the attention deficit hyperactivity disorder (adhd) patient a patient-centered, evidence-based...
TRANSCRIPT
The Attention Deficit The Attention Deficit Hyperactivity Disorder (ADHD) Hyperactivity Disorder (ADHD)
PatientPatientA Patient-Centered, Evidence-Based Diagnostic A Patient-Centered, Evidence-Based Diagnostic
and Treatment Processand Treatment Process1,2,31,2,3
A Presentation for SOMC Medical EducationA Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPASeptember 17, 2010September 17, 2010
1 I intend to offer practical information you can use in your work with patients tomorrow.2Please let me know whether I succeeded on your evaluation forms.3Please stop me in the hall, contact me on Facebook or email me with any questions or suggestions for improvement.
Why is this important?
• Around 5% of young children and 4% of adults struggle with ADHD.
• These patients are impaired (in at least two settings) from inattention, hyperactivity or impulsivity.
• These children and adults underperform, and they place great demands on their families, teachers and coworkers.
• ADHD and its treatment are controversial, but early recognition and successful treatment can make a huge difference in these sufferer’s lives—and in the lives of those closest to them.
• After listening to this presentation, you will be able to answer the following questions:– Why is this important?– How do these patients
present?– What are the
diagnostic criteria?– What is the differential
diagnosis?– What is the treatment?– What are some of the
treatment challenges?1
1 Refer to the presentation notes for additional information.
How do these (adult) patients present?1
• “I’m frustrated with myself.”
• “I can’t get anything done.”
• “I just can’t stay focused.”
• “I can’t finish anything.”
• “I’ve been this way my whole life.”
• “I thought this was just my personality.”
• “My brother acts the same way, and the doctor started him on some medication that he says has really helped.”
• “I lose important stuff all the time.”
• “My boss tells me I have to pay attention; I try but my mind just wanders.”
1 Here are a few patient stories on YouTube.
What are the diagnostic criteria?1,2,3
• Attention Deficit– Often fails to pay
attention to details– Often cannot sustain
attention– Often does not
appear to listen– Often does not
follow through– Often disorganized– Often avoids tasks
that require sustained attention
– Often is easily distracted
– Often forgetful
• Hyperactivity or Impulsivity– Often fidgets– Often leaves seat– Often appears
restless– Often has difficulty
in engaging in leisure activities quietly
– Often “on the go”– Often has trouble
waiting turn– Often interrupts or
intrudes
1 Some symptoms must be present before age 7.2There must be evidence of significant impairment.3These symptoms must not be better accounted for by another mental disorder.
What is the differential diagnosis?1,2
• Normal behavior• Pervasive Developmental
Disorder• Schizophrenia• Another Psychotic Disorder• Mood Disorder• Anxiety Disorder• Dissociative Disorder• Personality Disorder• Intoxication• Withdrawal
1Patients come in with whatever disorder is currently being discussed in what they are watching and reading.2A tenured professor came in to see me for his “learning disability.”
What is the treatment?
• Medication– CNS stimulants are the
first treatments of choice.
– Once-a-day dosing is preferred for obvious reasons.
– These drugs are usually safe and effective.
– Common side effects include
• Decreased appetite• Insomnia• Headache
• Psychotherapy– Obtain a careful history
from the patient and social networks.1,2
– Provide practical education.
– Stress that medication alone is usually not sufficient.
– Suggest social skills training for children.
– Explore the child’s feelings.
– Recommend parental training.
– Suggest the design and implementation of a reasonable structure.
– Recommend reputable self-help groups.
– Use the Internet.1 I depend a great deal on the reports of family members.2I asked a wife to send in a list of exactly what behaviors had improved on medication.
What are some of the treatment challenges?
• Parents (and adult) patients can be demanding of a miracle cure.
• A dispassionate comparative history may be difficult to obtain.
• Unrealistic expectations for a pill fix are common.
• The temptation to prescribe too quickly is great.1
• The effect of advertizing on the public is great.
• Anti-medication advocates may put the child’s learning at risk.
• This disorder is often used as an excuse for bad behavior; some will expect you to collude in this fraud.
• As always, motivation—or the lack of it—is a key factor in how things turn out.
1 A man came in requesting that I change his antidepressant to the one his daughter was selling.
The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking
some routine demographic questions.
• Ask me to list all of problems and concerns.
• Using my problem list as a guide, ask me clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.
• Ask about my family and social histories.
• Clarify my pertinent medical history.
• Perform an appropriate mental status examination.
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.
• Reassure me.• Outline your recommended
treatment plan while making sure that I understand.
• Repeatedly invite my clarifying questions.
• Be patient with me.• Provide me with the
appropriate educational resources.
• Invite me to call you with any additional questions I may have.
• Make a follow up appointment.• Communicate with my other
physicians.
1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.
Where can you learn more?
• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000
• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081
• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072
• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005
• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093
• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008
• Median, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008
• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
• Jacobson and Jacobson, Psychiatric Secrets, 2nd Edition, 2001
Where can you find evidence-based information about mental disorders?1
• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.
• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.
• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.
How can you contact me?1
Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center
Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.
1805 27th Street1805 27th StreetWaller BuildingWaller Building
Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662
740.356.8153740.356.8153
[email protected] [email protected] [email protected]@yahoo.com
www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com
1Speaking and consultation fees benefit the SOMC Endowment Fund.
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