Transcript PEDIATRIC PSYCHOPHARMACOLOGY

Attention Deficit Hyperactivity
Disorder
Stephanie Eken, M.D.
Child and Adolescent Psychiatrist
David Causey, Ph.D.
Clinical Child Psychologist
Square One: Specialists in Child and Adolescent
Development
ADHD
 Explanations of ADHD and related
problems are not the same as Excuses
 Understanding and identifying the disorder
can be preventative
 ADHD is often not about what a child does
behaviorally, but about when they do
certain behaviors
Attention Deficit
Hyperactivity Disorder
(ADHD) is a chronic
neurodevelopmental
disorder
ADHD: Current Working
Theory
Symptoms of ADHD are caused by
abnormality in the Executive Function of
the brain.
Brain Regions Implicated in
ADHD
Prefrontal Cortex
Frontal Lobes
Limbic System
Basal Ganglia
Caudate nucleus
Cerebellum
Scientific American, September 1998
Neurobiology of ADHD
 Neuroanatomic
 Decreased activity of dopamine &
norepinephrine in prefrontal cortex
 These areas govern inhibitory responses, control
of impulses, working memory, organization,
concentration, motivation
 Imaging studies show lower blood flow in
the prefrontal cortex and striatum
How the brain’s conductor
orchestrates activity
• Executive Function
– Develop and maintain problem solving
abilities to attain a future goal
– Major functions
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Nonverbal working memory
Verbal working memory
Self-regulation
Behavioral analysis
Response inhibition
Executive Function
Nonverbal working memory
Sense of self—understand past and future and
have cognitive awareness of self
Verbal working memory
Internalization of receptive and expressive
language
Self questioning and self-description
Verbal and Nonverbal memory provide the
basis for comprehension and conduct
Executive Function
Response inhibition
Delays or stops responses
Controls motor and verbal impulses
Executive Function continued:
Self regulation
• Control of emotions and motivation to
accomplish a goal
• Analyze what has been experienced in
working memory to put together a
new response (judgment)
• To accept or reject action to achieve a
goal (decision)
Executive Function continued:
“Working Part” of working memory involves:
 anticipation
 visualization
 freedom from interference
 internalization
 preparation to act
 self regulation
ADHD
The diagnosis of Attention Deficit Hyperactivity
Disorder is given to individuals who have
frequent failure to comply in an age appropriate
fashion with situational demands for inhibition of
impulsive responses and resistance to
distracting influences. These behaviors interfere
with the individual’s performance in social and
academic settings.
ADHD:Hyperactive/Impulsive
Often…
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fidgets or squirms
can’t stay seated
restless
loud, noisy
always “on the go”
talks excessively
blurts out
impatient
intrusive
ADHD: Inattentive
Often …
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Appears to not be listening
Follows through poorly on obligations
Disorganized
Dislikes sustained mental effort
Loses needed objects
Easily distracted
Forgetful
Careless errors, inattentive to detail
Sustains attention poorly
Course of Illness
 Chronic neurodevelopmental disorder
 Most children do not “outgrow” ADHD
 40-50% of adults in follow-up studies suffer
clinically significant symptoms of ADHD
 Long-term studies show children with ADHD
exhibit impaired academic functioning,
perform more poorly on cognitive tasks, and
are characterized by lower self-esteem and
poor social functioning
ADHD in Adolescents
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Problems with behavioral inhibition
Problems with focus, distractibility
Problems with restlessness
Problems initiating, organizing,
completing tasks
ADHD Epidemiology
 Prevalence: 3-12 % children
1-6% adults
 Boys are diagnosed with ADHD,
Combined Type in a frequency of 3:1
compared to girls
ADHD and Inheritance
 Inherited 57-97% (mean 80%)
– If parent has ADHD—offspring risk 20-54%
– 25-30% of fathers
– 15-20% of mothers
– Identical twins 55-92%
 Boy with ADHD—male sibling 35%
female sibling 15%
Genetics
 Complex genetic disorder
 Result of combined effects of several genes
and interactions with the environment
 Role of environment – early obstetrical
complications, prematurity, in utero exposure to
cocaine, alcohol or other toxins
 Genes typically implicated are associated
with the dopamine system
 Children with ADHD have a 50-80%
chance of having a parent with ADHD
Comorbid Conditions
 Learning Disabilities
 20-60% have reading, spelling or arithmetic learning
disorders
 Tic/Tourette Disorder
 50% of children with Tourette Disorder have ADHD
 Cognitive Deficits
 Drug or alcohol use
 Treatment of ADHD reduces substance use disorders
Comorbid Conditions
 Mood Disorders
 Depression (30%)
 Bipolar (10-20%)
 Anxiety
 30% of children with ADHD will meet criteria for an
anxiety disorder
 Obsessive Compulsive Disorder
 Behavioral Disorders:
 Oppositional Defiant disorder
 Conduct Disorder
 50% of children with ADHD meet criteria for ODD or Conduct
Disorder
What does it mean to have
Attention Deficit Hyperactivity
Disorder?
Core issues with ADHD
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Impulsivity
Poorly regulated activity—hyperactivity
Distractibility—poor sustained attention
Disorganization
Diminished rule governed behavior
Emotional over arousal
Poor/No generalization of information
Variability of task performance
What is it like to have ADHD
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Behavioral disinhibition
Dysfunction of cognitive ability
Poor adaptive function
Difficulty with rule governed behavior
Delays in internalization of language
“They tell me to get a planner. I have
twenty of them and can’t find any of them.”
Women with Attention Deficit Disorder
Sari Solden, MS, MFCC
Underwood Books, 1995
pg.69
Differences in youth with ADHD:
coping-temperament-subtypes
 ADHD with:
– Anxiety
– Obsessive
Compulsive
– Agitation
– Mania
– Defiance
– Aggression
– Mood reactivity
Qualities: ADHD Inattentive Type
(“ADD”)
 Often not identified until 5th grade, middle
school, or even high school
 May see substantial drop in grades around
middle school
 Compensate for struggles (mask it)
 Often described as “lazy”, “doesn’t care”,
“unmotivated”, “doesn’t try”
 Slower processing speed is common
 Often very quiet and well behaved – so not on
the “radar screen”
Typical Vulnerabilities
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Low self esteem
Humiliation
Feeling “dumb”
Always “in trouble”
Quick to lie about behavior
Become defensive
Feel defeated
Other ADHD qualities
 Sometimes work harder at avoiding work
than actually doing it
 Academic progress is often a roller coaster
– up and down all year
 Moody
 Really do want to do well
 Frustration
Strengths and “Gifts”
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Creative
Charming
Funny
Social
Sensitive and caring
Hyperfocus
Enthusiasm
These symptoms are
inherent in all of us. So what
makes ADHD a disorder?
Pathology occurs when the core
symptoms of ADHD are
pervasive, prominent and impair
functioning in all aspects of life.
What else could it be?
Sam was put into a behavioral disorders
classroom before it was realized he did have
ants in his pants.
modified from Ants in His Pants Absurdities
and Realities of Special Education
What else could it be?
 Psychosocial stressors
 Inappropriate behavior management
 Absence of rules to govern behavior
What else could it be?
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Improper diet
Sleep deprivation
Language problems
Abuse
What else could it be?
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Absence Seizures
Chronic illness
Language impairments
Processing impairments
Learning disabilities
Mental Retardation
The Core Symptoms of ADHD
are present as symptoms in a
variety of psychiatric
diagnoses
Other diagnoses with shared
symptoms
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Depression
Anxiety
Bipolar Disorder
Thought Disorder
Autism
Substance abuse
How is the Diagnosis of
Attention Deficit Hyperactivity
made?
ADHD Testing
 There is no ONE test to specifically
confirm the diagnosis of ADHD
 No specific psychological test battery
 No specific neurologic examination
 Quantitative EEGs
 There is no brain scan—as of yet
 Functional MRI’s are not used in daily clinical
practice
Who does ADHD Evaluations?
 Pediatricians and primary care physicians
 Evaluate and treat children/adolescents with ADHD
 Developmental Pediatricians
 Evaluate and treat children with ADHD and
developmental delays
 Child and Adolescent Psychiatrists
 Evaluate and treat children with ADHD and children
with comorbidities
 Child Psychologists
 Evaluate and provide behavior modification training
 May perform neuropsych/psychoeducational testing
To make the diagnosis of ADHD
 Psychological evaluation
 Medical evaluation
Psychological Evaluation
 Parent interview
 Child interview to include cognitive testing
and emotional evaluation
 Information about school behavior and
academic achievement
 Rating scales
 Observation of child
TREATMENT OF ADHD
Treatment Team
 Who should be on the team?
 Child or adolescent
 Educate about ADHD
 Allow them to participate at developmentally appropriate level
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Parents
Teachers
Doctor
Therapist
 Team members should work together to
determine a plan of action and treatment
objectives
Treatment
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Education
Behavior Management/Family Counseling
Medication
Consultation with school personnel
Behavior Management
 Emphasizes ways in which parents can
better manage and shape their child’s
behavior through behavior modification
 Teaches ways to be consistent
 Teaches problem solving techniques
 Breaking cycles of learned behavior
Family Support
 The stress on a family related to a child’s
behavior may prevent the family from
carrying out a treatment plan
 Family therapy can be helpful for siblings
and parents
 Helping siblings understand ADHD and
potential differences in parenting strategies
between children
Help in the Classroom
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Be sure you are dealing with ADHD
Seek assistance to clarify diagnosis
Communicate with teachers/parents
Include the child in making a plan
Ask the child what will help
Help the child to take ownership
Help in the Classroom
 Avoid being punitive
 Set positive goals
 Attempt to reinforce effort and not just
accomplishment of goals (sometimes
these children try their best and still don’t
meet basic goals for behavior)
 Remember all ADHD is NOT alike
Help in the Classroom
 Keep in mind that many behaviors may
reflect coping with frustration/anxiety
 Structure and clear expectations are vital
for success
 Need for cues, reminders, and repetition
 Be aware of and avoid “helping” strategies
that may humiliate the child
Help in the Classroom
 Use a “firm-flexibility” approach with the
child – combination of support,
accommodations, clear limits, and
expectations
 Daily schedules may help - visual
 Use visuals when possible
 Be cognizant of “high risk” times (e.g.,
unstructured, less supervised times)
Help in the Classroom:
ANY approach one takes should strive to
minimize penalizing the student for
struggles that are a direct result of ADHD.
That is, attempt to differentiate behaviors
that are much harder for the child due to
ADHD versus those that may occur by
choice.
Help in the Classroom
 Initiate communication with parents and
ask about:
– homework time
– Students understanding of tasks
– Time and effort spent with routine homework
Help in the Classroom
 If the child is clearly falling behind, take
the initiative to notify parents
 Be careful not to assume that problem
behaviors are intentional
 Try to stay positive
 Work with the student to set goals (but not
too many at once)
Help in the Classroom: Distraction
 Remember a child may be “listening” to
you but not attending to what you are
saying
 Provide extended time as needed
 Emphasize quality over quantity with
assignments and homework
Help in the Classroom: Distraction
 Have the student repeat directions and/or
demonstrate understanding
 Monitor student’s progress in completing
work so it doesn’t pile up
 Provide cues to help the child stay on task
(e.g., agree on “secret” cues)
Help in the Classroom:
Disorganization
 Consider allowing the student to have a
second set of books at home
 Make sure the child has correctly recorded
homework assignments
 Specifically request their homework and/or
find a system that works
 Suggest simple ways to organize papers
 Work with the child to organize locker
Help in the Classroom:
Hyperactivity/Impulsivity
 Provide adequate breaks and
opportunities to move or “reset”
 Use visual cues to help the child
remember to “STOP & THINK”
 When entering into a “high risk” situation,
talk through successful behavior with the
student beforehand
Help in the Classroom:
Working Memory
 A skill learned today is not necessarily
remembered tomorrow
 Note taking is often harder – be sure they
have relatively complete notes
 Suggest strategies that help the child
compensate for this weakness
ADHD Psychopharmacology
ADHD Treatment Study
 Multimodal Treatment Study of ADHD
 Investigated effects of various treatment modalities on
children with ADHD, combined type over 14 month
period (n=579)
 Results:
 Medication alone most effective treatment of core symptoms
of ADHD
 Medication with psychosocial treatments (behavior therapies)
was superior to other treatments for non-ADHD areas of
functioning – i.e. aggressive behaviors, parent-child relations,
teacher-rated social skills
ADHD Treatment
 Multimodal Treatment Study of ADHD (n = 579)
 Investigated effects of various treatment modalities on children
with ADHD, combined type over 14 month period
 Results
 Medication alone most effective treatment of core symptoms of
ADHD
 Medication with psychosocial treatments was superior to other
treatments for non-ADHD areas of functioning – i.e. aggressive
behaviors, parent-child relations, teacher-rated social skills
 Medication Classes
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Stimulants
Antidepressants
Antihypertensives
Wake-promoting agent used in narcolepsy
When Medications are Appropriate
 Indications for medicine
 Moderate to severe ADHD symptoms
 Persistent symptoms that impair function at
school, at home and in social contexts
 ADHD subtypes respond equally well to
medication
Medicines Can:
 Decrease fidgetiness and activity level
 Improve focus
 do more accurate work, sustain attention
 Decrease impulsivity
 follow rules better, think before acting
 Decrease reactivity
 less aggression
Medication Classes
 Stimulants
 Stimulants are the best studied medications in
child & adolescent psychiatry
 Over 200 controlled studies
 Antidepressants
 Antihypertensives
 Wake-promoting agent used in narcolepsy
ADHD Treatment
 Indications for medicine
 Moderate to severe ADHD symptoms
 Persistent symptoms that impair function at school, at
home and in social contexts
 ADHD subtypes respond equally well to
medication
 Stimulants are the best studied medications in
child & adolescent psychiatry
 Over 200 controlled studies
Stimulants
 First line medication treatment of ADHD
 Approximately 70% of children will respond
to the first stimulant prescribed
 Up to 90% respond to the first or second
stimulant attempted
 Do NOT “make” children perform better –
he/she has to do the work themselves
 Helps improve executive functioning so they
can successfully complete work
Why give a stimulant to a
hyperactive child?
 Work by “stimulating” the brain to make more of
the neurotransmitters (brain chemical) that help
focus attention, control impulses, organize and
plan, keep with routines
 Increase dopaminergic and noradrenergic activity in
frontal cortex (responsible for executive functioning)
 Research shows other treatments are more
likely to work if the child is taking a stimulant
Stimulants
 First line medication treatment of ADHD
 Approximately 70% of children will respond to
the first stimulant prescribed
 Up to 90% respond to the first or second
stimulant attempted
 Mechanism of Action
 Increase dopaminergic and noradrenergic
activity in frontal cortex
Stimulants
 Three types of stimulant formulations
 Short-acting
 Duration of action 2-4 hours
 Must be given 2-4 times per day
 Intermediate-acting
 Duration of action 6-8 hours
 Long-acting
 Duration of action 10-12 hours
 Current accepted practice is to initiate treatment
with an intermediate or long-acting preparation
Methylphenidate Class
 Short-acting
 Methylphenidate (Ritalin, Methylin)
 Focalin
 Intermediate-acting
 Ritalin LA/Ritalin SR
 Metadate CD/Metadate ER
 Long-acting
 Focalin XR
 Concerta
 Daytrana patch
Amphetamine Class
 Short Acting
 Adderall
 Abused in adolescent population
 Dexedrine/Dextrostat
 Desoxyn (Methamphetamine HCl)
 Intermediate-acting
 Dexedrine spansules
 Long Acting
 Adderall XR
 Vyvanse
 Prodrug – cleaved by stomach enzyme (less abusable)
Relative Contraindications for
Stimulants
 Should not use stimulants in children with
significant family history of Sudden Unexplained
Death
 Black Box for stimulant misuse/abuse and
Sudden Unexplained Death
 Children with structural cardiac defects must be
cleared by cardiologist for stimulant use
 May use in children with seizures if they are
well-controlled
Stimulant Side Effects
 Appetite suppression
 No evidence that long-term stimulant therapy will
result in permanent weight reduction by adulthood
 Typically do not require “drug holidays” on weekends
or during summer
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Growth – slows pace but not final height
Insomnia
Exacerbation of tics
Rebound hyperactivity/impulsivity
 As stimulants wear off, children may have increasing
difficulties
 They need more medication, not less
Monitoring on Stimulants
 Growth parameters
 Height
 Weight
 Blood pressure
 Stimulants may increase B/P
 Pulse
 Stimulants may cause tachycardia
Dosage
 Remember – best dose is one that
achieves the best possible results without
troublesome side effects
 Titrating dose
 Start at a low dose and gradual increase to
minimize side effects
 Treatment team members input
 Do teachers notice medicine “wears off”?
 Can child/adolescent notice a difference?
Stimulant Myths
 Stimulants are like “giving children cocaine”
 They both affect dopamine, but stimulants do not
have the same addictive potential when properly used
 Stimulants are overprescribed
 In many regions, children’s ADHD symptoms go
under-recognized (especially girls)
 Stimulants are a “gateway drug”
 Evidence that children and adolescents in treatment
are at decreased risk for substance abuse and legal
difficulties
Non-stimulant Medications
 Nonresponders to stimulants should be
reevaluated and then a non-stimulant
medication attempted
 About 20-30% of ADHD children will not
respond to a stimulant or will have
intolerable side effects to stimulants
 May be most effective choice for children
with ADHD and other comorbidities
Antidepressants
 Useful in patients with comorbidities
 Require 4 to 6 weeks to determine efficacy
 Have Black Box warning for increased
suicidal ideations
 May have sexual side effects
 Important for compliance in adolescents
Antidepressants
 Classes of Antidepressants used in ADHD
 Norepinephrine reuptake inhibitors
 Atomoxetine (Strattera)
 Buproprion (Wellbutrin)
 Also inhibits reuptake of dopamine
 Venlafaxine (Effexor)
 Also inhibits reuptake of serotonin
 Tricyclic Antidepressants
 Desipramine
 Imipramine
Atomoxetine (Strattera)
 Originally developed as antidepressant
 Good for use in children with comorbid
depression or anxiety
 Can be used in conjunction with stimulants
 Weight-based dosing
Atomoxetine (Strattera)
 Limited drug abuse potential
 Common side effects
 Dyspepsia
 Nausea/vomiting
 Headache
Tricyclic Antidepressants
 TCAs
 Significant side effects
 Need EKG monitoring
 Can be fatal in overdose
 Useful in children with comorbid tic
disorders or OCD
Antihypertensives
 Alpha-adrenergic agonists
 Data suggests enhanced cognitive
functioning in the prefrontal cortex
 Indicated in the treatment of children with
tic disorders and Tourette Syndrome
 Used in children with ADHD for impulsive
aggression, comorbid tic disorders, sleep
initiation disorders or rebound
hyperactivity
Antihypertensives
 Guanfacine (Tenex)
 Clonidine (Catapress)
 Tends to be sedating
 May be used as single agent or in
combination with other medication
Other Medications
 Modafinil (Provigil)
 Used in the treatment of narcolepsy
 Some evidence of efficacy in treatment of
ADHD
 Indirectly activates the frontal cortex
 Pemoline (Cylert)
 Use is not recommended
 Associated with hepatic toxicity and liver
damage
Sleep Disturbance
 Children/adolescents with ADHD have higher
incidence of sleep disorders
 Sleep latency
 May be a drug side effect
 May be physiologic reason
 Melatonin
 Hormone that spikes in the evening to regulate
circadian rhythms
 Study in children with ADHD showed subset with
decreased Melatonin spike
 Has good efficacy in reducing sleep latency
ADHD: Goals of treatment
 Prevent irreversible mistakes:
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MVA’s
Addiction
STD’s and unplanned pregnancies
Suicide/homicide
 Survive relatively intact into mid 20’s
– frontal lobe maturation continues despite delay of 2-4
years
 Keep as many life options open as possible
 Aid in child’s success in school and home
environment
Conclusions
 ADHD is a neurodevelopmental disorder that
typically spans into adulthood.
 ADHD symptoms in children still go
unrecognized and untreated.
 Stimulants are first-line well-studied medications
in the reduction of ADHD symptoms.
 Multi-modal treatment is important in building a
strong self-concept through success in different
environments for these children.
Support
 CHADD (Children and Adults with
Attention Deficit Disorders)
8181 Professional Place, Suite 201
Landover, MD 20785
http://www.chadd.org/
800-233-4050
ADHD Parent Support Group
 LDA of Kentucky
–www.ldaofky.org
Educational Intervention
 www.ed.gov
 www.schoolpsychiatry.org
Other Resources
• American Academy of Child & Adolescent Psychiatry
www.aacap.org
• The Attention Deficit Information Support Network, Inc.
58 Prince St. Needham, MA
02492 781-455-9895
www.addinfonetwork.com
• Attention Deficit Disorder Association
P.O. Box 543
Pottstown, PA 19464
484-945-2101
www.add.org
Other Resources
• Federation of Families for Mental Health
1011 King Street, Suite 420
Alexandria, VA 22314
703-684-7710
www.ffcmh.org
• National Information Center for Children and Youth with Disabilities
P.O. Box 1492
Washington, DC 20013
800-695-0285
www.nichcy.org
• National Institute of Mental Health (NIMH)
Office of Communications
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
800-615-6464 or 301-443-4513
www.nimh.nih.gov