Notes
Outline
Attention Deficit Hyperactivity
Disorder
Kevin Leehey M.D.
1980 E. Fort Lowell Rd. Suite 150
Tucson, AZ 85719
520-296-4280  fax 520-296-3835
http://leeheymd.com
kevino@leeheymd.com
Attention Deficit Hyperactivity Disorder
ADHD Inattentive Type
ADHD Hyperactive/Impulsive Type
ADHD Combined Type
ADHD NOS
Differential Diagnosis
Medical or neurologic or other psychiatric conditions, such as hyperthyroidism, medication side-effects, anxiety disorders, post traumatic stress, depression, immature character, and oppositional behaviors, may look like ADHD but not actually be ADHD.
Co-morbid
Anxiety disorders, Tourette’s Syndrome, depression, post traumatic stress difficulties, behavioral problems, learning difficulties, coordination disorders, sensory integration disorders, PDD, etc.
The most common condition associated with ADHD is a learning disorder (about 50 percent)
Diagnostic Criteria
A.
 Six (or more) of the symptoms of inattention have persisted for at least six-months to a degree that is maladaptive and inconsistent with developmental level
Or six (or more) of the symptoms of hyperactivity-impulsivity have persisted for at least six-months to a degree that is maladaptive and inconsistent with developmental level
Inattention :
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
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)
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort (such as schoolwork or homework)
Often loses things necessary for tasks or activities (ie: toys, school assignments, pencils, books, or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Hyperactivity:     Impulsivity:
Often fidgets with hands or feet and squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
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)
Often has difficulty playing or engaging in leisure activities quietly
Is often “on the go” or often acts as if “driven by a motor
Often talks excessively
Often blurts out answers before questions have been completed
Often has difficulty awaiting his/her turn
Often interrupts or intrudes on others (eg: butts into conversations or games)
More Diagnostic Criteria
B.   Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age seven years
C. Some impairment from the symptoms is present in two or more settings (ie: school, work, 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 (ie: Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)
Making the Diagnosis
ADHD is often diagnosed based on meeting at least the minimum criteria for ADHD from DSM-IV
Psychological testing, WISC-IV, Woodcock-Johnson-R
Rating scales such as the Connors or SNAP
Continuous Performance Task Tests
Observation of the child or adolescent’s behavior in school and non-school settings
Family history
Making the Diagnosis
Making the diagnosis for adults and preschoolers is more difficult.  Many of the diagnostic criteria are described in terms most relevant for elementary, middle school, and less so, high school age groups. For adults, past history and data regarding school experiences and testing is often crucial (along with current and past functioning and family history).
ADHD  trends
8 years old, third grade
Sixth grade, middle school
3X Boys - wrong
Missed - girls, minorities, ODD, inattentive only, bright, co-morbid, mild
5-7% of school age youth
ADHD is more difficult to diagnose in preschool
A wider range of behavior is expectable
Attention span normally increases with age, as does impulse control and a lessening of physical hyperactivity
Parenting styles and cultural norms vary markedly in this age group
Medication treatment is often less helpful and less researched
Other interventions are often worthwhile
ADHD will become more clear with time
Executive Function Disorder
Disorganization and poor time management skills
Follow-through and carrying out plans
Getting schoolwork/homework done or turned in
Failure to complete or turn in assignments
Do (fully or partially) their assignments but fail to turn them in or lose them
ADHD diagnosis myths
Video/computer games, television, movies
“He/she can if he/she wants to”
“He/she is fine at home”, or 1:1, or at the office
“Lazy”, underachiever, unmotivated
Prognosis, Outcome
ADHD can be mild, moderate, or severe
Learning disorders may also be mild, moderate, or severe
Associated conditions complicate
Ability of that youngster’s family, school, and even that youngster’s ability to adjust to his/her current developmental needs and to what is expected of him/her
ADHD prognosis
Hyperactivity resolves for 50% around puberty; 75% by age 21
Inattention often persists
“School of hard knocks”
25% have conduct disorders and or substance abuse
Higher risks MVA, job losses, relationship problems, depression, anxiety
Basic Medical Principles
H&P, labs, hearing, vision
Educational assessment
Experienced and well trained clinician
365 days, 24/7
Individualize and fine tune treatment
Treatment
Individual Therapy
Self esteem and impulse control
Family Therapy
It is more difficult to parent a youngster with ADHD
Treatment
3.   School/Work
Special education, 504 Accommodation
Positive home-school communication
The transition from elementary to middle school and again from middle school to high school
Environmental manipulation
4.   Medication
Treatment
5. Additional or Alternative treatments
Martial arts
Exercise/sports
Biofeedback (“Neurofeedback”)
Sensory integration treatment
Nutritious diet, sweets, “junk food”, sugar
Vitamins, herbs, and other supplements
“Dyslexia” is a language processing phonologic error in language areas of the brain, not a hearing or vision disorder
Medications for ADHD-1
Stimulants
Methylphenidate
Short and extended duration
Amphetamines
Short and extended duration
Pemoline (Cylert)
Medications for ADHD-2
Non-stimulants
Atomoxetine (Stattera)
Tricyclics (Imipramine, Desipramine)
Buproprion (Wellbutrin)
Partial alpha agonists [Guanfacine (Tenex), Clonidine]
Medications for ADHD-3
Combinations/polypharmacy
Avoid if possible
Stimulant and atomoxetine or other non-stimulant ADHD medication
Atomoxetine and SRI
Non psych medications
Stimulant plus SRI plus DDAVP is safer than desipramine alone
Medications for ADHD-4
Out of the Box
amantadine (Symmetrel)
modafinil (Provigil)
pramipexole (Mirapex)
ropinirole (Requip)
Medications for ADHD-5
Beads/sprinkle
Adderall XR, Ritalin LA, Metadate CD, Focalin XR
Liquid
Methylin, Amantadine (Symmetrel)
Chewable
Methylin
Patch
-  Catapres, MPH (soon)
Osmotic pressure release
-  Concerta
Compounding
Prescribing for ADHD-1
Co-morbidity: Depression, anxiety, tics, substances, bipolar, nicotine
Height, weight
Appetite decrease and low weight is the most common limiting stimulant side effect
Class II, no “refills”, 60 days, less on base post, out of state varies, 90 day mail order
Match side effects as well as good effects
Prescribing for ADHD-2
Duration
Convenience
Weight (height less of a concern)
Tics
“Meaner”
Abuse of stimulants
Truck driver, pilot
Prescribing for ADHD-3
Regular follow-up appointments
Not just “med checks”
Height, weight, growth curve
School, home, peers, activities, etc.
Patient and significant other input
Benefits and adverse effects
Kevin Leehey M.D.
1980 E. Fort Lowell Rd. Suite 150
Tucson, AZ 85719
520-296-4280  fax 520-296-3835
http://leeheymd.com
kevino@leeheymd.com