Attention Deficit Hyperactivity Disorder

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Attention Deficit Hyperactivity Disorder
2
Kevin Leehey M.D.

• 1980 E. Fort Lowell Rd. Suite 150
• Tucson, AZ 85719
• 520-296-4280 fax [phone]
• http//leeheymd.com
• kevino_at_leeheymd.com

3
Attention Deficit Hyperactivity Disorder

1. ADHD Inattentive Type
2. ADHD Hyperactive/Impulsive Type
3. ADHD Combined Type
4. ADHD NOS

Kevin Leehey, M.D. 296-3835
4
Differential Diagnosis

• Medical or neurologic or other psychiatric
  conditions, such as hyperthyroidism, medication
  side-effects, anxiety disorders, post traumatic
  stress, depression, immature character, and
  oppositional behaviors, may look like ADHD but
  not actually be ADHD.

Kevin Leehey, M.D. 296-3835
5
Co-morbid

• Anxiety disorders, Tourettes Syndrome,
  depression, post traumatic stress difficulties,
  behavioral problems, learning difficulties,
  coordination disorders, sensory integration
  disorders, PDD, etc.
• The most common condition associated with ADHD is
  a learning disorder (about 50 percent)

Kevin Leehey, M.D. 296-3835
6
Diagnostic Criteria

• A.
• Six (or more) of the symptoms of inattention
  have persisted for at least six-months to a
  degree that is maladaptive and inconsistent with
  developmental level
• Or six (or more) of the symptoms of
  hyperactivity-impulsivity have persisted for at
  least six-months to a degree that is maladaptive
  and inconsistent with developmental level

Kevin Leehey, M.D. 296-3835
7
Inattention

1. Often fails to give close attention to details or
   makes careless mistakes in schoolwork, work, or
   other activities
2. Often has difficulty sustaining attention in
   tasks or play activities
3. Often does not seem to listen when spoken to
   directly
4. Often does not follow through on instructions and
   fails to finish schoolwork, chores, or duties in
   the workplace (not due to oppositional behavior
   or failure to understand instructions)
5. Often has difficulty organizing tasks and
   activities
6. Often avoids, dislikes, or is reluctant to engage
   in tasks requiring sustained mental effort (such
   as schoolwork or homework)
7. Often loses things necessary for tasks or
   activities (ie toys, school assignments,
   pencils, books, or tools)
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities

Kevin Leehey, M.D. 296-3835
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Hyperactivity Impulsivity

• Often fidgets with hands or feet and squirms in
  seat
• Often leaves seat in classroom or in other
  situations in which remaining seated is expected
• Often runs about or climbs excessively in
  situations in which it is inappropriate (in
  adolescents or adults, may be limited to
  subjective feelings of restlessness)
• Often has difficulty playing or engaging in
  leisure activities quietly
• Is often on the go or often acts as if driven
  by a motor
• Often talks excessively

• Often blurts out answers before questions have
  been completed
• Often has difficulty awaiting his/her turn
• Often interrupts or intrudes on others (eg butts
  into conversations or games)

Kevin Leehey, M.D. 296-3835
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More Diagnostic Criteria

• B. Some hyperactive-impulsive or inattentive
  symptoms that caused impairment were present
  before age seven years
• C. Some impairment from the symptoms is present
  in two or more settings (ie school, work, home)
• D. There must be clear evidence of clinically
  significant impairment in social, academic, or
  occupational functioning
• E. The symptoms do not occur exclusively during
  the course of a Pervasive Developmental Disorder,
  Schizophrenia, or other Psychotic Disorder and
  are not better accounted for by another mental
  disorder (ie Mood Disorder, Anxiety Disorder,
  Dissociative Disorder, or a Personality Disorder)

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Making the Diagnosis

• ADHD is often diagnosed based on meeting at least
  the minimum criteria for ADHD from DSM-IV
• Psychological testing, WISC-IV,
  Woodcock-Johnson-R
• Rating scales such as the Connors or SNAP
• Continuous Performance Task Tests
• Observation of the child or adolescents behavior
  in school and non-school settings
• Family history

Kevin Leehey, M.D. 296-3835
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Making the Diagnosis

• Making the diagnosis for adults and preschoolers
  is more difficult. Many of the diagnostic
  criteria are described in terms most relevant for
  elementary, middle school, and less so, high
  school age groups. For adults, past history and
  data regarding school experiences and testing is
  often crucial (along with current and past
  functioning and family history).

Kevin Leehey, M.D. 296-3835
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ADHD trends

• 8 years old, third grade
• Sixth grade, middle school
• 3X Boys - wrong
• Missed - girls, minorities, ODD, inattentive
  only, bright, co-morbid, mild
• 5-7 of school age youth

Kevin Leehey, M.D. 296-3835
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ADHD is more difficult to diagnose in preschool

• A wider range of behavior is expectable
• Attention span normally increases with age, as
  does impulse control and a lessening of physical
  hyperactivity
• Parenting styles and cultural norms vary markedly
  in this age group
• Medication treatment is often less helpful and
  less researched
• Other interventions are often worthwhile
• ADHD will become more clear with time

Kevin Leehey, M.D. 296-3835
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Executive Function Disorder

• Disorganization and poor time management skills
• Follow-through and carrying out plans
• Getting schoolwork/homework done or turned in
• Failure to complete or turn in assignments
• Do (fully or partially) their assignments but
  fail to turn them in or lose them

Kevin Leehey, M.D. 296-3835
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ADHD diagnosis myths

• Video/computer games, television, movies
• He/she can if he/she wants to
• He/she is fine at home, or 11, or at the
  office
• Lazy, underachiever, unmotivated

Kevin Leehey, M.D. 296-3835
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Prognosis, Outcome

• ADHD can be mild, moderate, or severe
• Learning disorders may also be mild, moderate, or
  severe
• Associated conditions complicate
• Ability of that youngsters family, school, and
  even that youngsters ability to adjust to
  his/her current developmental needs and to what
  is expected of him/her

Kevin Leehey, M.D. 296-3835
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ADHD prognosis

• Hyperactivity resolves for 50 around puberty
  75 by age 21
• Inattention often persists
• School of hard knocks
• 25 have conduct disorders and or substance abuse
• Higher risks MVA, job losses, relationship
  problems, depression, anxiety

Kevin Leehey, M.D. 296-3835
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Basic Medical Principles

• HP, labs, hearing, vision
• Educational assessment
• Experienced and well trained clinician
• 365 days, 24/7
• Individualize and fine tune treatment

Kevin Leehey, M.D. 296-3835
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Treatment

• Individual Therapy
• Self esteem and impulse control
• Family Therapy
• It is more difficult to parent a youngster with
  ADHD

Kevin Leehey, M.D. 296-3835
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Treatment

• 3. School/Work
• Special education, 504 Accommodation
• Positive home-school communication
• The transition from elementary to middle school
  and again from middle school to high school
• Environmental manipulation
• 4. Medication

Kevin Leehey, M.D. 296-3835
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Treatment

• 5. Additional or Alternative treatments
• Martial arts
• Exercise/sports
• Biofeedback (Neurofeedback)
• Sensory integration treatment
• Nutritious diet, sweets, junk food, sugar
• Vitamins, herbs, and other supplements
• Dyslexia is a language processing phonologic
  error in language areas of the brain, not a
  hearing or vision disorder

Kevin Leehey, M.D. 296-3835
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Medications for ADHD-1

• Stimulants
• Methylphenidate
• Short and extended duration
• Amphetamines
• Short and extended duration
• Pemoline (Cylert)

Kevin Leehey, M.D. 296-3835
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Medications for ADHD-2

• Non-stimulants
• Atomoxetine (Stattera)
• Tricyclics (Imipramine, Desipramine)
• Buproprion (Wellbutrin)
• Partial alpha agonists Guanfacine (Tenex),
  Clonidine

Kevin Leehey, M.D. 296-3835
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Medications for ADHD-3

• Combinations/polypharmacy
• Avoid if possible
• Stimulant and atomoxetine or other non-stimulant
  ADHD medication
• Atomoxetine and SRI
• Non psych medications
• Stimulant plus SRI plus DDAVP is safer than
  desipramine alone

Kevin Leehey, M.D. 296-3835
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Medications for ADHD-4

• Out of the Box
• amantadine (Symmetrel)
• modafinil (Provigil)
• pramipexole (Mirapex)
• ropinirole (Requip)

Kevin Leehey, M.D. 296-3835
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Medications for ADHD-5

• Beads/sprinkle
• Adderall XR, Ritalin LA, Metadate CD, Focalin XR
• Liquid
• Methylin, Amantadine (Symmetrel)
• Chewable
• Methylin
• Patch
• - Catapres, MPH (soon)
• Osmotic pressure release
• - Concerta
• Compounding

Kevin Leehey, M.D. 296-3835
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Prescribing for ADHD-1

• Co-morbidity Depression, anxiety, tics,
  substances, bipolar, nicotine
• Height, weight
• Appetite decrease and low weight is the most
  common limiting stimulant side effect
• Class II, no refills, 60 days, less on base
  post, out of state varies, 90 day mail order
• Match side effects as well as good effects

Kevin Leehey, M.D. 296-3835
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Prescribing for ADHD-2

• Duration
• Convenience
• Weight (height less of a concern)
• Tics
• Meaner
• Abuse of stimulants
• Truck driver, pilot

Kevin Leehey, M.D. 296-3835
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Prescribing for ADHD-3

• Regular follow-up appointments
• Not just med checks
• Height, weight, growth curve
• School, home, peers, activities, etc.
• Patient and significant other input
• Benefits and adverse effects

Kevin Leehey, M.D. 296-3835
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Kevin Leehey M.D.

• 1980 E. Fort Lowell Rd. Suite 150
• Tucson, AZ 85719
• 520-296-4280 fax [phone]
• http//leeheymd.com
• kevino_at_leeheymd.com