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The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder


The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder Carla M. Thacker PAS 646 March 22, 2007 – PowerPoint PPT presentation

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Title: The Role of the Primary Care Provider in the Diagnosis and Treatment of Attention Deficit / Hyperactivity Disorder

The Role of the Primary Care Provider in the
Diagnosis and Treatment of Attention Deficit /
Hyperactivity Disorder
  • Carla M. Thacker
  • PAS 646
  • March 22, 2007

Basic ADHD Information
  • Most common neurological and behavioral disorder
    in childhood
  • One of the most frequently identified chronic
    childhood disorders seen in the primary care
  • Core symptoms are inattentiveness, hyperactivity,
    and impulsiveness

  • In 2003, the CDC reported that approximately 4.4
    million children ages 4-17 in the US had a
    diagnosis of ADHD
  • An estimated 4-12 of children in the community
    are affected by ADHD
  • There is a significant difference in the
    prevalence of ADHD in boys and girls, with
    estimates of 10 and 4, respectively

ADHD often results in the following
  • Difficulties in school
  • Poor relationships with parents and peers
  • Low self-esteem
  • Various other behavioral, learning, and emotional
  • Difficulties for the childs parents, including
    marital problems, increased stress, and poor
    relationships with their child

  • Exact etiology of ADHD is unknown
  • Thought to be a complex interaction between
    neurological, biological, environmental factors
  • Genetics and biological factors play the major
  • Variation in genes regulating dopamine,
    norepinephrine, serotonin in the brain

Predisposing Factors
  • Low birth weight
  • Low social status
  • Severe conflicts among parents
  • Being placed in foster care
  • Mother who smoked, consumed alcohol and/or drugs
    while pregnant.

Symptoms Suggestive of ADHD
  • Easily distracted by sights and sounds in their
  • Difficulty concentrating for long periods of time
  • Becomes restless easily
  • Excessive impulsiveness
  • Frequent daydreaming
  • Slow to complete tasks

  • Use of AAP guidelines
  • Evaluate children 6-12 yrs. presenting with core
    symptoms of ADHD
  • Must meet DSM-IV criteria
  • Gather information about symptoms from various
    settings from the parents school system
  • Assess for coexisting mental health learning
  • Order diagnostic tests as indicated by findings

  • Need a detailed patient family history
  • Interview with patient family
  • Obtain report cards teacher reports
  • Obtain a thorough physical examination including
    visual auditory screening
  • Refer patient to mental health specialist if
    coexisting mental disorders or learning
    disabilities suspected

Subtypes of ADHD (Based on DSM-IV Criteria)
  • Predominantly hyperactive-impulsive type no
    significant inattention
  • Predominantly inattentive type no significant
    hyperactive-impulsive behavior (previously known
    as ADD)
  • Combined type- both inattentive
    hyperactive-impulsive behaviors

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  • Currently no cure for ADHD
  • Three types of treatment
  • Medication management
  • Behavioral therapy
  • Combination of medication behavioral therapy

Medications for ADHD
  • Stimulants shown to improve core symptoms by
    increasing maintaining balance of dopamine
    serotonin in brain
  • Non-stimulants (atomoxetine) enhances
    noradrenergic function through presynaptic
    reuptake of norepinephrine

  • Some available in short-acting, long-acting, and
    extended release forms.
  • Produce relatively quick response in patient
  • Schedule II controlled substance potential for
  • Side effects loss of appetite, insomnia, HA,
    dizziness, abdominal pain
  • Begin with lowest dosage titrate up as

Commonly Used Stimulants
  • Methylphenidate (Ritalin) long-acting form is
    Concerta, extended-release forms are Ritalin SR,
    Metadate ER, Metadate CD
  • Amphetamine (Adderall)
  • Dextroamphetamine (Dexedrine, Dextrostat, and
  • Pemoline (Cylert) no longer considered
    first-line due to risk of hepatotoxicity

Non-Stimulants (atomoxetine)
  • Slower response times than stimulants
  • Non-scheduled drug no potential for abuse
  • Side effects similar to those of stimulants
  • Atomoxetine (Straterra) is the only non-stimulant
    approved by the FDA to treat childhood ADHD
  • More expensive than stimulants
  • Others sometimes used are antidepressants
    including bupropion (Wellbutrin) despiramine,
    antihypertensives including clonidine

Methylphenidate (Ritalin) vs. Atomoxetine
  • Recent study analyzed all clinical trials which
    compared the two drugs
  • More patients responded to Ritalin than Straterra
    responses were quicker with Ritalin
  • Study confirmed that stimulants are the most
    efficacious treatment for childhood ADHD
  • Straterra is a good alternative treatment when
    stimulants are not well tolerated or when drug
    abuse is a potential problem

New ADHD Treatment Option
  • The 1st and only stimulant prodrug,
    lisdexamphetamine (Vyvanse) was granted market
    approval by FDA in Feb. 2007
  • Therapeutically inactive until contact is made
    with GI tract only active if swallowed
  • May prevent abuse of drug by those who snort or
    inject crushed pills
  • Recent study showed that 95 of children taking
    Vyvanse produced much improved or very much
    improved rating on Clinical Global Impressions
    rating scale

  • ADHD is a disorder in which research must
    continue in order to determine its etiology to
    obtain more information regarding safety of
  • Due to increasing numbers of children with ADHD,
    it is very important for primary care physicians
    to become skilled at diagnosing and treating the

  • Adesman, A. The diagnosis and management of
    attention-deficit/hyperactivity disorder in
    pediatric patients. Primary Care Companion J
    Clin Psychiatry 2001 3 66-77.
  • Foy, J., Earls, M. A process for developing
    community consensus regarding the diagnosis and
    management of attention-deficit/hyperactivity
    disorder. Pediatrics 2005 115 e97-e104.
  • Furman, L. What is attention-deficit
    hyperactivity disorder (ADHD)? J Child Neurol
    2005 20(12) 994- 1003.
  • Gibson, A.P., Bettinger T.L., Patel, N.C.,
    Crismon, M.L. Atomoxetine versus stimulants for
    treatment of attention deficit/hyperactivity
    disorder. Ann Pharmacother 2006 Jun 40(6)
  • Greydanus, D.E. Pharmacologic treatment of
    attention-deficit hyperactivity disorder.
    Indian J Pediatr 2005 72 953-960.
  • Harpin, V.A. The effect of ADHD on the life of
    an individual, their family, and community from
    preschool to adult life. Arch Dis Child 2005
    90 i2-i7.
  • Karande, S. Attention deficit hyperactivity
    disorder A review for family physicians.
    Indian J Med Sci 2005 59 547-556.
  • Kuntsi, J., McLoughlin, G., Asherson, P.
    Attention deficit hyperactivity disorder.
    Neuromolecular Med. 2006 8(4) 461-84.
  • Leslie, L. The role of primary care physicians
    in attention deficit hyperactivity disorder
    (ADHD). Pediatr Ann 2002 August 31(8) 475-484.

References (Continued)
  • Leslie, L. et al. Implementing the American
    Academy of Pediatrics attention-deficit/hyperactiv
    ity disorder diagnostic guidelines in primary
    care settings. Pediatrics 2004 July 114(1)
  • Mental health in the United States. Prevalence
    of diagnosis and medication treatment for
    attention- deficit/hyperactivity disorderUnited
    States, 2003. MMWR Morb Mortal Wkly Rep 2005
    54(34) 842-7.
  • Olfson, M. New options in the pharmacological
    management of attention-deficit/hyperactivity
  • Am J Manag Care 2004 10 s117-s124.
  • Steer, C.R. Managing attention
    deficit/hyperactivity disorder unmet needs and
    future directions.
  • Arch Dis Child 2005 90 i19-i25.
  • Wolraich, M.L. et al. Attention-deficit/hyperacti
    vity disorder among adolescents A review of the
    diagnosis, treatment, and clinical implications.
    Pediatrics 2005 115(6) 1734-46.