Escolar Documentos
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After completing this activity, the participant should be better able to:
1
Overview
• Estimated prevalence:
– 6 to 8% of children
– 6% of adolescents
– 4% of adults
• 4:1 male to female ratio in children and adolescents
• Treatment utilization varies widely within and between cultures,
ethnicities, and socioeconomic status
ADHD Subtypes
*DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, Text Revision. Washington, DC. American
Psychiatric Association. 2000;48:85-93.
Etiology
Neuroanatomic Genetic
Neurochemical origins
ADHD
Environmental
CNS insults
factors
2
DSM-IV Diagnostic Criteria for ADHD
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, Text Revision. Washington, DC. American
Psychiatric Association. 2000;48:85-93.
3
Evidence of Persistence of ADHD Into
Adulthood
80 72
65 66
58
Percentage
60
40 31
20
0
1 2 3 4 5*
Age at
6 to 17 4 to 12 6 to 12 6 to 12 6 to 18
diagnosis
Age at follow-
10 to 21 12 to 20 16 to 23 21 to 33 16 to 28
up
1
Cumulative morbidity risk
ADHD
0.8 Control *
0.6
* *
0.4
*
*
0.2 †
0
MDD BPD OCD Tic ODD CD
disorders
*ADHD vs Control, P<.001
†P = .004
10-year follow-up of males with ADHD (n = 112) and case controls (n = 105)
Mean age at follow-up: 22 years
MDD = major depressive disorder; BPD = bipolar disorder; OCD = obsessive-compulsive disorder;
ODD = oppositional defiant disorder; CD = conduct disorder.
Biederman J, et al. Psychol Med. 2006;36:167-179.
4
Academic and Behavioral Impairments
Continue in Adolescence
License suspended
Speeding violations
Accidents
Fault
Injuries
More damage
0 2 4 6 8
Increased likelihood of outcome compared with
age-matched controls
Barkley RA, et al. Pediatrics. 1993;92:212-218.
Cox D, et al. J Nerv Ment Dis. 2000;188;230-234.
Barkley RA, et al. Pediatrics. 1996;98:1089-1095.
Murphy K, Barkley RA. Comp Psychiatry. 1996;37:393-401.
50%
Control
Percent Increase in Risk
ADHD
40%
30% 27%
10%
0%
Youth Adults
5
Sexual Behavior
Pregnancy P <0.001
0 10 20 30 40 50 60 70
Participants (%)
Control (n = 111) ADHD (n = 175)
Young men (aged 18–26) with and without childhood ADHD; self-reports
Flory K, et al. J Clin Child Adolesc Psychology. 2006;35:571-577.
Criminality
100
P <0.001
ADHD Control
80 P = 0.001
Participants (%)
60 P = 0.019
P <0.001 P <0.001
40
P = 0.025 P = 0.006
P = 0.005
20
0
Stolen Assault with Assault with Carried Ever arrested Arrested Misdemeanor Felony arrest
property fists weapon concealed twice or more arrest
weapon
Neurobiology of ADHD
PET: Positron Emission Tomography; fMRI: Functional magnetic resonance imaging; DAT: Dopamine transporter; SNAP: S-
nitroso-N-acetylpenicillamine; 5HT: 5-hydroxytryptamine
6
Treatment Considerations in
Adolescents with ADHD
• Psychoeducation
• Educational intervention/remediation
• Counseling
• Supportive problem-directed therapy
• Cognitive/behavioral intervention
• Coaching
• Family therapy
• Medication
Physicians’ Desk Reference. 59th ed. Montvale, NJ: Thomson PDR; 2005.
7
Dosing Stimulants
70
60
P ≤0.05, ADHD vs
50
control at endpoint
40 Earlier onset
30
20
10 Higher risk
0
0 10 20 30 40 50 60
Age at onset (years)
Wilens T, et al. J Nerv Ment Dis. 1997;185:475-482.
8
Pharmacotherapy and Substance
Abuse With Stimulants
5%
Misused
22%
5% No ADHD (n = 43)
Got high
10%
ADHD (n = 55)
5%
Used too much
22%
0%
Sold
11%
53% SUD
All ADHD
(N = 55)
31% CD
75%
Misuse
(n = 12)
58%
83%
Divert
(n = 6) 83%
9
Possible Predictors of Misuse of ADHD
Medications
25
20 IR-MPH
OROS-MPH
Feel an Effect
15
*
10 * †
*
*
5
0
0 1 2 3 4 5 6 7 8 9 10
10
Treatment with OROS MPH Increased Activation in
Regions Associated with Attention
11
Adolescent ADHD Summary
0.12
Percent of children <18
Respiratory
10% 0.08 0.07 Allergy
Learning
5%
Disability
0% ADHD
a
HD
y
rg
m
t
ili
th
D
lle
ab
A
As
is
ry
D
to
gn
ra
ni
pi
ar
es
(n=73,493) (n=61,354)
Le
R
(n=73,493) (n=61,354)
12
Consequences of Untreated ADHD
Increase with Age
• Antisocial
Behavior
• School
• Disruptive • Oppositional Exclusion
Behavior Defiant • Substance
• Poor Disorder Abuse
• Low
• ADHD only Social • Mood • Conduct
Self-
Skills Disorder Disorder
Esteem
• Learning • Challenging • Lack of
Delay Behavior Motivation
• Complex
Learning
Disorder
Society
Health Care Use
2X > Risk for SUD6
50% ↑ Bicycle accidents1
Earlier onset of SUD7
33% ↑ Emergency visits2
More likely to continue
>4x ↑ Vehicle accidents3
SUD into adulthood8
School/Work Family
46% Expelled4 >4x h Sibling fighting9
35% Dropped out4 >4x h Separation/divorce
Lower occupational status5 in adulthood10
0% 0
Less than High College; Post-grad Less than High College; Post-grad
high school; some post degree high school; some post degree
school some grad school some grad
college ADHD (n=500) college
No ADHD (n=501)
†
p<.001 for all comparisons. *p<.05; **p<001.
Biederman J, Faraone SV. MedGenMed. 2006;8:12.
13
ADHD Associated with Greater Use of
Hospital Care
Population based Cohort Study of Adolescents
(Mean Age: 15.3 years)
100% p=.005
ADHD
81%
No ADHD
Proportion requiring
74%
hospital services
75% n=4119
p=.006
0%
In-patient Care Out-patient Care ED Admission
Leibson CL, et al. JAMA 2001;285:60-66.
$900
$690
$600
$427*
$335*
$245 $222*
$300
$20 $66
$0
Primary Care Mental Pharmacy Total
Health Care
AAP
Practice Guideline
May 2000
14
Are Providers Using the Guidelines?
15
AAP Treatment Plan
Stimulants
Methylphenidate Amphetamine
Short Acting Intermediate Long Acting Short Acting Intermediate Long Acting
SODAS MPH MPH SR OROS MPH Dextroamphetamine Dextroamphetamine ER MAS XR
Dexmethylphenidate MPH SR Diffucaps MPH Dextroamphetamine tabs MAS
MPH LA
Dexmethylphenidate XR
MPH transdermal patch
Nonstimulant
Atomoxetine TCA
Modafinil; Bupropion
Guanfacine; Clonidine
Venlafaxine
SODAS = spheroidal oral drug absorption system; MPH = methylphenidate; SR = sustained release;
ER = extended release; OROS = osmotically controlled-release oral delivery system; LA = long acting;
XR = extended release; TCA = tricyclic antidepressants
16
Managed Care Considerations with
ADHD Therapy
17
Second and Third Line Interventions
18
Drug Delivery Systems May Reduce
Risk for Abuse and Diversion
• Polypharmacy
– Combination of long-acting agents
– Combination of short-acting agents
– Use with modafinil (Provigil), sedative hypnotics, etc.
– Different doctors
• Suboptimal dosing
– High DACON
• Appropriate use vs. potential for abuse
• Off-label use
• Polypharmacy
– Limit to one long-acting agent at one time (a short-acting in combination could be
allowed)
• Methylprenidate (Concerta; Adderall XR) would not be allowed at the same
time
– Limit to one short-acting agent at one time (a long-acting in combination could be
allowed)
• MPH IR and mixed amphetamine salts would not be allowed at the same time
• Dose optimization
– Methylprenidate (Concerta) 18 mg bid → methylprenidate (Concerta) 36 mg qd or
methylprenidate (Concerta) 18 mg qd + MPH IR qd
• Quantity limits
– One long-acting agent per day
19
Improving Adherence to Treatment
American Academy of Childhood and Adolescent Psychiatry. J Am Acad Child Adolsec Psychiatry 2007;46:894-921.
American Academy of Childhood and Adolescent Psychiatry. J Am Acad Child Adolsec Psychiatry 2007;46:894-921.
20
HEDIS ADHD Measure
National Committee for Quality Assurance. The state of health care quality: Industry trends and analysis. Washington, DC. 2007.
32% 33%
30%
Percent of Plans
20%
10%
0%
2005 2006
National Committee for Quality Assurance. The state of health care quality: Industry trends and analysis. Washington, DC. 2007.
21
Patient Management
Plan
Patient Management
Plan
Patient
Education
Materials
22
Physician Education
Materials
Summary
Summary (continued)
23