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ADHD, ODD or CD A Practical Approach to Treatment David Shadid, D.O.

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Presentation on theme: "ADHD, ODD or CD A Practical Approach to Treatment David Shadid, D.O."— Presentation transcript:

1 ADHD, ODD or CD A Practical Approach to Treatment David Shadid, D.O.

2 Attention-Deficit Hyperactivity Disorder (ADHD)

3 ADHD affects approximately 3% to 6% of children and adolescents, with some estimates as high as 16.1% 1 ADHD affects approximately 3% to 6% of children and adolescents, with some estimates as high as 16.1% 1  The prevalence of ADHD is underestimated 2,3 Comorbidities may mask diagnosis Comorbidities may mask diagnosis Girls with inattentive symptoms are under-recognized and undertreated Girls with inattentive symptoms are under-recognized and undertreated Difficult primary diagnosis in the adolescent Difficult primary diagnosis in the adolescent  A high proportion of youngsters with ADHD grow into adulthood with persistent ADHD symptoms 4 Leads to problems with social function, poor occupational achievement, and driving Leads to problems with social function, poor occupational achievement, and driving ADHD = attention deficit hyperactivity disorder. 1. Goldman LS et al. JAMA. 1998;279: ; 2. Datamonitor report DMHC2008, published 9/2004; 3. Biederman J et al. J Am Acad Child Adolesc Psychiatry. 1999;38: ; 4. Barkley RA. J Clin Psychiatry. 2002;63: Prevalence of ADHD in Children and Adolescents

4 Difficulty sustaining attention (meetings, reading, paperwork) Paralyzing procrastination Slow, inefficient Poor time management Disorganized Difficulty sustaining attention Doesn’t listen No follow through Can’t organize Loses important items Lifetime Course of ADHD Symptoms: Inattention Domain ChildhoodAdult APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

5 APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3): Inefficiencies at work Can’t sit through meetings Can’t wait in line Drives too fast Self-selects very active job Can’t tolerate frustration Talks excessively Makes inappropriate comments Interrupts others Squirming, fidgeting Can’t stay seated Can’t wait turn Runs/climbs excessively Can’t play/work quietly On the go/driven by motor Talks excessively Blurts out answers Intrudes/interrupts others ChildhoodAdult Lifetime Course of ADHD Symptoms: Hyperactivity/Impulsivity Domain

6 Low self- esteem Smoking and substance abuse Injuries Motor vehicle accidents Legal problems Occupational/ vocational difficulties ChildhoodAdolescenceAdulthood American Academy of Pediatrics. Pediatrics. 2000;105: ; Kelly PC et al. Pediatrics. 1989;83: ; Murphy K et al. Compr Psychiatry. 1996;37: ; Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7; Barkley RA et al. Pediatrics. 1996;98: ; Swensen A et al. J Adolesc Health. 2004;35:346.e1-9. Impaired family and peer relationships Academic limitations Potential Impact of Untreated ADHD Across the Lifespan

7 Longitudinal study following a sample of children with hyperactivity and community controls for at least 13 years Barkley RA et al. J Am Acad Child Adolesc Psychiatry. 2006;45: Outcomes of People Diagnosed With “Hyperactivity” (ADHD) as a Child and Controls Outcomes From the Wisconsin Longitudinal Study of People with ADHD

8 Annual costs of healthcare were 31% higher for children and adolescents with ADHD than for those without ADHD care accounted for >5% of all pediatric health expenditures in the state Extrapolated nationwide annual cost of caring for children and adolescents with ADHD was $2.15 billion *Population-based study conducted in North Dakota, case population = 7745 children and adolescents. Burd L et al. J Child Neurol. 2003;18: Annual Costs of Healthcare for Children and Adolescents with ADHD*

9 ADHD is associated with abnormal DA and NE neurotransmission in frontal/striatal areas 1,2 Corticostriatal circuits play an important role in ADHD 1,3,4 Efficacy of ADHD medications with pharmacologic activity affecting DA and NE lends support to the theory of monoamine dysfunction in ADHD 3 DA = dopamine; NE = norepinephrine. 1. Mercugliano M. Ment Retard Dev Disabil Res Rev. 1995;1: ; 2. Krause K-H et al. Neurosci Let. 2000;285: ; 3. Markowitz JS et al. Pharmacotherapy. 2003;23: ; 4. Zametkin AJ et al. J Clin Psychiatry. 1998;59(suppl 7): The Pathophysiology of ADHD Involves DA and NE Neurotransmission

10 Stimulant Effects on DA and NE  MPH and AMPH both block DA and NE transporters 1 Increases DA and NE in the synapse Increases DA and NE in the synapse  Clinical efficacy of MPH and AMPH is likely driven by synaptic DA and NE concentrations 1,2 AMPH = amphetamine; MPH = methylphenidate; EPH = epinephrine. 1. Biederman J et al. Biol Psychiatry. 1999;46: ; 2. Schiffer WK et al. Synapse. 2006;59: ;

11 Comorbidities Add to Personal and Economic Costs of ADHD Pediatric population with ADHD and controls by gender. Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7. Lifetime prevalence (%)

12 Comorbidities Add to Personal and Economic Costs of ADHD Pediatric population with ADHD and controls by gender. Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7. Lifetime prevalence (%)

13 Treatment Options in ADHD  Psychoeducation for patient and family members Support groups (www.chadd.org) Support groups (www.chadd.org) Coaching (www.coaching.com) Coaching (www.coaching.com)  Psychosocial/behavioral interventions Psychotherapy Psychotherapy Cognitive behavioral therapy Cognitive behavioral therapy  Pharmacotherapeutic interventions Stimulants Stimulants Non-stimulants Non-stimulants  Stimulant therapy is first-line treatment 1 and behavioral therapy may be offered to improve target outcomes 1,2 1. Greenhill L et al. J Atten Disord. 2002;6:S89-S American Academy of Pediatrics. Pediatrics. 2001;108:

14 Long-Term Outcomes of Therapies for ADHD in the MTA Study Hyperactive Impulsive Symptoms (Teacher Reports) Medication Management Combination Therapy (medication + behavior therapy) Behavior Therapy Community-based Therapy Improvement at 14 months (%) % 60% 45% 36% 25 MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:

15 Stimulants Brand Names d,l-methylphenidate Ritalin ®, Ritalin-SR ®, Ritalin LA ®, Concerta ®, Metadate ® CD, Methylin ® ER, Daytrana™ d-methylphenidate Focalin ®, Focalin ® XR Mixed amphetamine salts Adderall ®, Adderall XR ® d-amphetamine Dexedrine ®, Dexedrine Spansule ® Nonstimulant Atomoxetine Strattera ® *As of May Ritalin ®, Ritalin SR ®, and Ritalin LA ® are trademarks of Novartis Pharmaceuticals Corporation; Concerta ® is a trademark of ALZA Corporation; Metadate ® CD is a trademark of Celltech Pharma Limited; Methylin ® ER is a trademark of Mallinckrodt Inc; Daytrana™ is a trademark of Shire Pharmaceuticals Ireland Limited; Adderall ®, and Adderall XR ® are trademarks of Shire US Inc.; Dexedrine ® and Dexedrine Spansule ® are trademarks of GlaxoSmithKline; Strattera ® is a trademark of Eli Lilly and Company. FDA-Approved Medications Indicated for ADHD in Children or Adolescents*

16 Vyvanse (lisdexamfetamine dimesylate)  Prodrug- inactive molecule  FDA approved Ages 6-12 Ages 6-12  Lower abuse- related effects  Provides 12 hour symptom control  95% of children show overall improvement

17 Vyvanse (lisdexamfetamine dimesylate)  Inactive Vyvanse (lisdexamfetamine dimesylate) is a therapeutically inactive molecule Vyvanse (lisdexamfetamine dimesylate) is a therapeutically inactive molecule  Activated Following ingestion, Vyvanse is rapidly absorbed in the GI tract and converted to l-lysine and active Following ingestion, Vyvanse is rapidly absorbed in the GI tract and converted to l-lysine and actived-amphetamine

18 Vyvanse adverse event profile

19 SOCIAL IMPAIRMENT IN CHILDREN WITH ADHD

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22 Oppositional Defiant Disorder (ODD)

23 Oppositional Defiant Disorder  Associated with ODD: Negativity Negativity Defiance Defiance Disobedience Disobedience Hostility directed toward authority figures Hostility directed toward authority figures Uncooperative Uncooperative

24 Symptoms  Frequent temper tantrums  Excessive arguing with adults  Active defiance and refusal to comply with adult requests and rules  Deliberate attempts to annoy or upset people  Blaming others for his or her mistakes or misbehavior

25 Symptoms Continued  Often being touchy or easily annoyed by others  Frequent anger and resentment  Mean and hateful talking when upset  Seeking revenge

26 ODD  Occurs in 5-15% of all school-age children  Multiple settings, more noticeable at home and school  Persist 6 months  Disruptive to family at home  Oppositional behavior is part of normal development for 2-3 year olds and early adolescents

27 Possible Causes of ODD  Child’s inherent temperament  Family’s response to the child’s style  A genetic component that when coupled with certain environmental conditions, such as lack of supervision, poor quality daycare and instability  Biochemical or neurological factor  Child’s perception that he of she isn’t getting enough of the parents time and attention

28 Risk Factors  Having a parent with a mood or substance abuse disorder  Being abused or neglected  Harsh or inconsistent discipline  Lack of supervision  Poor relationship with one or both parents  Family instability such as multiple moves, changing schools  Parents with a history of ADHD, oppositional defiant disorder and conduct problems  Financial problems in the family  Peer rejection  Exposure to violence  Frequent changes in daycare providers  Parents who have a troubled marriage of are divorced

29 Co-morbidity  Oppositional Defiant Disorder usually does not occur alone 50-65% of ODD children also have ADHD 50-65% of ODD children also have ADHD 35% of these children develop some form of affective disorder 35% of these children develop some form of affective disorder 20% have some form of mood disorder, such as Bipolar Disorder or anxiety 20% have some form of mood disorder, such as Bipolar Disorder or anxiety 15% develop some form of personality disorder 15% develop some form of personality disorder Many of these children have learning disorders Many of these children have learning disorders

30 Screening and Diagnosis  Comprehensive evaluation  Information for parents, teachers, and other caregivers  ODD symptom screening checklist  Look for co-morbidity including ADHD, learning disabilities, mood and anxiety disorders

31 Treatment ODD  Parent training programs  Individual psychotherapy  Family psychotherapy  Cognitive Behavioral Therapy

32 Techniques  Effective time-outs  Avoid proven stressors  Remain calm  Praise good behavior  Offer choices  Build on positives  Good modeling  Don’t walk on eggshells  Use respite care

33 Self Care  Praise your childs positive behaviors  Model the behavior  Pick your battles  Set limits and enforce consistent reasonable consequences  Develop a consistent daily schedule  Work with your spouse to assure consistent and appropriate discipline procedures  Assign your child a household chore that is essential and won’t get done unless the child does it

34 Coping Skills  Learn ways to calm yourself  Take time for yourself  Be forgiving

35 Conduct Disorder (CD)

36 Symptoms of Conduct Disorder  Aggression to people and animals Bullies, threatens or intimidates others Bullies, threatens or intimidates others Often initiates physical fights Often initiates physical fights Has used a weapon that could cause serious physical harm to others Has used a weapon that could cause serious physical harm to others Is physically cruel to people of animals Is physically cruel to people of animals Steals from a victim while confronting them Steals from a victim while confronting them Forces someone into sexual activity Forces someone into sexual activity  Destruction of property Deliberately engaging in fire setting with the intention to cause damage Deliberately engaging in fire setting with the intention to cause damage Deliberately destroys others property Deliberately destroys others property

37 Symptoms of Conduct Disorder Continued  Deceitfulness, lying, or stealing Has broken into someone else’s building, house, or car Has broken into someone else’s building, house, or car Lies to obtain goods, or favors or to avoid obligations Lies to obtain goods, or favors or to avoid obligations Steals items without confronting the victim Steals items without confronting the victim  Serious violations of the rules Often stays out all night despite parental objections Often stays out all night despite parental objections Runs away from home Runs away from home Often truant from school Often truant from school

38 Conduct Disorder Features  1-4% of 9-17 year olds  Greater in boys  Higher rates of depression, suicidal thoughts, and suicide  Academic difficulties  Poor relationships with peers or adults  Sexually transmitted diseases  Difficulty staying in adoptive, foster, or group homes  Higher rates or injuries, school expulsions, and problems with the law

39 Risk Factors  Early maternal rejection  Separation from parents, without an adequate alternative caregiver  Early institutionalization  Family neglect  Abuse or violence  Parental mental illness  Parental marital discord  Large family size  Crowding  Poverty  Genetic/ neuropsychological

40 Treatment  Your child’s age, overall health, and medical history  Extent of your child’s symptoms  Your child’s tolerance for specific medications, procedure or therapies  Expectations for the course of the condition  Your opinion or preference

41 Treatment May Include  Cognitive-behavioral approaches  Family therapy  Peer group therapy  Medication  Structural environments: military school, group home, inpatient residential treatment military school, group home, inpatient residential treatment

42 Internal State  Experiencing internal distress  Anger  Frustration  Disappointment  Anxiety  Sorrow  Autonomy issues  Superego deficits

43 Conclusion  Every child’s mental health is important  Many children have mental health problems  These problems are real and painful and can be severe  Mental health problems can be recognized and treated  Caring families and communities working together can help


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