ADHD: Current Update Co-morbidity and Treatment …

1 ADHD: Current UpdateCo- morbidity and Treatment StrategiesCADDRA GuidelinesADHD: Current UpdateCo- morbidity and Treatment StrategiesCADDRA GuidelinesUmesh Jain, , for Addiction and Mental Health and the Hospital for Sick ChildrenDisclosure StatementDisclosure StatementPharmaceutical Company SponsorshipsSponsorships ResearchAdvisory BoardsEli LillyXXXGSKXXJ anssen-OrthoXXXN ovartisXXPurdue PharmaXXXS hire BiochemXXXW yethXXThis talk sponsored by Shire Biochem and Janssen-OrthoPharmaceutical Company SponsorshipsSponsorships ResearchAdvisory BoardsEli LillyXXXGSKXXJ anssen-OrthoXXXN ovartisXXPurdue PharmaXXXS hire BiochemXXXW yethXXThis talk sponsored by Shire Biochem and Janssen-OrthoCADDRACADDRAA national organization to advocate for all ADHD patients -physician lead but will soon include key stakeholders-involved in research.

2 Training and advocacy-produced the Canadian ADHD Practice guidelines (CAP- guidelines )A national organization to advocate for all ADHD patients -physician lead but will soon include key stakeholders-involved in research, training and advocacy-produced the Canadian ADHD Practice guidelines (CAP- guidelines )Executive CADDRAE xecutive CADDRAS arah SheaAtlanticUmesh JainOntarioChair/ AdminLily HechtmanQuebecAnnick VincentQuebecTrainingDerryck SmithMember at LargeAdvocacyAtilla TurgayOntarioGuidelinesDeclan QuinnPrairiesMargaret WeissBCResearchSarah SheaAtlanticUmesh JainOntarioChair/ AdminLily HechtmanQuebecAnnick VincentQuebecTrainingDerryck SmithMember at LargeAdvocacyAtilla TurgayOntarioGuidelinesDeclan QuinnPrairiesMargaret WeissBCResearchCADDRA Website and distributionCADDRA Website and distributionMaterial will be can be obtained from industry repsDirect distribution to physicians(only cost is Postage and Handling)Material will be can be obtained from industry repsDirect distribution to physicians(only cost is Postage and Handling)Objectives:Objectives.

3 To review the diagnosis of Attention-Deficit / Hyperactivity Disorder (ADHD) using the caddra guidelines To review new Treatment strategies To review the diagnosis of Attention-Deficit / Hyperactivity Disorder (ADHD) using the caddra guidelines To review new Treatment strategies Adult ADHD Studied19501950198019801968 19701968 1970198719871994199419371937 Minimal Brain Minimal Brain DysfunctionDysfunctionMinimal Minimal Brain Brain DamageDamageAttention Deficit/Hyperactivity Attention Deficit/Hyperactivity Disorder (Disorder (DSMDSM--IIIIII--RR))Attention Deficit Disorder Attention Deficit Disorder Hyperactivity (Hyperactivity (DSMDSM--IIIIII))Attention Deficit/Hyperactivity Disorder (Attention Deficit/Hyperactivity Disorder (DSMDSM--IVIV))Efficacy of Efficacy of AmphetamineAmphetamineHyperactive Child Hyperactive Child SyndromeSyndromeADHD: Timeline of DefinitionsADHD.

4 Timeline of Definitions19301930 Hyperkinetic ReactionHyperkinetic Reactionof Childhood (of Childhood (DSMDSM--IIII))19021902 First First Description of Description of ADHD by StillADHD by StillMedia Hype and ConfusionMedia Hype and ConfusionMyths and FactsMyths and FactsADHD is only a childhood disorder and applies only to boysIt is only found in Western countriesIt is a behavioral disorderIt reflects inadequate school funding and that kids are over diagnosedThe medical agenda is being pushed by drug companiesADHD is only a childhood disorder and applies only to boysIt is only found in Western countriesIt is a behavioral disorderIt reflects inadequate school funding and that kids are over diagnosedThe medical agenda is being pushed by drug companiesADHD is lifespan disorder and many girls with inattention are not identifiedICD-10 Criteria used elsewhere ADHD is a worldwide phenomenaIt is a medical

5 Disorder that affects learningThe prevalence rates are 5-9% though incidence has increasedThe MTA study was NIMH fundedADHD is lifespan disorder and many girls with inattention are not identifiedICD-10 Criteria used elsewhere ADHD is a worldwide phenomenaIt is a medical disorder that affects learningThe prevalence rates are 5-9% though incidence has increasedThe MTA study was NIMH fundedPrevalence RatesPrevalence RatesPrevalence ~8% of school age children1 ~50% persistence into adulthood2 of adults meet full criteria for persistent childhood-onset ADHD with significant impairment and comorbidity3 Prevalence ~8% of school age children1 ~50% persistence into adulthood2 of adults meet full criteria for persistent childhood-onset ADHD with significant impairment and comorbidity31. Faraone SV, et al.

6 World ;2 Faraone SV, et al. Biol ;48(1) Kessler RC. Presenting at: 157th APA Annual Meeting; May 1-6, 2004; New York, Rates of ADHDW orldwide Rates of ADHD05101520 Prevalence of ADHD (%)Puerto RicoNew York CityPittsburghIowaTennesseeMinnesotaOreg onMissouriVirginiaN. CarolinaNY, MI, WIChinaNetherlandsNew ZealandJapanBrazilUkraineGermanyNetherla nds/BelgiumSwitzerlandIsraelUnited KingdomIrelandCanadaNew ZealandSpain05101520 Prevalence of ADHD (%)(Faraone et al. World Psych:2003)Southeast AsiaADHD is impairingADHD is impairingCoping strategies may limit impairment if the person can find a suitable nicheImpairment can be found in many domains. Patients do not meet their potential Coping strategies may limit impairment if the person can find a suitable nicheImpairment can be found in many domains.

7 Patients do not meet their potential Potential Consequences of Untreated ADHD Throughout the DayPotential Consequences of Untreated ADHD Throughout the DayLate for WorkDelays Projects Until Deadlines Are ImminentForgetful of Things to Be DonePoor OrganizationEasily Bored by Tedious TasksImpulsive Job ChangesWorkHomePoor Driving HabitsFrequent Traffic Accidents/ ViolationsLow Self-EsteemSubstance AbuseFewer FriendsCriminal ActivitiesSignificant Marital ProblemsParenting and Child Care/ Management DifficultiesMore Chaotic Family RoutinesPoor Financial ManagementPoor HousekeepingTrouble Sustaining Intimate Relationships7:00 AMOutside Work/HomeFaraone SV, et al. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment . 2nd ed. The Guilford Press; 1998 :00 PM7:00 PMLong-term Educational ImpairmentLong-term Educational Impairment0 10203040506070 Grade retentionSuspensionExpulsionDrop-outDid not graduatecollegeControlADHD% of SampleBarkley RA.

8 J Clin ;63(suppl 12) ImpairmentOccupational RatioBarkley RA. J ;63(suppl 12):10-15 Change JobsMore OftenMore Likely toBe FiredADHD Classifications- DSM-TRADHD Classifications- DSM-TRADHD, Predominantly Combined Subtype (ADHD-C)- >50%ADHD, Predominantly Inattentive Subtype (ADHD-I) 35%ADHD, Predominantly Hyperactive-Impulsive Subtype (ADHD-HI) <10%ADHD, Predominantly Combined Subtype (ADHD-C)- >50%ADHD, Predominantly Inattentive Subtype (ADHD-I) 35%ADHD, Predominantly Hyperactive-Impulsive Subtype (ADHD-HI) <10% caddra Feedback Form Presented to family so they know how the diagnosis was made caddra Feedback Form Presented to family so they know how the diagnosis was made Impairment Scales WFIRS review domains of functioning Impairment Scales WFIRS review domains of functioningAssessment Algorithm for ADHDA ssessment Algorithm for ADHD Documentation using the caddra Child and Adolescent Template Inclusion strategies also include: Family History Childhood History (also school report cards and other assessments) Exclusion strategies caddra Co-morbidity Scales (Turgay) orCheckmate Plus Documentation using the caddra Child and Adolescent Template Inclusion strategies also include.

9 Family History Childhood History (also school report cards and other assessments) Exclusion strategies caddra Co-morbidity Scales (Turgay) orCheckmate Plus Screening DSM-TR + SNAP Questionnaires (ensure referral for psychometrist) Screening DSM-TR + SNAP Questionnaires (ensure referral for psychometrist)ADHD etiology: No simple solutionsADHD etiology: No simple solutionsBehavioralhyperactivityimpulsiv ityBehavioralhyperactivityimpulsivity CognitiveInattentionConcentrationMemory Socialisolationrejectionasocialantisocia l EmotionalTemperAffect regulationMood problemsBiological Evidence for ADHDB iological Evidence for ADHDPET StudiesCognitive DataNeuro-chemical evidenceGenetic DataPET StudiesCognitive DataNeuro-chemical evidenceGenetic DataPrepubescent Growth Spurt in Cortex(thickens just before puberty, then thins)Prepubescent Growth Spurt in Cortex(thickens just before puberty, then thins)J.

10 Giedd (2003) NIMHA ggregate of 52 MRI scaof normal kids scanned X@ 2 yr intervalsCortex thickness peaks a11 yo in in malesThen prunes for More efficient circuits[View of right orbital lateral cortex; blue is thinner]Positron Emission Tomography (PET) studies show that methylphenidate acts predominantly in the striatum of the human brain where it binds to DA transporters[11C]methylphenidatemethylph enidateExtensive PET studies of Methylphenidate in the Human BrainExtensive PET studies of Methylphenidate in the Human BrainVolkow et al. J Atten Disord2002 Ritalin improves glucose consumption in the brainRitalin improves glucose consumption in the brainADHD: Decreased consumptionIncreased consumption with RitalinFaraone. J Am Acad Child Adolesc ;39:1455-1457. Hemminki. Mutat ;25 Eur Resp.