ADHD: - PowerPoint Presentation

Slide1

ADHD: Co-occurring conditions and non-stimulant medication

Jack Levine, MD FAAPSlide2

Commercial Interests Disclosure

Jack Levine, MD, FAAP

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.

I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.Slide3

Learning Objective

Develop a deeper understanding of medication management for children with ADHD + co-morbidities, non-stimulant medication management and practical behavior management tipsSlide4

References

AAP ADHD GuidelinesM. Augustyn, B. Zuckerman, E. Caronna. Developmental and Behavioral Pediatrics for Primary Care

R. Voigt, M. Macias, S. Myers ed. Developmental and Behavioral Pediatrics. American Academy of PediatricsSlide5

Primary Care Advantage

A longitudinal, trusting relationship with patients and their families

Unique opportunities for prevention of mental health problems through anticipatory guidance at routine health supervision visits throughout childhood

Opportunities to screen for psychosocial problems in both the child and family

To intervene early, as symptoms are just emerging

The opportunity to recognize the barriers that often keep families from seeking help for their children’s problems—conflict within the family, denial, stigma, for example—and to address those barriers, facilitating the child’s and family’s readiness to engage in mental health care

To provide diagnostic assessment and treatment within the medical home

To refer for care, as needed, in the mental health specialty system

To monitor and coordinate that care as is done for children and youth with other special health care needs

“Moving Mental Health Forward” Barb Frankowski, MD, MPH, FAAP

Future of Pediatrics AAP 2011Slide6
Slide7

ComorbiditiesSlide8

ComorbiditiesSlide9

3/10 items

ODD/CDSlide10

Anxiety/Depression

3/7 Items

Learning DisabilitySlide11

ODD

4/8 itemsSlide12

CD

3/14 items

Anxiety

3/7 ItemsSlide13

Non-stimulant medications are less effectiveSlide14
Slide15

Non-Stimulant Medication

Non stimulants – generic name

Will only fill short acting – uh oh!!

Atomoxetine – no generic

10MG, 18MG, 25MG, 40MG, 60MG

Start .5mg/kg and titrate up to 1.2 mg/kg

Max 100mg – over 70 kg

Guanfacine ER – Intuniv

1mg, 2mg, 3mg, 4mg q day

Clonidine ER – Kapvay

0.1mg, 0.2mgBIDMax 0.2 mg bidMonitor blood pressureTaperSlide16
Slide17

80% respond to stimulant medications.

Switch to another stimulant or formulation if necessary

Inadequate dosing

Lack of adherence – unrealistic expectations, side effects

Incorrect diagnosis

Comorbid conditions

True nonresponse to stimulantsSlide18
Slide19
Slide20

Ryan

8 ½ year old boy in third grade – at the first teacher conference grandmother is informed that he is not listening, disrupting class and way behind in his academics.

You review his record and remember that he received ST through EI because of language delay and was in an integrated preschool class because of behavioral problems and language delay.

When he started Kindergarten, he was evaluated and found to have no problems except he was a “real boy.”

He struggled academically in first grade but was “really trying.”

He became a behavior problem in second grade but the school decided that he might mature in third grade.

You rule out any medical causes.

Jack Levine, MDSlide21

Next Step(s)?

Get Vanderbilt from school and grandmother

Discuss psychosocial circumstances with GM

Tell GM to talk to school about the need for a psychoeducational evaluation

Start low dose stimulant for probable ADHD

Reassure the grandmother that everything will be all right Slide22
Slide23

Psychosocial and Vanderbilt

GM and GF have been caring for Ryan since he was a baby. Mother and father both had academic issues, temper problems, substance abuse and father had been in jail for a short time. Slide24
Slide25
Slide26

Psychosocial and Vanderbilt

Vanderbilt from school is positive for ADHD, combined, some anxiety, all academic areas are problems and all performance items are problems.

GM Vanderbilt is positive for ADHD, IA and some impulsivity.Slide27

Thank God for Grandmas!!Slide28

Next?

Diagnose ADHD and begin stimulant medicationStart thinking this may be ADHD and LD and start stimulant medication

This is just LD and refer for tutoring

Refer for psychoeducational evaluation through school

Refer for psychoeducational evaluation privately – we don’t trust the schoolsSlide29
Slide30

We’re getting there!

Finally get psychoeducational evaluation which among other results shows:

WISC-V Full Scale IQ of 84

Verbal Comprehension Index of 75

Working Memory Index 80

Perceptual Reasoning Index of 102.

WIAT: Reading comprehension is 70. Math computation is 90.

This child has a language based learning disability AND ADHD.Slide31

Finally?

This child will need an IEP with academic support (modifications) and accommodations for ADHD

This child will need Section 504 accommodations only

Start stimulant medication and follow

Speak with child and GM and explain LD and ADHD

Refer for behavior therapy/counselingSlide32
Slide33

Discrepancy vs. Low Achievement

Discrepancy – old school

Low academic achievement with at least low average IQ scores

Reflected in Individual with Disabilities Education Act (IDEA)

Neurological (Brain) problem – heavy genetic implications

Life disability

One or more learning disorders

All levels of intelligence and is a persistent problem

Persistent and chronic condition with lifelong implications – “Poor Readers”Slide34

Over time, good readers and poor readers without intervention tend to maintain their relative positions along the spectrum of reading ability. Children who get off to a poor start in reading rarely catch up on their own.Slide35

Oral expression

Listening comprehension

Written expression

Basic reading skills - decoding

Reading fluency skills

Reading comprehension

Mathematics calculation

Mathematics problem solvingSlide36
Slide37
Slide38
Slide39
Slide40
Slide41

Educational modifications

Resource room

Collaborative – integrated

Self-contained

Separate schools – special programs

Remediation vs. Compensation

Extended school year – 12 month program

Transition planning – 14 yrs.

Related services

OT, PT, ST, counseling, social services

Mental health services vary

Augmentative devices

Testing accommodationsSlide42

Medical disability

Major impact on life

Accommodations in educational program – NOT modifications

Special programs and services

Food allergies

ADHD

Diabetes

Tutoring, preferential seating, separate exam site, extended time on testing, oral exams, keyboarding, aide, modified workload.Slide43

Classified with LD when response to validated intervention is inferior to peers

Scientifically based treatment

Considerable state attitude – wide variability even within districtsSlide44

School performance

Social settings

Sports

Hobbies, additional activitiesSlide45
Slide46
Slide47
Slide48
Slide49

Kathy

“Medication is making her worse!”

Kathy is an 8 year old girl in second grade who you started on methylphenidate last year after reviewing her Vanderbilts which were positive for ADHD, IA and nothing else.

Utilizing the results of follow up Vanderbilts she started second grade on MPH 5mg in the AM and at lunch. The major complaint is that she is refusing to do her homework.

Jack Levine, MDSlide50

What’s next?

Get follow-up VanderbiltsGet full Vanderbilts

Discuss symptoms in more depth

Switch to long acting MPH

Change stimulants

Refer for behavior therapy/counselingSlide51
Slide52

You ask for full Vanderbilts?

While waiting for them to be filled out you find out from the parents that she also bothers her siblings at home and is having frequent temper tantrums over the littlest things in the evenings and all day Saturday and Sunday.

No threats or any amount of discipline seem to be workingSlide53

Next?

Increase medication immediately – sounds badLet’s wait and see what the Vanderbilts look like

Refer for behavioral therapy – might be ODD

Give some behavioral techniques and schedule a revisit

Add non-stimulantSlide54
Slide55
Slide56

Vanderbilts are back – doing well in school – low scores on 1- 18. Everything else is good. Grades are somewhat of a problem – not handing in homework.

Parent Vanderbilts – annoying, temper tantrums, spiteful, angry, etc.Slide57

ODD?

Looks like ODD and ADHD but can’t be – school is okLooks like ODD and ADHD – increase stimulant

Looks like ODD and well controlled ADHD – refer for behavioral therapy

Looks like ADHD and a poorly behaved child – tell parents they need to be stricter and more punitive

Looks like ODD and ADHD – explain the disorder and the importance of treatment for everyone’s sake.Slide58
Slide59

ODD – 2%-15% of children!Slide60

ODD – 4 Symptoms for at least 6 MonthsSlide61
Slide62

Major concerns!Slide63

Jimmy

You are seeing Jimmy, age 8, in third grade, for a follow-up for otitis mediaMother mentions that he runs out of time on tests and has trouble paying attention in school.

Additionally, he has been saying that he doesn’t like school, gets nervous before tests and has been somewhat resistant to getting ready in the morning.

And BTW – he has been having trouble going to sleep at night.

Jack Levine, MDSlide64

Next?

Schedule an appointment to discuss the issues in more depth

Get Vanderbilts

Refer to neurology and/or psychiatry or DPEDS

Tell mother to ask teacher to give Jimmy more time on tests

Explain that it is normal for an 8 year old not to like schoolSlide65
Slide66
Slide67
Slide68

What’s Going On?

Here are the Vanderbilts that you so intelligently obtained before the next appointmentThey show criteria for ADHD, IA

Anxiety with some low self-esteem,

Problems in organization, peer relationships, assignment completion.

How are you going to figure out what is going on?Slide69

And?

Get detailed family history and school historyRefer to psychologist

Start stimulant medication

Administer the parent and child SCARED or another screen for anxiety

Tell the parents that the child has ADHD and that explains all his symptomsSlide70
Slide71

Family History

Heritability is 30-40%Environment

Temperament – Behavioral inhibitionSlide72
Slide73

SCARED

Child SCARED: 40 (anything over 25 is positive)Generalized anxiety disorder

Parent SCARED: 34

You now diagnose ADHD, IA and anxiety disorder.

You explain each diagnosis and hand out parent education material. What is your next step?Slide74

Anxiety and ADHD

Prescribe stimulant medication and schedule follow-up with VanderbiltsRefer to psychologist for behavioral counselling and CBT for anxiety

Prescribe Atomoxetine (stimulants can make anxiety worse)

Refer to DPEDS or psychiatry

Advise parents to get section 504 accommodationsSlide75
Slide76

Generalized anxiety disorder

Chronic and excessive worry in number of areas

Difficult to control

Separation anxiety disorder

Social phobia

Obsessive-Compulsive Disorder

Intrusive thoughts that produce uneasiness, apprehension, fear, or worry (obsessions)

Repetitive behaviors aimed at reducing the associated anxiety (compulsions)

Panic attacks – any anxiety disorderSlide77

ADHD NON STIMULANT CASES

Billy is an 8 year old who has moved into your area. He was previously diagnosed as having ADHD with mild anxiety. His Vanderbilt’s have shown 8/9 inattentive symptoms and 2/9 hyperactive/ impulsive symptoms in the past.

He was followed closely by his previous pediatrician and were receiving behavior management counseling. Billy had been on Metadate CD with initially good results. As he got older, the dose had to be adjusted and he began having anorexia, stomach aches and trouble sleeping.

His pediatrician switched him to Vyvanse in the smallest dose which he could not tolerate because it worsened his anxiety and sleep.

Parents’ are at their wits end. They want Billy to make a good impression at his new school and are concerned about his now untreated ADHD.

They come to you, their new physician for advice.

Alan G. Weintraub, MDSlide78

So….

Try him on another Methylphenidate with a different release pattern like Daytrana.

Try him on Atomoxetine (Strattera) as this is a class that has not been tried as of yet.

Try him on another amphetamine like Adderall XR.

Send him for CBT since medication doesn’t seem to be workingSlide79
Slide80

ANSWER

B. After two different stimulants have been used with significant side effects, it is recommended to try a non-psychostimulant.

Atomoxetine is effective for ADHD primarily inattentive subtype and will not cause the typical stimulant side effects. However, you must counsel the family that this will take longer to take effect and titrate up slowly to avoid the common side effects of nausea and potentially sedation.

The effect size for stimulants is 70-90% and that of Atomoxetine is 50-70%.Slide81

Charlie

Charles is a 16 year old who just started his junior year in high school. He has had a long history of ADHD combined type and refuses to take his psychostimulants any more.

He is on first string for the football team and although he was fine on his Vyvanse for years in elementary and middle school, now that he is playing varsity football, he doesn’t feel as competitive on his psychostimulant as he does off. He acknowledges that when he is off the Vyvanse, his teammates think he is great fun, but he constantly gets intro trouble.

Alan G. Weintraub, MDSlide82

You tell him:

“Grow up” and take your Vyvanse before he gets thrown off the team

You discuss options like an alpha adrenergic ER product such as Clonidine ER (Kapvay) or Guanfacine ER (Intuniv)

You discuss a Methylphenidate with him because he hasn’t been on one since early elementary school.

You tell him he doesn't need medication anymore because he is almost an adult, and he is outgrowing the ADHD anyway.Slide83
Slide84

Options

Decrease Lysdexamfetamine (Vyvanse) doseStart Guanfacine ER or Clonidine ER – address hyperactivity and impulsivity with 24 hour coverage

Try another stimulant.

Add long acting alpha adrenergic to lower Vyvanse dose

Role for atomoxetine?

Engage Charlie as an active partner in his treatment!Slide85

Matt

Matt is a 12 year who has been diagnosed as having Asperger’s syndrome. (by DSM IV!). He knows more about dinosaurs than anyone else in the school.

He has social communication issues because that’s all he talks about.

He can remember every genus and species of amphibians but he can’t remember his homework assignment and cannot concentrate long enough to write it down.

He is very anxious with thunderstorms, loud noises and bugs. He refuses to go outside in the spring and summer.

His parents and teachers have filled out Vanderbilt reports and he shows 7/9 inattentive criteria and 6/9 hyperactive / impulsive criteria. You are deciding how to treat him.

.

Alan G. Weintraub, MDSlide86

Decision?

You put him on a long acting alpha adrenergic because of his anxiety and OCD symptoms

You start him on a small dose of stimulant and repeat Vanderbilt follow-up forms in two weeks.

You start him on Atomoxetine (Strattera) because of his anxiety

You start him on an SSRI for his anxiety at the same time you start the stimulant so the anxiety “Won’t get out of control”.Slide87
Slide88

ANSWER

NOT D!

Stimulants are the first line of ADHD treatment even in individuals with autism.

Stimulants can sometimes exacerbate OCD behaviors, rigidity and anxiety in those with autism. So none of the first three choices are wrong. Follow closely.

Try another stimulant.

If that does not work then switch to a non-stimulant. You can think of starting with a non-stimulant.

If anxiety is overwhelming, then START with the SSRI and treat the anxiety BEFORE you introduce a psychostimulant.

SSRIs DO NOT treat perseverative and repetitive behaviors of autism.

If you are comfortable with using two medications, titrate ONE first to optimal response before you introduce a second.Slide89

Chaim

Chaim is now 9 years old. He is in 4th grade at a local private school that has very limited support services. He has been doing well on MPH ER 20 mg for the past 2 years but now is having problems. His grades are going down, he has been getting in trouble and f/u Vanderbilts reveal increasing IA and HA/Impulsivity

Jack Levine, MDSlide90

What to do?

Increase to MPH ER 30 mgSwitch to amphetamine

Switch to atomoxetine

Switch to guanfacine ER

Switch to clonidine ERSlide91
Slide92

Uh Oh!

Increase to MPH ER 30 and Chaim complains of headaches, stomachaches, weight loss and dizziness. He is too quiet in class and mother thinks he may be depressed.Slide93

If a first….

Go back to MPH ER 20 and try to get services in school

Switch to amphetamine

Add atomoxetine

Switch to atomoxetine

Switch to guanfacine ERSlide94
Slide95

Mother knows best!

Amphetamines cause side effects and are not well tolerated. Mother and child like MPH better – isn’t there something that you can do?Slide96

What now?

Try another MPH preparationSwitch to atomoxetine

Switch to guanfacine ER

Add guanfacine ER

Add atomoxetineSlide97
Slide98

Two medicines!

You add guanfacine ER 1mg to the MPH ER 20 and titrate to 2mg. All is well but Chaim is tired during the day and wants to stop all medication.Slide99

Solution?

Stop all meds and see how he is doingSwitch to atomoxetine

Give the guanfacine ER at night

Tell him to take naps when he comes home from school

Refer to psychiatry or DPEDSSlide100
Slide101

Behavior Therapy

Source:

Dr. Kelly Wesolowski

ADHD Expert, Ohio AAP Chapter

AAP CQN ADHD Project

Psychologist/Clinical Lead Supervisor

Nationwide Children’s Hospital Community Behavioral HealthSlide102

Practical Behavior Therapy Tips

Today you will learn about…

How you can prepare families to participate in behavior therapy

Simple strategies you can teach a family in the context of a visit

Resources to provide to familiesSlide103

Before we begin, let’s acknowledge…

Finding good behavior therapists is challenging and there is no great way to search for them

However, there are a few options (note these are not exhaustive lists)

CHADD (

http://www.chadd.org/Support/Directory.aspx?state=1111111

)

CAP-PC can help find resources

Call therapists in your area

Parent experiencesSlide104

Before we begin, let’s acknowledge…

Access to care is a problem in most communities and wait times for services are long (and by the time families are in your office problems have reached an unmanageable level and they want help NOW)

You can provide education to your families to help them become good consumers of services (i.e., Ask the provider what they know about ADHD and how they treat it and make sure that it fits with an evidence based model)Slide105

Why is Behavior Therapy Important?

Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions

, Pelham et al,

Journal of Child & Adolescent Psychology

, 2016

Outcomes included:

Beginning treatment with a low dose of behavior modification (8 group parent training sessions plus implementation of a daily report card at school) resulted in significantly lower rates of observed classroom rule violations relative to beginning with a low dose of medication

Adding medication secondary to initial behavior modification resulted in better outcomes on parent/teacher ratings of oppositional behavior than adding behavior modification to initial medication

Families’ rate of completing behavior therapy was higher if prescribed initially (approx. 70% completed 6 of 8 sessions if behavior therapy prescribed first as opposed to approx. 10% when meds prescribed first)

Plus

, the AAP Guidelines say it is!Slide106

Behavior Therapy

Is…

Action oriented

Goal is to increase desirable behaviors and decrease undesirable behaviors

Uses principles of classical and operant conditioning

Rooted in social learning theory – we learn from our environment and which behaviors were reinforced/ignored in the past

Is Not

…

Individual therapy for a child

Play therapy

Teaching a kid how to pay attention or be less hyperactive

Diving into the past to explain current problems (except when examining antecedents and establishing patterns of reinforcement)Slide107

Behavior Therapy Expectations

Physicians can help families prepare for entering therapy – Tell the therapist what you want!

Families need to know:

Most, if not all, of the work will be done with parents and the therapist may ask that your child does not come to session

Discussion and problem solving will occur in session, but the real work occurs outside of session. So do your homework!

Consistency and regular attendance is important – most behavior therapy can be completed with success in 8-12 sessionsSlide108

Behavior Therapy and ADHD

Changing/modifying environmental demands and structure at home and school

Providing external reinforcement for completion of tasks

Incorporating parents and teachers as models of skills and coaches

Remember – ADHD is a “point-of-performance” disorder. Kids have the skills, but they have trouble executing them in the moment.Slide109

Changing/Structuring Environment

Work to eliminate distractions (i.e., during homework) and provide more supervision

Consistent and predictable home routines

Turn verbal information into visual information by writing information down – making notes, using checklists, picture schedules

Break tasks into small components – single step directionsSlide110

Providing External Motivators/Incentives

Kids with ADHD are not intrinsically motivated…externalize it for them

Set up home reward system (i.e., sticker chart, tickets, tokens) to reward/reinforce specific behaviors

Classroom incentives including daily report card (school/home note) to track specific behavior(s)Slide111

Daily Report Card

What is a DRC?simple method of tracking specific target behaviors in the classroom and communicating success to parents

typically some sort of incentive is offered either through school or home for a specific percentage of positive ratings

Pediatricians can help support families in establishing a DRC and there are plenty of resources on the webSlide112

DRC ExamplesSlide113

Daily Report Card Resources

http://ccf.buffalo.edu/pdf/school_daily_report_card.pdf

http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2807/2829/2835/2837/2839/7c419ba8-cb5c-40ab-9285-e361ddd29c68.pdf

Check out Pinterest for creative ideasSlide114

Additional Resources for Pediatricians to Provide to Families

Barkley’s 14 Guiding Principles for Raising a Child with ADHD

https://dyslexia.wordpress.com/2007/07/03/14-guiding-principles-for-raising-a-child-with-adhd/

CHADD Handouts for Parents

http://www.chadd.org/Portals/0/Content/CHADD/NRC/Factsheets/parenting2015.pdf

http://www.chadd.org/Portals/0/Content/CHADD/NRC/Factsheets/Psychosocial%20Treatments%20for%20Children%20with%20ADHD.pdf

Dr. Russell Barkley’s You Tube Presentation – 30 Essential Things Parents Need to Know About ADHD

https://www.youtube.com/playlist?list=PLzBixSjmbc8eFl6UX5_wWGP8i0mAs-cvY

CHADD Online Parent to Parent Training

http://www.chadd.org/Training-Events/Parent-to-Parent-Program.aspx

**Note: This is not an evidence based intervention, but may be beneficial for families where behavior therapy services are not available. Families are encouraged to seek out evidence based behavioral intervention with a licensed mental health provider as a first line treatment.Slide115

Questions?