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• Review the DSM V diagnostic criteria • Review the history of diagnosis and
• Review conditions which can mimic
• Overview of treatment for the non-
• Fidgety Phil • Influenza epidemic • MBD • Large scale research- Multimodal
• DSM IV – statistical approach • DSM V – Change in age criteria before
7-12, decreased sx in adult criteria from 6-5
• Ukraine 20% of population • India 15% of population • USA 7-10% 10% NC, 12% RI, 7.5% MI • DSM V quotes 5% rate, 1973 rate quoted
which can be due to a host of environmental and cultural factors
• The rate of diagnosis has clearly increase
with 1.4% of children diagnosed in 1979 and 9.2% diagnosed in 1996.
– Changes in the law (IDEA) – Changes in disability funding – Changes in the culture with increased risk – Changes in the acceptance of diagnosis – Active promotion by drug companies
• The diagnostic criteria have changed over
the last 100 years as have the names but
• Syndrome rather than a specific entity • Multiple causes just as headaches can be
• Highly effective treatment is available • Without treatment there is serious
• Wiring Problem in the Frontal Cortex • Selective attention – dorsal anterior
• Sustained attention – dorsolateral
• Hyperactivity - prefrontal motor cortex • Impulse control - orbital frontal cortex
– Stephen Stahl. Stahl’s Essential Psychopharmacology
• Test computes the ratio of theta and beta
• Children with ADHD have a higher ratio of
• FDA approved in July of 2013 • No a stand alone test, but augments
• Adhd is a developmental failure of the
brain circuitry which monitors inhibition and self control. While many children may have 1-2 of the diagnostic symptoms, requiring the presence of 6 of 9 symptoms present before the age on 12 ( 5 sx /age17 for adults) and present in multiple settings over time effective distinguishes it from developmental issues and other diagnosis
• Bipolar Disorder • Drug Intoxication • FAS • PTSD • Traumatic Brain Injury • Learning Disabilities/MR • Thyroid Disorder • Anxiety
• Bipolar disorder – episodic • Drug intoxication – temporary • FAS - prominent language problems/ facial
• PTSD – hx associated features triggers • TBI - history • Learning disability/MR - IQ and
• Anxiety - associated symptoms MSE
• Starts before age 12 (17 for adults) • Symptoms present in 2 or more settings • Significant impairment is social academic
• 6 or more symptoms of inattention (5 for
• 6 or more symptoms of hyperactivity
• Makes careless mistakes • Difficulty sustaining attention • Does not seem to listen • Does not fol ow through on instructions • Avoids tasks that require sustained effort • Losses things • Easily distracted • Often forgetful in daily activities
• Fidgets or squirms • Leaves seat with out permission • Runs of climbs excessively • Difficulty playing quietly • On the go. Driven by a motor • Talks excessively • Blurts out answered • Difficulty taking turns • Interrupts into conversations
• There is no one set of features that can be
measured on psychological testing which wil define attention deficit disorder although it can be suggestive. One problem with IQ testing is that it does not give age of onset or impairment in multiple settings, duration or chronicity. It looks at one point in time.
• CPT best used to measure medication
response. It wil document inattention but not the cause of the inattention.
• Family history • Maternal smoking • Alcohol exposure during pregnancy • Low birth weights • Psychosocial adversity • Jaundice • Anything that interferes with brain
• Biofeedback is very promising for core sx
– Not covered by insurance in this country – Covered in Canada. Good research base
– Traditional therapy adds little to treatment of
core symptoms but may be of help with co-morbidity (MTA Study)
• 40% oppositional defiant disorder • 20% conduct disorder • 35% language disorder • 25% anxiety disorder • 25% learning disorder • 20% Mood disorder • 15% substance abuse disorder • 20% smoke cigarettes • Eating disorders in girls
Stimulants-Expect a 70% response rate. Up to 90% if wil ing to push the dose above current recommendations. Alpha Adrenergic- Catapres (clonidine), Invega (guanfacine) Noradrenergic Agents Strattera (atomoxitine) TCA’s (desipramine, imipramine)
• No one medication is superior to another,
al are equal y effective based on response percentages by class of drug
• General y stimulants are the most effective
class overal , and are more effective for hyperactivity than non-stimulants
– Vanderbilt free on line diagnostic criteria – Snap free as part of DSM V measures
medications are not addictive. They can be abused if snorted or injected, if taken in large quantities.
• No convincing evidence that stimulant
increase the rate of substance use in children with ADHD
• Treatment of ADHD decreases use of il icit
• All medications have side effects
• Oros Technology ( polymer expands to
laser dril ed whole.) The capsule does not
• The primary advantages are compliance
• Disadvantage-Must be able to swal ow
• Methodology short acting bead with 1/2
• This is the d isomer of dexedrine and it’s
dose is therefore ½ of that of dexedrine i.e. maximum dose .15 mg/kg/d. The medication has a very short ½ life which makes it useful for after school dose augmentation, but also makes it a favorite drug of abuse. Focalin LA has less abuse potential due to slower onset
• Mechanism. Causes release of long term dopamine
stores. Increases extra cel ular dopamine by blocking the
pre synaptic dopamine transport in prefrontal and striatal
areas. Also blocks nor epinephrine transport.
• Ritalin MPH dose 0.3 to 0.6mg/kg, duration of effects 3-4
• Ritalin SR, Methylin ER, Metadate ER duration of effects
6-8 hours, highly variable, cannot be chewed or crushed,
• Ritalin LA 50% immediate release 50% onset 30-60 min
duration 8 hours ok to sprinkle do not chew. Max dose
• Metadate CD 30% immediate release and
70 % delayed release onset 30-60 min and 8 hours duration. Can be used as a sprinkle. Do not chew. Max does 60mg
• Concerta 22% immediate release and
onset 30-60 min 10-14 hours duration max
• Dose conversion 5mg tid= 18mg Concerta • 10mg methylphenidate tid = 36mg
• Apply to hip for up to 9 hours duration of
• 3 hours until detectable in circulation in PK
studies. Manufacturer recommends applying 2 hours before effect needed
• Start with 10mg patch and increase by
10mg a week til effective or limited by side effects. Maximum dose 30mg patch.
• Dexedrine spansules onset 30-60 min
• Adderal onset 30-60 min duration 4-5
onset 60-90 minutes duration 10-12 hours
• Mechanism of action. Selectively binds to
dopamine transport and also to pre synaptic
neurons which induces the release of recently
formed dopamine into synapse. There is also NE
• Dextrostat approved age 3 and up*
grandfathered but no dbcs. Most researchers
prefer Ritalin which is not FDA approved due to
10 dbcs. Dose .15 to .3 mg/kg. onset 30-60 min
duration 4-5 hours more variable in very young
• Strattera .5mg/kg starting dose 1.4 mg/kg
take a month to see ful clinical effect.
• FDA approved pro drug Schedule 2. Watch for
drugs that effect the gut for unreported problems. Anything that shuts down the activating pathway wil inactivate the drug which is formed by cleaving off lysine in the gut. Excel ent choice for substance abusers or their family members. Doses are 30-50 and 70mg.
• Side effects anorexia, insomnia, headache, GI
• Stimulant class 3% develop chemical
hepatitis. Rarely used. 11/14 cases either died or required liver transplant.
• Kapvay (clonidine) alpha 2 agonist pre
synaptic- helps hyperactivity rather than
hypertension. Don’t use short acting form
• Similar mechanism to Catapres with
longer half life. In my experience is not wel tolerated in children under 40lbs. Starting dose .5mg/d guanfacine duration 6-12 hours or for brand name 1mg/d and increase by 1 mg per week
• Good evidence that TCA’s are helpful by
inhibition of nor epinephrine, but risk of accidental OD, sudden death with desipramine, and risk of inducing bipolar mood swings has limited clinical use. Starting dose is 1 mg/kg/d for imipramine.
• Mechanism- effect mainly on NE with
• Duration 4-6 hours short acting, Wel butrin
• DOSE starting 3mg/kg/d; max 6mg/kg/d.
With short acting no dose more than 150mg due to seizure risk.
• Treats co-morbid nicotine addiction
• Two studies showing effectiveness • FDA letter of approval 10-2006 • Not released due to 4% rate of skin rash with
one possible case of Stevens Johnson Syndrome
• Company withdrew application due to patent
consideration. L-isomer currently undergoing safety studies requested by FDA.
• Not effective even though it works on the
• Higher risk of side effects than other
• Cardiovascular: minimal insignificant
elevations in pulse and blood pressure short and long term. With a history of hypertension or heart disease use with caution. There is no evidence that use of stimulants causes hypertension or heart disease. FDA warning is related with syncope and sudden death associated with structural heart defects.
• Skin picking or al ergic reactions to trans-
• Can pre treat with aqueous based steroid
spray (nasal spray). Be sure to distinguish between local irritation and true drug reaction.
associated with hunger and decreased appetite. Encourage high calorie foods.
• Ask about time of day that symptoms are
most frequent, and if food makes it better.
• Monitor for height and weight. No
published guidelines but I wil not let a BMI go to 15. Many ADHD children are thin and have little physiological reserve.
• Potential y kids with ADHD have different
• Growth charts at http://www.cdc.gov/
hal ucinations, and irritability. Irritability may also be associated with medication rebound-end of day, and lack of food intake.
• Headaches and tics. MPH should be used rather
than DXT in people with tics or Tourettes,(1/3 worse, 1/3 better, and 1/3 no change.). If the headaches occurs with peak drug levels, be very suspicious. If it moves with time of administration you have confirmed medication as the cause.
• 70% of children suffer from initial insomnia
on stimulants. If severe, this wil negate
the beneficial effect of the drug. Melatonin
is an effective OTC sleep aid for children
with multiple positive studies in normal
children and ADHD children. Clonidine is
also used for initial insomnia. Children
are real y noticing sitting stil which is a
• Warning re use in children with history of
fainting, family history of sudden death or
structural cardiac defects. Screening EKG
The risk of sudden death for patients on
stimulant medications is less than that for
and dying, that it warrants caution in high
• Liver problems with impressive jaundice
10-15mg/dl range in 2 patients. Both recovered. One re chal enged and lft’s elevated.
• No recommendation for baseline labs but
patients should know the signs of liver problems, i.e. pruritis, dark urine, jaundice, RUQ pain, unexplained flu like symptoms.
• Risk is .5% above general populated as
compared to a 1-2% risk with other antidepressants. In 851 children in control NONE had suicidal thoughts which is what pushed Strattera into the statistical y significant difference range. Effect may not be real but the warning and recommendations are there for weekly follow up.
• Watch for P450 2D6 interactions with
• Highly variable metabolism with both slow
• Serious overdose with arrhythmias and
• FDA warning re increased suicidal
• Mood swings • Induction of mania • Problems with sleep and appetite less
• Use Long acting preparations • Discuss storage and safety • Parents need to supervise medication • Limit and keep track of pil s. • Use non stimulants or pro drugs for high
• Limit refil s for “lost” medication
• Monitor • Pittsburg Side Effects Scale • Informed consent
• Rating scales from teachers and or
• Observations in the office- informal and
• Tova or other continuous performance test • Task inhibition tests. I use with younger
children who wil not co-operate with digit span.
• Initial y these were introduced to limit side
effects. They are general y not recommended
since social dysfunction and family conflict are
significant parts of the il ness and they have not
been shown to be beneficial. They cannot be
easily done with Strattera since it must be
tapered and once restarted the FDA would
recommend once a week fol ow up for the first
month. By the time you do the taper and start a
month before school, there is just barely enough
time to get the child off and back on medication
• ADHD is a chronic condition • 1/3 of children may be able to do ok
• A brief trial off medication during the
basis. I do not tel the teacher and see if
they notice the difference. I do not do this
at the start of school, but after the teacher
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