CHILD ADOLESCENT ADHD SYMPTOMS, DIAGNOSIS AND TREATMENT

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CHILD ADOLESCENT ADHD SYMPTOMS, DIAGNOSIS AND
TREATMENT

• John R. Sealy, M.D., D.L.F.A.P.A.
• SEPTEMBER 15, 2009

2
DISCLOSURES

• Speaker for McNeil, Shire
• Own stocks in Johnson and Johnson, Shire, Novartis

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WHAT IS ADHD?

• ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
  (ADHD) IS A COMMON CHRONIC PERSISTENT
  NEUROBEHAVIORAL DISORDER WITH ONSET OF SYMPTOMS
  BEFORE AGE 7, DEVELOPMENTALLY INAPPROPRIATE
  LEVELS OF INATTENTION AND/OR HYPERACTIVITY AND
  IMPULSIVITY AND
  CLINICALLY
  SIGNIFICANT IMPAIRMENT IN 2 OR MORE SETTINGS (AT
  SCHOOL, AT HOME, AND IN PEER SETTINGS)

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HYPERFOCUS ON THE FLIP SIDE, THE HALLMARK
SYMPTOM OF ADHD IS THE PHENOMENON OF INTERESTED
BASE PERFORMANCE. THAT IS, PEOPLE WITH ADHD CAN
PERFORM AT A VERY HIGH LEVEL AS LONG AS THEY FIND
THE WORK INTERESTING, CHALLENGING AND NOVEL 1
1.Flippin, R., Breaking the Spell of Hyperfocus,
ADDitude. 2005 Oct/Nov33-34
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HYPERFOCUS

• HYPERFOCUS CAN BE SO STRONG AT TIMES, THAT AN
  ADHD PERSON CAN BE OBLIVIOUS TO THE WORLD AROUND
  THEM, EG. VIDEO GAMES, TV, SHOPPING, SURFING THE
  INTERNET
• HOURS CAN DRIFT BY AS IMPORTANT TASKS AND
  RELATIONSHIPS FALL BY THE WAYSIDE
• 1.Flippin, R., Breaking the Spell of Hyperfocus,
  ADDitude. 2005Oct/Nov33-34

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ADHD IS BETTER SEEN AS A DISREGULATED ATTENTION
SYSTEM

• LIKE DISTRACTIBILITY, HYPERFOCUS HAS BEEN THOUGHT
  TO RESULT FROM ABNORMALLY LOW LEVELS OF DOPAMINE
  IN THE PRE-FRONTAL CORTEX. NEW EVIDENCE SUGGESTS,
  NOREPINEPHRINE LEVELS ALSO PLAY AN IMPORTANT ROLE
• THIS MAKES IT HARD TO SHIFT GEARS TO TAKE UP
  BORING-BUT-NECESSARY TASKS
• R. BARKLEY, PHD, AGREES THAT ADHD PEOPLE HAVE
  DIFFICULTY WITH CONTROLLED SHIFTING OF ATTENTION
  FOR ONE THING TO ANOTHER.

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IN GENERAL,CHILDREN AND ADOLESCENTS WITH ADHD

• LIVE OUTSIDE OF TIME
• LIVE IN THE HERE AND NOW
• HAVE POOR PLANNING SKILLS
• DO NOT FOCUS IN A LINEAR PROGRESSION
• HAVE POOR SHORT TERM or WORKING MEMORY

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THE PREFRONTAL CORTEX REGULATES ATTENTION,
BEHAVIOR AND EMOTION IN THREE SUB-REGIONS

• DORSOLATERAL PFC
• THE RIGHT INFERIOR PFC
• THE VENTROMEDIAL PFC

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ADHD IS SEEN AS A CHEMCIAL IMBALANCE IN
PRE-FRONTAL CORTEXAFFECTING WORKING MEMORY

• DORSO-LATERAL PFC INHIBITORY PROJECTIONS TO
  PARIETAL, TEMPORAL AND OTHER MANTLE CORTICES ARE
  THOUGHT TO REGULATE ATTENION
• 1.Chao LL, Knight RT. Neuroreport.
  199561605-1610
• 2.Woods, DL, Knight RT. Neurology. 1986
  36212-216
• 3.Wilkins, AJ, et al. Neuropsychologia.
  1987253590365
• 4.Amsten AFT, et al. J. Child Adolesc
  Psychopharmacol. 2007 17393-406

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ADHD IS SEEN AS A CHEMCIAL IMBALANCE IN
PRE-FRONTAL CORTEXAFFECTING WORKING MEMORY

• RIGHT INFERIOR PFC PROJECTIONS INTO THE MOTOR
  AND PREMOTOR CORTICES, BASAL GANGLIA AND
  CEREBELLUM VIA PONS ARE THOUGHT TO BE INVOLVED IN
• BEHAVIOR INHIBITION. IMPAIRMENT MAY LEAD TO
  SYMPTOMS OF IMPULSIVITY AND HYPERACTIVITY
• 1.Aron AR, Poldrack RA. Biol Psychiatry.
  2005571285-1292
• 2.Aron AR, et al. Trends Cogn Sci. 20048170-177
• 3.Amsten AFT, et al. J. Child Adolesc
  Psychopharmacol. 2007 17393-406

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ADHD IS SEEN AS A CHEMCIAL IMBALANCE IN
PRE-FRONTAL CORTEXAFFECTING WORKING MEMORY

• THE VENTORMEDIAL PFC IS THOUGHT TO REGULATE
  EMOTION THROUGH THE BASAL GANGLIA, AMYGDALA,
  HYPOTHALAMUS AND BRAINSTEM. IMPAIRMENT MAY LEAD
  TO AGGRESSIVE AND OPPOSITIONAL BEHAVIOR.
• 1.Anderson SW, et al. Nat Neuorsci.
  199921032-1037
• 2.Amsten AFT, et al. J. Child Adolesc
  Psychopharmacol. 2007 17393-406
• 3.Price KL, et al. Prog Brain Re.
  1996107523-536

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IMPULSIVE BEHAVIOR IN CHILD/ADOLESCENT ADHD MAY
LEAD TO

• POOR DECISION MAKING
• POOR LISTENING, TENDENCY TO INTERRUPT
• IMPULSIVE BEHAVIOR
• LOW TOLERANCE FOR FRUSTRATION, QUICK TO ANGER
• POOR PEER RELATIONSHIPS
• RECKLESS DRIVING, SPEEDING
• DIFFICULTY WAITING TURN (LINES, TRAFFIC)
• RISKY SEXUAL BEHAVIOR

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HYPERACTIVITY IN CHILD/ADOLESCENT ADHD MAY CAUSE

• FIDGETING OF HANDS AND FEET
• INNER SENSE OF RESTLESSNESS
• EXCESSIVE TALKING
• INABILITY TO SIT STILL FOR LONG PERIODS (e.g.
  THROUGH CLASSES, HOMEWORK, CONVERSATIONS.)

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INABILITY TO SUSTAIN ATTENTION IN
CHILD/ADOLESCENT ADHD MAY LEAD TO

• POOR ACADEMIC OR JOB PERFORMANCE
• DEFICIENT READING COMPREHENSION
• DISTRACTIBILITY
• INABILITY TO FOLLOW DIRECTIONS, COMPLETE TASKS
• PROCRASTINATION, TROUBLE INITIATING TASKS
• FORGETFULNESS
• UNRELIABILITY

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ADHD HISTORICAL TIMELINE

• IN 1798, CRICHTON WROTE A CHAPTER ON ATTENTION
  AND BEHAVIOR REGULATION USING ANECDOTAL
  DESCRIPTIONS OF PATIENTS WHO HAD THE FIDGETS
• 1902 PEDIATRICIAN STILL PRESENTED 3 PAPERS ON A
  ATTENTION AND EMOTIONAL DYSREGULATION IN CHILDREN
• 1971 WENDER DESCRIBED MINIMAL BRAIN DYSFUNCTION

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ADHD IN PEDIATRIC PATIENTS OFTEN PERSISTS INTO
ADULTHOOD1

• ALTHOUGH SOME SYMPTOMS (PARTICULARLY MOTOR
  HYPERACTIVITY) MAY LESSEN DURING ADULTHOOD OTHERS
  ARE OFTEN ASSOCIATED WITH IMPAIRMENTS IN
  FUNCTIONAL DOMAINS (WORK, HOME SOCIAL
  SITUATIONS)2

1.Pliska, S et al, J Am Acad Child Psychiatry
200746894-921
2. American Psychiatric Assoc. DSM IV, 4th ED,
Text Rev. Washington,DCAmerican Psychiatric
Assoc2000
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ADHD IS A VALID DIAGNOSIS

• ADULTS WITH ADHD HAD SIGNIFICANT IMPAIRMENT IN
  AUDITORY SUSTAINED ATTENTION AND EXECUTIVE
  COMPONENTS OF VERBAL LEARNING AND ARITHMETIC
  SEIDMAN ET AL (1998)
• A LARGE PERCENTAGE OF LONGITUDINAL FOLLOW-UP
  STUDIES SHOWED YOUNGSTERS CONTINUED TO HAVE
  IMPAIRING ADHD SYMPTOMS INTO ADOLESCENCE AND
  ADULT HOOD SPENCER ET AL (2002)
• ADULTS WITH ADHD HAVE A HIGH LEVEL OF POSITIVE
  RESPONSE TO THE SAME STIMULANT AND NON-STIMULANT
  TREATMENTS USED WITH CHILDREN FARAONE ET
  AL (2004)

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PREVALANCE OF ADHD

• PREVALANCE OF ADHD IS ESTIMATED AT 3 TO 7 IN
  SCHOOL-AGED CHILDREN DSM IV, 4TH ED
• UP TO 65 WILL EXHIBIT SYMPTOMS IN ADULTHOOD1
• PREVALANCE OF ADHD IN ADULTS 4.4 KESSLER ET
  AL.
• 1.DULCAN M et al, J AM ACAD CHIL ADOLESC
  PSYCHIATRY, 199736 (SUPPL)85S-121S
• 2.KESSLER ET AL, AMER J PSYCHIATRY
  2006163716-723

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ADHD HAS STRONG GENETICUNDERPINNINGS

• FAMILY STUDIES SHOW PARENTS OF ADHD CHILDREN ARE
  2 TO 8 TIMES MORE LIKELY TO HAVE ADHD THEMSELVES
  (FARAONETSUANG, 1995)
• HIGHER RATES OF ADHD AMONG RELATIVES, EVEN AS
  ADHD CRITERIA HAVE CHANGED OVER TIME (BIEDERMAN
  ET AL 1990 FAFARONE ET 2000)
• TWIN STUDIES SUGGEST APPROXIMATELY 80
  HERITABILITY FOR ADHD AND ADOPTION STUDIES SHOW
  CONSISTENTLY HEREDITY IS CENTRAL IN TRANSMISSION
  (WILENS ET AL, 2002)

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CONSEQUENCES OF UNTREATED CHILD/ADOLESCENT/ADULT
ADHD AS COMPARED WITH NORMAL CONTROLS

• MORE GRADE RETENTION (42 vs 13)
• LOWER GRADE POINT AVERAGES(1.7vs2.6)
• HIGHER DROPOUT RATES (32 vs 0)
• HIGHER SUSPENSION RATES (60 vs 19)
• LOWER COLLEGE ENTRANCE (22 vs 77)
• LOWER COLLEGE GRADUATION(5vs35)
• IN WORK FORCE, LOWER WORK PERFORMANCE, MORE
  LIKELY TO BE FIRED AND HIGHER JOB TURNOVER
• BARKLEY, R ET AL, ADHD IN ADULTS, pp 130-169
  GUILFORD PRESS 2008

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CONSEQUENCES OF UNTREATED CHILD/ADOLESCENT/ADULT
ADHD AS COMPARED WITH NORMAL CONTROLS

• 2X HIGHER RISK FOR TOBACCO SMOKING
• 2.5X HIGHER RISK FOR ALCOHOL ABUSE
• 2X HIGHER RISK FOR SUBSTANCE ABUSE
• 4X MORE LIKELY TO CONTRACT STDS
• 10X HIGHER RISK FOR UNPLANNED PREGNANCY
• 2X TO 6X HIGER RATE FOR SUSPENDED OR REVOKED
  DRIVERS LICENSE, MORE TRAFFIC VIOLATIONS,
  SPEEDING TICKETS, ACCIDENTS, AUTO DAMAGE
• BARKLEY, R ET AL, ADHD IN ADULTS WHAT THE SCIENCE
  SAYS, pp 130-169 GUILFORD PRESS 2008

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CONSEQUENCES OF UNTREATED ADULT ADHD AS COMPARED
WITH NORMAL CONTROLS

• EMPLOYERS RATE ADHD EMPLOYEES AS HAVING VERY LOW
  PRODUCTIVITY AND HIGH RATES OF ABSENTEEISM
• HIGH RATES OF MOTOR VEHICLE ACCIDENTS
• COST FOR MEDICAL CARE TWICE AS HIGH FOR ADULTS
  WITH ADHD
• INCREASED SEXUAL AND REPRODUCTIVE RISKS

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DIAGNOSIS OF ADHD
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CLINICAL DIAGNOSIS OF ADHD

• SYMPTOM ASSESSMENT IS IMPORTANT, BUT CHRONICITY,
  PERVASIVENESS, AND IMPAIRMENT ARE CRITICAL TO
  DIAGNOSIS DSM IV 4TH ED TR
• DIAGNOSIS BASED ON CLINICAL ASSESSMENT
• -MEDICAL HISTORY1
• -FAMILY HISTORY1
• -ACADEMIC, SOCIAL, OCCUPATIONAL FUNCTIONING1
• -RATING SCALES ASSIST IN ESTABLISHING SYMPTOMS1
• -INTERVIEW WITH FAMILY MEMBERS IS HELPFUL1
• 1. Adler, L, Cohen, J. Psychiatr Clin NAm.
  200427187-201

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DIAGNOSING ADHD Based on DSM-IV-TR

• DIAGNOSIS OF ADHD INCLUDES
• -6/9 INATTENTIVE AND/OR 6/9 HYPERACTIVE-IMPULSIVE
  SYMPTOMS PERSISTENT FOR AT LEAST 6 MONTHS
• -IMPAIRMENT IN MULTIPLE SETTINGS
• -CHILDHOOD ONSET BEFORE AGE 7
• -SYMPTOMS NOT BETTER ACCOUNTED FOR BY ANOTHER
  MENTAL HEALTH DISORDER
• -CLEAR EVIDENCE OF CLINICALLY SIGNIFICANT
  IMPAIRMENT IN ACADEMIC, SOCIAL, OCCUPATIONAL
  FUNTIONING

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ADHD RATING SCALES FOR CHILDREN AND ADOLESCENTS

• ACADEMIC PERFORMANCE RATING SCALE(APRS)
• ATTENTION DEFICIT DISORDERS EVALUATION SCALE-3RD
  ED (ADDES-3)PARENT TEACHER
• ADHD RATING SCALE-IV
• CHILD BEHAVIOR CHECKLIST (CBCL)
• CONNERS PARENT RATING SCALE-REVISED AND CONNER
  TEACHER RATING SCALE-REV

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ADHD RATING SCALES FOR CHILDREN AND ADOLESCENTS

• CONNERS WELLS ADOLESCENT SELF-REPORT SCALE (CASS)
• HOME SITUATIONS QUESTIONNAIRE-REVISED (HSQ-R)
  SCHOOL SITUATIONS QUESTIONNAIRE REVISED (SSQ-R)
• INATTENTION/OVERACTIVITY WITH AGGRESSION (IOWA)
  CONNERS TEACHING SCALE
• VANDERBILT ADHD DIAGNOSTIC PARENT AND TEACHER
  SCALE

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HIDDEN ADHD PRESENTATIONS

• DEPRESSION THAT DOES NOT RESPOND TO
  ANTI-DEPRESSANTS
• RELATIONSHIP COMPLAINTS
• SEVERE CLUTTER
• DRIVING COMPLAINTS
• MEMORY COMPLAINTS
• DAYDREAMER ABSENT-MINDED SELF-ESTEEM
  COMPLAINTS
• ADDICTION TO MARIJUANA, NICOTINE, CAFFEINE,
  COCAINE, ALCOHOL
• ANTISOCIAL BEHAVIOR

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BARKLEYS FINDINGS CHALLENGE THE DSM-IV

• 18 SYMPTOMS ARE NOT REQUIRED.WAS ABLE TO DX WITH
  97 ACCURACY WITH ONE ITEM OFTEN BEING EASILY
  DISTRACTED BY EXTRANEOUS STIMULI
• NEED TO SEPARATE IMPULSIVITY (ESPECIALLY VERBAL)
  AS A GREATER PROBLEM IN ADULTS
• THE CRITERION OF 7 YEARS HAS NO SCIENTIFIC MERIT
  AND SHOULD BE INCREASED TO 14-16 YEARS OF AGE.
  URGES IGNORING 7 YEAR RULE
• DSM-V MUST HAVE SEPARATE ADULT CRITERIA WITH SIX
  SYMPTOMS
• BARKLEY, R.A., MURPHY K.R. AND FISCHER M. (2007).
  ADHD IN ADULTSWHAT THE SCIENCE SAYS. NEW
  YORKGUILFORD PRESS PP 128-129

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EVALUATION OF ADHD

• RULE OUT MEDICAL/PSYCHIATRIC CONDITONS THAT
  MIMIC OR MAY BE CO-MORBID WITH ADHD
• HEAD TRAUMA/ HEARING IMPAIRMENT
• LEARNING DISORDERS
• NARCOLEPSY/ SLEEP DISORDERS/ SLEEP APNEA
• PETIT MAL SEIZURES/ ENCEPAHALOPATHY
• HYPOTHYROIDISM, HYPOGLYCEMIA
• BORDERLINE INTELLECTUAL FUNCTIONING
• PERSONALITY DISORDERS
• BIPOLAR DISORDER
• DEPRESSION/ANXIETY

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EXAMPLES OF SYMPTOMS THAT MAY MIMIC OR BE
CO-MORBID WITH ADHD

• RESTLESSNESS, IMPULSIVITY (HYPOMANIA IN
  BIPOLAR TYPE II)
• FORGETFUL, POOR CONCENTRATION, SLUGGISH (SLEEP
  DISTURBANCE, HYPOTHYROID)
• DIFFICULTY FOLLOWING DIRECTIONS, SLOW PROCESSING
  (LEARNING DISABILTIES)
• IMPATIENCE, POOR CONCENTRATION (HYPOGLYCEMIA)

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MTA COMORBIDITY WITH ADHD7-10 YEARS OLD n579

• ANXIETY DISORDERS 34
• OPPOSITIONAL DEFIANT
• DISORDER 40
• CONDUCT DISORDER 14
• TIC DISORDER 11
• MOOD DISORDER 4
• Jensen PS, Hinshaw SP, Kraemer HC, et al. ADHD
  comorbidity findings from the MTA study comparing
  comorbid subgroups. J AM Acad Child Adolesc
  Psychiatry. 200140(2)147-158

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ADHD INCREASES LIABILITY FOR OTHER PSYCHIATRIC
DISORDERS

• MORE THAN 80 OF OUR ADHD GROUPS HAD AT
  LEAST ONE OTHER DISORDER, MORE THAN 50 HAD TWO
  OTHER DISORDERS AND MORE THAN A ONE-THIRD HAD AT
  LEAST THREE OTHER DISORDERS
• BARKLEY, R.A., MURPHY K.R. AND FISCHER M. (2007).
  ADHD IN ADULTSWHAT THE SCIENCE SAYS. NEW
  YORKGUILFORD PRESS P 439

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EVALUATING LEARNING DISORDERS

• LEARNING DISORDERS (e.g. READING DISORDER)
  GENERALLY DO NOT RESPOND TO MEDICATIONS1
• NEUROPSYCHOLOGICAL TESTING EVALUATES COGNITIVE
  STRENGTHS (e.g. GIFTEDNESS) AND WEAKNESSES (e.g.
  SLOW PROCESSING SPEED AND WORKING MEMORY)
• 1. HINSHAW SP. J CONSULT CLIN PSYCHOL.
  199260(6)893-903

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EVALUATION OF SUSPECTED ADHD

• REMEMBER, ADHD SYMPTOMS UNLIKE OTHER DIAGNOSES
  ARE ALWAYS
• PERVASIVE
• PERSISTENT
• PREDICTABLE

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COMMON DIAGNOSTIC MISTAKES

• NOT TAKING ENOUGH TIME. MAY MISS IMPORTANT
  SECONDARY DIAGNOSIS
• DIAGNOSING SYMPTOMS, NOT PRIMARY PROBLEM.
  ANXIETY/ DEPRESSION MAY BE SECONDARY TO ADHD
• THINKING ACADEMIC FAILURE IS INTRINSIC TO ADHD.
  MANY CHILDREN DUE WELL BECAUSE THEY WORK SO HARD
• THINKING HIGH IQ RULES OUT ADHD. CHILD MAY BE
  LABELED LAZY, UNDISCIPLINED, BUT SUFFER ADHD OR A
  LEARNING DISORDER

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WHY GIRLS ARE MORE LIKELY THAN BOYS TO GO
UNDIAGNOSED OR MISDIAGNOSED

• YOUNG GIRLS TRY HARDER TO COMPENSATE OR COVER UP
  SYMPTOMS
• YOUNG GIRLS MORE WILLING TO PUT IN EXTRA HOURS OF
  STUDYING AND ASK FOR HELP
• MORE LIKELY TO BE PEOPLE PLEASERS
• TEACHERS OFTEN THINK ADHD IS A DISORDER OF
  HYPERACTIVITY IN BOYS
• GIRLS COMMONLY DO NOT HAVE HYPERACTIVITY AND TEND
  TO BE LABELED SPACY OR DAYDREAMERS

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ADULT ADHD CONCERNS
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BARKLEYS SUGGESTED CRITERIA FOR ADULT ADHD(AT
LEAST 4 OF THE FIRST 7 OR 6 OF 9)

• OFTEN IS EASILY DISTRACTED BY EXTRANEOUS STIMULI
• OFTEN MAKES DECISIONS IMPULSIVELY
• OFTEN HAS DIFFICULTY STOPPING ACTIVITIES OR
  BEHAVIOR WHEN HE OR SHE SHOULD DO SO.
• OFTEN STARTS A PROJECT OR TASK WITHOUT READING OR
  LISTENING TO DIRECTIONS CAREFULLY
• OFTEN SHOWS POOR FOLLOW-THROUGH ON PROMISES OR
  COMMITMENTS MADE TO OTHERS

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BARKLEYS SUGGESTED CRITERIA FOR ADULT ADHD
(CONTINUED)(AT LEAST 4 OF THE FIRST 7 OR 6 OF 9)

• 6. OFTEN HAS TROUBLE DOING THINGS IN THEIR
  PROPER ORDER OF SEQUENCE
• OFTEN DRIVES A MOTOR VEHICLE MUCH FASTER THAN
  OTHERS. FOR NON DRIVERS, OFTEN HAS DIFFICULTY
  ENGAGING QUIETLY IN LEISURE OR ENJOYABLE
  ACTIVITIES
• OFTEN HAS DIFFICULTY SUSTAINING ATTENTION IN
  TASKS OR RECREATIONAL ACTIVITIES
• OFTEN HAS DIFFICULTY ORGANIZING TASKS AND
  ACTIVITIES.
• BARKLEY RA, MURPHY KR, FISCHER M. ADHD IN
  ADULTSWHAT THE SCIENCE SAYS. NEW YORK,
  NYGUILFORD PRESS2008

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DIAGNOSTIC SCALES FOR ADULT ADHD ASSESSEMENT

• CAADID (CLINICIAN ADMINISTERED)
• BARKLEYS CURRENT SYMPTOM SCALE-SELF REPORT FORM
• BROWN ATTENTION-DEFICIT DISORDER (ADD) SCALES
  DIAGNOSTIC FORM
• TOVA

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SYMPTOM RATING SCALES ADULT ADHD

• CONNERS ADULT ADHD RATING SCALE (CAARS)
  (www.mhs.com)
• ADHD-RS-IV (18 ITEM RATING SCALE)(in syllabus
  with prompts)
• BROWN ADD SCALE (Brown ADD-RS) (pearsonassess.com)
  
• ADULT SELF-REPORT SCALE (ASRS) SYMPTOMCHECKLIST(ww
  w/med/nyu.edu/Psych/training/adhd.html) in
  syllabus

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OTHER SYMPTOM RATING SCALES ADULT ADHD

• WENDER UTAH RATING SCALE
• WENDER-REIMHERR ADULT ADD SCALE (WRAADS) ASSESSES
  MOOD LABILITY SX
• DODSON CHECKLIST FOR ADULT ADHD

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TREATMENT OF CHILD/ADOLESCENT ADHD
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STIMULANT TREATMENT

• ALTHOUGH STIMULANTS ARE TREATMENT OF CHOICE
  FOR ADHD,1 ALL CHILDREN/ ADOLESCENTS ARE UNIQUE,
  THEREFORE, THERE IS NO ONE MEDICATION THAT FITS
  ALL PATIENTS
• 1. AMERICAN ACADEMY OF PEDICATRICS PEDIATRICS
  2001, 1081033-1044

46
FDA APPROVED MEDICATIONS FOR ADHD

• METHYLPHENIDATE FAMILY
• SHORT ACTING
• RITALIN, METHYLIN, METHYLIN CHEWABLE,
  FOCALIN
• INTERMEDIATE ACTING
• METADATE ER, METHYLIN ER, RITALIN SR, METADATE
  CD, RITALIN LA
• LONG ACTING
• CONCERTA, DAYTRANA
• AMPHETAMINE FAMILY
• SHORT ACTING DEXEDRINE, DEXTROSTAT, ADDERALL,
• LONG ACTING DEXEDRINE SPANSULE, ADDERALL XR,
  VYVANSE
• NON-STIMULANTS (ATOMOXETINE)
  STRATTERA
• APPROVED FOR ADULTS
  

47
AMERICAN ACADEMY OF PEDICATRICS

• SHORT-ACTING STIMULANTS OFTEN USED AS INITIAL
  TREATMENT IN SMALL CHILDREN (lt16KG) BUT HAVE
  DISADVANTAGE OF BID OR TID DOSING TO CONTROL
  SYMPTOMS THROUGHOUT THE DAY.
• ONCE DAILY, LONG ACTING STIMULANTS ARE NOW
  RECOMMENED AS FIRST LINE MEDICATION.

48
CONCERTA

• DELIVERS METHYLPHENIDATE USING
  IMMEDIATE-RELEASE COATING AND DELAYED-RELEASE
  OSMOTIC MECHANISM
• 22 IMMEDIATE RELEASE
• 78 DELAYED RELEASE
• ONCE A DAY 12 HOUR SMOOTHER EFFECT THAN RITALIN
  BID OR TID
• LOWER ABUSE POTENTIAL

49
METADATE CD

• USES IMMEDIATE AND DELAYED RELEASE BEADS OF
  METHYLPHENIDATE WITHIN A CAPSULE TO PROVIDE 6 TO
  8 HOURS OF EFFECT
• HAS WIDE RANGE OF DOSES AVAILABLE. SOME REPORT
  FASTER ONSET OF ACTION
• HELPFUL DURING SCHOOL HOURS. SHORTER ACTING
  ALLOWS MANAGEMENT OF APPETITE SUPPRESSION/WEIGHT
  LOSS ISSUES BECAUSE DINNER HOUR IS LESS AFFECTED.

50
FOCALIN XR

• USES IMMEDIATE AND DELAYED RELEASE BEADS OF
  DEX-METHYLPHENIDATE WITHIN A CAPSULE TO PROVIDE
  10 TO 12 HOURS OF EFFECT
• D-METHYLPHENIDATE IS THE ACTIVE ISOMER OF RACEMIC
  METHYLPHENIDATE(MPH)
• TWICE AS POTENT AS METHYLPHENIDATE (WHICH HAS
  BOTH LEVO AND DEXTRO ISOMERS). USE ½ LOWER DOSING
  THAN MPH.
• 10 TO 12 HOUR EFFECT

51
DAYTRANA

• A METHYLPHENIDATE (MPH) TRANSDERMAL DELIVERY
  SYSTEM WHICH CAN PROVIDE VARIABLE DURATION OF
  EFFECT OF DELIVERY FROM 2 TO 12 HOURS WITH A 9
  HOUR WEAR TIME
• THE PATCH IS APPLIED TO ALTERNATE HIP EACH AM
  TO REDUCE COMMON ERYTHEMA/IRRITATION WITHIN THE
  PATCH SITE. REACTIONS OUTSIDE THE PATCH SITE
  SUGGEST ALLERGIC REACTION.
• HELPFUL WITH CHANGING DAILY SCHEDULES, THOSE WITH
  LATE-DAY SIDE EFFECTS, INSUFFICIENT DURATION
  EFFECT, OR GI DISEASE THAT CAN BE AGGRAVATED BY
  ORAL MPH. LOWER ABUSE POTENTIAL.

52
ADDERALL XR

• DELIVERS MIXED SALTS OF AMPHETAMINE USING
  IMMEDIATE- AND DELAYED-RELEASE BEADS WITHIN A
  CAPSULE
• 50 IMMEDIATE RELEASE
• 50 DELAYED
• DESIGNED FOR 12-HOUR EFFECT

53
VYVANSE

• DEXTROAMPHETAMINE WITH LYSINE MOLECULE
  (DEXTROAMFETAMINE) ATTACHED RENDERING IT NOT
  LIPID SOLUABLE SO IT CANNOT CROSS THE BLOOD BRAIN
  BARRIER, IN ESSENCE INERT (PRODRUG), . NO
  IMMEDIATE EFFECT IF SNORTED OR GIVEN IV. HENCE
  LOWER ABUSE RISK.
• ACTIVATED BY LYSINE REMOVAL IN BLOOD STREAM
  THROUGH RATE LIMITED HYDROLYSIS AFTER ABSORBTION
  IN GI TRACT. HENCE, A CHEMICAL VERSUS MECHANICAL
  DELIVERY .
• SMOOTHER MORE PREDICTABLE RESPONSE OVER 12 TO 13
  HOURS.
• INDEPENDENT OF PH AND MOTILITY

54
NON-STIMULANT ADHD MEDICAIONS
55
STRATTERA

• CONTINUOUS EFFECT
• NEEDS 3-6 WEEKS TO REACH BLOOD LEVEL FOR FULL
  BENEFIT.
• MUST BE INITIATED SLOWLY TO AVOID NAUSEA,
  DIZZINESS, SOMNOLENCE. BEST TAKEN AFTER FULL
  EVENING MEAL FOR MOST.
• PURELY NORADRENERGIC REUPTAKE INHIBITOR (SNRI)
  NOT CONTROLLED, HENCE, LOW ABUSE POTENTIAL.

56
INTUNIV

• GXR EXTENDED RELEASE GUANFACINE,(A SELECTIVE
  ALPHA-2-A POST SYNAPTIC AGONIST (INTUNIV) JUST
  APPROVED BY THE FDA. NOT CONTROLLED. LOW ABUSE
  POTENTIAL
• TAKES 2 WEEKS TO GAIN FULL BENEFIT
• GUANFACINE (TENEX) HAS BEEN USED OFF LABEL FOR
  MANY YEARS, BUT VERY SHORT ACTING REQUIRING
  DOSING 3-4 X PER DAY

57
SHORTER ACTING METHYPHENIDATE MEDS FOR ADHD

• METHYLPHENIDATE
• RITALIN 2-3HRS
• FOCALIN 3-4HRS
• RITALIN SR 4-5HRS
• RITALIN LA 6-8HRS

58
SHORTER ACTING AMPHETAMINE MEDS FOR ADHD

• AMPHETAMINE
• DEXADRINE 2-3HRS
• DEXADRINE SPANSULES 4-5HRS
• DESOXYN 2-3HRS
• ADDERALL (now generic) 5-6HRS

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OTHER MEDICATIONS WITH POSSIBLEBENEFITS FOR ADHD

• BUPROPION (eg.WELLBUTRIN SR)
• VENLAFAXINE (EFFEXOR XR)
• MODAFINIL (PROVIGIL)
• desipramine, nortriptyline, imipramine
• Omega fatty acids, zinc, iron

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NOVEL/INVESTIGATIONAL MEDICATION TREATMENTS FOR
ADHD

• TRIPLE BEADED MIXED AMPHETAMINE SALTS
• VENLAFAXINE (EFFEXOR)METABOLITES
• MODAFINIL METABOLITES
• NICOTINIC AGENTS

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SPECIAL CONSIDERATIONSIN PRESCRIBING STIMULANTS

• CARDIOVASCULAR RISK
• MISUSE AND DIVERSION
• BIPOLAR DISORDER

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CARDIOVASCUAR RISK

• IT IS IMPORTANT TO TAKE A DETAILED PATIENT
  CARDIAC DISEASE HISTORY.
• ASK SPECIFICALLY FOR HISTORY OF PALPITATIONS,
  SHORTNESS OF BREATH, CHEST PAIN, SYNCOPE,
  SEIZURES, POST-EXERCISE SYMPTOMS, RHEUMATIC
  FEVER, HIGH BP, HEALTH SUPPLEMENTS (EG RED BULL,
  MONSTER), MEDICATIONS

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CARDIOVASCUAR RISK

• IT IS IMPORTANT TO TAKE A DETAILED FAMILY CARDIAC
  DISEASE HISTORY.
• ASK SPECIFICALLY FOR HISTORY OF SUDDEN DEATH OR
  HEART ATTACK IN MEMBERSlt35 YEARS OF AGE, CARDIAC
  ARRHYTHMIAS, HYPERTROPHIC CARDIOMYOPATHY, LONG
  QT, BRUGADA, WOLFF-PARKINSON-WHITE OR MARFAN
  SYNDROME

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AMER ACAD PEDIATRICS 2008

• GIVEN CURRENT EVIDENCE, THE AAP ENCOURAGES
  PRIMARY CARE AND SUBSPECIALITY PHYSICIANS TO
  CONTINUE CURRENTLY RECOMMENDED TREATMENT FOR
  ADHD, INCLUDING STIMULANT MEDICATIONS, WITHOUT
  OBTAINING ROUTINE ECGS OR ROUTINE SUBSPECIALTY
  CARDIOLOGY EVALUATIONS FOR MOST CHILDREN BEFORE
  STARTING THERAPY WITH THESE MEDICATIONS

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CARDIOVASCUAR RISK

• REMEMBER, CATASTROPHIC CARDIOVASCULAR EVENTS ARE
  EXTREMELY RARE.
• EKGS WILL NOT UNCOVER STRUCTURAL ABNORMALITIES
• THE SMALL RISK IS GREATLY REDUCED BY
  PRE-TREATMENT SCREENING
• BALANCE THE RISK WITH THE SEVERITY OF ADHD
  IMPAIRMENTS SUFFERED BY THE PATIENT

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MISUSE AND DIVERSION

• MISUSE REFERS TO USAGE OF A MEDICATION WITHOUT A
  RX OR FOR REASONS THE OTHER THAN PRECRIBED
• DIVERSION MEANS DIVERTING LEGAL RX INTO ILLEGAL
  USE BY OTHER THAN THE PATIENT
• ABUSE IS TO ACHIEVE A HIGH

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MISUSE AND DIVERSION

• OVERALL, THERE WERE NO HIGHER RATES OF ABUSE AND
  THERE WAS MOSTLY REDUCED RISK FOR SUBSTANCE ABUSE
  IN TREATED ADHD PATIENTS
• STIMULANT MISUSE WAS 5 TO 35 IN COLLEGE AGE
  YOUNG ADULTS
• LIFETIME DIVERSION WAS 16 TO 29
• IMMEDIATE RELEASE STIMULANTS WERE MORE OFTEN
  ABUSED THAN LONG-ACTING STIMULANTS
• SPENCER, T.J., (2008) ADULT ADHDDIVERSION AND
  MISUSE OF MEDICATIONS
• CNS SPECT 1310(SUPPL 15)9-13

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ADHD AND DRUG USE

• PT. LIKELY TO HAVE ANTISOCIAL PERSONALITY
  DISORDER OR HISTORY OF CD
• EARLY AND AGGRESSIVE TREATMENT INTO DETOX OR
  REHAB PROGRAMS OFFERS BEST CHANCE OF SUCCESS
• IGNORING LIKELY TO RESULT IN RECURRENT TREATMENT
  FAILURES DUE TO SIGNIFICANT SELF-REGULATION
• BARKLEY, R.A., MURPHY K.R. AND FISCHER M. (2007).
  ADHD IN ADULTSWHAT THE SCIENCE SAYS. NEW
  YORKGUILFORD PRESS P 244

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GUIDELINES FOR USING STIMULANTS IN BIPOLAR
DISORDER

• START STIMULANTS ONLY WHEN BIPOLAR ILLNESS IS
  WELL-STABILIZED
• USE CAUTION USING IN MANIC OR HYPOMANIC STATES
• AVOID USING WITH SEVERE INSOMNIA, SLEEP
  FRAGMENTATION, ACTIVE SUICIDAL IDEATION OR
  PSYCHOTIC SYMPTOMS
• START DOSE LOW, GO SLOW
• SCHEDULE FREQUENT OFFICE VISITS
• GONZALEZ R. AND SUPPES T. (2008). STIMULANTS FOR
  ADULT BIPOLAR DISORDER?. CURRENT PSYCHIATRY
  733-45

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POSSIBLE HELP FOR ADHD

• EDUCATION AND SUPPORT
• COGNITIVE-BEHAVIORAL THERAPY (CBT) AUGMENTATION
• IDENTIFY SPECIFIC DISTRACTIONS AND ADJUST
  ENVIRONMENT
• PRACTICE ORGANIZATION
• CONSIDER EEG BIOFEEDBACK
• ACUPUNCTURE

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POSSIBLE HELP FOR ADHD

• HIRE AN ORGANIZATIONAL SPECIALIST OR ADHD COACH
• USE CELL PHONE CAMERA MEMORY
• JOIN CHADD
• USE DAY PLANNERS, CHECKLISTS, TIMERS, WATCHES,
  PDAS
• PERSONAL TAPE RECORDER
• MEDITATION

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SUMMARY OF TRUTHS ABOUT ADHD

• ADHD IS A CHRONIC, LIFESPAN DISORDER, NOT
  EPISODIC
• COMORBIDITY IS THE RULE, NOT THE EXCEPTION
• CHILDHOOD HISTORY MUST EXIST, ADULT ONSET OF ADHD
  DOES NOT OCCUR BY DEFINITION

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SUMMARY OR TRUTHS ABOUT ADULT ADHD

• THERE IS NO SPECIFIC TEST FOR ADULT ADHD
• GIRLS/WOMEN ARE HIGHLY UNDER-DIAGNOSED
• ADULTS WITH ADHD HAVE A HIGH LEVEL OF RESPONSE TO
  THE SAME MEDICATIONS USED IN CHILDREN
• EVERY PATIENT IS UNIQUE. NO ONE MEDICATION IS
  SUITABLE FOR ALL

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SUMMARY OR TRUTHS ABOUT ADULT ADHD

• STIMULANT THERAPY ALSO REDUCES THE RISK OF
  SUBSTANCE ABUSE IN A POPULATION AT INCREASED RISK
  FOR THIS COMORBIDITY

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POSSIBLE EXPLANATIONS FOR ADHD AND ADDICTIVE
BEHAVOIRS

• YOUNG MARIJUANA USERS OFTEN DESCRIBE A CALMING OF
  INTERNAL RESTLESSNESS (POSSIBLY THE DECAY OF
  HYPERACTIVE SYMPTOMS)
• ADULTS WITH NICOTENE DEPENDENCE WERE LESS LIKELY
  TO QUIT THAN NON-ADHD COUNTERPARTS. THEY
  DESCRIBED IMPROVED ATTENTION AND EXECUTIVE
  FUNCTIONING.

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POSSIBLE EXPLANATIONS FOR ADHD AND ADDICTIVE
BEHAVOIRS

• UNTREATED ADHD MAY LEAD TO THE FIRST STEP IN A
  SERIES OF CHANGES THROUGH AGRESSIVITY AND CONDUCT
  DISORDER TO ANTISOCIAL PERSONALITY. ONE STUDY
  SUGGESTS SUBSTANCE USE IS RELATED TO
  DEMORALIZATION AND FAILURE. (MANNUZZA,S. ARCH
  PSYCH 1986, 46(12)

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CONSEQUENCES OF UNTREATED OR UNDERTREATED ADULT
ADHD IN THE SUBSTANCE ABUSER ARE SERIOUS AND CAN
BLOCK FOCUS AND SUCCESS IN RECOVERY
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ADULT ADHD IS A EMINENTLY TREATABLE DISEASE.
PROPERLY TITRATED MEDICATIONS ALONG WITH
EDUCATION ABOUT MANAGING THE DISORDER, IMPROVES
THE LIVES OF MOST PATIENTS
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ADULT RESPONSES TO TREATMENT

• I CAN FINALLY READ A BOOK FROM START TO FINISH
• I HAVE A MUCH DEEPER RELATIONSHIP WITH MY SPOUSE
  THAN EVER BEFORE
• I CAN FALL ASLEEP AND STAY ASLEEP
• IM SOOOOOOOO MUCH MORE FOCUSED AT WORK
• OVERALL, IM A MUCH BETTER PARENT NOW

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ADULT RESPONSES TO TREATMENT

• 6. MY CREATIVITY HAS BEEN ENHANCED, NOT DAMPENED
  BY THE MEDICATION
• 7. MOST OF THE TIME I ACTUALLY KNOW WHERE MY
  CELL PHONE AND CAR KEYS ARE
• 8. IM FINALLY GETTING MY COLLEGE DEGREE
• 9. IM PROUD OF MY HOME, WHICH IS NOW MORE
  ORGANIZED THAN IT HAS EVER BEEN
• 10. IM DOING MORE ACTIVITIES THAT ARE JUST FOR
  FUN

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CHILD/ADOLESCENT ADHDSYMPTOMS, DIAGNOSIS AND
TREATMENT

• John Sealy, M.D., D.L.F.A.P.A

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THANK YOU
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