1. TREATING ADHD: A Parent’s Guide
Lisa B. Campbell, MD
Medical Director, ADHD Specialty Clinic
Children’s Mercy Hospitals and Clinics

2. Things that don’t (or rarely*) cause ADHD
Sugar
Allergies
Immunizations
Food additives*
Environmental toxins*
Head injuries*

3. DSM Symptoms of ADHD Inattention
Often does not pay attention to details/ makes careless mistakes in schoolwork or other activities
Often has trouble keeping attention on tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow instructions and fails to finish schoolwork, chores, or other tasks
Often has trouble organizing activities

4. DSM Symptoms of ADHD Inattention (cont)
Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort (such as schoolwork or homework)
Often loses things needed for tasks and activities
Is often easily distracted
Is often forgetful in daily activities

5. DSM Symptoms of ADHD Hyperactivity
Often fidgets with hands or feet or squirms in seat when sitting still is expected
Often gets up from seat when remaining in seat is expected
Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless)
Often has trouble playing or doing leisure activities quietly
Is often "on the go" or acts as if "driven by a motor"
Often talks excessively

6. DSM Symptoms of ADHD Impulsivity
Often blurts out answers before questions have been finished
Often has trouble waiting turn
Often interrupts or intrudes on others

7. What is ADHD? Neurobiological disorder
Decreased activity in parts of brain that control:
Problem solving
Attention
Reasoning
Planning

8. ADHD and the Brain

9. Copyright © 2012 American Medical Association. All rights reserved.
From: Meta-analysis of Functional Magnetic Resonance Imaging Studies of Inhibition and Attention in Attention-deficit/Hyperactivity Disorder:  Exploring Task-Specific, Stimulant Medication, and Age Effects
JAMA Psychiatry. 2013;70(2): doi: /jamapsychiatry
Figure Legend:
Figure 1. Inhibition tasks and attention tasks. A, All inhibition tasks together. Regions of decreased (red and orange) and increased (blue) activation in patients with attention-deficit/hyperactivity disorder compared with healthy controls. Decreased activation in patients with attention-deficit/hyperactivity disorder relative to healthy controls is shown in the right inferior prefrontal cortex (IFC) extending into the insula, in a cluster comprising the supplementary motor area (SMA) and the cognitive division of anterior cingulate cortex (ACC), in the left caudate extending into the putamen and insula, and in the right mid-thalamus. B, Attention tasks. Decreased activation in patients with attention-deficit/hyperactivity disorder is shown in the right dorsolateral prefrontal cortex (DLPFC), in the left putamen and globus pallidus, in the right posterior thalamus (pulvinar) and caudate tail extending into the posterior insula, in the right inferior parietal lobe, and in the precuneus and superior temporal lobe. Increased activation in patients with attention-deficit/hyperactivity disorder relative to healthy controls was seen in the left cuneus and in the right cerebellum.
Date of download: 6/18/2013
Copyright © 2012 American Medical Association. All rights reserved.

11. Copyright © 2012 American Medical Association. All rights reserved.
From: Meta-analysis of Functional Magnetic Resonance Imaging Studies of Inhibition and Attention in Attention-deficit/Hyperactivity Disorder:  Exploring Task-Specific, Stimulant Medication, and Age Effects
JAMA Psychiatry. 2013;70(2): doi: /jamapsychiatry
Figure Legend:
Figure 2. Inhibition tasks. A, All inhibition tasks together, with cross sections showing regions of decreased activation in patients with attention-deficit/hyperactivity disorder compared with healthy controls. Shown are the right inferior prefrontal cortex, insula, right thalamus, left caudate, left putamen, and left insula. B. Motor response inhibition only, showing the right inferior prefrontal cortex and insula, right supplementary motor area and anterior cingulate cortex, right thalamus, left caudate, and right fusiform gyrus. C, Interference inhibition only, showing the right inferior prefrontal cortex and insula, left anterior cingulate cortex, right caudate (head), and left posterior parietal lobe and posterior insula. The right side of the image corresponds to the right side of the brain. Distance from the anterior or posterior commissure is indicated in millimeters for the z coordinate.
Date of download: 6/18/2013
Copyright © 2012 American Medical Association. All rights reserved.

13. Diagnosis of ADHD No single test or group of tests
How child is doing at home and at school academically, emotionally and socially
Rating scales
Symptoms
Performance or function
Report cards
Behavior reports
Interview

14. Treatment for ADHD Medical Behavioral Educational About ADHD
About educational interventions

15. Proven treatment for ADHD
Medication
Behavioral therapy
Gold standard= Combination of both

16. Medication Treatment for ADHD
NOT used to control behavior
Used to improve symptoms

17. Medication Treatment of ADHD
Stimulants
Methylphenidate
Amphetamine
Non-stimulants
Guanfacine/Intuniv
Clonidine/Kapvay
Atomoxetine (Strattera)

18. Medication Treatment of ADHD
One-size-fits-all approach doesn’t work
Each child’s response is individual
Medication
Dose
Side effects
More than one medication and/or dose may be tried

19. Stimulants Come in a variety of forms Tablets Chewable tablets
Capsules
Sprinkles
Liquids
Skin patches

20. Stimulants Methylphenidate Short-acting (3-4 hours) Ritalin
Methylin (tablet, chewable tablet or solution)
Focalin (dexmethylphenidate)

21. Stimulants Methylphenidate Intermediate-acting (6-8 hours) Methylin ER
Metadate ER
Ritalin SR
Metadate CD
Ritalin LA

22. Stimulants Methylphenidate Long-acting (8-12 hours) Concerta
Focalin XR (dexmethylphenidate)
Daytrana*
Quillivant XR (solution)
* Duration can be longer

23. Stimulants Amphetamine Short-acting (4-5 hours) Dexedrine
Adderall (mixed amphetamine salts)
Procentra (solution)

24. Stimulants Amphetamine Long-acting Dexedrine Spansule
Vyvanse (lisdexamfetamine)
Adderall XR (mixed amphetamine salts)

25. Stimulants
First line
Initial response rate 65-75% with single stimulant
85% if both classes tried
No difference head-to-head between classes

26. Stimulants Excellent evidence for short-term improvement Core symptoms
Academics
Efficiency and accuracy
Tasks attempted and completed
Homework completion
Behavior
Noncompliance
Aggression
Poor social interactions
Disruptive behavior
Driving performance (in lab)

27. Stimulants Longer term
F/U at 8 years (MTA study) showed no differences
Problems
Only definitely ON medication for 14 mos
Not “active” treatment data
Only 32% had taken medicine for more than 50% of the days in the previous year.

28. Stimulants Non-core symptoms may not improve Injuries
Social functioning
Educational outcomes

29. Stimulants: Side Effects
Most common
Decreased appetite and weight loss
Trouble falling asleep
Headache
Stomachache
Personality changes
Irritability
Anxiety
Cognitive dulling
Over focus
Rebound
Usually mild and respond to waiting, changes in dose, timing or type of medication

30. Stimulants: Side Effects
Heart
Pulse < 5 bpm
BP < 5 mmHg
No serious events—no increased risk of sudden unexplained death without family history
No need for EKG unless
Existing heart disease
Family history

31. Stimulants: Side Effects
Growth
Reduced growth rate first 4-12 months
Generally not significant
Responds to medication holidays or non-stimulants

32. Stimulants: Side Effects
Tics
Short-term studies don’t show significant increase in new onset or worsening of existing.
Tics may improve.
Long-term appear to be safe.

33. Non-stimulants Atomoxetine (Strattera) Antidepressant
Works 50-60% of time
Takes 6-12 weeks
Side effects
Abdominal pain/nausea/appetite loss
Sedation
Aggressive behavior
Liver toxicity
Sometimes used if co morbid anxiety or substance abuse present

34. Non-stimulants Guanfacine/Intuniv Blood pressure medication
Alone or as add-on therapy
Alone Intuniv works 40-80% of time
Adjunctive Intuniv works additional 30-40% of time
Guanfacine immediate-release (Tenex) taken 2X/day
Guanfacine XR (Intuniv) taken 1X/day
Side effects
Sleepiness/fatigue (often improves over time)
Abdominal pain
Dizziness/low blood pressure
Irritability

35. Non-stimulants Clonidine/Kapvay Blood pressure medication
Alone or as add-on therapy
Alone Kapvay works ~70 % of time
Clonidine IR (Catapress) taken 2-4 X/day
Clonidine XR (Kapvay) taken 2X/day
Side effects
Sleepiness/fatigue (often improves over time)
Headache
Abdominal pain
Constipation
Dizziness/low blood pressure

36. Nothing works? Is it really ADHD?
Could it be something else or in addition to ADHD?
Depression
Anxiety
ODD/CD
Learning disability
Is there a genetic problem with medication response?
IPTC
NEEDS BEHAVIOR THERAPY!

37. Resources: Websites
National Institute of Mental Health
CHADD
CDC
American Academy of Child and Adolescent Psychiatry
American Academy of Pediatrics
ADDvance: Answers to your Questions about ADD (ADHD)
Learning Disabilities Association of America
MPACT Parent Training and Information

38. Resources: Books and Magazines
ADHD: What Every Parent Needs to Know, 2nd Edition, American Academy of Pediatrics
Taking Charge of ADHD, 3rd edition, Russell A. Barkley, PhD