adhd and psychopharmacology by monica robles m.d

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

noncomplianceImpulsive aggressionSocial interactionAcademic efficiencyAcademic accuracyEnhanced vigilanceImprove reaction timeImprove 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

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