1. Guidelines and Treatment Updates in the Diagnosis and Management of Attention Deficit Hyperactivity Disorder (ADHD) MNPA Fall Conference Freeport, ME November 15, 2015 Jennifer Parks, MSN, PMHNP-BC

2. Disclosures None

3. Objectives 1.To provide an update on diagnostic criteria for ADHD. 2.To provide updates on current medication management of ADHD. 3.To review other modalities of treatment, outside of medication management, for ADHD. 4.To briefly review insurance implications/requirements for ADHD medications

4. ADHD One of the most common neurodevelopmental disorders in children, affecting anywhere between 5%-8% of children Also affects 1%-6% of adults Males are more affected than females Primary neurotransmitters involved are dopamine and norepinephrine

5. Diagnosis of ADHD Changes from DSM-IV to DSM-5 Must occur in two settings Must impair functioning Symptoms not attributable to another illness Rating scales, observations, histories

6. ADHD Symptoms Hyperactive/Impulsive Fidgets or taps hands/feet Often leaves seat when staying seated is expected Runs or climbs in inappropriate situations Unable to play quietly Unable to sit still for any notable period of time Talks excessively Blurts out answers Has difficulty waiting for turn Interrupts often Inattentive Failure to pay attention to details Difficulty sustaining attention Does not seem to listen Does not follow instructions well Difficulty organizing tasks Reluctance to engage in tasks requiring mental effort Loses things often Easily distracted by external stimuli Forgetful in daily activities

7. Pharmacology for ADHD Psychostimulants Non-stimulants – Strattera – Antidepressants – Alpha-2 agonists

8. Stimulants First line treatment 70-80% response rate Work by increasing dopamine and norepinephrine signals to the brain by acting on dopamine and norepinephrine transporters and changing tonic and phasic dopamine releases – Increased dopamine signal leads to decrease extraneous noise – Increase norepinephrine signal leads to increased strength of signals to the prefrontal cortex Two classes – Methylphenidates – Amphetamine salts Immediate-release and extended-release formulations Fast acting

9. Stimulants Methylphenidates Ritalin (5-60 mg daily) Concerta (18-72 mg daily) Daytrana (10-30 mg daily) Focalin (5-20 mg daily) Amphetamines Vyvanse (10-70 mg daily) Adderall (5-40 mg daily)

10. Side Effects of Stimulants Common Headaches Insomnia Induction or exacerbation of tics Irritability Tremor Anorexia Growth suppression Skin reactions Rare but Serious Seizures Hallucinations/psychosis Activation of hypomania or mania Monitor height/weight, blood pressure, and heart rate throughout treatment

11. Atomoxetine (Strattera) May be monotherapy or adjunct to stimulant Non-stimulant medication that acts by enhancing norepinephrine and dopamine in PFC Preferred medication if substance use is present or if stimulant side effects are intolerable Slower acting (may take several weeks to see full effectiveness) May have some bonus antidepressant/anxiolytic effects 0.5-1.2 mg/kg (max 1.4 mg/kg or 100 mg daily) Side effects – Black Box Warning

12. Bupropion (Wellbutrin) NDRI (Norepinephrine Dopamine Reuptake Inhibitor) – Boosts dopamine and norepinephrine 150-450 mg (XL), 225-450 mg (IR) Do not prescribe if there is a history of seizures or eating disorder Side effects

13. Tricyclic Antidepressants May lessen hyperactive and impulsive behaviors by affecting norepinephrine Evidence is mixed Risk of side effects may outweigh benefits of use – Cardiac arrhythmias – Anticholinergic – Seizures

14. Alpha-2 Agonists Frequently used as adjuncts Increase strength of NE signals to PFC, where there are many alpha-2 receptors May be particularly effective for impulsive symptoms Guanfacine (Tenex and Intuniv) – Start with 0.5 or 1 mg QD or BID, then increase to no more than 2 mg (IR) or 4 mg (ER) total daily dose – May be useful if tics are present – Sedation (less than Clonidine), dry mouth, hypotension Clonidine/Kapvay – Start with 0.05 or 0.1 mg QD, then increase to no more than 0.4 mg total daily dose – May cause sedation; dose initially only at night – Sedation, dry mouth, hypotension, syncope Be mindful of rebound hypertension with discontinuation Must monitor pulse and BP daily!

15. Non-pharmacological Interventions for ADHD Behavioral Interventions – Identifying antecedents and setting consequences – Operant conditioning and reinforcement – Modeling Behavioral Parent Training Behavioral Classroom Training Child Skills Training

16. Treatment Recommendations NIMH Multimodal Treatment of ADHD Study – Multiple research sites across the U.S. – Included 600 children who were treated with medications alone, therapy alone, or a combination – Results showed combination of medication and therapy to be superior to either as monotherapy – Drug doses were lower in subjects who received concomitant therapy – Medication alone is superior to therapy alone

17. Treatment Recommendations (cont.) American Psychological Association, American Academy of Pediatrics, and American Academy of Family Physicians’ most recent stance regarding treatment is: – Behavioral therapy alone for preschool children initially – Behavioral therapy plus medication for school aged children and adolescents

20. Treatment of ADHD and Comorbid Disorders Comorbid conditions may lead to further cognitive, social, and psychological impairments General consensus is to treat mood first and ADHD second; however, it some cases it is possible to treat both – Texas Algorithm for depression says to treat whichever is more severe General consensus is to avoid stimulant in bipolar disorders General consensus is to treat substance use disorders before ADHD

23. Untreated ADHD Academic problems Interpersonal problems Unemployment/occupational underachievement Mood instability/depression Substance Use Increased suicide/risk taking behaviors Family disruption

24. Insurance Guidelines Stimulants must be tried first, unless there is a documented substance use disorder – Ritalin is preferred methylphenidate – Vyvanse is preferred amphetamine Strattera may be used after failures with both classes of stimulants as well as failure of guanfacine if patient is under 17 years old Guanfacine and clonidine are preferred Long acting guanfacine and clonidine require trial with stimulants, Strattera, and short acting alpha agonists

25. Questions?

26. References 'AAP Releases Guideline On Diagnosis, Evaluation, And Treatment Of ADHD'. American Family Physician 87.1 (2013): 61-62. Print. Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatric disease and treatment, 4(1), 107. Nathan, P. E., & Gorman, J. M. (Eds.). (2015). A guide to treatments that work. Oxford University Press. 'New Guidelines For ADHD Among Children'. Monitor on Psychology 43.3 (2012): 65. Print. Pliszka, S., & AACAP Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention- deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), 894-921. Pliszka, Steven R., et al. "The Texas Children's Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder." Journal of the American Academy of Child & Adolescent Psychiatry 43.3 (2006): 642-657. Stahl, S. M. (2011). The prescriber's guide. Cambridge University Press.