ADHD

Etiology 8.4% of children Boys>Girls Deficit of catecholamines _____ & ______________________ Decreased threshold for stimuli (_________________) Delay in self-regulation (________________, ______________________)

Clinical Manifestations DSM V Criteria Children must have at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while older adolescents and adults (over age 17 years) must present with five. While the criteria have not changed from DSM-IV, examples have been included to illustrate the types of behavior children, older adolescents, and adults with ADHD might exhibit. The descriptions will help clinicians better identify typical ADHD symptoms at each stage of patients’ lives. Using DSM-5, several of the individual’s ADHD symptoms must be present prior to age 12 years, compared to 7 years as the age of onset in DSM-IV. This change is supported by substantial research published since 1994 that found no clinical differences between children identified by 7 years versus later in terms of course, severity, outcome, or treatment response. Inattentive Hyperactivity for 6 months Impulsivity for 6 months Some symptoms present before age ___________ Present in 2 or more settings Impairment in social, academic or occupational functioning Not accounted by another Mental Illness

Diagnosis Family history Birth history G&D milestones Sleeping & eating patterns School performance Social & environmental conditions PE-R/O neurological cause

Social Implications Parents Children

Co-morbidities Co-morbidities

Therapy Environmental Behavior Diet Medications

Medications-Stimulants improve ADHD symptoms in about 70% of adults and 70% to 80% of children shortly after starting treatment. Improvements include reduced interrupting, fidgeting, and other hyperactive symptoms, as well as improved task completion and home relationships. Increase synaptic levels of dopamine & norepinephrine 2-4 weeks to titrate dose for effect Long-acting Short-acting Chewable forms Reduces interrupting, fidgeting, (hyperactive sx) Improves task completion & home relationships

Medications - Stimulants Adderall® (intermediate-acting) Adderall XR® (long-acting) Concerta® (long-acting) Daytrana® (long-acting patch) Dexedrine® (short-acting) Dexedrine® Spansule® (intermediate-acting) Focalin® (short-acting) Focalin XR® (long-acting) Metadate CD® (long-acting) Metadate® ER (intermediate-acting) Methylin™ ER (intermediate-acting) Ritalin® (short-acting) Ritalin LA® (long-acting) Ritalin SR® (intermediate-acting) Vyvanse® (long-acting)

Medications-Stimulants Adverse Effects _________________ Headaches Abdominal discomfort ___________________ Irritability Social withdrawal Lowers seizure threshold

Medications-Nonstimulants The nonstimulants are usually considered second- and third-line medications. *Not a controlled substance = less likely for abuse * increased attention span and reducing impulsive behavior and hyperactivity. Antidepressants - increase levels neurotransmitters, such as norepinephrine, serotonin, and dopamine have effects similar to other ADHD stimulant Norepinephrine reuptake inhibitor atomoxetine (Strattera) - 1-2 X a day Less potential of substance abuse Risk for ______________ Biggest side effect – _____________________ Anti-depressants Ideal for ADHD + depression not as effective as stimulants or Strattera at improving attention span and concentration. Tricyclic antidepressants: Pamelor™ (nortriptyline), Tofranil® (imipramine), and Norpramin® (desipramine)  Wellbutrin, Effexor, Monoamine oxidase inhibitors (MAOIs) 

Alpha Adrenergic Agonists use alone or with stimulant drugs can improve mental functioning as well as behavior in people with ADHD. reserved for those who respond poorly to and cannot tolerate stimulants or Strattera These drugs can rarely cause irregular heartbeats. They can lower blood pressure and slow heart rate. Extended-release meds - guanfacine (Intuniv) - clonidine (Kapvay) *used if no response to stimulants *used as adjunct for partial response to stimulants

Future substance abuse Recent research – people with ADHD had a lower incidence of substance use if treated than not treated. According to the National Institute of Drug Abuse, the answer is no. "The studies conducted so far have found no differences in later substance use for children with ADHD who received treatment and those that did not. This suggests treatment with ADHD medication appears not to affect (either negatively or positively) an individual’s risk for developing a substance use disorder." (National Institute of Drug Abuse, 2014).

Follow-up How often should we follow-up and why?

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