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Hyperactivity Disorder
(ADHD)
Justin A. Glass, MD
21 February 2008
Emory Family Medicine
ADHD Epidemiology
Prevalence
Survey average: 8-10% in children of
school age
Parent reported prevalence age 4-17
Boys 11%
Girls 4.4%
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
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
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
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
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)
Learning Disability
Schoolwork performance issues
Reading
Writing
Mathematics
Substance Abuse
High index of suspicion in teens
Pervasive Developmental
Delay NOS
Autistic spectrum, but not meeting
autism criteria
Lets go to Vanderbilt
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
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
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!)
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