1. Disruptive Behavior Disorders

2. Multiple Psychiatric Comorbidities
Tic
ADHD
ODD/CD
Depression/anxiety disorders
BPD
Learning disorders
This figure illustrates that many patients with ADHD are comorbid with more than 1 disorder. Patients with multiple comorbidities are those most likely to be considered for a diagnosis of BPD.
Learning disorders are comorbid with most major psychiatric disorders in children; however, most patients with ADHD do not have learning disorders. Because learning disorders do not affect the pharmacotherapy of the patient with ADHD, this particular comorbidity will not be discussed further in this presentation. The school should be involved in conjunction with the parent. Further evaluation may be needed if a learning disability is suspected. Under the Individuals with Disabilities Act (IDEA) and Section 504 of the Rehabilitation Act, schools receiving federal funding are required to offer special education and related services for a child with ADHD when there is significant impairment in educational performance and learning. A learning disorder need not be present for eligibility for these services.
Pliszka. Pediatr Drugs. 2003;5:741.

3. Co-Morbidities
Co-morbid disorders are very common with ADHD and must be considered when planning treatment.
Commonest Co-morbidities:
Oppositional Defiant Disorder (ODD)
Conduct Disorder (CD)
Substance Abuse
Learning Disability

4. Oppositional Defiant Disorder (ODD)
Characterized by a pattern of negativistic, defiant, disobedient and hostile behaviors, at least 6 month duration and 4 out of 8 of the following:
often loses temper
often argues with adults
often actively defies rules or refuses to comply
often deliberately annoys other people
often blames others for mistakes
often touchy or easily annoyed by others
often angry and resentful
often spiteful and vindictive

5. Oppositional Defiant Disorder (ODD)
Causes clinically significant impairment in social, academic or occupational functioning
Doesn’t occur exclusively during psychotic or mood disorder Doesn’t meet criteria for conduct disorder

6. Conduct Disorder (CD)
… pattern of violating the rights of others and/or major social norms, in the past twelve months, in at least 3 of the following:
Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violation of rules

7. Learning Disabilities
Need to be identified and accommodations made informed by testing

8. Some of the co-morbidities can complicate treatment planning…
Tourette’s Syndrome
Sleep Disorders
Anxiety Disorders
Learning Disability
Hearing Problems
Pervasive Developmental Disorder
Side effects from meds
Measuring treatmen response

9. Why Treat ADHD?
Interpersonal problems / family conflict/peer difficulties
Associated psychopathologies
2-3 times greater risk for depression
3 times greater risk for substance abuse
Vocation-related problems:
Higher rate of high school drop out
Higher rates of absenteeism
 productivity
↑ Rate of legal difficulties, traumatic injury, accidents
References
1. Weiss M, et al. Adults with attention-deficit/hyperactivity disorder: current concepts. J Psychiatr Pract. 2002;8(2):
2. Barkley RA, et al. Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. J Int Neuropsychol Soc. 2002;8(5):
3. Barkley RA, et al. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics. 1996;98(6 Pt 1):
4. Kessler RC, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):
5. Barkley RA. Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2002;63(Suppl 12):10-5.
6. Kessler RC, et al. The prevalence and effects of adult attention deficit/hyperactivity disorder on work performance in a nationally representative sample of workers. J Occup Environ Med. 2005;47(6):
7. Biederman J, et al. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. J Clin Psychiatry. 2006;67(4):

10. Multimodal Treatment of ADHD
Psychoeducation
Medications:
Stimulants vs Non-stimulants
Agents for co-morbid disorders
Psychotherapy
Individual: CBT
Family Therapy
Social skills training
Educational/vocational planning
ADHD is one of the few medical conditions where more clinical research has been conducted in children than in adults. Stimulants remain the treatment of choice, but adult ADHD patients also respond to non-stimulants and anti-depressants.
The treatment of adult ADHD is multimodal, and should include psychoeducation to explain the disorder, expectations, and side effects before prescribing medication. Psychosocial interventions, such as cognitive behavioural therapy may also be of value, and help play a role in treatment of associated symptoms of depression and anxiety.

11. Educating the Patient/Parent
Identify target symptoms
Outline risks and benefits of various medication options Discuss the psychosocial and behavioral treatment
Inform about risks of not treating

12. Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (or MTA)
The MTA included 579 elementary school boys and girls with ADHD. Four programs were compared:
(1) medication management alone
(2) behavioral treatment alone
(3) a combination of both
(4) routine community care.
Best improvements: Group (1) and (3)
Combined treatment led to the biggest improvements in anxiety, academic performance, oppositionality, parent-child relations, and social skills
Some children in the combined group could be successfully treated on lower does of medication than those on medication alone.

13. Choosing an agent What co-morbid illnesses are present? Medical
Psychiatric (anxiety, tics, substance abuse)
When is symptom control required? (coverage in the evening hours)
What medications have already been tried?
Is there a family member that has had good results with a particular agent?

14. Choosing an agent
How quickly does symptom control have to occur? (urgency of situation)
Affordability (what is covered by their drug plan?)
What other non-Adhd medications is the person taking?
Are the logistics of swallowing pills an issue?

15. CADDRA Recommendations
Long acting agents will be first line
Across the lifespan but particularly for adolescents and adults
Short acting agents will be considered adjuvant treatments in the first line

16. CADDRA Guidelines for Pharmacological Treatment of ADHD
1st line
2nd line
3rd line
Long Acting +
Approved by
Health Canada
Adderall XR
(Biphentin)
Concerta
Strattera
Short Acting +
Approved by
Health Canada
Dexedrine
Dex-Spansules
Ritalin
Ritalin-SR
"Off label"
if drugs fail
Imipramine
Wellbutrin SR
(Wellbutrin XL)
Key Points:
The 2006 Canadian ADHD Practice Guidelines from CADDRA* recommend long-acting preparations first-line for ADHD. Psychostimulants are considered the “gold standard”.
Biphentin is a new addition in the updated CADDRA Practice Guidelines.
Moderate-acting and short-acting preparations are second-line.
In third-line are “off label” treatments which can be used in the event of treatment failure.
Wellbutrin XL is a new addition in the updated CADDRA Practice Guidelines.
* CADDRA, Canadian Attention Deficit Hyperactivity Disorder Resource Alliance
Reference:
CADDRA. Canadian ADHD Practice Guidelines.
CADDRA. Canadian ADHD Practice Guidelines.

17. Management of ADHD Side Effects of Stimulants: Loss of appetite
Headache
Mood lability
insomnia
tics
abdominal pain
tachycardia
hypertension
growth suppression
Rarely Psychotic Symptoms

18. Co-morbid Oppositional Defiant Disorder
• Both stimulants and ATX reduce it markedly if ADHD comorbid
Parent training in behavior management
methods more effective< 13
Problem-solving skills/ social skills training
explosive anger may require use of atypical antipsychotics or
antihypertensives

19. Co-morbid conduct disorder
• Stimulants and ATX may reduce aggressive behavior and antisocial acts due to co-morbid impulsivity
Atypicals antipsychotics (risperidone) or antihypertensives may be needed for highly aggressive youth
• Parent and family interventions o required
– Problem-solving, communication training – Multi-systemic therapy where available
• Involvement of juvenile justice agencies likely

20. What To Do When Parents Believe That Treatment Is Unnecessary
Discuss the side effects and potential risks of treatment
Educate parents on the risks of not treating
Together, compare the pros and cons of treatment versus non-treatment
If parents insist against treatment, chart that they have taken this decision despite a discussion of the risks of non-treatment (for medico-legal reasons)
Key Points:
Discussions about changes to treatment should involve elucidation of both the risk of treatment (i.e. side effects and safety issues) and the risks of not treating ADHD properly, then a careful weighing of these risks should be made.
For medico-legal reasons, some ADHD specialists recommend charting that parents have insisted against treatment despite a discussion of the risks of non-treatment.
Clinical Pearls:
Non-treatment of ADHD is associated with a higher risk of many adverse outcomes. Different parents will be swayed by different information. Some (especially the parents of adolescents) may be alarmed to learn that patients with un-treated or under-treated ADHD have a higher risk of traffic violations (including speeding tickets) and motor vehicle accidents.1,2 Others may find it important that non-treatment or under-treatment of ADHD can prevent a patient from reaching his/her full academic and occupational potential.3,4
In the 7th edition of its publication Determining Medical Fitness to Operate Motor Vehicles, the Canadian Medical Association (CMA) lists ADHD among the psychiatric conditions to consider when assessing patients’ fitness to drive. It states that the use of stimulants in this population—particularly long-acting stimulants—will likely reduce the risk of moving violations and crashes. (Full document available at or through the CMA Member Service Centre at )
References:
Barkley RA et al. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Pediatrics 1993;92(2):212-8.
Barkley RA et al. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics 1996;98(6 Pt 1):
Mannuzza S et al. Educational and occupational outcome of hyperactive boys grown up. J Am Acad Child Adolesc Psychiatry 1997;36(9):
Barkley et al. The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1990;29(4):

21. Managing Sleep Disturbances in ADHD Patients
Clarify the history of the sleep problem (i.e. is it related to medication?)
Review sleep hygiene and make recommendations, if necessary
Consider non-medical treatment (e.g. tryptophan, melatonin)
Consider low-dose clonidine once-daily
Consider atypical neuroleptics if management of aggressive behaviour is needed
Key Points:
It is important to clarify the history of the sleep problem to determine if it is related to medication.
Simple “common sense” changes to patients’ sleep hygiene often substantially reduces sleep disturbances. Non-medical treatments can also help.
If non-pharmacological interventions fail, low-dose clonidine once-daily could be considered. If the sleep disturbances are related to aggressive behaviour that does not resolve with tighter control of ADHD symptoms, consider atypical neuroleptics.

22. Psychosocial interventions. Necessary for effective treatment
Education.
Structured consistent environment
Parent training
Organizational skills
School accommodations Self regulation. Social skills training

23. Summary Highly co morbid diagnoses. High morbidity untreated.
Multimodal treatment most effective.