ADHD: An Overview and

Approach to Management

Carrie P. Peek, M.D., Ed.M.

Department of Neurology

Boston Children’s Hospital

Disclosure

• I have no financial relationship with a

commercial entity producing health-care

related products and/or services

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Objectives

• To review diagnosis of ADHD in the

primary care setting

• To review important considerations in the

pharmacological management of ADHD

• To explore the integrated care model for

ADHD management

Case: Kevin

• 8 year old male presents for evaluation of

current medication treatment

• Diagnosed at 7 years with ADHD, using

structured questionnaires

Kevin

• Height 125 cm, Weight 24 kg, BMI 15.4

(39th percentile)

• Currently taking 10 mg regular (short-

acting) methylphenidate (MPH) at 7:30 AM

– for the past 2 months

– approx. 0.5 mg/kg/day dosing

Kevin

• Teacher reports that he is in good

behavioral control and well-focused in the

mornings.

• He eats lunch well.

• But by 2 pm, he begins to have attention

problems.

Kevin

• You discuss medication options including

switching to:

– twice daily dosing of MPH

– once daily extended release MPH formulation

• Decide collectively to switch to MPH LA 20

mg daily at 7:30 AM

Kevin

• Teacher now reports “He’s wired” around

10:00 AM, several hours after am dose

• Stops eating lunch

• However, he is “more like himself” (and

back in behavioral control) in afternoons

Kevin

• You discuss medication options including:

– switch stimulant formulation (given MPH response)

– switch to non-stimulant (if this effect is concerning…)

• Begin alternate MPH (Ritalin SR 20 mg)

– No longer “wired”

– His appetite improves at lunch.

– In behavioral control and focused through school

– But parents now want an appointment immediately…he is blinking “incessantly”

Kevin

• Kevin presents to your office at 2 PM for a

follow-up visit.

• He is attentive and cooperative.

• Height 126 cm, weight 24 kg, BMI 15.2

(39th percentile)

• On exam, he blinks very rapidly every

fifteen seconds; parents say this has been

new in the last two weeks.

What would you do?

Kevin

• Kevin was switched to an amphetamine

class stimulant.

• He returns for a 1 month follow-up visit.

• His attention has significantly improved,

and he no longer has tics.

Introduction

• ADHD is a clinical syndrome that starts in

childhood with symptoms of inattention,

hyperactivity, and/or impulsivity.

• These symptoms affect the child’s overall

functioning cognitively, academically,

behaviorally, emotionally, and socially.

Epidemiology

• Prevalence estimates reported vary widely

• Recent meta-analysis showed that overall

prevalence of ADHD in children and

adolescents is 5.9-7.1 % (Willcutt 2012)

• More common in boys than girls

Epidemiology

• Prevalence in boys: 13.2%

• Prevalence in girls: 5.6 %

• Male-to-female ratio is 4:1 for predominantly

hyperactive type

• Male-to-female ratio is 2:1 for the predominantly

inattentive type

• Prevalence of ADHD increases with age

Pathogenesis

• Results of twin studies estimate the

heritability to be 76%.

• ADHD has been associated with markers

at chromosomes 4, 5, 6, 8, 11, 16, and 17

• Genes with statistically significant evidence

of association with ADHD:– dopamine 4 and 5 receptors

– dopamine transporter

– dopamine beta-hydroxylase

– serotonin transporter gene

DSM-5 ADHD Diagnostic

Criteria• A persistent pattern of inattention and/or

hyperactivity-impulsivity that interferes with

functioning or development, as characterized in

(1) and/or (2):

– (1) Six or more symptoms of inattention

– (2) Six or more symptoms of hyperactivity-

impulsivity

– Symptoms for at least 6 months to a degree that is

inconsistent with developmental level and that

negatively impacts directly on social and

academic/occupational activities

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DSM-5 Updates

• Several inattentive or hyperactive-impulsive symptoms were

present prior to age 12 years.

• Specify whether:

– Combined presentation

– Predominantly inattentive presentation

– Predominantly hyperactive/impulsive presentation

ADHD Diagnosis

• Obtain information from home and school settings before the

office visit

• Questionnaires such as Vanderbilt or Conners’ Rating Scales

can be used alone or in combination

– http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-

assessment-scales

ADHD Diagnosis

• Clinical interview

• Structured questionnaires

• Medical evaluation

• Neurological examination

ADHD Diagnosis

• Continuous performance tasks

– Gordon Diagnostic System

– Normed for 4 years of age to adult

ADHD Management

• Pharmacotherapy as a first-line treatment

of ADHD is strongly supported in the

literature

• MTA study showed that medication alone

or medication combined with behavioral

therapy had better outcomes compared to

behavioral therapy alone.

ADHD Medication

Considerations• When do you want medication effect?

• Does this change from day to day? Month

to month?

• Are there special situations?

• Start med trial on the weekends to see

how the child responds.

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ADHD Medication

Considerations

• Response and side effects can vary across the day

– Time limited response with short acting stimulant

– Peak tension/jitteriness

• Response and side effects can occur simultaneously

– Positive response and low appetite

ADHD and Tics Considerations

• Important to inquire about any (even transient) tics before starting

• Important to inquire again… if there is a history of tics if tics emerge “for the first time” on medication

• Tics may wax/wane independently

• Change in stimulant formulation may be sufficient to address common side effects including tics

ADHD Formulations

• Choice should be based on child’s needs and

profile

• Can remain within the stimulant class if:

• there is a detectable response

• side effects are in the mild range, or transient or

intermittent (but a concern)

Methylphenidate

• Primarily acts by releasing amines from

storage sites

• Also blocks re-uptake and inhibits

monoamine oxidase

• Readily absorbed across gut

• Poorly bound to protein

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Methylphenidate

• Peak level 1-2 hours

• Duration of Action 3-4 hours

• Both of these have wide variability

• 90% metabolites are not effective

• Side effects related to dopamine

stimulation, and rate of change of

dopamine stimulation

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Methylphenidate

• Total daily dose of regular formulation methylphenidate: 0.5-1.5 mg/kg/day

• Start low, move as indicated by response

• Monitor response in multiple ways (at home and at school)

• Important dosing safety issue: The methylphenidate derivatives do not have equivalent durations of action or dosing.

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Methylphenidate

• Wax matrix preparations– (1st generation long acting)

• OROS-based presentation

• Bead dispersal systems

• Transdermal patch

• Dextro-isomer (available as pills or bead dispersal system)

• Ritalin SR, Metadate ER

• Concerta

• Ritalin LA

• Daytrana

• Focalin, Focalin XR

Amphetamine

• Releases amines from storage sites

• Also blocks reuptake and inhibits

monoamine oxidase

• Easily absorbed across gut

• Poorly bound to protein

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Amphetamine

• Peak in 2 hours

• Duration 2-3 hours

• Both of these are variable

• Metabolites all inactive

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Amphetamine

• Dextroamphetamine pills

and spansules: latter are

wax-matrix based

technology

• Prodrug (lisdexamfetamine)

• Racemic mixture of D- and

L-isomers: bead dispersal

• Dextroamphetamine, Dexedrine Spansule

• Vyvanse

• Adderall,

Adderall XR

Amphetamine

• Total daily dosing of short-acting amphetamine derivatives: 0.25 - 0.75 mg/kg/day

• Start low, move as indicated by response

• Monitor response in multiple ways (at home and at school)

• Important dosing safety issue: The amphetamine derivatives do not have equivalent durations of action or dosing.

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Non-stimulant medications

• Consider if at least one stimulant from

each class of stimulants has either failed

to show efficacy or side effects are

moderate-marked or are clinically

concerning

Atomoxetine (Strattera)

• Selective Norepinephrine Reuptake Inhibitor

• Consider starting with 0.5 mg/kg/day

• Increase every 1-2 weeks, towards 1.2 mg/kg/day (max 100mg)

• BID dosing will likely improve tolerability, may improve efficacy

• Patience while awaiting clinical response– in 1-3 months vs. weeks with stimulant class

medications

Alpha-adrenergics

• First agents to receive FDA approval for adjunctive therapy to stimulant medications and monotherapy indication

– Clonidine extended release (Kapvay)

– Guanfacine extended release (Intuniv)

Alpha-adrenergics

• May be optimal choice for tics or

significant impulsivity in a younger child

• Clonidine

– Reduce NE release

– Monitor for sedation (less with patch

formulation)

• Guanfacine

– Modulate: prefrontal increase NE activity

– Less sedating vs clonidine

side effects

can occur alongside

response in ADHD

Tics may occur during

ADHD treatment

Shared Care

• Care coordination is essential for effective

care and management of children with

chronic health conditions.

• Shared care involves collaboration of

families, PCP’s, and subspecialists.

– Ex. Shared care algorithm for ADHD

developed at BCH in collaboration with the

department of neurology

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BCH Neurology Consultation

• 617.355.8348, for either advice or urgent

appointment

• Expected call back time to referring MD is less

than 30 minutes

• Can get appointments same day or next day for

urgent patients

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Thank You