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ADD Update Kristi Maroni, MD Lance Feldman, MD, MBA, BSN.

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Presentation on theme: "ADD Update Kristi Maroni, MD Lance Feldman, MD, MBA, BSN."— Presentation transcript:

1 ADD Update Kristi Maroni, MD Lance Feldman, MD, MBA, BSN

2  Drs. Maroni & Feldman have no disclosures to report Disclosures

3  Outpatient  4 physicians & 1 nurse practitioner  2 therapists  Inpatient  7N (24 adult beds)  7S (8 child / adolescent beds)  Consultation service Our Practice

4 1. Providers will be able to explain the diagnosis of ADHD 2. Providers will be able to understand the medical management of ADHD in children and adults Goals & Objectives

5  Inattention: >/= 6 or more for children; >/= 5 for 17 and older and adults:  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.  Often has trouble holding attention on tasks or play activities.  Often does not seem to listen when spoken to directly.  Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).  Often has trouble organizing tasks and activities.  Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).  Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).  Is often easily distracted  Is often forgetful in daily activities. ADHD Overview – Diagnostic Criteria

6  Hyperactivity and Impulsivity: >/= 6 or more for children; >/= 5 for 17 and older and adults:  Often fidgets with or taps hands or feet, or squirms in seat.  Often leaves seat in situations when remaining seated is expected.  Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).  Often unable to play or take part in leisure activities quietly.  Is often "on the go" acting as if "driven by a motor".  Often talks excessively.  Often blurts out an answer before a question has been completed.  Often has trouble waiting his/her turn.  Often interrupts or intrudes on others (e.g., butts into conversations or games) Diagnostic Criteria, Cont’d

7  Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months  Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity- impulsivity, were present for the past six months  Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months. Diagnostic Criteria, Cont’d

8  Forms (parent & teacher)  Vanderbilt  Connors  Testing  Connors CPT  Psycho-educational testing Confirming a Diagnosis…

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11  Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.  Several symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).  Keep in mind possible secondary gain (NC controlled substance database) Adult Onset vs. Child Onset

12  Medication  Therapy  Behavior Modification Treatment

13  Stimulants  Methylphenidate people  Dextroamphetamine people  Non-Stimulants  Alpha 2 agonists  Norepinephrine reuptake inhibitor Medications

14 Methlyphenidate  Concerta  Daytrana  Focalin & Focalin XR  Metadate CD & ER  Ritalin, Ritalin LA & SR  Quillivant  >6 y/o choose long acting first  Costs vary widely  Method of administration (tab, cap, liquid, patch)  Time release differences

15 Dextroamphetamine  Adderall & Adderall XR  Procentra (3 y/o!)  Vyvanse  >6 y/o choose long acting first  Costs vary widely  Method of administration (tab, cap, liquid)  Vyvanse is a pro-drug

16 Alpha 2 Agonists  Intuniv (tenex / guanfacine)  Once daily dosing  Kapvay (clonidine)  More sedating  BID dosing (if >0.1 mg)  6-17 y/o  Monotherapy or adjunct treatment  Costly (consider generics)

17  Ages 6+  Weight based dosing if <70kg (start 0.5 mg/kg, max 1.4mg/kg)  Increased risk of suicidality in children/adolescents  Norepinephrine reuptake inhibitor  Non-stimulant alternative in adults  Costly Strattera (Atomoxetine)

18  Interpersonal interactions  Study skills  Organizational improvement  Playing well with others  Common cognitive distortions: all-or-nothing thinking, mind reading, magnification and minimization, emotional reasoning, comparative thinking Therapy Pearls

19  Classroom seating assignment  Minimize distractions  Take frequent breaks  Encouragement and positive reinforcement  Parent skills training  Partnering with teachers / co-workers Behavior Modification

20  Methylphenidate v. Dextroamphetamine  Stimulant v. Non-Stimulant  Long acting first if >6 y/o  Ages (3+, seriously…)  Keep in mind dosing ranges General Prescribing Thoughts…

21  When to switch or add adjunct tx  0 x 0 = 0  How to deal with side effects…  Worsening of tics  Exacerbation of mood / anxiety  Sleep / Appetite Deep Thoughts…

22  3+ medication failures  Untoward side effects  Significant treatment contraindications  Concomitant mood or anxiety concerns When to Refer…

23 Thanks! Any Questions?


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