Attention Deficit

Hyperactivity Disorder
(ADHD)
Justin A. Glass, MD
21 February 2008
Emory Family Medicine

Attention Deficit Hyperactivity

Disorder (ADHD)
What is the role of the primary care
physician in diagnosis and treatment
of ADHD?

ADHD Talk Objectives

You will understand ADHD diagnostic
criteria
You will will know where to find and how to
use assessment tools for diagnosing ADHD
You will know when to refer a patient w/
ADHD for specialty care
You will understand tx options for ADHD
You will want to see a child with ADHD in
your clinic in the near future

ADHD Epidemiology
Prevalence
Survey average: 8-10% in children of
school age
Parent reported prevalence age 4-17
Boys 11%
Girls 4.4%

Male: Female ratio

2:1 - 4:1

ADHD Pathogenesis
Multiple theories
Imbalance of catecholamine metabolism
in cerebral cortex
Impaired executive functions
Impaired response inhibition

Diagnosis of ADHD
Inattention
Hyperactivity
Impulsivity

Diagnosis of ADHD
Inattention
Forgetful outside of school
Incomplete performance on school tasks
Missing details
Missing homework
Poor performance on schoolwork

Diagnosis of ADHD
Hyperactivity
Always in motion
Difficulty during quiet times
Constant talking

Diagnosis of ADHD
Impulsivity
Unable to wait turn
Answers for others
Unsafe behavior

DSM IV Criteria ADHD

(Inattention)

Often fails to give close attention to detail or makes

careless mistakes in schoolwork, work or other
activities.
Often has difficulty sustaining attention in tasks of
play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails
to finish homework, chores or other duties
Often has difficulty organizing tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks
that require sustained mental effort
Often loses things required to complete tasks
Is often easily distracted
Is often forgetful in daily activities
Six (or more) of the following symptoms have persisted for at least
six months to a degree that is maladaptive or not consistent with
development level.

DSM IV Criteria ADHD

(Hyperactivity)
Often fidgets with hands or feet or squirms in seat
Often leaves seat in situations in which remaining
seated is expected
Often runs about or climbs excessively in situations
in which it is inappropriate
Often has difficulty in playing quietly
Is often on the go or acts as if driven by a
motor
Often talks excessively
Often blurts out answers before questions are
completed
Often has difficulty waiting turn
Often interrupts of intrudes on others

Six (or more) of the following symptoms have persisted for at least six
months to a degree
that is maladaptive or not consistent with development level.

Diagnosis of ADHD
Additional Criteria:
Some inattentive or hyperactive/impulsive
symptoms were present before the age of
seven.
Some impairment from the symptoms is
present in two or more settings (e.g. at
school and at home)
Clear evidence of clinically significant
impairment in social, academic or
occupational functioning

DSM IV Criteria - ADHD

Three types
Inattention predominant (ADHD-IA) (3040%)
Hyperactivity predominant (ADHD-H/I)
(10%)
Combined type (ADHD-C) (50-60%)

Diagnosis of ADHD
Screening questions
How is your child doing in school this year?
Is your child happy to go to school?
Have you heard from the teacher(s)
regarding any concerns about behavior or
performance in school?
How does your child do with chores around
the house?
How does your child do with homework?

Diagnosis of ADHD
Objective approach
Data needs to be collected from more
than one source
Parents
Teachers
Others

Diagnosis of ADHD
What kind of data?
Standardized forms
Conners Rating Scale (CATRS)
ACTeRS Form
Vanderbilt ADHD Diagnostic Rating Scale

Diagnosis ADHD
Need to develop a differential
diagnosis

Diagnosis of ADHD

Oppositional Defiant Disorder

Conduct Disorder
Depression
Anxiety
Learning disability
Special senses disability
Substance Abuse
Pervasive Developmental Delay NOS

Oppositional Defiant
Disorder

A pattern of negativistic, hostile and defiant

behavior lasting at least six months, during
which four or more of the following are present:

Often
Often
Often
Often
Often
Often
Often
Often

loses temper
argues with adults
actively defies or refuses to follow adults rules
deliberately annoys people
blames others for his/her mistakes
is touchy / easily annoyed by others
is resentful
is spiteful / vindictive

The disturbance in behavior causes significant impairment in social, academ

occupational functioning. The symptoms are not due to a mood disorder or

Conduct Disorder
Repetitive and persistent pattern of
behavior in which the basic rights of
others or major age appropriate
norms or rules of society are violated.
Aggression to people or animals
Destruction of property
Deceitfulness or theft
Serious violation of rules

Depression

Depressed mood
Change in sleep (S)
Loss of interest / pleasure in activities (I)
Thoughts of worthlessness or guilt (G)
Loss of energy (E)
Trouble concentrating (C)
Change in appetite or weight (A)
Change in psychomotor activity (P)
Thoughts of suicide or death (S)

5 of the 9 symptoms present frequently for at least two

weeks. One of the 5 symptoms must be depressed mood
or loss of interest in usual activities. Symptoms can not
be due to substance use of another psychiatric diagnosis.

Learning Disability
Schoolwork performance issues
Reading
Writing
Mathematics

Special Senses Disability

Visual disturbance
Hearing loss

Substance Abuse
High index of suspicion in teens

Pervasive Developmental
Delay NOS
Autistic spectrum, but not meeting
autism criteria

When should I refer a child I

suspect has ADHD?
Age younger than six
Co-existent psychiatric conditions
Co-existent neurologic conditions

Lets go to Vanderbilt

ADHD Management Plan

Clear communication with parents
and teachers
Phone calls
Email
Progress notes
Daily School-Home Report Card

ADHD Management Plan

Parenting skills
Homework rules
Sleep rules
T.V. / Videogame rules

ADHD Management Plan

Stimulant Medications
Dextroamphetamine / Levoamphetamine
Adderall
Adderall XR

Dextramphetamine
Dexedrine
Dexedrine Spansule
Dextrostat

Methyphenidate

Ritalin
Ritalin LA
Ritalin SR
Concerta
Methylin
Metadate ER
Metadate CD
Focalin
Daytrana

ADHD Management Plan

Stimulant Medications
Adverse effects

Anorexia
Weight loss
Sleep disturbance
Tics
Tachycardia
Hypertension

ADHD Management
Stimulant Medication
Use the least amount needed
Use extended release preparations when
possible
Give drug holidays if appropriate
Reassess regularly as to response

ADHD Management
Stimulant Medications are Schedule 2
drugs
30 day supply with written prescription
Rule change 2007 allows up to 90 day
supply
Three 30 day scripts
Each dated sequentially for fill date

Atomoxetine is not a restricted

medication

ADHD Management Plan

Non stimulant medication
Atomoxetine (Strattera)

Norepinephrine reuptake inhibitor

Starting dose 0.5 mg/kg
Maximum dose 1.4 mg/kg or 100 mg /day
ADHD scores improve with atomoxetine vs
placebo
ADHD scores are equal to / slightly worse
than stimulant medications

ADHD Management
Non-stimulant Medication
Atomoxetine side effects

Anorexia
Weight loss
Abdominal pain
Nausea / Vomiting
Sleep disturbance
Suicidal ideation (0.4% vs 0% placebo)
Liver injury (VERY RARE -- 2 cases!)

When else should I refer a child

I suspect has ADHD?
Failure to respond to a reasonable
trial of stimulant / non-stimulant
medications and behavior
interventions

Conclusions: ADHD
Performing an ADHD evaluation is within
the spectrum of practice of a family doctor
Observer data is needed from at least two
settings in the childs life
Co-morbid / alternate diagnoses should be
ruled out
A comprehensive management plan offers
the patient the best chance for success in
school

ADHD Resources
Caring for Children with ADHD: A Resource
Toolkit for Clinicians, AAP, 2008.
http://www.nichq.org/NICHQ/Topics/ChronicCond
itions/ADHD/Tools/
Individual forms are available here for download
http://www.nichq.org/resources/toolkit
A compressed folder of all ADHD forms is
available for download.

Additional References
Changes and Challenges: Managing
ADHD in a Fast-Paced World, Michael J
Manos, et al, Manag Care Pharm.
2007;13(9)(suppl S-b):S2-S13
Obtaining Systematic Teacher Reports
of Disruptive Behavior Utilizing DM-IV,
Mark L. Woraich, et al, Journal of
Abnormal Child Psychology, Vol 26(2),
1998: 141-152.

Adult ADHD
Childhood ADHD commonly persists:
22-85% of adolescents
4-50% of adults

Adult ADHD
Symptom complex can differ from
childhood
Inattention and impulsivity >
hyperactivity

Adult ADHD
Wender (Utah) Criteria
Hyperactivity and inattention plus (2) of
below

Labile emotions
Hot temper
Inability to complete tasks
Inability to tolerate stresss
Impulsivity

Adult ADHD
Treatment
Stimulants
Response rate decreased versus childhood
ADHD

Atomoxetine
Lower cadiovascular risk profile
Minimal abuse potential

Management of ADHD
Stimulant Misuse (22%) / Diversion
(11%)
Continuously escalating dosage
Repeated lost prescriptions / dispensing
errors
Demand for immediate release preparation
Infrequent user
Psychosis
Palpatations