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