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

Basic ADHD Information

Most common neurological and behavioral disorder in childhood

One of the most frequently identified chronic childhood disorders seen in the primary care setting

Core symptoms are inattentiveness, hyperactivity, and impulsiveness

Statistics

In 2003, the CDC reported that approximately 4.4 million children ages 4-17 in the US had a diagnosis of ADHD

An estimated 4-12% of children in the community are affected by ADHD

There is a significant difference in the prevalence of ADHD in boys and girls, with estimates of 10% and 4%, respectively

ADHD often results in the following:

Difficulties in school Poor relationships with parents and peers Low self-esteem Various other behavioral, learning, and

emotional problems Difficulties for the child’s parents, including

marital problems, increased stress, and poor relationships with their child

Etiology

Exact etiology of ADHD is unknown Thought to be a complex interaction between

neurological, biological, & environmental factors

Genetics and biological factors play the major roles

Variation in genes regulating dopamine, norepinephrine, & serotonin in the brain

Predisposing Factors

Low birth weight Low social status Severe conflicts among parents Being placed in foster care Mother who smoked, consumed alcohol

and/or drugs while pregnant.

Symptoms Suggestive of ADHD:

Easily distracted by sights and sounds in their environment

Difficulty concentrating for long periods of time

Becomes restless easily Excessive impulsiveness Frequent daydreaming Slow to complete tasks

Diagnosis

Use of AAP guidelines: Evaluate children 6-12 yrs. presenting with core

symptoms of ADHD Must meet DSM-IV criteria Gather information about symptoms from various

settings from the parents & school system Assess for coexisting mental health & learning

problems Order diagnostic tests as indicated by findings

Diagnosis

Need a detailed patient & family history Interview with patient & family Obtain report cards & teacher reports Obtain a thorough physical examination

including visual & auditory screening Refer patient to mental health specialist if

coexisting mental disorders or learning disabilities suspected

Subtypes of ADHD (Based on DSM-IV Criteria)

Predominantly hyperactive-impulsive type – no significant inattention

Predominantly inattentive type – no significant hyperactive-impulsive behavior (previously known as ADD)

Combined type- both inattentive & hyperactive-impulsive behaviors

Treatment

Currently no cure for ADHD Three types of treatment:

Medication management Behavioral therapy Combination of medication & behavioral therapy

Medications for ADHD

Stimulants – shown to improve core symptoms by increasing & maintaining balance of dopamine & serotonin in brain

Non-stimulants (atomoxetine) – enhances noradrenergic function through presynaptic reuptake of norepinephrine

Stimulants

Some available in short-acting, long-acting, and extended release forms.

Produce relatively quick response in patient Schedule II controlled substance – potential for

abuse Side effects – loss of appetite, insomnia, HA,

dizziness, abdominal pain Begin with lowest dosage & titrate up as necessary

Commonly Used Stimulants

Methylphenidate (Ritalin) – long-acting form is Concerta, extended-release forms are Ritalin SR, Metadate ER, & Metadate CD

Amphetamine (Adderall) Dextroamphetamine (Dexedrine, Dextrostat,

and Focalin) Pemoline (Cylert) – no longer considered

first-line due to risk of hepatotoxicity

Non-Stimulants (atomoxetine)

Slower response times than stimulants Non-scheduled drug – no potential for abuse Side effects similar to those of stimulants Atomoxetine (Straterra) is the only non-stimulant

approved by the FDA to treat childhood ADHD More expensive than stimulants Others sometimes used are antidepressants;

including bupropion (Wellbutrin) & despiramine, & antihypertensives; including clonidine & guanfacine

Methylphenidate (Ritalin) vs. Atomoxetine (Straterra)

Recent study analyzed all clinical trials which compared the two drugs

More patients responded to Ritalin than Straterra & responses were quicker with Ritalin

Study confirmed that stimulants are the most efficacious treatment for childhood ADHD

Straterra is a good alternative treatment when stimulants are not well tolerated or when drug abuse is a potential problem

New ADHD Treatment Option

The 1st and only stimulant prodrug, lisdexamphetamine (Vyvanse) was granted market approval by FDA in Feb. 2007

Therapeutically inactive until contact is made with GI tract – only active if swallowed

May prevent abuse of drug by those who snort or inject crushed pills

Recent study showed that 95% of children taking Vyvanse produced “much improved” or “very much improved” rating on Clinical Global Impressions rating scale

Conclusion

ADHD is a disorder in which research must continue in order to determine it’s etiology & to obtain more information regarding safety of treatments.

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.

References

Adesman, A. The diagnosis and management of attention-deficit/hyperactivity disorder in pediatric patients. Primary Care Companion J Clin Psychiatry 2001; 3: 66-77.

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.

Furman, L. What is attention-deficit hyperactivity disorder (ADHD)? J Child Neurol 2005; 20(12): 994-1003.

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.

Greydanus, D.E. Pharmacologic treatment of attention-deficit hyperactivity disorder. Indian J Pediatr 2005; 72: 953-960.

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.

Karande, S. Attention deficit hyperactivity disorder: A review for family physicians. Indian J Med Sci 2005; 59: 547-556.

Kuntsi, J., McLoughlin, G., Asherson, P. Attention deficit hyperactivity disorder. Neuromolecular Med. 2006; 8(4): 461-84.

Leslie, L. The role of primary care physicians in attention deficit hyperactivity disorder (ADHD). Pediatr Ann 2002 August; 31(8): 475-484.

References (Continued)

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.

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. Olfson, M. New options in the pharmacological management of attention-deficit/hyperactivity disorder.

Am J Manag Care 2004; 10: s117-s124. Steer, C.R. Managing attention deficit/hyperactivity disorder: unmet needs and future directions.

Arch Dis Child 2005; 90: i19-i25. 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. www.cdc.gov www.nimh.nih.gov www.shire.com www.webcenter.health.webmd.netscape.com www.wellmark.com

Questions?