ADHD

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Attention Deficit DisorderFebruary 2004Diagnosis and Treatment : 

Attention Deficit DisorderFebruary 2004Diagnosis and Treatment John A. Salvato, M.D., F.A.A.P. Medical Director Edmund Ervin Pediatric Center Maine General Medical Center

Attention Deficit Disorder : 

Attention Deficit Disorder ADHD is a chronic neurobehavioral disorder affecting from 4% - 12% of school aged children

Diagnosis : 

Diagnosis Core symptoms: developmentally inappropriate levels of inattention, hyperactivity and impulsivity It affects children 24 hours, 7 days a week

Diagnosis : 

Diagnosis Associated with significant impairment across multiple domains of functioning: academic family and peer relationships low self esteem

Neurotransmitters : 

Neurotransmitters Dopamine (DA) Enhances signal Improves attention Norepinephrine (NE) Dampens noise Increases inhibition

Attention Deficit Disorder : 

Attention Deficit Disorder Symptoms present before age 7 Symptoms are noted for 6 months or more Symptoms are noted in >= 2 settings Need to distinguish between the symptoms of ADHD and the impairments those symptoms cause.

Attention Deficit Disorder : 

Attention Deficit Disorder Not all children with ADHD have functional impairments Some who have impairments at a young age don’t as the mature Some with mild symptoms become significantly impaired because of family stresses and environmental issues

Risk Factors : 

Risk Factors A child’s vulnerability rests on the interaction of: genetic factors medical issues environmental risks temperament protective factors

Genetic Risks : 

Genetic Risks A Family History of hyperactivity, conduct disorder, alcoholism, sociopathy, mood disorders, anxiety disorders and learning disabilities increases risk

Medical Risks : 

Medical Risks Maternal smoking during the peri-natal period Maternal alcohol use during the first trimester Preeclampsia, premature labor, low birth weight ( May impair development of the central nervous system )

Temperamant Risks : 

Temperamant Risks A child who reacts intensely to stimuli A child who seeks novelty A child who is difficult to console or is fearful A child with eating and sleeping issues

Environmental Risks : 

Environmental Risks Lead Carbon Monoxide Heavy Metals Pesticides Effect on the early embryologic neuro-developmental system

Family Risks : 

Family Risks Single parent households Multiple moves Domestic violence Child abuse Unstructured household Low parental intelligence

Protective Factors : 

Protective Factors Positive family environment Good nutritional habits zinc/cadmium calcium/lead High intelligence Early treatment

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Medical Risks Genetic Risks Environmental risks Vulnerability index Temperament Protective factors Cognitive processing deficits (IQ, learning disability) Behavioral self-regulation deficits Interpersonal processing deficits Affective processing deficits

Functional Outcomes : 

Functional Outcomes The level of impairment in social interaction is the best predictor of long-term outcome. Children with ADHD more likely to: steal lie destroy property Be cruel to animals Set fires

Functional Outcomes : 

Functional Outcomes Teens show more: mood lability alcohol and substance abuse smoking sexually transmitted diseases early pregnancy motor vehicle accidents/citations

Functional Outcomes : 

Functional Outcomes Adults have more subtle impairments: difficulty organizing responsibilities change jobs often marital and social problems

Are ADHD symptoms causing impairment? : 

Are ADHD symptoms causing impairment?

Evaluation : 

Evaluation History prenatal postnatal early infancy/childhood preschool/school daycare

Evaluation : 

Evaluation Habits appetite sleep electronic rituals/tics toileting/hygiene

Evaluation : 

Evaluation Temperament affect aggression self injurious hypomania symptoms organizational skills

Evaluation : 

Evaluation Family History anxiety/depression thyroid seizures/epilepsy learning problems sudden death

Evaluation : 

Evaluation Family History substance use/abuse pets guns confidante friends

Evaluation : 

Evaluation Physical exam dysmorphology thyroid heart, pulse, BP height, weight, head circumference abdomen

Evaluation : 

Evaluation Physical exam neurological soft signs mental status experimentation safety trauma

Evaluation : 

Evaluation Tests CBCL TRF CDI PHSI RCMAS

Evaluation : 

Evaluation Tests Family drawing Handwriting Photographs CPT Memory Prior intellectual/achievement

Evaluation : 

Evaluation Labs Lead Fragile X TSH MRI EEG

Co-morbid Conditions : 

Co-morbid Conditions Oppositional Behavior Disorder Depression Anxiety PTSD Child neglect and abuse

Co-morbid conditions : 

Co-morbid conditions Learning disorder Conduct disorder Bipolar disorder Substance use/abuse Family systems issues

Complications of unmanaged ADHD : 

Complications of unmanaged ADHD ADHD Low self-esteem Family disruption Disruptive behavior Poor social skills School failure Learning delay Oppositional-defiant disorder Mood disorder Challenging behavior Antisocial behavior School exclusion Substance abuse Conduct disorder Lack of motivation Age 6 10 14-16 16-adult

Oppositional Defiant Disorder : 

Oppositional Defiant Disorder Argumentative Irritable Defiant Angry Annoying

Oppositional Defiant Disorder : 

Oppositional Defiant Disorder Loses Temper Obscene Language For 6 or more months Occurs in >= 2 settings

Treatment : 

Treatment Family structure/routines/rules/meals Behavioral training parents and teachers academic accomodations peer training/support Medication stimulant alternatives

Adderrall XR Shire : 

Adderrall XR Shire Dopamine (DA) and Norepinephrine (NE) modulating agent (DNmA) Increase levels of DA and NE in the synpase. Mixed salts of Dextroamphetamine and Amphetamine.

Adderall XR Shire : 

Adderall XR Shire Once daily dosing, 5mg, 10mg, 20mg, 25mg, 30mg capsules. A sprinkle option available Schedule II controlled substance

Adderall XR Shire : 

Adderall XR Shire Common side effects: decreased appetite insomnia abdominal pain emotional lability insomnia exacerbate motor and vocal tics precipitate psychosis

Concerta McNeil : 

Concerta McNeil Long acting central nervous stimulant Mixed d and l-isomer methylphenidate OROS delivery system provides smooth release over course of the day.

Concerta McNeil : 

Concerta McNeil Once daily dosing 18 mg, 27 mg, 36 mg, 54 mg tablets Schedule II controlled substance

Concerta McNeil : 

Concerta McNeil Common side effects loss of appetite insomnia headache abdominal pain exacerbate motor and vocal tics

Focalin Novartis : 

Focalin Novartis A short acting central nervous stimulant the d-isomer of methylphenidate, “the right half”

Focalin Novartis : 

Focalin Novartis Twice daily dosing 2.5 mg, 5 mg, 10 mg tablets Schedule II controlled substance

Focalin Novartis : 

Focalin Novartis Common side effects: abdominal pain decreased appetite nausea insomnia exacerbate motor and vocal tics psychosis

Ritalin LA Novartis : 

Ritalin LA Novartis A long acting central nervous stimulant Mixed d and l-isomers of methylphenidate

Ritalin LA Novartis : 

Ritalin LA Novartis Once daily dosing 20 mg, 30 mg, 40 mg capsules Schedule II controlled substance

Ritalin LA Novartis : 

Ritalin LA Novartis Common side effects: decreased appetite insomnia headache abdominal pain psychosis may exacerbate motor and vocal tics

Straterra Lilly : 

Straterra Lilly A selective norepinephrine (NE) reuptake inhibitor R-isomer of atomoxetine Increase DA in the prefrontal cortex DA is not increased in the nucleus accumbens thus no euphoriant properties DA is not increased in the striatum thus not associated with motor activity ( tics)

Straterra Lilly : 

Straterra Lilly Once daily dosing Rx 0.5 mg/kg for first 4 -7 days then up to 1.2 mg/kg qd 10 mg, 18 mg, 25 mg, 40 mg, 60 mg capsules Not a controlled substance; can be refilled and called in.

Efficacy Results of Once-Daily Atomoxetine : 

Efficacy Results of Once-Daily Atomoxetine

Alternatives : 

Alternatives Tricyclic antidepressants Nortriptyline, Desipramine Useful especially with co-morbid anxiety/depression, sleep issues Anticholinergic side effects, cardiac effects, need to monitor

Alternatives : 

Alternatives Tetracyclic antidepressant Bupropion/Wellbutrin/Zyband Decreases hyperactivity, improves mood and may improve cognitive performance. Takes 2-6 weeks to see effects, dosed bid, lowers seizure threshold in susceptible individuals

Alternatives : 

Alternatives Blocking agents Clonidine, Guanfacine/Tenex Decrease hyperactivity and impulsivity Helps with sleep onset Sedation, depression, enuresis, poor for inattention

Alternative : 

Alternative New medication Atomoxetine/Straterra Excellent for inattentiveness Once daily dosing Continuous symptom relief Does not aggravate sleep issues/anxiety,tics Not a controlled substance No long term weight or EKG issues

Conclusion : 

Conclusion

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