the adhd journey - npac-aiipc€¦ · * “overall, adhd is one of the best-researched disorders in...
TRANSCRIPT
TheADHDJourneyAngelinaWiwczor,NursePractitioner
* Idonothaveanyconflictsofinteresttodeclare
Disclosure
* 1.EpidemiologyofADHD* 2.ReviewDSM5diagnosticcriteriaforADHD* 3.Discusstreatmentoptions,includingbehaviouralandmedications* 4.DiscusswhentoreferpatientswithADHD
Objectives
* 8y.o.Grade2* ParentsarerequestinganassessmentforGeorgebecauseheis
alwaysgettingintotroubleatschool* Hegetsintofightsontheplaygroundanddoesn’thaveanyclose
friendsthatparentsknowof* Helikestodothingshisownwayandwhenplayingwithpeersis
quicktointerruptorredirectthem* Georgetendstogetalongbetterwithchildrenyoungerthanhim* GeorgeissmartandgetsallA’sandB’s* Georgeloveslegoandcansitforhoursbuildingthings,but
generallyheisa“kidonthego”andcanplaywithamultitudeoftoysinanafternoon
* Dadsays“GeorgeisjustlikemewhenIwashisage!”
Case#1:George
* 11y.o.Grade4* TeachershaverequestedthatAngelabeassessedforADHD* Parentsdon’thaveanyissueswithAngelaathome* Shehasalwaysbeenabitofadaydreamer,butsheisagoodkid
andhasseveralgoodfriends* HoweveratschoolthisyearAngela’sgradeshavedroppedfrom
mostlyB’stomostlyC’s* Sheisdaydreaminginclass,forgettingtohandinwork,andthe
workshedoeshandinisoftenrushedandincomplete* Angelaisfrustratedwithherhomeworkafterschool* Angela’sroomhasalwaysbeenmessyathome* Sheisanonlychildandparentsprompthertogetreadyinthe
morningandstayontime* Angelaisinvolvedinkarate,swimming,andgirlguides
Case#2:Angela
* ADHDisthemostcommonpsychiatricdisorderinpediatricsaffectingbetween5-12%schoolagedchildren* Verywellstudiedandwidelyacceptedneurobiological
condition* Upto60%ofchildren/adolescentswithADHDcontinueto
haveimpairmentsintoadulthood* “Overall,ADHDisoneofthebest-researcheddisordersin
medicine,andtheoveralldataonitsvalidityarefarmorecompellingthanformanymedicalconditions”.(Goldmanetal.,1998)
Epidemiology
Polanczyk,G.,etal.,TheworldwideprevalenceofADHD:asystema?creviewandmetaregressionanalysis.AmJPsychiatry,2007.164(6):p.942-8.
CanadianADHDResourceAlliance(CADDRA)-h"p://www.caddra.ca
* “Apersistentpatternofinattentionand/orhyperactivity-impulsivitythatinterfereswithfunctioningordevelopment,ascharacterizedbyinattentionand/orhyperactivity”* Symptomsinterferewithfunctioningordevelopment* Symptomsstartbeforeage12* Symptomsidentifiedin2ormoresettings
ADHDDiagnosis
* Sixormore(children)fiveormore(adolescent/adult)offollowingsymptomsforatleast6months:
* Oftenfailstogivecloseattentiontodetailsormakescarelessmistakes
inschoolwork,atwork,orwithotheractivities.* Oftenhastroubleholdingattentionontasksorplayactivities.* Oftendoesnotseemtolistenwhenspokentodirectly.* Oftendoesnotfollowthroughoninstructionsandfailstofinish
schoolwork,chores,ordutiesintheworkplace(e.g.,losesfocus,side-tracked).
* Oftenhastroubleorganizingtasksandactivities.* Oftenavoids,dislikes,orisreluctanttodotasksthatrequiremental
effortoveralongperiodoftime(suchasschoolworkorhomework).* Oftenlosesthingsnecessaryfortasksandactivities(e.g.school
materials,pencils,books,tools,wallets,keys,paperwork,eyeglasses,mobiletelephones).
* Isofteneasilydistracted* Isoftenforgetfulindailyactivities.DiagnosticCriteria-DSM-5
Inattention
* Sixormore(children),fiveormore(adolescent/adult)offollowingsymptomsforatleast6months:
* Oftenfidgetswithortapshandsorfeet,orsquirmsinseat.* Oftenleavesseatinsituationswhenremainingseatedisexpected.* Oftenrunsaboutorclimbsinsituationswhereitisnotappropriate
(adolescentsoradultsmaybelimitedtofeelingrestless).* Oftenunabletoplayortakepartinleisureactivitiesquietly.* Isoften"onthego"actingasif"drivenbyamotor".* Oftentalksexcessively.* Oftenblurtsoutananswerbeforeaquestionhasbeencompleted.* Oftenhastroublewaitinghis/herturn.* Ofteninterruptsorintrudesonothers(e.g.,buttsintoconversationsor
gamesDiagnosticCriteria-DSM-5
Hyperactivity/Impulsivity
* Madebyacombinationof:1. Medicalhistory2. Parent/teacherratingscales3. Physicalexamination4. Supportingdocumentation(IPRC,IEP,reportcardsetc.)
* Variousratingscalesexist:* SNAP-IV* ADHDChecklist* Vanderbilt
Diagnosis-Datagathering
* Historiesaresubjective
* Symptomsneedtobepresentin2ormoresettings* Inyoungchildren,thereisnotoftenconsensusonwhether
thereisaproblem* Discordoftenbetweenparentandteacherquestionnaires
(Schooloftenpromptsthereferral)
* Officevisitsaretooshortforfullassessment* Officebehaviourisaninsensitivemeasureofdaily
behaviour* CADDRAguidelinesoffertoolstohelporganizeanADHD
assessmentovermultiplevisits
Difficultiesinmakingadiagnosis
* School-poormarks,behaviouraldifficultiesetc.* Home-poorfamilialrelationships,ADLs,dangerousbehavioursetc.* Extra-curricularactivities* Socialrelationships-friends,teachersetc.* Emotionally-self-esteem,mood,anxietyetc.
Assessingdysfunction
* Anythingthatcanaffectattentionlevelsneedtobeconsideredinthedifferentialdiagnosis* Ourjobistoruleoutothermedicalconditionsthatcauseinattention* Helpswiththe“buyin”oftheADHDdiagnosis* Thoroughhistory,ROS,andphysicalexamwillhelptoidentifyanypossibleconditions* Bloodworkorotherinvestigationsrarelyevernecessaryifnormalassessment
DifferentialDiagnosis
DifferentialDiagnosis
* Learningproblems* SpecificLearningDisorder,cognitivedisability
* Psychiatric/psychologicconditions* Autism,oppositionaldefiantdisorder,mooddisorder,anxiety,panic
attacks,obsessivecompulsivedisorder,Tourettesyndrome,substanceuse,bipolardisorder
* Medicalconditions* Geneticdisease(FragileX,Neurofibromatosis,metabolicdisease)* Medicaldisease(anemia,thyroid,absenceseizures)
* Other* FetalAlcoholSpectrumDisorder* Sleepdisorder* Post-concussive* Hearing/Vision
* 50-90%ofchildrenhaveatleastonecomorbidity* ~50%have2ormorecomorbidities* Specificlearningdisordersoccurin40%ofpatientswithADHD
Comorbidities
CanadianADHDResourceAlliance(CADDRA)-h"p://www.caddra.ca
* MoodDisorders* AnxietyDisorders* BehaviouralDisorders* LearningDisorders* ASD* Medical* Seizures,tics,sleep-relateddisorders
Comorbiditiescaninclude…
* Educationofpatientsandfamilies* Behavioural/occupationinterventions* Psychologicalassessment/treatment* Educationaccommodations* Medicalmanagement
PrinciplesofManagement
* Child* Siblings* Parents
RecognizetheImpact
* Oncediagnosisismade,discussmedicalandnon-medicaloptions* Non-medical* Behaviortherapy* Omega-fattyacids(EPAdoses>600mg)* Literaturesuggestsnoroleforothernutritionalinterventions* Howevereachcaseisdifferentandmanyfamiliesare
convincedthatacertainfoodtypeisimplicatedintheirchild’sbehavior* Deciderisk/benefit(ex.reddyeversusglutenfree)
* Environmentalaccommodations(ex.Classroom)
Management
Bloch,M.Omega-3Fa"yAcidSupplementa<onfortheTreatmentofChildrenwithA"en<on-Deficit/Hyperac<vityDisorderSymptomatology:Systema<cReviewandMeta-Analysis.JournaloftheAmericanAcademyofChildandAdolescentPsychiatryOctober2011,50(10).
Millichap,G.TheDietFactorinA"en<on-Deficit/Hyperac<vityDisorder.Pediatrics2012;129;330.
* Directinstruction,repetition,andfrequentclarification* Preferentialseatingtoalleviatedistractibility* Additionaltimeforassignmentsandclasswork* Testingoncomputerororallywhereappropriate* Quietenvironmentfortests/assignments* Listeningtoheadsetduringindividualclassworktime* Assignmentsbrokendownintomanageablechunks* Assistancewithtimemanagement* Scribeswherenecessary/appropriate
Environmentalaccommodations
* Staypositive* Establishstructureandsticktoit* Setclearexpectationsandrules* Encouragemovementandsleep* Balancednutrition* Teachsocialskills
ParentingTips
* Firstlineoptions:stimulantmedications* Methylphenidate-basedversusamphetamine-based* Largeevidencetosupporttheefficacyofstimulantsin
treatingADHD* Allaremarketedaslong-acting,once-a-day
* Secondlineoption:Strattera(Atomoxetine)* Thirdline/Adjunctivetreatment:IntunivXR(GuanfacineXR)
Management-MedicalOptions
CanadianADHDResourceAlliance(CADDRA)-h"p://www.caddra.ca
* Allstimulantshavesimilarcommonside-effectsymptoms:* Appetitesuppression* Increasedsleeplatency* Abdominalpain* Headaches* Exacerbationoftics* Bloodpressurechanges
Management
* Rarebutsevereside-effects/reactions:* Exacerbationofotherpsychiatricdisorders(ex.bipolar)* Stimulant-inducedpsychosis* Loweredseizurethreshold* Abuse/Dependence* Suddencardiacdeath(?)
Management
* In2005,postmarketingdatafromtheFDAindicatedasmallbutpotentiallyincreasedriskofsuddencardiacdeathinchildrentakingAdderallXR* InresponsetothisHealthCanadainitiallyremoved
Adderallfromthemarket,thenreinstateditssalewithablackboxwarningsimilartowhatwasreleasedbytheFDA:* “Suddendeathhasbeenreportedinassociationwith
amphetaminetreatmentatusualdosesinchildrenwithstructuralcardiacabnormalities.AdderallXRgenerallyshouldnotbeusedinchildrenoradultswithstructuralcardiacabnormalities.”
SuddenCardiacDeath(SCD)
VeXer,V.CardiovascularMonitoringofChildrenandAdolescentsWithHeartDiseaseReceivingMedica<onsforA"en<onDeficit/Hyperac<vityDisorder.Circula?on2008;117(18).
* Inresponse,theAmericanHeartAssociation(2008)suggestedECGscreeningforallpatientspriortostartingstimulants
* Incontrast,theCanadianPediatricSocietyfeltthedatasuggestingcardiovascularriskwasweakandthatevidencedidnotexistthatroutineECGscreeningwouldsomehowpreventdeathinpredisposedpatients
* SincethenseverallargerstudieshaveshowntheriskofSCDinpatientsonstimulantstobethesameasthegeneralpopulation
* Currentrecommendationssuggestascreeninghistoryforpossibleunderlyingcardiacdiseaseonlyandavoidprescribinginpatientswithpositivehistory
SuddenCardiacDeath(SCD)
Belanger,S.Cardiacriskassessmentbeforetheuseofs?mulantmedica?onsinchildrenandyouth.PaediatrChildHealth2009;14(9):579-85
ScreeningQuestionsforSCD(CPS)
Belanger,S.Cardiacriskassessmentbeforetheuseofs?mulantmedica?onsinchildrenandyouth.PaediatrChildHealth2009;14(9):579-85
* Basedprimarilyon:* Canpatientswallowpills?* Onsetofactionanddurationofcoverageneeded* Age/weightofpatient,dosingtitration* Familyhistoryofmedicationuse* Affordability* Medicationinteractions* Comorbidconditions* Riskofside-effects* Physiciancomfort/preference
Medicationchoices
* Stimulantsarecontrolledsubstances* Dispensingamount,
frequencyandtotalquantity* Nosubstitutions
forgenericproducts
Writingprescriptions
* Alwaysstartonlowestpossibledoseandtitrateupslowly* Explaintoparents* Whatsymptomswearetargeting* WhatsymptomsweareNOTtargeting
* Goal:appropriatebenefittoside-effectbalance
MedicationDecisions
* Re-evaluatebenefitsandside-effectsofmedicationateachvisit* Useparent/teacherratingscalesasobjectiveevidence* Maychoosetoseeevery1-2weeks,slowlytitrateupdosetodesiredeffect(goslow,norush!)* Decisiontoincrease/decreasedosebasedentirelyonbalanceofbenefitstoside-effects
Follow-upplans
* If“severe”side-effects,justdiscontinuemedication* Infuturemayconsidertryinganothermedication(preferablyfromadifferentcategory)* IfthereiseitherinsufficientbenefitorexcessiveS/E* Consideradjustingdose* Determinetimingofsymptomsandneedforlonger
actingstimulant* Consideraddingadjunctivetherapytotargetdesired
symptoms(ex.Intuniv,SSRI,etc…)
Follow-upplans
* Children<6y.o.* Consideringusingadjunctivemedications* Significantsideeffectsfrommedications* Comorbiddiagnoses
WhentoRefer…
* ADHDisaclinicaldiagnosis* ADHDcancausesignificantimpairmentinallaspectsoflife* Don’tstressaboutmakingthediagnosisrightaway,thereisno
rush!* Multimodaltreatmentincludes:* Education* Behaviouralinterventions* Psychologicalassessment/treatment* Medication
* ItisourjobtoeducatefamiliesonADHD,butintheendit’suptothepatientandparentsasfaraswhattheywanttodoaboutit
* Refer:complexcase,multipledrugs,comorbiddx
Summary
* 8y.o.Grade2* ParentsarerequestinganassessmentforGeorgebecauseheis
alwaysgettingintotroubleatschool* Hegetsintofightsontheplaygroundanddoesn’thaveanyclose
friendsthatparentsknowof* Helikestodothingshisownwayandwhenplayingwithpeersis
quicktointerruptorredirectthem* Georgetendstogetalongbetterwithchildrenyoungerthanhim* GeorgeissmartandgetsallA’sandB’s* Georgeloveslegoandcansitforhoursbuildingthings,but
generallyheisa“kidonthego”andcanplaywithamultitudeoftoysinanafternoon
* Dadsays“GeorgeisjustlikemewhenIwashisage!”
Case#1:George
* SNAPquestionnaireswerepositiveforsignificantinattentionandhyperactivity/impulsivity* Parentsandteachershavealreadybeenimplementingbehaviouralinterventionsforyears* Parentsagreetotrialmedication* Biphentin–startat15mg,increaseto20mg* Followupin6weeks* ParentsnoticeabigdifferenceinGeorge’sabilitytoplaywithpeershisownage
Case#1:George
* 11y.o.Grade4* TeachershaverequestedthatAngelabeassessedforADHD* Parentsdon’thaveanyissueswithAngelaathome* Shehasalwaysbeenabitofadaydreamer,butsheisagoodkid
andhasseveralgoodfriends* HoweveratschoolthisyearAngela’sgradeshavedroppedfrom
mostlyB’stomostlyC’s* Sheisdaydreaminginclass,forgettingtohandinwork,andthe
workshedoeshandinisoftenrushedandincomplete* Angelaisfrustratedwithherhomeworkafterschool* Angela’sroomhasalwaysbeenmessyathome* Sheisanonlychildandparentsprompthertogetreadyinthe
morningandstayontime* Angelaisinvolvedinkarate,swimming,andgirlguides
Case#2:Angela
* SNAPquestionnaireswerepositiveforinattention* Parentsagreetotrialmedication* Concerta–startat18mg,increaseto27mg* Angelanoticesabigdifferenceinherabilitytoconcentrateandcompleteherhomework
Case#2:Angela
* 1.EpidemiologyofADHD* 2.ReviewDSM5diagnosticcriteriaforADHD* 3.Discusstreatmentoptions,includingbehaviouralandmedications* 4.DiscusswhentoreferpatientswithADHD
Objectives
* Belanger,S.Cardiacriskassessmentbeforetheuseofs?mulantmedica?onsinchildrenandyouth.PaediatrChildHealth2009;14(9):579-85
* Bloch,M.Omega-3Fa"yAcidSupplementa<onfortheTreatmentofChildren
withA"en<on-Deficit/Hyperac<vityDisorderSymptomatology:Systema<cReviewandMeta-Analysis.JournaloftheAmericanAcademyofChildandAdolescentPsychiatryOctober2011,50(10).
* CanadianADHDResourceAlliance(CADDRA)-h"p://www.caddra.ca* Millichap,G.TheDietFactorinA"en<on-Deficit/Hyperac<vityDisorder.
Pediatrics2012;129;330.
* Polanczyk,G.,etal.,TheworldwideprevalenceofADHD:asystema?creviewandmetaregressionanalysis.AmJPsychiatry,2007.164(6):p.942-8.
Resources