ADHDSIV FASCI, MD FAAPDEVELOPMENTAL-BEHAVIORAL PEDIATRICSDELL CHILDREN’S MEDICAL CENTER 9TH ANNUAL PEDIATRIC CONFERENCE - MARCH 24, 2016

Objectives

Epidemiology Risk Factors Diagnosis Co-morbidities Treatment When to refer

Trends

CDC data

Percent of children 5-17 years of age ever diagnosed with ADHD: 10.1% (2011-2013)

Percent of boys 5-17 years of age ever diagnosed with ADHD: 14.0% (2011-2013)

Percent of girls 5-17 years of age ever diagnosed with ADHD: 5.9% (2011-2013)

Number of ambulatory care visits (to physician offices, hospital outpatient and emergency departments) with attention deficit disorder as primary diagnosis: 9.0 million (average annual, 2009-2010)

Risk Factors Genetic

+FH 80% heritability

Neurodevelopmental disorders (Schizophrenia, autism and epilepsy) share genetic variants with ADHD

Prematurity Perinatal stress Prenatal alcohol, drugs, smoking IUGR Environmental lead

Brain-Based Disorder

Frontal lobe Parietal lobe Temporal lobe Thalamus Basal ganglia Cerebellum

Pathophysiology Catecholamines

Dopamine, norepinephrine

Mediate CNS functions: Motor control, Cognition, Emotion, Memory processing

White Matter: axons and myelin sheath Limbic system (amygdala,

hippocampus, interior parts temporal, frontal, pariental lobes – “primitive” responses, controls our immediate, automatic responses to stimuli (reward network)

AAP 2011

Evaluation

History: Rule out alternative causes and assess for co-morbidities lead toxicity, trauma, absence seizure, hearing

problem, autism, developmental delay, IDD, LD, language disorder, encephalopathy, substance abuse, depression, anxiety, psychosis, sleep disorder, obstructive sleep apnea

Physical exam: mental status exam, soft neurologic signs, fine motor deficits, motor tics

PCP Work-up

DSM – based questionnaire: Vanderbilt(Teacher/Parent)

ASQ, MCHAT, PSC-Y Audio Cbc, lead

CASE STUDY

Treatment

Behavior and psychotherapy Medication

Stimulant

Nonstimulant

Special education 504 plan

IEP

Treatment ADHD medication and behavior therapy among

children with ADHD (ages 4-17) with special health care needs

Functional Impairments

Academic performance Peer relations Adaptive skills Family functioning

Medical decision making

Is there harm in delaying treatment? What's the risk of medication at 4-5 years age?

behavioral therapy first line, medication if fails to improve with therapy and moderate to severe symptoms

Age 6-18, medication+behavior therapy Rule out substance abuse in adolescents

Low abuse meds: Nonstimulants, Vyvanse, Concerta

Medical decision making

Clinical rating scales Formal assessment

Communication with school

Informed consent General guidelines

20% do not respond to medication Only 50% respond well to either stimulant class Children respond to medication differently at

different ages Long acting formulations are not for everybody

Regular follow-up visits

When to Refer

Fails to respond to psychostimulants/nonstimulant Concern for other medical conditions: seizures,

genetic syndrome, developmental disorder, obstructive sleep apnea

Multiple co-morbidities Severe mental health concerns

Resources

American Academy of Child and AdoscentPsychiatry http://www.aacap.org/aacap/families_and_youth/r

esource_centers/ADHD_Resource_Center/Home.aspx

American Academy of Pediatrics Healthy Children – AAP website for parents

Caring for Children with ADHD: A Resource Toolkit for Clinicians - many useful handouts

ResourcesNational Resource Center on ADHD - a national clearinghouse for science-based information about all aspects of attention-deficit/hyperactivity disorder (AD/HD). Funded by the Centers for Disease Control and Prevention, NRC provides information on ADHD and has an online library of materials.

CHADD: Children and Adults with Attention-Deficit/Hyperactivity Disorder is a national non-profit organization serving people with AD/HD and their families. CHADD has local chapters- there is a chapter in the Valley. The membership fee of $45 gives you access to an information-packed website and to an online magazine named “Attention”.

ADD Warehouse – a source for books and DVD’s on ADHD, Learning disabilities, and childhood mental health disorders

ADD Store – Products that can help organize, remind (pill boxes with alarms) and make life easier (e.g. clothing for hypersensitive skin) for people with ADHD

Resources

Learning Disabilities

LD OnLine - web site on learning disabilities and ADHD

Learning Disabilities Association of America - the largest non-profit group for people with learning disabilities. Over 200 local affiliates in 42 states, including Arizona.

National Center for Learning Disabilities

Great Schools – Website with many handouts about Learning Difficulties (LD & ADHD). Can be searched by age group.

Healthy Children – American Academy of Pediatrics