either 1 or 2:1. Six or more of a list of nine symptoms of inattention have been present forat least 6 months, to a degree that is maladaptive2. Six or more of a list of nine symptoms of hyperactivity-impulsivity havebeen present for at least 6 months, to a degree that is maladaptiveB Some symptoms that cause impairment were present before age 7 years.C Some impairment from the symptoms is present in two or more settings (e.g. atschool/work and at home).D There must be clear evidence of significant impairment in social, school, or workfunctioning.E The symptoms are not better accounted for by another mental disorder
ADHD DSM-IV-TR CriteriaInattention(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities(b) often has difficulty sustaining attention in tasks or play activities(c) often does not seem to listen when spoken to directly(d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace(not due to oppositional behavior or failure to understand instructions)(e) often has difficulty organizing tasks and activities(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolworkor homework)(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)(h) is often easily distracted by extraneous stimuli(i) is often forgetful in daily activitiesHyperactivity -Impulsivity(a) often fidgets with hands or feet or squirms in seat(b) often leaves seat in classroom or in other situations in which remaining seated is expected(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, maybe limited to subjective feelings of restlessness)(d) often has difficulty playing or engaging in leisure activities quietly(e) is often "on the go" or often acts as if "driven by a motor"(f) often talks excessively(g) often blurts out answers before questions have been completed(h) often has difficulty awaiting turn(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
Is ADHD Real?• One of the most studied disorders of childhood withseveral thousand publications in peer refereed journals• Affects 5% to 8% of US children• Statistics replicated throughout the world• However, there is a small but vocal segment that insistsADHD was invented by pharmaceutical companies tosell drugs
Jan Steen - The Village School- 1665Kast & Altschuler; The earliest example of the hyperactivity; 2008 South African medical journal
Sir Alexander Crichton (Scottish MD)• In 1798 in the chapter of Attention in his book: Aninquiry into the nature and origin of mentalderangement• Described a mental state with al the essential features ofthe inattentive subtype of ADHD, the restlessness,problems with attention, the early onset and how it canaffect the ability to perform in school.
ADHD is highly heritableAccording to a metastudy by Faraone et alin Biol Psych 2005;57:1313-1323, ADHDmean heritability is 0.75 reaching almostthe heritability of height.
According to Shaw, Arch GenPsychiatry. 2006;63:540-549, cortical thickness inADHD compared with controls is significantlythinner regions in the ADHD group.
Academic Impairment• Very well documented▫ Failure to perform academically is the single most commonsource of referral for children and adolescents• Children with ADHD▫ Perform poorly on achievement tests and fail grades /courses significantly more often than children withoutADHD▫ Complete 3 fewer years of education than matched controls▫ More likely not to graduate from high school (35%)• Academic impairment more profound when learningdisabilities are presentWeiss & Hechtman Hyperactive Children Grown Up 1993Manuzza & Klein The Economics of Neuroscience, 2001:47-53
Social Impairment• Social problems begin in childhood, persist intoadolescence▫ Fewer friends, more limited social skills▫ Lower self esteem on assessment scores▫ 3X’s as likely to have trouble getting along with peers▫ ½ as likely to have good friends▫ 2Xs as likely to get picked on by peers▫ 3Xs as likely to have problems that limit after schoolactivitiesSuppl. JAACAP Practice Parameters for Use of Stimulant Medications 2002;41:26S-49SI.M.P.A.C.T. Survey;NYU Child Study Center;2001
Diagnostic Approach• Despite significant advances inanatomical/genetic research, there is NO currentvalidated biological marker• Psychiatric interview and history remain the bestdiagnostic tools▫ Rule in (ADHD)▫ Rule out (Mimics)
Rule in Approach• Psychiatric Interview▫ Family (family hx of ADHD)▫ Child (school/social performance)▫ Parents (marital/parental function)• Collateral Information▫ Rating Scales from Teacher (most reliable guide oftreatment progress)▫ Discussion with teacher if available▫ Discussion with grandparents if involved
Psychiatric Mimics of ADHDPsychiatric Disorder Features Shared With ADHD Distinctive FeaturesMajor depression •Impaired concentration•Impaired attention/memory•Difficulty with task completion•Enduring dysphoric mood•Anhedonia•Appetite disturbanceBipolar disorder •Hyperactivity•Impaired attention/focus•Mood swingsEnduring euphoric mood•Insomnia•DelusionsSubstance abuse or dependence •Impaired concentration•Impaired attention/memory•Mood swings•Pathologic patterns ofsubstance use (frequently withsocial consequences)•Physiologic tolerance/withdrawal•Psychologicaltolerance/withdrawalAdapted from Searight et al. Am Fam Physician. 2000;62(9):2077-2086.
Medical Mimics of ADHD• Thyroid disease• Medication adverse effects▫ Antiasthmatics▫ Anticonvulsants▫ Benzodiazepines▫ Antihistamines• Seizure disorder and other neurologic disorder• Excessive caffeine consumption• Sleep apnea• Hearing impairment• Chronic diseaseStein. CNS Spectr. 2008;13(10 suppl 15):14-16.
Differential Diagnosis Tools• Physical Exam▫ Specialists if necessary (Neurologist, Endochrinologist,etc)• Rating Scales for current symptoms▫ Conners’ ADHD Rating Scale• Laboratory testing▫ Chemistries (CBC, TFTs, etc)▫ Sleep Lab▫ EEG• Psychological testing▫ Not pathognomonic but helpfulBrown, ed. ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults.Washington, DC: American Psychiatric Press; 2009.
Trends in Prevalence of Stimulant Use1987–2008Zuvekas Am J Psychiatry. 2012;169(2):160-166Since 1987, there has been a signficantincrease overall for ages 0-17. However, thelargest increase has been for ages 12-17 whilethere was a decrease for ages 0-5.
Societal and Workplace Impact of ADHD• ADHD cost the U.S. economy between 143 billion and266 billion in 2010• That is roughly $2,000 per household• Although commonly thought of as a childhood disorder,adults with ADHD accounted for 73% of those estimatedcosts• The majority of these costs were the result of lostproductivity (62%), healthcare (26%), education (10%),and the criminal justice system (2%)• Effective treatment plans can improve the outcome ofADHD and reduce these costs to society*Congressional briefing on societal and workplace impact of untreated ADHD, November 30,2011
Stimulants• Gold standard, first line treatment• There are two chemical families with almost identicaltherapeutic properties▫ Amphetamines (AMPH)▫ Methylphenidates (MPH)• Amphetamines first used in 1937• Stimulants are very effective (80%) and very safe.• Only difference amongst multiple preparations isduration of action
Short Acting Stimulants (up to 4hrs)• MPH products▫ Ritalin▫ Methylin▫ Focalin• AMPH products▫ Dexedrine▫ Dextrostat▫ Adderall
Long Acting Stimulants (More recentlyapproved)• MPH products▫ Oral (6-10 hrs) Methylphenidate-SR Ritalin (SR or LA) Methylin-ER Metadate (CD or ER) Concerta (8-10 hours) Focalin XR (8-10 hours)▫ Patch (duration depends on length of time patch on) Daytrana• AMPH products Adderall XR (8-10 hours) Vyvanse (at least 13 hours in children)
Choice of Stimulant• It does not matter which MPH or AMPH starts first• Most children will respond to one or the other• If one is not effective or induces side effects, the child isswitched to the other one▫ This strategy improves over 80% of patients• Over 70% of psychiatrists prefer long actingformulations▫ Avoids having to see the nurse at noon▫ Longer duration helps with homework▫ Avoids rebound emotional lability as dose wears off
Stimulant Side Effects• FREQUENT▫ Decrease appetite▫ Difficulty falling asleep▫ Mood lability▫ Stomach upset▫ Dry Mouth▫ Irritability• INFREQUENT▫ Clinically significant increased pulse or blood pressure▫ Motor tics, Tourette’s▫ Weight loss, slowed growth▫ Psychosis• Do not use in those with arrhythmias or other heart abnormalities• Can be used as substance of abuse, to be avoided in active SA
Incomplete Diagnosis Can Lead toInadequate Treatment• Sometimes ADHD is correctly diagnosed, appropriatetreatment and proper medication are initiated, but thestudent only partially responds• When this occurs it is necessary to look for co-existingpsychiatric disorders that may also require treatment• As many as two thirds of children and adolescents withADHD have at least one other co-existing condition
Is Substance Abuse More Common in TeenagersWho Are or Were Treated with Stimulants?• Youths with ADHD are at increased risk for substanceabuse; about one-and-a-half times greater risk than non-ADHD youths*• Current research documents that those adolescents withADHD prescribed stimulant medication are less likely tosubsequently use illegal drugs than are those notprescribed medication ***Wilens, T, et al. (2011). Does adhd predict substance-use disorders? A 10-Year follow-up study of young adults with adhd. Journa of the American Academy of Child andAdolescent Psychiatry 543-553: v50, i6**Biederman, J, et al. (1999). Pharmacotherapy of attention deficit/hyperactivitydisorder reduces risk for substance use disorder. Pediatrics 104:e20
Non-Stimulants and NewApproachesGabriel Kaplan, MD
Stimulants vs. Non-Stimulants• Stimulants strengths▫ Act right away▫ Very effective▫ Gold standard▫ Many preparations, multiple dosage strengths▫ Well tolerated• Stimulants weaknesses▫ Controlled substances▫ 20% non response▫ Some patients do not tolerate AEs
When to use a Non Stimulant• A Stimulant trial has failed▫ Non effective or intolerable side effects• Parents do not want to use a controlledsubstance• There is active drug abuse in the patient orfamily• There is a contraindication▫ Sensitivity, heart problems▫ Presence of Co-morbidities: ODD, Anxiety
Strattera• Takes 3-4 weeks to work• Selective Norepinephrine Reuptake Inhibitor SNRI (itmakes more NE available)• Once per day dosage• Although studies proved efficacy, in clinical practice,physicians have been disappointed and is used less andless often
Intuniv• Guanfacine Extended Release• Approved 9/2009• Acts on the same receptor as Norepinephrine (SelectiveAlpha 2A)• Its action, thus, mimics increased NE• Taken once per day• Takes a minimum of 2 weeks but most likely up to 4weeks to work
Intuniv Side Effects• FREQUENT▫ Sedation▫ Somnolence▫ Fatigue▫ Headache▫ Increased appetite• INFREQUENT▫ Clinically significant low BP or heart rate▫ Syncope▫ Dizziness
Kapvay• Clonidine Extended Release• Approved 10/2010• Acts on the same receptor as Norepinephrine (Alpha 2non selective)• Its action, thus, mimics increased NE• Taken twice per day• Takes a minimum of 2 weeks but most likely up to 4weeks to work
Kapvay Side Effects• FREQUENT▫ Sedation▫ Somnolence▫ Fatigue▫ Headache▫ Increased appetite• INFREQUENT▫ Clinically significant low BP or heart rate▫ Syncope▫ Dizziness
How do you know the medication works1. Executive Functions have improved Decreased impulsivity and motor behavior Increased attention2. As shown by teacher reports (the most reliableoutcome measure) Via Rating scales: Conners, etc or phone contactwith the provider directly or via parents3. And there are no significant side effects
Newly Approved Combination Therapy• Use a stimulant and a non stimulant at the same time• Approved recently for Kapvay (2010) and Intuniv (2011)but in use for decades with IR preparations• For stimulant partial responders
Newly Approved Combination Therapy• Stimulant Side Effects▫ Anorexia▫ Insomnia▫ Hypertensive• Non Stimulant Kapvay/Intuniv Side Effects▫ Increased appetite▫ Sedation▫ Hypotension
Despite the Well Documented Benefits ofMedication for ADHD• As many as 20% of children with ADHD deriveinadequate benefit from medication• Side effects prevent some from receiving medication onan extended basis• Even those who benefit from medication may still havedifficulties with primary ADHD symptoms or associatedproblems which must be targeted via other means• Mild ADHD may be managed without medication• Some parents and teens will refuse medication
A Cognitive-Behavioral Model of Impairment in ADHDMoodDisturbance:•Depression•Guilt•Anxiety•AngerFailure to UtilizeCompensatoryStrategies-examples:•Organizing•Planning (i.e. task list)•ManagingProcrastinationAvoidancedistractibilityCore(Neuropsychiatric)Impairments in•Attention•Inhibition•Self-Regulation(impulsivity)History of:•Failure•Underachievement• Relationship ProblemsDysfunctionalCognitions and Beliefs(“I can’t do it.”)(“I am a loser.”)FunctionalImpairment
Behavior Therapy Based on Principles AboutWhat Leads Children to Behave Appropriately• Children want to please their parents and feel goodabout themselves when their parent is proud of them• Children behave appropriately to obtain positiveconsequences (privileges/rewards)• Children want to avoid negative consequences thatfollow inappropriate behavior
Behavior Therapy Core Concept• Increase the frequency of desirable behavior withpositive consequences for good behavior• Reduce inappropriate behavior with negativeconsequences for bad behavior
• Be very clear about what behavior is expected of thestudent in order to earn a reward• “Listen to what I say” is too vague• “Take your seat without talking the first time I ask youto do so” is more specificPositivePositive Reinforcement Basic Principles 1
PositivePositive Reinforcement Basic Principles 2• Make sure that the expectations you have for a studentare reasonable – do not set the student up for failurewith expectations that are not appropriate for his/herabilities• This includes in class activities as well as homeworkassignments
PositivePositive Reinforcement Basic Principles 3• Don’t try to work on too many different things at onetime• It is better to concentrate on a few things that are veryimportant rather than taking on too much at once –choose your battles carefully!
PositivePositive Reinforcement Basic Principles 4• Let the student participate in the type of rewards he orshe can earn – they will be more invested in a programwhen they have input into its design. Let it be somethingyou are doing with them rather than to them• Design the program so that there is a good chance toexperience initial success – this will enhance motivationand you can gradually raise the bar
PositivePositive Reinforcement Basic Principles 5• Provide many social rewards (praise) in addition totangible rewards that can be earned – this will increasethe student’s desire to please you and generate positivefeelings between you• Be consistent – apply the program daily and alwaysprovide rewards when they are earned
NegativeNegative Reinforcement Basic Principles• When a negative behavior is consistently followed bynegative consequences that behavior should diminish infrequency and intensity• The punishment for specified bad behaviors is clear –e.g., time-out, loss of privilege, loss of points or tokens• The student will understand that there is simply no pay-off for bad behavior
NegativeNegative Reinforcement Basic Principles(Cont.)• Try not to overdo the negative consequences• Students get discouraged and lose interest in theprogram if they are used too frequently• Resorting to negative consequences too often means youshould re-evaluate your program and possibly redesign it• Utilize a pre-planned graded series of punishments forpersistent misbehavior
Modifications to a Behavioral ProgramSpecific to an ADHD Student• Give more frequent feedback to the student about howthey are meeting teacher expectations – e.g., hourlyinstead of daily• Utilize short term goals, with shorter intervals betweenthe opportunity to earn rewards – points or tokens areespecially helpful• More frequent reminders about expectations and whatcan be earned by good behavior• Frequent changes in the program to sustain interest in it
Integrated Model for Optimal Treatment of ADHD