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Slide 1
Lisa B. Campbell, MD Medical Director, ADHD Specialty Clinic
Childrens Mercy Hospitals and Clinics
Slide 2
Things that dont (or rarely*) cause ADHD Sugar Allergies
Immunizations Food additives* Environmental toxins* Head
injuries*
Slide 3
DSM Symptoms of ADHD Inattention Often does not pay attention
to details/ makes careless mistakes in schoolwork or other
activities Often has trouble keeping attention on tasks or play
activities Often does not seem to listen when spoken to directly
Often does not follow instructions and fails to finish schoolwork,
chores, or other tasks Often has trouble organizing activities
Slide 4
DSM Symptoms of ADHD Inattention (cont) Often avoids, dislikes,
or doesn't want to do things that take a lot of mental effort (such
as schoolwork or homework) Often loses things needed for tasks and
activities Is often easily distracted Is often forgetful in daily
activities
Slide 5
DSM Symptoms of ADHD Hyperactivity Often fidgets with hands or
feet or squirms in seat when sitting still is expected Often gets
up from seat when remaining in seat is expected Often excessively
runs about or climbs when and where it is not appropriate
(adolescents or adults may feel very restless) Often has trouble
playing or doing leisure activities quietly Is often "on the go" or
acts as if "driven by a motor" Often talks excessively
Slide 6
DSM Symptoms of ADHD Impulsivity Often blurts out answers
before questions have been finished Often has trouble waiting turn
Often interrupts or intrudes on others
Slide 7
What is ADHD? Neurobiological disorder Decreased activity in
parts of brain that control: Problem solving Attention Reasoning
Planning
Slide 8
ADHD and the Brain
Slide 9
Date of download: 6/18/2013 Copyright 2012 American Medical
Association. All rights reserved. From: Meta-analysis of Functional
Magnetic Resonance Imaging Studies of Inhibition and Attention in
Attention-deficit/Hyperactivity Disorder: Exploring Task-Specific,
Stimulant Medication, and Age Effects JAMA Psychiatry.
2013;70(2):185-198. doi:10.1001/jamapsychiatry.2013.277 Figure 1.
Inhibition tasks and attention tasks. A, All inhibition tasks
together. Regions of decreased (red and orange) and increased
(blue) activation in patients with attention-deficit/hyperactivity
disorder compared with healthy controls. Decreased activation in
patients with attention-deficit/hyperactivity disorder relative to
healthy controls is shown in the right inferior prefrontal cortex
(IFC) extending into the insula, in a cluster comprising the
supplementary motor area (SMA) and the cognitive division of
anterior cingulate cortex (ACC), in the left caudate extending into
the putamen and insula, and in the right mid-thalamus. B, Attention
tasks. Decreased activation in patients with
attention-deficit/hyperactivity disorder is shown in the right
dorsolateral prefrontal cortex (DLPFC), in the left putamen and
globus pallidus, in the right posterior thalamus (pulvinar) and
caudate tail extending into the posterior insula, in the right
inferior parietal lobe, and in the precuneus and superior temporal
lobe. Increased activation in patients with
attention-deficit/hyperactivity disorder relative to healthy
controls was seen in the left cuneus and in the right cerebellum.
Figure Legend :
Slide 10
Slide 11
Date of download: 6/18/2013 Copyright 2012 American Medical
Association. All rights reserved. From: Meta-analysis of Functional
Magnetic Resonance Imaging Studies of Inhibition and Attention in
Attention-deficit/Hyperactivity Disorder: Exploring Task-Specific,
Stimulant Medication, and Age Effects JAMA Psychiatry.
2013;70(2):185-198. doi:10.1001/jamapsychiatry.2013.277 Figure 2.
Inhibition tasks. A, All inhibition tasks together, with cross
sections showing regions of decreased activation in patients with
attention-deficit/hyperactivity disorder compared with healthy
controls. Shown are the right inferior prefrontal cortex, insula,
right thalamus, left caudate, left putamen, and left insula. B.
Motor response inhibition only, showing the right inferior
prefrontal cortex and insula, right supplementary motor area and
anterior cingulate cortex, right thalamus, left caudate, and right
fusiform gyrus. C, Interference inhibition only, showing the right
inferior prefrontal cortex and insula, left anterior cingulate
cortex, right caudate (head), and left posterior parietal lobe and
posterior insula. The right side of the image corresponds to the
right side of the brain. Distance from the anterior or posterior
commissure is indicated in millimeters for the z coordinate. Figure
Legend :
Slide 12
Slide 13
Diagnosis of ADHD No single test or group of tests How child is
doing at home and at school academically, emotionally and socially
Rating scales Symptoms Performance or function Report cards
Behavior reports Interview
Slide 14
Treatment for ADHD Medical Behavioral Educational About ADHD
About educational interventions
Slide 15
Proven treatment for ADHD Medication Behavioral therapy Gold
standard= Combination of both
Slide 16
Medication Treatment for ADHD NOT used to control behavior Used
to improve symptoms
Medication Treatment of ADHD One-size-fits-all approach doesnt
work Each childs response is individual Medication Dose Side
effects More than one medication and/or dose may be tried
Slide 19
Stimulants Come in a variety of forms Tablets Chewable tablets
Capsules Sprinkles Liquids Skin patches
Stimulants First line Initial response rate 65-75% with single
stimulant 85% if both classes tried No difference head-to-head
between classes
Slide 26
Stimulants Excellent evidence for short-term improvement Core
symptoms Academics Efficiency and accuracy Tasks attempted and
completed Homework completion Behavior Noncompliance Aggression
Poor social interactions Disruptive behavior Driving performance
(in lab)
Slide 27
Stimulants Longer term F/U at 8 years (MTA study) showed no
differences Problems Only definitely ON medication for 14 mos Not
active treatment data Only 32% had taken medicine for more than 50%
of the days in the previous year.
Slide 28
Stimulants Non-core symptoms may not improve Injuries Social
functioning Educational outcomes
Slide 29
Stimulants: Side Effects Most common Decreased appetite and
weight loss Trouble falling asleep Headache Stomachache Personality
changes Irritability Anxiety Cognitive dulling Over focus Rebound
Usually mild and respond to waiting, changes in dose, timing or
type of medication
Slide 30
Stimulants: Side Effects Heart Pulse < 5 bpm BP < 5 mmHg
No serious eventsno increased risk of sudden unexplained death
without family history No need for EKG unless Existing heart
disease Family history
Slide 31
Stimulants: Side Effects Growth Reduced growth rate first 4-12
months Generally not significant Responds to medication holidays or
non-stimulants
Slide 32
Stimulants: Side Effects Tics Short-term studies dont show
significant increase in new onset or worsening of existing. Tics
may improve. Long-term appear to be safe.
Slide 33
Non-stimulants Atomoxetine (Strattera) Antidepressant Works
50-60% of time Takes 6-12 weeks Side effects Abdominal
pain/nausea/appetite loss Sedation Aggressive behavior Liver
toxicity Sometimes used if co morbid anxiety or substance abuse
present
Slide 34
Non-stimulants Guanfacine/Intuniv Blood pressure medication
Alone or as add-on therapy Alone Intuniv works 40-80% of time
Adjunctive Intuniv works additional 30-40% of time Guanfacine
immediate-release (Tenex) taken 2X/day Guanfacine XR (Intuniv)
taken 1X/day Side effects Sleepiness/fatigue (often improves over
time) Abdominal pain Dizziness/low blood pressure Irritability
Slide 35
Non-stimulants Clonidine/Kapvay Blood pressure medication Alone
or as add-on therapy Alone Kapvay works ~70 % of time Clonidine IR
(Catapress) taken 2-4 X/day Clonidine XR (Kapvay) taken 2X/day Side
effects Sleepiness/fatigue (often improves over time) Headache
Abdominal pain Constipation Dizziness/low blood pressure
Slide 36
Nothing works? Is it really ADHD? Could it be something else or
in addition to ADHD? Depression Anxiety ODD/CD Learning disability
Is there a genetic problem with medication response? IPTC NEEDS
BEHAVIOR THERAPY!
Slide 37
Resources: Websites National Institute of Mental Health
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-
disorder/index.shtmlhttp://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-
disorder/index.shtml CHADD http://www.chadd.org CDC
http://www.cdc.gov/ncbddd/adhd/ American Academy of Child and
Adolescent Psychiatry
http://www.parentsmedguide.org/ParentGuide_English.pdf American
Academy of Pediatrics
http://patiented.aap.org/content2.aspx?aid=6050
http://pediatrics.aappublications.org/content/suppl/2006/02/15/108.4.1033.DC1/P2_1033.pdf
ADDvance: Answers to your Questions about ADD (ADHD)
http://www.addvance.com/ http://www.cldinternational.org/ Learning
Disabilities Association of America http://www.ldanatl.org/ MPACT
Parent Training and Information www.ptimpact.org
Slide 38
Resources: Books and Magazines ADHD: What Every Parent Needs to
Know, 2 nd Edition, American Academy of Pediatrics Taking Charge of
ADHD, 3 rd edition, Russell A. Barkley, PhD