Transcript adhd - LA Care Health Plan

CHILD
ADOLESCENT ADHD
SYMPTOMS, DIAGNOSIS AND
TREATMENT
John R. Sealy, M.D., D.L.F.A.P.A.
SEPTEMBER 15, 2009
DISCLOSURES
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Speaker for McNeil, Shire
Own stocks in Johnson and Johnson, Shire,
Novartis
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)
“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/Nov:33-34
HYPERFOCUS
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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. 2005;Oct/Nov:33-34
ADHD IS BETTER SEEN AS A
DISREGULATED ATTENTION
SYSTEM
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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.
IN GENERAL,
CHILDREN AND
ADOLESCENTS WITH ADHD
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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
THE PREFRONTAL CORTEX
REGULATES ATTENTION,
BEHAVIOR AND EMOTION IN
THREE SUB-REGIONS
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DORSOLATERAL PFC
THE RIGHT INFERIOR PFC
THE VENTROMEDIAL PFC
ADHD IS SEEN AS A CHEMCIAL
IMBALANCE IN PRE-FRONTAL CORTEX
AFFECTING 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. 1995;6:1605-1610
2.Woods, DL, Knight RT. Neurology. 1986; 36:212-216
3.Wilkins, AJ, et al. Neuropsychologia. 1987;25:3590365
4.Amsten AFT, et al. J. Child Adolesc Psychopharmacol. 2007; 17:393-406
ADHD IS SEEN AS A CHEMCIAL
IMBALANCE IN PRE-FRONTAL CORTEX
AFFECTING 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. 2005;57:1285-1292
2.Aron AR, et al. Trends Cogn Sci. 2004;8:170-177
3.Amsten AFT, et al. J. Child Adolesc Psychopharmacol. 2007; 17:393-406
ADHD IS SEEN AS A CHEMCIAL
IMBALANCE IN PRE-FRONTAL CORTEX
AFFECTING 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. 1999;2:1032-1037
2.Amsten AFT, et al. J. Child Adolesc Psychopharmacol. 2007; 17:393-406
3.Price KL, et al. Prog Brain Re. 1996;107:523-536
IMPULSIVE BEHAVIOR IN
CHILD/ADOLESCENT ADHD MAY LEAD
TO:
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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
HYPERACTIVITY IN
CHILD/ADOLESCENT ADHD MAY
CAUSE:
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FIDGETING OF HANDS AND FEET
INNER SENSE OF RESTLESSNESS
EXCESSIVE TALKING
INABILITY TO SIT STILL FOR LONG
PERIODS (e.g. THROUGH CLASSES,
HOMEWORK, CONVERSATIONS.)
INABILITY TO SUSTAIN ATTENTION IN
CHILD/ADOLESCENT ADHD MAY LEAD TO:
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POOR ACADEMIC OR JOB PERFORMANCE
DEFICIENT READING COMPREHENSION
DISTRACTIBILITY
INABILITY TO FOLLOW DIRECTIONS, COMPLETE
TASKS
PROCRASTINATION, TROUBLE INITIATING TASKS
FORGETFULNESS
UNRELIABILITY
ADHD HISTORICAL TIMELINE
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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
ADHD IN PEDIATRIC
PATIENTS OFTEN PERSISTS
INTO ADULTHOOD
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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 2007:46:894-921
2. American Psychiatric Assoc. DSM IV, 4th ED, Text Rev.
Washington,DC:American Psychiatric Assoc:2000
ADHD IS A VALID
DIAGNOSIS
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ADULTS WITH ADHD HAD SIGNIFICANT IMPAIRMENT IN
AUDITORY SUSTAINED ATTENTION AND EXECUTIVE
COMPONENTS OF VERBAL LEARNING AND ARITHMETIC
SEIDMAN ET AL (1998)
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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 NONSTIMULANT TREATMENTS USED WITH CHILDREN
FARAONE ET AL (2004)
PREVALANCE OF ADHD
 PREVALANCE
OF ADHD IS
ESTIMATED AT 3% TO 7% IN
SCHOOL-AGED CHILDREN
 UP TO 65% WILL EXHIBIT
SYMPTOMS IN ADULTHOOD
 PREVALANCE OF ADHD IN
ADULTS = 4.4%
DSM IV, 4TH ED
1
KESSLER ET AL.
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1.DULCAN M et al, J AM ACAD CHIL ADOLESC PSYCHIATRY, 1997:36 (SUPPL):85S-121S
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2.KESSLER ET AL, AMER J PSYCHIATRY 2006;163:716-723
ADHD HAS STRONG GENETIC
UNDERPINNINGS
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FAMILY STUDIES SHOW PARENTS OF ADHD
CHILDREN ARE 2 TO 8 TIMES MORE LIKELY TO
HAVE ADHD THEMSELVES (FARAONE+TSUANG, 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)
CONSEQUENCES OF UNTREATED
CHILD/ADOLESCENT/ADULT ADHD AS
COMPARED WITH NORMAL CONTROLS
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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(5%vs35%)
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
CONSEQUENCES OF UNTREATED
CHILD/ADOLESCENT/ADULT ADHD AS
COMPARED WITH NORMAL CONTROLS
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2X HIGHER RISK FOR TOBACCO SMOKING
2.5X HIGHER RISK FOR ALCOHOL ABUSE
2X HIGHER RISK FOR SUBSTANCE ABUSE
4X MORE LIKELY TO CONTRACT STD’S
10X HIGHER RISK FOR UNPLANNED
PREGNANCY
2X TO 6X HIGER RATE FOR SUSPENDED
OR REVOKED DRIVER’S 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
CONSEQUENCES OF UNTREATED ADULT
ADHD AS COMPARED WITH NORMAL
CONTROLS
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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
DIAGNOSIS OF
ADHD
CLINICAL DIAGNOSIS OF ADHD
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SYMPTOM ASSESSMENT IS IMPORTANT, BUT
CHRONICITY, PERVASIVENESS, AND IMPAIRMENT
ARE CRITICAL TO DIAGNOSIS DSM IV 4 ED TR
DIAGNOSIS BASED ON CLINICAL ASSESSMENT
TH
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-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. 2004;27:187-201
DIAGNOSING ADHD Based on
DSM-IV-TR
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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
ADHD RATING SCALES FOR CHILDREN
AND ADOLESCENTS
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ACADEMIC PERFORMANCE RATING
SCALE(APRS)
ATTENTION DEFICIT DISORDERS
EVALUATION SCALE-3RD ED (ADDES3)PARENT TEACHER
ADHD RATING SCALE-IV
CHILD BEHAVIOR CHECKLIST (CBCL)
CONNERS PARENT RATING SCALE-REVISED
AND CONNER TEACHER RATING SCALE-REV
ADHD RATING SCALES FOR CHILDREN
AND ADOLESCENTS
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CONNERS WELLS ADOLESCENT SELFREPORT SCALE (CASS)
HOME SITUATIONS QUESTIONNAIREREVISED (HSQ-R) SCHOOL SITUATIONS
QUESTIONNAIRE REVISED (SSQ-R)
INATTENTION/OVERACTIVITY WITH
AGGRESSION (IOWA) CONNERS TEACHING
SCALE
VANDERBILT ADHD DIAGNOSTIC PARENT
AND TEACHER SCALE
HIDDEN ADHD PRESENTATIONS
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DEPRESSION THAT DOES NOT RESPOND TO ANTIDEPRESSANTS
RELATIONSHIP COMPLAINTS
SEVERE CLUTTER
DRIVING COMPLAINTS
MEMORY COMPLAINTS
“DAYDREAMER” “ABSENT-MINDED” SELF-ESTEEM
COMPLAINTS
ADDICTION TO MARIJUANA, NICOTINE, CAFFEINE,
COCAINE, ALCOHOL
ANTISOCIAL BEHAVIOR
BARKLEY’S FINDINGS
CHALLENGE THE DSM-IV
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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 ADULTS:WHAT THE SCIENCE SAYS. NEW
YORK:GUILFORD PRESS PP 128-129
EVALUATION OF ADHD
RULE OUT MEDICAL/PSYCHIATRIC
CONDITONS THAT MIMIC OR MAY BE COMORBID 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
EXAMPLES OF SYMPTOMS THAT MAY MIMIC
OR BE CO-MORBID WITH ADHD
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RESTLESSNESS, IMPULSIVITY
(HYPOMANIA IN BIPOLAR TYPE II)
FORGETFUL, POOR CONCENTRATION,
SLUGGISH (SLEEP DISTURBANCE,
HYPOTHYROID)
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DIFFICULTY FOLLOWING DIRECTIONS,
SLOW PROCESSING (LEARNING
DISABILTIES)
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IMPATIENCE, POOR CONCENTRATION
(HYPOGLYCEMIA)
MTA COMORBIDITY WITH ADHD
7-10 YEARS OLD n=579
ANXIETY DISORDERS
OPPOSITIONAL DEFIANT
DISORDER
CONDUCT DISORDER
TIC DISORDER
MOOD DISORDER
34%
40%
14%
11%
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. 2001;40(2):147-158
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”
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BARKLEY, R.A., MURPHY K.R. AND FISCHER M. (2007). ADHD IN ADULTS:WHAT
THE SCIENCE SAYS. NEW YORK:GUILFORD PRESS P 439
EVALUATING LEARNING DISORDERS
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LEARNING DISORDERS (e.g. READING
DISORDER) GENERALLY DO NOT
RESPOND TO MEDICATIONS
NEUROPSYCHOLOGICAL TESTING
EVALUATES COGNITIVE STRENGTHS
(e.g. GIFTEDNESS) AND WEAKNESSES
(e.g. SLOW PROCESSING SPEED AND
WORKING MEMORY)
1
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1. HINSHAW SP. J CONSULT CLIN PSYCHOL. 1992;60(6):893-903
EVALUATION OF SUSPECTED ADHD
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REMEMBER, ADHD SYMPTOMS
UNLIKE OTHER DIAGNOSES ARE
ALWAYS:
PERVASIVE
PERSISTENT
PREDICTABLE
COMMON DIAGNOSTIC
MISTAKES
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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
WHY GIRLS ARE MORE LIKELY THAN
BOYS TO GO UNDIAGNOSED OR
MISDIAGNOSED
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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”
ADULT ADHD CONCERNS
BARKLEY’S SUGGESTED CRITERIA FOR ADULT
ADHD
(AT LEAST 4 OF THE FIRST 7 OR 6 OF 9)
1.
2.
3.
4.
5.
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
BARKLEY’S SUGGESTED CRITERIA FOR ADULT
ADHD (CONTINUED)
(AT LEAST 4 OF THE FIRST 7 OR 6 OF 9)
6.
7.
8.
9.
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 ADULTS:WHAT THE SCIENCE SAYS. NEW YORK, NY:GUILFORD PRESS;2008
DIAGNOSTIC SCALES FOR ADULT
ADHD ASSESSEMENT
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CAADID (CLINICIAN ADMINISTERED)
BARKLEY’S CURRENT SYMPTOM
SCALE-SELF REPORT FORM
BROWN ATTENTION-DEFICIT
DISORDER (ADD) SCALES
DIAGNOSTIC FORM
TOVA
SYMPTOM RATING SCALES ADULT
ADHD
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CONNER’S 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(www/med/nyu.e
du/Psych/training/adhd.html) in syllabus
OTHER SYMPTOM RATING SCALES
ADULT ADHD
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WENDER UTAH RATING SCALE
WENDER-REIMHERR ADULT ADD
SCALE (WRAADS) ASSESSES MOOD
LABILITY SX
DODSON CHECKLIST FOR ADULT
ADHD
TREATMENT OF
CHILD/ADOLESCENT
ADHD
STIMULANT TREATMENT
ALTHOUGH STIMULANTS ARE
TREATMENT OF CHOICE FOR
ADHD, ALL CHILDREN/
ADOLESCENTS ARE UNIQUE,
THEREFORE, THERE IS NO ONE
MEDICATION THAT FITS ALL
PATIENTS
1
1. AMERICAN ACADEMY OF PEDICATRICS PEDIATRICS 2001, 108;1033-1044
FDA APPROVED MEDICATIONS FOR
ADHD
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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
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AMPHETAMINE FAMILY
SHORT ACTING: DEXEDRINE, DEXTROSTAT, ADDERALL,
LONG ACTING: DEXEDRINE SPANSULE, ADDERALL XR*, VYVANSE*
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NON-STIMULANTS (ATOMOXETINE)
STRATTERA *
* APPROVED FOR ADULTS
AMERICAN ACADEMY OF
PEDICATRICS
“SHORT-ACTING STIMULANTS OFTEN
USED AS INITIAL TREATMENT IN
SMALL CHILDREN (<16KG) 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.”
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
METADATE CD
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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.
FOCALIN XR
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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
DAYTRANA
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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.
ADDERALL XR
DELIVERS MIXED SALTS OF
AMPHETAMINE USING IMMEDIATEAND DELAYED-RELEASE BEADS
WITHIN A CAPSULE
50% IMMEDIATE RELEASE
50% DELAYED
DESIGNED FOR 12-HOUR EFFECT
VYVANSE
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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
NON-STIMULANT ADHD
MEDICAIONS
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.
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
SHORTER ACTING
METHYPHENIDATE MEDS FOR
ADHD
METHYLPHENIDATE
RITALIN
2-3HRS
FOCALIN
3-4HRS
RITALIN SR
4-5HRS
RITALIN LA
6-8HRS
SHORTER ACTING AMPHETAMINE
MEDS FOR ADHD
AMPHETAMINE
DEXADRINE
2-3HRS
DEXADRINE SPANSULES 4-5HRS
DESOXYN
2-3HRS
ADDERALL (now generic)
5-6HRS
OTHER MEDICATIONS WITH
POSSIBLE
BENEFITS FOR ADHD
BUPROPION (eg.WELLBUTRIN SR)
VENLAFAXINE (EFFEXOR XR)
MODAFINIL (PROVIGIL)
desipramine, nortriptyline, imipramine
Omega fatty acids, zinc, iron




NOVEL/INVESTIGATIONAL
MEDICATION TREATMENTS FOR
ADHD
TRIPLE BEADED MIXED
AMPHETAMINE SALTS
VENLAFAXINE
(EFFEXOR)METABOLITES
MODAFINIL METABOLITES
NICOTINIC AGENTS
SPECIAL CONSIDERATIONS
IN PRESCRIBING STIMULANTS
 CARDIOVASCULAR
RISK
 MISUSE AND DIVERSION
 BIPOLAR DISORDER
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, POSTEXERCISE SYMPTOMS, RHEUMATIC FEVER,
HIGH BP, HEALTH SUPPLEMENTS (EG RED
BULL, MONSTER), MEDICATIONS
CARDIOVASCUAR RISK

IT IS IMPORTANT TO TAKE A DETAILED
FAMILY CARDIAC DISEASE HISTORY.
ASK SPECIFICALLY FOR HISTORY OF
SUDDEN DEATH OR HEART ATTACK IN
MEMBERS<35 YEARS OF AGE, CARDIAC
ARRHYTHMIAS, HYPERTROPHIC
CARDIOMYOPATHY, LONG QT,
BRUGADA, WOLFF-PARKINSON-WHITE
OR MARFAN SYNDROME
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 ECG’S OR ROUTINE
SUBSPECIALTY CARDIOLOGY
EVALUATIONS FOR MOST CHILDREN
BEFORE STARTING THERAPY WITH
THESE MEDICATIONS”
CARDIOVASCUAR RISK




REMEMBER, CATASTROPHIC
CARDIOVASCULAR EVENTS ARE EXTREMELY
RARE.
EKG’S 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
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”
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 ADHD:DIVERSION AND MISUSE OF MEDICATIONS
CNS SPECT 13:10(SUPPL 15)9-13
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 ADULTS:WHAT THE SCIENCE
SAYS. NEW YORK:GUILFORD PRESS P 244
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 7:33-45




POSSIBLE HELP FOR ADHD






EDUCATION AND SUPPORT
COGNITIVE-BEHAVIORAL THERAPY
(CBT) AUGMENTATION
IDENTIFY SPECIFIC DISTRACTIONS
AND ADJUST ENVIRONMENT
PRACTICE ORGANIZATION
CONSIDER EEG BIOFEEDBACK
ACUPUNCTURE
POSSIBLE HELP FOR ADHD






HIRE AN ORGANIZATIONAL
SPECIALIST OR ADHD COACH
USE CELL PHONE CAMERA MEMORY
JOIN CHADD
USE DAY PLANNERS, CHECKLISTS,
TIMERS, WATCHES, PDA’S
PERSONAL TAPE RECORDER
MEDITATION
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
SUMMARY OR TRUTHS ABOUT
ADULT ADHD




THERE IS NO SPECIFIC TEST FOR
ADULT ADHD
GIRLS/WOMEN ARE HIGHLY UNDERDIAGNOSED
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
SUMMARY OR TRUTHS ABOUT
ADULT ADHD

STIMULANT THERAPY ALSO
REDUCES THE RISK OF SUBSTANCE
ABUSE IN A POPULATION AT
INCREASED RISK FOR THIS
COMORBIDITY
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 NONADHD COUNTERPARTS. THEY DESCRIBED
IMPROVED ATTENTION AND EXECUTIVE
FUNCTIONING.
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)
CONSEQUENCES OF UNTREATED
OR UNDERTREATED ADULT ADHD
IN THE SUBSTANCE ABUSER ARE
SERIOUS AND CAN BLOCK FOCUS
AND SUCCESS IN RECOVERY
ADULT ADHD IS A EMINENTLY
TREATABLE DISEASE. PROPERLY
TITRATED MEDICATIONS ALONG
WITH EDUCATION ABOUT MANAGING
THE DISORDER, IMPROVES THE LIVES
OF MOST PATIENTS
ADULT RESPONSES TO
TREATMENT
1.
2.
3.
4.
5.
“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”
“I’M SOOOOOOOO MUCH MORE FOCUSED
AT WORK”
“OVERALL, I’M A MUCH BETTER PARENT
NOW”
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. “I’M FINALLY GETTING MY COLLEGE DEGREE”
9. “I’M PROUD OF MY HOME, WHICH IS NOW MORE
ORGANIZED THAN IT HAS EVER BEEN”
10. “I’M DOING MORE ACTIVITIES THAT ARE JUST FOR
FUN”
CHILD/ADOLESCENT
ADHD
SYMPTOMS, DIAGNOSIS AND
TREATMENT
John Sealy, M.D., D.L.F.A.P.A
THANK YOU