Head for the Hills presentation from Roger Hofford, MD

1. What’s New and What is Our Data
By Roger A. Hofford, M.D. FAAFP, CPE
Associate Professor of Family & Community Medicine
Virginia Tech Carilion Family Medicine Residency
Virginia Commonwealth University
Virginia College of Osteopathic Medicine

2. Disclosures:
 None

3. Goals and Objectives:
 Briefly review the diagnosis of ADHD
 Review latest treatment options/algorithms for ADHD
 Review recent Virginia Medicaid ADHD data and how
do we compare with North Carolina and the United
States

4. Recent ADHD News Headline
 “Study finds 17% of
college students
misuse ADHD drugs”
 “Stimulant treatment
for ADHD may also
reduce smoking risk”
 “ADHD Medications
Don't Lead To Drug Or
Alcohol Abuse”
 “ADHD drugs 'do not
stunt children's
growth,' say AAP”
 “Can Fish Oil Help
Boys With ADHD Pay
Attention? Perhaps, but
it won't take the place of
medication, expert says”

5. Recent ADHD News Headline
 “Children with ADHD
more likely to have
eating disorder”
 “Is the Internet giving us
all ADHD?”
 “Too Little Behavioral
Therapy for Kids with
ADHD – CDC”
 “Are Antipsychotic meds
being overprescribed in
ADHD?”
 “Intense physical activity
is associated with better
cognitive control
performance in ADHD
disorder”
 “ADHD Drug Decreases
Binge Eating”
 “FDA: Daytrana patch
may cause permanent
depigmentation”

6. Recent ADHD News Headline
 “Maternal Chemical
Drug Intolerances:
Potential Risk Factors for
Autism & ADHD” - JABFM
 “Examining the
Association Between
PTSD & ADHD: A
systematic Review &
Meta-analysis” – J Cl Psy

7. What is ADHD?
 Most common chronic
neurobehavior/neurodevelopmental childhood
disorder
 Persistent inattention, hyperactivity and/or
impulsivity compared to their peer group

8. ADHD DSM-V Criteria
A. Either 1 or 2 or 3
 1) Six (or more) of the following symptoms of
inattention have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with
developmental level:

9. ADHD DSM-V Criteria
 Inattention
 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
schoolwork, 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 schoolwork or 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 activities

10. ADHD DSM-V Criteria
2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for
at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
 Hyperactivity
 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, may be 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
 Impulsivity
 a) Often blurts out answers before questions have been completed
 a) Often has difficulty awaiting turn
 b) Often interrupts or intrudes on others (e.g., butts into conversations or games)

11. ADHD DSM-V Criteria
3) Combined – child exhibits six or more symptoms of
Inattention, hyperactivity and impulsivity for greater
than six months

12. ADHD DSM-V Criteria
 B. Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before 7 years of age.
 C. Some impairment from the symptoms is present in 2 or more
settings (e.g., at school [or work] or at home).
 D. There must be clear evidence of clinically significant
impairment in social, academic, or occupational functioning.
 E. The symptoms do not occur exclusively during the course of a
pervasive developmental disorder, schizophrenia, or other
psychotic disorder and are not better accounted for by another
mental disorder (e.g., mood disorder, anxiety disorder,
dissociative disorder, or personality disorder).

13. ADHD Incidence (CDC):
 Boys are two times greater than girls
 More likely to be Caucasian or African-American
 May affect up to 11% of children between the ages of 4
through 17 y.o.
 Prevalence is increasing over last 12 years per CDC
Surveys:
2003 2007 2011
Virginia 9.3% 10.2% 11.8%
United States 7.8% 9.5% 11%

14. ADHD Incidence (APA):
 2.5% of U.S. Adults
 5% of U.S. children

15. Higher incidence of ADHD
 Most likely genetic
 Second-hand smoke
 Premature birth - 2.64 X more likely
 Maternal hyperthyroidism
 Maternal smoking – 2.4 – 3.0 X
 Maternal excessive alcohol use – 2.5X
 Childhood traumatic brain injury requiring
hospitalization – 20%
 Childhood lead exposure in 3rd quartile lead level – OR
2.3

16. Complications of ADHD Untreated
 Increase risk of injury
 Increased risk of driving offenses
 Increased substance abuse
 Increased cigarette use/abuse

17. Prognosis of ADHD
 Hyperactivity and impulsivity tend to decrease with
age
 Approximately 50% of ADHD children will continue
into adulthood with ADHD symptoms
 Increased risk of suicide in adulthood
 Increased risk of obesity in adulthood

18. Treatment Benefits:
 Better learning and education
 Less accidents
 Less criminal behavior
 Better social interactions
 Better employment opportunities

19. Associated Comorbidities:
 Increase in other psychiatric comorbidities in a
referred population:
 Anxiety disorder (29%)
 Conduct disorder (15%)
 Depression (15%)
 Bipolar (7%)

20. Associated Physical Conditions:
 Tics
 Sleep Apnea
 Sleep disturbances:
 Bedtime resistance
 Difficult sleep onset
 Hard to wake up in the AM
 Increased night time awakenings
 Less sleep time
 Loud snoring at 2-3 y.o – increase risk of ADHD
 ADHD & Enuresis 40% in 6-12 y.o.

21. Evaluation:
 Obtain information from multiple sources e.g Conner
or Vanderbilt forms
 Are other neurobehavioral disorders present?
 Are developmental disorders in speech, learning,
hearing present?
 Home situation?
 School situation?

22. Differential Diagnoses:
 Conduct Disorder – stealing, destroying property,
cruelty
 Depression – excessive crying or worrying; recurrent
thoughts of death/suicide
 Oppositional Defiant Disorder – argues, intentionally
defies rules, loses temper frequently
 Hx of sexual abuse – inappropriate sexual behavior
 Tourette Syndrome – repetitive sounds or motor tics
 Learning disorder – ADHD sx in a particular setting

23. Medications that can give
symptoms suggestive of ADHD
 Albuterol
 Steroids
 Antipsychotics
 Antihistamines
 Decongestants
 Anticonvulsants

24. Physical Exam
 HEENT – can patient hear, vision OK
 Pulmonary –
 Cardiac – BP, rate, rhythm, murmurs, extra heart
sounds
 Neuro exam

25. Testing (AAP Recommendations):
 Labs: Not routinely recommended if medical history
negative – do not routinely check TSH or lead levels
 Neuropsych testing: Not routinely recommended
unless history suggests it (low general cognitive ability,
low language or math ability). If classic ADHD sxs, do
not need to do neuropsych testing
 EKG:
 - AAP does not recommend routine EKG testing
(Quality Evidence D)
 - AHA recommends (Level C recommendation)

26. Testing (AAP Recommendations):
 Neuroimaging – not routinely recommended unless
strong evidence for neurological pathology. Soft
neurological findings are not an indication.
 EEG: not routinely recommended unless history
suggest reason for doing

27. ADHD Treatment Options:
(4-5 year olds)
 Try first treatment with parent- and/or teacher
administrated behavior therapy (AAP Strong
Recommendation -Evidence Quality A)
 If no improvement and moderate-severe dysfunction
consider methylphenidate (AAP Recommendation – Evidence
Quality B)

28. Behavioral Intervention
 Positive reinforcement
 Time out
 Withdrawal of privileges or rewards
 Token economy
 Routines
 504 Education Plan
 IEP

30. ADHD Treatment Options:
(6-11 year olds)
 FDA – approved medications (best evidence for
stimulants) (AAP strong recommendation, Evidence Quality A)
 Parent- and/or teacher-based behavioral therapy
(AAP recommendation, Evidence Quality B)

31. ADHD Treatment Options:
(12-18 year olds)
 FDA – approved medications (best evidence for
stimulants) (AAP strong recommendation, Evidence Quality A)
 Parent- and/or teacher-based behavioral therapy
(AAP recommendation, Evidence Quality C)

32. Child with ADHD Diagnosis/Meds
4 y.o thru 17 y.o.
Plan Va. Premier Anthem Coventry Optima INTotal Kaiser CCNC CDC 2011 CDC 2011
VA
MCOs
VA National
ADHD MCO Data 4 thru 17
Child with ADHD DX 11,794 12,428 1,772 5,487 1,745 59 11.1-13% 11% 33,285
Child rx ADHD meds 13,460 15,165 1,233 10,649 1,687 49 65,121 42,243
ADHD_Meds/DX 114.13% 122.02% 69.58% 194.08% 96.68% 83.05% 126.91%
No. Child in plan 116,231 148,989 20,252 94,913 39,391 2,069 920,040 421,845
Percent Rx/No in
plan 11.58% 10.18% 6.09% 11.22% 4.28% 2.37% 7.08% 6.60% 6.10% 10.01%

33. Adults with ADHD Diagnosis/Meds
18 y.o thru 25 y.o.
Plan Va. Premier Anthem Coventry Optima INTotal Kaiser VA MCOs
ADHD MCO Data 18 thru 25
College age with
ADHD Dx 629 1,050 80 298 114 6 2177
College age rx ADHD
med 1081 1,269 81 962 123 6 3522
ADHD_Meds/DX 171.86% 120.86% 101.25% 322.82% 107.89% 100.00% 161.78%
No. College age in
plan 24,463 17,096 2,908 15,158 5,404 347 65376
Percent Rx/No in
plan 4.42% 7.42% 2.79% 6.35% 2.28% 1.73% 5.39%

34. Stimulant Medications: Short acting
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Methylphenidate
(Ritalin)
(Methylin)
20-30
minutes
3-6 hrs BID-
TID
$76
$84
$536
Take 30 min
before meals;
Avoid in cardiac
conditions
Dexmethylphenidate
(Focalin)
30
minutes
3-6 hrs BID $67
$78
Take with/after
meals
Mixed
amphetamine
Salts
(Adderal)
30
minutes
5-7 hrs Qd <5yo;
>5yo
BID-
TID
$142
$295
Take with/after
meals
Dextroamphetamine
(Dexedrine)
20-60
minutes
4-6 hrs Qd <5yo;
>5yo
BID-
TID
$142
$318-342
Take with/after
meals

35. Stimulant Medications: Intermediate acting
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Methylphenidate
(Ritalin- SR)
(Metadate-ER)
60-90
minutes
3-8 hrs
(highly
variable)
Daily;
½ dose
in early
afterno
on
$NA
$88
$108
Take with/after
meals; may need
to add short-
acting in
afternoon
Dextroamphetamine
(Dexedrine Spansules)
60-90
minutes
6-10 hrs
(highly
variable)
Daily $147
$338
Take with/after
meals; may need
to add short-
acting in
afternoon

36. Stimulant Medications: Long-acting
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Methylphenidate
(Ritalin LA)
(Methadate CD)
Concerta
Daytrana Patch
Aptensio(just FDA
approved)
1.8 hrs
90 min
30-60 min
3 hours
60 min
7-9 hrs
7-9 hrs
10-12 hrs
10-12 hrs
12 hrs
Daily $130-135
$213
$206
$208-265
$251
$195
Take with food/after
meal;
Avoid using in patients
with structural heart
disease
Dexmethylphenidate
(Focalin XR)
30 min 12 hrs Daily $227-253 Avoid taking with
antacids
Mixed
amphetamine
Salts
(Adderal XR)
30 min ~8 hrs Daily $157
$214
Take with
food/after meals
Lisdesamfetamine
(Vyvanse)
2 hours 10 hrs Daily $199 Avoid using in
patients with
structural heart
disease

38. Non-Stimulant Medications:
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Atomoxetine
(Strattera)
Slow onset-
weeks
~24 hrs 0.5 mg/kg
up to 1.2
mg/kg
$303 Not for child <6 y/o.;
some med interaction
CYP2D6 – liver; If
worried about
substance abuse
Buproprion
Wellbutrin
Wellbutrin SR
Wellbutrin XL
Indications:
Intolerant of
ADHD meds;
Has
depression,
aggression,
irritabilty;
smoking
cessation
IR: BID
SR: BID
XL:Daily –
titrate to
XL using
IR/SR
$29-34
$102-123
$74-207
(284-396)
Lowers sz threshold;
Black Box warnings;
Avoid bedtime dosing
Side Effects

39. Other Second Line Medications:
Medication Indications Dose Costs Comments
Clonidine ER
Catapres***
Kapvay
ADHD+tics;
ADHD+ PTSD;
ADHD+Insomnia
ADHD+ODD
ADHD+Aggression
Start 0.05 mg
qHS, Not prn;
Can be used BID
in severe cases
$114
$75-200
$158
Sedation –
improves w/ time;
Watch BP;
Baseline EKG; Do
not stop abruptly
Guanfacine
ER
Tenex ***
Intuniv
ADHD+tics; ADHD+
PTSD;
ADHD+Insomnia
ADHD+ODD
ADHD+Aggression
Start 0.5 mg qHS
Start 0.5 mg qHS
Start 1 mg qAM
$250
$78-230
$291
Sedation;
Baseline EKG;
Watch BP
Risperidone
Risperdal
ADHD+tics
ADHD+aggression
ADHD+ mood swings
ADHD severe
insomnia
Start 0.5 mg qHS $78-102
$219-330
Side effects; Be
careful if using
fluoxetine &
sertraline –
increases
risperidone levels

40. Other Second Line Medications:
Medication Indications Dose Costs Comments
Divalproex
Depakote
Depakote ER
ADHD+Aggression Start 10-15
mg/kg/day in
divided dose
$36-92.99
$45-145
$88-130
Use if > 10 yo;
caution in liver ds.
Desipramine
Norpramin
ADHD+tics; ADHD+
PTSD;
ADHD+Insomnia
ADHD+ODD
ADHD+Aggression
Start 10 mg PO qd $37-145
$54-122
Sedation;
Baseline EKG;
Trazodone ADHD+insomnia
ADHD+aggression
Start 25 mg qHS $35-48 Monitor BP and
heart rate

41. Top Chronic Disease Drugs Requiring Prior
Authorization in Virginia (Preliminary Data)
 2. Vyvanse
 4. Strattera
 5. Methylphenidate
 10. Amphetamine

43. Algorithm for the Psychopharmacological Management of
Attention Deficit Hyperactivity Disorder (ADHD)
 This algorithm is intended for new patients who have never been
on ADHD medications in their lifetime.

 Stage 1: Long-acting preferred if school age to avoid dosing in
school. Either methylphenidate or mixed amphetamine. Twice
daily dosing is useful if late evening behavior problems. Titrate
dose every one to three weeks until maximum effective dose
reached or goals reached at lower dose or side effects prevent
further dosing increases.

 Atomoxetine (Strattera) (prior authorization) should be
considered Stage 1 if patient has comorbid anxiety or tic disorder
or household concerns for substance abuse. If atomoxetine
(Strattera) is used, give at least 6 weeks to see if effective.

44. Algorithm for the Psychopharmacological Management of
Attention Deficit Hyperactivity Disorder (ADHD)
 Stage 2: If patient fails on one of the above either
methylphenidate or mixed amphetamine, try the other
class before moving to one of the medications below.

 Stage 3: If patient fails on mixed amphetamines and
methylphenidate, physician should request prior
authorization for amoxetine (Strattera) or
lisdexametafine (Vyvanse). Failing on medication
would be due to significant side effects such decreased
appetite, weight loss, and/or decreased sleep that does
not respond to time.

45. Algorithm for the Psychopharmacological Management of
Attention Deficit Hyperactivity Disorder (ADHD)
 Stage 4 &5: Consider re-evaluating ADHD diagnosis
or other co-morbidities present before going to this
stage; If ADHD confirmed consider behavioral therapy
before add- on medication for Stage 3 or 4
medications. Often necessary to use add-on
medication if co-morbid aggression or to reduce side
effects of tics or insomnia

 If discontinuing an add-on medication, titrate dose
downward over 1-2 week period to avoid sudden drop
in blood pressure.

46. Conversion from One Medication
to Another
 Methylphenidate (MPH) – IR to ER: milligram to
milligram
 Mixed amphetamines (Adderal) – IR to ER: milligram
to milligram
 Switching from MPH to mixed amphetamines
(Adderal): reduce mixed amphetamine milligram by
50%
 Switching from MPH to Concerta: Increase Concerta
dose by ~20% (e.g MPH 10-15 mg to Concerta 18 mg)

47. Conversion from One Medication
to Another
 Stimulant to atomoxetine (Strattera): It takes several
weeks for atomoxetine to start working – start at
recommended starting dose; Therefore, slowly taper
off stimulant over several weeks as it takes several
weeks for atomoxetine to work.
 Dexmethylphenidate (Focalin) IR to XR: milligram to
milligram
 Oral methylphenidate to patch: milligram to milligram
is NOT equivalent

48. Conversion from One Medication
to Another
 Short-acting to long-acting alpha agonists:Taper off
short-acting guanfacine(e.g. Tenex) completely before
starting long-acting guanfacine (e.g. Intuniv) then
start long –acting at starting dose

49. Recent Cochrane Reviews
 “Social skills training for children aged between 5 & 18
with ADHD”
 - There is little evidence to support or refute social
skills training (11 randomized trials) December 2011
 “Family therapy for ADHD in children”
 - Further research needed to determine effectiveness.
(2 studies)March 2010;

50. Recent Cochrane Reviews
 “Tricyclic antidepressants for ADHD (with and w/o
tics) in children and adolescents”
 - TCA’s, particularly desipramine, had a beneficial
effect in the short term for core symptoms. Mild
increases in BP and pulse rate. (RCT=6) September
2014
 “Medications for ADHD in children with tics”
 - MPH, clonidine, guanfacine, desipramine and
atomaxetine appear to reduce ADHD symptoms in
children with tics. (RCT=8) April 2011

51. Recent Cochrane Reviews
 “Atypical antipsychotic drugs for disruptive behaviour
disorders in children and youths”
 - There is some limited evidence of efficacy of
risperidone reducing aggression and conduct
problems in children aged 5 to 18 (RCT=8) September
2012
 - There is no evidence so far to support the use of
quetiapine (Seroquel) as of September 2012

52. Diet
 Insufficient evidence for decreasing sugar, increasing
vitamins or using herbs (SORIII)
 Restricting artificial color dyes (Level 2 Evidence)
 Omega-3 fatty acid supplement – modest effect

53. Other Modalities
 Neurofeedback – may improve IQ
 Sleep intervention/hygiene – 2 counseling sessions by
psychologist on sleep hygiene –BMJ 2015 (LOE 1B-)
 Family-centered Care – using collaborative care team
March 2015 publication
 Exercise

54. Adult ADHD
 Affects 1-6% of adults
 Affects academic performance, interpersonal
relationships, employment, and driving performance
 Not many studies in adults
 Cochrane Review: good high quality evidence for
immediate-release methylphenidate (Ritalin) and
suggest side effects are not serious. (RCT=11)
September 2014

55. Urine Drug Screens
 Methylphenidate is not usually picked up in the
routine Urine Drug Screens we order
 Be sure to check the Virginia PMP database

56. Thank you!