adhd practical point review from egypt: osha program

ADHD Practical Point review from Egypt: OSHA program : 

ADHD Practical Point review from Egypt: OSHA program Dr Husein Abdeldayem, MD,PhD Prof of Pediatric Neurology, Faculty of Medicine, Alex University ICNC international conference 2010

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A developmental disorder involving a delay in development of two traits as the child grows older In ADHD the delays occur in: Attention The child is easily distracted, finds it difficult to complete tasks and has difficulty returning to the task at hand - Activity-Impulse Control The child acts impulsively, moves and speaks rapidly and excessively, often responds or acts inappropriately ‘without thinking What is ADHD?

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DSM-IV Patient shows 6+ symptoms of either inattention or hyperactive-impulsive behaviour Symptoms are inappropriate for the patient’s age They have existed for at least 6 months They occur in more than one setting, e.g. home and school They result in impairment in major life activities Onset of symptoms producing impairment by 7 years of age Symptoms are not best explained by another disorder 3 Types: Inattentive Hyperactive Combined In Europe, another common criteria used to diagnose ADHD is ICD-10. Criteria for Diagnosing ADHD

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SELECTIVE ATTENTION DEFICIT DSM V

Rule outs for the Diagnosis of ADHD : 

Rule outs for the Diagnosis of ADHD Myth : 1- ADHD child Can do Video Games Watch TV Computers Play Sports Build Lego's

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1902 Defects in moral character 1934 Organically driven 1940 Minimal Brain Syndrome 1957 Hyperkinetic Impulse Disorder 1960 Minimal Brain Dysfunction (MBD) 1968 Hyperkinetic Reaction of Childhood (DSM II) Different Names for ADHD Through the years:

Different Names for ADHD Through the years: : 

Different Names for ADHD Through the years: 1980 ADD (DSM III) - with hyperactivity - without hyperactivity - residual type 1987 ADHD (only combined symptoms) 1994 AD/HD – 3 TYPES (DSM IV) Combined Type ( 50-70%), Inattentive type (~30%), Hyperactive-Impulsive Type (~10%)

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ADHD : Attention Disorder with or without Hypekinetic/Impulsive Disorder ASHD: Attention Selectivity HD

7-9% of children and adolescents : 

PREVALENCE 7-9% of children and adolescents

AD/HD in school aged childrenEducational disorder : 

AD/HD in school aged childrenEducational disorder For every 10 students in class: 4 with AD/HD

ADHD in Children : 

ADHD in Children More prevalent in boys 6:1, 3:1, 1:1

ADHD in Children : 

ADHD in Children Symptoms of ADHD are first seen in children before age 7

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It is important to identify and treat children with ADHD as early as possible 2y 2010

ADHD in Preschoolers : 

ADHD in Preschoolers Sleep problems Colic Constantly in motion Unresponsive to requests Trouble staying seated Demanding of attention Rapidly shift from one activity to another Resist passive activities Wander off alone Inappropriate touching/handling objects

WHY : 

WHY I AM A BUSY MOTHER WE ARE NOT A GOOD FAMILY HE IS A SPOILED BABY

Hereditary ADHD : 

Hereditary ADHD Twin. adoption

ADHD Is highly heritable : 

ADHD Is highly heritable HEIGHT ADHD SCHIZOPHRENIA IQ DEPRESSION DBH, 5HTT, SNAP-25

Recent studies suggest that causalpathways in some cases involve complex interactions betweengenetic and environmental factors. : 

Recent studies suggest that causalpathways in some cases involve complex interactions betweengenetic and environmental factors. 2009

Adult ADHD : 

Adult ADHD Family Work Friends Accident Addiction Attention-Deficit Disorder Isn't Just for Kids. Why Adults Are Now Being Diagnosed, Too Wall Street Journal April 2010

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= dopamine transporter gene (DAT1) = dopamine receptor gene (DRD) * D4 *D5 = serotonin 5HTT = others: DBH, HTR1Bm SNAP-25

ADHD is a Chemical Problem : 

ADHD is a Chemical Problem Dysfunction of dopaminergic and noradrenergic systems Dopamine and norepinephrine are important in drugs that treat ADHD In ADHD children, the rate of glucose metabolism in basal ganglions and in the frontal cortex is reduced

EF networks depends 1ry on 2 chemicals : 

EF networks depends 1ry on 2 chemicals Dopamine Norepinephrine Not release and reload effectively Medications : slow reuptake so longer in contact with receptors

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Methyl phenidate & Atomoxetene (strattera) Mode of action: – prevents the reuptake of norepinephrine into the presynaptic neuron Amphetamines: Mode of Action – causes a release of norepinephrine Pemoline, – Mode of action - unknown, but may cause an increased production of dopamine

Imaging Studies : 

Imaging Studies Reduction of total brain size Reduction of certain brain regions Decrease blood flow in the striatum Structural changes in the caudate and putamen

Where we are : 

Where we are What we don’t know? Exact Cause – Multi-factorial 1- MRI studies – Abnormalities » Pre-fontal Cortex » Basal Ganglia » Corpus Callosum 2- Brain Imaging Studies – Size difference » Cerebrum » Temporal Gray Matter » Total Volume What we do know? – Chemicals in the brain are responsible for nerve transmission. 1- Norepinephrine – Enhances alertness and info processing – Helps the mind to shift focus of attention 2- Dopamine – Along with Norepinephrine helps the brain process and respond to input data

What is ADHD ? EF : 

What is ADHD ? EF Impairment of Executive Function set and development

What is ADHD ? EF : 

What is ADHD ? EF Impairment of Executive Function set and development

Executive Function Domains : 

Executive Function Domains Planning Organizing Starting and stopping activity Managing behavior Persisting on tasks Problem solving Working memoryThese are called Executive Functions

Effects of ADHD on EF : 

Effects of ADHD on EF 1-response inhibition 2- planning 3- time response/set shifting 4- working memory 5- inner talk 6- emotional stability/lability 7- expectation

Executive FunctionsDevelopment and Demands : 

Executive FunctionsDevelopment and Demands In early childhood, others perform all executive functions for the child (parents, sibs and other caretakers) Thereafter, the child should be able (or is forced to) perform these functions for self Onset before 7

Executive Functionschallenges may reveal Weakness : 

Executive Functionschallenges may reveal Weakness EF weakness may not noticeable until one’s self-management is challenged by increased demands of adult life EEG ECG

EF networks depends 1ry on 2 chemicals : 

EF networks depends 1ry on 2 chemicals Dopamine Norepinephrine Not release and reload effectively Medications : slow reuptake so longer in contact with receptors

Why the Explosion in ADHD? : 

Why the Explosion in ADHD? There are more children now who actually have ADHD We are better at finding and helping children and adults who really do have ADHD There are more children now who actually have ADHD We have loosened the definition so more kids are being diagnosed. We are actually diagnosing many children who don’t have ADHD, even by a loosened definition.

Why the Explosion in ADHD? : 

Why the Explosion in ADHD? Less effective parenting - mother not in home, father working more. Everyone more stressed. educational curriculum and process Higher demands on children Egypt:

Recognition and Referral : 

Recognition and Referral Assessment

When are ADHDimpairments Noticeable? : 

When are ADHDimpairments Noticeable? some: preschool Some : middle elementary school Some : college or later Most in 1ry school

AIM : 

AIM DIAGNOSIS of ADHD DD of other disorders as ASD, bipolar disorder Diagnosis of other co-morbid disorders

DD for ADHD : 

DD for ADHD 1- anxiety disorders 2- conduct disorder 3- oppositional defiant disorder 4- impulse-control or mood disorders 5- learning disorders 6- mental retardation 7- gifted children 8- pervasive developmental disorders

DD for ADHD (contin.) : 

DD for ADHD (contin.) 9- depression 10-Bipolar disorders, Schizophrenia 11- Drugs : PB, CZP 12- Misfits between the child and school, or even the child and teacher. 13- substance abuse: stimulants, cocaine phenyclidine

The Diagnosis of ADHD : 

The Diagnosis of ADHD Myth : 1- ADHD child Can do Video Games Watch TV Computers Play Sports Build Leggos

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At present there is no biomedical laboratory test for ADHD Neuropharmacology 57 (2009) 579–589 DD 70%

The Diagnosis of ADHD : 

The Diagnosis of ADHD Myth : 2- ADHD child with Laboratory tests EEG Brain CT/MRI

The Diagnosis of ADHD : 

The Diagnosis of ADHD Myth : 2-respond to medications. 20-30% of AD/HD children do NOT respond Only 50 -55% respond academically when medicated. 20-25% respond to medications (False Positives) in no ADHD children

OSHA TRIANGLE ASSESSMENT : 

OSHA TRIANGLE ASSESSMENT

OSHA TRIANGLE ASSESSMENT : 

OSHA TRIANGLE ASSESSMENT 1- DSM 4 2- conner’s* psychological Profile Developmental Skills learning readiness and achievement Individual, scholastic and social adjustment Intellecual and cognitive F Motor adjustment and coordination language and speech assessment and evaluation including academic language Parental Attitude and Family adjustment Teacher Q

Assessment Team : 

Assessment Team Must get the story from all sides -the child, the family, the school, and significant others. Careful, thorough exploration of all the issues before leaping to conclusions.

ADHD TREATMENT : 

ADHD TREATMENT

Recognition and Referral : 

Recognition and Referral Assessment Initiation of treatment

OSHA Protocol of B- treatment : 

OSHA Protocol of B- treatment *OSHA Family role Child role Medicine Environment

Untreated ADHD Children’s Consequences : 

Untreated ADHD Children’s Consequences 90% have poor school performance 25-70% have learning disabilities 50-70% have poor peer relations 25-45% develop antisocial behavior Rule 1

Untreated ADHD Children’s Consequences : 

Untreated ADHD Children’s Consequences ADHD will threaten child’s academic success (90%) ADHD will threaten child’s career success excluded from social activities due to ADHD symptoms trouble with others in neighbourhood Substance abuse

Untreated ADHD : 

Untreated ADHD School underachievement Impulsive actions Smoking,etc Careless, accident Opositional defiant disorder/conduct disorders Carrier underemployment Impulsive life decisions Addiction Serious accident Antisocial personality Children Adults Rule 2

Untreated ADHD Parents’ consequences : 

Untreated ADHD Parents’ consequences Chronic stressed or worried about child’s ADHD Frustration Blaming, guilt Social isolation Parents’ marriage has been negatively affected Economic burden Rule 3

No “magic cure” : 

No “magic cure” There is no “quick fix”. No single intervention will correct the problems for every child-need a toolbox Rule 4

Parents’ Fear of Medications for ADHD: : 

Parents’ Fear of Medications for ADHD: Dependence Change personality or IQ Being labeled, attribution problems Reactions of others – teachers, peers, family Use special prescription Cost Lastly: anorexia, insomnia, tics, height, suicide

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Treatment needs to target not only the core symptoms but also co-morbid and coexisting disorders and other psychosocial adversities Rule 5

Aim of treatment : 

Aim of treatment 1- Improvements in core symptoms reduced hyperactivity reduced impulsivity improved attention 2- Improvements in related symptoms reduced oppositional behavior Improved social relations improved academic performance

OSHA Protocol of B- treatment : 

OSHA Protocol of B- treatment Family role Child role Medicine Environment 1- Family counseling 2- Group therapy Drug 1-Behavior modification sessions 2-Academic sessions 3- Group therapy ( ADHD DAY) Teacher orientation Class guidance

Family Group Therapy : 

Family Group Therapy

Friday Group Therapy : 

Friday Group Therapy

MEDICINE : 

MEDICINE IDEAL CHOICE: 1- not before age 6 years** 2- compliance 3- available 4- no other effects 5- specific and not symptomatic MEDICATION

Medications : 

Medications Stimulants Non-stimulants Others Methylphenidate (Ritalin) Availble in Egypt

Drugs Used For Treatment Approved by FDA Stimulants : 

Drugs Used For Treatment Approved by FDA Stimulants : Methylphenidate Ritalin) b) Dextro-amphetamines

Methylphenidate (Ritalin) : 

Methylphenidate (Ritalin) Ritalin is actually stimulating cerebral cortex and subcortical structures improving overall circulating levels of the neurotransmitters.

Methylphenidate (Ritalin) : 

Methylphenidate (Ritalin) action : Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system Onset: 0.5-1hr, Maximum: 3 hr duration 4-6 hr; metabolized by liver excreted by kidneys

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Ritalin (methylphenidate) 0.3 -0.8 mg/kg/dose lowest dose 7 days/week Dose -breakfast and lunch; increase by 0.1g/kg/ dose or by 5-10mg/dose at weekly intervals. Max dose 2mg/kg/day or 60mg/day.

Forms of Methylphenidate : 

Forms of Methylphenidate a) short acting 3-6 hrs: Ritalin (10mg) Focalin ( isomere of methylphenidate) (2.5, 5, 10 mg) (Out recently) b) intermediate acting 6-8 hrs: SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs): Metadate CD Concerta (ER) (18, 27, 36 and 54 mg) ( 11- 12 H) Ritalin LA (20, 30, 40 mg) (Sprinkle) e) recent route: transdermal MPH (daytrana)

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rebound agitation or exaggeration of pre-medication symptoms as it is wearing off Other effects > S/E

contraindications : 

contraindications Tics Failure to thrive ??? Epilepsy MAO inhibitors ( absolute contraindication) Allergy to ritalin (absolute contraindication) glaucoma PrecautionsUse cautiously in patients with marked anxiety, motor tics or with family history of Tourette syndrome, or history of substance abuse.

RITALIN is symptomatic only : 

RITALIN is symptomatic only

Medications : 

Medications Non-stimulants Others Ritalin Atomoxetine (strattera) Stimulants Availble in Egypt

Drugs Used For Treatment FDA approval (non stimulant) : 

Drugs Used For Treatment FDA approval (non stimulant) Atomoxetine (Strattera) =Selective Norepinephrine reuptake inhibitors Since 2002 Availble in Egypt

Atomoxetine for ADHD : 

Atomoxetine for ADHD ADHD ADHD with epilepsy ADHD with R. anxiety ADHD with depression ADHD in ASD ADHD with tics Strong family desire not to use stimulant

Atomoxetine for ADHD : 

Atomoxetine for ADHD Safe Single dose Effective Doses follow mg/kg dosing benefits tend to persist into evening & sometimes into morning No insomnia Night concentration

Atomoxetine is specific for ADHD mechanism : 

Atomoxetine is specific for ADHD mechanism Persist after no medicine Can be stopped with still benefit

Atomoxetine for ADHD : 

Atomoxetine for ADHD Start: 0.5- 0.8 mg/kg/d Target 1.2 mg/kg/d Available in 10mg, 18mg, 25mg, 40mg and 60mg strengths Some improvements may be seen in 1 – 2 wks , full effects not until 6-8 wks

Atomoxetine : 

Atomoxetine Rapidly absorbed after oral intake Absorption unaffected by food Brain concentrations > plasma concentrations Metabolized by P450 2D6 (neither inhibits nor induces) ~ 80% of dose excreted in urine Data on file, Ell Lilly and Company

Side effects of Atomoxetine : 

Side effects of Atomoxetine Anorexia Dyspepsia Nausea Emesis Sedation Fatigue ? Suicidal thought insomnia Dizziness Mood swings Growth delay?? Cost July 2007 Dev Med Ch Neurol

Rational for a non-stimulant medication for treatment of ADHD : 

Rational for a non-stimulant medication for treatment of ADHD 1- poor response or tolerability in some patients 2- act for a maximum of 12 hrs 3- suboptimal response is not uncommon 4- relative or contraindicated for some co-morbid conditions as tics, anxiety, substance abuse 5- some parents refuse stimulants 6- risk for abuse

Medications : 

Medications Non-stimulants Others 1- buproprion 2- resperidone 3- clonidine 4- ??? Benefit - LCPUFA Ritalin atomoxetine Stimulants

Drugs Used For Treatment (others) : 

Drugs Used For Treatment (others) Antidepressant Buproprion (Wellbutrin*) =Antidepressant (norephinephrine/dopamine reuptake inhibitor). *150 mg /tab ADHD + ANXIETY OR DEPRESSION

: 

Other Antidepressant Tricyclics : imipramine, desipramine, nortriptyline Always monitor cardiovascular side effects

Risperidone : 

Risperidone Action: Unclear, but may be related to antagonism for dopamine and serotonin receptors.. Peak plasma level in 1-2 hr, Hepatic metabolism excreted by liver Side effects: dry mouth, stomatitis, taste alteration (rare) ) ADHD + ASD

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Alpha2 antagonist antihypertensives Clonidine (catapres) Guanfacine

“Cod Liver Oil “LCPUFA : 

“Cod Liver Oil “LCPUFA cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA) Promotes normal bone formation, vision and reproduction Promotes immunity Promotes appetite Promotes concentration amd mental function For : autism, ADHD/ADD

?? Can FOOD ameliorate ADHD symptoms : 

?? Can FOOD ameliorate ADHD symptoms dietary modification

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الشيكولاتة تحسن القدرات العقلية أكدت دراسة أمريكية أن تناول الشيكولاته يحسن القدرات العقلية وأكدت الدراسة التي أجرتها جامعة ويلنج جيسوت بولاية ويست فيرجينيا أن الشيكولاته تحتوي علي العديد من المواد التي تعمل كمحفزات تزيد النشاط والانتباه وبالتالي زيادة القدرات العقلية وأكد الباحثون أن الشيكولاته السوداء هي الافضل تليها شيكولاته الحليب ‏.‏الشيكولاته تحسن القدرات العقلية الكافيين ينشط مراكز الذاكرة في المخ باحثون من النمسا ان الكافيين الموجود في القهوة والشاي والمشروبات الغازية والشوكولاته ينبه مناطق في المخ تتحكم في الذاكرة على المدى القصير والإدراك

?? can FOOD aggravate ADHD symptoms : 

?? can FOOD aggravate ADHD symptoms

Recognition and Referral : 

Recognition and Referral Assessment Initiation of treatment Monitoring progress

Ritalin4 weeks titration : 

Ritalin4 weeks titration drug response dependent (symptomatic)

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Atomoxetine6 - 8 weeks titration Continuous Effect after its stoppage (specific)

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RITALIN v1 v2 STRATTERA V1 V2

Choosing the right first treatment : 

Choosing the right first treatment Initiating and titrating medications Monitoring ongoing medication Making changes in treatment

Ritalinfirst choice in many casesspecially with the need of rapid response : 

Ritalinfirst choice in many casesspecially with the need of rapid response Atomoxetineshould be considered as 1st choice in: Don’t use antipsychotic in normal children with ADHD Anxiety disorders Tics Strong family desire not to use stimulant Current or past substance misuse 24 hrs duration of action is strongly required

Why should we change the medication? : 

Why should we change the medication? Have I titrated properly? Is the patient at the maximum dose? Is this drug/preparation working well at any times during the day? Are parents and school in agreement about the effects of the drug? Is the medication working but effects limited by S/E? Have I missed any comorbidity? Is the diagnosis right?

ADHD and EPILEPSY : 

ADHD and EPILEPSY Studies in pediatric epilepsy have found a 2.5-fold to 5.5-fold-increased risk of ADHD compared with healthy controls a 2.7-fold greater incidence of epilepsy among children with ADHD than in controls Pediatric NeurologyVolume 42, Issue 5, May 2010

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AED associated with ADHD-like S/E : PB, CZP, TPM, gabapentin and vigabatrin. Methylphenidate for treatment of ADHD comorbid with epilepsy: has a good risk-benefit ratio. Amphetamine, atomoxetine, clonidine only have case series to support their use bupropion should be avoided. Hamoda HM, Guild DJ, Gumlak S, Travers BH, Gonzalez-Heydrich J. Expert Rev Neurother. 2009 Dec;9(12):1747-54 ADHD and EPILEPSY (cont.)

Acknowledgement : 

Acknowledgement ADHD children and Family Prof Dr Shawky Elkhateeb Dr Omayma Selim Team of SCC

Methylphenidate Transdermal System (Daytrana) for Pediatric ADHD : 

Methylphenidate Transdermal System (Daytrana) for Pediatric ADHD will be available in 10-, 15-, 20-, and 30-mg dosage strengths. The initial recommended daily dose is 10 mg (12.5 cm2) and may be titrated upwards as needed at 1-week intervals to 15 mg (18.75 cm2), 20 mg (25 cm2), and a maximal dose of 30 mg (37.5 mg2).