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ADHD and Psychopharmacology

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

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ADHD and Psychopharmacology

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  1. ADHD and Psychopharmacology By Monica Robles M.D

  2. 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

  3. Pharmacotherapy ADHD • It is the cornerstone of treatment • Decision to treat should be based on severity of symptoms

  4. Impairment related to ADHD • Psychiatric comorbidity • School failure • Peer relationship dysfunction • Legal difficulties • Smoking and substance abuse • Accidents and injuries • Family conflict • Parent stress

  5. 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

  6. Results MTA study • All the treatment groups were effective • BUT MEDICATION MANAGEMENT ALONE BETTER THAN COMBINATION

  7. 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

  8. 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.

  9. ADHD pharmacotherapy • ADHD has largest body of data of any medication treatment for childhood psychiatric disorder

  10. What do stimulants do • Improve core symptoms of ADHD • inattention • Impulsivity • hyperactivity

  11. What do stimulants do • noncompliance • Impulsive aggression • Social interaction • Academic efficiency • Academic accuracy • Enhanced vigilance • Improve reaction time • Improve short term memory

  12. Stimulants: mechanism of action • They work inside of our brain controlling release of neurotransmitters and inhibiting reuptake

  13. Stimulants • Methylphenidate • Amphetamine preparations

  14. 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

  15. Stimulants: amphetamine • Short-acting Adderall , Dexedrine, Dextrostat • Long-acting Adderall XR, Dexedrine Spansule, Vyvanse

  16. Stimulants(adverse effects) • Use caution in hx of drug dependency and alcoholism Serious cardiac history history of psychotic symptoms or bipolar disorder

  17. Stimulants side effects • Decrease appetite • Gastrointestinal problems

  18. Stimulants side effects • Headache

  19. Stimulants side effects • Sleep difficulties

  20. Stimulants side effects • Jitteriness • Irritability • Anxiety • Depression

  21. Stimulants side effects • Psychosis and paranoia

  22. Stimulants side effects • Tics or abnormal movements

  23. Stimulants side effects • Nail biting • Skin picking

  24. Stimulants side effects • Rebound

  25. Stimulants side effects • Cardiac side effects 1.Increases blood pressure 2.Cardiac complications

  26. 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

  27. Stimulants side effects • Growth Effects Adult height appears to be uncompromised

  28. Abuse potential of stimulants • No scientific data that ADHD children abuse meds when appropriately administered.

  29. Alternatives to stimulants Around 15% nonresponders Intolerable side effects Symptom rebound Complicated ADHD with comorbidity.

  30. Alternatives to stimulants • Atomoxetine(Strattera) • Tricyclic antidepressants • Clonidine and guanfacine • Bupropion • Others

  31. Atomoxetine • Approved by FDA 2002 • Non stimulant med approved for kids and adults • Selective NE reuptake inhibitor • Minimum abuse potential

  32. Atomoxetine side effects • Appetite suppression • Sleep disturbance • Jitteriness and irritability • NAUSEA • Small increase of pulse and Blood pressure

  33. Black Box warning • Hepatitis( 2 cases) Notify doctor if: dark urine, abdominal pain , yellow skin or eyes. • Suicidality

  34. Atomoxetine benefits • It lasts all day • Little or no rebound • No abuse potential

  35. 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

  36. 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

  37. 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

  38. 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 FOLLOW UP

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