Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved. Treatment Basics for ADHD Roy Q. Sanders, MD Medical Director Marcus Autism Center
May 21, 2015
Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Treatment Basics for ADHD
Roy Q. Sanders, MD
Medical Director
Marcus Autism Center
2 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Introduction
One of the most common childhood psychiatric diagnoses. ADHD effect 4-7 % of children and generally persists into Adulthood. There are significant issues with co-morbidity including but not limited to conduct disorder, intellectual and learning issues, as well as substance abuse.
3 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
After Diagnosis
The symptoms of poor attention, poor concentration, hyperactivity and impulsivity are probably the final common pathway of different basic neurological function.
Clues in history and examination lead to an exact understanding of what the problems are and how to proceed with treatment. Are there other diagnoses or complicating factors that may require referral?
Try to tease out etiology to create an appropriate comprehensive treatment plan.
4 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Treatment Planning
• After trying to figure out the causes of the symptoms the treatment plan begins by determining the specific behaviors that are problematic and then setting up a specific behavior plan to address those behaviors.
• Schools and others caretaker should be involved in this phase of treatment planning.
5 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Other Helpful Interventions
The information that I give to parents includes changes in the child’s environment and the family’s life style.• No television during the week and only limited television on
the weekend, parents watching with children• Restricted computer games and limited handheld and other
video games.• One hour of outside activity every day for home and included
in any IEP at school. • Daily aerobic exercise.• Parents must sit and eat one meal with the children• Breakfast every day and increased protein content. Limit dyes
and preservatives. Other diet changes if parents recognize problems.
• I tell parents they need to stop smoking.
6 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Alternative Treatments
Other parents I have worked with are more comfortable and even more eager to try environmental/alternative treatments• We have used with varying success referrals
for massage therapy, acupressure / acupuncture, chiropractic consultation.
• Some parents opt for private or even home schooling
7 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
One of the most common reasons psychoactive medication is prescribed in children is related to problems associated with disruptive behavior. In particular problems with concentration, and arousal regulation. These difficulties are most often diagnosed as ADHD.
Medications
8 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Medication Commonly Prescribed for Problems of Attention, Concentration and Arousal
Regulation
There are several classes of medication that are commonly prescribed to help with these symptoms. The class of medications most often prescribed is the stimulant class. Others types of medications include some antihypertensive medications, antidepressant medications, anticonvulsant medications and even anti-psychotics. We will explore these medication groups and some specific medications within these groups.
9 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Stimulant Medications
Basically there are two classes of stimulant medications. There are methylphenidates and amphetamines.
10 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Methylphenidate (Ritalin) is one of the oldest of the stimulant medications used in the treatment of attention and concentration problems. In general, methylphenidate is well tolerated and works well to increase concentration and attention and to decrease hyperactivity. It works about 80% of the time to reduce up to 80% of the symptoms a person is experiencing.
Methylphenidate
11 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Methylphenidate
Side effects include decreased appetite, decreased or disturbed sleep, sometimes headaches and gastrointestinal pains. At times motor or vocal tics emerge. There can also be problems with mood instability and with irritability. In overdose you can see psychotic symptoms or symptoms of delirium.
12 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Methylphenidate
Problems can also arise with methylphenidate because of the short half-life of the standard formulation. Theoretically dosing can occur every four hours but clinical experience leads to dosing as frequently as very 150 minutes. There are other forms of the medication that have longer duration of action including but not limited to Ritalin LA, Metadate CD, Concerta, and most recently the Daytrana patch.
13 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
D-Methlyphenidate
D-Methylphenidate is the “dextro” form of methylphenidate. The trade for this stimulant is Focalin. There are currently short acting form of Focalin and extended release form of the medication. Efficacy and side effects for this agent are similar to other stimulant medications.
14 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Mixed Amphetamine Salts
Mixed amphetamine salts have also been available in the treatment of attention and concentration for many years. They are currently available in generic and under the trade name of Adderall and AdderallXR.
These medications are very effective in decreasing the symptoms of poor attention, poor concentration, and hyperactivity. Their effectiveness is similar to methylphenidate and they are very widely used.
15 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Mixed Amphetamine Salts
Side effects are also similar to those listed above with methylphenidate but in clinical experience they are slightly more likely to create some mood lability and irritability than the other stimulant medications.
16 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Lisdexamfetamine(Vyvanse)
A prodrug consisting of the psycho stimulant d-amphetamine coupled with the essential amino acid L-Lysine. Lisdexamfetamine was developed so that the psychostimulant is released and activated more slowly as the prodrug molecule is hydrolyzed—consequently cleaving off the amino acid-during the first pass through the intestines and/or the liver.
17 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Dextroamphetamine
Dextroamphetamine has also been used for years in the treatment of problems with attention, concentration and the regulation of activity level.
Dextroamphetamine is effective in reduction of symptoms at a level consistent with the treatments listed above.
Side effects are similar to those listed above.
18 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Atomoxitine (Strattera)
A noradrenergic reuptake inhibiter that appears to have relatively good effectiveness in decreasing levels of hyperactivity and in helping with increasing attention, concentration, and organization. It has been approved for use in children as young as 6 years old weighing above forty pounds. It generally has lasting effects throughout the day and into the evening. Problems have included changes in appetite and also nausea along with some sleep problems
19 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Other Medication Options for Attention, Concentration and Over activity
The mainstay of therapy for problems with concentration and attention is stimulant medication. While stimulants are very effective medications there have been problems with their use because of the relatively short half life of each of these preparations. Even at their longest the medications rarely last greater than 8 hours and often times patients can experience a sort of rebound hyperactivity once the medication has “worn off”.
20 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Centrally acting alpha adrenergic agonist
Clonidine and guanfacine have also been very useful in decreasing levels of hyperactivity and in increasing attention and concentration. They are not necessarily as effective as stimulant medications but they are effective in a group of very aroused patients. Side effects are limited to problems with drowsiness and with hypotension.
Intuniv is a long acting formulation of guanfacine.
21 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Venflaxamine (Effexor)
Venflaxamine (Effexor) a mixed serotonin and noradrenergic reuptake inhibiter that has been used in the treatment of difficulties related to concentration, attention and regulation of activity level with some limited success. Recently, Venflaxamine has come under increasing scrutiny because of issues related to possible increased suicidal ideation and suicidal behaviors in children and adolescents taking serotonin reuptake inhibiters. Other problems have included increased irritability and possible increases in blood pressure.
22 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Buproprion (Wellbutrin)
Buproprion (Wellbutrin) is an anti-depressant medication that is sometimes used in the treatment of problems with attention and concentration. Buproprion can be reasonably effective in the reduction of symptoms but must be used with caution in children or adolescents with history of seizures, head injury or bulimia. (This medication has also been included in the list of antidepressants where care as to be given secondary to fears of increased suicidal thoughts or behaviors.)
23 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Tri-cyclic Antidepressants
Tri-cyclic antidepressants have also been used successfully in the treatment of problems with attention, concentration and regulation of activity levels. The tri-cyclics used in children most often include imipramine and nortrityline. They generally have good effectiveness over twenty four hours but they can have troublesome side effects that include a widening of the QRS as measured on EKG. Also they can lead to drowsiness, weight gain, dry mouth and constipation. It is also generally important to check serum levels of these medications while a child is being treated.
24 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
25 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
26 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Psychiatric Annals 37:7 July 2007 pp 479&480
27 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Mondafanil, amantadine, nemantadine, anticholinesterase inhibitors.
There have been some studies but no definitive work. Generally these have not been found to be helpful
28 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Case Study
17 yo who presents to inpatient hospitalization at a treatment facility for SUD. The patient is acutely suicidal and has attempted suicide with overdose leading to the admission.
Diagnosed with ADHD at age 4. At that point there was a history of severe hyperactivity, inattention, and impulsivity.
Treated initially with Ritalin. Problems persisted. Eventually changed to Adderall, then Concerta, and eventually Dexedrine at age 9 yo. Required very very large doses of Dexedrine. There was a response.
29 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Case Study (cont.)
At age 11 developed symptoms consistent with depression and became suicidal. Treated with Serzone and responded very well. He had a great year.
At age 13 became involved with juvenile court authorities for vandalism.
At age 14 changed to Strattera and did “wonderfully”. It was like a wonder drug according to his mother.
At age 15 parents divorced in very bitter divorce. Patient moved to live with father in another state.
30 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Case Study (cont.)
At age 16 dropped out of school. Began to sell and became involved with
organized crime. Increasing problems with aggression and mood instability. Violence toward girl friend. Involvement with the authorities. First hospitalization for 30 day treatment. Released and rapidly relapsed.
Father disclosed new “information” about patient’s mothere. Patient attempts suicide. Current admission
31 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Questions
What do we need to know?
What is the differential?
Where do we start with treatment?
What are the major issues related to treatment?
What is the prognosis?