Special Feature: Q&A

We asked our participants for their insights and opinions on the impact of social and emotional impairments associated with ADHD, considerations for the patient, consequences for the payer, and cost implications across the life span. Strattera® (atomoxetine HCl) is indicated for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children age 6 and older, adolescents, and adults.

Given that many psychiatric disorders are characterized by overlapping symptoms, how important is it to consider all potential diagnoses when evaluating a patient?JY: Outpatients seeking mental health services may present with several common chief complaints. They may be anxious,

depressed, substance abusing, personality disordered, psychotic, or be suffering from dementia, attentional, or behavioral problems. It is essential for clinicians to be able to diagnose and treat all of these conditions. Many clinicians are comfortable

with SSRIs and have a tendency to over diagnose anxiety and depressive conditions, sometimes to the exclusion of other diagnoses. Many times adolescent and adult patients with ADHD have been diagnosed as having a mood disorder. The reverse is also true, but happens far less commonly.

CE: Co-morbidity is fairly common in children with ADHD, even more so in adults with ADHD. There are also many overlapping symptoms. Sometimes there may be true co-morbidity and sometimes the symptoms so strongly overlap that from

screening tools, the patient will be positive for both disorders. As practitioners, we need to take the symptoms and screen for all the related disorders to find the right diagnosis or we won’t get the maximum response to treatment. If true co-morbid disease exists, then prioritize treatment. ADHD and bipolar is a prime example. There are often clues to which is the right diagnosis even if both the Conners and the MDQ are positive. Early age of onset and consistent symptoms are more likely signs of ADHD, as opposed to intermittent symptoms or onset of symptoms later in life.

JO: The diagnosis of ADHD involves first and foremost documentation that the patient meets DSM-IV-TR criteria for the disorder. However, because many children with ADHD eventually develop at least one co-morbid psychiatric disorder, evaluation must include consideration of additional symptoms (oppositional behavior, depressed mood, anxiety, learning disabilities, sleep problems, etc) both at initial presentation and on an ongoing basis.

Why do you think so many clinicians infrequently consider ADHD in their differential diagnosis when evaluating a patient with a psychiatric disorder? How can we educate physicians to change this?JY: There seems to be a schism among clinicians with regard to the diagnosis and treatment of ADHD. Clinicians trained from

a developmental perspective such as pediatricians, child psychiatrists, and psychologists are quite sensitive to this condition,

whereas adult psychiatrists and neurologists are not exposed to ADHD in their residency training and as a result, they are far

less comfortable treating this disorder. I have been disappointed that many residencies have not added training about adolescent

and adult ADHD to their curriculum. Nearly 9% of American school-age children have ADHD; 50-70% persist into adulthood

with ADHD having impairments such as lower educational achievement, higher rates of unemployment, more tumultuous

interpersonal relationships and higher rates of co-morbid psychiatric conditions. From a basic clinical presentation and natural

history to treatment options, mood disorders are entirely different from ADHD and we need to differentiate them from one

another for these patients to be optimally served.

CE: Many practitioners still have a stereotype of ADHD patients having poor school performance with difficulty concentrating.

There is a pattern of recognition that needs to be taught to physicians in order to pick up those socially and emotionally

impaired ADHD patients. Physicians often do not associate the disturbed child or the troubled and addicted teen or the anxious

adult with ADHD. I think a campaign to educate practitioners on these patterns of recognition is essential. Keywords like

“impulsive,” “risk takers,” “drug dependant,” “defiant,” “frustrated,” and “anxious” are needed to go along with the keywords

now in use like “hyperactive” or “distracted.”

JO: Most clinicians recognize the cardinal symptoms of deficits in attention and focusing, distractibility, impulsivity, and motoric hyperactivity (when present) as essential features of ADHD. However, they are less aware that children with ADHD frequently have difficulty regulating emotion, just as they do attention and behavior. Furthermore, clinicians may not always be skilled in recognizing the manifestations of ADHD in children at different developmental levels; for example, observable behavioral hyperactivity in a five-yearold may appear quite different from the internal sense of restlessness that is the developmental equivalent in an adolescent.

What tools/screeners do you find helpful in your practice for evaluating patient for possible ADHD?JY: At their first visit, each of our outpatients receives a screening test to assess their level of anxiety, depression substance use,

and ADHD. For adults, the Adult Self Report Scale (ASRS) is a useful screening instrument. It is brief questionnaire based on

established criteria, but unlike the child focused DSM-IV-TR; the ASRS questions reflect the adult ADHD experience. Requesting collateral input about a patient from his parent or spouse is a prudent method of validating reported symptoms.

CE: I still leave the ASRS short version screeners in every exam room on the magazine racks for patients to use at their

discretion. When I have a red flag or suspicion about ADHD as the diagnosis I use the Conners. Before a practitioner can use

a screening test, there must first be some red flags in his mind that will trigger him to give the screener keywords or symptoms

that make him suspicious of the diagnosis. Also, when there is a family history of ADHD, or a co-morbid disorder currently

being treated that has overlapping symptoms, a screener should be given. There is a lot of depression, anxiety, and bipolar

being treated out there that is really ADHD. These should especially be considered for ADHD screening in those failing to

respond to treatment.

JO: There are a number of well-standardized tools (ADHD-RS, Conners questionnaires) that are helpful in gathering supportive data from a number of sources, including parents and teachers, as well as in subsequently tracking response to treatment. We use a data collection form that includes “prompts” to solicit information about domains of impairment (eg, social situations, organized sports) found frequently in children with ADHD. This form also includes a sleep screening tool we developed called the “BEARS” (B=bedtime problems, E=Excessive daytime sleepiness, A=Awakenings at night, R=Regularity

and duration of sleep, and S=Snoring), which screens for common sleep problems accompanying ADHD.

Finally, I find it quite helpful to ask the parent(s) and child to “describe a typical day”, which often elucidates issues

(difficulty getting organized in the morning, conflicts with siblings, difficulty sitting through a meal) that helps to corroborate

the diagnosis and to identify areas for further intervention.

What are some of the consequences for a patient with ADHD that can result from an incorrect or partial diagnosis? What impact can this have on the patient’s family?JY: ADHD is a common diagnosis that should always be considered when evaluating distressed patients. The majority of individuals with ADHD have co-morbid conditions—often anxiety or depression—but the reverse is true as well. For instance,

15-20% of individuals with major depression will have a comorbid diagnosis of ADHD. To obtain the best outcome, both

disorders need to be identified and treated. We have found that a number of individuals diagnosed with treatment-resistant

depression ultimately respond to antidepressant treatment once their overlooked ADHD is addressed.

CE: One of the best ways to convince parents and kids of the importance of treatment is to explain the consequences of ADHD. High school drop-out rate; college completion rate; chances of being fired or having failed marriages; the chances

of addiction and prison; teen pregnancy rate—all are negatively affected by ADHD. These real-life consequences of ADHD in

children and adolescents strike very close to home and get their attention. Treatment includes those kids who no one used to be able to stand that now people actually like to be around, or the angry and frustrated kid that now is happy and confident. Also there is the difficulty placed in the way of the functioning adult. It is when two people have the same amount of papers in their in-box and one is done in an hour and home with the family while the ADHD person takes two hours because he has to keep focusing back on his work and fighting distraction. How much is an extra hour a day worth to a high functioning person? It is the frustration of disorganization and the extra 15 minutes spent every time he goes into a department store. It may be the numerous uncompleted tasks. The consequences of ADHD have many faces.

JO: Perhaps the most obvious consequence of an incorrect ADHD diagnosis is the failure to obtain appropriate treatment.

This applies both to children with other conditions (eg, obstructive sleep apnea) who are “misdiagnosed” with ADHD and thus do not receive appropriate intervention, as well as to children who do have ADHD but are labeled instead as “lazy” or “spacey.” These scenarios not only have a clear impact on the self-esteem and quality of life of these children, but result in considerable frustration for caregivers and can erode the relationship with their child’s healthcare provider.

From a payer perspective, how might an incorrect or partial diagnosis affect the cost of treating a patient who has ADHD?JY: The failure to identify ADHD has a significant impact on the cost of treatment both emotionally and economically. Individuals with ADHD have higher absenteeism, lower productivity, and greater conflict with their employers. Inevitably, they develop impaired self-esteem and are viewed unfavorably by their family. Treatment of their ADHD including both pharmacological and psychosocial interventions seems to mitigate this effect.

CE: I know the data on bipolar diagnosis is 10 years and at least four misdiagnosis before someone finally is diagnosed for bipolar. I don’t know the data for ADHD, but I know it is missed a lot. The cost to the healthcare industry is multiple visits and misdiagnosis. The cost to society is poor work performance, addiction, unemployment, crime, etc. But the greatest cost is to the patient not reaching their potential, losing jobs, all the trouble they may have been in, family problems, disorganization, etc. This applies to both dysfunctional and high-functioning patients.

JO: Pharmacologic treatment of children with ADHD often involves a certain amount of “trial and error,” a process that

can be frustrating, time-consuming, and expensive for both caregivers and clinicians. An incorrect diagnosis, or the failure

to appreciate and target symptoms of co-morbid mood and behavioral conditions, frequently results in a further substantial

outlay of time and money spent on ineffective treatments.

How do you incorporate factors such as a patient’s behavioral symptoms, emotional and social needs, and/or co-morbid conditions into your treatment decision-making process?JY: ADHD comes in three basic variants. The least common is ADHD, predominately-hyperactive impulsive subtype. This is

most frequently diagnosed in younger male children and disruptive behavioral symptoms are the hallmark feature. More

recently, ADHD, predominately inattentive subtype has been identified. This is frequently referred to as ADD, as inattention

and distractibility are predominant, rather than hyperactivity. Girls and women are represented in the subtype. By far the

most common is ADHD, combined type and this is characterized by a mixed state of hyperactivity, impulsivity and inattention.

Although the presentation is different and they seem to afflict different groups almost all individuals with ADHD benefit

from medications and psychosocial interventions such as counseling or coaching.

CE: Those with social and emotional issues need to be screened more closely for the correct diagnosis, co-morbid disorders and overlapping symptoms. Keep following symptoms and don’t accept just improvement in some areas.

JO: It is important for clinicians to take a “big picture” approach to designing and implementing treatment strategies for children

with ADHD. This means that ADHD symptoms in a variety of settings (eg, school, home, after-school daycare, social settings)

should be considered, and that behavioral, cognitive, and affective impairments and the impact on quality of life must all be explored and addressed. Most children with ADHD benefit from a “treatment package” approach, that includes behavioral interventions; educational accommodations; social skills development programs; study, time management, and organizational skills coaching; and individual and family therapy, as well as medication.

What are some of the considerations you take into account when selecting ADHD medications?JY: The number and quality of medications available to treat ADHD patients grew significantly over the past decade and the

future looks bright for further development. Stimulant medications have long been the mainstay of ADHD pharmacology. In

the marketplace there are a number of variants of methylphenidate some short others longer acting. Commonly prescribed

methylphenidate products include Concerta^®,1 Metadate CD^®, and the skin patch, Daytrana™. A popular isomer of methylphenidate is Focalin^®1 and Focalin^® XR.1 The other major stimulants are the amphetamines (Vyvanse™1 and dextroamphetamine1) and mixed amphetamine salts (Adderall^®1 and Adderall^® XR1) which also are manufactured in short and long acting preparations. Stimulants work quickly and are effective for a full range of ADHD patients. Stimulants are controlled substances and physicians and parents may worry about diversion and misuse. The only non-stimulant currently available is atomoxetine. Atomoxetine is long-acting and has no abuse potential. As a selective norepinephrine reuptake inhibitor, it does not affect striatal dopamine and as such does not exacerbate tics. Strattera^® (atomoxetine HCl) is particularly useful in individuals with ADHD and a co-morbid anxiety, and it is important to note that Strattera is not contraindicated with anxiety. Strattera often takes 4-6 weeks to work, so it may not be a first choice in patients with acute needs or who come in with an urgent behavioral need.

How do you select medications for your patients with ADHD? What criteria do you use to match the right medication to the right patient?JO: Although treatment of ADHD does involve some element of educated guesswork, consideration of factors such as the

child’s age and developmental level (eg, ability to swallow pills), specific needs (eg, onset of treatment effect, duration of action

sufficient to cover evening homework hours), symptom constellation (eg, primarily hyperactive/impulsive vs inattentive),

drug treatment side effects (eg, somnolence, GI effect, appetite suppression, increase in anxiety), ancillary symptoms (eg, difficulty with sleep initiation), patient preference (eg, stimulant vs non-stimulant), and avoidance of specific risks associated with

medication treatment (eg, diversion) helps to highlight certain drug choices and eliminate others less likely to fit the individual

patient’s profile.

How do you evaluate whether a medication is “working? What benchmarks and/or milestones do you use when assessing treatment efficacy?JY: Patients prescribed ADHD medications should be evaluated routinely. At these regular meetings, the physician should

inquire about how the patient is feeling and how he is functioning. Specific evaluation of the patient’s focus, concentration,

productivity and energy level is in order. Ideally, the patient’s family member should have input as well. The Conners Global

Index Progress Tracking Form can be employed to help patients quantify their baseline symptoms and level of improvement.

I advise physicians never to become complacent when treating their ADHD patients. Always strive to reach a higher level

of improvement, use the medications at recommended dosages, and urge patient compliance. Some agents, particularly atomoxetine and methylphenidate, tend to be under-dosed which results in a suboptimal level of clinical benefit.

CE: To follow efficacy and determine “remission” I do the following: I have the patient list the three or four targets of treatment. These are the ADHD symptoms that are causing the most dysfunction and warrant medication. When they come back, we review those targets and I ask that they tell what percentage improvement they have had in each of the targets: 25%, 50%, 75%, or 90%. Remission to me is when all their targets are 75% or better improved.

JO: Targeting of specific symptoms, appropriate goal setting of measurable target behaviors, designation of tracking methods,

and frequent follow-up are key elements of treatment efficacy assessment. Treatment goals should be discussed and decided

upon in cooperation with the child and caregivers (eg, “what are the three things you would most like to change about your child’s behavior?”). In addition, information should be obtained from multiple sources to complete a “total picture.” For example, one goal might be that “Matt will sit at the kitchen table and complete his homework between 5 and 6PM, Monday-Thursday, without prompting; homework completion will be confirmed by his mother reviewing his assignment book, which is also checked daily by his teacher at the end of the school day.”

What are the most important factors that affect patient’s medication compliance?JY: Patients tend to benefit from simple medication regimens. Once a day medications are preferable to multiple doses. In

general, the medication should be titrated up slowly to avoid initial adverse events like delayed onset of action, dyspepsia, or

insomnia. These adverse events are usually transient and it is unfortunate to dismiss prematurely a medication that might be

helpful after the side effects clear.

CE: If it is parents giving it to kids it seems to be related to efficacy. Tolerability is a big issue especially initially. Dosing is

an issue when trying to use short acting stimulants. Cost and formulary is always an issue but seems to be less so in ADHD

than many other disorders.

JO: A given treatment may be “effective” but ultimately lack “efficacy” if certain factors interfere with the patient’s willingness

to adhere to that treatment. Compliance in ADHD treatment necessarily involves a “team” relationship, and ongoing education

of and dialog with both the patient and caregivers. In particular, children should have medication use explained to them (“this pill

will help your engine speed up and slow down when you need it to”) and should be engaged in the treatment process in developmentally appropriate ways (eg, “would you rather take your medicine before or after breakfast?”). It is important to be proactive in discussing issues that may affect compliance, such as dosing schedules, method of administration, potential side effects, and expectations regarding onset and duration of treatment effect. Caregivers may also have unrealistic expectations about what a medication can and cannot do, which must be addressed up front. Finally, patients and caregivers should be encouraged to be open with providers regarding compliance issues in a non-judgmental atmosphere that is focused on creative problem-solving.

Do you factor cost implications into your medication selection process? How does noncompliance increase long-term cost of treatment?JY: Cost factors permeate many medical decisions and it is unfortunate that many of the best medications are unavailable to many Americans. In my estimation, the treatment of ADHD is so vital to the well-being and productivity of a patient, that

compliance, safety and efficacy along with cost consideration need to be part of the medications selection process. Many of

the generic preparations need to be taken three times a day and in my clinical experience, patients have a difficulty keeping

up with this schedule. ADHD is a chronic condition and convenience may be an essential factor in choosing a medication.

Short-acting stimulants will last three to four hours, which means that if the patient takes the medication once or twice

a day most of the day he does not derive clinical benefit. We would not want to treat diabetes or hypertension part time. As

physicians have understood this phenomenon, once-a-day long-acting medications have become increasingly popular.

CE: More than cost implications, I discuss with patients the consequences of not treating ADHD. These are more encompassing than just cost, but also include the cost of not getting into remission (failure to graduate from HS, or college or excel in jobs, addiction, increased chance of trouble leading to prison, accidents, loss of jobs, divorce, etc).

JO: In the age of managed care, some practical consideration has to be given to the out-of-pocket cost of medication for families. Reduced co-payments for formulary drugs, use of sample medication, and availability of generic formulations may help

defray costs for some caregivers. If a patient is noncompliant with treatment, the clinician may draw inappropriate conclusions

regarding effectiveness, leading to multiple medication “switches” and increased costs. Non-compliant patients and families may also become discouraged about medication use in general and abandon it as a treatment option if they do not perceive a consistent benefit, potentially resulting in long-term costs to the individual’s productivity and quality of life.