Part 1 - Healthcare Professionals

managing complicated ADHD
in primary care
Nhung T. Tran, MD, FAAP
[email protected]
Developmental-Behavioral Pediatrics
Scott & White Healthcare
Section of Child Development
Associate Professor
Texas A&M Health Science Center
College Of Medicine
faculty disclosure
 Discussion will reference some pharmaceuticals
that are not approved by the FDA for use in
children and adolescents.
 I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed
in this CME activity
4 th A n n u a l C e n t r a l T e x a s P e d i a t r i c S u b s p e c i a l t y
Update for the Primary Care Provider
objectives
 Know common comorbidities in ADHD and their
prevalence
 Know the management of ADHD with
comorbidities in primary care and when to refer
 Be familiar with issues of monopharmacy versus
polypharmacy
 Know the management of ADHD in preschool aged
children
AAP clinical practice guidelines (2011)
 Action statement 1: PCP should initiate an evaluation for




ADHD for any child 4 through 18 years who present with
symptoms
Action statement 2: To make the diagnosis, PCP should
determine DSM-IV-TR criteria have been met
Action statement 3: In the evaluation of a child for
ADHD, the PCP should include assessments for coexisting conditions
Action statement 4: PCP should recognize ADHD as
chronic condition
Action statement 5: Recommendation for treatment will
vary with age
history
ADHD Brief Overview
Fidgety Phil
Heinrich:
Hoffman,
physician
(1809-1894)
1844
1902
Postencephalitic
behavior
disorder
First treatment
with
benzedrine:
Charles Bradley
(1902-1979)
1917-28
1932 1937 1944
Defect of moral
control:
Sir George
Frederic Still,
physician
(1868-1941)
Hyperkinetic
disorder of
infancy:
Franz Kramer
(1878-1967)
and Hans
Pollnow
(1902-1943),
physicians
Minimal
brain
damage
Hyperkinetic
Reaction of
Childhood:
DSM-II
ADHD:
DSM-IV
1948 1963 1968 1980 1994
Methylphenidate
synthesized:
Leandro Panizzon
(marketed as
Minimal
Ritalin in 1954)
brain
dysfunction
Attention
Deficit Disorder
(with or
without
hyperactivity):
DSM-III
(Lange KW, et al, 2010)
1
what’s next
 Slowed cortical
development (Shaw et al,
2012)



n=234 with ADHD
n=231 controls
Most pronounced difference
in right frontal lobe
 EEG marker: theta to
beta ratio (Loo & Makeig,
2012)
prevalence
 Prevalence:
 2-8% of preschool-age children
 4-12% of school-age children
 3-8% of adolescents
 ~4% in adults
DSM-IV criteria: inattention
 Careless mistakes
 Difficulty sustaining attention
 Does not seem to listen
 Does not follow through
38% still met full diagnostic criteria at 19 years old
 72% still had at least 1/3 of symptoms persist into adulthood

 Male-female ratio is 3:1, but girls less recognized
 Etiologies:
 Genetic versus non-genetic factors
 Parenting, diet, and culture do not cause ADHD, but influence
the outcome
 Avoids tasks that require mental effort
 Cannot organize tasks
 Loses necessary items
 Easily distracted
 Forgetful in daily activities
DSM-IV criteria: hyperactivity-impulsivity
DSM-IV criteria
Hyperactivity
Impulsivity
 Symptoms must be present before age 7 years of age
 Fidgets, squirms in seat
 Blurts out answers
 Significant impairment in ≥2 settings (e.g., school
 Leaves seat
 Difficulty waiting turn
 Runs about or climbs
 Interrupts or intrudes
excessively
 Difficulty playing quietly
 “On the go” or “driven by
a motor”
 Talks excessively
on others
 Symptoms present for ≥6 months
and home) and in social, academic or occupational
functioning
 Symptoms not accounted for by another mental
health disorder
 Subtypes:



ADHD, primarily inattentive-type
ADHD, primarily hyperactive/impulsive type
ADHD, combined-type
2
diagnosis
ADHD Treatment
 Goal:
 Distinguish ADHD from age-appropriate behaviors
 Tips:
 Obtain observation from multiple sources
 Problems only at home is inconsistent with ADHD
 Avoid personal biases
 Under-diagnosis can be more harmful than over-diagnosis
 Medical conditions are not significant considerations
 Psychological or psychoeducational assessments not necessary
for diagnosis
stimulants
stimulants
 Extensively studied
Generic
Brand
 MPH and AMP have equal efficacy, side effects
methylphenidate (MPH)
Ritalin®, Ritalin® SR, Ritalin® LA
Metadate® CD, Metadate® ER
Methylin®, Methylin® ER
Concerta®
Daytrana®
Quillivant XR®
 Wide individual variation in how individual patients
will respond
 Avoid prescribing the same stimulant
stimulants: dosing
d-methylphenidate (d-MPH)
Focalin®, Focalin® XR
dextroamphetamine sulfate
(dexAMP)
Dextrostat®,
Dexedrine®, Dexedrine® Spansules
ProCentra®
Zenzedi™
mixed amphetamine salt (MAS)
Adderall®, Adderall® XR
lisdexamfetamine (LDX)
Vyvanse®
stimulants: side effects
Medication
Starting
dose
Maximum
dose*
Usual
dosing
MPH
d-MPH
5 mg qd/bid
2.5 mg qd/bid
2 mg/kg/d up to 80 mg/d
1 mg/kg/d up to 40 mg/d
tid (3-4h)
bid (5-6h)
Oros-MPH
MPH CD
MPH LA
d-MPH XR
MTS
18 mg qd
10 mg qd
10 mg qd
5 mg qd
10 mg qd
2 mg/kg/d up to 72-108 mg/d
2 mg/kg/d up to 80 mg/d
2 mg/kg/d up to 80 mg/d
1 mg/kg/d up to 40 mg/d
up to 30 mg/d
qd (10-12h)
qd (6-8h)
qd (6-8h)
qd (10-12h)
qd (9-12h)
MAS
MAS XR
2.5-5 mg qd
5-10 mg qd
1 mg/kg/d up to 40-60 mg/d
1 mg/kg/d up to 40-60 mg/d
bid (4-6h)
qd (10-12h)
dexAMP
2.5-5 mg qd
dexAMP Spansules 5 mg qd
LDX
20 mg qd
1 mg/kg/d up to 40-60 mg/d
1 mg/kg/d up to 40-60 mg/d
70-100 mg/d
bid-tid (4-6h)
qd (6-8h)
qd (10-12h)
*Maximum dose may exceed FDA approved dose limits
(Efron et al, 1997)
(Cortese et al, 2013)
3
stimulants: common concerns
 Growth: mixed evidence
 Faraone SV, et al (2008): dose-related reductions, typically
small and attenuate over time
 Zhang et al (2010): Change in height for methylphenidate
group was -1.86+/-0.82 cm compared to controls 0.26+/-0.51
cm (P<0.001). (n=147)
stimulants: concerns
 Later substance abuse
(Humphreys et al, 2013)


 Sudden cardiac death: relatively solid evidence (Olfson
et al, 2012)




Population: 0.8-1 per 100,000 person-years
MPH: 0.2 per 100,000 person-years (n= 10,734,000 Rx)
AMPH: 0.3 per 100,000 person-years (n=70,699,000 Rx)
Atomoxetine: 0.5 per 100,000 person years (n=9,419,000 Rx)

stimulants: common concerns
 Growth deficiency: good evidence it can
 Faraone SV, et al (2008): dose-related reductions, typically
small and attenuate over time
 Zhang et al (2010): Change in height for methylphenidate
group was -1.86+/-0.82 cm compared to controls 0.26+/-0.51
cm (P<0.001). (n=147)
 Later substance abuse:
solid evidence it won’t
(Humphreys et al, 2013)


won’t (Olfson et al, 2012)



Population: 0.8-1 per 100,000 person-years
MPH: 0.2 per 100,000 person-years (n= 10,734,000 Rx)
AMPH: 0.3 per 100,000 person-years (n=70,699,000 Rx)
Atomoxetine: 0.5 per 100,000 person years (n=9,419,000 Rx)
 Specific noradrenergic

Cannot tolerate stimulant
Co-morbid tic disorder
Co-morbid anxiety
disorder
 Dosage forms:
 10 mg, 18 mg, 25 mg, 40 mg, 60 mg capsules (swallowed
whole)
 Side effects:



Similar to stimulants,
except for abdominal pain
Rare hepatitis
Rare suicidal ideation
Wilens, et al (2002)
 Dosing:
 Starting dose: 0.5 mg/kg/d
 Target dose: 1.2 mg/kg/d up to 1.4 mg/kg/d or 100 mg/d
(whichever is lower)
 Usual dosing: qd or bid (for higher doses)
reuptake inhibitor
 Consider if:


Meta-analysis of 15
longitudinal studies
(n=2,565)
Objective: determine
association between
stimulant treatment and
later substance outcomes
(use, abuse, dependence)
 Alcohol, cocaine, marijuana,
nicotine, nonspecific drugs
Results: outcomes
comparable in children with
or without treatment
atomoxetine: dosing
atomoxetine

Wilens, et al (2002)
stimulants: concerns
 Sudden cardiac death: relatively solid evidence it

Meta-analysis of 15
longitudinal studies
(n=2,565)
Objective: determine
association between
stimulant treatment and
later substance outcomes
(use, abuse, dependence)
 Alcohol, cocaine, marijuana,
nicotine, nonspecific drugs
Results: outcomes
comparable in children with
or without treatment
(Newcorn et al, 2008)
 Tips:
 Drug-drug interaction with SSRI: decrease dose of
atomoxetine
 Switching from stimulant: d/c stimulant, start atomoxetine
monotherapy, then re-evaluate need for stimulant add-on
4
alpha-agonist
alpha-agonist
 Clonidine
 Declining use in daytime
due to sedation
 Most often used as single
dose QHS for insomnia
 Most often used as
adjunctive treatment
 Guanfacine
 Guanfacine extended-release (Intuniv)
(Palumbo et al, 2008)
 Clonidine extended-
release (Kapvay)


Tolerated as
monopharmacy
Most often used as
adjunctive treatment
(Wilens et al, 2012)
(Biederman et al, 2008)
(Kollins et al, 2011)
alpha-agonist: dosing
alpha-agonist
 Consider if:


Did not tolerate stimulant
or atomoxetine
Co-morbid tic
 Side effects:


Sedation
Constipation
Dosage (mg)
(weight <45 kg)
Dosage (mg)
(weight >45 kg)
Baseline
Clonidine
Guanfacine
Clonidine
1-2
0.05 qhs
0.5 qhs
0.1 qhs
1.0 qhs
3-4
0.05 bid
0.5 bid
0.1 bid
1.0 bid
5-6
0.05 tid
0.5 tid
0.1 tid
1.0 tid
Week
 Monitor:

Week
Blood pressure, heart rate
Guanfacine
Dosage (mg)
Baseline
Kapvay
1
0.1 qhs
Intuniv
1 qd (usually qpm)
2
0.1 qam & 0.1 qhs
2 qd
3
0.1 qam & 0.2 qhs
3 qd
4
0.2 qhs & 0.2 qhs
4 qd
(Biederman et al, 2008)
ADHD Favorite Resources
ADHD and Co-morbidities
1. ADHD medication guide:
www.adhdmedicationguide.com
2. ADHD medication handout from CHADD:
www.adhdmedicationguide.com/adhd_me
d_guide.pdf
3. Texas children’s medication algorithm
project: Pliszka SR et al, 2006.
5
common co-morbidities
 Prevalence (Larson et al, 2011)
n=61,779
No
ADHD
(%)
common co-morbidities
 Prevalence (Larson et al, 2011)
ADHD
(%)
Adjusted
Relative
Risk
Learning disability
5.3
46.1
7.79
Conduct disorder
1.8
27.4
12.58
Anxiety
2.1
17.8
7.45
Depression
1.4
13.9
8.04
Speech problem
2.5
11.8
4.42
Autism spectrum d/o
0.6
6.0
8.72
Hearing problem
1.2
4.2
2.77
Epilepsy or seizure
0.6
2.6
3.93
Vision problem
1.4
2.3
1.47
Tourette syndrome
0.09
1.3
10.70
Any MH/ND d/o
11.5
66.9
5.12
Percentage of children with ADHD who
have comorbid disorders (n=5,028)
16%
Three
18%
Two
One
33%
Zero
33%
0
screening tools
10
20
30
40
Oppositional Defiant Disorder
(ODD)
 ADHD: NICHQ Vanderbilt Assessment Scale
 Others:




Mood and Feeling Questionnaire (MFQ)
Self Reported Child Anxiety Related Disorders (SCARED)
Child Mania Rating Scale (CMRS)
See Massachusetts General Hospital
http://www2.massgeneral.org/schoolpsychiatry/screeningt
ools_table.asp
ODD
 Recurrent pattern of negativistic, disobedient, hostile
behaviors
 Prevalence:


2-16% in general population
Up to 50% in children with ADHD
 Etiologic considerations:



Genetic factors (slight)
Environmental factors (significant)
Temperamental factors (significant)
 Presentation:
 Worse in > out of home.
 In young children, ODD symptoms often secondary to ADHD.
 In older children, ODD symptoms often mimic inattention.
ODD
 Symptoms:









Tantrums
Persistent stubbornness
Resistance to directions
Inflexibility
Deliberate, persistent testing of limits
Aggression
Labile mood
Low frustration tolerance
Low self-image
6
ODD
 Diagnostic criteria: at least 6 months, during which
four (or more) of the following are present:








often loses temper
often argues with adults
often actively defies or refuses to comply with adults' requests
or rules
often deliberately annoys people
often blames others for his or her mistakes or misbehavior
is often touchy or easily annoyed by others
is often angry and resentful
is often spiteful or vindictive
ODD
 Treatment:

Psychosocial therapy – primary
Cognitive-behavioral therapy
Family therapy
 Collaborative Problem Solving (www.livesinthebalance.org)




Parenting (parent training)
Anticipatory guidance (e.g., limit exposure to violence), avoid
giving parenting advice
ADHD and co-morbid ODD
Aggression
 Optimize treatment of ADHD
 Treatment for ADHD effective with or without ODD
 Aggressive outbursts (in the absence of mania and/or
psychosis) is not a contraindication to treating ADHD
 Intermittent substance abuse is not a contraindication to
treating ADHD
 Stress to parents that psychosocial therapy is even
more important
aggression
 Often co-occurs with ADHD + ODD
 Prevalence:
 Not well studied
 Estimated 45% of children with ADHD
 Presentation:
 Property (destructive)
 People
 Self
 Animals
 Useful to distinguish occasional outbursts versus
daily or nearly daily “rages”
aggression
Impulsive
Predatory
Non-profitable damaging of own
property
Steals others’ property
Displays aggressive acts in front of
people
Hides aggressive acts
Completely out of control when
aggressive
Can control their own behavior when
aggressive
Exposes self to physical harm when
aggressive
Very careful to protect self when
aggressive
Fights with stronger children
Fights with weaker children
Is aggressive without a purpose
Tried to get something from, has a
reason for being aggressive
Aggression is unplanned, out of the blue Plans aggressiveness
Expresses remorse after aggression
Looks proud of being aggressive
7
psychosis
ADHD and co-morbid aggression
 Does your child ever say that he hears voices talking




to him? Does he talk to people who are not there?
(Exclude imaginary friends in young children)
Does your child ever say he is seeing things?
Does your child feel people are always trying to get
him or does he act paranoid?
Does he believe strange things that other kids his age
just don’t believe?
Refer for psychiatric evaluation
 First, rule out mania/psychosis
 Refer to psychiatrist if symptoms of mania/psychosis or if an
imminent threat to self or others
 Then, use Texas Children’s Medication Algorithm
Project [Pliszka et al, 2006]




Begin treatment for ADHD: stimulants significantly improve
aggression in ADHD (Connor, et al, 2002; Blader et al, 2012)
Add psychosocial therapy if no improvement
Add second-generation antipsychotic (SGA)
If no response, refer to psychiatrist.
second generation antipsychotics
ADHD and co-morbid aggression
 Aman, et al, 2014
 Basic treatment group (n=84): parent training + stimulant
 Augmented treatment group (n=84): parent training +
stimulant + risperidone
Generic
Brand
aripiprazole (L)
Abilify®
clozapine (L)
Clozaril®
olanzepine (M)
Zyprexa®
quetiapine (M)
Seroquel®
risperdone (H)
Risperdal®
ziprasidone (M)
Geodon®
L=low potency, M = medium or intermediate potency, H=high potency
 Side effects: drooling in the absence of EPS (common), weight
gain, elevated prolactin, sedation
 Baseline measures: CMP, lipid panels, HT, WT (repeat in 3
months then every 6 months
second generation antipsychotics: weight
second generation antipsychotics: weight
Distribution of weight change in double-blind short-term
studies at 4-12 weeks (Parsons, et al, 2009)
Distribution of weight change in double-blind long-term
studies at 1 year (Parsons, et al, 2009)
60
50
40
<-7% (loss)
>7% (gain)
30
20
10
0
Placebo
n=187
Mean change -0.5 lb
Weighted average (%)
Weighted average (%)
60
50
40
30
<-7% (loss)
>7% (gain)
20
10
0
Ziprasidone Haloperidol Risperidone Olanzapine
n=1,063
n=229
n=112
n=92
+1.4 lb
+0.1 lb
+4.3 lb
+11.1 lb
Placebo
n=30
Mean change +0.09
Ziprasidone Haloperidol Risperidone Olanzapine
n=321
n=16
n=82
n=15
-0.36
+0.41
+0.62
+0.8 in lb/month
8
second generation antipsychotics: dosing
Risperidone
Aripiprazole
Quetiapine
Week
Preadolescents
Adolescents
1-2
0.5 qhs
1 mg qhs
3-4
0.5 mg bid
1 mg bid/tid
5-6
1 mg bid/tid
2 mg bid/tid
1-2
2.5-5 mg/d
5-10 mg/d
3-4
10-15 mg/d
15-20 mg/d
1-2
2.5-5 mg/d
5-10 mg/d
1-2
25 mg qd/bid
50 mg bid
3-4
50 mg bid
200 mg bid
5-6
100-200 mg bid
300 mg bid
depressive disorder
 Prevalence:
1-2% of pre-pubertal children, 3-8% in adolescents
 Estimated 13.9% in children with ADHD (Larson et al, 2011)
 Etiologic considerations:
 Genetic
 Environmental
 Neurodevelopmental factors/stages
 Medical
 Types:
 Major depressive disorder
 Dysthymia
 (Adjustment disorder with depressed mood)

depressive disorder
 Treatment:
 Psychosocial therapy - primary
Cognitive Behavioral Therapy (CBT)
Interpersonal Psychotherapy (IPT)
 Family/group therapy



depressive disorder
 Core symptom: sadness versus irritability
 Use different words like sad, grouchy, down in the dumps,
irritable, unhappy
 Quantify
 How often do they occur?
 How long do each episodes last?
 How long has your child felt this way?
 Always ask about
 Neurovegetative signs
 Self-esteem
 Suicidal ideation
 Past episodes of depression
depressive disorder
 TADS, 2004:
 N=439, ages 12-17
 Response rates: FLX + CBT: 71%
CBT: 43%
FLX: 61%
Placebo: 35%
Pharmacotherapy



Depressive Disorders
Selective Serotonin Reuptake Inhibitors (SSRI)
Non-SSRIs
Educational


Supports
Special Education under “Emotional Disturbance” if severe
9
irritability
irritability
 ODD-type
 Brief episodes of anger related to frustration, mood returns to
normal as soon as frustration passes
 Mad/cranky
 “Slow burn” of prolonged negative mood, not related to
stressors, pessimistic (unipolar in nature)
 Super angry/grouchy
 Explosive rages, intermixed with silliness and excitement
(bipolar in nature)
 Depressive episode:








 Manic episode
Sleep changes
Interest loss
Guilt, worthlessness
Energy loss
Concentration loss
Appetite/weight loss or gain
Psychomotor retardation or
agitation
Suicidal ideation








Abnormal mood: euphoria
+ irritability (extreme,
persistent, threatening, outof-control, rages)
Distractibility
Increased activity/energy
Grandiosity
Flight of ideas
Activities with bad outcome
Sleep decreased
Talkativeness
(Mick E, et al, 2005)
ADHD and co-morbid depressive d/o
 First, distinguish demoralization versus depression
 Refer to psychiatry if (1) suicidal ideation, or (2)
depressed/irritable mood for at last an hour (3-5 times per
week)
 Then, use Texas Children’s Medication Algorithm
Project [Pliszka et al, 2006]


Treatment based on the presentation
Treat depression or ADHD first, depending on which is more
severe
ADHD and co-morbid depressive d/o
Primary care
Psychiatry
Age 9-17 years
<9 years
MDD, dysthymia only
Atypical depression
ADHD comorbidity only
Aggression or severe ODD comorbidity
No substance abuse
Substance abuse
No psychosis
Persecutory delusions or hallucinations present
Only passive suicidal ideation
Suicidal intent, clear plan
ADHD and co-morbid depressive d/o
SSRI antidepressant dosing
 4% with SI on SSRI (compared to 2% from placebo)
with was statistically significant (FDA analysis of
n=4,000), but no completed suicide
 Fluoxetine or other SSRI first line
 Observe for feelings of self-harm, increase in
agitation
 Follow-up:



Child (mg/d)
Adolescent (mg/d)
Start
Max
Start
Fluoxetine
5-10
20
10-20
Max
60
Sertraline
25-50
100
50
200
Citalopram
10
20
10-20
40
Escitalopram
10
20
10-20
40
1 month or earlier if issues
Monthly for 2-3 months
Every 4 months for 1 year or until depression free
10
anxiety disorders
Anxiety Disorders
 Prevalence:


13% of children and adolescents
Estimated 17% in children with ADHD (Larson et al,
2011)
 Etiologic considerations:
Genetic
Environmental
 Temperamental


 Prognosis:

Often chronic, persistent into adulthood
anxiety disorders
 Types
Simple phobia (10-11%)
 Generalized anxiety disorder (3-10%)
 Obsessive compulsive disorder (2.5%)
 Separation anxiety disorder (4%)
 Social phobia (10-11%)





Generalized versus non-generalized
Selective mutism
Posttraumatic stress disorder (1-14%)
Panic disorder (1.5-3.5%)
anxiety disorders
 Presentation:
 Cognitive – catastrophic thoughts, poor school performance
 Physical – nausea, pain, headaches, eating problems,
sleeping problems
 Emotional – fears, worry
 Behavioral – avoidance, escape, emotional outbursts
 Ask about
 Duration, frequency, intensity
 Anticipatory vigilance
anxiety disorders
 Treatment:

Psychosocial therapy – primary
Parent training for children <8 years old
 Cognitive Behavioral Therapy (CBT) for children >8 years old


Pharmacotherapy – when severe impairments



Selective Serotonin Reuptake Inhibitors (SSRI)
Non-SSRIs
ADHD and co-morbid anxiety d/o
 Distinguish between developmentally appropriate
worries, fears
 Then, use Texas Children’s Medication Algorithm
Project [Pliszka et al, 2006]


Begin with atomoxetine or stimulant
Add stimulant, atomoxetine or SSRI depending on response
Educational


Supports
Special Education under “Emotional Disturbance” if severe
(Geller et al, 2007)
11
tic disorders
Tic Disorders
 Prevalence:
 Estimated 20% in children with ADHD (Larson et al, 2011)
 Tics occurring during stimulant treatment are
usually transient, rarely becoming chronic
ADHD and co-morbid tic disorder
 Use Texas Children’s
Medication Algorithm
Project (Pliszka et al, 2006)
ADHD in preschool age
children
alpha-2 agonist
(monopharmacy)
stimulant
(monopharmacy)
 Or alternative (but
similar) algorithms
(see right) (Rizzo, et al,
stimulant +
alpha-agonists
2013)
atomoxetine or
SGA
adhd in preschool age children
 Red flags of moderate-severe ADHD:
 Ejection or threatened ejection from school or child care center
 Exhausted, exasperated caregivers
 Discord between caregivers because of child’s behavior
 Rejected by, isolated from peers
 Risk of injury to self and others
 Risks factors: strong family history of ADHD, underlying
medical condition (e.g., prenatal alcohol exposure)
adhd in preschool age children
 AAP guidelines (2011) say try psychosocial therapy
first
 Before medications, consider:
 Deferring until has had structured learning opportunities
 Whether benefits outweigh risks (school, home, social,
personal safety)
 Referral to specialist
 Consider medications if:
 Inadequate response to psychosocial therapy
 Moderate to severe impairment in functioning
 Persistent symptoms for >9 months
12
final tips
summary
 Screens negative for co-morbidity
 For 5 years and younger: consider psychosocial therapy before
or concurrently with ADHD medication
 For 6 years and older: proceed with ADHD medication
 Screens positive for ODD
 Proceed with ADHD medication + behavioral therapy
 Screens positive for aggression
 For occasional episodes: proceed with ADHD medication +
behavioral therapy
 For severe episodes: seek in depth psychiatric assessment
final tips
final tips
 Screens positive for mania
 Seek in depth psychiatric assessment
 Medications should not be avoided because of
 Screens positive for depression or anxiety
 If symptoms below threshold: proceed with ADHD medication
 If symptoms above threshold*: defer ADHD medication,
proceed with treatment for depression or anxiety first
*Threshold: sad/irritable/anxious mood 3-5 times per week for
at least an hour; neurovegetative symptoms; separation
problems
 Parenting and behavior therapy works, but has limits
unrealistic fears
 Failure is not an option
 Avoid underrecognition, undertreatment
 Special education not an answer to every issue
 Screens positive for tic disorder
 Proceed with ADHD medication
references
questions?
 Faraone SV, et al. Effect of stimulants on height and weight: a review of the
literature. Journal of the American Academy of Child and Adolescent
Psychiatry, 2008, 47(9): 994-1009.
 Geller D, et al. Atomoxetine treatment for pediatric patients with ADHD with
comorbid anxiety disorder. Journal of the American Academy of Child and
Adolescent Psychiatry, 2007, 46(9): 1119-1127.
 Humphreys KL, et al. Stimulant medication and substance use outcomes: a
meta-analysis. JAMA Psychiatry, 2013, 70(7): 740-749.
 Jain R, et al. Clonidine extended-release tablets for pediatric patients with
attention-deficit/hyperactivity disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 2011, 50(2): 171-179.
 Kollins SH, et al. Clonidine extended-release tablets as add-on therapy to
psychostimulants in children and adolescents with ADHD. Pediatrics, 2011,
127(6): e1406-e1416.
 Lange KW, et al. The history of attention deficit hyperactivity disorder. ADHD,
[email protected]
2010, 2: 241-255.
13
references
references
 Larson K, et al. Patterns of comorbidity, functioning, and service use for US
 Parsons B, et al. Weight effects associated with antipsychotics: a
 March J, et al. Fluoxetine, cognitive-behavioral therapy, and their combination
 Pliszka SR, et al. The Texas Children’s Medication Algorithm Project: revision
children with ADHD, 2007. Pediatrics, 2011, 127(3): 462-470.




for adolescents with depression: Treatment for Adolescents with Depression
Study (TADS) randomized controlled trial. JAMA, 2—4: 292: 807-820.
Mick E, et al. Heterogeneity of irritability in attention-deficit/hyperactivity
disorder subjects with and without mood disorders. Biol Psychiatry, 2005,
58(7):576-82.
Newcorn JH, et al. Atomoxetine and osmotically released methylphenidate for
the treatment of attention deficit hyperactivity disorder: acute comparison and
differential response. American Journal of Psychiatry, 2008, 165: 721-730.
Olfson M, et al. Stimulants and cardiovascular events in youth with attentiondeficit/hyperactivity disorder. Journal of the American Academy of Child and
Adolescent Psychiatry, 2012, 51(2): 147-156.
Palumco DR, et al. Clonidine for attention-deficit/hyperactivity disorder: I.
Efficacy and tolerability outcomes. Journal of the American Academy of Child
and Adolescent Psychiatry, 2008, 47(2): 180-188.
comprehensive database analysis. Schizophrenia Research, 2009, 110: 101-110.
of the algorithm for pharmacotherapy of ADHD. Journal of the American
Academy of Child and Adolescent Psychiatry, 2006, 45(6): 642-657.
 Rizzo R, et al. Tourette Syndrome and comorbid ADHD: current pharmalogical
treatment options. European Journal of Paediatric Neurology, 2013, 17:421428.
 Subcommittee on ADHD, Steering Committee on Quality Improvement and
Management. ADHD: Clinical practice guidelines for the diagnosis, evaluation
and management of ADHD in children and adolescents. Pediatrics, 2011,
128(5): 1-16.
 Wilens TE, et al. A controlled trial of extended-release guanfacine and
psychostimulants for attention-deficit/hyperactivity disorder. Journal of the
American Academy of Child and Adolescent Psychiatry, 2012, 51(1): 74-85.
references
 Wilens TE, et al. Attention deficit/hyperactivity disorder across the lifespan.
Annual Review in Medicine, 2002, 53: 113-131.
 Zhang H, et al. Impact of long-term treatment of methylphenidate on height
and weight of school age children with ADHD. Neuropediatrics, 2010, 41(2):
55-9.
14

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