ADHD and Psychopharmacology

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ADHD and Psychopharmacology

• By Monica Robles M.D

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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

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Pharmacotherapy ADHD

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

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Impairment related to ADHD

• Psychiatric comorbidity
• School failure
• Peer relationship dysfunction
• Legal difficulties
• Smoking and substance abuse
• Accidents and injuries
• Family conflict
• Parent stress

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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

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Results MTA study

• All the treatment groups were effective
• BUT MEDICATION MANAGEMENT ALONE BETTER THAN
  COMBINATION

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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

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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.

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ADHD pharmacotherapy

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

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What do stimulants do

• Improve core symptoms of ADHD
• inattention
• Impulsivity
• hyperactivity

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What do stimulants do

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

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Stimulants mechanism of action

• They work inside of our brain controlling release
  of neurotransmitters and inhibiting reuptake

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Stimulants

• Methylphenidate
• Amphetamine preparations

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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

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Stimulants amphetamine

• Short-acting
• Adderall , Dexedrine, Dextrostat
• Long-acting
• Adderall XR, Dexedrine Spansule, Vyvanse

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Stimulants(adverse effects)

• Use caution in
• hx of drug dependency and alcoholism
• Serious cardiac history
• history of psychotic symptoms or bipolar
  disorder

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Stimulants side effects

• Decrease appetite
• Gastrointestinal
• problems

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Stimulants side effects

• Headache

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Stimulants side effects

• Sleep difficulties

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Stimulants side effects

• Jitteriness
• Irritability
• Anxiety
• Depression

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Stimulants side effects

• Psychosis and paranoia

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Stimulants side effects

• Tics or abnormal movements

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Stimulants side effects

• Nail biting
• Skin picking

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Stimulants side effects

• Rebound

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Stimulants side effects

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

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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
  

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Stimulants side effects

• Growth Effects
• Adult height appears to be uncompromised

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Abuse potential of stimulants

• No scientific data that ADHD children abuse meds
  when appropriately administered.

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Alternatives to stimulants

• Around 15 nonresponders
• Intolerable side effects
• Symptom rebound
• Complicated ADHD with comorbidity.

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Alternatives to stimulants

• Atomoxetine(Strattera)
• Tricyclic antidepressants
• Clonidine and guanfacine
• Bupropion
• Others

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Atomoxetine

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

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Atomoxetine side effects

• Appetite suppression
• Sleep disturbance
• Jitteriness and irritability
• NAUSEA
• Small increase of pulse and Blood pressure

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Black Box warning

• Hepatitis( 2 cases)
• Notify doctor if dark urine, abdominal pain
  , yellow skin or eyes.
• Suicidality

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Atomoxetine benefits

• It lasts all day
• Little or no rebound
• No abuse potential

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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

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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

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Psychosocial therapy

• Childs 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

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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