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 http://www.cdc.gov/ncbddd/adhd/diagnosis.html

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 http://www.cdc.gov/ncbddd/adhd/diagnosis.html

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 http://www.cdc.gov/ncbddd/adhd/diagnosis.html

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

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 http://www.cdc.gov/ncbddd/adhd/diagnosis.html

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 http://www.additudemag.com/adhd/article/912-2.html

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?