ACTIVITY DISCLAIMER. Pediatric Attention Deficit and Disruptive Behavior Disorders: ADHD and Comorbid DISCLOSURE. Learning Objectives

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1 Pediatric Attention Deficit and Disruptive Behavior s: ADHD and Comorbid Ravi Grivois-Shah, MD, FAAFP ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. This educational activity is supported by an independent medical education grant from Shire. DISCLOSURE Ravi Grivois- Shah, MD, FAAFP It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Associate Professor, Department of Family and Community Medicine, University of Arizona (UA), Tucson; Medical Director, UA Alvernon Clinic, Tucson. Dr. Grivois-Shah is a graduate of the University of Illinois College of Medicine, Chicago. He completed his family medicine residency at Advocate Illinois Masonic Medical Center Family Medicine Residency Program, Chicago, and earned his Master of Public Health (MPH) degree from the University of Illinois- Chicago. Working with residents and students on the inpatient service at the Banner University Medical Center South (formerly the University of Arizona Medical Center South Campus), as well as the maternal-child service at the Banner University Medical Center, Dr. Grivois-Shah is committed to both practice transformation and moving the system closer to a patient-centered medical home (PCMH). A full-service family physician and former member of the AAFP Board of Directors, he is passionate about public health advocacy, leading the way on various issues that include bicycle safety, advocacy, and promotion, as well as protecting communities in southwest Chicago from coal plant pollution. Dr. Grivois- Shah previously served as medical director of a high school health center, and works with a robust pediatric patient population. Learning Objectives 1. Utilize current AAP evidence-based guidelines and DSM-V criteria to diagnose and evaluate ADHD in symptomatic child. Audience Engagement System Step 1 Step 2 Step 3 2. Screen all children diagnosed with ADHD for other primary conditions or comorbidities. 3. Develop a management plan that included multimodal interventions of other concomitant conditions and comorbidities, as well as pharmacologic and non-pharmacologic interventions to manage ADHD. 4. Counsel children and family members on successful management of ADHD, including transition management from adolescence to adulthood. 1

2 Outline I. Intro to ADHD A. Pathophysiology B. Epidemiology II. Diagnosing ADHD A. DSM criteria B. Screeners C. Differential III. Natural History of ADHD IV. Treating ADHD A. Stimulants B. Atomoxetine C. Others V. Disruptive, Impulse Control, and Conduct s A. Oppositional Defiant B. Conduct Case Scenario 1 Jimmy: 8 year old school physical, no past medical / surgical / or significant family history Changing schools because of difficulties at current school: teachers complained about him getting out of seat and running around room, kicked off school bus because running among the seats Also a challenge at home: not able to sit and read, unable to get chores done POLL QUESTION 1 You discuss your concerns with Jimmy s dad who states, I ve heard a lot about ADD on the news. He curiously asks, Who really gets this problem? What do you tell him? A. Around 15-20% of school-aged children meet diagnostic criteria B. Boys and girls are affected equally C. ADHD is more common in children who have close relatives with ADHD D. Kids with ADHD have the same incidence of other psychiatric conditions as kids without ADHD Definition of ADHD that manifests in childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Pathophysiology What to Ask? The Brain How is your child doing at school? Have you or the teacher noticed any problems with learning? Environmental / Societal Factors Is your child happy in school? Does your child have any behavioral problems at school, home, or when playing with friends? Genetic Factors Millichap, JG. Etiologic classification of attention-deficit/hyperactivity disorder. Pediatrics 2008; 121:e358 Does your child have problems completing school assignments at school or home? 2

3 Epidemiology 2003 Epidemiology 2007 Centers for Disease Control. ADHD: Prevalence. Access 7/14/15 Centers for Disease Control. ADHD: Prevalence. Access 7/14/15 Epidemiology 2011 Epidemiology (Male to female ratio ranges from 2:1 to 9:1) American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention- Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7):894Y921. Centers for Disease Control. ADHD: Prevalence. Access 7/14/15 Perou R, Bitsko RH, Blumber SJ, et al.; Centers for Disease Control and Prevention. Mental health surveillance among children United States, MMWR Surveill Summ. 2013;62(suppl 2):1035. Poll Question 2 How do we know if my son has this ADHD? Jimmy s dad asks. Which of the following do you tell him about diagnostic criteria? A. Jimmy must meet 6 or more from both inattentive and hyperactive to get the diagnosis. B. Jimmy must have had symptoms starting before the age of 6 C. Even if Jimmy had no symptoms in other locations, as long as he met criteria at school, he could be diagnosed with ADHD since classroom symptoms are most important D. Symptoms must have been present for at least 6 months Diagnosing ADHD (1) Inattention: 6+ of the following for at least 6 months, and they are inappropriate for developmental level: (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has trouble holding attention on tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has trouble organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (eg. toys, school assignments, pencils, books, or tools) (h) is easily distracted (i) is often forgetful in daily activities American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association,

4 Diagnosing ADHD (2) Hyperactivity/Impulsivity: 6+ of the following for at least 6 months to an extent that is disruptive and inappropriate for the person s developmental level: (a) often fidgets with or taps hands or feet, or squirms in seat (b) often leaves seat in situations when remaining seated is expected (c) often runs about or climbs in situations in which it is inappropriate (in adolescents/adults, may be limited to feeling restlessness) (d) often unable to play or take part in leisure activities quietly (e) is often on the go or often acts as if driven by a motor (f) often talks excessively (g) often blurts out answers before questions have been completed (h) often has trouble waiting his or her turn (i) often interrupts or intrudes on others (eg. butts into converstaions or games) American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Diagnosing ADHD: Cheat Sheet 1) Poor academic performance Struggling in school 2) Inattentive Doesn t pay attention Regularly makes on assignments, chores Is not able to complete tasks due to Is not able to maintain a physically environment, often 3) Hyperactive / Impulsivity Gets in trouble often or Teacher / school complaints Regularly displays physically behavior Regularly displays verbally disruptive behavior Diagnosing ADHD A. Either (1) or (2) B. Several inattentive or hyperactive-impulsive symptoms were present before age 12 years C. Several symptoms are present in two or more settings (eg. at school/work and at home) D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. E. The symptoms do not happen only during the course of schrizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (eg. Mood, Anxiety, Dissociative, or a Personality ) American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Diagnosing ADHD Subtypes 1. ADHD, Combined Type: 6+ of both inattention and hyperactivity-impulsivity have persisted for at least 6 mos. - accounts for most children and adolescents 2. ADHD, Predominantly Inattentive Type - may still have significant clinical features of hyperactivity, but does not meet criteria 3. ADHD, Predominantly Hyperactivity-Impulsivity Type - may still have significant clinical features of inattention, but does not meet criteria - children tend to act immaturely, no set physical boundaries, exhibit destructive behavior Fluidity American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Diagnosing ADHD: Screeners Vanderbilt Tool ens%20health/adhd/res ources/ vanderbilt%20assessme nt%20scales Differential Diagnosis of ADHD What lab and imaging testing to do? NONE (usually) Consider sleep studies, lead level, TSH, neuroimaging, EEG if warranted based on specific H&P findings, but NOT routinely needed 4

5 Differential Diagnosis of ADHD Differential Diagnosis of ADHD ADHD Mood disorder (esp. bipolar) Anxiety disorder Personality disorder Substance abuse (20 40% coexisting) Oppositional defiant or conduct disorder Dissociative disorder or Psychotic disorder (schizophrenia) Learning (late 90s NIH Age appropriate behaviors in active Mental retardation (adjust behavior Understimulating environments survey says 50% of kids < 11 with children for child s mental age) (children with high intelligence) ADHD also have learning disorder) Stereotypic Movement s with repetitive motor behavior Use of certain medications: (more focused and fixed, like body rocking and self biting, as opposed Bullying / victim of bullying Victim of sexual abuse bronchodilators, isoniazid, to fidgetiness/restlessness) akasthesia from neuroleptics Up to 50% of ADHD pts. with coexisting Tic disorders American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7):894Y921. Disruptive, Impulse Control, and Conduct s MID POINT FOR Q/A Oppositional Defiant Intermittent Explosive Kleptomania Pyromania Conduct Antisocial Personality Poll Question 3 What can we expect about Jimmy s ADHD as he grows? his father asks. Which of the following is true? A. The high school drop out rate for kids with ADHD more than triples compared to those without. B. Up to 85% of adults diagnosed as children still meet criteria of ADHD. C. Adults diagnosed with ADHD as children are twice as likely to be unemployed. D. Children who are given ADHD medication are twice as likely to abuse substances as adults vs. those with ADHD who did not take medication Natural History of ADHD Toddlers Early Childhood 3 year olds can sit through picture 1 st diagnosed in elementary school books Inattentive often missed Stable until adolescence 5

6 Natural History of ADHD: Adolescents Natural History of ADHD: Adults ADHD Most still symptomatic Less hyperactive Outcomes 25 33% high school drop out rate (1 9% controls) 15% bachelors completion rate (50% controls) More teen pregnancies ADHD 40% young adults still meet criteria 90% had 5 symptoms + low Global Functioning score Employment Lower status jobs Poorer performance evals Avoid desk jobs Life More marital difficulties More injuries and accidents 2 fold increase in arrest rates by age 21 Mental Health Antisocial Personality (12 23% vs. 2 3%) Nearly 2 times LESS substance abuse in those who received stimulants Treatment of ADHD: Long-Term Benefits? Study looked at > 400 youth with ADHD on long-term medical therapy and looked 6 to 8 years later: No difference between randomly assigned tx groups in 21 outcome measures (ADHD symps. reported by parents or teachers, grades earned, arrests, ODD symps. reported by parents or teachers, car accidents/tickets, etc.) Regardless of treatment assigned, ADHD kids did significantly worse on 19 of the 21 outcomes (not anx. and accident/tickets) Other studies showed some long-term benefits Improvement on some academic factors (such as reading skills) Less risk of ODD, CD, depression, anxiety, substance abuse Mostly male sample Poor long-term compliance: decr. medication by 62% after 14-mos. Symptom trajectory in first 3 years predicted 55% of the long-term outcomes Benefits of treatment sustained only with sustained treatment effort, resources, etc. Treatment of ADHD: Algorithm 2. Atomoxetine (Straterra) 1. Stimulants 3. Combo? Molina, BS, et. al. The MTA at 8 years: Prospective follow-up of children treated for combined-typed ADHD in a multisite study. J. Am. Acad. Child and Adolesc. Pyschiatry, 48:5, May 2009, Charach A, et. al. Attention Deficit Hyperactivity : Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44. AHRQ Publication No. 12-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality. October Refer? 5. Other: Buproprion (wellbutrin), tricyclics, etc. Treatment of ADHD: Consider Referral Younger than 6 years old Comorbid psychiatric conditions (oppositional defiant, conduct disorder, substance abuse, emotional problems) Comorbid neurological conditions (seizure disorder, Tourette s, Pervasive Developmental Delay) Lack of response to stimulant and atomoxetine Case Scenario 2 Maria is a 15 year old sophomore seen at the high school health center you staff. The main reason for her visit is to start OCPs. You conduct a full HEADDSS assessment and the main concern noted is her worsening academic performance. I was doing fine through Junior High, but there is just so much going on with my classes that I can t keep organized and concentrate during and after school! After a thorough history and physical, you don t believe that there are any comorbid conditions. Her mother joins her for a follow up appointment, confirms difficulties with attention at home (such as completing chores, having a disorganized desk, etc.). You diagnose her with inattentive type ADHD and discuss treatment options. 6

7 Treatment of ADHD: Stimulants Methylphenidate (MPH) and Amphetamine (AMP) Most evidence for efficacy and safety (50 years of use) Efficacy: Symptoms reduction in approximately 70-90% Both subtypes equally as effective Mechanism of action: Increased release of dopamine and NE from synapses at brain stem, midbrain, and frontal cortex increased attention span and concentration Stimulants: Short vs. Long Acting Short-acting is best for small children (< 16kg) since no long-acting dosage available Long-acting is as effective as matched multiple doses of immediate-release Also makes substance abuse less likely Can combine short- and long-acting for greatest efficacy American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7):894Y921. Pliszka, Steven R., et. al. The Texas Childen s Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc.Psychiatry, 45:6, June 2006, Treatment of ADHD: Stimulants, Specific Medications MPH (short, 3-4 hours): Ritalin, Methylin Start 5mg BID, usually need 10-20mg BID-TID MPH (long, 6-10 hours): Concerta start 18mg QAM, increase 18mg weekly, usually need 18-54mg QAM Ritalin start 20mg daily, usually need 20-40mg daily Daytrana patch worn 9 hours a day (start 10mg, up to 30mg) AMP (intermediate, 3-4 hours up to 6): Adderall (mixed salts = dextroamphetamine / amphetamine); Dexedrine (dextroamphetamine, single salt) Start 5mg daily or BID, usually need 5-30mg daily or 5-15mg BID AMP (long, 6-10 hours): Adderall XR; Dexedrine SR; Vynase Start 10mg QD, up to 30mg QD Treatment of ADHD: Stimulants, Specific Medications MPH (short, 3-4 hours): Ritalin, Methylin Start 5mg BID, usually need 10-20mg BID-TID MPH (long, 6-10 hours): Concerta start 18mg QAM, increase 18mg weekly, usually need 18-54mg QAM Ritalin start 20mg daily, usually need 20-40mg daily Daytrana patch worn 9 hours a day (start 10mg, up to 30mg) AMP (intermediate, 3-4 hours up to 6): Adderall (mixed salts = dextroamphetamine / amphetamine); Dexedrine (dextroamphetamine, single salt) Start 5mg daily or BID, usually need 5-30mg daily or 5-15mg BID AMP (long, 6-10 hours): Adderall XR; Dexedrine SR; Vynase Start 10mg QD, up to 30mg QD Poll Question 4 What are the side effects of stimulants? Maria asks you. A. Stimulants use often result in shorter height B. Stimulants often cause drowsiness C. Stimulants often cause a decrease in appetite D. Stimulants often decrease the heart rate and blood pressure Treatment of ADHD: Stimulants, Adverse Effects Quality Short duration, dose dependent Less in older kids Common Appetite Weight Sleep Less Common HR, BP Headaches, stomach discomfort Social withdrawal, irritability Growth Treatment of ADHD: Stimulants, Adverse Effects CVS Screen for family hx No EKG needed! Psychiatric Hallucinations / Delusions Mania Motor Tics Tic disorder 7

8 Treatment of ADHD: Stimulants, How to Use Treatment of ADHD: Stimulants, How to Use Initiation Start on weekend so parents can watch for adverse effects Titrate up slowly over 2 4 weeks Should see effects immediately Periodic assessment Assess monthly with parents and teacher questionnaires as you titrate up dose Eventually change to Q 3 4 months once in maintenance stage Short acting Dose morning and noon After meals Should see effects minutes after administration Drug holidays Min Monday morning teacher reported disruption and no weekend parental affects Long acting Don t dose after noon Can combine long and short If switching, match total dose of short acting Stopping / Switching Can be d/c d all at once (no tapering needed) If one stimulant not effective (but well tolerated), try another stimulant before moving on to another class of medications Treatment of ADHD: Stimulants, Monitoring and Abuse Drug Contract Screening UDS Redirect to other classes Poll Question 5 Maria and her mom are not thrilled about taking stimulants and want more information about other options. What do you tell them about atomoxetine (Straterra)? A. Like stimulants, atomoxetine is immediate-acting and you should see the effects within an hour B. While slightly less so than stimulants, atomoxetine still harbors a significant risk for abuse C. Atomoxetine should not be combined with stimulants D. Atomoxetine causes more nausea and GI discomfort than stimulants Treatment of ADHD: Atomoxetine Not as effective as stimulants Ok for first line if active substance abuse problem, family opposition to stimulants, contraindication to stimulants, or if severe side effects from one stimulant Not a controlled substance Mechanism of action: selective NE RI Pliszka, Steven R., et. al. The Texas Childen s Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc.Psychiatry, 45:6, June 2006, Treatment of ADHD: Atomoxetine, Adverse Effects Less effects on appetite and sleep than stimulants More nausea, GI distress Monitor kids for onset of SI, especially in the first four weeks of treatment (Black Box warning) Consider checking LFTs after starting and titrating up dose American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7):894Y921. Pliszka, Steven R., et. al. The Texas Childen s Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc.Psychiatry, 45:6, June 2006,

9 Treatment of ADHD: Atomoxetine, How to Use May take up to 6 weeks to observe full effects < 70 kg start at 0.5mg/kg/D, then titrate up over 1 3 weeks to daily dose of mg/kg div daily or BID > 70 kg start at 40mg/D x 3 days, up to 80 mg after 2 4 weeks; max 100mg Initiation Dosing Drug holidays Stopping Can give in late afternoon or QHS But consider BID for most effectiveness with less side effects No! No need to titrate off medication Treatment of ADHD, Combo Can use low doses of atomoxetine with low-dose stimulants Especially good when atomoxetine fails to improve daytime symptoms as well as stimulants, but stimulants did not cover evening symptoms well Treatment of ADHD, Other Medications Poll Question 6 Guanfacine (Tenex, Intuniv) Antidepressant therapy Buproprion Tricyclics Clonidine Maria and her mom wonder about the role of behavioral therapy for ADHD. What do you tell them? A. Behavioral therapy is superior to medication for treatment of ADHD. B. Behavioral therapy with medication may help lower the total dose needed for an effective response. C. Behavioral therapy should only be used when there are comorbid mental health diagnoses. Treatment of ADHD, Behavioral Therapy Instead of medications With medications < Age 6, Comorbid mental health conditions, etc. Treatment of ADHD, Comorbid Depression / Anxiety Treat one, the other improves! MDD: SSRI or buproprion Anxiety: atomoxetine American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7):894Y921. Pliszka, Steven R., et. al. The Texas Childen s Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc.Psychiatry, 45:6, June 2006,

10 Oppositional Defiant Oppositional Defiant Conduct Antisocial Personality Disruptive, Impulse Control, and Conduct s Intermittent Explosive Kleptomania Pyromania Three types Angry/irritable mood Argumentative / defiant behavior Vindictiveness Lasts at least 6 mos, at least 4 symptoms American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Oppositional Defiant American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Oppositional Defiant Oppositional Defiant Age 8 or earlier up to adolescence 1 16% of kids Prevalence Boys > girls early More equal in older kids Most often with people he or she knows well Authority figures Questions to ask Does the child argue with adults and actively defy rules? Does the child often lose his or her temper? Does the child deliberately annoy others? Does the child often blame other people for his or her own mistakes or misbehavior? Oppositional Defiant Let the kid grow out of it? Behavioral Therapy 67% symptom free after 3 years Substance abuse Delinquency Oppositional Defiant A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/Irritable Mood Often loses temper. Is often touchy or easily annoyed. Is often angry and resentful. Argumentative/Defiant Behavior Often argues with authority figures or, for children and adolescents, with adults. Often actively defies or refuses to comply with requests from authority figures or with rules. Often deliberately annoys others. Often blames others for his or her mistakes or misbehavior. Vindictiveness Has been spiteful or vindictive at least twice within the past 6 months. American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association,

11 Aggression with physical harm to people / animals Conduct Serious violations of rules Conduct Deceitfulness or theft Property loss or damage Questions to screen Is the child violent or cruel toward people or animals? Is the child a bully? Has the child deliberately destroyed others property? Does the child get injured often? Does the child steal? Does the child get into serious trouble frequently? Conduct 2 10% Most remit by adulthood Middle childhood to adolescence 40% Antisocial PD Conduct A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals Often bullies, threatens, or intimidates others. Often initiates physical fights. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). Has been physically cruel to people. Has been physically cruel to animals. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). Has forced someone into sexual activity. Destruction of Property Has deliberately engaged in fire setting with the intention of causing serious damage. Has deliberately destroyed others property (other than by fire setting). Deceitfulness or Theft Has broken into someone else s house, building, or car. Often lies to obtain goods or favors or to avoid obligations (i.e., cons others). Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules Often stays out at night despite parental prohibitions, beginning before age 13 years. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. Is often truant from school, beginning before age 13 years. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Sources American Academy of Child and Adolescent Psychiatry. Facts for Families: Conduct. Aug 2013, No. 33. American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7): American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Oppositional Defiant. Psychiatry, 2007; 46(1): American Psychiatric Association: Diagnostic and Statistical Manual of Mental s, 5th edition. Arlington, VA., American Psychiatric Association, Bolea-Alamanac, Blanco, et. al. Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2014, Vol 28(3) Centers for Disease Control. ADHD: Prevalence. Access 6/5/14 Charach A, et. al. Attention Deficit Hyperactivity : Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44. AHRQ Publication No. 12-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality. October Coccaro, Emil. Intermittent Explosive as a of Impulsive Aggression for DSM-5. Am J P sychiatry ; : Millichap, JG. Etiologic classification of attention-deficit/hyperactivity disorder. Pediatrics 2008; 121:e358 Molina, BS, et. al. The MTA at 8 years: Prospective follow-up of children treated for combined-typed ADHD in a multisite study. J. Am. Acad. Child and Adolesc. Pyschiatry, 48:5, May 2009, Perou R, Bitsko RH, Blumber SJ, et al.; Centers for Disease Control and Prevention. Mental health surveillance among children United States, MMWR Surveill Summ. 2013;62(suppl 2):1035. Perrin, James, et. al. Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit/Hyperactivity. PEDIATRICS Vol. 122 No. 2 August 1, 2008 pp Practice Recommendations 1. If the Patient s Medical History Is Unremarkable, Laboratory or Neurological Testing Is Not Indicated (Sort C) 2. Stimulants should be considered the first-line of therapy for ADHD, followed by atomoxetine (Sort C) 3. If a Patient With ADHD Has a Less Than Optimal Response to Medication, Has a Comorbid, or Experiences Stressors in Family Life, Then Psychosocial Treatment in Conjunction With Medication Treatment Is Often Beneficial (Sort C) 4. Patients Treated With Medication for ADHD Should Have Their Height and Weight Monitored Throughout Treatment (Sort C) American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(7):894Y921. Bolea-Alamanac, Blanco, et. al. Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2014, Vol 28(3) Pliszka, Steven R., et. al. The Texas Childen s Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity. J. Am. Acad. Child Adolesc.Psychiatry, 45:6, June 2006,

12 Q & A CONTACT INFORMATION Ravi Grivois-Shah, MD MPH FAAFP 12