NorthShore ADHD Clinic Creating Clarity 1 Anthony M. Ocana MSc, MD, CCFP, ABAM...

NorthShore ADHD Clinic

Creating Clarity

1

Anthony M. OcanaMSc, MD, CCFP, ABAM

[email protected]


604-913-8183northshoreadhd.com

ADHDPractical Office Solutions

2 NorthShore ADHD Clinic

DisclosuresDr. Ocana has received…

speaker honoraria from… Astra, Janssen, Lilly, Shire, Purdue and Wyeth…

consulting fees from… Lilly, Lundbeck, Shire and Janssen

educational grants from… Janssen, Lilly, Shire, Purdue, GSK

research funding from GSK and Shire

Some of the treatments mentioned in today’s seminar have not been approved by the Canadian HPB or American FDA.

3 NorthShore ADHD Clinic

Practical Office Solutions Overview

ADHD…What does it look like?

What is it?

Is it real?

How do I make the diagnosis?

What are the treatment options/ benefits/ risks?

When should I refer?

© NorthShore ADHD Clinic4 NorthShore ADHD Clinic

NorthShore ADHD Clinic5

ADHD…What is it?

Overview Genetic differences… in dopamine circuits made dysfunctional… by changes in environment

Hallmark Symptoms Can’t focus Can’t get things done (on time) Can’t sit still Impulsive/ Impatient


Dopamine Circuit Symptom Narrative

Attention Inattention Can’t focusMake mistakesCan’t stick to taskCan’t listenLoseForget

Executive Function Disorganization Can’t organizeCan’t prioritizeCan’t manage time

Motor Control Hyperactivity FidgetCan’t sit stillBusy mindTalk too much

Impulse Control Impulsivity Can’t foresee consequencesBlurts things outInterrupts

Reward Boredom ProcrastinateStart, but lose interestCan’t wait


Stimulant Circuits

Reward

Executive Function

MotivationImpulse Control

Attention

Motor Control

ADHD is A Family Affair

Heritability genotype is 80% (Twin studies) phenotype is 40-60% (ADHD Parents will have ADHD child) Transmission is 25% (ADHD Children will have and ADHD parent)

Increased risk of ODD Correlates with family history of Addiction

Murray & Johnston, J Abnorm Psychol, 2006; Sonuga-Barke et al. Am Acad Child Adolesc Psych, 20028


ADHD… Is it real?

Genetics Defective genes are dopamine associated D4, D5, DAT, DBH, SNAP-25, 5HTT

Anatomy Size/ activity reductions in dopamine-rich areas prefrontal cortex, basal ganglia, cerebellum

PhysiologyDegree of dopamine deficit predicts ADHD Symptoms distractibility, irritability, impulsivity, executive dysfunction

Pharmacology Symptom remission with dopaminergic agents Stimulants, Wellbutrin, Strattera

Co-morbidity Hypo-dopaminergic phenotype associated with other impulse control disorders

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ADHD… is it real?

Failed activation of cingulate gyrus in ADHD

Bush et al. Biol Psychiatry 1999;45:1542NorthShore ADHD Clinic

Current Standard of Care

Controversial

Do not diagnose

Do not treat


Treatment Gap… not over-treated


Only 50% with ADHD seek help…

Few MDs comfortable diagnosingOnly 25% receive an accurate diagnosis…

Even fewer MDs are comfortable managing ADHD Only 10% receive any treatment

Common medications have ++ side effectsOnly 5% are properly treated to full remission at 1yr

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Empathy Gap

Lack of empathy for suffering

Under-function is misunderstood

Stigma - moral/ ethical prejudice

(stupid, lazy, incompetent)

Extreme Implications

education/ vocation/ legal/ medical/ justice


14

0% 10% 20% 30% 40% 50% 60%

Fired from job

Incarcerated

Arrested

Serious car accident

Accident prone

Substance abuse

STD

Teen pregnancy

< high school

Repeat a grade

Subjects (%)

ADHD

Non-ADHD

1. Barkley. Attention-deficit hyperactivity disorder, 1998; 2. Barkley et al. JAACAP 1990; 3. Biederman et al. Arch Gen Psych 1996; 4. Weiss et al. JAACAP 1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995.

Functional Impairment


Attention


Inattention



ADHD Assessment…in four to five visits (not less)

Narrative

Clinician-administered ASRS

Review of Co-morbidity

Risk Assessment/ Exam

Treatment Options


Narrative Assessment

What symptoms do you have?Have you had these all your life?

How much of a problem have they caused?

Who else in your family has these traits?

How do they affect your life?

ADHD Functional Enquiry

How do they affect your life?

Childhood

School

Home

Work

Financial

Career

Interpersonal

Family of origin

Intimate (partner, children)

Social

Health


Cognitive / Executive

1. Easily Distracted2. Can’t stick to task3. Careless mistakes4. Difficulty listening 5. Forgets6. Loses/ misplaces7. Difficulty organizing 8. Avoid / procrastinate9. Fails to finish tasks (on time)

Hyperactive / Impulsive

1. Fidgets2. Leaves seat3. Busy Mind4. Difficulty unwinding/relaxing5. Talks excessively6. Lack of fore-sight / hindsight7. Speak out of turn8. Interrupts others 9. Difficulty waiting

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Adult Self Report Scale


ADHD Diagnosis… it’s all about impairment

Narrative endorses impairment of function since childhood more than two domains

ASRS endorses 6/9 symptoms either cognitive/ executive or hyperactive/ impulsive associated with moderate/ severe or extreme impairment

Lifetime Impact is severe/ extreme or catastrophic


ADHD and Co-morbid Disorders

Depression

Substance Use

Bipolar DisorderImpulse Control Disorder

Eating Disorder

Personality Disorder

Sleep Disorder

ADHD

Co-Morbidity

Mood DisorderAnxiety

Depression

Mood and Behavioural InstabilityBipolar

Substance Abuse

Impulse Control DisorderImpulsive Aggression

Gambling/ Shopping/ Eating/ Sex

Self Injurious Behaviour

Psychosis


24

40

20 2015

47

20

30

Anxiet

y

Mood

Anti-Soc

ial

Bipol

ar

Learn

ing

Impul

se

Substa

nce

ADHD and Co-morbid Disorders

Biederman. Am J Psychiatry. 1993;150(12):1792. Biederman. Psychiatry Research 1994;53:13 Shekim. Compr Psychiatry. 1990;31(5):416. Kessler et al. Am J Psychiatry. 2006; 163:716-723

Prev

alen

ce (%

)



Physical Exam

Family Hx sudden cardiac death cardiac defect pediatric cardiac surgery

Personal Hx cardiac Hx/ sx fainting during exercise

Other Hx Hx of seizure Hx of sleep apnea Hx of head injury

Exam

Ht/ Wt BP/ HR Cardio-pulmonary


What can we do?

Assess

Support/ Validate

Educate

Activity/ Diet / Sleep/ LifestyleCoaching/ CounsellingStress Management

Medicate

Advocate


Mechanism of Action of Medication

Dopamine

Dopamine

Dopamine

AtomoxetineBlocks re-uptake of dopamine in PFC

Methylphenidate blocks re-uptakeof dopamine

Amphetamine blocks re-uptake…and stimulates release of dopamine

Stimulant Protocol

Use long-acting stimulants

Biphentin®, Adderall XR®, Concerta® or Vyvanse®

Start at the lowest dose

Increase dose every 5-10 days until response

Review at 3 - 6 - 9 weeks

Slowly increase dose to complete remission of symptoms



Stimulant Dose - Response Curve

Hyperactive

Increasing Dosage

Response

Valley of the Zombies

Remission

Agitation/ Anxiety

Mania / Psychosis

Time (weeks) 0-------1-------2 -------3-------4-------5-------6-------8-------9-------10


Effect - Side effect

Time

Symptom Improvement

7 am 7 pm Midnight

Area of maximal side effectsFatigue, irritability, insomnia

Noon

Overstimulation, palpitations, loss of appetite

Stimulant Side Effects

Over-stimulation Hyper/ talkative Loss of appetite Dry mouth

Under-stimulation Fatigue Headache ADHD symptoms return Hyper-focus

Rebound Jaw tension Agitated Reward Seeking Insomnia


Stimulant Risk Management

Over-stimulation/ agitation/ mania/ psychosis

Hx of mood instability, bipolar, active psychosis caffeine…cannabis …stimulants…cocaine…

Stop stimulants/ decrease cannabis Avoid meds if sleep deprived, sick or ++ stress Pre-treat with mood stabilizer (refer)


Summary

Primary Care MDs Index of suspicion Take your time…to assess… manage

Validate ADHD Assess Co-morbidity… Manage risk Educate patient and family Treat to complete remission

Refer complicated cases Rewarding to treat – Large effect size – Dramatic improvement



Anthony M. OcanaMSc, MD, CCFP, ASAM

604-913-8183 ext 2235

North ShoreADHD Clinic

Creating Clarity

northshoreadhd.com

NorthShore ADHD Clinic Creating Clarity 1 Anthony M. Ocana MSc, MD, CCFP, ABAM...

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