ADHDPay Attention!

Lisa Samson-Fang MDGeneral and Developmental Behavioral Pediatrics

Intermountain Medical Group

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Practice Size: 2000 children

www.medicalhomeportal.org

Diagnosis• Clinical history

• Data from 2 settings

• DSM criteria

• Beware: anxiety, OCD, PTSD, LD, mild ID, depression, mild ASD, reactive attachment disorder

• Repeat

• if young

• ? if new to your care

DSM V: Softened Criteria

• 6/9 inattention (5/9 for adult) and/or 6/9 hyperactive (5/9 for adult)

• “some” symptoms before 12

• meets criteria in one environment with “some” symptoms in other environments

• “interferes with or reduces quality of academic, social, occupational function”

Preschoolers

http://pcptoolkit.beaconhealthoptions.com/wp-content/uploads/2016/01/cms-quality-child_adhd_rating_scale_screener.pdf

3-5 years• First Line: behavior

management and environment adjustment

• Behavioral Parent Training

• Parent Interaction Training

• Not counseling or play therapy

• Meds second line - get used in up to 50%

Behavior Therapy (60 secs)

• Change parent perception (disability vs bad)

• not listening=impulsive, destructive=hyperactive, defiant=can’t stay on task

• Structure environment (time and space)

• State what you want and reinforce positive behavior

• Ignore minor infractions

• Target few/serious behaviors w/ consequences

• Success = gradual reduction in intensity and frequency

School Aged

• Medication

• Behavioral therapy: particularly important for children w/ co-morbid issues

• Environmental adjustment (home and school)

• Self awareness and development of strategies

Med Choices

• Stimulants (methylphenidate/amphetamine)

• Atomoxetine

• Alpha 2 agonists (guanfacine/clonidine)

• (Buproprion hydrochloride)

Stimulants

• Catecholamine re-uptake inhibitors

• Track record for safety and efficiency

• Methylphenidate (methylphenidate, dexmethylphenidate)

• Amphetamine (mixed salts, lisdexamfetamine, dexedrine)

• Appetite, sleep, anxiety/irritability/zoned, tics(?), rare heart arrhythmia or increased BP, misuse/diversion

www.adhdmedicationguide.com

www.adhdmedicationguide.com

Picking a stimulant• amphetamine vs methylphenidate: no data to determine

best choice for particular patient

• family preference or family hx

• ability to swallow pill

• cost considerations

• generally go for longer acting

• you don’t have to do 30 pills (5-10 for a trial)

What is on patients formulary?

Paying out of pocket?

Duration of Action

Atomoxetine

• not a stimulant,SNRI, also increases dopamine

• headache, nausea, abd pain, behavioral change, rare liver failure

• +may impact anxiety, 24 hour coverage

• -expensive, no skipping, 4 week trial w/ 50% success

• stand alone vs an adjuvant

alpha 2 agonist

• guanfacine ER, clonidine ER, activates frontal lobe pathways

• low BP/tiredness/irritability/wt gain/potential for cardiac

• don’t chew, don’t take w/ high fat, work up/wean off

• 24 hour coverage, doesn’t trigger anxiety, calming impact

• stand alone vs adjuvant

Short vs Long Acting

www.uacap.org

www.uacap.org

www.uacap.org

Med Check

• what is going on in child’s life (#1 goal is preservation of self esteem)

• is med working for target symptoms (rating scales)

• is it tolerated (parent/child’s opinion)

• appetite, sleep, anxiety, well being, tics, VS/BMI, cost

• is impact and duration optimal

• co-morbid issues to address!!!

Co-morbid Conditions

• Dramatically impact treatment strategy

• Repeatedly consider (particularly if not doing well)

• Anxiety, autism, OSA, ODD, Depression, LD, Tourettes, OCD, adjustment concerns, family challenges, bullied, sleep, RLS, substance abuse, encopresis, not taking meds etc.

• Use screening tools at med checks

Executive Dysfunction

• organizing/prioritizing/starting

• sustaining/shifting attention

• emotion management/self regulating/inhibition

• alertness/processing

• memory/working memory

• self monitoring

School• Collaboration: Testing for LD

• 504: accommodation for disability (mostly supports executive function), Increasingly offering social skills support and counseling

• IEP: special educational programming (less common, ADHD is not a qualifier (use other health impaired category)

• Private testing: can be expensive, generally needed if autism is a concern.

“The medication stopped working”

• what is happening and when is it happening

• med responsive symptom?

• during medication window?

• changes or stressors (home and school), environments change faster than drug metabolism!

• unaddressed co-morbid issues

• increase/change med or extend (3 pm short acting dose)

• +adjuvant (guanfacine ER (hyperaroused), risperidone (ODD))

High School• ACT/SAT accommodations (needs track

record of accommodations via 504).

• Vocational rehabilitation support if significant hurdles to employment or college

• Visit the office of supports for students with disability at colleges under consideration!!

• Executive Function: consider private tutor or coach (prevents the snow ball!)

• Medication planning

• Self determination

• Medication timing challenges (e.g., sleeping in)

• Many student health services won’t prescribe!

The Adult

Medication• Stimulant first line unless contraindication

• Anxiety: SSRI + stimulant

• Depression: bupropion

• SUD: ? no club drug/stimulant/cocaine abuse, consider stimulant, otherwise atomoxetine

• Cognitive behavioral therapy is helpful

• Modafinil, alpha 2 agonists + TCAs: limited data for use in adults

Thank you