Guidelines and Treatment Updates in the Diagnosis and

Management of Attention Deficit Hyperactivity Disorder (ADHD)

MNPA Fall ConferenceFreeport, ME

November 15, 2015Jennifer Parks, MSN, PMHNP-BC

Disclosures

• None

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

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

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

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

Pharmacology for ADHD

• Psychostimulants• Non-stimulants– Strattera– Antidepressants– Alpha-2 agonists

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

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)

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

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

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

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

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!

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

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

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

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

Untreated ADHD

• Academic problems• Interpersonal problems• Unemployment/occupational

underachievement• Mood instability/depression• Substance Use• Increased suicide/risk taking behaviors• Family disruption

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

Questions?

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87.1 (2013): 61-62. Print.

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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.