ADHD and Psychopharmacology By Monica Robles M.D

ADHD: prevalence and treatment Recent studies suggests that ADHD is under diagnosed in the US 1300 children were interviewed in 4 US communities 5% met criteria for ADHD Only 14% of them had been treated with medication in the past 12 months

Pharmacotherapy ADHD It is the cornerstone of treatment Decision to treat should be based on severity of symptoms

Impairment related to ADHD Psychiatric comorbidity School failure Peer relationship dysfunction Legal difficulties Smoking and substance abuse Accidents and injuries Family conflict Parent stress

MTA study 579 kids ages 7-9 with ADHD were studied for 14 months 1.Medication management by child psychiatrist 2.Behavioral therapy 3.Combination of medication and therapy 4.Community visits with the pediatrician

Results MTA study All the treatment groups were effective BUT MEDICATION MANAGEMENT ALONE BETTER THAN COMBINATION

Summary of the study Well delivered medication may be enough for the treatment of ADHD Behavioral management is also an acceptable method for those who prefer not to use medication

ATTENTION: ask for therapy Parent-child conflict or family stress Serious academic difficulties Social skills Anxiety symptoms or depression Oppositional or aggressive symptoms If the family wants it.

ADHD pharmacotherapy ADHD has largest body of data of any medication treatment for childhood psychiatric disorder

What do stimulants do Improve core symptoms of ADHD  inattention  Impulsivity  hyperactivity

What do stimulants do noncompliance Impulsive aggression Social interaction Academic efficiency Academic accuracy Enhanced vigilance Improve reaction time Improve short term memory

Stimulants: mechanism of action They work inside of our brain controlling release of neurotransmitters and inhibiting reuptake

Stimulants Methylphenidate Amphetamine preparations

Stimulants Short-acting Focalin, Methylin, Ritalin Intermediate-acting Metadate ER and CD, Methylin ER,Ritalin LA and SR Long-acting Concerta, Focalin XR and Daytrana

Stimulants: amphetamine Short-acting Adderall, Dexedrine, Dextrostat Long-acting Adderall XR, Dexedrine Spansule, Vyvanse

Stimulants(adverse effects) Use caution in hx of drug dependency and alcoholism Serious cardiac history history of psychotic symptoms or bipolar disorder

Stimulants side effects Decrease appetite Gastrointestinal problems

Stimulants side effects Headache

Stimulants side effects Sleep difficulties

Stimulants side effects Jitteriness Irritability Anxiety Depression

Stimulants side effects Psychosis and paranoia

Stimulants side effects Tics or abnormal movements

Stimulants side effects Nail biting Skin picking

Stimulants side effects Rebound

Stimulants side effects Cardiac side effects 1.Increases blood pressure 2.Cardiac complications

Areas of concern and controversy When to do EKG Family history of sudden death Personal history of congenital cardiac defects syncope,CP, palpitation or increase BP

Stimulants side effects Growth Effects Adult height appears to be uncompromised

Abuse potential of stimulants No scientific data that ADHD children abuse meds when appropriately administered.

Alternatives to stimulants Around 15% nonresponders Intolerable side effects Symptom rebound Complicated ADHD with comorbidity.

Alternatives to stimulants Atomoxetine(Strattera) Tricyclic antidepressants Clonidine and guanfacine Bupropion Others

Atomoxetine Approved by FDA 2002 Non stimulant med approved for kids and adults Selective NE reuptake inhibitor Minimum abuse potential

Atomoxetine side effects Appetite suppression Sleep disturbance Jitteriness and irritability NAUSEA Small increase of pulse and Blood pressure

Black Box warning Hepatitis( 2 cases) Notify doctor if: dark urine, abdominal pain, yellow skin or eyes. Suicidality

Atomoxetine benefits It lasts all day Little or no rebound No abuse potential

Non-pharmacological treatment Education and Support: parent centered advocacy groups such as CHADD Decrease stimulation and increase structure School intervention Parent therapy/guidance (behavioral) Social skills therapy

School intervention Evaluate for comorbid learning disabilities Provide special education support Classroom accommodations Resource room if needed( smaller classroom) Aides in the class Individual tutoring

Psychosocial therapy Child’s ADHD symptoms are mild with minimal impairment Uncertainty of ADHD diagnosis Marked disagreement about ADHD diagnosis Preference of the family Presence of comorbid disorders or problems that usually respond to therapy Family problems need to be address

Summary :ADHD treatment We need to recognize ADHD as a chronic disorder Define the target behaviors Create an alliance that will include patient/parents/teacher and clinician Provide patient and parents education about ADHD Make a rational decision about the use of medication Include psychosocial therapy when needed SYSTEMATIC MONITORING, REVIEW and FOLLOW UP