ࡱ> XZW%` 7bjbjNN .R,,/, <i$2hhhhhhhh#######$%h(\$hh$hh#$^hh##Vd"@(#h\ _H|j" #9$0i$"x_(_((#_((#h| hhh$$ hhhi$ Developmental-Behavioral Pediatrics, 2008 Josh Mandelberg ADHD Intro Behavioral syndrome of cluster of suggestive behaviors, not simple diagnosis Young children interfere with relationships (parents, peers, teachers), discipline problems Adolescent and Adult impair job/academic achievement, relationships, associated with legal difficulties, MVAs, smoking, substance abuse Current theory - Thought to represent d/o of executive function (Russell Barkley) problems with behavioral inhibition or self-regulation (non-verbal working memory, speech internalization, affect, emotion, motivation, arousal), problems with delayed behavior / long term-consequences Epi Most common neurodevelopmental d/o of childhood (anxiety is more common child psych problem but ADHD treated more) Recognized initially 1902, more prevalent after Flu Pandemic Best estimate probably 4-8% prevalence in children and adolescents, 4% in adults (criteria for inclusion vary and make prevalence estimates vary), more common in lower SES, 2:1 Male:Female (older studies undercapture female internalizing behaviors), similar rates in other countries Combined type (50-75%), inattentive (20-30%, more overlooked), hyperactive/impulsive (<15%). Average rate of treatment ~55%, 4 of 6 recent population studies suggest under-treatment 5 fold increased prevalence in 1st degree relatives, Twin study genetic concordance rate is 0.8 (Height in 0.9, Asthma is 0.4) Environmental risks low birth weight (<1500g have 3x risk), perinantal injury, maternal smoking and alcohol, lead exposures, psychosocial adversity Comorbidities (some estimate 50-75% of all kids with ADHD have comorbid 2nd dx) Question whether other dx caused by ADHD or if other dx coexisted with ADHD sx ODD, conduct, depression, anxiety, LD, speech/lang delay/disorders, mild mental retardation, bipolar d/o, tic disorder/Tourettes, PTSD Etiology (likely common pathway for host of neurological and environmental risks) Genetic very high identical twin concordance 0.6-0.8, 1st degree relative risk of 20-25%. Possible role of dopamine related genes Medical risks in utero exposure to tobacco and alcohol, low birth weight, prematurity. Lead, carbon monoxide, heavy metals implicated in some cases. PET / fMRI suggest underactivity in areas of cerebral cortex especially in frontal lobe. Other implicated areas include cerebellar vermis, cingulated gyrus, frontal-striatal connections, basal ganglia, brainstem Environmental risks (parental psychopathology, low SES) likely exacerbate rather than cause. Clinical Classically - core sx are inattentiveness, hyperactivity and impulsiveness, present in childhood before age 7 Other associated issues emotional lability, resistance to environmental reinforcement (behavioral techniques less effective), lower sense of physical safety (accidents), aggressive (worse prognosis, may lead to conduct d/o), oppositional stance (also worse prognosis, may lead to ODD), poor social skills (socially tone deaf, few friends, estimate 2y social delay), low self esteem Younger kids (3-5y/o) motor restlessness, dont nap, hard time settling, difficulty completing developmental tasks, family difficulties, vigorous disruptive play, demanding, argumentative, defiant, may have motor or language delay, excessive temper tantrums, kicked out of preK Adolescents (13-18y/o) inner restlessness, disorganized school work with poor follow through, fails to work independently, risk taking behaviors, problems with authority figures, poor self esteem and peer relationships, anger, emotional lability Adults disorganized, poor planning ahead, forgetful, lose things, problems with relationships, misjudge time, procrastinate and trouble finishing projects or tasks, impulsive decisions in job / finance. Study shows IQ matched professionals with ADHD earn $50K/year less than non-ADHD Dx No definitive test, involves integrating report of multiple observers, different settings, extended period of time, significant compared to peers of similar developmental age, causing significant problems in functioning and relationships. May see the more intelligent the child, the later the diagnosis Key Questions Tell me about the behaviors that concern you (specifics) Who concerned about these behaviors? (multiple settings or just parent or teacher?) When did you become concerned? (onset) Tell me about his attention span. (listening, completing, watching) Tell me about his activity level (overactive, fidgety) Is he impulsive? (interrupt, remorseful, act without thinking) Tell me about how he expresses emotions? (angry, sad, anxious) Does he get along with other kids? Friends? (ADHD often poor social relationships, causing unhappiness and low self esteem) How is he doing in school / daycare? (dysfunction?) How do you think these problems have affected his self-esteem? (important index of treatment, may be overlooked) How do you deal with these behaviors? What has and has not worked? (often many negative, ineffectual and punitive responses have been tried) Why do you think these problems are occurring? What do others say is the cause? (elicits parents feelings, theories on causation, differences between parents thoughts) In office May behave self with novelty, small group setting, fear of MD (ADHD is a problem in usual settings). Misbehaving even in office may be more extreme sx. Exam often unrevealing, look for neuro signs, dysmorphic features, autonomic disturbance Evaluation Questionnaires (obtain info from teachers, other family, babysitters and caretakers in other settings) ADHD specific - Vanderbilt, Revised Conners, Behavior Assessment System for Children (BASC), SNAP (ADHD.net) Can do broader screen (Child Behavior Checklist) because of frequent comorbidity Look for consistency to help make dx in combo with clinical judgment Inconsistent responses Problem at home only may reflect problems/stress in home environment. Problems only at school may be LD, stress, bullying, anxiety, etc but may also be parents being too accepting or in denial or resistant to dx. If dx still unclear look at significance of dysfunction School records, standardized test scores Psychological and educational testing useful if significant academic problems to look for comorbid LD. Can get IEP or privately. Hearing and vision screening Medication and substance use history Lab/Imaging - Not indicated routinely unless suggested by exam (TFT, EEG, MRI). Consider EKG / Cards eval if known cardiac defect, h/o fainting, syncope, seizures or FHx sudden death Consider sleep problems (sleep apnea) as part of differential Continuous performance task is not reliable for dx or response to tx Keep an eye for co-morbidities since are very common Prognosis Symptoms often persist into adulthood but often change in nature (hyperactivity becomes restlessness, inattention often remains, problem is that may think cured because less external sx and go off treatment) Risk of antisocial behaviors (20%), substance abuse (15%), other DSM diagnoses (35%). Substance abuse suggested to be less in those on meds Other impacts seen: Family: 3-5x rate of divorce in parents Teen: 7-8x rate of teen pregnancy, 4x rate of STDs, 3x rate of grade repetition, 2x rate incarceration, 2x rate of smoking (start younger, 1/2 chance of being able to quit), 2-3x rate of suspended drivers license (increase risk of MVA), 2x rate of suicide attempt Adult: 2x rate of being fired from job Majority do well, especially if not aggressive or oppositional, high IQ and higher SES Treatment (goal enhance functioning, relationships and self esteem) Education Resistant parents may benefit from time to review literature on ADHD and talking to parents with kids who have the dx Giving diagnosis may make parents more accepting of child. Idea that behaviors are biological and more out of his control Explain chronic nature of diagnosis although sx may change in time. Explain that decisions to treat or not treat can be changed at any time. Medicines (if stable dose can give 3 triplicates with do not fill before date on 2nd and 3rd) Stimulants monthly triplicate, abuse potential. Often independently help oppositional defiant disorder, do not make anxiety worse, may worsen tics (see tics in 9% on stimulants but persist in <1%). Strattera (norepinephrine reuptake inhibitor, approved 2003) Other meds - clonidine, guanfacine, buproprion (3rd line, least effective) but may use adjunctively or for side effects Good to start tx or make changes on weekend so parents can watch effects Adjunctive modes of treatment - Does not change child, just the fit of the environment Behavior management training teach parents how to set limits, provide incentives, minimize disruptive responses. Can do in small group (doubles as support group) or individually. Individual therapy if oppositional or aggressive, self-esteem problems / depression. Social skills training may help problems with peer relationships Monitoring Brief weekly report initially and then 1-2x/month once on stable treatment (clinical attention profile sheet CAPS. Free at dbpeds.org) Medicines are very effective 70-80% effective. For non-responders to 1 of 2 stimulant classes, 66-80% respond to the other class. Watch for improvement in all areas (academic, behavior, esteem, disruptiveness, relationships, safety) Successful response should be dramatic and clearly beneficial Monitor height and weight, HR and blood pressure regularly Decide to treat on weekend and summer if has problems with relationships, peers or safety or if needs to focus on academic work (i.e. weekend homework or summer school) Expect to treat into adolescence (only 10-20% outgrow dx). If concern can consider trial off meds during times of low stress Consider referral if not responding to meds, unacceptable side effects, ongoing ambiguous diagnosis. Medications: Methylphenidate (approved 1960) Long acting (%immediate release / %sustained release) Focalin XR (5, 10, 15, 20 ER) duration 10-12h, 2x as potent as Ritalin, may sprinkle on applesauce, ~$4.10/pill Concerta (18, 27, 36, 54 ER) (22%/78%), duration 10-12h, $4.33/pill Ritalin SR (20 ER) duration 4-8h, may dose BID 8h apart, $1.93/pill Ritalin LA (10, 20, 30, 40 ER), (50%/50%) duration 8-12h, may sprinkle on applesauce, $3.66/pill Daytrana patch (10, 15, 20, 30 / 9h), (diffusion release) onset 2h, effect may persist for 5h after patch removed, ~$5/patch Metadate CD (10, 20, 30, 40, 50, 60 ER) (30%/70%) duration 8-12h, ?sprinkle, ~$3.50/pill Metadate ER (10, 20 ER) duration 4-8h, $1.40/pill Methylin ER (10, 20 ER) duration 4-8h Methylphenidate ER generic (20 ER), duration 4-8h, $1.20/pill Short acting Focalin (2.5, 5, 10) duration 3-5h, 2x as potent as Ritalin, ~$1.55/pill Ritalin (5, 10, 20) duration 3-5h, give 30-45min before meals, ~$1.70/pill Methylin (5, 10, 20 pill. 2.5, 5, 10 chew, 5/5, 10/5 liq) Methylphenidate generic (5, 10, 20), duration 3-5h, ~$0.87/pill Amphetamine salts (approved 1950s) Long Acting (%immediate release / %sustained release) Adderall XR (5, 10, 15, 20, 25, 30 ER) (50%/50%) duration 8-12h, $4.70/pill Vyvanse (20, 30, 40, 50, 60, 70), may open cap and dissolve in water to titrate dose, ~$4.50/pill Dexedrine ER (5, 10, 15 ER) duration 6h, ~$2.58/pill Dextroamphetamine ER generic (5, 10 ER), ~$1.38/pill Short Acting Adderall (5, 7.5, 10, 12.5, 15, 20, 30) duration 4-6h, ~$3.25/pill Dexedrine Spansules (5), sprikle, duration 4h Dextroamphetamine generic (5, 10, 15 ER), duration ~4-6h, ~$0.70/pill Amphetamine/dextroamphetamine salts generic (5, 7.5, 10, 12.5, 15, 20, 30), duration ~4-6h, ~$1.30/pill Strattera (norepinephrine reuptake inhibitor, approved 2003) Second line treatment (i.e. less effective) No abuse potential, can prescribe on regular Rx with refills Start 0.5mg/kg/d for 2 wks, gradually increase to 1.2-1.4 mg/kg/d (in AM if no drowsiness or else in HS) References: Parker, Developmental and Behavioral Pediatrics, 2nd Ed, Asperger Syndrome. Ch 25. 114-123. 2005. 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