The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit /...
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Transcript of The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit /...
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?