ADHDDiagnosis, Treatment & DSM-5 Considerations
Sala S.N. Webb, MDOld Dominion Medical Society
June 8, 2013
Outline Define ADHD
Highlight common co-morbid & confounding conditions
Discuss assessment & treatment considerations
The Diagnostic & Statistical Manual of
Mental Disorders
Minimal Brain DysfunctionHyperkinetic Reaction of Childhood (DSM-II, 1968)Attention Deficit Disorder: With & Without Hyperactivity (DSM-III, 1980)Attention Deficit Hyperactivity Disorder (DSM-IV, 1994)Attention Deficit/Hyperactivity Disorder (DSM-5, 2013)
Attention-Deficit/Hyperactivity Disorder
Criteria: DSM-5 At least 6 symptoms of
InattentionAND/OR
At least 6 symptoms of Hyperactivity-Impulsivity
Persistent for at least 6 months
Maladaptive Inconsistent with
developmental level
Present before age 12 years
Problems in two or more settings
Impairment in social, academic or occupational functioning
Not due to other condition
Inattention• Makes careless mistakes• Difficulty with sustained
focus• Does not follow through
on instructions• Unable to organize• Avoids tasks requiring
sustained attention• Loses things needed for
tasks• Easily distracted• Often forgetful
Hyperactivity
Fidgets, squirms Difficulty remaining seated Runs & climbs excessively Difficulty playing quietly Acts as if “driven by a motor” Talks excessively
Impulsivity
Blurts out answers
Interrupts others
Can be intrusive Limited patience
Types
Combined Presentation Predominantly Inattentive Presentation Predominantly Hyperactive/Impulsive
Presentation Mild/Moderate/Severe Other Specified ADHD Unspecified ADHD
Etiology Deficits in executive functioning Genetic & Neurobiological contributors:
perinatal stress, low birth weight, TBI, maternal smoking, severe early deprivation
Decreased frontal & temporal lobe volumes
Decreased activation of frontal lobes, caudate and anterior cingulate
Epidemiology
6%-12% prevalence 4%-10% treated with medications 60%-85% will continue to meet criteria
through teenage years Adult prevalence varies: by self report (2%-
8%), parent report (46%), developmentally modified criteria (67%)
Rule of 3rd’s
By adulthood: 1/3rd will continue to need medications 1/3rd will have mild/residual symptoms but functional without medications 1/3rd will no longer meet clinical criteria
Confounding & Co-Morbid Conditions
Medical Conditions
Hearing impairment Hyperthyroidism Metals or toxins In -utero exposure
Medical Conditions
Seizures(Absence, Complex Partial)
Severe head injuries Sensory Integration
Disorders Sleep Apnea
Disruptive, Impulse Control & Conduct Disorders Oppositional-Defiant
Disorder Conduct Disorder Intermittent Explosive
Disorder
Substance Related Disorders Alcohol Amphetamines Cannabis Caffeine Cocaine Hallucinogens Inhalants Nicotine Opiate Sedative or Hypnotic
Abuse Dependence Intoxication Withdrawal
Neurodevelopmental Disorders Communication
Disorders
Autism Spectrum Disorders
Intellectual Disabilities
Specific Learning Disorders
Motor Disorders
Anxiety Disorders
Separation Anxiety Disorder Generalized Anxiety Disorder Specific Phobia Social Anxiety Disorder Adjustment Disorder with
Anxiety Panic Disorder
Obsessive Compulsive Disorders
Obsessive Compulsive Disorder Trichotillomania Excoriation
Depressive Disorders Major Depressive Disorder Persistent Depressive Disorder Disruptive Mood
Dysregulation Disorder Adjustment Disorder
with depressed mood
Manic Disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Trauma – Related Disorders
Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder
Evaluation Presenting symptoms Perinatal & developmental
histories Medical history Family history Educational history Social history Patient & parent interviews Physical examination Collateral information
Assessment Considerations
Onset , frequency & duration
Setting Context Level of disruption Stressors or trauma
Intensity Level of impairment Ability to self-regulate Insight
Scales
Conner’s Parent’s Rating Scale Conner’s Teacher’s Rating Scale Brown ADD Vanderbilt ADHD Child Behavior Checklist
Treatment
Psychoeducation Clarify diagnosis Give contextual framework Be honest & sincere about your opinion Anticipate developmental challenges Provide or recommend resources: fact sheets,
books, websites etc.
School Resources Talk with child’s main teacher Talk with guidance counselor If applicable, encourage parents to request in writing testing
or Child Study Suggest accommodations, if solicited
Behavioral Therapies
Initial therapy for mild symptoms and uncertain diagnosis
Per parental preference Focuses in parental management and molding
of behaviors Can be in-home or outpatient
Behavioral Therapies
Cognitive Behavioral Therapy (CBT) more efficacious in adolescents & adults than younger children
Metacognitive Therapy (MCT) combines CBT with training on improving executive functioning
Pharmacotherapy
First Line Approved by FDA for ADHD Stimulants Atomoxetine
Second Line Buproprion α Agonists Tricyclic Antidepressants
Stimulants
Methylphenidate Short acting (2-6 hrs):
Focalin, Ritalin, Methylin Intermediate acting (4-8
hrs): Metadate CD, Methylin ER, Ritalin SR, Ritalin LA
Long acting (8-12 hrs): Concerta, Focalin XR, Daytrana Patch
Amphetamine Short acting: Dexedrine,
Dextrostat, Adderall Intermediate acting:
Dexedrine Spansules Long acting: Adderall XR,
Vyvanse
Stimulants
Side Effects Decreased appetite, weight loss Insomnia, headaches Tics, emotional lability, irritability Visual & tactile hallucinations Contra-indicated in pre-existing heart
condition
Atomoxetine Selective Norepinephrine
Reuptake Inhibitor (SNRI) Strattera Not as effective as stimulants Can use if negative side
effects experienced on stimulants
Requires 6 weeks to see full effect
Effective in treating co-morbid anxiety
Side Effects Nausea, decreased
appetite Headaches Sedation (can give as
single night dose) Suicidality
Buproprion Dopamine
Norepinephrine Reuptake Inhibitor (DNRI)
Wellbutrin, Wellbutrin SR, Wellbutrin XL
Helpful in co-occurring depression
Less effective for inattention, no effect on hyperactivity
Delayed onset of action
Side Effects Insomnia Headaches Nausea Contraindicated in
seizure disorders Use with caution in
eating disorders Can induce seizures in
overdose
α 2 Adrenergic Agonists Guanfacine (Tenex,
Intuniv) Clonidine (Catapres,
Kapvay) Effective for impulsivity
and hyperactivity; not inattention
Helpful in co-occurring traumatic flashbacks, aggression, insomnia & tics
Side Effects Sedation Dizziness Hypotension Rebound hypertension
with rapid discontinuation
Tricyclic Antidepressants
Imipramine, Nortriptyline, Desipramine
Inhibits reuptake of NE EKG at baseline and
each dose increase Once symptom control
achieved, check serum level for toxicity
Side Effects Dry mouth, constipation Vision changes,
sedation Tachycardia Cases of sudden death
reported in children & adolescents with desipramine
When to Refer… For evaluation & treatment For consultation with
resumption of treatment Concerns for safety Significant impairment in
functioning No improvement after 6-8
weeks of first-line intervention
Diagnostic conundrum History suggestive of
trauma with current impact Difficulty coping with
chronic medical illness
Can always seek collegial consultation without face-to-face evaluation of patient
References
Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition American Psychiatric Association, 2013
Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit-Hyperactivity Disorder J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46 (7): 894-921
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