Published on February 22, 2014
ADHD: Rethinking an old diagnosis Robert L. Quillin, MD, FAAP
Disclosures Speaker and consultant for VayaPharma, makers of Vayarin Previous research support provided by Pernix Therapeutics Will discuss off label use of medications, medical foods, and supplements.
Presentation Outline morbidity of the attention disorders current diagnostic approach to attention disorders the neurobiochemistry of attention approach to stimulant use in attention disorders paradigm shift in the treatment of attention disorders
Faces not easy to forget
STATE OF THE UNION
Impact of ADHD Approximately 11% of children 4-17 years of age (6.4 million) have been diagnosed with ADHD as of 2011. The percentage of children with an ADHD diagnosis continues to increase, from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011. Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 and an average of approximately 5% per year from 2003 to 2011. Boys (13.2%) were more likely than girls (5.6%) to have ever been diagnosed with ADHD. The average age of ADHD diagnosis was 7 years of age Prevalence of ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 18.7% in Kentucky. http://www.cdc.gov/ncbddd/adhd/data.html#us
Financial Impact of ADHD Using a prevalence rate of 5%, the annual societal ‘‘cost of illness’’ for ADHD is estimated to be between $36 and $52 billion, in 2005 dollars. It is estimated to be between $12,005 and $17,458 annually per individual. There were an estimated 7 million ambulatory care visits for ADHD in 2006. The total excess cost of ADHD in the US in 2000 was $31.6 billion. The annual average direct cost for each per ADHD patient was $1,574, compared to $541 among matched controls. ADHD creates a significant financial burden regarding the cost of medical care and work loss for patients and family members. http://www.cdc.gov/ncbddd/adhd/data.html#cost
“I CAN CALCULATE THE MOTION OF HEAVENLY BODIES, BUT NOT THE MADNESS OF PEOPLE” Sir Isaac Newton
What exactly is ADHD? ADHD is one of the most common neurodevelopmental disorders of childhood. Initial diagnosis in childhood and often lasts into adulthood Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active. The ADHD Molecular Genetics Network. Report from the third international meeting of the attention-deficit hyperactivity disorder molecular genetics network. American Journal of Medical Genetics, 2002, 114:272-277.
ADHD defined by DSM-5 INATTENTION: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often has trouble organizing tasks and activities. Is often easily distracted Is often forgetful in daily activities.
ADHD defined by DSM-5 HYPERACTIVITY AND IMPULSIVITY: Six or more symptoms of hyperactivityimpulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games) Is often "on the go" acting as if "driven by a motor“. Often talks excessively.
Basic types: 1) ADHD, predominantly inattentive type 2) ADHD, predominantly hyperactive-impulsive type 3) ADHD, combined type
Comorbidity: the rule, not the exception
From: Comorbid Psychiatric Disorders in Youth in Juvenile Detention (female) Arch Gen Psychiatry. 2003;60(11):1097-1108. doi:10.1001/archpsyc.60.11.1097
From: Comorbid Psychiatric Disorders in Youth in Juvenile Detention (male) Arch Gen Psychiatry. 2003;60(11):1097-1108. doi:10.1001/archpsyc.60.11.1097
Tuesday, October 6, 2009 Baseball Players with ADHD http://studentacademichelp.blogspot.com/2009/10/ baseball-players-with-adhd.html#ixzz2bFzBnnv0
What’s missing? Learning disorders Dyslexia, dysphasia, dysgraphia Autism spectrum disorders, including PDD and Asperger’s syndrome Tic disorders Tourette’s syndrome Congenital genetic disorders – Down syndrome, DiGeorge syndrome, and others Cancers – leukemia, brain tumors?
Don’t forget your fundamentals
NEURO-developmental disorder I. II. III. IV. V. History and Physical – with interview covering emotional and psychosocial concerns, particularly early development Hearing and vision screen . . . particularly hearing Labs Complete blood count – anemia due to low iron, low B12? Lead level – consider your patient’s exposures Thyroid – too much or too little? EEG – is it a seizure? Behavior Checklists
Tools of the trade Behavior Rating Scales subjective evaluations by teachers and parents, self report Vanderbilt Assessment Scale: 6-12 years Conners 3rd edition: 6-18 years, More ADHD specific vs. Conners CBRS SNAP-IV R: 6-18 years
The big players
Is that all to ADHD?
Where they act
Aren’t you glad that’s over?
To treat or not to treat? Gold standard – The stimulant Ritalin, Adderall, Focalin Daytrana, Vyvanse, Quillivant XR Other choices: Nonstimulants – Intuniv, Kapvay, Straterra Medical foods – Vayarin Vitamins – B’s, D’s, Mg, Zinc
Where to start? COMPARE 4-5 years old, <50 pounds Short acting better? Hyperactive Family history Side effects Parental ambivalence CONTRAST 5 years old, 50+ pounds Long acting best? Inattentive New diagnosis Comorbidities Parental Fear
Prescription Medical Foods Defined as: “a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” Section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3))
FDA Regulation of Prescription Medical Foods Foods FDA GRAS for Safety Dietary Supplements No Pre-Market FDA Approval for pre1994 ingredients Prescription Medical Foods FDA GRAS for Safety of Ingredients -ORFDA review for new dietary ingredients FDA Required Clinical Evidence for Efficacy Prescription Drugs FDA Approval for Safety & Efficacy
Time is right for a change Omega3 + Phosphatidylserine - Vayarin B-vitamins: folate, B6, B12, choline – Deplin, Cerefolin Vitamin D Magnesium Zinc
PS-Omega-3 showed an endpoint that no longer qualified as ADHD in the TOVA Vaisman, N., et al., Correlation between changes in blood fatty acid composition and visual sustained attention performance in children with inattention: effect of dietary n-3 fatty acids containing phospholipids. Am J Clin Nutr, 2008. 87(5): p. 1170-80.
Folate J Pediatr. 2008 Jan;152(1):101-5. Folate pathway genetic polymorphisms are related to attention disorders in childhood leukemia survivors. Krull KR, Brouwers P, Jain N, Zhang L, Bomgaars L, Dreyer Z, Mahoney D, Bottomley S, Okcu MF. Learning Support Center for Child Psychology, Texas Children's Hospital, Houston, TX, USA. CONCLUSION: Preliminary data imply a strong relationship between MTHFR polymorphisms and the inattentive symptoms of ADHD in survivors of childhood ALL.
Magnesium/Vitamin B6 Magnes Res. 2006 Mar;19(1):46-52 Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6. I. Attention deficit hyperactivity disorders. Mousain-Bosc M1, Roche M, Polge A, Pradal-Prat D, Rapin J, Bali JP 1Explorations Fonctionnelles du Système Nerveux, Centre Hospitalier Universitaire Carémeau, Nîmes, France. CONCLUSION: In almost all cases of ADHD, Mg-B6 regimen for at least two months significantly modified the clinical symptoms of the disease . . .hyperemotivity/aggressiveness were reduced, school attention was improved. . .When the Mg-B6 treatment was stopped, clinical symptoms of the disease reappeared . . .
Zinc Acta Med Croatica. 2009 Oct;63(4):307-13. [The role of zinc in the treatment of hyperactivity disorder in children]. Dodig-Curković K1, Dovhanj J, Curković M, Dodig-Radić J, Degmecić D. 1University Department of Child and Adolescent Psychiatry, University Department of Psychiatry, Osijek University Hospital, Osijek, Croatia. email@example.com CONCLUSION: The dose of zinc sulfate used was 55 mg/day, which is equivalent to 15 mg zinc. The improvement achieved in ADHD children with the use of zinc sulfate appears to confirm the role of zinc deficiency in the etiopathogenesis of ADHD. Additional studies are needed to identify the real and efficient dose of zinc.
Vitamin D Pediatr Int. 2014 Jan 13. doi: 10.1111/ped.12286. [Epub ahead of print] Vitamin D Status in Children with Attention Deficit Hyperactivity Disorder. Goksugur SB1, Tufan AE, Semiz M, Gunes C, Bekdas M, Tosun M, Demircioglu F. 1Department of Pediatrics, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey. CONCLUSION: 25-OH-vitamin D level in ADHD group and control group was respectively; 20.9±19.4 ng/mL and 34.9±15.4 ng/mL (p=0.001). Our results suggest that there is an association between lower 25-OH-vitamin D concentrations and ADHD in childhood and adolescence.
C O N C L U S I O N
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